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

Obesity What 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 Obesity.

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

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  1. ObesityWhat is it in Asia?Why is it in Asia?

  2. 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?

  3. Definition of Obesity Classification 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

  4. Prevalence of Obesity (Males)

  5. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1991 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

  6. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1998 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

  7. Obesity in the Middle East

  8. Overweight & Obesity in Asia

  9. Source : Ismail et al. (1995) BMI in Urban Malaysian Males

  10. Prevalence Obesity Taiwan1993-96 Nutrition & Health Survey

  11. Obesity Prevalence Korea1994-7

  12. 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

  13. 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

  14. 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

  15. 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)

  16. 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 Overweight & Obesity in Asia

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

  18. Risks of Obesity RR >> 3 RR 2-3 RR 1-2 Type 2 diabetesCHD Cancer DyslipidaemiaHypertension PCOS Insulin Resistance Gall bladder disease Osteoarthritis Infertility Sleep apnoea Gout Anaesthetic risk

  19. Relative Risk of Metabolic DiseaseTaiwan Series 2000, age & sex adjusted, 148,545 individuals

  20. 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

  21. Obesity in Asia BMI Classification Action 18.5-22.9 HealthyMaintain 23-25 Overweight At least maintain or reduce 25-30 Obesity 1 Program Drug 30 + Obesity IIProgram + Drug ± VLCD

  22. Obesity (BMI >25) in China

  23. Relative risk 24 20 16 12 8 4 0 <71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 96.4 Waist circumference (cm) Adapted from Carey et al. Am J Epidemiol 1997; 145: 614–9, with permission Relative risk of type 2 diabetes according to waist circumference (women)

  24. Abdominal Adiposity 3Men & WomenDespres et al., 1994

  25. 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 !

  26. 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 > 2% 2.4% 2% 4% 2.5% 5.7%

  27. Obesity in perspective

  28. Aetiology of Obesity • Genes haven’t changed Therefore • Environment has changed • Relative affluence • Availability of food • Urbanisation • Alteration in Food intake • Less Activity

  29. Genetics & Obesity • Several single gene defects • Leptin synthesis • MCR4 gene • “cleavage” enzyme • Extreme obesity, hypogonadotrophic hypogonadism • Varying types of inheritance • Mainly recessive

  30. Energy Intake in Japan 1955-95

  31. % Fat in Chinese diet 1992

  32. 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!

  33. 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

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

  35. Body weight Natural course of further weight gain Successes 1. Sustained weight, no increase Obese 2. Minor weight loss with dietary change to reduce risk of complications 3. Modest weight loss with clear risk factor reduction e.g. B.P. Overweight Normal 4. Weight normalisation: rare Years of management or intermittent monitoring Adapted from Rössner, 1997 The management of obesity

  36. 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 medicationsSIGN, 1996

  37. 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 Reality

  38. Program • Eating • Activity • Incidental • Exercise • Behaviour & Habit • Medical • Pharmacotherapy • Follow up

  39. Obesity in our region BMI WHO Asia 18.5 -24.9 Healthy 18.5 - 23 Healthy 23 - 25 “At risk” 25 - 29.9 Pre-obeseObese I 30 - 34.9 Obese IObese II 35 - 39.9 Obese II 40 + Obese III

  40. 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

  41. Use of Sibutramine in Asia • BMI > 25 • Program • Add Sibutramineif no loss in 12 weeks • BMI > 25 with risks • Program • Add Sibutramine • Treat risks (diabetes, BP, dyslipidaemia) • BMI > 30 • Program & Sibutramine • Consider additional therapy

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