Obesity What is it in Asia? Why is it in Asia?

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

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Definition of Obesity

• Classification BMI Risk
  of Co-morbidities
• Underweight lt 18.5 Low (risk of other clinical
• problems increased)
• Normal range 18.5 - 24.9 Average
• Overweight gt 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 gt 40.0 Very Severe

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Prevalence of Obesity (Males)

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Prevalence of Obesity among U.S. AdultsBRFSS,
1991
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1998
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Obesity in the Middle East
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Overweight Obesity in Asia
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BMI in Urban Malaysian Males
Source Ismail et al. (1995)
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Prevalence Obesity Taiwan 1993-96 Nutrition
Health Survey
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Obesity Prevalence Korea1994-7
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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

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Historical Facts

• Japanese higher BP for weight compared to
  Americans
• (Comstock et al., 1985, Baba et al., 1991)
• Australian Aboriginals (ODea)
• Diabetes at BMI gt 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

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History continued

• Cervical Cancer (Guo et al., 1994)
• Mortality related to BMI gt 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

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Coronary Heart Disease and BMI in Asian
populations.

• Japanese Americans (Burchfield et al., 1996)
• Risk increases at BMI gt 23
• Risk doubles at BMI gt 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)

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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 womens weight increases after 1st child

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Differences in the relationship between body fat
percent and body mass index between Indonesian
and Dutch males and females.
Deurenberg et al, 1999
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Risks of Obesity

• RR gtgt 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

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Relative Risk of Metabolic DiseaseTaiwan Series
2000, age sex adjusted, 148,545 individuals
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Risks of Obesity (Korea)

• Annual Health Examination Survey 1994-7
• BMI gt 28 (adjusted for age sex)
• hypertension 4.1
• diabetes 2.2
• dyslipidaemia 3.7
• Kim et al., 1997
• BMI gt 26 (m), BMI gt 25 (f)
• diabetes 3.2
• increased TG 2.1

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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

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Obesity (BMI gt25) in China
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Relative risk of type 2 diabetes according to
waist circumference (women)
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Abdominal Adiposity 3Men WomenDespres et al.,
1994
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Abdominal Adiposity in Asia

• Knowledge that abdominal adiposity
• More common
• Greater at lower BMI
• Recommendations for high risk
• Male gt 90 cm (102 cm)
• Female gt 80 cm (88 cm)
• These need to be determined !

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Conservative estimates of the direct healthcare
costs of obesity
Estimated direct costs
National healthcare costs
Country
Year
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
gt 2 2.4 2 4 2.5 5.7
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Obesity in perspective
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Aetiology of Obesity

• Genes havent changed
• Therefore
• Environment has changed
• Relative affluence
• Availability of food
• Urbanisation
• Alteration in Food intake
• Less Activity

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Genetics Obesity

• Several single gene defects
• Leptin synthesis
• MCR4 gene
• cleavage enzyme
• Extreme obesity, hypogonadotrophic hypogonadism
• Varying types of inheritance
• Mainly recessive

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Energy Intake in Japan 1955-95
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Fat in Chinese diet 1992
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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!

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Prenatal environment

• Small babies (lt2.5kg) 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

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Management Strategies

• Prevention of weight gain
• Promotion of weight maintenance
• PUBLIC HEALTH PROGRAMS
• Management of co-morbidities
• Promotion of weight loss
• INDIVIDUAL TREATMENT PROGRAMS

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The management of obesity
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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

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Reality

• Assessment
• Anthropometry
• BMI
• waist
• Risks
• BP
• glucose, insulin
• lipids
• heart disease
• sleep apnoea

• Management
• 1. general advice
• 2. activity
• 3. eating
• 4. Program
• 5. Drugs
• Sibutramine
• 6. VLCDs
• 7. Surgery

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Program

• Eating
• Activity
• Incidental
• Exercise
• Behaviour Habit
• Medical
• Pharmacotherapy
• Follow up

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Obesity in our region

• BMI WHO Asia
• 18.5 -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

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When to use Sibutramine

• High BMI (gt30)
• Relate BMI and risk - in Asia BMI gt 25
• Abdominal adiposity
• Diabetes
• Dyslipidaemia
• IHD
• OSA
• Inadequate loss after 12 weeks in Lifestyle
  Program
• Acute loss necessary

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Use of Sibutramine in Asia

• BMI gt 25
• Program
• Add Sibutramine if no loss in 12 weeks
• BMI gt 25 with risks
• Program
• Add Sibutramine
• Treat risks (diabetes, BP, dyslipidaemia)
• BMI gt 30
• Program Sibutramine
• Consider additional therapy