Download Obesity: An Emerging Public Health Problem in Asia

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
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5. Raghuram, T.C., Pasricha, S. and Sharma,
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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
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13. Wee, S., Williams, S., Gray, S., and Horbain, J.:
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endurance running capacity. Medi Sci Sports Exerc
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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:
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P.M.:
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67, 1996.
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nutrition:
Nutrition
f/,
Gardew) Chichester:Wiley.54-
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D.J.P.:
Mothers,
babies
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S.J.: Early
growth
18. Ashworth,
A.: Growth
protein-calorie
C.R.,
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WHO/IASO/IOTF,
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syndrome'
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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
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Disease:
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class. Possible role of genetic and environfactors. World Review of Nutrition & Dietet-
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series
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of
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recover-
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1969.
P.: Visceral
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of India.
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R. and Bjorntorp,
P.: Psychosocial
and socio-economic
factors in women and their
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6:
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