This is how you do it

How do you create an obesity epidemic in a country with nearly the lowest percentage of “obese” people in the world?

You begin by changing the definition.

On Tuesday, Health Ministry officials in India released the country’s first Guidelines for the Prevention and Management of Obesity and Metabolic Syndrome. It begins by making significant departures from World Health Organization definitions for overweight and obesity. According to new cutoffs enacted by Indian health officials, anyone with a body mass index of 23 kg/m2 is now labeled as overweight. And a BMI of 25 and over is now defined as obese — considerably more stringent than the international cut-off of a BMI 30.

[As you may remember, overweight used to be defined as a BMI of 27 before the U.S. National Heart, Lung and Blood Institute changed the definition to 25 to match new international guidelines in 1998.]

As the Daily News & Analysis in Mumbai (Bombay) reported , men with waistlines of 35 inches or more and women with waistlines of 31.5 inches or more are now considered obese by the new norm. These, too, are well below the WHO cut-offs of 40.2 and 34.6 inches, respectively.

Not only have the definitions dramatically changed, but according to the new guidelines, any Indian with a BMI of 25 is now “a fit case for drug therapy to control obesity” and those at a BMI of 32.5 are to have bariatric surgery.

According to the news, “obesity has reached an alarming stage” and based on these new definitions, every second a person in New Delhi meets the criteria of obesity. The head of diabetes and metabolic diseases at Fortis Hospitals in New Delhi, Dr. Anoop Mishra, told reporters that Indians have different body compositions that put them at risk for diabetes and metabolic syndrome, making the need to lower international guidelines for obesity “almost urgent.” India was predicted to be the global capital of diabetes and metabolic syndrome by 2050.

This move was endorsed by Dr. PK Chowbey, identified by the news as a senior surgeon at Delhi’s Sir Gangaram Hospital, who stated that clinical presentations of obesity are different among Indians compared to other populations, such as Americans or Europeans. In actuality, Dr. Pradeep K. Chowbey is a bariatric surgeon and the President of the Obesity Surgery Society of India. On his website, he says obesity is a health problem of epidemic proportions and that bariatric surgery is the only method to achieve long-term weight loss.

“Alarming” obesity epidemic: fact or fiction

It’s quite a shock to hear claims of an obesity epidemic in India, necessitating “almost urgent” governmental action.

India is in the midst of The Great Hunger of 2008, the worst since the Bengal famine of 1943-4, due to the world food crisis which has nearly doubled the price of corn, wheat, rice, soybeans and oil, essential foodstuffs among poor countries. The latest India National Sample Survey figures of undernourished people, with caloric intakes below minimum daily requirements, had risen to 67% in rural areas by 2002 and 51% of urban households — up from 43% and 37% in 1987, respectively. Two million Indian children die a year — 6,000 every day — from hunger and malnutrition.

The United Nations estimates that the food crisis reached acute levels this year. According to a CNN-IBN investigative report, nearly 60% of children in Lalitpur district of Uttar Pradesh are malnourished. As BBC News reported last week, the India State Hunger Index found that Madhya Pradesh had the worst levels in India, comparable to Chad and Ethiopia. Sixty percent of children under the age of six in the state are malnourished. Despite these facts, advocacy groups “say the government is in complete denial,” according to the BBC, and the Hindu nationalist Bharatiya Janata Party, which rules the state of Madhya Pradesh, doesn’t even mention the issue in its manifesto.

The India State Hunger Index report, released on October 14, 2008, developed by the International Food Policy Research Institute, ranked India 66^th out of 88 developing countries. “It ranks slightly above Bangladesh and below all other South

Asian nations,” states the report. India “even ranks below several countries in Sub-Saharan Africa, such as Kenya, Nigeria, Cameroon, and even Congo and Sudan.” The report found a shocking 42.5% of children under age five is underweight.

According to the latest figures from the International Obesity Task Force, the percentage of the adult Indian population with a BMI>30 (the international definition for obese) is a mere 1.3% of men and 2.8% of women. The only figures in the entire world where obesity rates are lower than India’s are women in Central Africa Republic and Nepal (1.1%) and Ethiopia (0.8%). By comparison, South Africa has rates of female overweight and obesity of 25.9% and 27.9%.

With such widespread malnutrition, not surprisingly, life expectancy in India is a decade less than in the United States, averaging 68 years. Only 5.2% of India’s population lives to age 65 or beyond.

So, as of Tuesday, Indian government officials made every man and woman formerly labeled as overweight, now obese. This change raised the “obesity” rosters by 8 and 9.8%, respectively — comparable to Niger — and added millions of new ‘obese’ patients to be targeted for weight management.

The fact that government health officials would deem weight loss interventions its most pressing priority, while millions are dying of malnutrition, underweight and true nutrition-exacerbated diseases, disabilities and neurological damage is what is most alarming.

Definition controversy

Media also didn’t report that there is no sound science to support lowering BMI thresholds to redefine overweight and obesity for Asian-ethnic groups, nor is this a new idea. At the International Congress on Obesity in San Paulo, Brazil, in 2002, this suggestion was debated. Dr. Mishra argued for the change, based on risk indices (higher blood sugars, blood pressure and cholesterol levels) associated with BMIs in the normal range and that Asians have higher percentages of body fat at ‘normal’ ranges of BMI than Caucasians.

This claim was countered in depth by Dr. June Stevens, associate professor of nutrition and epidemiology at the University of North Carolina at Chapel Hill, whose review of the science was published in a 2003 issue of the International Journal of Obesity. She pointed out that cutoffs for obesity are arbitrary and it’s necessary to separate the scientific- from the politically-linked BMI cutpoints used to trigger public health or clinical action.

Essentially, BMI is a risk factor — a correlation — associated with countless social, political, economic and health confounding factors associated with morbidity and mortality figures in various countries. “Using the very same logic as that applied to ethnic groups, a case could be made for different BMI cutpoints for obesity for individuals of different educational levels, family medical history, fitness level as well as other characteristics,” she wrote. The data supports the use of other confounding factors, no differently than ethnicity.

While Asians on average high a higher body fat and waist circumference at various BMIs than Caucasians, the literature also shows that at the same BMI, African-Americans have a lower percentage of body fat and waist circumferences than white Americans. “In addition, there is a considerable amount of evidence that the BMI associated with the lowest mortality is higher in African Americans than in white Americans,” she wrote. “Nevertheless, parallel arguments to increase the BMI cutpoint for obesity in African-Americans are not heard from those advocating lower cutpoints in Asians.”

Instead, she said, calls to lower BMI cutoffs help win attention and gather resources for obesity treatment and prevention programs. “This is not a scientific argument, but a political one.”

The best evidence to date fails to support ethnic-specific BMI definitions or lower BMIs as healthier for Asians. [The most recent research was covered here.] Among the research Dr. Stevens cited was the Asia-Pacific Cohort Studies Collaborative study of more than 300,000 people in 33 countries, It found no relationship between ethnicity and BMIs associated with heart disease or stroke, she said. A recent review of the research she led, published in Nutrition Reviews in 2003, found no indication for higher mortalities among Asians with BMIs in the ‘normal’ range. Several studies have examined the association between BMI and mortality among Asian populations in men and women. The Tsugane et al. study of 54,498 Japanese adult men and women followed for ten years, beginning in 1990, for example, “provided no evidence that the range of BMI currently designated as the lowest risk (18.5-24.9) is set too high for Asians.” The results of this study illustrate, the data “provide no evidence that Asian populations require a lower overweight/obesity BMI cut-point,” she said.

She took issue with using any disease risk factor to set standards for obesity as they “have little to offer as outcomes,” she wrote. “Risk factors generally do not by themselves affect quality or length of life.” They are only related to clinical outcomes, but each can differ among populations and unless a risk factor is equally relevant among various groups, it’s illogical to use it to set policy. It cannot be assumed that risk factors will have the same impact on hard outcomes among different populations, nor can we assume BMI has a causal role, since many things that impact BMI can be impacted by BMI.

Claims of a skyrocketing epidemic of type 2 diabetes in India are equally unsupported. The very first incidence* study on diabetes in India was just published in the March 2008 online edition of the Journal of Association of Physicians of India. Not only does a single study not make a trend, but this study was focused only on two residential colonies with middle and lower income residents, not country-wide population surveys. [* Incidence “reflects the rate at which healthy people in the population acquire the disease,” said the authors.]

The Chennai Urban Population Study was conducted by Dr. V. Mohan and colleagues from the Dr. V. Mohan’s Diabetes Specialties Centre in Chennai. This ongoing epidemiological study began in 1996, enrolling 1,262 adults free of diabetes, average age 40. Eight years later, the researchers obtained blood samples on 513 participants, with the rest lost in follow-up. They reported no differences among those lost to follow-up and those who completed the study. Among the 513 blood tests, 79 had type 2 diabetes as diagnosed by their private physicians’ prescribing medications, or by fasting blood sugars 126 mg/dl and higher or 2-hour post glucose 200 mg/dl or higher. They reported no correlation between those who developed diabetes and their physical activity, with significantly higher rates of diabetes among those with one or both parents with diabetes.

Incidence of diabetes at follow-up was directly related to age: 1.03% among those 20-29 years; 2.07% among those in their 30s; 2.52% among those in their 40s; and 2.34% among those 50 years of age and older. While this was a small study of two neighborhoods, with high attrition, the authors made conclusions for the entire country. They concluded that this study found “that incidence rates of diabetes and prediabetes in India are higher compared to other ethnic groups and western populations.”

While the Madras Diabetes Research Foundation describes an epidemic of diabetes in India and says that India has the highest number of diabetics in the world, it’s easy to forget that India has one sixth of the entire world’s population, about 1.13 billion people.

We’ve just witnessed the birth of an epidemic ... in name only.

© 2008 Sandy Szwarc