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Year : 2012  |  Volume : 1  |  Issue : 1  |  Page : 37-41

Obesity in India: The weight of the nation


1 Department of Endocrinology, Bharti Hospital and B.R.I.D.E., Karnal, Haryana, India
2 Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Web Publication3-Apr-2012

Correspondence Address:
Sanjay Kalra
Department of Endocrinology, Bharti Hospital and B.R.I.D.E, Karnal, Haryana
India
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DOI: 10.4103/2278-019X.94634

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  Abstract 

India is gaining weight. Traditionally known for malnutrition, Indians now report more and more frequently with overweight, obesity, and their consequences. Indians exhibit unique features of obesity: Excess body fat, abdominal adiposity, increased subcutaneous and intra-abdominal fat, and deposition of fat in ectopic sites (such as liver, muscle, and others). Obesity is a major driver for the widely prevalent metabolic syndrome and type-2 diabetes mellitus (T2DM). Although this phenomenon is a global one, India is unique in that it has to grapple with both over- and undernutrition at the same time. This article reviews the weight of the problem of obesity in India.

Keywords: Diabesity, India, obesity


How to cite this article:
Kalra S, Unnikrishnan A G. Obesity in India: The weight of the nation. J Med Nutr Nutraceut 2012;1:37-41

How to cite this URL:
Kalra S, Unnikrishnan A G. Obesity in India: The weight of the nation. J Med Nutr Nutraceut [serial online] 2012 [cited 2014 Dec 20];1:37-41. Available from: http://www.jmnn.org/text.asp?2012/1/1/37/94634


  Introduction Top


Obesity can be seen as the first wave of a defined cluster of noncommunicable diseases called "New World Syndrome," creating an enormous socioeconomic and public health burden in poorer countries. The World Health Organization has described obesity as one of today's most neglected public health problems, affecting every region of the globe. [1]

India is the second most populous country in the world that comprises ~17% of the world's population and contributes to 16% of the world's deaths. Nutritional status of the Indian population varies significantly across the regions. Certain regions are associated with extremely high rates of childhood undernutrition (ranging from 20% to 80%), whereas others have a high prevalence of adult undernutrition (>50%), and some have both. [1]

Earlier, developing countries, including India, had focused scarce public health resources primarily on the high prevalence of undernutrition. However, these nations are currently facing the double burden of undernutrition as well as overnutrition. Data regarding the nutritional status of adults, as determined by body mass index (BMI), indicate that 50% of Indian adults suffer from different types of chronic energy deficiency, in that they have a BMI<18.5 kg/m 2 . In the same survey, it was observed that the BMI values were similar in men and women; however, there were more overweight/obese (BMI≥25 kg/m 2 ) women (6.6%) than men (3.5%). In certain regions, obesity and consequent diseases are posing an enormous public health problem. [1]


  Obesity in India Top


According to the National Family Health Survey (NFHS), the percentage of ever-married women aged 15-49 years who are overweight or obese increased from 11% in NFHS- 2 to 15% in NFHS-3. Undernutrition is more prevalent in rural areas, whereas overweight and obesity are more than three times higher in urban areas. This may be due to lesser physical activity in the urban areas. Furthermore, undernutrition and overweight/obesity are both higher for women than men. [2] This dual disease pattern in women may have an endocrine basis, but more probably has its roots in societal and cultural mores, which prevent women from leading a healthy lifestyle. The prevalence of overweight and obesity is three times higher among women with 12 or more years of schooling than those with no education. [2]

The percentage of women who are overweight or obese is highest in Punjab (30%), followed by Kerala (28%) and Delhi (26%), all of which are relatively richer states. [2]

The prevalence of underweight and overweight among men shows similar variations by age, education, and wealth index. [2]

[Table 1] is a list of the states of India ranked in order of percentage of people who are overweight or obese, based on data from the 2007 NFHS. [3]
Table 1: States of India ranked in order of percentage of people who are overweight or obese, based on data from the 2007 National Family Health Survey[3]


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Obesity and other cardiovascular disease risk factors

The Jaipur Heart Watch (JHW) was a combination of multiple cross-sectional epidemiologic studies, performed in India in rural and urban locations. From these cohorts, subjects aged 20-59 years (men 4102, women 2872) were included. The prevalence of various risk factors: Smoking/tobacco use, overweight/obesity (BMI≥25 kg/m 2 ) truncal obesity (WHR≥0.95 men, ≥0.85 women), hypertension, dyslipidemias, metabolic syndrome, and diabetes was determined. Trends were examined using least squares regression. [4]

Smoking/tobacco use was more in rural men (50.0% vs 40.6%) and urban women (8.9% vs 4.5%, P<</i>0.01). Obesity, truncal obesity, hypertension, hypercholesterolemia, diabetes, and metabolic syndrome were more in urban cohorts (P<</i> 0.001). Age-adjusted prevalence (%) of obesity in various cohorts, rural JHW, and urban JHW-1, JHW-2, JHW-3, and JHW-4, respectively, in men was 9.4, 21.1, 35.6, 54.0, and 50.9 (r2 =0.92, P=0.009) and in women 8.9, 15.7, 45.1, 61.5, and 57.7 (r2 =0.88, P=0.018). The prevalence of truncal obesity in men was 3.2, 19.6, 39.6, 41.4, and 31.1 (r2 =0.60, P=0.124) and in women 10.1, 49.5, 42.1, 51.7, and 50.5 (r2 =0.56, P=0.1467). In successive cohorts increasing trends were observed in the prevalence of hypertension (r2 =0.93, P=0.008) and metabolic syndrome (r2 =0.99, P=0.005) with weaker trends for hypercholesterolemia (r2 =0.41, P=0.241) and diabetes (r2 =0.79, P=0.299) in men. In women, significant trends were observed for hypertension (r2 =0.98, P=0.001) and weaker trends for others. Increase in generalized obesity correlated significantly with hypertension [two-line regression (r2 ): M en 0.91, women 0.88], hypercholesterolemia (0.53, 0.44), metabolic syndrome (0.87, 0.94), and diabetes (0.84, 0.93). Truncal obesity correlated less strongly with the risk factors, such as hypertension (0.50, 0.57), hypercholesterolemia (0.88, 0.61), metabolic syndrome (0.76, 0.33), and diabetes (0.75, 0.33).

Thus in Asian Indian subjects, escalating population-wide generalized obesity correlates strongly with increasing cardiovascular risk factors. [4]

Socioeconomic factors

[Figure 1] shows the increasing trend in obesity among the urban and also in the rural population (>20 years) in Chennai, South India. In a decade, the prevalence of obesity had increased by 1.7-fold in the city. Obesity rates were higher among women, as reported from many other countries. The prevalence of overweight was lower among the urbanizing rural population, than in the urban areas. However, the rural population had a more rapid change as shown by nearly 8.6-fold increase in a period of 14 years. [5]
Figure 1: Temporal changes in prevalence (%) of obesity (≥25 kg/m2) among urban and rural Asian Indians. (a) The data for urban population; (b) the data for rural population

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The study indicated that the living conditions in rural areas had improved considerably. Transport facilities, medical care and food habits, educational status, and family income had dramatically improved which along with easy access to city and television watching resulted in changes in life style. These eventually led to significant increase in BMI as well as abdominal obesity in both sexes as compared with a similar study conducted in the year 1989. The prevalence of overweight rose from 2% to 17.1%. The changing life style of the rural dwellers was found to be a contributory factor for the rising rates of obesity and associated metabolic diseases, such as diabetes. [5]

Data from the India NFHS showed that in the country, the overall prevalence of overweight was low, whereas undernutrition remained high. Overweight was more prevalent among the urban and high socioeconomic status groups, especially among women. [5]

A higher prevalence of obesity seen in the urban areas in developing countries is associated with the change from rural to urban lifestyle causing decreased levels of physical activity and an increase intake of energy-dense diet. [5]

Physical activity

A cross-sectional survey was conducted in 6-12 urban streets in each of five cities in five different regions of India using a common study protocol and criteria of diagnosis to find out the prevalence of overweight, obesity, undernutrition, and physical activity status in the urban populations of India. [6]

A total of 6940 subjects (3433 women and 3507 men) of 25 years and older were randomly selected from the cities of Moradabad (n=2002), Trivandrum (n=1602), Calcutta (n=900), Nagpur (n=894), and Bombay (n=1542). Evaluation and validation were performed by a physician and dietitian-administered questionnaire at Moradabad. After pooling of data, all subjects were divided into various age groups for men and women. Obesity (BMI>30 kg/m 2 ), overweight (BMI=2.25-29.9 kg/m 2 and >23 kg/ m 2 ), and waist-to-hip ratio (WHR) (>0.85 in women and >0.88 in men, central obesity) were calculated and physical activity status assessed by a validated questionnaire. [6]

The overall prevalence of obesity was 6.8% (7.8 vs 6.2%, P<0.05) and overweight 33.5% (35.0 vs 32.0%, P < 0.05) among women and men, respectively. The highest prevalence of obesity (7.8%) and overweight (36.9%) was found among subjects aged 35-44 years in both sexes. The prevalence of obesity was significantly (P < 0.05) greater in Trivandrum (8.5%), Calcutta (7.1%), and Bombay (8.3%) compared with Moradabad (6.2%) among women and in Trivandrum (7.4%) and Bombay (7.2%), compared with Nagpur (5.0%) among men. There was a significant decreasing trend in obesity (P < 0.05) and overweight (P < 0.05) with increasing age above 35-44 years in both the sexes. The overall prevalence of subjects with BMI>23 kg/m 2 was 50.8% and central obesity 52.6%. The overall prevalence of sedentary behavior was 59.3% among women and 58.5% among men. Both sedentary behavior and mild activity showed a significant increasing trend in women after the age of 35-44 years. In men, such a trend was observed above the age of 45 years. Sedentary behavior was significantly (P < 0.05) greater in Trivandrum, Calcutta, and Bombay compared to Nagpur. Sedentary behavior was significantly (P < 0.001) associated with obesity in both sexes, compared with nonobese men and women. The overall prevalence of undernutrition was 5.5% (n=380), which was significantly more common in Moradabad, north and Nagpur, central India compared with other cities. [6]

Obesity, overweight, and central obesity and sedentary behavior coexist with undernutrition, and have become a public health problem in all the five cities of India. The prevalence of obesity and sedentary behavior was significantly greater in Trivandrum, Calcutta, and Bombay compared with Moradabad and Nagpur. Sedentary behavior was significantly associated with obesity compared with nonobese subjects in both sexes, which may be due to greater economic development in metro cities. [6]

Male-female differences

A cross-sectional survey was carried out on an endogamous group of 577 adults (307 females and 270 males) aged 25-60 years in Delhi, India, to assess the obesity differences between males and females in a sample Indian population. [7]

Data were collected for weight, height, waist circumference (WC), and blood pressure using standardized procedure. BMI, WHR, waist-to-height ratio, and grand mean thickness were calculated to assess obesity. Also, the sex-specific prevalence estimates for various BP categories was calculated. Correlation was calculated between systolic and diastolic BP and various indices of obesity. Odds ratios for association of hypertension with obesity indices were obtained using multiple logistic regression. [7]

Prevalence of prehypertension and hypertension was higher among males and prevalence of obesity was higher in females. Correlations of BP with all indices of obesity were significant. Odds ratio of hypertension was higher in males than in females for all the indices of obesity at 95% CI. [7]

In this sample population, although obesity was found to be higher among females, males were found to be at higher risk of hypertension. [7]

A comparison of two major studies in a sample population conducted by NFHS-2 in 1998-1999 and NFHS-3 in 2005-2006 showed 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 and 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 undernutrition 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. [8]

The problem of diabesity

Obesity in type-2 diabetic patients is a very common phenomenon and often termed as "Diabesity." Diabetes, obesity, hypertension, dyslipidemia are grouped under one name "Metabolic syndrome." The rising prevalence of these lifestyle disorders in India is of concern as singly or in combination, which act as major risk factors for coronary artery diseases (CAD). Increased predisposition to diabetes and premature CAD in Indians has been attributed to the "Asian Indian Phenotype" characterized by less of generalized obesity measured by BMI and greater central body obesity as shown by greater WC and WHR. [9]

Many Indians fit into the category of metabolically obese, normal weight individuals. Despite having lean BMI an adult Indian has more chances of having abdominal obesity. The body fat percentage of an Indian is significantly higher than a western counterpart with similar BMI and blood glucose level. It has been hypothesized that excess body fat and low muscle mass may explain the high prevalence of hyperinsulinemia and the high risk of type-2 diabetes in Asian Indians. [10]

Focus on childhood obesity

Following the increase in adult obesity, the proportion of children and adolescents who are overweight and obese have also been increasing. The most important consequence of childhood obesity is its persistence into adulthood with all its health risks. The health risks include cardiovascular diseases, diabetes, osteoarthritis, gallbladder disease, and some sex hormone-sensitive cancers. It is more likely to persist when its onset is in late childhood or adolescence. If the underlying causes of the obesity epidemic are not addressed, it has the potential to overwhelm health systems throughout the world. Mortality risk increases with increased weight of children. [11],[12],[13],[14],[15]

Globally, an estimated 10% of school-aged children, between 5 and 17 years of age, are overweight or obese. In India, many studies have shown that the prevalence of overweight among adolescents varies between 10% and 30%. [11],[12],[13],[14],[15]

The results of studies among adolescents from parts of Punjab, Maharashtra, Delhi, and South India revealed that the prevalence of overweight and obesity was high (11%-29%). In Ludhiana, Punjab, urban children in the age group of 11-17 years of age were more overweight (11.6%) than their rural counterparts (4.7%). In Pune, Maharashtra, studies among 1228 boys in the age group of 10-15 years indicated that ~20% were overweight, whereas 5.7% were obese. A study carried out in Ludhiana, Punjab, on school children in the age group of 9-15 years revealed that the overall prevalence of overweight and obesity were 11% and 14%, respectively. Another study carried out in Delhi, India, among 5000 private school children in the age group of 4-18 years in 2002 by the Nutrition Foundation of India revealed that the prevalence of overweight was 29%. A similar study conducted in Chennai, South India, showed that the prevalence of overweight was ~17% and of obesity was 3%. [16]

Low levels of physical activity, watching television, and consuming junk foods are associated with a higher prevalence of overweight. Thus, participation in household activities and regular physical exercise could help in lowering the prevalence of overweight. Therefore, the role of physical activity, games, and sports should be emphasized, and facilities should be provided for outdoor games in schools, with compulsory hours of sports and games. There is an urgent need to educate the urban community on the aspects of healthy food habits and desired lifestyles to prevent overweight/obesity and its associated ill effects. [16]

Conclusions

Given the rapid rise in obesity in India, it is important to know the "weight of the nation." Due to the long-term consequences, the cost burden of obesity on the health care system is enormous. A better understanding of the numbers and causes can help overcome barriers to the primary prevention of obesity for youth and adults in communities, medical care, schools, and workplaces.

The Indian metabolic community has woken up to the need to achieve a healthy weight, in order to ensure health of the country. Innovative, yet simple and low-cost suggestions, such as yoga, meditation, and folk dance, can be used to maintain optimal weight of our country men and women. [17]



 
  References Top

1.Pednekar MS. Association of body mass index with all-cause and cause-specific mortality: Findings from a prospective cohort study in Mumbai (Bombay), India. Int J Epidemiol 2008;37:524-35.  Back to cited text no. 1
    
2.http://www.nfhsindia.org/nfhs3.html. Accessed on 6 March, 2012.  Back to cited text no. 2
    
3.Available from: http://en.wikipedia.org/wiki/Obesity_in_India. [Last accessed on 2011 Jun 12].  Back to cited text no. 3
    
4.Gupta R, Gupta VP. Obesity is major determinant of coronary risk factors in India: Jaipur Heart Watch studies. Indian Heart J 2008;60:26-33.  Back to cited text no. 4
    
5.Ramachandran A, Snehalatha C. Rising burden of obesity in Asia. J Obes 2010;2010.  Back to cited text no. 5
    
6.Singh RB, Pella D. Prevalence of obesity, physical inactivity and undernutrition, a triple burden of diseases during transition in a developing economy. The Five City Study Group. Acta Cardiol 2007;62:119-27.  Back to cited text no. 6
    
7.Gupta S, Kapoor S. Sex differences in blood pressure levels and its association with obesity indices: Who is at greater risk. Ethn Dis 2010;20:370-5.  Back to cited text no. 7
    
8.Garg C, Khan SA. Prevalence of obesity in Indian women. Obes Rev 2010;11:105-8.  Back to cited text no. 8
    
9.Yajnik CS, Ganpule-Rao AV. The obesity-diabetes association: What is different in Indians? Int J Low Extrem Wounds 2010;9:113-5.  Back to cited text no. 9
    
10.Pandya H, Lakhani JD, Patel N.Obesity is becoming synonym for diabetes in rural areas of India also-an alarming. Int J Biol Med Res 2011;2:556-60.  Back to cited text no. 10
    
11.Kotian MS. Prevalence and determinants of overweight and obesity among adolescent school children of south Karnataka, India. Indian J Community Med 2010;35:176-8.  Back to cited text no. 11
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12.Stigler MH. Weight-related concerns and weight-control behaviors among overweight adolescents in Delhi, India: A cross-sectional study. Int J Behav Nutr Phys Act 2011;8:9.  Back to cited text no. 12
    
13.Gupta DK, Shah P, Misra A, Bharadwaj S, Gulati S, Gupta N, et al. Secular trends in prevalence of overweight and obesity from 2006 to 2009 in urban Asian Indian adolescents aged 14-17 years. PLoS One 2011;6: e17221.  Back to cited text no. 13
    
14.Raj M. Dynamics of growth and weight transitions in a pediatric cohort from India. Nutr J 2009;8:55.  Back to cited text no. 14
    
15.Bharati DR. Correlates of overweight and obesity among school going children of Wardha city, Central India. Indian J Med Res 2008;127:539-43.  Back to cited text no. 15
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16.Laxmaiah A, Nagalla B, Vijayaraghavan K, Nair M. Factors affecting prevalence of overweight among 12- to 17-year-old urban adolescents in Hyderabad, India. Obesity (Silver Spring) 2007;15:1384-90.  Back to cited text no. 16
    
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