ObesityWhat is it in Asia?Why is it in Asia?

What is obesity?

• Obesity is not weight or size

• Obesity is extra fatness– How can this be measured?

• Obesity is a health problem

• Obesity is not a fashion problem– How can we get this through?

Definition of ObesityClassification BMI Risk of Co-morbidities

Underweight < 18.5 Low (risk of other clinical

problems increased)

Normal range 18.5 - 24.9 Average

Overweight > 25

Pre-obese 25 - 29.9 Increased

Obese class I 30.0 - 34.9 Moderate

Obese class II 35.0 - 39.9 Severe

Obese Class III > 40.0 Very Severe

Prevalence of Obesity (Males)

5

10

15

20

25P

reva

len

ce (

%)

1975

1980

1985

1990

1995

2000

E Germany

Netherlands

UK

USA

Australia

Prevalence of Obesity* among U.S. AdultsBRFSS, 1991

(*Approximately 30 pounds overweight)

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

<10% 10% to 15% >15%

Prevalence of Obesity* among U.S. Adults BRFSS, 1998

(*Approximately 30 pounds overweight)

<10% 10% to 15% >15%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

Obesity in the Middle East

0

10

20

30

40

50

60

Pre

vale

nce

(%

)

Overweight Obese

Lebanon F

Lebanon M

Bahrain F

Bahrain M

Saudi F

Saudi M

Overweight & Obesity in Asia

0 10 20 30 40 50 60Percentage (%)

Australia

Thailand

Korea

Malaysia

Japan

Cou

ntr

y

Obesity

Overweight

BMI in Urban Malaysian Males

Source : Ismail et al. (1995)

0

10

20

30

40

50

60

3rdCED

1st CED Normal 2ndObese

BMI

MalayChineseIndian

Prevalence Obesity Taiwan1993-96 Nutrition & Health Survey

0

5

10

15

20

25P

reva

lenc

e (%

)

25-30 >30

Women

Men

Obesity Prevalence Korea1994-7

0

1

2

3

4

5

6

Pre

vale

nce

(%

)

>28 >30BMI

What is “obesity” in the Asian region ?

• A long history of discussion & indecision

• Previous meetings• IOTF discussions

• WHO Technical Report 1997

• Regional Forum (held with PASOO)

• Formation of Asia Pacific Region of IASO

• WHO Meeting Tokyo 1998

• Meeting Hong Kong (IASO, IOTF & WHO)

• Meeting Milan 1999

• Working Group on Obesity in China 2000 (and 2001)

• Asia Pacific Perspective, February 2000

Historical Facts

• Japanese higher BP for weight compared to Americans

(Comstock et al., 1985, Baba et al., 1991)

• Australian Aboriginals (O’Dea)

– Diabetes at BMI > 22

• Haemoglobin A1C increased (Tai et al., 1992)

– BMI of 24.1 in urban Japanese

– BMI of 23.1 Chinese (Taiwan)

• Melbourne Chinese (Hsu-Hage et al., 1993)

– 50% the overweight & obesity yet same hypertension & dyslipidaemia– High WHR

History continued

• Cervical Cancer (Guo et al., 1994) – Mortality related to BMI > 22

• Blood Pressure in Japanese (Inoue)

– 3 times risk at BMI 24.9

– Increment at 22.3

• Southern Chinese (Folsom etal., 1994)

– Despite low BMI - dyslipidaemia, BP

Coronary Heart Disease and BMI in Asian populations.

• Japanese Americans (Burchfield et al., 1996)

– Risk increases at BMI > 23

– Risk doubles at BMI > 26

• Hong Kong Chinese (Ho et al., 1994)

– BMI 20.4 -23.7, lowest mortality in women

– [Remember, age standardised CHD mortality in Hong Kong Chinese & in Japanese

is 25% of that for USA and UK]

(Woo et al., 1998)

Overweight & Obesity in Asia

• Japan– High W/H ratios

– Nadir of BMI = 22.2

– Hypertension (3x increased at BMI 24.9)

– BMI increase related to fat intake

• Malaysia– Appearing in rural population

– Android obesity in females (30.6%)

– Younger are overweight not obese

– Indian women’s weight increases after 1st child

Dutch

Indonesian40

Corrected body mass index (kg/m2)

302010

Bod

y fa

t per

cent

60

50

40

30

20

10

males

females

males

females

Differences in the relationship between body fat percent and body mass index between Indonesian

and Dutch males and females.

Deurenberg et al, 1999

Risks of Obesity

RR >> 3 RR 2-3 RR 1-2

Type 2 diabetes CHD Cancer

Dyslipidaemia Hypertension PCOS

Insulin Resistance

Gall bladder disease Osteoarthritis Infertility

Sleep apnoea Gout Anaesthetic risk

18 20 22 24 26 28 30 32 341.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

6.6

6.2

5.8

Total cholesterol

Triglycerides

HDL cholesterol

Body Mass Index (kg/m²)

0

10

20

30

40

50

60

mm

ol/l

SBP

% w

ith h

igh

SB

P

Obesity: cardiovascular risk

Data from British Regional Heart Survey.

The risk of diabetes in relation to weight and weight change.

BMI at 21 years

Weight change since age 21

0

5

10

15

20

25

<5 kg 5-10 kg 11+ kg

<22

22-23

24+

1.0

1.0

2.1

2.5

3.6

5.3

6.3

9.1

21.1

From: Chan et al. 1994, Diabetes Care, 17: 961.

Relative Risk of Metabolic DiseaseTaiwan Series 2000, age & sex adjusted, 148,545 individuals

0

2.5

5

7.5

10

Rel

ati

ve

Ris

k

<2

3

23

25

30

BMI

NASH

Dyslipidaemia

BP

Diabetes

Risks of Obesity (Korea)

• Annual Health Examination Survey 1994-7– BMI > 28 (adjusted for age & sex)

• hypertension 4.1

• diabetes 2.2

• dyslipidaemia 3.7

• Kim et al., 1997– BMI > 26 (m), BMI > 25 (f)

• diabetes 3.2

• increased TG 2.1

Obesity in Asia

BMI Classification Action

18.5-22.9 Healthy Maintain

23-25 Overweight At least maintain

or reduce

25-30 Obesity 1 Program

Drug

30 + Obesity II Program + Drug

± VLCD

Obesity (BMI >25) in China

0

5

10

15

20

25

30

Pre

vale

nce

(%

)

1982

1989

1992

2002

Year

Relative risk of type 2 diabetes according to waist circumference (women)

Relative risk

71–75.9

24

20

16

12

8

4

0<71 76–81 81.1–86 86.1–91 91.1–96.3 96.4

Adapted from Carey et al. Am J Epidemiol 1997; 145: 614–9, with permission

Waist circumference (cm)

Abdominal Adiposity 3Men & Women

Despres et al., 1994

Lean Men Lean Women Obese MenObese Women0

1

2

3

4

5

6

7

chol

TG

HDL

mm

ol/L

Abdominal Adiposity in Asia

• Knowledge that abdominal adiposity• More common• Greater at lower BMI

• Recommendations for high risk

– Male > 90 cm (102 cm) – Female > 80 cm (88 cm)

• These need to be determined !

Country YearEstimated

directcosts

% Nationalhealthcare

costs

Australia

Canada

France

Netherlands

NZ

US

1989/90

1997

1992

1981/89

1990/91

1995

AUD $464 million

Can $1.8 million

FF 12 billion

Guilders 1 billion

NZ $135 million

US $52 billion

> 2%

2.4%

2%

4%

2.5%

5.7%

Conservative estimates of the direct healthcare costs of obesity

Obesity in perspective

-5 -2.5 0 2.5 5 7.5 10 12.5

Attributable DALYs as proportion of total DALYs

Tobacco

Physical Inactivity

Hypertension

Alcohol harm

Alcohol benefit

Overweight & Obesity

Lack of fruit & veg

High cholesterol

Illicit drugs

Occupation

Unsafe Sex

females

males

Aetiology of Obesity

• Genes haven’t changed

Therefore

• Environment has changed– Relative affluence

– Availability of food

– Urbanisation

– Alteration in Food intake

– Less Activity

Genetics & Obesity

• Several single gene defects– Leptin synthesis– MCR4 gene– “cleavage” enzyme

• Extreme obesity, hypogonadotrophic hypogonadism

• Varying types of inheritance– Mainly recessive

22

25

24

23

21

20

5 10 15 20 25 30 35

Cassava, maize, beans (US$99 - 418)

Rice, beans, lard (US$220 - 990)

Wheat, rice, oil, meat, milk (US$1700 - 8500)

Household diet and adiposity in Brazil according to Household diet and adiposity in Brazil according to dietary staples.dietary staples.

Bo

dy

Mas

s In

de

x (m

en)

Fat content of diet (% energy)

Redrawn from WHO Tech. Report Series 797,1990 - p.73.

Dietary pattern (Household income range)

Energy Intake in Japan 1955-95

0 20 40 60 80

100

Percentage (%)

1955

1965

1975

1980

1985

1990

1994

1995

Yea

r

Carbohydrate

Fat

Protein

% Fat in Chinese diet 1992

0 10 20 30 40Fat %

Beijing

Shanghai

Guangzhou

Tiajin

Energy balance and dietary fat

Daily Energy Balance (MJ)

Low activity

High activity

Dietary fat (energy - %)200 40 60 80

4

3210

-1-2-3-4-5-6 25% 54%

Taken from Stubbs, J. 1998

Weight, Fat & Activity

• UK period 1970-90

Energy intake -750 cal

BMI + 1.0

Body weight + 2.5kg

(Prentice & Jebb, 1995)

• Energy needed for weight gain

+ 50 cal/day

• Physical activity must have fallen by 800 cal/day!

OBESITY26

25

24

23

22

1940 1960 1980 2000

INACTIVITY200

180

160

140

120

100

801940 1960 1980 2000

Per

ce

nta

ge

ch

an

ge

fro

m f

irs

t re

cord

s

Bo

dy

Ma

ss

Ind

ex

TV ownership

Car ownership

Source: Prentice & Jebb, 1995.

Obesity and inactivity in the UK

Prenatal environment

• Small babies (<2.5kg) more likely to develop metabolic disease as adults– Problem in India

– Urban poor, late adolescence

» 50% hypertension

» 15% diabetes, 15% IGT

• ? Due to inadequate nutrition

• ? Particular problem in whole of Asia

24 28 325

6

7

8

9

Adult BMI

Blo

od

glu

cose

mm

ol/l

Famine: late pregnancy 21

Famine: mid pregnancy 14

Famine: early pregnancy 16

Born before famine 15

Conceived after famine 15

Diabetes or glucose intolerance %

Adult glucose intolerance and diabetes after fetal nutritional deprivation.

Ravelli et al. Lancet 1998, 351, 173.

Management Strategies• Prevention of weight gain

• Promotion of weight maintenance– PUBLIC HEALTH PROGRAMS

• Management of co-morbidities

• Promotion of weight loss– INDIVIDUAL TREATMENT PROGRAMS

The management of obesityBody weight

Years of management or intermittent monitoring

Normal

Overweight

Obese

Natural course of further weight gain

Successes

1. Sustained weight, no increase

2. Minor weight loss with dietary change to reduce risk of complications3. Modest weight loss with clear risk factor reduction e.g. B.P.

4. Weight normalisation: rare

Adapted from Rössner, 1997

Effects of 10% weight loss

• Mortality– 20% decrease in overall

– 30% decrease in diabetes related deaths

– 40% decrease in cancer related deaths

• Blood pressure– 10 mm Hg decrease

• Lipids– 15% decrease in cholesterol

– Decreases in other lipids

• Diabetes– Better control

– Less medications SIGN, 1996

Reality• Assessment

– Anthropometry• BMI• waist

– Risks• BP• glucose, insulin• lipids• heart disease• sleep apnoea

• Management1. general advice2. activity3. eating4. Program5. Drugs

Sibutramine

6. VLCDs7. Surgery

Program

• Eating• Activity

– Incidental

– Exercise

• Behaviour & Habit• Medical• Pharmacotherapy• Follow up

Obesity in our region

BMI WHO Asia18.5 -24.9 Healthy

18.5 - 23 Healthy

23 - 25 “At risk”

25 - 29.9 Pre-obese Obese I

30 - 34.9 Obese I Obese II

35 - 39.9 Obese II

40 + Obese III

When to use Sibutramine

• High BMI (>30)

• Relate BMI and risk - in Asia BMI > 25• Abdominal adiposity• Diabetes• Dyslipidaemia• IHD• OSA

• Inadequate loss after 12 weeks in Lifestyle Program

• Acute loss necessary

Use of Sibutramine in Asia

• BMI > 25• Program

• Add Sibutramine if no loss in 12 weeks

• BMI > 25 with risks• Program

• Add Sibutramine• Treat risks (diabetes, BP, dyslipidaemia)

• BMI > 30• Program & Sibutramine

• Consider additional therapy