Prevalence And Risk Factors Of Obesity In India: A Narrative Literature Review

Risk Factors of Obesity in Adults

Definition and Impact of Obesity on Health

Discuss about the Prevalence and Risk Factors of Obesity in Adults with Age Group 40-70 in Ethnic Indian Population.

Obesity is considered as the health condition in which body accumulates excess fat in a high rate that could affect the health condition of individual, thus could reduce the expectancy of life and increase enormous health issues. In Western countries obesity is defined as a condition when BMI is measured by dividing the weight of a person by the square of the height of the person and the result exceeds 30 kg/m². The BMI range from 25-30 kg/m² is considered as overweight (1). The paper will focus on the prevalence and risk factors of obesity in India as obesity has reached the epidemic level in the country.

Background:

Like the other countries in the world obesity has become a threat for the health care system in the ethnic Indian population (2). The major ethnic Indians include Indo-Aryan, Dravidian and Mongoloid. There are 72% population in India that are Indo-Aryan, 25% are Dravidian and 3% are Mongoloid. Indo Aryans are mainly located in the central north part of India, Mongoloids are resided in the borders of India with Nepal and China and Dravidians are located in the south part of India. Research has been found that obesity has reached to the epidemic level in the ethnic Indian population in the 21^st century and Indo-Aryan population is more vulnerable to obesity (3). The rate of morbid obesity in the population is 5%. Unhealthy and poorly processed food has become highly accessible in the country and India has integrated continuously in the global food markets (4). Such situation has lead to the increase in the average calorie intake in individual. According to the research obesity is one of the major causes of severe disease such as cardiovascular risk and cancer (5). Thus, it has created pressure in the health workforce. According to a study the rate of obesity has been increased in last 10 years. In India 12.1% males and 16% females are suffering from obesity. Near about 3.4 million adults die per year due to obesity (6).

Significance of the study:

Research has been introduced in order to recognize the factors that influence obesity. Researchers have indicated various factors such as overeating, lack of physical activity, genetics, lifestyle and many others. Based on the research interventions have been introduced to reduce the rate of obesity in the population. However, instead of reduction, the obesity rate is increasing gradually in the country (7). It has been found that lack of awareness regarding the harmful effects of obesity plays a vital role in creating obstacle in the prevention of obesity in the population. People are more addicted towards unhealthy food. Lack of information related to the importance of healthy diet and proper nutrition also contributes to the increasing rate of obesity in the population. Thus, the research is important because it is necessary to provide adequate evidence to the population regarding the prevalence of obesity and its harmful effect on health in order to create awareness in the country. In this regards the following paper will provide brief information about the findings provided by the earlier research on obesity.

Obesity in the Ethnic Indian Population

Research Gap of Previous Studies:

Previous research has provided effective information regarding the factors influencing obesity and interventions to address them in ethnic Indian population. However, research has failed to create awareness and provide adequate way to utilize the interventions in order to address the issue of obesity in the ethnic Indian population. The study will focus to bridge the gap in an effective manner to reduce the prevalence of obesity and increase well-being in the ethnic Indian population.

Research Questions:

• Why the prevalence of obesity in adults with 40-70 years age in ethnic Indian population is increasing?
• What are the factors that influence obesity in the ethnic Indian population?
• How can these factors be addressed to reduce the prevalence of obesity in ethnic Indian population?

Research Aims:

• To find out the reason of increase in the prevalence of obesity in the ethnic Indian population.
• To investigate the factors of obesity in order to introduce effective strategies to mitigate the issue of obesity in the ethnic Indian population.
• To provide adequate information to determine how can these factors be addressed to reduce the rate of obesity in ethnic Indian population.

Research Objectives:      

• To find out relevant literature from databases and analyse them to identify the factors influencing obesity and strategies to address them.
• To identify why the prevalence of obesity is increasing in adults with 40-70 years age in ethnic Indian population.
• To establish clear theme.

Narrative literature review define as the description and discussion of subject, state of science, theoretical approaches, contextual points and themes of relevant articles to summarise the findings of the articles regarding the topic and increase knowledge. Such narrative review would help to find out previous research materials regarding obesity and help to provide adequate knowledge to the people in the country in order to create awareness regarding the consequence of obesity. It would help to identify the gap of the previous studies so that further study could conduct in order to address the gap (8).

Data collection:

In this study in order to address the research questions, electronic bases were searched for studies which were conducted in relation to the prevalence of obesity focusing mainly the prevalence of the disorder in India. Journals were also hand searched in order to retrieve information from the journals. Use of appropriate key words that were required in order to carry out the review of literature. There was no requirement of ethical approval required for conducting the review since it was narrative in nature. The electronic database sources included Pubmed and Google Scholar. In this way the narrative review would help to answer the research questions and achieve expected outcomes.

Data Analysis:

The aim of the methodology consisted of reviewing the journals and compiling the information that is retrieved from those journals. The collected data was further required to be synthesizes. After this thematic analysis of the data will be carried out in order to identify the various risk factors that are related with the prevalence of obesity mainly in India. Additionally focus will be given on the factors associated with obesity in the individuals of the age group of 40-70 years. Easy language, relevant content and literature from current year that is not older than 5 years would be the focus of the data analysis. A total of 52 articles were selected and out of them 23 best evidences were reviewed in order to conduct the study. With the help of narrative review, in a short period of time a wide overview of the research those have been conducted can be identified.

Risk Factors and Contributing Factors to Obesity

Among the chosen journals, most of them focused on the factors and the risk factors associated with obesity. Some of the papers highlighted the context of obesity in India. Whereas few of them discussed the prevalence of the disease in the older adults especially of the given age group.

It is expected that the papers that are reviewed would show the relation of obesity with cardiovascular disease and discuss about the childhood overweight and obesity prevalent in India. Several studies would show the link between the body mass index (BMI) with obesity along with the occurrence of diabetes. The studies identified obesity to be a major cause of various disease and disorders, one being diabetes. The papers also identified obesity as being epidemic in certain situations as stated. It is expected that result would provide effective interventions that have been taken to counter the issue of obesity in the population.

List of the reviewed paper:

Name of database: Google scholar

Ethnic Indian population	Obesity	Risk Factors	Factors that influence the risk factors	Interventions	Hits	First screen: Hits (Abstract)	Second screen: Quality: Hits
Cohn BS. Notes on the History of the Study of Indian Society and Culture. InStructure and change in Indian society 2017 Nov 13 (pp. 3-28). Routledge	1.      Kalra S, Unnikrishnan AG. Obesity in India: The weight of the nation. Journal of Medical Nutrition and Nutraceuticals. 2012 Jan 1;1(1):37. 2.      Youngson NA, Morris MJ. What obesity research tells us about epigenetic mechanisms. Phil. Trans. R. Soc. B. 2013 Jan 5;368(1609):20110337. 3.      Carvajal R, Wadden TA, Tsai AG, Peck K, Moran CH. Managing obesity in primary care practice: a narrative review. Annals of the New York Academy of Sciences. 2013 Apr;1281(1):191-206. 4.      Wright J, Harwood V, editors. Biopolitics and the’obesity epidemic’: governing bodies. Routledge; 2012 Mar 22. 5.      Wright J. Biopower, biopedagogies and the obesity epidemic. InBiopolitics and the’Obesity Epidemic’ 2012 Mar 22 (pp. 9-22). Routledge. 6.      Abarca-Gómez L, Abdeen ZA, Hamid ZA, Abu-Rmeileh NM, Acosta-Cazares B, Acuin C, Adams RJ, Aekplakorn W, Afsana K, Aguilar-Salinas CA, Agyemang C. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128· 9 million children, adolescents, and adults. The Lancet. 2017 Dec 16;390(10113):2627-42. 7.      Pischon T, Nimptsch K, editors. Obesity and Cancer. Springer; 2016 Dec 1.	Severe health issues and death as well.	Income, smoking, diet, substance abuse, genetics.	Socioeconomic intervention, providing knowledge, introduce clinical interventions, create awareness.	24	16	8
Other search terms which relate to your population	Other search terms	You might want to list certain ones?	Other factors	Public health initiative etc,
Indian, Ethnicity in India, Indian demography.	Overweight, prevalence of obesity, intervention of obesity, risk factors of obesity, genetics and obesity.	Diabetes, cardiovascular risk, respiratory disorder, cancer	Poverty, education, lack of nutrition.	Healthy diet, physical activity, change lifestyle.

Name of database: PubMed

Ethnic Indian population	Obesity	Risk Factors	Factors that influence the risk factors	Interventions	Hits	First screen: Hits (Abstract)	Second screen: Quality: Hits
None	1.      Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, Sherwood LL, Nembhard HB. A silent response to the obesity epidemic: decline in US physician weight counseling. Medical care. 2013 Feb 1;51(2):186-92. 2.      Unnikrishnan AG, Kalra S, Garg MK. Preventing obesity in India: Weighing the options. Indian journal of endocrinology and metabolism. 2012 Jan;16(1):4. 3.      Apovian CM, Gokce N. Obesity and cardiovascular disease. Circulation. 2012 Mar 6;125(9):1178-82. 4.      Smith KB, Smith MS. Obesity statistics. Primary Care: Clinics in office practice. 2016 Mar 1;43(1):121-35. 5.      CFlegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. Jama. 2012 Feb 1;307(5):491-7. 6.      Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. Jama. 2013 Jan 2;309(1):71-82. 7.      Malik VS, Willett WC, Hu FB. Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology. 2013 Jan;9(1):13. 8.      Ranjani H, Mehreen TS, Pradeepa R, Anjana RM, Garg R, Anand K, Mohan V. Epidemiology of childhood overweight & obesity in India: A systematic review. The Indian journal of medical research. 2016 Feb;143(2):160. 9.      Cheung WW, Mao P. Recent advances in obesity: genetics and beyond. ISRN endocrinology. 2012 Mar 5;2012. 10.  Xia Q, Grant SF. The genetics of human obesity. Annals of the New York Academy of Sciences. 2013 Apr 1;1281(1):178-90. 11.  Johnson CL, Paulose-Ram R, Ogden CL, Carroll MD, Kruszan-Moran D, Dohrmann SM, Curtin LR. National health and nutrition examination survey. Analytic guidelines, 1999-2010. 12.  Bastien M, Poirier P, Lemieux I, Després JP. Overview of epidemiology and contribution of obesity to cardiovascular disease. Progress in cardiovascular diseases. 2014 Jan 1;56(4):369-81. 13.  Bahammam AS, AL?JAWDER SE. Managing acute respiratory decompensation in the morbidly obese. Respirology. 2012 Jul;17(5):759-71. 14.  nop M, Foufelle F, Velloso LA. Endoplasmic reticulum stress, obesity and diabetes. Trends in molecular medicine. 2012 Jan 1;18(1):59-68. 15.  Guthman J. Opening up the black box of the body in geographical obesity research: Toward a critical political ecology of fat. Annals of the Association of American Geographers. 2012 Sep 1;102(5):951-7.	Severe health condition and death.	Income, smoking, diet, alcohol intake, genetic factors..	Socioeconomic intervention, providing knowledge, introduce clinical interventions, create awareness.	28	13	15
Other search terms which relate to your population Indian	Other search terms	You might want to list certain ones?	Other factors	Public health initiative etc,
	Overweight, risk of obesity, prevalence of obesity in India, interventions for obesity, public health interventions.	Diabetes, cardiovascular risk, respiratory disorder, cancer	Poverty, education, lack of nutrition.	Proper diet, physical exercise and other activities, change lifestyle. Such as food habits and reduce smoking.

Research Activities	15th July- 20th July	21st July-31st  July	1st Aug- 5th Aug	6th Aug- 12th aug	13th Aug- 20th Aug	20th Aug- 31st Aug
selection  of Research topic
Literature Review
Data collection
Data analysis
Final Research thesis

The following paper will discuss about the result that means the information gathered from the literatures mentioned above in the chart.

Definition of Obesity:

Obesity is a health condition which is caused by excessive accumulation of fat in individual. Some researchers have informed that obesity is a condition of abnormal body weight which is normally more than 20% and above the average weight according to particular age, height and structure of bone. It has been also elaborated by the researcher that obesity is a severe health condition during which body accumulates excessive fat that could lead to adverse effect and severe health issues (9). It has been reported by a study that the most acceptable clinical definition of obesity is abnormal increase in body weight (10). The definition is still used but it is not the accurate measure of obesity. Height and weight tool is one of the most popular tools to measure obesity; however, it could not explain the specificity or degree of obesity within a patient. It has been found that, BMI is closely related to the grades of obesity and effective in case of measuring obesity (11).

Types of Obesity:

Healthy weight varies according to the age and sex. Obesity is not considered as the absolute number but with respect to a normal historical group it is refer to the BMI greater than 30. The percentiles based on the data of 95^th percentile from 1963 to 1994. Thus, the data have not been considered the increase in weight in recent year. The different types of obesity are classified below (12).

Classification	BMI (kg/m2)
Underweight	< 18.50
Normal weight	18.50–24.99
Overweight	25.00–29.99
Class I obesity	30.00–34.99
Class II obesity	35.00–39.99
Class III obesity	≥ 40.00

Interventions to Address Obesity

 Assessment of Obesity:

            Research has indicated that assessment of obesity can be conducted in 4 ways-

• Firstly the visual inspection which is a simple method but not accurate or precise.
• The second method is related to measurement of standard weight and height.
• The third method is known as BMI method that defines the Body Mass Index of individual and evaluates fat distribution through waist-hip ratio and the risk factors of cardiovascular disease. In this process the weight of the subject is divided by the square of the height and it is measured as follow-
  • BMI ≥ 35 or 40 kg/m² is considered as severe obesity.
  • BMI ≥40–44.9 kg/m² and occurrence of obesity related severe health issue is considered as morbid obesity.
  • BMI ≥ 45 or 50 kg/m² is considered as super obesity.
• The fourth method includes skin fold thickness method that estimates fat distribution in the body (13).

Such processes are helpful in the assessment of obesity and the processes provide effective result that helps to understand and measure the prevalence of obesity in a population.

Etiology:

The primary causes of obesity has been identified as being the environmental, physical, behavioral factors along with the social and cultural factors that leads to imbalance in energy and deposition of excessive fat in the body of the individual.  There has been an increased rate of occurrence of obesity primarily due to the sedentary lifestyle of the individuals along with the energy intake in excessive amount. Other factors that are identified include sleep deprivation, several endocrine disruptors that are environmental pollutants and reduced variability in optimum temperature (14). Elevated use of medications is also responsible for causing weight gain especially in cases like atypical antipsychotics. Often late pregnancy might lead to susceptibility of obesity in children including the epigenetic risk factors that are inherited in a generation wise manner (15)

Intake of unbalanced diet results in obesity since often the fat consumption is high in the diet. The selection of higher Body Mass Index (BMI), and assortative mating might lead to more focus of obesity risk factors. By the year of 2006, it was reported that 41 or more human genome sites have been related to obesity development, in an auspicious environment. People possessing two copies of the FTO gene (fat mass and obesity associated gene) have been identified to weigh 3–4 kg or more, having a 1.67 fold higher risk of obesity in comparison to the people that does not carry any the mutated allele (16) 

Complications of Obesity:

Several syndromes that occur in humans like the Prader–Willi syndrome and the Cohen syndrome, a major characteristic feature of these syndromes is obesity. Individuals who suffer from early onset of obesity, they tend to possess a single point DNA mutation in most of the cases (17). A study conducted by Data related to children and adolescents, it showed cross-sectional nationally representative US surveys: cycles II and III of the National Health Examination Survey (1963–1965 and 1966–1970). The first, second, and third National Health and Nutrition Examination Surveys: NHANES I (1971–1974), II (1976–1980), and III (1988–1994) (18). Three of these methods that were implemented were seen to provide results of similar nature however the results were not identical. In case of children, the reference values were lower in estimation as compared to the CDC-US growth charts (American). Research has indicated that obesity may leads to various severe health issues that could lead to death. For example, cardiovascular risk is one of the most common issues that have been found in obese people (19). A major portion of people that are suffering from obesity has been found to suffer from respiratory disorder as well (20). Diabetes is also associated with obesity (21). Cancer is another severe consequence of obesity that is one of the biggest threats to the health status of the population (22).

Reports have shown that, more than 10% of the total population of the world who were adults was identified as obese. In the year of 2013, it was reported that about 42 million of children around the world were obese overweight. However in recent times it is seen that it equally affects the population of the countries belonging to low- and middle-income, especially in the urban population (23).

It has been found that there are limitations of the study in terms that the review was done single headedly by an individual researcher therefore there might be some biasness regarding the interpretation of the results. Most of the studies that was conducted included a cross-sectional research approach. Often narrative reviews can lead to misleading results. Often due to scarcity of evidences there might be loss of credibility of the data that is collected and further analyzed. The research paper that are selected for the narrative review have provided effective data and information regarding the prevalence of obesity in India. It has provided relevant evidence for supporting the findings. Factors that influence obesity in the population have been identified. Barriers are creating obstacles in the way of effective interventions have been mentioned. However, the research carried out for the narrative review has not provided adequate information regarding a specific factor such as genetics. Role of FTO gene in obesity has been identified but there are other factors related to genetics that are not identified by the study. Genetic transformation of obesity from parents to children and the types of genes responsible for such incident are not mentioned in the study. Further research is needed to elaborate the genetic factors in depth

References:

1. Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, Sherwood LL, Nembhard HB. A silent response to the obesity epidemic: decline in US physician weight counseling. Medical care. 2013 Feb 1;51(2):186-92. pubmed
2. Unnikrishnan AG, Kalra S, Garg MK. Preventing obesity in India: Weighing the options. Indian journal of endocrinology and metabolism. 2012 Jan;16(1):4. pub
3. Cohn BS. Notes on the History of the Study of Indian Society and Culture. InStructure and change in Indian society 2017 Nov 13 (pp. 3-28). Routledge.
4. Kalra S, Unnikrishnan AG. Obesity in India: The weight of the nation. Journal of Medical Nutrition and Nutraceuticals. 2012 Jan 1;1(1):37.
5. Apovian CM, Gokce N. Obesity and cardiovascular disease. Circulation. 2012 Mar 6;125(9):1178-82. pub
6. Smith KB, Smith MS. Obesity statistics. Primary Care: Clinics in office practice. 2016 Mar 1;43(1):121-35. pub
7. Youngson NA, Morris MJ. What obesity research tells us about epigenetic mechanisms. Phil. Trans. R. Soc. B. 2013 Jan 5;368(1609):20110337.
8. Carvajal R, Wadden TA, Tsai AG, Peck K, Moran CH. Managing obesity in primary care practice: a narrative review. Annals of the New York Academy of Sciences. 2013 Apr;1281(1):191-206.
9. Wright J, Harwood V, editors. Biopolitics and the’obesity epidemic’: governing bodies. Routledge; 2012 Mar 22.
10. Wright J. Biopower, biopedagogies and the obesity epidemic. InBiopolitics and the’Obesity Epidemic’ 2012 Mar 22 (pp. 9-22). Routledge.
11. CFlegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. Jama. 2012 Feb 1;307(5):491-7.pub
12. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. Jama. 2013 Jan 2;309(1):71-82. pub
13. Abarca-Gómez L, Abdeen ZA, Hamid ZA, Abu-Rmeileh NM, Acosta-Cazares B, Acuin C, Adams RJ, Aekplakorn W, Afsana K, Aguilar-Salinas CA, Agyemang C. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128· 9 million children, adolescents, and adults. The Lancet. 2017 Dec 16;390(10113):2627-42.
14. Malik VS, Willett WC, Hu FB. Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology. 2013 Jan;9(1):13. pub
15. Ranjani H, Mehreen TS, Pradeepa R, Anjana RM, Garg R, Anand K, Mohan V. Epidemiology of childhood overweight & obesity in India: A systematic review. The Indian journal of medical research. 2016 Feb;143(2):160. pub
16. Cheung WW, Mao P. Recent advances in obesity: genetics and beyond. ISRN endocrinology. 2012 Mar 5;2012. pub
17. Xia Q, Grant SF. The genetics of human obesity. Annals of the New York Academy of Sciences. 2013 Apr 1;1281(1):178-90. pub
18. Johnson CL, Paulose-Ram R, Ogden CL, Carroll MD, Kruszan-Moran D, Dohrmann SM, Curtin LR. National health and nutrition examination survey. Analytic guidelines, 1999-2010. pub
19. Bastien M, Poirier P, Lemieux I, Després JP. Overview of epidemiology and contribution of obesity to cardiovascular disease. Progress in cardiovascular diseases. 2014 Jan 1;56(4):369-81. pub
20. Bahammam AS, AL?JAWDER SE. Managing acute respiratory decompensation in the morbidly obese. Respirology. 2012 Jul;17(5):759-71. pub
21. nop M, Foufelle F, Velloso LA. Endoplasmic reticulum stress, obesity and diabetes. Trends in molecular medicine. 2012 Jan 1;18(1):59-68. pub
22. Pischon T, Nimptsch K, editors. Obesity and Cancer. Springer; 2016 Dec 1.
23. Guthman J. Opening up the black box of the body in geographical obesity research: Toward a critical political ecology of fat. Annals of the Association of American Geographers. 2012 Sep 1;102(5):951-7.pu