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Urban Rural Divide? How to Manage Obesity?

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Urban Rural Divide? How to Manage Obesity? 1 : 4 IS INDIA REALLY GETTING FATTER- URBAN RuRAL DIVIDE? HOW TO MANAGE OBESITY? WEIGHT CONTROL IS A JOURNEY, NOT A DESTINATION Vitull K Gupta, Sonia Gupta, Bhatinda The second half of the twentieth century witnessed major imparts health risk. (20% more than Ideal Body Weight). health transitions in the world, propelled by socio-economic and Lean but very muscular individuals may be overweight by arbitrary technological changes which profoundly altered life expectancy standards without having increased adiposity. Obesity is effectively and ways of living while creating an unprecedented human defined by assessing its linkage to morbidity or mortality. capacity to use science to both prolong and enhance life. Dietary deficits and excesses and the lifestyle changes that accompany METHODS TO CALCULATE OBESITY industrialization and urbanization with economic development make a significant contribution to the most globally pervasive Body Mass Index (BMI): weight in Kg / height in meter 2 (kg/ change of the rising burden of obesity and non-communicable m2), skin-fold thickness, Densitometry (underwater weighing), diseases (NCDs). Computed tomography (CT) or MRI, Waist to Hip Ratio (Central Obesity), Ideal Body Weight (Kg) = {(Height in cm-100) X 0.9}. Obesity was identified as a disease thirty years ago when, the World Health Organization (WHO) listed obesity as a disease Body Mass Index (BMI): BMI is recommended as a practical condition in its International Classification of Diseases in 1979. approach for assessing body fat in the clinical setting. It provides Analysis of mortality trends suggests that large increases in NCDs a more accurate measure of total body fat compared with have occurred in developing countries, particularly those in rapid the assessment of body weight alone.3 The typical body transition (e.g. Brazil, china and India.).1 The epidemic of rapid weight tables are based on mortality outcomes, and they do nutrition transition and its adverse health consequences in the not necessarily predict morbidity. However, BMI has some Asian region are now beginning to get noticed.T hese include insulin limitations. For example, BMI overestimates body fat in persons resistance, type 2 diabetes, hypertension, coronary artery disease, who are very muscular, and it can underestimate body fat in hyperlipidemia, metabolic syndrome (Syndrome X), stroke and persons who have lost muscle mass (e.g., many elderly). certain cancers. Mortality from cardiovascular disease is expected to rise by about 60%, and overtake deaths from infectious diseases CLASSIFICATION OF BMI:4 5 by 2015-2020. The prevalence of type 2 diabetes has increased by 40% in Chennai between 1988 and 1994. It is predicted that the • Underweight (<18.5Kg/m2).{ Mildly thin (17.0- 18.4Kg/m2) prevalence of type 2 diabetes will rise from 4% to 5.4% by 2025, Moderately/ severely thin (<17.0 Kg/m2) } and the proportional rise will be greatest in developing countries • Normal (18.5-24.9 Kg/m2). (48%), especially India (59%). India will have more people with diabetes (~ 57 million), than any other country, with the greatest • Overweight (25-29.9kg/m2) numbers in the 45-64 years age group. The economic and health • Obese (30- 34.9 Kg/m2). consequences of obesity epidemic can spell disaster for the nation unless immediate remedial measures are instituted.2 The complex • Sever Obesity ( 35- 39.9Kg/m2) range of factors that interact to determine the nature and course • Morbid Obesity (>40Kg/m2) of obesity epidemic needs to be understood in order to adopt preventive strategies to help developing societies like India deal Several studies from India have attempted to modify the with this burgeoning problem. threshold for obesity and abdominal obesity using various metabolic abnormalities as gold standard. These studies have WHAT IS OBESITY? suggested cut-off for BMI ranging from 19-22Kg/m2 while that of waist circumference ranges from 72-85cm in men and Obesity is a state of excess adipose tissue mass that Medicine Update 2010 Vol. 20 6 65.5-80 cm in women. Several reports suggest that for any men with lowest wealth index, prevalence of obesity was 1.4% and given BMI, Indians tend to have increased waist circumference. 23.6% among men with highest wealth index. (Tabl e: 1). Further Indians also tend to have excess body fat, abdominal Available data on prevalence of obesity from different published and truncal adiposity. For any given waist circumference, Indians studies suggest that the prevalence ranged from 10 to 50 %.6 There have increased body fat accumulation and for any given body fat, are several reports from various parts of India mostly urban which Indians have increased insulin resistance.7 8 These features have provide some insight into the problem. A study from Bombay been referred to as the “Asian Indian Phenotype or Paradox”.9. revealed the prevalence of obesity among young adult males The WHO has revised the BMI cut-off for Asian Indians and varied from 10.7% to 53.1%.16 A report from Kashmir showed suggested a BMI of 25kg/m2 to define obesity against the 30kg/ prevalence of obesity to be 15.0%, with 23.7% females and 7% m2 recommended for Europeans.10 males.17 .A report from Nutrition Foundation of India Suggested that the prevalence of obesity varies with socio economic status IS INDIA REALLY GETTING FATTER- URBAN in urban India, with those in upper strata having higher prevalence RURAL DIVIDE? rates (32.2% among males, 50% among females) than middle class (16.2% among males, 30.3% among females) followed by the lower The prevalence of obesity is increasing world wide. Data from the socio economic group (7% among males, 27.8% among females) National Health and Nutrition Examination Surveys (NHANES) and the poor in urban slums with the lowest (1% among males, 4% show that the percent of the American adult population with among females).18 In a study by Reddy, et al., more than 28% of adult obesity (BMI > 30) has increased from 14.5% (between 1976 males and 47% of adult females in urban Delhi were overweight and 1980) to 30.5% (between 1999 and 2000). As many as 64% by WHO standards.19 In the same study the corresponding figures of U.S. adults 20 years of age were overweight (defined as BMI for overweight in a neighboring Haryana rural area were 7% in > 25) between the years of 1999 and 2000. Extreme obesity males and 9% in females. Conversely, as many as 38% of males 11 (BMI 40) has also increased and affects 4.7% of the population. and 36% of females in the rural area were actually ‘underweight’ As a Consequence of rapid industrialization and urbanization by BMI standards. A study from Punjab by Vitull et al concluded leading to rise in living standards, prevalence of obesity is rapidly that prevalence of overweight was 5.1% in males and 3.4% in rising posing a greater threat to health of Indian nation. Obesity females and the prevalence of obesity in males was 0.3% and has reached epidemic proportions in India in the 21st century, 0.4% in females was recorded in rural population which is quite 12 affecting 5% of the country’s population. India is following a trend less than that of prevalence reported in several urban studies.20 of other developing countries that are steadily becoming more NFHS -3 data also reveal the extent of underweight population obese and is currently experiencing an increase obesity epidemic. both male and female population which was more in rural and In 1990’s National Nutrition Monitoring Bureau documented the poor population. (Table: 2) Such an ‘urban, rural divide’ has been prevalence of obesity in Indian women to be 4.1% and National documented in other Indian studies too.21 The prevalence of Family Health Survey -2 13(NFHS-2) reported obesity prevalence underweight or malnutrition is really disturbing giving arises to rates ranging from 3.5% to 4.1%. National Family Health Survey-3 double nutritional burden on Indians of obesity on one hand and (NFHS-3)5 reviled obesity as a substantial problem among several malnutrition on the other. groups of women in India particularly older women, urban, well Childhood obesity was considered a problem of affluent countries. educated, women from households with high standard of living Today the problem is started appearing even in developing and among Sikhs. Data from NFHS-3 showed that 12.6% of Indian countries. The calculated global prevalence of overweight women were obese (23.5% urban and 7.4% rural). Among men (including obesity) in children aged 5-17 years is estimated by the the total prevalence of obesity was 9.7% (15.9% urban and 5.6% International Obesity Task Force (IOTF) to be approximately 10%, rural). The percentage of ever-married women age 15-49 who are but this is ‘unequally distributed’ with prevalence ranging from overweight or obese increased from 11% in NFHS-2 to 15% in over 30% in Americas to <2% in sub Saharan Africa.22 Prevalence NFHS-3. The percentage of women who are overweight or obese of overweight amongst Australian children has increased from is highest in Punjab (30%), followed by Kerala (28%) and Delhi 11% in 1985 to 20% in 1995.4. Childhood obesity has tripled in (26%). Similar variations are seen by state in the percentage of men Canada in last 20 years. Currently the prevalence of obese school who are overweight and obese. Further analysis of data showed children is 20% in U K and Australia, 15.8% in Saudi Arabia, 15.6% that out of 12.6% obese women 9.8% were overweight (BMI of in Thailand, 10% in Japan and 7.8% in Iran.23 24 25-29.9) and 2.8% were obese (BMI of > 30).
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