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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