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 Table of Contents  
REVIEW ARTICLE
Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 25-29

Obesity in India: Opportunities for clinical research


Pennington Biomedical Research Center, Infection and Obesity Laboratory, Baton Rouge, LA 70808, USA

Date of Submission16-Aug-2013
Date of Acceptance25-Oct-2013
Date of Web Publication30-Dec-2013

Correspondence Address:
Nikhil V Dhurandhar
Pennington Biomedical Research Center, Infection and Obesity Laboratory, 6400 Perkins Road, Baton Rouge, LA 70808
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9906.123874

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  Abstract 

Obesity is a complex disease with a multifactorial aetiology and is linked with numerous adverse health conditions. Obesity research in the past several decades has generated considerable information about various aspects of obesity, including genetics, physiology, biochemistry and socio-epidemiology. However, effective strategies for obesity prevention, or long-term weight loss and maintenance, have remained elusive, as evident from the global presence of obesity. Traditionally, obesity took a backseat in India, when debilitating infections and undernutrition dominated public health concerns. It is now evident that an urgent and effective response is needed for treating and preventing obesity in India and health care professionals and researchers are stepping up to the new challenge. It appears that obesity in the Indian context offers unique attributes that could be investigated to develop obesity-management modalities of relevance to the Indian subcontinent. Even if India was somewhat late in joining the global obesity research efforts, it may be a blessing in disguise. It is not necessary to repeat research studies or approaches that have already shown limited value in controlling obesity at the population level. Instead, it may be wise to build on what has been learned about obesity. Some clinical research possibilities are discussed.

Keywords: Body weight, India, obesity, obesity research, policy, treatment, weight loss


How to cite this article:
Dhurandhar NV. Obesity in India: Opportunities for clinical research. J Obes Metab Res 2014;1:25-9

How to cite this URL:
Dhurandhar NV. Obesity in India: Opportunities for clinical research. J Obes Metab Res [serial online] 2014 [cited 2018 May 27];1:25-9. Available from: http://www.jomrjournal.org/text.asp?2014/1/1/25/123874


  Introduction Top


The year 2013 is a landmark for the field of obesity. In June 2013, the American Medical Association declared that obesity be considered a disease. This recognition is likely to bring about a lot of attention, legitimacy and resources to treat and prevent this highly prevalent chronic disease. In India, the year is an additional milestone. Although the prevalence of overweight individuals and obesity in modern India is well-documented, [1],[2] in a country fraught with undernutrition (Available from: http://www.unicef.org/india/children_2356.htm), it is understandable that obesity was traditionally not considered a serious issue and even desirable in some situations. Perhaps, when tuberculosis and other debilitating conditions were not uncommon, individuals with excess weight faired relatively well - which may explain the traditional Indian use of the term "healthy", to describe an obese individual. We now know that both, under- and over-nutrition, coexist in India. The good news is that in India undernutrition is decreasing, [3] but the bad news is that obesity and its associated comorbidities are on the rise, particularly in some urban and higher socio-economic groups. [4] The need to treat obesity seriously was recognised by Dr. Vinod Dhurandhar, the visionary Founder/President of the All India Association for Advancing Research in Obesity, who started treating obesity as a clinical specialty around 1962. Now, in 2013, about 50 years later, starting of the Journal of Obesity and Metabolic Research signals the recognition of the next step in India's fight against obesity - research!


  Obesity - Clinical Practice and Research, Both are Needed Top


In the field of obesity, clinical practice and research are like two wheels of a carriage, essential, yet distinct. Clinical practice treats those who need relief from obesity. Whereas, research is about developing approaches and strategies that would be more effective in managing the condition. Indian health care professionals have risen up to the challenge and have been treating obesity at various outlets including clinics, hospitals and institutions and by applying obesity-management modalities from various schools of medicine and surgery. Furthermore, the potential economic burden associated with obesity-related conditions such as cardiovascular disease and diabetes is extremely worrisome and various policy changes have been suggested to combat obesity. [5],[6] A consensus statement has been developed for diagnosing and medically and surgically treating obesity in India. [7] Yet, there has been no relief in sight. Although this seems discouraging, it is not necessarily a reflection on the lack of effort put in by Indian health care professionals. With the exception of bariatric surgery (which is limited to a subgroup of candidates), treatment of obesity to achieve and maintain substantial weight loss at a population level has been disappointing universally. [8] Certainly, currently available and medically sound approaches should be continued for treating obesity, until advances in research yield superior approaches. Much like cancer or human immunodeficiency virus treatments, this sets a dire need for obesity research.


  Building on What We Have Learned Top


While obesity research has greatly advanced our understanding of obesity, overall, the previous 5 or 6 decades have shown that simplistic solutions that are intuitive and sound in theory, fall disappointingly short in countering obesity. The continued high prevalence of global obesity is a testament to this inadequacy of treatment measures. Nonetheless, this endeavour has been a learning experience about "what does not work for producing sustained and effective weight loss". Moving forward, obesity research needs to build on past experience. To quote Einstein, "Insanity is doing the same thing over and over again and expecting different results". Insanity should be avoided. For instance, numerous research studies have already shown that modest weight loss is possible by producing negative energy balance by introducing positive life-style changes. So, yet another research study to show that behavioural changes can induce weight loss does not advance the knowledge much. Instead, research is needed to answer questions such as: Why weight loss is only modest? Why it generally does not continue after 4-6 months of treatment? What could be done to prevent almost certain weight regain? And perhaps most importantly, how could these results be successfully applied to free-living population in need of weight loss?


  More Effective Therapeutics Top


One way to enhance weight loss outcome is to use anti-obesity medications, when indicated. Although anti-obesity drugs may have the potential risk of adverse effects, many produce greater weight loss than what life-style changes can do alone. This may be partly due to the ability of anorectic drugs to increase treatment adherence when compared with a low-energy diet. Thus, developing new anti-obesity therapeutics is an attractive opportunity, particularly within the Indian context. While various botanicals, nutraceuticals or food combinations that could increase patient treatment adherence to weight-loss regimens may be good candidates, a strong base in alternative medicine such as Ayurvedic or Homoeopathic systems of Medicine offers numerous such candidates. For instance, a simple search of PubMed (Available from: http://www.ncbi.nlm.nih.gov/pubmed; Last accessed xx, xx, 2013) using the keywords "Ayurvedic" and "obesity" yield 43 publications, reporting the use of such compounds as Triphala, honey, Shilajatu, Salacia oblonga, Salacia reticulata, or Terminalia bellirica in obesity. Despite this wealth of potential candidates, they have to pass the generally accepted medical criteria to be considered effective and safe obesity treatments. [9],[10],[11] The conceptual and methodological issues involved in testing Ayurvedic compounds for obesity have been well outlined [12],[13] and solutions have been proposed. [14],[15]

For effective translation of a candidate for clinical use, it is not adequate to demonstrate the effect of a particular compound only in adipocytes or animals. Its efficacy, effectiveness and its population-based application needs to be demonstrated in humans, which are distinct steps. A compound that significantly reduces food intake acutely (efficacious), may still not be effective in lowering body weight. Furthermore, a compound/product that is effective also needs to help at a wider population-based level to make a meaningful contribution. Many of the dietary strategies have been suggested to increase satiety, but not all may induce weight loss. [16] For instance, consumption of a breakfast containing eggs reduces lunchtime food intake (efficacy) and increases weight loss in study subjects (effectiveness). [17],[18] However, it is not yet known if this approach could be feasible and helpful for the majority of the population in debate.


  Susceptibility of Indians to Diabetes Top


A peculiarity of obesity among Indians is the vulnerability of individuals to metabolic disorders, such as insulin resistance or diabetes, at a much lower level of body fat or body mass index compared with Caucasians. [19],[20]

Many theories have been proposed to explain this phenomenon. [21] The greater metabolic risk in South Asians is probably due to the preferential deposition of body fat in the visceral depot (vs. subcutaneous depots) [22] and has led to lowering the cut-off values for the overweight and obese in this population. [7]

Other possibilities are sarcopenic obesity and lipodystrophy - prevalent in Asian and Indian populations, which are linked with diabetes and its related metabolic disorders. [23],[24],[25] A better understanding of this phenomenon is required for mounting an effective disease-management response.

The link between ectopic fat deposition, mainly in the liver and the metabolic syndrome has been convincingly documented. [26],[27] The important question is: What are the upstream factors that predispose individuals of Indian origin to preferentially store body fat ectopically? It is known that chronic low-grade inflammatory response associated with obesity [28],[29] is also linked with ectopic fat deposition. [30],[31],[32] Low-grade inflammation in Indians has been reported, [33],[34] which is also linked with non-alcoholic fatty liver disease. [35] Compared with Caucasians, do Indians have disproportionately higher inflammatory response to adiposity? And if so, why? Is the peculiar fat distribution or skeletal muscle mass linked to specific food patterns? behavioural/cultural practices? Is air pollution linked to pronounced inflammation? [36] Answers to these questions may provide the insight needed to deal with this important comorbidity of obesity.

Perhaps, an important and related consideration may be foetal programming. Maternal and foetal undernutrition is linked with obesity and diabetes in the developing child. [37],[38],[39],[40],[41] Maternal obesity is also linked with obesity, metabolic disorders and mortality in children. [42],[43] Considering the widespread prevalence of maternal and childhood malnutrition, as well as maternal obesity in India, [44],[45],[46] it may be important to determine whether the propensity of Indians to acquire diabetes at a relatively lower body fat (than non-Indians) is rooted in foetal programming. [47]


  Bariatric Surgery in India Top


Due to their vulnerability to diabetes, Indian obese individuals also offer an important research opportunity to understand the role of bariatric surgery in improving metabolic disorders. Bariatric surgery has been highly effective in reducing obesity-related morbidity and mortality [48],[49] and in improving glycemic control. [50],[51] This feature of bariatric surgery may be of particular help for obese individuals of Indian region, since they are susceptible to acquiring diabetes. Although bariatric surgery is rapidly increasing in popularity in Asia and India, [52] the feasibility and practicality of treating every obese diabetic individual with bariatric surgery is very low. Instead, it is hoped that research will harness the underlying mechanisms that bariatric surgery triggers off that would help in designing non-surgical treatment strategies, which may potentially have a wider reach. It would also be highly illustrative to determine if the mode of action of bariatric surgery on metabolic parameters is different among individuals of Indian origin.


  Obesity is a Disease, Not a Choice Top


Finally, it should be noted that even though obesity shares some similarities with other chronic diseases such as diabetes or hypertension, it has some distinct characteristics.

Similar to diabetes or hypertension, obesity - has a multifactorial aetiology, an insidious onset and many associated comorbidities, is not an acquired disease by choice and is not a condition that represents the lack of effort to control the disease. Neither is diabetes nor obesity curable by the patient deciding to "get rid of it". They both need effective clinical management. This understanding is important for obesity related treatment, research and policies.

However, there are also some important differences: screening for undetected diabetes or hypertension has high remedial benefits - once detected, appropriate treatment and medications could be initiated to manage the diseases; several options of medications are available to treat diabetes or hypertension; obesity is relatively easy to diagnose and cannot go undetected; obesity has only a handful of approved medications available.

Simplistic sounding Naïve Solutions are often suggested to control obesity, including educating people about the dangers of obesity - which assumes that an individual's obesity is due to a lack of awareness about the risks of obesity and providing information would motivate the person to take action and lose weight. However, considering the highly limited success of weight-loss treatments even in the hands of outstanding clinicians and in highly motivated population, [8] weight loss is not a mere matter of "deciding to lose weight".


  Summary Top


In summary, obesity is a complex disease with multifactorial aetiology. As the 19 th Century American poet John Godfrey Saxe noted in his poem "The blind men and the elephant", an elephant is not only like a wall, a rope or a tree trunk as the blind men touching the elephant declared, but, an elephant is all that and much more. Similarly, multiple factors contribute to the development of obesity and a truly multidisciplinary approach is needed to fully understand and manage the condition. Only a few examples of important clinical questions that could be asked in the setting of obesity in India are outlined here - many more will follow.

 
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Obesity - Clinic...
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More Effective T...
Susceptibility o...
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Obesity is a Dis...
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