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INTRODUCTION: Health is a common theme in most cultures. In fact all communities have their own concepts of health as part of their culture. Among the definition still used probably the oldest is that health is the “absence of disease”. But according to WHO “Health is the state of complete physical, mental and social well being and not merely the absence of disease or infirmity”. Good health is a vital part of great experience of living. So attempts are being made to give every one a fair chance to lead a healthier and fuller life. To maintain good health, a diet containing the essential food and nutrient is very important. Adequate nutrition is necessary for vitality, longevity and sound health. It has direct bearing on the work efficiency and cultural productivity. Food is essential for human existence just like air we breathe or the water we drink (Park, 2000: 1). Health is not a static phenomenon, but a dynamic life process which begins at birth and is governed by the genetic, nutritional and environmental factors throughout life. The calorie and nutrient intake affect work capacity and output and if the nutrient intake is either too much or too low, it results in obesity and malnutrition. The word obesity comes from a Latin word “Obesus” which originally meant “eaten away” or wasted, but in a relative sense came to mean a person or even a bird that had eaten fat. 17 to 38 percent of the Indian populations are obese. (Thilakavathi and Vijayalakshmi, 2002: 153). Obesity may be defined as a condition in which excessive accumulation of fat in the adipose tissues has taken place. It arises when the intake of food is in excess of physiological needs. Obesity is the most common nutritional disorders in the western countries and among the high income groups in the developing countries (Swaminathan, 1998). An excess of twenty percent above the ideal body weight can be termed as obesity. Maintenance of body weight within the limits of facilitating optimum health is of prime importance for maintaining good health. Obesity or excess fatness is the commonest problem of the affluent and it is the night mare of every woman above twenty years and of middle aged men. The prevalence of obesity in our country is high enough to make 1 it a serious health problem. In strict terms, the diagnosis of this disorder depends on the demonstration of an increased body fat content (Naidu and Begum, 1992: 154). The prevalence of obesity, aptly described as a genetic misfortune, has reached epidemic dimension worldwide and is continuing to rise at an alarming rate even in developing countries where human hunger is the other side of the coin. It is estimated that more than 300 million people world wide are obese. According to Koon the prevalence rates of overweight and obesity in India are 12.8 and 10.3 percent respectively. Diet, eating pattern, physical inactivity, sedentary life styles, environmental factors, alcohol consumption and psychological factors contribute to obesity. This global epidemic is related to increased mortality and morbidity rates with excess body fat being a significant risk factor for a number of chronic disorders such as cardiovascular diseases, gout, gall stones, intestinal blockage, kidney disease, sleep apnea, hernia and arthritis. It also increases the likelihood of backache and flat foot. So ways and means of reducing the occurrence of this life threatening problem needs to be urgently explored. (Vijaylakshmi and Anitha, 2003: 436). Obesity is a condition in which there is an excess of body fat. Being too fat, especially to the point of obesity, is positively harmful to the health. Of late, obesity is emerging as one of the most prevalent metabolic disorders. The voluminous researches have been carried out which revealed that wide spread derangements in various metabolic and endocrine functions are associated with obese state. It is associated with number of health hazards like it increases mortality and morbidity rates causing certain diseases such as cardiovascular and cerebrovascular diseases, respiratory insufficiency, diabetes and hypertension. It also reduces the life expectancy and it leads to mechanical disabilities. In women obesity increases the risk of cancer of gall bladder, breast and the womb (Asthana and Gupta: 1999: 263). The obesity epidemic moves through a population in a reasonably consistent pattern over time and this is reflected in the different patterns in low and high income countries. In low income countries, obesity is more 2 common in people of higher socio economic status and in those living in urban communities. It is often first apparent among middle aged women. In more affluent countries, it is associated with lower socio-economic status especially in women and rural communities. The sex differences are less marked in affluent countries and obesity is often common amongst adolescents and younger children. The standard definition of overweight (BMI≥25 kg/m2) and obesity (BMI≥30kg/m2) have been mainly derived from populations of European descent. However in population with large body frames, such as Polynesians, higher cut-off points have been used. In populations with smaller body frames, such as Chinese populations, lower cut-off points have been proposed and studies are being undertaken to separate appropriate cut off points for a variety of Asian populations (Swinburn, et al, 2004: 124). Obesity is prevalent in several developing countries, affecting children, adolescents and adults particularly in those countries experiencing rapid industrialization and urbanization, obesity is growing faster and coexists with under-nutrition and infections diseases, becoming one of the greatest public health problems (Ribeiro, et al, 2003: 659). Obesity is a public health problem in the west. Its prevalence in developing countries is generally believed to be low, but documented information in this regard is scanty. In India, main emphasis has been placed on under nutrition, but over-nutrition another profile of malnutrition has not been investigated in much detail. The magnitude of the problems is not known, but hospital experience has shown that a large number of obese patients need management for obesity (Sood, et al., 1985: 42). Obesity is essentially a disorder of energy balance characterized by an excess of body fat. It is chronic in nature and often associated with a wide range of metabolic abnormalities and degenerative diseases, some of which could be life threatening. Further, it creates psychological problems and reduces the quality of life. This complex condition of multifactorial origin is considered to be the scourge of modern affluent societies, both in developed and developing countries. The ability to store energy in the form of adipose tissue can be considered as a survival strategy. This trait is, how - 3 ever, not conducive to good health in case of affluent populations with sedentary lifestyles and abundant availability of food. Even in situation in which a genetic disposition to obesity exists, interactions between genetic and environmental factors play a part in the development of obesity. The body exerts a stronger defense against under nutrition and weight loss than over -nutrition and weight gain. The primary form in which the potential chemical energy is stored in the body is fat that is triglycerides. The amount of fat in the adipose tissue is the sum total of the differences between food/ energy intake and energy expenditure. Energy balance is controlled by energy intake and expenditure mediated through endocrinal (hormonal), nutrient, neuronal, gastrointestinal and metabolic signals which are all processed by the central nervous system. Energy requirements of an individual reflect the sum of the basal expenditure, thermo genesis and physical activity. Thus there are several factors involved in energy balance. The amount of body fat ultimately is influenced by age, gender, composition of diet, and level of physical activity. In humans, obesity depends on a variety of social, cultural and behavioral factors which act on physiological and biochemical mechanisms that dictate food intake and energy expenditure. Despite physiological regulation of body weight, small deviations in total energy intake and expenditure over a period of time could result in gain in body weight, with a new set point and physiological / metabolic control for body weight regulation (Krishnaswamy, 1999: 1). Rapidly changing diets, physical activity patterns, and lifestyles are fueling the global obesity epidemic. Already, there are more than one billion overweight people world wide and some 300 million of these are estimated to be obese. In many developed countries obesity epidemic has already reached crisis proportions. According to the 1999-2000 National Health and Nutrition Examination survey (NHANES), the proportion of overweight or obese adults in the United States has risen to 64%. Once considered a problem related to affluence, obesity is now fast growing in many developing countries and in poor neighborhoods of the developed countries. In many developing countries with increasing urbanization, mechanization of jobs and transportation, availability of processed and fast 4 foods and dependence on television for leisure, people are fast adopting less physically active lifestyles and consuming more “energy dense, nutrient poor” diets. As a result, overweight and obesity and associated chronic health problems, such as diabetes, hypertension, cardiovascular disease and cancer, are increasing rapidly, particularly among the middle class, urban populations. Even in countries like India, which are typically known for high prevalence of under- nutrition, significant proportions of overweight and obese now coexists with the undernourished. 1.1 WOMEN AND NUTRITION: India constitutes one seventh (about 1000 millions) of the worlds population of which about 406 millions are women and about 12 million girls are born in India every year. India has the dubious distinction of being the only country in the world where the ratio of women to men has been declining and where the life expectancy of women is low than the men. In 1981, the number of female per 1000 males was 933 and in 2001 it was 929 (Cherian, 1994:32) Women are more vulnerable to malnutrition for social and biological reasons; as children they are often discriminated against in getting access to health care, food and education, and as teenagers they have the risk of early pregnancy and suffer from retarded growth, ill health and deprivation, (ACC/SCN second report 1992:51) Nutrition is one of the basic requirements of any living organisms to grow and sustain life. But the quality and quantity of nutrition necessary to keep an organism in good health during its life span vary not only with age of the organisms but also with many other factors. Any major deviation in quantity from its requirements can affect the growth and life span in a number of ways. The human being needs a wide range of nutrients to keep him healthy and active and he must derive most of these nutrients through his daily diet. Several of these nutrients are known to be quite essential since deficiencies due to inadequate intake of these nutrients are often encountered in the human subjects. The chief source of nutrient is food. It provides energy to 5 keep the body warm and muscle active, supplies building material needed for growth and development. Compensating for the loss incurred by daily wear and tear, food also serves as the protective function. The food requirement varies according to age, sex and activity of the individual. Special demands are made during periods of stress such as pregnancy and lactation. The amount of food requirement of women has been cited in the table 1.1. Table 1.1 Amount of food stuffs (g) required per day for women of different activities groups Food stuffs (g) Sedentary work Moderate work Heavy work Cereal 410 440 575 Pulses 40 45 50 Green leafy vegetables 100 100 100 Roots and tubers 40 40 100 Other vegetables 50 50 60 Fruits 30 30 30 Milk 100 150 200 Fats and oils 20 5 40 Meat, fish and egg -- -- -- Sugar and Jaggery 20 20 40 (Source: ICMR 1980 and 1990) Natural food stuffs contain nutrients in minute quantities and each nutrient is responsible for a specific task in the body. The major nutrients are energy, protein, calcium and iron and fat soluble vitamins like vitamin-A and vitamin D and water soluble vitamins like ascorbic acid and B- Complex vitamins like thiamine, riboflavin, nicotinic acid, pyridoxine, folic acid and vitamin B12. The major nutrients like energy, protein and minerals like calcium and iron are essential for growth and maintenance of the integrity of the body tissues. The other nutrients namely vitamins and trace minerals are required for the metabolisms of these major nutrients and to maintain tissues at an optimum level of activity. Studies have been carried out on the 6 quantitative requirements of these nutrients. The dietary requirement of above nutrients depend upon the age, sex and quality of mans habitual diet. The dietary allowance as recommended by ICMR (1990) for the Indian women in different activity groups are presented in the table 1.2. Table 1.2 Nutrient requirement per day for women of different activity groups Nutrients Sedentary work Moderate work Heavy work Energy (Kcal) 1875 2225 2925 Protein (g) 50 50 50 Mineral Iron(mg) 30 30 30 Thiamine (mg) 0.9 1.1 1.2 Riboflavin (mg) 1.1 1.3 1.5 Niacin (mg) 12 14 16 Vitamin C(mg) 40 40 40 Vitamin-A (g) 2400 2400 2400 Folic Acid (g) 100 100 100 Vitamins Nutrition plays a very important role in the physical, mental and emotional development of human beings. The nutritional requirements of females also follow the same pattern in males, but they differ from males in certain important aspect during certain age periods. There is less difference between men and women in nutritional requirements during infancy and early childhood. During adolescent and adult periods, however the nutrients of women’s are lower than men, since the growth rate during adolescence and adult body weight attained are lower in women than in men. During reproductive age period, due to blood loss during the menstrual period, women’s need for certain nutrients concerned with blood formation (viz. Iron, folic acid, vitamin B12) is much higher than in men. The recommended dietary allowances for Indian women in general are 1800 Kcal energy, 50 g protein, 400 mg calcium, 30 mg iron, 600 g retinol (Vitamin A), thiamine 1.1 mg, riboflavin 1.3 mg and folic acid 100 g 7 daily (Gopalan et al. 1996). A poor Indian mother’s calorie intake is 1400 – 1800 Kcal/ day and her protein intake is 40 g/ day or less. Studies in Gujarat sowed that the proportion of women who consumed less than 2000 Kcal / day was 43 percent (Srikantia, 1990:108) 1.2 WOMEN AND OBESITY: Adolescents with special reference to girls are concerned about their weight. Obesity occurring in adolescents tends to remain throughout life. Storz and Greene state that above one third of adolescents studied were obese and remained so as adults. In a developing country like India, obese adolescent girls are common these days which may be attributed to changed eating habits of adolescents. Excessive intake of energy and fat has adverse effect on the body dimension and therefore may have an effect in their blood cholesterol levels also. Studies on the prevalence of obesity among Indian adolescent’s girls and blood cholesterol level are very few till now (Sasirekha and Tamilarasi, 1990: 35). In India, women constitute about 48 percent of all human resources and work force. Thus, their good health is of paramount importance. Obesity, a world wide problem, associated with a reduced life span, has been extensively documented in the western countries. A high prevalence has been reported in the female sex (Dua and Seth, 1988: 338). Obesity is an established risk factor for post-menopausal, but not premenopausal, development of breast cancer. Evidence for a positive association between obesity and breast cancer mortality is mounting. Avoiding adult weight gain and maintaining a healthy body weight may contribute importantly to decreasing breast cancer risk and mortality, especially in postmenopausal women. The relationship between obesity and breast cancer incidence and mortality is complex and especially difficult to interpret (Petrelli, et al., 2002: 325) The relationship between weight status and the occurrence of breast cancer is complex. Nonetheless; overweight and obesity have been implicated as risk factors for breast cancer in postmenopausal women (Barnett, 2003; Connolly et al, 2002; Stephenson and Rose, 2003). Connolly 8 and colleagues, in their Meta analysis of 19 studies, suggested that the risk of breast cancer increased as waist to hip ratio increased. This risk was independent of general obesity (overall BMI), as well as other known breast cancer risk factors. Further more obesity and poor breast cancer outcomes are more prevalent in African American women than in Caucasian women”. (Blackburn, Copeland, Khaodhiar, and Buckley, 2003 :185). Evidence shows that dietary fat intake may play a significant role in the development of breast cancer (Blackburn et al., 2003). Diets low in saturated fats and high in fruits, vegetables and whole grains may protect against breast cancer. Furthermore, the type of fat ingested, specifically marine fatty acids has been found to inhibit the proliferation of breast cancer cells in animals and in vitro studies (Terry, Rohan and Wolk, 2003). However, similar findings have not been obtained in studies using human participations. Terry and associates (2003) in their review of 7 prospective cohort studies and 19 case control studies concluded that evidence to support this assertion remains unclear. Consumption of fish and marine fatty acids was not associated with a decrease in the incidence of breast cancer. As with cardiovascular health, a diet high in fruits, vegetables and high-fiber carbohydrates and low in fats seem to offer protection against breast cancer. Women who followed the dietary guide liens and ate in this manner decreased their risk of breast cancer by 15% (Blackburn et al., 2003). These investigators concluded that lifestyle modifications, including diet, protect middle aged and older women from breast cancer. There does not seem to be an association between intake of foods high in dietary carotenoids such as lycopene and protection against breast cancer (Terry, Jain, Miller, Howe and Rohan, 2002), unlike the possible association between lycopene and decreased risk for cardiovascular disease (Sesso et al., 2004). Current age adjusted data from the National Health and Nutrition Examination survey 1999-2000 indicate that 64.5% of a U.S. Sample of 4115 men and women are overweight (Body mass index 25) and 30.5% are obese. When one consider the data specifically in relation to women, the incidence of obesity is even more alarming. Almost 62% of women over the age of 20 years are overweight, of these, 33.4% are obese. 9 The incidence of obesity is even greater is non Hispanic black and Mexican American women. Canadian women are not immune to increasing weight. The proportion of overweight women (Defined as BMI>27) increased from 14% to 23% from 1985 to 1996-1996 (Health Canada, office of nutrition policy and promotion, 2003). Nutritional challenges are particularly relevant to women. Almost 62% of women are overweight; of these women 33% are obese. The incidence of obesity is even greater in non Hispanic black and Mexican American women. Women who are overweight or obese experience a greater number of adverse health outcomes, including an increased incidence of cardiovascular disease and breast and colon cancer. Dietary patterns influence health outcomes, with a heart healthy pattern having the most positive health outcomes. Health care providers should encourage women to consume a diet high in fruits and vegetables and low in total and saturated fats (Morin, et al, 2004: 823) Summary comparison of two major studies conducted by National family health survey (NFHS-2) in 1988-1999 and NFHS-3 in 2005-2006 shows that prevalence of obesity among Indian women has elevated from 10.6% to 12.6% (increased by 24.52%). The prevalence is more profound in the women of age between 40-49 years (23.7%), residing in cities (23.5%) having high qualification (23.8%), belonging to Sikh community (31.6%) and households in the highest wealth quintile (30.5%). Highest percentage of obese women is found in Punjab (29.9%). Although this number seems small in the international perspective, it is significant because of the sheer size of population in India. While the problem of under- nutrition still exists in many parts of India, the additional burden of obesity due to increasing sedentary lifestyle, junk food habits in some urban and economically sound areas is really alarming. Prevention and control of this serious problem through awareness programmes to adopt diversified nutritional food and healthy life style are strongly recommended (Garg, et al, 2009). 10 1.3 OBESITY AND ASSOCIATED FACTORS: Considering the health hazards of obesity, researchers have tried to identity the factors which lead to the development of obesity. Broadly speaking, the biological, nutritional, social and psychological factors have been identified. Since obesity is predominantly a metabolic disorder the role of biological and nutritional factors are more important in its development than the other factors. Biological factors may be described in terms of heredity, age, sex, marital status and also in terms of certain event in life of women such as pregnancy, use of contraceptive, and menopause which may be associated with weight gain (Asthana and Gupta, 1999: 263). Demographic profile which also increases the incidence of obesity consists of mean age, marital status, occupation, family size, educational level, caste and culture etc. Food behavior denotes the aspects of type of diet consumed and daily intake of nutrients of obese adults (Naidu and Begum, 1992: 154). There is an association between obesity with food behavior and some related factors like parity, duration of lactation, physical activity pattern and familial traits. Food behavior denotes the different aspects of food consumption like selection and preparation, dietary intake, eating patterns, food likes, dislikes and habits and food intake in response to socio-cultural, environmental and physiological pressures (Dua and Seth, 1988: 338). Socio–economic status (SES) is a characteristic of an individual (often measured by personal income or educational attainment), its underlying determinants are closely linked to the wider environment, especially to social, economic employment and educational policies. The relationship between obesity and socioeconomic status is complex. The patterns are more exaggerated in women compared to men and children and generally show that in low income countries obesity is more prevalent in high socioeconomic status individuals and in affluent countries it is more prevalent in low socioeconomic status individual. The change in obesity prevalence patterns can be seen in some countries that have monitored obesity prevalence rates over a period of economic transition. It seems that in developed countries, the relationships may be bi directional (i.e. low SES 11 promotes obesity and obesity promotes low SES) as well as both obesity and low SES being independently influenced by other common factors such as intelligence. The mechanisms by which high SES in developed countries provides some protection against have not been well characterized and are likely to be multiple, including behaviors such as restrained eating practices and increased levels of recreational activity, living in less obesogenic environments with greater opportunities for healthy eating and physical activity and a greater capacity to manipulate their micro-environments to suit their needs. People living at low SES circumstances may be more at the mercy of the increasingly obesogenic environment and end up taking the default choices on offer. Poorer neighborhoods tend to have fewer recreation amenities, be less safe and have a higher concentration of fast food outlets. Overall, there is consistent support for the concept that, in affluent countries, a low SES is risk factors for obesity in women and part of that effect is likely to be related to environments that are relatively deprived of healthier for choices and opportunities for physical activity. The home and family environment is undoubtedly the most important setting in relation to shaping children’s eating and physical activity behaviors, but surprisingly, very little is known about the specific home influences. A recent review by Campbell and Crawford, however, has highlighted a number of elements in the home environment that are likely to be influential. The availability, accessibility and exposure to arrange fruits and vegetables in the home was correlated with consumption and at least two studies showed that repeated exposure to new foods seemed to reduce the propensity for young children to rejects them. Some aspects of the mother’s nutrition knowledge, attitudes and behaviors are also significant predictors of a child’s consumption of fruits, vegetables and confectionery. Fast food restaurants and energy dense foods and drinks are among the more advertised products on television and children are often the targeted market. The fat, sugar and energy content of foods advertised to children is very high compared to their daily needs and most of the foods advertised fall into the ‘eat least’ or ‘eat occasionally’ sections of the recommended dietary guidelines. The prevalence of overweight and obesity 12 is higher among children who watch more television and the increased energy intakes of these children may be partly responsible. Advertised products are more often requested for purchase and consumed by children. There are a wide variety of settings in which people gather and that involve food and eating. Most of the evidence for their impact on eating patterns comes from cross sectional surveys or intervention studies. Restaurants, workplaces, super markets, and a variety of other settings probably each provide modest influences on dietary intakes and obesity but good evidence is either limited or non existent. (Swinburn, et al., 2004: 133-134). Several authors have demonstrated a positive association between the time spent in watching TV, reduced physical activity, and obesity in children and adolescents. According to Gortmaker et al time of TV viewing during childhoods is associated positively with obesity prevalence and incidence. According to Neutzling et al environmental factors represent important risk factors for overweight and obesity. At a given stage of development better socio-economic condition favour nutrition and health aspects and contribute to the rise of obesity in the population (Ribeiro, et al., 2003: 659). The relationship between social factors and childhood obesity remains equivocal and poorly understood. Physical factor for example, region, season and population density and social factor for example, ethnicity, family size, excessive television viewing, short sleep duration, and rearing conditions have all been associated with adiposity in children and risk of overweight in young adult-hood. The role of socioeconomic status has probably been studied the most extensively, but the associations with childhood obesity are inconsistent. However, data from the 1946 British birth cohort show that low socioeconomic background in child hood and a high relative weight at age of 14 years are associated with higher mean BMI throughout adult life. Moreover, this is only partially confounded by educational attainment and by adult socioeconomic status, suggesting a long term impact of biological and behavioral processes on BMI. At present, it is not clear whether obesity develops because of an excess energy intake (EI) relative to energy expenditure (EE), a reduced EE 13 relative to EI or most likely a combination of both. While young children appear quite capable of self regulating their EI under unsupervised conditions, this regulatory capacity appears to be easily undermined by a variety of factors including the degree of parental control and attitude towards the children intake. The pressures on children to eat and the opportunities for them to eat may be greater than ever before. However considerable caution needs to be applied when scrutinizing EI data sets as a basis for explaining the origins and development of pediatric obesity. Epidemiological studies of food habits and dietary intake in children and adolescents face a number of measurement difficulties which are more or less specific to these age groups (Livingstone, 2004: 111-113). Considerable data indicate that energy from beverages does not displace energy from other foods throughout the day, often leading to energy imbalance, and numerous studies have documented that beverages are a leading contributor to energy intake among Native Americans. Prevention programs that target pregnant women and parents of infants and very young children are necessary to halt the epidemic of obesity among Native Americans. Across all age groups and ethnicities, the well recognized epidemics of overweight and obesity grow worse with each passing year. The majority of adults in the United States are overweight or obese based on body mass index (BMI (Kg/m2) and between 10 and 15% of U.S. children are overweight. Preventing and treating overweight and obesity are high priorities because these conditions are associated with an increased risk for chronic diseases, including cardiovascular diseases, diabetes, hypertension, pulmonary stress and orthopedic problems (Wharton, et al, 2004; 153). Data from the 1994-1996 Continuing survey of Food intakes by Individuals (CSFIT) show that Americans frequently choose beverages, especially colas, as snacks. Chanmugam et al, compare the dietary intakes between 1989-1991 and 1994-1996 and showed that soft drink intake increased significantly (P<0.05) and that this change was responsible for most of the increase in energy intake from beverages. Of all the food groups assessed, whole milk and soft drink intakes changed the most during the brief time interval. Whole milk intake decreased by ~100 g/day and soft 14 drink intake increased by ~90 g/day. An increase of approximately 85g/day in reduced fat milk consumption was noted in these data as well. This was nearly enough to offset the large decrease in whole milk consumption. Other findings by Mrdjenovic and Levitsky, however showed that consumption of sugary beverages displaced milk in children’s diets, leading to significantly lower intakes of protein, calcium, magnesium and vitamin A (Heaten, et al., 2003, 3). Risk factors may vary amongst and within societies exposed to different environmental influences. Demographic, epidemiological and nutritional transition processes have different characteristics in different countries. In Latin America, the social, economic and demographic transformations that have taken place during the last decades coincided with modifications in the regions epidemics, logical profile and dietary and physical activity patterns (Neutzling, et al., 2003: 743). For many individuals depressed physical activity is the main cause of calorie imbalance. Modern living patterns require less of physical mobility while eating patterns remain of excessive calories. Currently, obesity is viewed as an outcome of multiple etiological factors. The factors influencing the food intake and energy expenditure have social, economic, somatic, emotional and genetic elements. Numerous studies have been conducted in the field of obesity and psychiatry. It has been indicated that obese individuals respond to their environment in a manner quite different from that of persons having normal weight. Obese persons are frequently found to be frustrated, hostile, and often depressed. It is also agreed that persistence in overeating is an emotional problems (Lakhanpal, 1978: 8384). In general the factors known to predispose to obesity are common to both children and adults. At a fundamental level it is necessary to have an excess of energy intake over expenditure, and ever a small excess may, over a number of years, lead to very considerable obesity. The excess may come about through overeating or though reduced energy expenditure or a combination of both. The situation in child-hood differs somewhat from that found in adult life. Eating habits of school children are the subject of 15 continued pressure from the peer groups, especially in the type and frequency of between-meal snacks, many of which have a high energy density. Adolescence also presents particular problems in that there may be a disturbance of body image, especially in girls and in that the sexual connotations of body shape are very intrusive at this age. Growth hormone deficiency is associated with relative overweight and the combination of shortness and fatness should ring alarm bells. ‘Normal’ obese children are usually above average in height. There is no doubt that genetic factors are important and this has been demonstrated both in general population studies and in studies of identical twins reared apart. From the available data, it appears that heritability is particularly important in fat children over 10 years of age, while in children fewer than 10 environmental factors are probably more important. It has however, been shown that the children of obese parents, through not yet themselves obese, have lower daily energy expenditure than the children of thin parents. So genetic factors may have greater influence than has been indicated by population surveys of established obesity. The first factor usually considered when faced with an obese individual is food intake. In infancy there is more definite association between over feeding and obesity, than there is in older children. It is very difficult to measure energy intake in children accurately, but to measure energy expenditure accurately over a long enough period to mean anything is virtually impossible with present techniques. Even so there is good circumstantial evidence that variations in energy expenditure are important. For example in situations where expenditure is reduced because of physical inactivity, obesity is common, and the wide variation in energy intake which is known to occur in normal children could not be accommodated without gross changes in body fatness unless there were equivalent and compensating alternations in energy expenditure. A proportion of fat children (but not all) will have important emotional difficulties which may contribute to, or ever be the original cause of, the obesity. Eating is quite often a coping mechanism, helping the children to deal with stress. Overeating may be a symptom of depression and depressed children tend to be lethargic, increasing the likelihood of obesity. There 16 may be complex psychological undercurrents in adolescence, especially in girls who may overeat to avoid being too thin or alternatively to make themselves less attractive, there by postponing the threat of sexuality. As soon as obesity is established it becomes a psychological factor in its own right, leading to peer group decision and initiating a vicious cycle. (Brooke and Abernethy, 1985:304-308) 1.4 OBESITY AND DISEASES: Obesity is a major risk factor for high morbidity and mortality its association with hyperlipidaemia, hyperglycemia and insulin resistance are well established. Diseases such as coronary artery disease, cerebrovascular accident, hypertension, diabetes, certain cancers, cholelithiasis and reproduction problems such as polycystic ovarian syndrome and muscular skeletal problems are more often associated with a body mass index greater than 30 kg/m2. The detrimental effects are related to body weight, body fat, and magnitude overweight gain during adulthood and sedentary lifestyles. More recently, regional distribution of fat within the body has been the focus of attention. Excess abdominal fat or ‘android’ obesity or ‘central obesity’ appears to be far more deleterious than ‘gynoid’ obesity where fat is distributed peripherally around the body. Further, the X syndrome of hyperglycemia, hyperlipidaemia (elevated triglycerides) and dense LDL and hyperinsulinaemia (insulin resistance) and hypertension, is more often associated with abdominal obesity which is believed to be more common in south Asians (Krishnaswamy, 1999: 1). Obesity, or the over-nutrition associated with obesity, causes an increase in height growth during childhood. Obese children thus tend to be taller than average. However, puberty also occurs earlier, and the halting of growth which follows may result in an adult height which is below average (Lloyd et al, 1961), since the whole process of skeletal maturation has been accelerated without leaving enough time for full genetic height potential to be realized. Impaired glucose tolerance occurs in about 25 percent of obese children (Martin and Martin, 1973). Since hyper insulinaemia also occurs 17 after oral glucose, it must be assumed that insulin resistance develops. This is reversible on weight loss. Frank diabetes is not usually found. The distribution of adipose tissue in obesity may give a false impression of gonadal abnormalities in boys, since fat on the chest may mimic breast enlargement and since the penis may be partly buried in pubic fat and therefore appear small. In fact there are no major disturbances of sex hormone function. Young infants with obesity are more prone to respiratory infections than thin infants (Hutchinson- Smith, 1975). The reason for this are not understood. Extreme obesity in children and adolescents may result in a state of chronic hypoventilation, particularly severe during sleep, and causing respiratory failure with CO2 retention and hypoxemia. The CO2 retention results in a drowsiness so often seen in this syndrome, which has been named ‘Pickwick syndrome’ after Dickens’s fat boy. If the situation is allowed to persist heart failure and death can occur. Hypertension is seven times more frequent among obese than non obese children (Brooke and Abernethy, 1985: 309). Few studies have assessed the relationship between obesity and breast cancer mortality. Obesity has been shown to increase the breast cancer mortality in women after menopause in the nurse’s health study by Huang et al and in a large Norwegian study by Treetli. The recently published study in cancer causes and control by Petrelli et al strongly supports these findings. The association between obesity and breast cancer mortality may be attributed to co morbidity issues that come with increased obesity. The evidence for the relationship of obesity to a number of co morbidity such as diabetes, hypertension, cardiovascular disease, gall bladder disease, and some cancers is strong. In addition higher frequency of large tumors, lymph node metastases and poorer prognosis in obese compared with lean breast cancer patients have been observed. Obese women with breast cancer have been found to have decrease survival rates and increases recurrence. According to Petrelli et al., the higher death rate found in their study may be due to a true biologic effect of obesity or to delayed diagnosis in heavier women which are 50 to 100% higher among heavy than in leaner women. Estradiol levels in post -menopausal women 18 have been reported to increase with increasing BMI. In addition, the level of unbound or loosely bound biologically available estrogen is higher in obese than in lean women because sex hormone binding globulin level is lower in obese women. Estrogen sensitive tissues in obese women are therefore exposed to more stimulation, which leads to more rapid growth of metastatic tissues, than those of leaner women. Breast cancer is also more likely to be detected later in obese women. This is because detection of breast tumor is more difficult in obese than in lean women. Late stage tumors have been associated with poor prognosis (Barnett, et al, 2003: 73). Obesity is associated with a number of health hazards like it increases morbidity and mortality rates causing certain diseases such as cardiovascular and cerebrovascular diseases, respiratory insufficiency, diabetes and hypertension. It also reduces the life expectancy and it leads to mechanical disabilities. In women obesity increases the risk of cancer of gall bladder, breast and the womb (Asthana and Gupta, 1999: 263). Overweight among children carries heavy individual and public health consequences and is on the rise in the United States. In less than 30 years, the rates of overweight among children and adolescents have more than doubled. In the year 1999-2000 National Health and Nutrition Examination Survey (NHANES III), 15.5% of adolescents aged 12-19 years and 15.3% of children aged 6-11 years were overweight compared with 10.5% and 11.3% respectively in 1988-1994 (NHANES III). Reports from the centers for disease control and prevention (CDC) indicate that overweight is occurring in children as early as preschool age, with NHANESIII (1999-2000) reporting that 10.4% of children aged 2-5 years are overweight. Overweight children not only suffer from negative psychosocial interaction and repercussions from their peers, sleep apnea and orthopedic complications, but older overweight children and adolescents are now also presenting with type II diabetes mellitus and hypertension, which are normally seen in the obese adult and / or the elderly. The overweight child is also at much higher risk for becoming an overweight adult. Approximately 30% of overweight children become overweight adults. The persistence of overweight into adult-hood results in more extreme overweight as an adult, 19 with higher morbidity and mortality than experienced in adults whose overweight began in adulthood. Therefore, programmes to promote healthy life styles need to start early in life, to prevent overweight in childhood and subsequently adulthood. (Slusser, et al., 2005: 141). Several studies have shown that abdominal obesity, independent of general obesity is associated with a high risk of developing non-insulindependent diabetes, CHD and Stroke (Walker et al., 1996; Rexrode, et al., 1998, 2001; Lakka, et al., 2002) and of mortality (Bigaard, et al., 2003 and Halkjaer et al., 2004: 735). The evidence of a relationship between obesity and asthma is not conclusive; however, several studies find a relationship between obesity and asthma in females but not in males. Others have found no relationship between obesity and asthma. Still others have concluded the reverse relationship that asthma is a risk factor for obesity. The evidence for the adverse effects of obesity on women’s health is overwhelming and indisputable. Obesity, especially abdominal obesity is central to the metabolic syndrome and is strongly related to polycystic ovary syndrome (PCOS) in women. Obese women are particularly susceptible to diabetes and diabetes, in turn, puts women at dramatically increased risk of cardiovascular disease (CVD). Obesity substantially increases the risk of several major cancers in women, especially postmenopausal breast cancer and endometrial cancer. Overweight and obesity are associated with elevated mortality from all cases in both men and women and the risk of death rises with increasing weight. Curbing the two epidemics of obesity and diabetes calls for not only changes in the diet and life style at individual levels, but also changes in physical and social environments, and cultural norms. 1.5 PREVENTION OF OBESITY: In discussing preventing measures for obesity in a community, the first important step is in locating the individuals at risk. To detect early cases of obesity screening procedures are suggested. Several types of screening programmes depending on available resources and priorities can 20 be designed in order to offer proper guidance and care to the needy. Prevention is more effective if obesity is detected at an early stage, and this is particularly emphasized for childhood obesity. Weight reduction efforts exerted by individuals on their own initiative or under the direction of their physicians have been widespread for many years. However, many of these measures do not seem to reach a sufficient number people because of expense involved. Other group efforts in dealing with medically uncomplicated and moderate obesity have more hope of success in reaching the millions of persons who require some kind of expert support and guidance. Dwyer and his associates have suggested approaches for more effective prevention and treatment of obesity including group’s efforts, establishment of middle aged clubs, particularly for men, to encourage physical exercise and dieting through organized classes and other facilities. ‘Weight watchers’ and health spa’s are other ideas where group’s therapies and groups techniques are used in the prevention of obesity. Many persons are using such facilities gainfully, where a combination of ‘low calories’ diet and a programme of physical exercise is instituted in a social atmosphere and comradeship. Success in weight reduction program through such clubs and spas will necessitate the education of instructors in the rudiments of scientific nutrition, energy balance, energy metabolism and weight control. This type of education is needed in order to reduce chances of dissemination of common misconceptions about foods, facts and fads. The health clubs and spas do not entirely serve the purpose of controlling obesity in a community, and there is an ever present need for designing weight control programmes tailored to the requirements of the community. This may calls for nutrition education of the particular population and collaboration between nutritionists and health workers of others disciplines. No one kind of diet can be said to be best for all individuals. Also, dieting is difficult to adhere to for a successful weight regulation programme because of several social and economic factors. Modern food technology will probably help to develop a low calorie, high nutritive value foods which are inexpensive, tasty, safe and socially acceptable. This product will allow 21 dieters to loose weight and at the same time to avoid the monotony of dieting and yet maintain good nutrition status. Since obese children usually become obese adults, measures in preventing obesity in children should begin at an early age. Also, it must be recognized that a well established obesity is difficult to cure. Further, our knowledge of predisposing factors in childhood obesity remains fragmentary. It is believed that obesity in childhood may be an outcome of environmental situations or psychological traumas. The factors that greatly affect obesity in childhood are obesity in parents or siblings, unwanted pregnancies, family setup or physical handicaps that limit mobility. These and other factors such as body image disturbances underline the need for efficient psychiatric, diagnostic and therapeutic services. For any meaningful programme to be effective in prevention of obesity, adequate facilities for exercise and opportunities for the development of physical activity programmes, for both adults and children must be provided in the community. This is because physical activity plays an important role in maintaining the desired energy balance. Furthermore, counseling in foods, and nutrition and other health care matter must also be available to the community. Prevention rather than treatment of obesity is by for the best course (Lakhanpal, 1978: 88-90). Reducing energy intake is simple in principle, but very hard in practice. It is very difficult to eat less than you want to and a great deal of support is necessary for the maintenance of a low energy intake. Adults probably get most help from self-help groups, but such groups do not normally allow children to attend. If there is any other members of the family who is even mildly overweight, he or she should be encouraged to join the child in dieting, since this provides support and an element of mild competition. A pediatric dietitian should be involved from the start wherever possible. There is no particulate magic in the type of diet used, although strong claims have been made for very high fiber diets and diet containing high concentration of protein. In practice it is difficult to persuade children to make major changes in the quality of their diets, and it is usually best to organize a low energy intake within the framework of the child’s normal 22 dietary pattern, while ensuring that it is of adequate nutritional quality and given in a satisfactory meal pattern. There of course no harm in combining diet with a bit of health education, but it may be very hard to get working class children to eat whole-meal bread, fresh salad or cooked vegetables. There may well be an advantage in attempting to provide a higher protein energy ratio than normal because post prodigal thermo genesis is greater with such diets and the increased energy expenditure will contribute to weight loss. Regular weighing and clinic visits are important. Thrice weekly weighing and charting on a wall-chart are aids to compliance as well as indicators to the dietitian or physician that compliance has failed. Ketonuria should occur during weight loss as depot fat is metabolized. Exercise should be encouraged vigorously, not merely as an adjunct to the more important measure of reduced food intake, but also to maintain muscle mass and reduce the tendency towards loss of lean tissue which occurs to some extent on weight losing regimens. Exercise alone, however, has much less effect on energy balance than reduced energy intake. Energy output can be increased by the use of thermogenic drugs and there is abundant evidence in animals that they will produce weight loss in all types of experimental obesity (Dulloo and Miller, 1984). The majorities which have been tested are adrenergic stimulant drugs and are likely to have side effects if given in dosages sufficient to cause weight loss in humans. Thyroid hormones produce increased thermo genesis and thyroxin and T2 have been used as adjuncts in the treatment of obesity (Bray, 1976). We occasionally use T3 in particularly refractory cases in older children, but only on the basis of carefully controlled assessment during hospital admission, giving just sufficient to increase the sleeping pulse rate. The place of such agents is at present uncertain and they should only be used for short periods of time. Long term results are no more satisfactory than dietary treatment alone. Psychiatric help is often necessary. Behavior disturbance may be obvious or there may be evidence of depression. In either case psychiatric referral forms part of the management, class cooperation being maintained with the psychiatrist to ensure a consistent approach. Proper psychological management will help to resolve conflicts within the home but rarely results 23 in an improvement in the prognosis for the obesity. The role of psychiatric treatment in the primary management of obesity, by modification of eating behavior, is not well evaluated in children but has been successfully applied in adults (Brownell and Stunkard, 1978). If a fat child can not manage to lose weight as an out patient or if obesity is so severe as to impair health, hospital admission must be considered. With adequate supervision all obese children will lose weight in hospital and although a very expensive form of treatment it does have the advantages of demonstrating to the family that weight loss is possible and of allowing a leisurely psychological evolution of the family situations (Brooke Abernethy, 1985: 310-312). As obesity is a life threatening problem, giving rise to various complications, ways and means of reducing the occurrence of obesity needs to be explored. Naturopathy is one of the systems that provide a positive solution for the problem of obesity, as exercise has been the major element of the system. Exercise not only facilitates weight loss through direct energy expenditure but burns fat both during and after exercise. Exercise can tilt energy balance towards negative and enhance a weight loss programme. In addition exercise tones up the muscles, reduces appetite and improves the psychological outlook in life. Yogasana is another recognized and practiced health tool which is a powerful way for physical fitness. Since gradual weight reduction can be achieved by means of naturopathic treatment without any side effects, this method is becoming popular among people who would like to reduce weight (Vijayalakshmi, et al., 2003: 1). A common treatment for obesity is weight reduction. Although short term weight loss programmes have proved to be successful, long term weight maintenance is a major problem (Kramer, et al., 1989). Successful weight maintenance is of importance for lowering risk factors for cardiovascular and other diseases. To improve the metabolic profile, it is not necessary to achieve the ideal body weight. A weight reduction of 5-10% is often sufficient to induce a clinically relevant effect (Goldstein, 1992). To preserve these beneficial effects of weight reduction, an improvement in long term weight maintenance is necessary. Pasman et al (1999) showed that weight regain was slower when the body composition of the weight 24 regained consisted of a greater but fat free mass (FFM) due to physical activity. There is a hypothesis that weight regain may be limited if the inevitable increase in body weight consists of a larger FFM, for instance achieved by the consumption of an appropriate substrate. For this, there is suggestion for an increased protein intake, because of its potential to increase FFM (Jean et al., 2001). Furthermore, it is known that of all the macronutrients, protein seems to be the most satiating. Protein consumption suppresses short term food intake more than that of fats or carbohydrates and even more than is expected from its energy content alone (Anderson, 1994). Several studies have shown that a high protein lunch decreases later food intake more than a lunch low in proteins. (Booth et al., 1970; Barkeling et al., 1990; Latner and Schwartz, 1999). Westerterp Plantenga et al., (1999) showed an increased satiety effect of a high protein diet despite similar energy intake. Finally, protein has also been shown to have low energy efficiency during overfeeding, a situation that is comparable to a weight regain situation. Although the effect of dietary protein has been examined in weight-loss studies, the effect of additional protein intake on weight maintenance has not yet been studied (Manuela, et al., 2005: 281). 1.6 OBESITY AND HEALTH CONSCIOUSNESS: Obesity has now become an important health problem in developing countries particularly in India which is currently experiencing a rapid epidemiological transition. Available data on prevalence of obesity from different published studies suggest that the prevalence ranged from 10 to 50 percent (Parimalavalli et al, 2009). Obesity is considered to be the link between insulin resistance and metabolic abnormalities inclusive of diabetes, hypertension and dyslipidaemia, all of which are risk factor for coronary artery disease (Mohan et al, 2001). Many developing countries including India today face the dual burden of diseases of poverty as diseases of affluence. Some of the reasons for this change among many are urbanization and adaptation of westernized life style (Popkin 1994; Drewnowski and Popkin; 1997). India is passing through a 25 transitional phase of socioeconomic development. There is an increase in women’s employment due to economic pressure. The gainful employment of women, which ensures increase in income, may lead to better nutrition for themselves. (D’ souza and Bhujza 1982; Gulati 1982;). Improved health facilities, increase in income, availability of food and decrease in physical activity have contributed to this epidemic form of overweight and obesity especially in the urban areas of the developed and developing countries. (Vijaylakshmi et al, 2005). According to the published data, during the last 30 years, along with the increase in consumption of fast foods, the incidence of obesity, diabetes and circulatory system diseases has rose up rapidly (Bowman 2004; Cheng 2003; Ebbeling et al 2004; Isganaitis and lustig 2005; zwierzyk 2005). With rapid urbanization in recent years, there is a boom in fast foods in India, majority of fast foods contain high amount of saturated and trans fatty acids and less dietary fiber, which is the main cause of obesity (Kumar et al, 2007). From National Family Health Survey (NFHS) it was found that Indian women are more obese than Indian men. Moreover, as per the NFHS data there is not a single state in India where more number of men are obese than women. Only Tripura is one state where this difference is small of 0.1% (in Tripura number of obese male 5.2% & number of obese female 5.3%), while in rest of state this difference is very significant. Whereas Punjab tops overall obese people chart with 30.3% obese male and 37.5% obese female. Overall, India results are 12.1% obese male and 16% obese female. From this data, we can clearly conclude that women are more obese than men in India. In recent years obesity has increased significantly in India and it looks that this trend has affected Indian women more than Indian men. It is difficult to define exact reason between these trends and why Indian women are more obese than Indian men, however, it looks that Indian women are enjoying life more comfortably than Indian men because comfortable life is mostly associated with obesity. Overall, this is not a good sign for health conscious women, because chances of numbers of health related problems increases significantly. 26 Awareness among the women about health and nutrition and obesity is the only way to reduce the epidemic of overweight and obesity. There are a number of Government and Non-government organizations in India that are working to generate awareness among women about health and nutrition. CHETNA (Centre for Health Education, Training and Nutrition Awareness) is a unique resource agency which provides support to Government and civil society organizations; which raises health and nutrition consciousness among women, youth and children from disadvantaged social sections. It strives to bring about comprehensive gender sensitive polices at the state, national, regional and international levels and networks globally to build strategic partnerships. CHETNA activities were initiated in 1980 as an activity of the Nehru Foundation for Development, which is registered under the Bombay public trust Act 1950. MASUMs (Mahila Sarvangeen Utkarsha Mandal) women’s health programme is unique in the sense that it focuses on women’s health concerns with a feminist perspective and works with a rights based approach to health care. It enables the most deprived sections in the community to get access to basic health services. The women’s health programme is built on the self help principle, which aims to empower women with knowledge of their own bodies and addresses unequal relationship between the provider and receiver because of the possession of knowledge and skills with the provider, by sharing information. It recognizes the emotional, social & environmental factors that affect health and works towards addressing these issues. It assists women to recast their self image and confidence by validating their experiences and knowledge and creates a space for women to ventilate their problems and share their feelings. Awareness of women’s risks for diabetes and cardiovascular diseases must be promoted by health care professionals. Vulnerable times for weight gain during a woman’s life cycle include early adulthood, the child bearing years and menopause. Thus, healthy diet and exercise behaviors must be particularly emphasized during these years. Foods comprising diets associated with reduced cardiovascular disease and type-II diabetes risks 27 tend to be unrefined plant foods (vegetables, legumes, fruits, whole grains, nuts, and seeds), low fat dairy products, fish rich in omega-3 fatty acids and lean sources of protein. A balance of micro nutrients and fiber should be obtained from wholesome food sources rather than supplements. Dietary counseling for women should consider the context in which they live (Ryan, 2007:S3-S7). Nutrition education has an important role for promoting health and reducing the risk of developing chronic diseases of life style. Various sources are available for the communication of nutrition messages to the public, such as mass media(articles in magazines, news paper, radio & television), health education materials and books as well as through food labeling and food packaging (Charlton, et al, 2004; 809). 1.7 SIGNIFICANCE OF THE PRESENT STUDY: Good health is a vital part of great experience of living. So attempts are being made to give every one a fair chance to lead a healthier and fuller life. To maintain good health, a diet containing the essential food and nutrient is very important. The nutrients and other substances in their action, interaction and balance are related to health and diseases. Nutritional balance is very essential to maintain health and to prevent major diseases like diabetes coronary heart diseases, stroke, cancer, overweight and obesity. Overweight and obesity is most common among all. Both overweight and obesity affect health of an individual and favour the development of secondary conditions. As obesity is strongly associated with the main causes of morbidity and mortality, its reduction is a necessary health goal. Obesity is a global health problem. The magnitude of the problem appears to be increasing with affluence, urbanization and mechanization. It is now estimated that, world-wide there are over 100X106 obese subjects. The results of current methods of treatment are disappointing and of limited value. Obesity and weight cycling are now recognized as important risk factors for several diseases with high morbidity and mortality. Body mass index provides the most useful population measured of obesity. In an 28 average man, the percentage body fat is in the order of 15-20 percent while in women, it vary between 25-30 percent. In spite of the problems magnitude, however little is known about the factors that contribute to the world wide obesity epidemic. It is therefore urgent to evaluate the factors that determine this process in every different culture (Neutzling et al, 2003). India is passing through a transitional phase of socio economic development. While acute infectious diseases are on the decline, chronic non- communicable diseases like cardiovascular diseases, diabetes and cancers are becoming major contributors to the disease burden. While the country has still to overcome problems arising from under-development and poverty, it is also likely to increasingly face problems related to affluence, generally seen in developed countries, in the years ahead. With industrialization, urbanization and economic betterment, more individuals survive to enter middle age. With increasing affluence, several undesirable life styles, like alterations in the form of diets rich in saturated fats, salt and excess calories; decreased physical activity; addictions like tobacco and alcohol; and the augmentation of psychosocial stress, come into play. The chain of slimming centers, which claim to promise rapid weight reduction, cannot solve the problem of obesity at the public health level. The deleterious effects of repeated loss and gain of fat are now well reported. So the answer lies in the prevention. Sambalpur is one of the under developed district of Western Orissa. In spite of the rapid increase in the knowledge and awareness on health through the mass media and health centers, most of the people do not know the hazardous effect of overweight and obesity in life. No detailed study has been made on the health awareness, obesity; its causative factors and problems related to it. With this background the proposed study will be a modest attempt to find out the prevalence and problems of obesity among the urban women of Sambalpur, Orissa, with varying degree of health consciousness. 29 1.8 OBJECTIVES: The present study was undertaken with the following objectives. To find out the degree of health consciousness present among the women, on the basis of knowledge, attitude and practice on health. To assess the prevalence of obesity and type of obesity among the urban women by using the criteria of body mass index (BMI) and waist hip ratio (WHR). To record dietary pattern and estimate the food and nutrient intake, anthropometric measurements of the women and to observe the influence of socio-economic variables, obesity and health awareness on it. To assess the metabolic aberration with respect to blood pressure, blood glucose and blood lipid profile in obese subject. To find out the morbidity pattern of the respondents and to ascertain the factors influencing such morbidity incidences. 30