Anoop Misra

Obesity and the Metabolic Syndrome in Developing Countries

CONTEXT Prevalence of obesity and the metabolic syndrome is rapidly increasing in developing countries, leading to increased morbidity and mortality due to type 2 diabetes mellitus (T2DM) and cardiovascular disease. EVIDENCE ACQUISITION Literature search was carried out using the terms obesity, insulin resistance, the metabolic syndrome, diabetes, dyslipidemia, nutrition, physical activity, and developing countries, from PubMed from 1966 to June 2008 and from web sites and published documents of the World Health Organization and Food and Agricultural Organization. EVIDENCE SYNTHESIS With improvement in economic situation in developing countries, increasing prevalence of obesity and the metabolic syndrome is seen in adults and particularly in children. The main causes are increasing urbanization, nutrition transition, and reduced physical activity. Furthermore, aggressive community nutrition intervention programs for undernourished children may increase obesity. Some evidence suggests that widely prevalent perinatal undernutrition and childhood catch-up obesity may play a role in adult-onset metabolic syndrome and T2DM. The economic cost of obesity and related diseases in developing countries, having meager health budgets is enormous. CONCLUSIONS To prevent increasing morbidity and mortality due to obesity-related T2DM and cardiovascular disease in developing countries, there is an urgent need to initiate large-scale community intervention programs focusing on increased physical activity and healthier food options, particularly for children. International health agencies and respective government should intensively focus on primordial and primary prevention programs for obesity and the metabolic syndrome in developing countries.

Childhood Obesity in Developing Countries: Epidemiology, Determinants, and Prevention

Rapidly changing dietary practices and a sedentary lifestyle have led to increasing prevalence of childhood obesity (5-19 yr) in developing countries recently: 41.8% in Mexico, 22.1% in Brazil, 22.0% in India, and 19.3% in Argentina. Moreover, secular trends indicate increasing prevalence rates in these countries: 4.1 to 13.9% in Brazil during 1974-1997, 12.2 to 15.6% in Thailand during 1991-1993, and 9.8 to 11.7% in India during 2006-2009. Important determinants of childhood obesity include high socioeconomic status, residence in metropolitan cities, female gender, unawareness and false beliefs about nutrition, marketing by transnational food companies, increasing academic stress, and poor facilities for physical activity. Childhood obesity has been associated with type 2 diabetes mellitus, the early-onset metabolic syndrome, subclinical inflammation, dyslipidemia, coronary artery diseases, and adulthood obesity. Therapeutic lifestyle changes and maintenance of regular physical activity through parental initiative and social support interventions are the most important strategies in managing childhood obesity. Also, high-risk screening and effective health educational programs are urgently needed in developing countries.

High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India

BACKGROUND AND AIMS: In this study, a prevalence survey of various atherosclerosis risk factors was carried out on hitherto poorly studied rural–urban migrants settled in urban slums in a large metropolitan city in northern India, with the aim of studying anthropometric and metabolic characteristics of this population in socio-economic transition.DESIGN: A cross-sectional epidemiological descriptive study.SUBJECTS: A total of 532 subjects (170 males and 362 females) were included in the study (response rate approximately 40%).METHODS AND RESULTS: In this study, diabetes mellitus was recorded in 11.2% (95% CI 6.8–16.9) of males and 9.9% (95% CI 7.0–13.5) of females, the overall prevalence being 10.3% (95% CI 7.8–13.2). Based on body mass index (BMI), obesity was more prevalent in females (15.6%; 95% CI 10.7–22.3) than in males (13.3%; 95% CI 8.5–19.5). On the other hand, classifying obesity based on percentage body fat (%BF), 10.6% (95% CI 6.4–16.2) of males and 40.2% (95% CI 34.9–45.3) of females were obese. High waist–hip ratio (WHR) was observed in 9.4% (95% CI 5.4–14.8) of males and 51.1% (95% CI 45.8–56.3) of the females. All individual skinfolds and sum of skinfolds were significantly higher in females (P<0.001). In both males and females above 30 y of age, there was a steep increase in the prevalence of high WHR, and in females, %BF was very high (particularly in %BF quartile>30%). Furthermore, total cholesterol and low-density lipoprotein cholesterol were high in both males and females. Stepwise multiple linear regression analysis showed that for both males and females BMI, WHR and %BF were positive predictors of biochemical parameters, except for HDL-c, for which these parameters were negatively associated.CONCLUSIONS: Appreciable prevalence of obesity, dyslipidaemia, diabetes mellitus, substantial increase in body fat, generalised and regional obesity in middle age, particularly in females, need immediate attention in terms of prevention and health education in such economically deprived populations.

BMI does not accurately predict overweight in Asian Indians in northern India

Asian Indians are at high risk for the development of atherosclerosis and related complications, possibly initiated by higher body fat (BF). The present study attempted to establish appropriate cut-off levels of the BMI for defining overweight, considering percentage BF in healthy Asian Indians in northern India as the standard. A total of 123 healthy volunteers (eighty-six males aged 18--75 years and thirty-seven females aged 20--69 years) participated in the study. Clinical examination and anthropometric measurements were performed, and percentage BF was calculated. BMI for males was 21.4 (sd 3.7) kg/m(2) and for females was 23.3 (sd 5.5) kg/m(2). Percentage BF was 21.3 (sd 7.6) in males and 35.4 (sd 5.0) in females. A comparison of BF data among Caucasians, Blacks, Polynesians and Asian ethnic groups (e.g. immigrant Chinese) revealed conspicuous differences. Receiver operating characteristic (ROC) curve analysis showed a low sensitivity and negative predictive value of the conventional cut-off value of the BMI (25 kg/m(2)) in identifying subjects with overweight as compared to the cut-off value based on percentage BF (males >25, females >30). This observation is particularly obvious in females, resulting in substantial misclassification. Based on the ROC curve, a lower cut-off value of the BMI (21.5 kg/m(2) for males and 19.0 kg/m(2) for females) displayed the optimal sensitivity and specificity, and less misclassification in identification of subjects with high percentage BF. Furthermore, a novel obesity variable, BF:BMI, was tested and should prove useful for interethnic comparison of body composition. In the northern Indian population, the conventional cut-off level of the BMI underestimates overweight and obesity when percentage BF is used as the standard to define overweight. These preliminary findings, if confirmed in a larger number of subjects and with the use of instruments having a higher accuracy of BF assessment, would be crucial for planning and the prevention and treatment of various obesity-related metabolic diseases in the Asian Indian population.

Clinical and pathophysiological consequences of abdominal adiposity and abdominal adipose tissue depots

OBJECTIVES To highlight the clinical and metabolic correlates of abdominal obesity and various abdominal adipose tissue depots. METHODS We researched the topic using the search terms abdominal obesity, central obesity, visceral obesity, regional obesity, and subcutaneous adipose tissue from MEDLINE (National Library of Medicine, Bethesda, MD), PubMed (National Library of Medicine, Bethesda, MD), Current Contents (Institute for Scientific Information, Thomson Scientific, Philadelphia, PA), and using manual search for the cited references. RESULTS Abdominal obesity contributes significantly to the metabolic perturbations and cardiovascular risk in human beings. Abdominal adipose tissue depots (intraabdominal and subcutaneous [deep subcutaneous, posterior subcutaneous]) are metabolically active and appear to be important for the pathogenesis of insulin resistance, dyslipidemia, glucose intolerance, hypertension, hypercoagulable state, and cardiovascular risk. Adipocyte anatomy (size), physiology (growth, catecholamine sensitivity, lipolysis, insulin action), and biochemistry (leptin, plasminogen activator inhibitor-1, cytokines, renin-angiotensin system) are reported to be relatively site-specific, highlighting unique roles of regional adipose tissue depots. CONCLUSIONS Several physiological and metabolic parameters are site-specific in abdominal adipose tissue. The epidemiological, clinical, and prognostic significance and relative importance of the regional adipose tissue depots, however, remain to be ascertained.

Waist circumference cutoff points and action levels for Asian Indians for identification of abdominal obesity

Objective:To test the validity of internationally accepted waist circumference (WC) action levels for adult Asian Indians.Design:Analysis of data from multisite cross-sectional epidemiological studies in north India.Subjects:In all, 2050 adult subjects >18 years of age (883 male and 1167 female subjects).Measurements:Body mass index (BMI), WC, waist-to-hip circumference ratio, blood pressure, and fasting samples for blood glucose, total cholesterol, serum triglycerides, and high-density lipoprotein cholesterol.Results:In male subjects, a WC cutoff point of 78 cm (sensitivity 74.3%, specificity 68.0%), and in female subjects, a cutoff point of 72 cm (sensitivity 68.7%, specificity 71.8%) were appropriate in identifying those with at least one cardiovascular risk factor and for identifying those with a BMI >21 kg/m2. WC levels of ⩾90 and ⩾80 cm for men and women, respectively, identified high odds ratio for cardiovascular risk factor(s) and BMI level of ⩾25 kg/m2. The current internationally accepted WC cutoff points (102 cm in men and 88 cm in women) showed lower sensitivity and lower correct classification as compared to the WC cutoff points generated in the present study.Conclusion:We propose the following WC action levels for adult Asian Indians: action level 1: men, ⩾78 cm, women, ⩾72 cm; and action level 2: men, ⩾90 cm, women, ⩾80 cm.

Obesity, the Metabolic Syndrome, and Type 2 Diabetes in Developing Countries: Role of Dietary Fats and Oils

Developing countries are undergoing rapid nutrition transition concurrent with increases in obesity, the metabolic syndrome, and type 2 diabetes mellitus (T2DM). From a healthy traditional high-fiber, low-fat, low-calorie diet, a shift is occurring toward increasing consumption of calorie-dense foods containing refined carbohydrates, fats, red meats, and low fiber. Data show an increase in the supply of animal fats and increased intake of saturated fatty acid (SFAs) (obtained from coconut oil, palm oil, and ghee [clarified butter]) in many developing countries, particularly in South Asia and South-East Asia. In some South Asian populations, particularly among vegetarians, intake of n-3 polyunsaturated fatty acids (PUFAs) (obtained from flaxseed, mustard, and canola oils) and long-chain (LC) n-3 PUFAs (obtained from fish and fish oils) is low. Further, the effect of supplementation of n-3 PUFAs on metabolic risk factors and insulin resistance, except for demonstrated benefit in terms of decreased triglycerides, needs further investigation among South Asians. Data also show that intake of monounsaturated fatty acids (MUFAs) ranged from 4.7% to 16.4%en in developing countries, and supplementing it from olive, canola, mustard, groundnut, and rice bran oils may reduce metabolic risk. In addition, in some developing countries, intake of n-6 PUFAs (obtained from sunflower, safflower, corn, soybean, and sesame oils) and trans-fatty acids (TFAs) is increasing. These data show imbalanced consumption of fats and oils in developing countries, which may have potentially deleterious metabolic and glycemic consequences, although more research is needed. In view of the rapid rise of T2DM in developing countries, more aggressive public health awareness programs coupled with governmental action and clear country-specific guidelines are required, so as to promote widespread use of healthy oils, thus curbing intake of SFAs and TFAs, and increasing intake of n-3 PUFAs and MUFAs. Such actions would contribute to decelerating further escalation of “epidemics” of obesity, the metabolic syndrome, and T2DM in developing countries.

High prevalence of insulin resistance in postpubertal Asian Indian children is associated with adverse truncal body fat patterning, abdominal adiposity and excess body fat.

OBJECTIVE: The objectives were to study the relationships of insulin resistance with generalized and abdominal obesity, and body fat patterning in urban postpubertal Asian Indian children.DESIGN: Cross-sectional, population-based epidemiological study.SUBJECTS: In all, 250 (155 males and 95 females) healthy urban postpubertal children.MEASUREMENTS: Anthropometric profile, percentage of body fat (%BF), fasting serum insulin, and lipoprotein profile.RESULTS: Fasting insulin correlated significantly with body mass index (BMI), %BF, waist circumference (WC), central and peripheral skinfold thicknesses and sum of four skinfold thicknesses (∑4SF) in both sexes, and with systolic blood pressure and waist–to hip circumference ratio (W–HR) in males only. Consistent increase in fasting insulin was noted with increasing values of central skinfold thickness at each tertile of peripheral skinfold thickness, WC, and %BF. Central skinfold thickness correlated with fasting insulin even after adjusting for WC, W–HR, and %BF. The odds ratios (OR) (95% CI) of hyperinsulinemia (fasting insulin concentrations in the highest quartile) were 4.7 (2.4–9.4) in overweight subjects, 8 (4.1–15.5) with high %BF, 6.4 (3.2–12.9) with high WC, 3.7 (1.9–7.3) with high W–HR, 6.8 (3.3–13.9) with high triceps skinfold thickness, 8 (4.1–15.7) with high subscapular skinfold thickness, and 10.1 (5–20.5) with high ∑4SF. In step-wise multiple logistic regression analysis, %BF [OR (95% CI): 3.2 (1.4–7.8)] and ?4SF [OR (95% CI): 4.5 (1.8–11.3)] were independent predictors of hyperinsulinemia, similar to insulin resistance assessed by HOMA (homeostatic model of assessment) in the study.CONCLUSION: A high prevalence of insulin resistance in postpubertal urban Asian Indian children was associated with excess body fat, abdominal adiposity, and excess truncal subcutaneous fat. Primary prevention strategies for coronary heart disease and diabetes mellitus in Asian Indians should focus on the abnormal body composition profile in childhood.

Effect of Supervised Progressive Resistance-Exercise Training Protocol on Insulin Sensitivity, Glycemia, Lipids, and Body Composition in Asian Indians With Type 2 Diabetes

OBJECTIVE—To evaluate the effect of supervised progressive resistance-exercise training (PRT) protocol on insulin sensitivity, glycemia (blood glucose and A1C levels), lipids, and body composition in Asian Indians with type 2 diabetes. RESEARCH DESIGN AND METHODS—Thirty patients with type 2 diabetes underwent 12 weeks of PRT of six muscle groups (two sets, 10 repetitions each). The subjects were evaluated with detailed anthropometry and with measurements of the disappearance of glucose per unit time (K) during the short insulin tolerance test (KITT) for assessment of insulin sensitivity; of fasting blood glucose, A1C, lipids, and high-sensitivity C-reactive protein (hsCRP); of total body fat, regional fat, and lean body mass by dual-energy X-ray absorptiometry; and of cross-sectional skeletal muscle area of upper arm and thigh by computed tomography scan. RESULTS—Insulin sensitivity improved significantly from mean ± SD KITT 1.22 ± 0.73 to 2.13 ± 0.75 (P < 0.0001) after the intervention. Significant decline (mean difference ± SD) from baseline was recorded in levels of the following parameters: A1C (0.54 ± 0.4%, P < 0.001), fasting blood glucose (2.7 ± 2.2 mmol/l, P < 0.001), total cholesterol (0.39 ± 0.7 mmol/l, P = 0.003), serum triglycerides (0.39 ± 0.5 mmol/l, P < 0.001), and truncal and peripheral subcutaneous adipose tissue compartments (SCAT) (P < 0.001). However, no significant changes were noticed in BMI or levels of total body fat, truncal fat, lean body mass, cross-sectional skeletal muscle area of the extremities, or hsCRP levels. CONCLUSIONS—Moderate-intensity PRT for 3 months resulted in significant improvement in insulin sensitivity, glycemia, lipids, and truncal and peripheral SCAT in patients with type 2 diabetes. Resistance training should be an integral part of exercise regimen in Asian Indians with type 2 diabetes.

Correlations of C-reactive protein levels with anthropometric profile, percentage of body fat and lipids in healthy adolescents and young adults in urban North India

OBJECTIVE To investigate the relationships of sub-clinical inflammation and regional and generalized obesity and lipids in adolescent and young adult Asian Indians in north India. METHODS We determined serum levels of C-reactive protein (CRP), a marker for sub-clinical inflammation, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (W-HR), four skinfolds (biceps, triceps, subscapular and suprailiac), percentage of body fat (% BF) and lipid profile in 377 healthy adolescents and young adults (331 males and 46 females, age range: 14-25 years). RESULTS Overweight subjects (BMI>85th percentile), and subjects with high values (>85th percentile) of WC and triceps skinfold thickness had significantly higher median CRP levels (P=0.04, P=0.001 and P=0.007, respectively) as compared with subjects with lower values of the variables. Elevated levels of CRP (>2.1 mg/l) were observed in 21.8% of the overweight subjects and 24.5% of the subjects with high (>85th percentile) % BF. After adjusting for age and gender, the odds ratios (95% CI) for elevated levels of CRP were 2.3 (1.1-4.7, P=0.02) for overweight subjects, 2.6 (1.2-5.4, P=0.01) for subjects with high % BF, and 3.7 (1.7-7.9, P=0.001) for subjects with high triceps skinfold thickness. Levels of CRP correlated significantly with % BF (r=0.13, P=0.009), W-HR (r=0.11, P=0.02), biceps skinfolds (r=0.13, P=0.01) and triceps skinfolds (r=0.13, P=0.01) for males only. CONCLUSIONS The observations of substantial prevalence of elevated CRP levels in adolescents and young adults having increased generalized and abdominal adiposity may be important for the development of metabolic syndrome and atherosclerosis in Asian Indian adults.