Obesity: Interview with Dr. Anoop Misra

Obesity: Interview with Dr. Anoop Misra
Obesity

In a recent interview with Dr. Anoop Misra, Best Doctor team discussed a big issue of these days – “Obesity”. With the changing lifestyle that people has, obesity is growing day by day. Below are few answers to the queries people generally have related to Obesity:

1. What is obesity?

Obesity is defined as an excessive accumulation of fat in thebody resulting in adverse effects on health of the individual.Two simple measures of obesity are widely used in clinicalpractice; 1) body mass index (BMI)and2) Waist Circumference (WC). The most widely used method to define thinnessand fatness is BMI, a ratio of weight in kilograms dividedby height in meters squared (kg/m2).However, both BMI and WC should be used together (with equalimportance) for population- and clinic-based metabolicand cardiovascular risk stratification.

Body mass index (BMI) is a practical, easily obtainable and reproducible measure of obesity. It is considered an indicator of body fatness, and is a measure of weight adjusted for height, calculated as weight in kilograms divided by the square of height in meters (kg/m2).

The formula to calculate your BMI = Weight in kilograms (Height in m) 2

The BMI cut offs for Indians are:

BMI (kg/m2) Weight Status
Below 18.0 Underweight
18.0 – 22.9 Normal
23.0 – 24.9 Overweight
25.0 and above Obese

The waist circumference should be

2. What is childhood obesity and how can it be controlled?

Childhood obesity is a medical condition that affects children and adolescents. It occurs when a child is well above the normal weight for his or her age and height. Obesity among children and adolescents is emerging as a serious health burden and is acquiring epidemic proportions in developing countries such as India. It has been reported that childhood obesity tracks into adulthood and is associated with an increased risk of mortality, independent of weight loss later in life.Our research group has developed age and gender specific BMI cut offs for Asian Indian adolescents (14-18years) for overweight/obesity.
BMI Cut-offs for Adolescents for overweight/ obesity (14 – 18 yrs)

BMI Cut Offs

BMI Cut Offs

Prevention of obesity should be directed to encourage a health centered, rather than weight-centered approach that focuses on the individual as a whole. The emphasis should be on a healthy and active lifestyle and creating a nurturing environment that helps the youth recognize their own worth and respect cultural food ways. It is recognized that obesity, eating disorders, hazardous weight loss, nutrient deficiencies and size discrimination are all interrelated and need to be addressed in a comprehensive manner.

Lifestyle changes for preventing obesity should include:

• Increasing physical activity: It is important that children/adolescents are encouraged to daily include at least 45 – 60 minutes of moderate intensity outdoor physical activity. Physical education may improve academic performance, self-confidence, and mental health in school children.
• Balanced Diet: Following a balanced diet low in simple carbohydrate and fat, including a minimum of 5-6 servings of vegetables and fruit should be consumed to prevent obesity. Avoid eating high calorie foods like pizzas, burgers, aerated sugary drinks

The following approaches have also shown to play an important role in management and prevention of obesity:

• Nutrition Education: Parents should guide their children on making the right food choices and planning a balanced meal. Social events such as healthy eating clubs and interesting food preparations can be organized to encourage diet changes.

• Encouraging Healthy Eating: Attempts should be made to limit the availability of fried and fatty foods and carbonated beverages in school cafeteria and provide healthier options for children.
• Encouraging Parents Involvement: Parents should try to set examples by themselves eating healthy meal. They should share at least one meal with children.

Steps to control the increasing pattern of obesity
The following Public Health Interventions for Prevention and Control of Obesity in Developing Countries like India is recommended.

Public Health Interventions

Public Health Interventions

Further community based interventions should aim at providing a conducive environment for children to follow a healthy lifestyle, promote healthy food alternatives, and bring awareness and need about an increase in physical activity.

In India, we have initiated comprehensive programs aiming at childhood obesity, namely “CHETNA” (Hindi for “The Awareness”) [Children Health Education through Nutrition and Health Awareness program], and “MARG” (Hindi for “The Path”) [Medical Education for Children/ Adolescents for Realistic Prevention of Obesity andDiabetes and for Healthy Ageing] (http://www.worlddiabetesfoundation.org/composite-1279.htm). Children are given nutritional and physical activity education through lectures and leaflets, and with the help of debates, skits, and drama related to health topics. Parents and children also take part in making healthy recipes. The MARG program is the first large scale community intervention project in South Asia which focuses 100% on primary prevention of not only obesity, but on non-communicable diseases in general.

3. What are the benefits of being physically active?

Physical activity benefitspeople of all ages. The body responds positively to physical activity, which impacts the musculoskeletal, cardiovascular, respiratory and endocrine systems. This results in positive health outcomes, including reduced risk of several lifestyle related disorders like obesity, type 2 diabetes, the metabolic syndrome, cardiovascular diseases and several cancers, as well as other health conditions.Regular physical activity has several benefits:

• It is one of the principle components of healthy lifestyle and improves the chances of living a healthy and full life.
• It plays a key role in preventing as well as managing obesity.
• It helps protect from developing heart disease and stroke or its precursors, high blood pressure and undesirable blood lipid patterns
• It helps prevent type 2 diabetes and the metabolic syndrome (a constellation of risk factors that increases the chances of developing heart disease and diabetes).
• Improves heart-lung and muscle fitness
• It helps protect from developing certain cancers, like colon and breast cancer, and possibly lung and endometrial cancer.It helps prevent the insidious loss of bone known as osteoporosis and leads to stronger muscles and bones
• Itreduces the risk of falling and improves cognitive function among older adults
• Itrelieves symptoms of depression and anxiety and improves mood
• Itimproves sleep

According to the consensus Physical Activity Guidelines for Asian Indians, a total of 60 min of physical activity is recommended every day for healthy Asian Indians in view of the high predisposition to develop T2DM and CHD. This should include at least 30 min of moderate-intensity aerobic activity, 15 min of work related activity, and 15min of muscle-strengthening exercises.

For children, moderate-intensity physical activity for 60 min daily should be in the form of sport and physical activity.

Ref: Misra et a. Consensus physical activity guidelines for Asian Indians. Diabetes TechnolTher. 2012; 14(1):83-98.

4. What is the recommended weight for a person? How is it calculated?

Ideal body weight refers to a weight that is believed to be maximally healthful for a person, based chiefly on height but modified by factors such as gender and build. Thus ideal body weight for an individual depends on his her gender, height and built. The table below provides the most followed up formula for calculating ideal body weight for a person.

Calculation of Ideal Body Weight

Calculation of Ideal Body Weight

Calculation of Ideal Body Weight

Example: According to the above calculations an Asian Indian manwith medium body frame, 165cm tall, should ideally weigh62 kg.
Ref: Misra et al. Consensus dietary guidelines for healthy living and prevention of obesity, the metabolic syndrome, diabetes, and related disorders in Asian Indians. Diabetes TechnolTher. 2011 Jun;13(6):683-94.

5. Will drugs help to reduce the obesity of a person?

These medicines are meant to help people who may be having health problems related to excess weight. The doctor may recommend weight-loss medication if other methods of weight loss haven’t worked. Few approved drugs for weight loss must be given appropriately.

6. Is there any special diet and lifestyle prescribed for a person with obesity?

Managing obesity: There are no magic diets, surgeries, gadgets or pills that can change that physiological fact.There are four main goals in the treatment of obesity:

 preventing further weight gain
 gradually losing weight through a combination of a calorie-controlled diet and regular exercise
 avoiding regaining any lost weight
 improving general health and reducing the risk of obesity-related complications

Obese individuals are advised to adopt permanent lifestyle changes which includesfollowing a low calorie balanced diet (depending on their BMI and activity level) along with regular physical activity. The key components of a weight reducing diet are:

Energy: Low calorie (depending on their BMI and activity level)
Carbohydrates &Fibre:The daily carbohydrate intake should be approximately50–60% of the total calorie intake. The primary source of complex carbohydrates in the diet should be cereals (whole wheat, brown rice, etc.), millets (pearl millet [bajra], finger millet [ragi], great millet [Jowar]), pulses (red gram [tur dal], green gram [sabutmoong], etc.), and legumes (soya, horse gram [kulthi]). Complex carbohydrates should be preferred over refined carbohydrates and its products (e.g., whole grain bread over white [maida] bread).

 The total dietary fiber in daily diet should be 25–40 g/ day. A minimum of 4-5 servings/day of fruits and vegetables is recommended.Fruit juices and simple sugars like crystalline sugar, sugarcane juice, sweetened carbonated beverages, fruit juices, and sugar syrups should be avoided.

Fats: Fats should provide not more than 30% of total energy/day and SFAs should provide no more than 10% of totalenergy/day. For individuals having low-density lipoprotein cholesterol of ≥100 mg/dL, saturated fats (SFA) should be<7% of total energy/day.Essential poly unsaturated fats (PUFAs) (Linoleic acid; LA) should provide 5–8% of totalenergy/day. α-linolenic acid (ALA) should be 1–2% of total energy/day. Long-chain n-3 PUFAs should be obtained from fish,walnuts, flaxseeds, canola oil, etc.Cismonounsaturated fats (MUFAs) should provide 10–15% of total energy/day. Trans fats (TFAs) should be <1% of total energy/day.Cholesterol intake should be limited to 200–300mg/day.Consumption of butter and ghee (clarified butter)should be kept to a minimum.Use of partial hydrogenation of vegetable oils (vanaspati)as the cooking medium should be strictlyavoided.

Protein: Protein intake should be based on body weight. Thisshould be 1 g/kg/day, considering the quality of proteinin a usual Indian vegetarian diet. In conjunction with energy intake, the protein intakeshould provide 10–15% of the total calories/day insedentary to moderately active individuals. Recommended protein sources:
a. Non-vegetarian: egg white, fish, and lean chicken.
b. Vegetarian: soya, pulses, whole grams (channa, rajma,green gram, etc.), milk, and low fat dairy products.

Water: An individual should have 1.5–2 L (8–10 glasses) of water every day; intake could be increased inhot climates.
Ref: Misra et al. Consensus dietary guidelines for healthy living and prevention of obesity, the metabolic syndrome, diabetes, and related disorders in Asian Indians. Diabetes TechnolTher. 2011 Jun;13(6):683-94.

Physical Activity: Obese persons, after starting aerobic activity at a lowintensity and for a short duration, should escalate slowly toachieve 60 min of continuous moderate-intensity aerobic exerciseseven times per week (Table 1). Once an individualloses weight, a maintenance phase with a similar or greaterduration, intensity, and frequency of exercise should bemaintained for an indefinite period.

Guidelines for Physical Activity

Guidelines for Physical Activity

Ref: Misraet a. Consensus physical activity guidelines for Asian Indians. Diabetes TechnolTher. 2012; 14(1):83-98.

7 Is there a connection between obesity and other diseases?

Obesity increases the likelihood of various diseases and is therefore a prominently associated with increased risk of type 2 diabetes mellitus (T2DM), the metabolic syndrome, hypertension, dyslipidemia, polycystic ovarian syndrome (PCOS), and coronary heart disease (CHD), and some of these metabolic derangements start in childhood.

Likelihood of obese adolescent girls to suffer from Polycystic Ovarian Syndrome, a syndrome of variable combinations of menstrual irregularity, acne with obesity and insulin resistance is much higher.
Childhood obesity is associated with significant other morbidities including gallstone, dyslipidemia, obstructive sleep apnea syndrome, early puberty or menarche, eating disorders, skin infections, orthopedic disorders, asthma and other respiratory disorders.

8. Is there a connection between obesity and depression, or other psychological problems?

The relationship between obesity and depression/common psychological disorders is complex. Some researchers suggest that obesity can lead to common mental health disorders, whilst others have found that people with such disorders are more prone to obesity.

 Obese people, particularly those who perceive themselves as overweight, often experience weight-related stigma and social discrimination, and consequently present with symptoms of low self-esteem, low self-worth, and guilt. Obesity is associated with socioeconomic disadvantage and low levels of physical activity, both of which are strong predictors of depression.

 Obesity may constitute a chronic stressful state, which in turn can cause significant physiological dysfunction. Such dysfunction would then predispose individuals to depressed mood and associated symptoms.

 Obesity is also associated with an increased risk for a variety of chronic diseases, most of which are associated with depression which in turn can precipitate chronic disease due to diminished treatment adherence and/or response.

Studies have found depression to correlate with the onset of obesity and obesity to predict the onset of depression. A recent systematic review of longitudinal studies point towards bi-directional associations between depression and obesity. According to it, obese persons had a 55% increased risk of developing depression over time, whereas depressed persons had a 58% increased risk of becoming obese.
There are various underlying factors which help explain the relationship between obesity causing depression/mental health disorders in adults, these include low self-esteem, stigma (social), dieting and weight cycling, medication, and hormonal and functional impairment.

9. Do women with obesity have any complication during pregnancy?

Obesity can have a major impact on health of the mother as well as the baby. Being obese can also harm women’s fertility by inhibiting normal ovulation.

Being obese increases the risk of various pregnancy complications, including:

 Gestational diabetes: Women who are obese are more likely to have diabetes that develops during pregnancy (gestational diabetes) than are women who have a normal weight.

 Preeclampsia: Women who are obese are at increased risk of developing high blood pressure and protein in the urine after 20 weeks of pregnancy (preeclampsia), which is a serious medical condition both for the mother and the unborn child.

 Infections: Women who are obese are at increased risk of urinary tract infections. Obesity also increases the risk of postpartum infection, whether the baby is delivered vaginally or by Cesarean.

 Thrombosis:Obese women are at increased risk of a serious condition in which a blood clot forms inside a blood vessel (thrombosis).

 Obstructive sleep apnea:Obese women during pregnancy might be at increased risk of a potentially serious sleep disorder in which breathing repeatedly stops and starts (obstructive sleep apnea). Pregnancy might also worsen existing obstructive sleep apnea.

 Labor problems:Labor induction is more common in women who are obese. Obesity can also interfere with the use of certain types of pain medication, such as an epidural block.

 Cesarean (C-section): Obesity during pregnancy increases the likelihood of elective and emergency C-sections. Obesity also increases the risk of C-section complications, such as delayed healing and wound infections. Women who are obese are also less likely to have a successful vaginal delivery after a C-section (VBAC).

 Pregnancy loss:In some extreme cases obesity increases the risk of miscarriage and stillbirth.

Obesity during pregnancy can cause various health problems for a baby, including:

 Macrosomia: Women who are obese are at increased risk of delivering an infant who is significantly larger than average (macrosomia) and has more body fat than normal. Research suggests that as birth weight increases, so does the risk of childhood obesity.

 Chronic conditions: Being obese during pregnancy might increase the risk that the baby will develop heart disease or diabetes as an adult.

 Birth defects: Research suggests that obesity during pregnancy slightly increases the risk of having a baby who’s born with a birth defect, such as a problem with the heart or a condition affecting the brain or spinal cord (neural tube defect).

One can limit the impact of obesity on pregnancy and ensure a good health for the mother and the baby by following simple steps:

 Regular prenatal care: Prenatal visits can help thedoctorclosely monitor the health of mother and the baby and screen for medical conditions such as diabetes, high blood pressure or sleep apnea, and suggest ways of managing them.

 Eating a healthy diet:Being obese does not mean going on crash diets specifically during pregnancy instead, following a well-balanced diet under the supervision of doctor and a registered dietitian helps to maintain a healthy diet and avoid excessive weight gain.

 Be physically active: Consult your health care provider about safe ways to stay physically active during your pregnancy.

Obesity during pregnancy can increase the risk of complications, to ease away anxiety and avoid major complications one has to follow the instructions of doctor. They can help to avoid excessive weight gain, manage any medical conditions, and monitor baby’s growth and development.

10. Is there anything else which you would like to share?

In view of the high predisposition to develop obesity, type 2 diabetes (T2DM), the metabolic syndrome, dyslipidemia and heart diseases among Asian Indians, our research group has developed certain guidelines specific to Asian Indian population. These have been very useful in diagnosis as well as managing obesity, the metabolic syndrome and related disorders.

 Misra et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India. 2009 Feb;57:163-70.

 Misraet a. Consensus physical activity guidelines for Asian Indians. Diabetes TechnolTher. 2012; 14(1):83-98.

 Misra et al. Consensus dietary guidelines for healthy living and prevention of obesity, the metabolic syndrome, diabetes, and related disorders in Asian Indians. Diabetes TechnolTher. 2011 Jun;13(6):683-94.

Special Thanks to:

Dr. Anoop Misra

Dr. Anoop Misra

Dr. (Prof.)AnoopMisra
Chairman,Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology
Director, Centre of Internal Medicine (CIM),Fortis Hospital, VasantKunj, New Delhi
Chairman, National Diabetes, Obesity and Cholesterol Foundation(N-DOC)
Director, Diabetes and Metabolic Diseases, Diabetes Foundation(India) (DFI)
Website: www.fortiscdoc.com, www.anoopmisra.com

Dr. Swati Bhardwaj
Vice Head; Center of Nutrition and Metabolic Research (C-NET)
Head, Nutrition & Fatty Acid Research; National Diabetes, Obesity and Cholesterol Foundation (N-DOC)
Senior Research Officer (Nutrition); Diabetes Foundation (India) (DFI),

Dr. Suchitra Behl
Fellow Endocrinology and Advanced Diabetes
Consultant, Fortis C-DOC Centre of Excellence for Diabetes,Metabolic Diseases & Endocrinology
email: suchitra.md@gmail.com
www.fortiscdoc.com

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