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team consisting of a diabetologist, dietitian, nurse, diabetes educator and probably a psychologist to ensure longterm adherence. Paper presented Management the IX Asian of Chronic Congress The author at the Symposium Degenerative Diseases' Director, Prakash 'Dietary M. V. Shetty at of Nutrition. is the Managing Obesity: An Emerging Public Health Problem in Asia Dia- betes Specialities Centre and Madras Diabetes Research Foundation, Gopa/apuram, Chennai 600086. References 1. American Diabetes Association: Standards of medical care for patients with diabetes mellitus (position statement). Diabetes Care (suppl. 1): S23S31,1998. 2. Tinker, L.F., Heins, J.M., and Holler, H.J.: Commentary and translation: 1994 nutrition recommendations for diabetes. J Am Diet Assoc 94:507-511, 1994. 3. Saroja: Diet Manual for Diabetes., M.V Diabetes Specialities Centre, Gopalapuram, Chennai, 2000. 4. Viswanathan, M. and Mohan, V.: Dietary Management of Indian vegetarian in diabetics. NFl Bulletin. 12:1-3; 1991. 5. Raghuram, T.C., Pasricha, S. and Sharma, R.D.: Diet and diabetes. National Institute of Nutrition, Hyderabad. 12: 42-45; 1993. 6. Christine, A., Beebe: Nutrition therapy for type 2 diabetes, ch 4: American Diabetes Association Guide to Medical Nutrition Therapy for Diabetes, p46; 1999. 7. Rosalba, Giacco et a/: Long-term dietary treatment with increased amounts of fibre-rich lowglycaemic index natural foods improves blood glucose control and reducesthe number ofhypoglycaemic events in type 1 diabetic patients. Diabetes Care, 23:10; 1461,2000. 8. Lafrance, L., Rabesa-Lhoret, Poisson, D., Ducros, F., and Chiasson, L.: Effects of different glycaemic index foods and dietary fibre intake on glycaemic control in type 1 diabetic patients on intensive insulin therapy. Diabetic Medicine, 15: 972, 1998. 9. David, J.A., Jenkins, Cyril, W.C., Kendall, Livia, SA, Augustin, et al: Glycaemic index: Overview of implications in health and disease. AJCN. 266S73S; 2002; 76(suppl). 10. Wolever, T.M.S.: The glycaemic index. World Rev Nutr Diet 62: 120-85; 1990. 11. Jarvi, A.E.; Karlstrom, B.E., Granfeldt, Y.E., Bjorck, I.E., Asp, N.G. and Vessby, B.O.: Improved glycaemic control activity and low GI diet in type 2 diabetic patients. Diabetes Care. 22: 10-18; 1999. 12. Brand Miller, J.C.: Importance of glycaemic index in diabetes Am J.CIi Nutr 1994;59 (suppl), 7475-525. 13. Wee, S., Williams, S., Gray, S., and Horbain, J.: influence of high and low glycaemic index meals on endurance running capacity. Medi Sci Sports Exerc 31 :393-399,1999. 14. Janette, C., Brand-Miller, Susanna, H.A. Holt, Dorota, B. Pawlak, and Joanna, McMillan. Glycaemic index and obesity. AJCN 281 S-5S; 2002. Obesity is becoming an increasingly important public health problem. It is now estimated that over a 100 million people worldwide are obese. Obesity is an important factor in the increasing morbidity and mortality due to chronic, non-communicable diseases (NCDs), both in the developed industrialised world and an increasing threat to health in the developing world. Industrialised, developed countries have been showing increasing trends in the prevalence of obesity over the last two or more decades while developing countries are showing a rise in overweight and obesity among their populations along with economic development and urbanisation. Two critical factors that have influenced this explosion in the occurrence of obesity are changes in dietary patterns and levels of physical activity, which accompany the lifestyle changes that have occurred. Obesity is the result of energy intake being chronically in excess of energy expenditure, resulting in a positive energy balance and weight gain. In developed countries, despite the steady decline in per capita energy intake over the last few decades, levels of physical activity have declined with increasingly sedentary lifestyles. The growing concern of industrialised, affluent societies about secular trends in the prevalence of obesity, particularly among children, are also mirrored in the developing economies particularly those in rapid transition in the Asian region. This paper provides a brief overview of this emerging public health problem in the Asian region. It will also outline two important features relevant to this - the links between undernutrition and obesity and the issue of increased risk of co-morbidities associated with obesity among South Asians. EMERGING EPIDEMIC OF OBESITY IN THE ASIAN REGION The epidemiology of obesity in developing societies based on population estimates of BMI is very disturbing. High prevalences have been 6 reported in several developing countries and the Asian region has not been spared'. The Republic of Korea's National Nutrition Survey of 1995, found 1.5 per cent of the population classified as obese and 20.5 per cent as overweight. In Thailand, 4 per cent were obese and 16 per cent overweight. In Malaysia, 4.7 per cent of men and 7.7 per cent of women were obese. Among Malaysian women, ethnic differences were evident: 16.5 per cent of Indian women were obese compared to 4.3 per cent of Chinese and 8.6 per cent of Malays. In China, in the National Nutrition Survey of 1992, low rates of obesity were found among men and women (2 per cent). In Japan, in the National Nutrition Survey of 1990-94, less than 3 per cent of the population was classified as obese, with approximately 24.3 per cent of men and 20.2 per cent of women being classified as overweight. There are even less reliable and representative data on obesity among adults in India. According to a study in Bombay, the prevalence of obesity among young adult males varied from 10.7 per cent to 53.1 per cent2, while another study on urban Delhi adults showed an overall prevalence of 27.8 per cent3. A recent report from the Kashmir valley in adults studied by multi-stage sampling showed the obesity prevalence to be 15.0 per cent; with females having a higher prevalence of 23.7 per cent as compared to 7.0 per cent among males4. Unfortunately, all these reports have used a cut-off of BMI >25.0 which would suggest that the true prevalence of obesity in India may be overestimated in these reportss. Urban-rural differences in the prevalence of obesity are also evident in Asia. In urban regions of China the prevalence of overweight was 12.3 per cent for men and 14.4 per cent for women, while comparable figures for rural regions are 5.3 and 9.8 per cent. In China, between 1982 and 1992, the prevalence of overweight and obesity increased from 9.7 to 14.9 per cent in urban and from 6.8 to 8.4 per cent in rural regions6. A report from urban India suggests that the prevalence of obesity varies with the socio-economic status 7 with those in the upper strata having higher prevalence rates than those in lower socio-economic groups, with the poor in the urban slums having the lowest prevalence rates indicating that India has not yet showed the increase in prevalence of obesity among the urban poor which is characteristic of Brazil and South Africa. Recent Malaysian data demonstrates increasing prevalence of obesity with increasing ages. Obesity in children was higher among boys than girls and ethnic differences were also found, especially among the boys. In China, about 10 per cent of school children were obese in 1992. Recent data from Japanese school children show the prevalence of obesity ranging between 5 to 11 per cent9. Between 1992 and 1998 the prevalence of obesity among Singaporeans remained unchanged at 6 per cent. However, secular trends in increasing obesity prevalence were evident among certain ethnic groups. There are regional, ethnic and cultural variations in the temporal trends for obesity and overweight. CO-MORBIDITIES ASSOCIATED WITH OBESITY The main health risk of obesity is premature death due to heart disease, hypertension and other chronic diseases5. In women, obesity seems to be one of the best predictors of cardiovascular disease. Longitudinal studies have demonstrated that weight gain, both in men and women, is significantly related to increases in cardiovascular risk factors. Weight gain was strongly associated with increased blood pressure, elevated plasma cholesterol and triglycerides and hyperglycaemia. The distribution of fat in the body in obesity also contributes to increased risk. The coexistence of non-insulin dependent diabetes mellitus (NIDDM) among the obese is also an important contributor to morbidity and mortality. Obesity also carries increased risk of gall bladder stones, breast and uterine cancer in females and possibly of prostate and renal cancer in males. Body weight increase is also associated with increasing mortality both in smokers and nonsmokers. Overweight and obesity is normally assumed to indicate an excess of body fat. However, measurement of BMI alone does not account for the wide variation in body composition and body fat stores and the effect this may have on the relationship with increased health related risks. BMI does not distinguish between weight associated with muscle mass from weight due to excess body fat and, hence, a given BMI may not correspond to the same degree of fatness in different population groups. It is well recognised that for the same BMI, different populations or ethnic groups may have quite different amounts of body fat. NorganlO showed that rural individuals from India, Ethiopia and Papua New Guinea had 12, 7 and 1 per cent body fat respectively for the same BMI of 20. More recently, it has been shown that Polynesians have a much lower proportion of fat for an identical BMI compared to Caucasians from Australia11• Some ofthe countries in the Asian region with multi-ethnic populations show marked ethnic and cultural variations in the prevalence of obesity. The extremely high age-standardised prevalence of obesity observed in many multi-ethnic populations of Asian origin in the Pacific islands and in Mauritius provides strong indications of the increased risk among the Asian diaspora worldwide. Populations seem to differ in the level of risk of comorbidities of obesity such as cardiovascular disease (CVD) and diabetes (that is, NIDDM) associated with the range of BM!. It is now undisputed that the risk of co-morbidities is much higher among South Asians (Indians, Pakistanis, Bangladeshis) at a lower BMI range12•13• This finding is further complicated by the variation in the pattern of accumulation of fat (that is, more central or abdominal deposition of fat) in these groups and its relationship with known health risks. Abdominal accumulation of fat can vary markedly for the same percent total body fat or BM!. Waist circumference and waist-hip ratio (WHR) are good indicators of abdominal obesity, which increases risk of comorbidities. Populations differ in their level of risk associated with abdominal obesity and South Asians show a disproportionate increase in risk14• This has prompted the need to reevaluate the recommended cut-offs for obesity and the need for population specific cut-offs for obesity. The report of the recent WHO Expert Con- sultation on 'Appropriate BMls for Asian populations and its implications for policy and intervention strategies' is awaited. ROLE OF MALNUTRITION IN OBESITY Malnourished populations in developing societies in Asia may have an increased predisposition to obesity and more specifically abdominal obesity. The causal link between the two operates by a range of mechanisms. Recovery from episodes of undernutrition results in alterations in body composition with increases in the amount of fat gained and probably intra-abdominal fat deposition. The altered body composition may result in a reduced BMR and a reduction in the energy costs of physical activity. There may be changes in the ability to regulate food intake and in the ability to oxidise fat. All these changes as a result of prenatal and postnatal malnutrition will increase susceptibility to obesity under the right environmental influences such as an increasing intake offat in the diet and a reduction in levels of physical activity characteristic of economic development and urbanisation in these societies. There may be critical periods early in life, when the nutritional status might programme increased risk of obesity in adulthood. The Dutch famine demonstrated that prenatal effects of food restriction, its timing and duration as well as the effect of refeeding on subsequent obesity15. The cohort born to mothers who were exposed to food restriction in the last trimester had a reduced prevalence of obesity at the age of 18 years as compared to those exposed to undernutrition during the first two trimesters of pregnancy. Barker's hypothesis links low birth weight and other anthropometric characteristics at birth resulting from poor maternal nutrition as being important markers that programme the individual to having an increased risk of a range of chronic non-communicable diseases16. Law and others17 showed that retarded growth in foetal life and subsequently in infancy is associated with abdominal obesity. They also showed that for any level of obesity there was more abdominal fat in men who had weighed less at birth. These findings suggest that body weight and adiposity is entrained during postnatal life and that abdominal obesity is programmed and inversely related to early growth. An increase in body fat gain has been demonstrated in malnourished children who were nutritionally rehabilitated. Ashworth18 reported an increase in percent body fat following nutritional rehabilitation of malnourished children while Fjeld and others19 made similar conclusions when they expressed the fat gained as a proportion of the total weight gained during catch-up growth in malnourished children, both during early and late recovery. Whether there is an increased tendency to deposit fat intra-abdominally or whether the nature of the diet during rehabilitation influences this fat gain in any way has not been investigated. Bjorntorp20 has suggested that the pattern of endocrine perturbations associated with abdominal obesity for example, elevated cortisol, increased insulin secretion and raised androgens (in women) along with low levels of growth hormone may contribute both to abdominal fat accumulation and insulin resistance. He suggests that this is due to a hypersensitive hypothalamicpituitary-adrenal (HPA) axis. He suggests that the increase in abdominal obesity seen in psycho-social conditions associated with stress is a feature of life in lower social classes with low education, unemployment and work stress as well as low levels of physical activity21. There is a suggestion of a close link between increase in stunting in populations in developing societies and the emerging epidemic of obesity. Stunting in children is likely to alter the relationship of the appropriateness of weight for height in individuals with short stature and thus exaggerate the apparent prevalence of obesity in a population. Clearly, the links between undernutrition and obesity appear to be strong and may explain the recent findings of both undernutrition and obesity occuring together and in the same low income households22. These findings have enormous significance for developing societies emerging from poverty and continuing to bear the 'double burden' of both forms of malnutrition in their populations. [email protected] Designed and produced adults and Chronic or Dsisease: 14. McKeigue, P.M.: Metabolic sity (Editors: Chadwick 67, 1996. 15. Susser, nutrition: Nutrition f/, Gardew) Chichester:Wiley.54- I, Z.: Timing M. ar, D.J.P.: Mothers, babies Simmonds, S.J.: Early growth 18. Ashworth, A.: Growth protein-calorie C.R., 20. Bjorntorp, 1. WHO/IASO/IOTF, obesity syndrome' Office Western 2. Dhurandhar, of obesity The Asia-Pacific and its treatment. in Bombay. International Metabolic 3. N., Chadha, Gopinath, perspective: WHO Regional S. and Tandon, obesity in adults Journal Disorders. of Obe- 16:367-75, 1992. S.L., Jain, P., Shekhawat, R.: An epidemiological in the urban population Journal of the Association 42:212-215, 1994. study of of Delhi. of Physicians fat46, rates in children malnutrition. of obesity in adults study from Kashmir Valley - an epidemiological of the Indian nent. Journal of the Association India. 48:1170-1174, 2000. 5. WHO: Obesity: epidemic. subconti- of Physicians preventing WHO middle mental Report D.A. and 8. 2001. M.N. and Tan, C.: Prevalence in Malaysia, Country Report sory Board on Obesity, pines, 9. of obesity on the Regional August 1998, Manila AdviPhilip- 1998. Ito, K. and Murata, childhood obesity. rics. 52:1182-1187, 10. Norgan, N.G.: M.: Diagnostic Japanese 1999. Body criteria Journal of of Paediat- Mass Index and body en- ergy stores in developing countries. European Journal of Clinical Nutrition. 36C: 79-84, 1990. 11. Swinburn, B.A., Craig, P.L., Daniel, R., Dent, D.P. and Strauss, B.J.: Body composition differences between Polynesians and Caucasians assessed Journal by bioelectrical impedance. International of Obesity & Related Metabolic Disorders 20:889-894, 1996. epidemiology of In: Diet, Nutrition and Chronic Perspective An Asian of India, C-13 Qutab Institutional by Media Workshop relationship bution. 1999. (Ed i- Area, New Delhi 110016. India Pvt Ltd. e-mail: Research. to obesity International of Clinical obesity: Nu- a 'civilisation 1: 206-222, 1993. and regional Journal body fat distri- of Obesity. 23: 138-45, 22. Doak, C., Adair, L., Bentley, M., Fengying, Z. and Popkin, B.: The underweight/overweight household: an exploration of household sociodemographic and dietary factors in China. Public Health Nutrition. 5:215-221, 2002. FOUNDATION NEWS • Study Circle [email protected] Lecture Dr Anura V. Kurpad (Dean, Institute of Population Health and Clinical Research, Professor of Physiology and Nutrition, St John's National Academy of Health Sciences, Bangalore) spoke on 'Body composition: techniques for measurement and implications', on June 17, 2003. • Task Force Meetings for the following projects were held: June 17, 2003: Obesity in Children and Adolescents of Delhi; and Natural History of Stunting. June 18, 2003: Efficacy of supplementation of n-3 fatty acids in abdominal obesity. The Nutrition is grateful 12. Reddy, K.S.: The emerging cardiovascular disease in India. Disease: K.H.: the class. Possible role of genetic and environfactors. World Review of Nutrition & Dietet- Ismail, Brown, of children recovering from semalnutrition at two rates of series 1997. ics. 90:127-143, Jour- of and managing Technical recover- British 1969. P.: Visceral Obesity Health. of India. 4. Zargar, A.H., Masoodi, S.R., Laway, B.A., Khan, AX, Wani, A.I., Bashir, M.1. and Akhtar, S.: Prevalence in 21. Rosmond, R. and Bjorntorp, P.: Psychosocial and socio-economic factors in women and their Pacific Region pp 56, 2000. N.V. and Kulkarni, P.R.: Prevalence sity & Related and disease Comm catch-up growth. American Journal trition 50: 1266-1275, 1989. redefining Study. and abdominal ness in adult life. J.Epidemic 184-186, 1992. Division, Italy. References in prenatal later life. British Medical Association, London, 1994. 17. Law, C.M., Barker, D.J.P., Fall, C.H.D. and Schoeller, Rome of migrant of Obe- a reprise of the Dutch Famine Reviews. 52: 84-94, 1994. 16. Barker, p consequences Body composition vere protein-energy Organisation, (Edi- Smith-Gordon. and boy fat pallern: lessons from In: The Origin and Consequences 19. Fjeld, & Agriculture Nutrition Perspective The author is Chief, Nutrition Planning, Assessment and Evaluation Service, and Food & Nutrition Food small at birth Diet, London: 23: 835-845, of Nutrition. In: An Asian tors: Shelly & Gopalan). 43-46, 1998. obesity studies. Smith-Gordon. in Indians: both? nal of Nutrition. Congress 7. Gopalan, C.: Rising incidence of obesity, coronary heart disease and diabetes in the Indian urban Edited by Mrs Anshu Sharma for the Nutrition Foundation C.S.: Diabetes as Asian 175-179, e-mail: big ing from 894. Geneva:World Health Organisation, 2000. 6. Ge, L.: Body Mass Index in young Chinese adults. Asia Pacific Journal of Clinical Nutrition. 6: The Proceedings of the IXAsian Congress of Nutrition are now under publication and will be released shortly. The book will contain all the articles (nearly 145 papers) presented at the Plenary Sessions, Plenary Lectures and Symposia and will be valuable resource material. The book is priced at Rs 650 within India and US$50 outside India (inclusive of registered postage charges). Since only a limited number of copies will be available, we request those desirous of obtaining copies may book in advance. A Demand Draft of amount may made in favour of the "Nutrition Foundation of India" and posted to C-13, Qutab Institutional Area, New Delhi 110 016, India. 13. Yajnik, or London: Paper presented at the Symposium 'Obesityan Emerging Public Health Problem in Asia' at the IX global ANNOUNCEMENT tors: Shelly & Gopalan). p50-54, 1998. matching Foundation to grants of this FAO of India and WHO towards the publication website: www.nutritionfoundationofindia.org for cost