obesity and its parameters

OBESITY

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CONTENTS

• Definition of obesity• Etiology of obesity• Pathophysiology of obesity• Types of obesity• Obesity and its complications• Metabolic syndrome• Measures of body composition• Childhood obesity• Obesity statistics• Review of literature• Dietary and physical activity guidelines WHO, NPCDCS and

NIN/ICMR.

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DEFINITION OF OBESITY

• A condition of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired.

• Underlying disorder is an undesirable positive energy balance and weight gain.

• Chronic excessive nutrient intake relative to energy expenditure

↑ 2% in energy balance = 2.3 kg weight gain in a year

1. WHO. Obesity: Preventing and Managing the Global Epidemic, 2000. (TRS 894)

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ETIOLOGY OF OBESITY

1. Genetic factors

a) Sex

b) Case of identical twins and kids of obese parents

c) Genetic syndromes (Prader-Willi, Laurence-Moon-Biedl, Ahlstrom's, Cohen's, Carpenter's )

d) ob gene (leptin) and db gene (leptin receptor)

2. Environmental factors

a) Metabolic imbalances (hypothyroidism, Cushing’s disease)

b) Socio-cultural and economic factors

c) Physical inactivity

d) Sleep deprivation

e) Obesigenic viral infections?

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PATHOPHYSIOLOGY OF OBESITY

CONCEPT 1: ENERGY IMBALANCE

When energy intake exceeds energy expenditure,

• Excess energy is stored in the fat cells of adipose tissue.

Obese people have LARGER as well as MORE fat cells than healthy-weight people.

When energy expenditure exceeds energy intake,

• The size of fat cells decreases, but number remains constant.

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CONCEPT 2: HORMONAL AND SEX DIFFERENCES

The enzyme lipoprotein lipase promotes fat storage and its activity is partially regulated by gender-specific hormones.

• In women, fat cells in the breasts, hips, and thighs produce abundant LPL, while in men, fat cells in the abdomen produce abundant LPL.

• The release of lower body fat is less active in women than in men. Also, the rate of fat breakdown is lower in women than in men.

Consequently, WOMEN have a more difficult time losing fat in general, and from the hips and thighs in particular.

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CONCEPT 3: SET POINT THEORY

Obese people have more LPL activity in their fat cells than lean people, so even modest excess in energy intake have a more dramatic impact on them.

• After weight loss, LPL activity increases, most dramatically in people who were fattest prior to weight loss.

• This provides an explanation for the observation that some inner mechanism seems to set a person's weight or body composition at a fixed point;

The body will adjust to restore the weight set point even if the person tries to change it.

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TYPES OF OBESITY

• Abdominal/Android obesity

a) intra-abdominal fat

b) abdominal subcutaneous fat

• Peripheral/Gynoid obesity

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OBESITY AND ITS COMPLICATIONS12-04-2012

Ebbeling et al, Lancet 2002; 360: 473-82

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REVIEW OF LITERATURE: COMPLICATIONS OF OBESITY

Metabolic Obesity: The Paradox Between Visceral and Subcutaneous Fat

Osama Hamdy, Sriurai Porramatikul and Ebaa Al-Ozairi Joslin

Current Diabetes Reviews, 2006, Vol. 2

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• Abdominal obesity is associated with an increased risk of CVD and type 2 DM risk while gynoid obesity is seldom associated with metabolic complications.

• Even within the normal range of BMI, accumulation of visceral fat remains an independent CVD risk factor.

1.Vague J. Sexual differentiation, a factor affecting the forms of obesity. Presse Med. 1947;30:339-340.

2.Despres JP, Moorjani S, Lupien PJ, Tremblay A, Nadeau A, Bouchard C. Regional distribution of body fat, plasma lipoproteins, and cardiovascular disease. Arteriosclerosis. 1990;10:497-511.

3.Boyko EJ, Fujimoto WY, Leonetti DL, Newell-Morris L. Visceral adiposity and risk of type 2 diabetes: a prospective study among Japanese Americans. Diabetes Care. 2000;23:465-471.

4.Kuk JL, Katzmarzyk PT, Nichaman MZ, Church TS, Blair SN, Ross R. Visceral fat is an independent predictor of allcause mortality in men. Obes Res. 2006;14:336-341.

5.Report of International chair on cardio-metabolic risk, 2009.

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• A strong relationship exists between intra-abdominal fat accumulation and insulin resistance.

a) Lipo-toxicity theory

- visceral fat cells are lipolytically active (β3-adrenergic receptors)

- Try64Arg allele polymorphism of the β3-adrenergic receptor gene

b) Cytokine theory

visceral adipose tissue produce pro-inflammatory cytokines (TNF-α, IL-6) which induce insulin resistance.

1. Després JP. Abdominal obesity as important component of insulin resistance syndrome. Nutrition l993;9:452 9.

2. Walton C, Lees B, Crook D, Godsland IF, Stevenson IC. Relationships between insulin metabolism, serum lipid profile, body fat distribution and blood pressure in healthy men. Atherosclerosis 1995;118:35-43.

3. Kahn BB, Flier IS. Obesity arid insulin resistance. J Clin Invest 2000;106:473-81.

4. Bergman RN, Mittleman SD. Central role of the adipocyte in insulin resistance. J Basic Clin Physiol Pharmacol 1998, 9:205–221

5. Widen E, Lehto M, Kanninen T, et al. Association of polymorphism in the β3-adrenergic receptor gene with features of the insulin resistance syndrome in Finns. N Engl J Med 2004;333:348-51.

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• Large hip circumference has been found to be an independent predictor of lower cardiovascular and diabetes-related mortality.

• The protective effect of a large hip circumference may be due to the low fatty acid turnover of gluteo-femoral adipose tissue.

• Peripheral fat mass has also shown an independent negative correlation with insulin sensitivity and atherogenicity.

1.Lissner L, Bjbrkelund C, Heitmann BL, et al. Larger hip circumference independently predicts health and longevity in a Swedish female cohort. Obes Res. 2001;9:644-646.

2.Seidell IC, Perusse L, Despres JP et al. Waist and hip circumferences have independent and opposite effects on cardiovascular disease risk factors: the Quebec Family Study. Ant J Gun Nutr. 200l;74:315-321.

3.Williams MJ, Hunter GR, Kekes-Szabo T, et al. Regional fat distribution in women and risk of cardiovascular disease. Am J Clin nutr. l997;65:855-860.

6. Raynaud F, Perez-Martin A, Bran IF, et al. Insulin sensitivity measured with the minimal model is higher in moderately overweight women with predominantly lower body fat. Horm Metab Res. I999;31:415-4I7.

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METABOLIC SYNDROME (International Diabetes Federation, 2001)

a) Central obesity

b) raised TG level ≥150 mg/dL

c) reduced HDL cholesterol < 40 mg/dL in males and

< 50 mg/dL in females

d) raised blood pressure SBP ≥ 130 or DBP ≥ 85 mm Hg, or on treatment of HTN

e) raised FBG ≥ 100 mg/dL, or previously diagnosed type 2 DM.

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CENTRAL OBESITY

• WC ≥ 94cm for European men and ≥ 80cm for European women;

• ≥90 cm and ≥80 cm respectively for Asians/Indians; and

• ≥102 cm and ≥88 cm respectively for Americans

1. Report of International Diabetic Federation, 2001.

2. WHO. Obesity: Preventing and Managing the Global Epidemic, 2000. (TRS 894).

3. WHO/IOTF/IASO (2000). The Asia-Pacific perspective: Redefining Obesity and its Treatment.

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MEASURES OF BODY COMPOSITION

• Anthropometry

1. BMI 2. WC 3. WHR 4. WHR

5. Conicity index (C=waist/0.109 √ weight/height)

6. Skinfold thickness

7. Abdominal volume index (AVI=[2(waist)(waist)+0.7(waist/hip)(waist/hip)]/1000)

• MRI/CT• Densitometry (underwater weighing)• Bio-electric impedance analysis• Dual energy x-ray absorptiometry (DEXA)• Air displacement plethysmography

1. Report of International chair on cardio-metabolic risk, 2008.

2. IAP National Task Force for Childhood Prevention of Adult Diseases: Childhood Obesity, 2004.

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ANTHROPOMETRIC MEASUREMENTS FOR OBESITY

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1. BODY MASS INDEX (BMI)

Weight/square of height (Unit is kg/m2)

• Does not differentiate between fat and muscle• Underestimates body fat• Does not give estimate of body fat distribution

• Indians have more abdominal adiposity compared to Caucasians at similar or even lower BMI.

• Indians have HIGHER pre-disposition to insulin resistance at lower BMI.

• 66% men and 88% women with BMI less than 25 had at least one cardiovascular risk factor.

1. Vikram et al. Diab Nutr Metab 2003;16:32-40.

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BMI CUT OFF VALUES FOR ADULTS

Asians/Indians 2000• Underweight < 18.5 < 18.5• Normal range 18.5 – 24.9 18.5 – 22.9• Overweight (pre-obese) 25.0 – 29.9 23.0 – 24.9• Obese class I 30.0 – 34.9 25.0 – 29.9• Obese class II 35.0 – 39.9 ≥ 30.0• Obese class III ≥ 40.0

1. WHO. Obesity: Preventing and Managing the Global Epidemic, 2000. (TRS 894).


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Asian/Indians 2004

a) The WHO cut-off points of 18.5, 25, 30 and 40 are retained.

b) BMI 23, 27.5, 32.5 and 37.5-points of PUBLIC HEALTH ACTION.

AOP: Normal: 18.0-22.9

Overweight: 23.0-24.9

Obesity: ≥25

NIN/ICMR: Overweight: ≥ 23

Obesity: ≥ 27

1. WHO Expert Consultation, Appropriate body mass index for Asian populations and its implication for policy and intervention strategies, 2004.

2. ASSOCIATION OF PHYSICIANS, INDIA, 2009. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management.

3. Dietary guidelines for Indians: a manual. NIN along with ICMR, 2011.

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2. WAIST CIRCUMFERENCE

WC cut-off points for increased risk of metabolic diseases

Men Women

94cm (37 inches) 80cm (32 inches)

WHO Asian/Indians 2000 90cm (35 inches) 80cm (32 inches)

( NIH: ≥102 cm and ≥88 cm respectively for Americans)

1. World Health Organisation . Obesity: Preventing and Managing the Global Epidemic, 2000. (TRS 894).



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RR (and 95% CI) for type 2 DM based on WC, stratified by BMI

RELATIVE RISK (95% CI) PER 1 CM HIGHER WAIST CIRCUMFERENCE

BMI ˂ 25 BMI 25 - ˂ 30 BMI ≥ 30

MEN 1.13 (1.06-1.20) 1.09 (1.07-1.14) 1.06 (1.04-1.08)

WOMEN 1.11 (1.06-1.17) 1.11 (1.08-1.14) 1.05 (1.04-1.07)

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3. WAIST TO HIP RATIO

• A WHR ˃1.0 in men and ˃0.85 in women has become accepted as the clinical method of identifying patients with central obesity.

WC is a better reflection of the intra-abdominal fat volume than the WHR or BMI.

1. Pouliot MC, Després JP, Lemieux S, Moorjani S, Bouchard C, Tremblay A, et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol. 1994;73:460-468.

2. WHO. Obesity: Preventing and Managing the Global Epidemic. (TRS 894).

3. Van der Kooy K, Seidell JC. Techniques for the measurement of visceral fat: a practical guide. Int J Obes l993;l7: 187-96.

4. Dobbelsteyn C J, Joffres M R, MacLean D R, Flowerdew G. A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys. International Journal of Obesity (2001) 25, 652-661.

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WAIST CIRCUMFERENCE MEASUREMENT

Sites: suprailiac, midabdomen, umbilicus, narrowest waist

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WC AND COMPARISON BETWEEN NIH AND WHO PROTOCOLS

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WAIST CIRCUMFERENCE DIFFERENCE BETWEEN WAIST CIRCUMFERENCE MEASURED BY NIH AND WHO PROTOCOLS

≤80 CM 0.47 CM

80-90 CM 0.34 CM

90-97 CM 0.54 CM

≥97 CM 0.54 CM

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4. SKINFOLD THICKNESS AND BODY FAT CALCULATION

Equations of Durnin and RahamanPredicted body fat density:• Boys= 1.1533-0.0643 X (log sum of 4 skinfolds)• Girls= 1.1369-0.0598 X (log sum of 4 skinfolds)

Equations of Slaughter et alBF% for children with triceps and subscapular skinfolds <35 mm:• Boys= 1.21 (sum of 2 skinfolds)-0.008 (sum of 2 skinfolds2)-1.7• Girls= 1.33 (sum of 2 skinfolds)-0.013 (sum of 2 skinfolds2)-2.5

BF% for children with triceps and subscapular skinfolds >35 mm:• Boys=0.783 (sum of 2 skinfolds)-1.7• Girls=0.546 (sum of 2 skinfolds)+9.7

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Equations of Johnston et alPredicted body fat density:• Boys= 1.1660-0.0070 X (log sum of 4 skinfolds)• Girls= 1.144-0.060 X (log sum of 4 skinfolds)

Equations of BrookPredicted density:• Boys= 1.1690-0.0788 X (log sum of 4 skinfolds)• Girls= 1.2063-0.0999 X (1og sum of 4 skinfolds)

Equations of DeurenbergPredicted density(pre-pubertal):• Boys= 1.1133-0.0561 X (log sum of 4 skinfolds) + 1.7 (age X 10-3)• Girls= 1.1187-0.063 X (log sum of 4 skinfolds) + 1.9 (age X 10-3)

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IOTF REPORT, 2003

Suggested body fat is 15-20% for males, 20-25% for females.

Essential Trained Healthy Unhealthy

Females 8% 9‐19% 19‐32% >32%

Males 5% 6‐16% 16‐25% >25%

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BODY FAT VERSUS SKINFOLD THICKNESS - MALES

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BODY FAT VERSUS SKINFOLD THICKNESS - FEMALES

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CHILDHOOD OBESITY

• The National Centre for Health Statistics/CDC charts 2001

85th percentile of BMI for age and sex as a reference point for overweight and the 95th percentile for obesity

These cut-off points correspond to 23 and 25 BMI respectively at age 18 years.

• The IOTF Charts (new international standards)

Age- and sex-specific BMI cut-off points for overweight and obesity in children have been derived by identifying percentiles in children analogous to adult BMIs of 25 and 30, respectively.

Developed by Cole et al (UK, Netherlands, Singapore, Hong Kong, USA, Brazil) in 1999. NIN/ICMR Dietary Guidelines, 2011.

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IAP National Task Force for Childhood Prevention of Adult Diseases: Childhood Obesity

By Sheila Bhave, Ashish Bavdekar, Madhumati Otiv. Indian Paediatrics, Vol. 41, 2004.

Both the charts can be utilized for childhood obesity assessment, though IOTF chart more useful as international comparison is possible.

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BMI Cut-offs for Screening for Childhood Overweight and Obesity in Indian Children

By VV Khadilkar, AV Khadilkar, AB Borade and SA Chiplonkar. Indian Paediatrics, Vol. 49, 2012.

Cut-off points of 23 and 28 respectively for overweight and obesity more appropriate.

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OBESITY STATISTICS

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OBESITY STATISTICS

• India, 2005-06, National (NFHS-3)

• Sample size 177523, Age group 15-49 years

• Men Overweight-8

Obesity-1.3

• Women Overweight-9.8

Obesity-2.8

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MEAN BMI 18.5-24.9 ≥25 25-29.9 ≥30

India 20.5 51.8 12.6 9.8 2.8

North

Delhi 22.9 58.7 26.4 18.6 7.8

Haryana 21.1 51.2 17.4 13.0 4.4

HP 20.8 56.6 13.5 11.4 2.1

J & K 21.4 58.6 16.7 13.4 3.3

Punjab 22.9 51.2 29.9 20.8 9.1

Rajasthan 20.1 54.4 8.9 7.1 1.8

Uttaranchal 20.8 57.2 12.8 10.1 2.7

Central

Chhattisgarh 19.5 51.0 5.6 4.3 1.3

MP 19.7 50.8 7.6 6.2 1.4

UP 20.1 54.8 9.2 7.5 1.7

East

Bihar 19.4 50.4 4.6 4.0 0.6

Jharkhand 19.5 51.7 5.4 4.5 0.9

Orissa 19.7 52.0 6.6 5.5 1.1

WB 20.2 49.6 11.4 9.4 2.0

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MEAN BMI 18.5-24.9 ≥25 25-29.9 ≥30

Northeast

AP 21.1 74.8 8.8 7.7 1.1

Assam 20.0 55.7 7.8 6.9 0.9

Manipur 21.5 72.0 13.3 11.4 1.9

Meghalaya 21.0 80.1 5.3 4.5 0.8

Mizoram 21.2 75.0 10.6 9.4 1.2

Nagaland 20.8 76.2 6.4 5.7 0.7

Sikkim 22.1 73.5 15.4 12.4 3.0

Tripura 19.9 55.9 7.1 6.4 0.7

West

Goa 21.5 51.9 20.2 15.4 4.8

Gujarat 20.8 47.0 16.7 12.1 4.6

Maharashtra 20.6 49.3 14.5 10.9 3.6

South

AP 20.9 50.9 15.6 11.5 4.1

Karnataka 20.7 49.2 15.3 11.6 3.7

Kerala 22.6 53.9 28.1 23.1 5.0

Tamil Nadu 21.6 50.6 20.9 15.8 5.1

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MEAN BMI 18.5-24.9 ≥25 25-29.9 ≥30

India 20.2 56.5 9.3 8.0 1.3

North

Delhi 22.0 67.4 16.8 14.3 2.6

Haryana 20.5 58.3 10.8 8.9 1.8

HP 20.5 59.7 10.6 9.7 0.9

J&K 20.3 65.8 6.2 5.5 0.7

Punjab 22.0 57.2 22.2 18.2 4.0

Rajasthan 19.7 53.3 6.2 5.4 0.8

Uttaranchal 20.5 63.7 7.9 6.7 1.2

Central

Chhattisgarh 19.6 56.6 4.9 4.4 0.5

MP 19.5 54.1 4.3 4.0 0.3

UP 19.8 54.4 7.3 6.3 1.0

East

Bihar 19.9 58.5 6.3 5.5 0.8

Jharkhand 19.6 56.5 4.9 4.4 0.5

Orissa 19.8 58.3 6.0 4.9 1.1

WB 20.0 59.4 5.5 5.1 0.4

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MEAN BMI 18.5-24.9 ≥25 25-29.9 ≥30

Northeast

AP 20.9 77.6 7.1 7.1 0.0

Assam 19.8 59.5 5.0 4.6 0.4

Manipur 21.0 74.5 9.2 8.3 0.9

Meghalaya 21.2 79.9 5.9 5.6 0.3

Mizoram 21.5 79.4 11.4 10.9 0.5

Nagaland 20.8 80.2 5.7 5.2 0.5

Sikkim 21.8 75.9 11.9 10.8 1.2

Tripura 19.6 53.5 4.8 4.8 0.0

West

Goa 21.2 59.9 15.4 13.2 2.3

Gujarat 20.3 52.6 11.3 9.3 2.0

Maharashtra 20.5 54.6 11.9 10.3 1.6

South

AP 20.8 55.6 13.6 11.7 1.9

Karnataka 20.4 55.1 10.9 9.2 1.7

Kerala 21.6 60.6 17.8 15.7 2.1

Tamil Nadu 21.1 58.4 14.5 12.5 2.0

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1. Prevalence of overweight and obesity amongst school children in Delhi, India

Supreet Kaur et alAsia Pac J Clin Nutr 2008;17 (4):592-596

• A total of 16,595 children (LIG 5087, MIG 5134 and HIG 6368) were covered. Overweight and obesity were assessed using Body Mass Index (BMI) and Triceps Skin Fold Thickness (TSFT) utilizing age and sex specific cut off points.

• The prevalence of obesity and overweight in LIG school children was 0.1 and 2.7% respectively, amongst MIG 0.6 and 6.5% and in HIG 6.8 and 15.3% (p<0.001).

• Result: The prevalence of overweight and obesity was higher in the HIG children as compared to the MIG and the LIG for all age groups.

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2. The High Burden of Obesity and Abdominal Obesity in Urban Indian Schoolchildren: A Multicentric Study of 38,296 Children

Anoop Misra et alAnn Nutr Metab 2011;58:203-211

• The mean age was 13.3 years and mean BMI was 18.3.• The prevalence of overweight and obesity in children, respectively, was

14.4 and 2.8% by IOTF cut-offs, and 14.5 and 4.8% by CDC cut-offs.• The overall prevalence of abdominal obesity in urban was 4.5%.• The prevalence of overweight and abdominal obesity was significantly

higher in females than males (p < 0.001).• High socioeconomic status and residing in cities with a population

greater than 4 million were independently associated with overweight and abdominal obesity (p < 0.001).

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3. Descriptive epidemiology of BMI of an urban adult population in Western India

H C Shukla et al,J Epidemiol Community Health 2002;56:876–880

Cross sectional representative survey of 99 598 adults (40 071 men and 59 527 women) aged >35 years in Mumbai.

Results

19% of men and 30% of women were overweight.

The OR and 95% CI for overweight were 2.25, 2.20-2.58 for college educated men and 1.90, 1.64-2.20 for college educated women, respectively, p<0.001.

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4. The Effect of Rural-to-Urban Migration on Obesity and Diabetes in India: A Cross-Sectional Study

Shah Ebrahim et al,The Indian Migration Study group, PLoS Med. 2011 May; 8(5): 10

4 Indian factories (Lucknow, Nagpur, Hyderabad and Bangalore).

A 25% random sample of non-migrants was invited to participate in the study. Non-migrants were also asked to invite a sibling who resided in the same city but did not work in the factory.

A total of 6,510 participants (42% women) were recruited.

Among urban, migrant, and rural men the age-adjusted percentages classified as obese were 41.9%, 37.8%, and 19.0%, respectively.

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5. GLOBAL BURDEN OF OBESITY IN 2005 AND PROJECTIONS TO 2030

T Kelly, W Yang, C S Chen, K Reynolds and J He

International Journal of Obesity (2008) ,32, 1431-1437

Pooling analysis of databases from 106 countries (88% population).

Sex- and age-specific prevalence of overweight and obesity were applied to the 2005 population to estimate the numbers of overweight and obese individuals, with and without adjusting for secular trends, to forecast the number of overweight and obese individuals in 2030.

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Results:

23.2% of the world’s adult population in 2005 was overweight (24.0% men and 22.4% women), and 9.8% was obese (7.7% men and 11.9% women).

The estimated total numbers of overweight and obese adults in 2005 were 937 million and 396 million, respectively.

By 2030, the respective number of overweight and obese adults was projected to be 1.35 billion and 573 million individuals respectively without adjusting for secular trends.

When recent secular trends were applied, the absolute numbers were projected to total 2.16 billion overweight and 1.12 billion obese individuals.

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WHO Technical Report Series 916DIET, NUTRITION AND THE PREVENTION OF CHRONIC DISEASES

• Report of a Joint WHO/FAO Expert Consultation

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Consensus Statement for

Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome

for ASIAN INDIANS and Recommendations for

Physical Activity, Medical and Surgical Management

ASSOCIATION OF PHYSICIANS, INDIA, FEB 2009

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• Consensus Statements

1. BMI

Normal: 18.0-22.9, Overweight: 23.0-24.9, Obesity: >25

2. WC Measurement

WC is to be preferred over WHR as a measure of abdominal obesity with Asian Indian specific cut-offs.

3. WC Cut-offs for Asian Indians

Action level 1: Men: 78 cm, women: 72 cm.

Action level 2: Men: 90 cm, women: 80 cm.

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4. Metabolic syndrome diagnosis

Modification of IDF definition (ethnic specific WC).

3 out of 5 criteria have to be abnormal for diagnosis the metabolic syndrome.

5. Physical activity

Inactive people should start slow and gradually increase physical activity.

Brisk walking is preferred initial mode of exercise.

In general, a total of 60 minutes of physical activity is recommended every day; this includes aerobic, work-related and muscle strengthening activities.

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Physical activity can be accumulated throughout the day in blocks as short as 10 minutes.

Work-related activity should be encouraged wherever possible.

Physical activity must be individualized on the basis of person’s abilities and comorbidities.

Children should undertake at least 60 min of outdoor physical activity. Screen time (television/computers) should be less than 2 hours a day.

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6. BACKDROP

International Guidelines for Drug Treatment of Obesity

BMI above 27 with risk factors or co-morbidities (Type 2 DM, HTN, dyslipidaemia) or

BMI above 30 without comorbidity.

International Guidelines for Surgical Treatment of Obesity

BMI above 35 with co-morbidity, or

BMI above 40 without comorbidity.

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6A. Consensus Statement for drug treatment in Asian Indians

BMI above 27 without co-morbidity, or

a BMI above 25 with co-morbidity.

The cut-offs for WC for initiating pharmacotherapy is the WC measurement 10 cm more than the upper limit of gender-specific normal value for adult Asian Indians.

Sibutramine is the drug of choice.

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6B. Consensus Statement for surgical treatment in Asian Indians

BMI above 32.5 with co-morbidity, and

BMI above 37.5 without co-morbidity.

The Surgical Options for Weight Loss Surgery:

a) Restrictive Procedures: Adjustable gastric banding (LAGB) & sleeve

Gastrectomy

b) Combined Procedures: Roux-en-Y Gastric Bypass (RYGBP)

c) Malabsorptive Procedures: Bilio-pancreatic diversions (BPD)

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Recommended levels of physical activity for health (5–17 years old)

1. Children and young people aged 5–17 years old should accumulate at least 60 minutes of moderate to vigorous-intensity physical activity daily.

2. Physical activity of amounts greater than 60 minutes daily will provide additional health benefits.

3. Most of daily physical activity should be aerobic.

4. Vigorous-intensity activities should be incorporated, including those that strengthen muscle and bone, at least 3 times per week.

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Recommended levels of physical activity for health (18–64 years old)

1. Adults aged 18–64 years should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, or at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week.

2. Aerobic activity should be performed in bouts of at least 10 minutes duration.

3. For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week.

4. Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

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Recommended levels of physical activity for health (65 years and above)

1. Adults aged 65 years and above should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week.

2. Aerobic activity should be performed in bouts of at least 10 minutes duration.

3. For additional health benefits, adults aged 65 years and above should increase their moderate intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous intensity aerobic physical activity per week.

4. Adults of this age group with poor mobility should perform physical activity to enhance balance and prevent falls on 3 or more days per week.

5. Muscle-strengthening activities should be done involving major muscle groups, on 2 or more days a week.

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• 1/4 adult population and 1/5 school children are overweight.• National program for prevention and control of diabetes cardiovascular

disease and stroke NPDCS launched as pilot project in 4th Jan 2008 in ten districts in 10 states.

• Components:

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Dietary Guidelines for Indians: A ManualNIN along with ICMR, 2011

Guidelines for obesity management

• Weight reduction diets should contain at least 1000 Kcal/day and provide all nutrient requirements, except energy.

• Loss of half a kg/week is generally considered safe.

• In children, obesity should be controlled by increasing physical activity rather than restricting food intake.

• Modifications in dietary habits have to be incorporated into one's lifestyle along with adequate exercise to keep the body weight within the normal limits.

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• As fat contains more than twice the calories (9 kcal) per gram of either protein (4 kcal) or carbohydrate (4 kcal), weight reducing diets should limit the fat intake.

• Refined sugars and alcohol provide empty calories (7 kcal) and should be avoided.

• Plant foods that provide complex carbohydrates and fibre may be preferred as they reduce blood glucose, cholesterol and triglycerides.

• Weight reducing diets must be rich in proteins and low in carbohydrates and fats.

• Consumption of plenty of fruits and vegetables would not only result in satiety but could also help to maintain adequate micronutrient intake.

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Aerobic Activities

These speed your heart rate and breathing while improving heart and lung fitness. Examples: brisk walking, jogging and swimming.

Resistance, Strength Building, and Weight-Bearing Activities

These help build and maintain bones and muscles by working them against gravity. Lifting weights, carrying a child, and walking are a few examples.

Balance and Stretching Activities

Dancing, gentle stretching, yoga, martial arts, and tai chi reduce risk of injuries by improving physical stability and flexibility.

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Thank you…

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REFERENCES

1. WHO. Obesity: Preventing and Managing the Global Epidemic, 2000. (TRS 894)



4. Report of International chair on cardio-metabolic risk, 2008.

5. IAP National Task Force for Childhood Prevention of Adult Diseases: Childhood Obesity, 2004.

6. WHO Expert Consultation, Appropriate body mass index for Asian populations and its implication for policy and intervention strategies, 2004.


8. Dietary guidelines for Indians: a manual. NIN along with ICMR, 2011.

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9. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India.

10. WHO Technical Report Series 916. DIET, NUTRITION AND THE PREVENTION OF CHRONIC DISEASES, 2003.

11. Global Recommendations on Physical Activity for Health. WHO, 2010.

12. A guide to health workers. NPCDCS, 2008.

13. Dietary Guidelines for Indians: A Manual. NIN along with ICMR, 2011

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INTERNATIONAL ASSOCIATION FOR STUDY OF OBESITY

• While the earliest identified discussions on the need for an organization addressing obesity took place in Great Britain as early as 1961, it was not until 1966 that a steering committee was formed.

• The first meeting of the "Obesity Association" was held in London in 1967.

• In the 1970s, Philip James and John Waterlow prepared an analysis of obesity-related research needs for the Department of Health and the UK Medical Research Council, enticing medical establishments to start funding obesity research.

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• This era also witnessed the development of the first obesity treatment drug, Fenfluramine.

• Around the same time, the first Fogarty Centre International Conference on Obesity was organized by a committee led by Dr George Bray, and was held in October 1973 at NIH in Bethesda, Maryland, USA.

• As a result of such efforts, the 1st International Congress on Obesity (ICO) was held at the Royal College of Physicians in London in October 1974, with over 500 attendees from 30 countries.

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• In 1980, at the meeting of the Nutrition Committee of the American Heart Association, Dr John Brunzell and Dr George Bray discussed the lack of an organized American group with an obesity focus.

• Shortly afterwards, American scientists interested in obesity were invited to convene and the North American Association for the Study of Obesity (NAASO) was born.

• At the 4th ICO in New York, the benefits of organising an international group of obesity scientists, later to be identified as International Association for Study of Obesity, were discussed and the IASO came into being in 1985.

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• During the 1990s, obesity meetings were occurring throughout Europe on an annual basis, and IASO nurtured the establishment of newer regional associations.

• The number of publications dedicated to obesity grew with the founding of "Obesity Research" by NAASO in 1993, and IASO’s addition of a new review journal entitled "Obesity Reviews" in 1998.

• The other significant development was the formation by Philip James in 1995 of the International Obesity Task Force (IOTF).

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• The IOTF was formed to alert the world to the growing health crisis of obesity. Comprised of leaders in the academic obesity community worldwide, the IOTF prepared the first scientific research report on the global epidemic of obesity, which served as the basis for the first WHO expert consultation on obesity held in Geneva in 1997.

• In August 2002, IASO and IOTF merged to become a single entity capable of confronting the challenges posed by the global obesity epidemic in the 21st century.

• The new IASO became a registered NGO in the WHO system when the IOTF’s work with the WHO was formalised.

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• A major educational programme was launched in 2003 by IOTF: SCOPE (Specialist Certification of Obesity Professionals in Education) aimed to recognise obesity specialists and enhance the quality of obesity education for medical professionals in Europe. The ‘E’ in SCOPE initially stood for Europe, but it was soon realised that the need for education extended far beyond that region alone.

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PORTION OF FOOD ITEM (WHO)

• Chapatti 1• Rice 1/3 cup• Bread slice 1• Dal 1/2 cup• Vegetables 1/2 cup

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ANTHROPOMETRIC MEASUREMENTS

• Height• Weight• Waist circumference• Hip circumference

Training and Practical Guides, Trainer's Guide,

WHO STEPS Surveillance, June 2008

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HEIGHT MEASUREMENT

• Ask the participant to remove their:

a) footwear

b) head gear

(If it would be insensitive to seek removal of a scarf or veil, the measurement may be taken over light fabric.)

• Ask the participant to stand on the measuring board facing you.

• Ask the participant to stand with:

a) feet together

b) heels against the back board

c) knees straight.

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• Ask the participant to look straight ahead and not tilt their head up.

• Make sure eyes are the same level as the ears.

• Move the measure arm gently down onto the head of the participant and ask the participant to breathe in and stand tall.

• Read the height in centimetres at the exact point.

• Ask the participant to step away from the measuring board.

• Record the height measurement in centimetres.

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WEIGHT MEASUREMENT

• Ask the participant to remove their footwear (shoes, slippers, sandals, socks).

• Ask the participant to step onto scale with one foot on each side of the scale.

• Ask the participant to:

a) stand still

b) face forward

c) place arms on the side and

d) wait until asked to step off.

• Record the weight in kilograms on the participant’s instrument.

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SKINFOLD THICKNESS

• CENTRAL

a) Subscapular

b) Suprailiac

c) Anterior axillary fold

• PERIPHERAL

a) Biceps

b) Triceps

c) Thigh

d) Calf

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Triceps• Measured on the posterior aspect of the right arm, over the triceps muscle,

midway between the lateral projection of the acromion process of the scapula and the inferior margin of the olecranon process of the ulna.(1)

• The postero-lateral border of the left acromion is identified by palpation and the upper end of a cloth measuring-tape is placed against this border and the tape run down to touch the upper border of the olecranon. The distance between these two points is read to the nearest 1 mm and an ink mark is placed mid-way between them (standard mid-point). A skinfold is pulled out in the vertical plane approximately 1 inch above the standard mid-point with the left thumb and forefinger. Holding the callipers horizontally in the right hand, the jaws are applied so that the ink mark is in the centre of the jaws.(2)

1. Chennai urban rural epidemiological study, 2003.

2. Department of Medical Statistics and Epidemiology, London School of Hygiene and Tropical Medicine, 1999.

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obesity and its parameters

Health & Medicine