Episode 89: Understanding Obesity: A Growing Epidemic

[Music] Good morning and jagged to all our listeners. Welcome to another enlightening episode of the AFMC Department of Internal Medicine podcast series. I am delighted to introduce today's session which focuses on a condition that has rapidly emerged as one of the greatest public health challenges of our time that is obesity. Obesity is far more than a cosmetic concern. It is a complex chronic multifactorial disease that significantly increases the risk of type 2 diabetes, cardiovascular disease, fatty liver, osteoarthritis and even certain cancers. It reflects not just an imbalance between calorie intake and expenditure but also deep interactions amongst genetics, environment, behavior and socio-cultural factors. To help us navigate this multifaceted topic, we are privileged to have with us wing commander Sandeep Kumar, associate professor and endocrinologist at the Department of Internal Medicine Armed Forces Medical College. Wing commander Sandeep has extensive experience in managing metabolic disorders and obesity and has been at the forefront of clinical, academic and research work in endocrinology. In today's episode, we will explore the pacifizology of obesity, its clinical and metabolic implications and the contemporary approaches to management ranging from lifestyle modification and pharmacotherapy to bariatric interventions and emerging trends in metabolic medicine. So, let us dive in and gain insights into the science, challenges and solutions surrounding obesity. So, I welcome Wing commander Sandeep. Thank you sir. So, to begin with, could you give us an overview of the epidemiology of obesity globally and especially in India and are there any unique characteristics seen in the Indian population? So, once again, thank you sir for giving me this opportunity and greetings to all beloved students who are listening to today's podcast. So, I will begin first of all by just driving important message to our listeners that we must remove stigma around obesity. People with obesity are often blamed or judged even by health professionals. It is often commonly seen that people say that you are obese just because of your sin or if we are your faults. So, we must understand that obesity is a chronic relapsing and biological disease much like any other diseases like hypertension or diabetes malitis and it is not a more moral failing of individual. Leading endocrine societies like American Association of Clinical Endocrinologists in fact has gone to an extent that they have named this disease as ABCD means adiposity-based chronic disease. So, that people consider this disease as a chronic disease like any other disease. So, this is a high time we should work to empower people with obesity and we should partner with them so that we can solve this unique problem. So, and coming to epidemiology sir, you have already highlighted. So, this is a basically root cause of very severe diseases like coronary artery disease, chronic kidney disease, metabolic problems, osteoarthritis, even depression and many cancers as well. So, I will not go into that and just to give you a few numbers. So, first of all let us begin from the western data and if we go by CDC number from USA, it has been seen that adult population about 30 percent of adult population there is obese and very alarming numbers have come from the adolescent population children and the data has shown that 20 percent of the children in the US are obese and this is very, very alarming and this number is going to rise in coming times and see sir, these people are the, this is the population which is going to live with this disease for a very longer duration of that time. And then if we take an Indian perspective, so we have a very beautiful data which has come up from the landmark trial done by ICMR and this trial is called as ICMR India program and I would recommend this paper to all students, not only MD students, but also to undergraduate students and this paper has got out data with regard to all lifestyle diseases in India and this paper has shown that prevalence of abdominal adiposity, obesity in India is about 39.5 percent and we can assume it is about 40 percent. So, huge 40 percent of the population is having a abdominal adiposity and this number, this paper also showed that prevalence of diabetes is about 11.4 percent, prevalence of hypertension is 35 percent. So, what I am trying to bring out here is that compared to the other diseases like hypertension and diabetes, the number of obesity is way higher and this paper has also shown that there are certain hot spots like southern states like Tamil Nadu, northern like Punjab which has a prevalence of obesity as high as 50 percent. So, 50 percent of the population of that state is being obese. But what is happening is that students would agree today that we understand hypertension and diabetes in better detail, we understand their pathophysiology in a better way, we have a more therapeutic strategies or interventions which are available to that which is required definitely because they are very important diseases. But on the contrary, we are not having a very clear structured pathophysiological understanding or any therapeutic molecule with respect to obesity whose number are as high as hot due to 50 percent. So, in fact, there has been little strategic shift which has happened of later, there we have a more better understanding with respect to pathophysiology of obesity and also with respect to various therapeutic armamentarium and we would be discussing certain molecules which have come up. Now, as which has is true with diabetes and insulin resistance, there's also certain unique peculiar characteristics of Indian population. So, it has been seen that Indian has a higher body fat at a lower body mass index. So, if for example, if a person in the US is having a body mass index of 30 and if Indian person is having a body mass of index of 23, the 20 Indian that Indian person might be having the same cardio metabolic risk as the person was 30 in the US. In fact, he may be having higher also. So, what I'm trying to say is that Indian are having higher fat in the body at lower body mass index. That is very important to understand and this was beautifully conveyed by the landmark phenomena which was given by Dr. Yajnik who was from Pune itself and he gave the this phenomenon, this phenomenon as Y by Paradox. But did he do way back about two and a half decades back, he did his body mass index which was 21, his friend whose name was Dr. Yajnik, his body mass index was also 21 and he did a body fat measurement by the DEXA. To his surprise, he found out that the body fat in the Dr. Yajnik who was a western person was 9% and his body mass index was two and a half, his body fat percentage was about two and a half times higher. So, this is important thing to understand and students should you know go back today with this message that Indians at lower weight may be having a higher fat percentage and because of this and this fat is getting accumulated not in the subcutaneous tissue sir. This fat is going and accumulating in the distal organs in the organs and leading to and this fat is not inert. This is hormonally or active which is metabolic, metabolically actively which is creating certain natipochines, cytokines which is leading to you know insulin resistance and further various cardiometabolic diseases. So, that means not only Indian as a population are different than the west and we are in more obesity, but also that per person if we see Indians they have got more fat than the western person to person that is a very dangerous thing that we have to go. Okay now sir, so we know that this much is the prevalence of obesity, it is a highly rampant disease almost equivalent to the tuberculosis I think again 40 to 50, 50% enemy and obesity is all under the same prevalence rates. So, now can you just tell us how should the obesity be diagnosed in clinical practice and can you also explain the WHO criterion and the southeast Asian regional cutoffs and also tell us about the limitation of body mass index in detecting the obesity. Yes sir. So, as you have already told sir, so it is so once we understood this that obesity is a great problem, so we need to diagnose it. So, what are the tools which are available to us and often it has been seen and again this is another important message which I want to drive to students who are listening today that whenever you dealing with the patients like our students, MD students in the OPDC it is very important to take a weight and height and weight circumference. So, any or there should always be attempt made to you know document whether obesity is present or not you may be dealing with whatever patients. So, that is very important and that should be done. So, basically weight and height and weight circumference are the three important tools which are available to us with which we can diagnose obesity. So, there is a cutoff which has been given by World Health Organization and which is this says that person is said to be overweight if he is having a body mass index of 25 kilogram per meter square and I hope students know that you calculate body mass index by dividing weight in gauges by the height in meter square and you get a body mass index. And if according to WHO if your body mass index is more than 30 kilogram per meter square it means that you are obese. But again as I told in the previous the discussion that Indians are having the higher body fat percentage even at a lower body mass index. So, with this contest someone you know applied their mind and gave a separate cutoff guidelines and the learned societies thought that we need to have a lower cutoff guidelines for the southeast Asian people and that is how we have arrived at southeast Asian region cutoff. So, this is important with Indian contest and if your body mass index is equal to or more than 23 kilogram per meter square you consider that person to be having to be overweight and if your body mass index is more than 25 kilogram per meter square you consider the person to be obese. So, that is how we have a different cutoff for Indian population and we call it as a southeast Asian region. And not only body mass index is very important like I told you it is a abdominal depositive which we are looking for because it is a reflection of a visceral fat. So, that is how the fat accumulate in the south Asian people and India per se. So, the waist circumference is another important tool which we should always do and if your waist circumference in men is more than 90 centimeter and it is more than 80 centimeter women we say that the person is having a higher waist circumference or person is having a adiposity and just a quick recap for undergraduate student how to take a waist circumference very simply make a person to stand and we can be standing with his feet separated as a shoulder width apart and find the top of the hip bone that is called iliac crest and the bottom of the rib cage a place where the lower most rib is there place a non stretchable you know the tape midway between these two points and then take that reading and if your reading is more than 90 and 80 in men and women respectively you diagnose the patient to having centimeter centimeter. You say said to be say the person is having a higher body fat percentage. So, now having understood this so I am not trying to undermine that body mass index and waist circumference are not important. In fact, they are the most important tools which we should be applying but when we are discuss about obesity we should also remember that the B body mass index is also not you know free from shortcomings. So, what body mass index is telling us is body mass index tells us about the presence of the you know entire mass in the body which constitute your bone also your muscle also and fat also. So, at times you may get a fallacious reading. So, person might be having a normal body mass index but he might be having higher fat. For example, I might be having a patient who is having a body mass index of 22.5 kilogram per meter square and if I go by Southeast Asian region cutoff guidelines I would label that individual to be having a normal BMI but on the contrary if I go ahead and do is body fat percentage in appropriate setting and if I might be surprised to see that he might be having higher body fat percentage and a low mass you know lean mass in that. So, that is how these shortcomings were realized and now the you know the scientific community is graduating towards utilizing various direct tools of measuring body fat percentage and with that regards we have like gold standard dexa machine can be utilized we are like and we are dexa calculates your body fat percentage but all of you would you know agree with me that dexa available to dexa machine is only there in tertiary care center only endocrine centers in tertiary care medical college would be having a dexa machine. So, there are huge short shortage of dexa machine. So, doing a body fat percentage that is not possible practically in the country like India where the you know the population spread out through entire region the majority of population staying in the rural India and 40% is the 40% is the prevalence. So, always your anthropometric parameters are very important but in an appropriate setting kindly please in the selected patient you should make an attempt to calculate the direct body fat also and there is a new development which has happened so now because of the we have a portable bioelectrical impedance devices which are approved and become available in India and they have been compared with the dexa machine and they have proven to be non-inferior in head to head trial and we can utilize them also by doing the calculating body fat percentage and it has been seen that if by you know by direct measuring the body fat if your body fat is more than 25% in men and more than 30% in women you can label that person to be a obese. So, obviously that direct measurement would be definitely far better but the practical utility of that is an availability is a problem. But I think in future the availability might increase and then that might be the standard of care in diagnosed obese obesity. Some recent papers mention the terms as like metabolically healthy or unhealthy obesity, normal weight obesity and sarcopenic obesity. So, can you please explain what these terms they mean in simple clinical way? Yes sir. So, again so we have few terms which students should be knowing and like metabolically healthy obesity, metabolically unhealthy obesity, normal weight obesity in sarcopenic obesity. So, I will give you examples sir. We have two Indian people. I am talking about only Indian native population, person A who has a body mass index of 30. We have a person B who is having a body mass index of 30. Both of them have a same body mass index, same gender. But we might be surprised that person A might not be having any you know diseases with regard to which because of the obesity like he might not be having any hypertension, diabetes, obstructive sleep apnea. On the contrary person B with the same body mass index might be having certain cardiometabolic diseases like coronary artery disease, pre-diabetes or diabetes or hypertension. And if we go further ahead as we discussed in the previous discussion that we if we calculate the body fat percentage we might be surprised that person A might be having a lower body fat percentage and compared to the person with the body person B. This in this scenario the person A is said to be having a metabolically healthy obesity. So, what is happening in this is that the person A is having higher body mass index but his body fat percentage is not very higher. Even if he has a equivalent body fat percentage his body fat is distributed more in a subcutaneous tissue and less in the visceral tissue and we already discussed that when the fat accumulate in the organs it is a metabolically active and it secretes various you know adipokines and cytokines which are made to insulin resistance. So, this is the concept of metabolically healthy or unhealthy obesity. Coming to the normal weight obesity I have already highlighted in previous discussion that and that is very important in the individual perspective. So, in fact we have a very you know landmark papers from Dr. Kapoor Attal has done from CMC Velour where they have done the body fat percentage measurement in the person with the body mass index of less than 23 and to their surprise they got a significant number of the people who were having a higher fat percentage with a lower body mass index less than 23 and that fat percentage constituted them to be in the diagnostic criteria of the obesity. This is called as normal weight obesity means your weight is normal you might be happy that my body weight is normal or my body mass index is less than 23 but you may get surprised if you do the body fat percentage it might be higher. Coming to sarcopenic obesity very important concept it is more valid in the you know elderly population. So, as the name suggests sarcopenic means less muscle and obesity means more fat. So, what happened in this situation is that person in this scenario also the person might be having a falsely normal or low body mass index but when we calculate his body fat percentage he might be having a higher body fat with low muscle mass. So, how do we diagnose this as I told you it is generally seen in the you know elderly people. So, we don't diagnose sarcopenic obesity directly by doing the body composition analysis we suspect it only when the person comes to us and he is having a functional impairment of his muscle. For example, if an elderly person come to my open and I see that he is having some functional limitation with respect to his muscle strength which I document objectively like I can do a hand grip analysis hand grip dynamometer and I document that person is having some kind of limitation in his muscle activity then if I go ahead and document that he is having a higher muscle a low muscle mass and higher body fat percentage I label that individual to be having sarcopenic obesity and this is not done labeling is just not done for the fancy work because once the person is having a sarcopenic obesity there is a robust evidence to this respect that person with sarcopenic obesity has a adverse outcome with respect to obesity and other a cardiometric diseases. So, now another question a very important question that comes is that many people they lose weight initially but they struggle to sustain it in the long run. So, why does this happen and what are the physiological and behavioral mechanisms which are involved in this very commonly occurring situation? Yes sir. So, this is a common scenario and not only with respect to patient we also when we want to you know do the weight loss program for our own self. So, mostly what we are we all of us majority of us are motivated initially and but the problem is sustain us we are not able to sustain it over the longer period of time and few of us who loses weight also tend to regain it with weight very soon. So, let us understand why does it happen it is a very beautiful phenomena and first of all we must understand that there is a central set point of the weight or hypothalamic set point of the weight which God has you know predetermined for every one of us like animals you would have seen that animals never become obese. So, they remain between a you know fixed weight throughout their life. Similarly, for human beings also the almighty have given a fixed central set point of weight. For example, if a person is destined is having a set point of 60 kilograms he would always be 60 kilograms according to the God's design plus minus 2 kgs here and there he can you know shift during his lifetime but you would be asking me the question then why do we get obese this is happening because there is a certain problems in the trans appetite they they settle you know hormones which are dealing with appetite and satiety there is some problem which is happening with respect to that and two hormones which the students should remember is a leptin and ghrelin. So, one should understand what does leptin does. So, if we consume more food or if we are replenished with the food your leptin will increase and that will reduce your appetite and if you are having a deficiency of the food your leptin will fall and your appetite will increase and at the same time your ghrelin will also increase and your appetite will increase and your weight will come back to that set point. So, this was a the system of leptin and the balance of the leptin and ghrelin was devised by the God so that we remain within that set point of 60 kilograms but now because of the various pathophysiological mechanism our lifestyles inflammatory markers certain genetic changes what has happened is there is a development of the leptin resistance similarly like the insulin resistance which we understand with the pathophysiology of diabetes. So, now what is happening is the person who gains weight or he is consuming extra calories his leptins are rising with the attempt so that person his appetite should get suppressed but that leptin is not having any physiological effect on decreasing the appetite because there is a development of leptin resistance. Not that same individual who has consuming excess calories and whose leptin is having a resistance if he follows a weight losing program or lifestyle modification he will lose like little weight and there would be delta fall in the leptin which will happen. So, delta fall in the leptin even to the minuscule level causes the rebound increase in the appetite and the person start and also of the ghrelin agreement happens because of that their appetite is increased. So, that is why because of this person is not able to reduce the weight because when he consumes excess his appetite is not getting suppressed because of the excess leptin resistance and when he reduces little weight there is a delta fall little change in the leptin fall in the leptin because the rebound appetite increase and also the ghrelin also causes a rebound weight increase and it has been seen that people in the practical scenarios with lifestyle they are not able to reduce more than 4 percent of the weight of the lifestyle modifications. That is a very good point I think the point no like many of us will not be knowing about this point which you have just told. Now, there are there is a lot of buzz about different diet trends like ketro diets or intermittent fasting, vegan, low carb, high proteins and so on. So, what is your take on the benefits versus potential harms of these so called fancy diets? Yes, a beautiful question sir and yes there are many fancy diets which are available and basically and the people have more access to this information because of the availability of various social media and various influences which are available. So, I just want to you know give a word of caution that many of these diets have not been scientifically proven. In fact, there are certain diets which you know where there is evidence which has emerged which it has shown that might be having the adverse cardio metabolic outcomes. In fact, certain diets have demonstrated increased cardiac mortality also. So, I am coming to the keto diets. So, keto diet is basically sir you consuming 70 to 80 percent of calories from your fat and it causes the weight reduction drastically, but now we have a evidence which has demonstrated that you know the in fact, systematic reviews are there which has shown that keto diet causes the elevation in LDL and they causes deficiency of various micro nutrients, it causes a hepatic stress and it causes keto related side effect in the susceptible individuals and there has been the you know cardiovascular deaths also. And then we have certain diets like intermittent fasting which whatever limited evidence we have it has given some benefit only we do not have any you know harmful data which has come up, but then intermittent fasting is very akin to the Indian cultural practices. So, for example, we fast and this intermittent fasting means that like we can you know the person is consuming food only for 8 calories for 8 hours and he being not consuming any calories for 18 hours or he is consuming calories for 5 days and not consuming for 2 days this is called as intermittent fasting. So, concept of you know you like religious fasting etc. was nothing but intermittent fasting only. So, that is easily doable and is akin to the cultural practices also. In fact, individual people can you know do it like if they have an early dinner and do the late breakfast that will also translate into intermittent fasting. So, as of now although the evidence is emerging, but intermittent fasting has shown some benefit. Similarly, we have a Mediterranean diet and we have a predimate trial which was done with regard to this. Basically, it consumes it includes consumption of more antioxidant kind of food, legumes, olive oil, vegetables and fruits and it has also in meta analysis shown benefit with respect to cardiovascular health. So, what I am trying to say here is that we do not have a clear cut data with respect to various fancy diets and certain diets like keto diets have shown adverse outcomes in trials. Certains data with respect to others are emerging, but the clinical clue is no one diet is universally superior. Pick an evidence based nutritionally complete plan that the patient that you can sustain and tailor your cultural preferences and co-mobilities. For example, if someone is diabetic and he is having kidney disease. So, his diet would be different according to his condition which he is having and always take these diets under the supervised healthcare professional and because and more important thing to remember in this is these diets can lead to various nutrient deficiencies also and which can lead to certain side effects which are very difficult to pick up like big you know neuropathies can be there which can go on undiagnosed for the longer duration of time. So, basically two important mantra is to remain within a calorie budget to focus more on fresh foods and vegetables to consume less processed foods to consume less energy dense foods and rather than speaking to one fancy names and that is a prudent tactical approach to the diet in obesity. So, very well said. So, now lastly what are some of the newer advances or current advocacy trends in obesity? Yes sir. So, as we discussed in the in the starting sir the obesity is the prevalence of obesity is huge but what was happening is that we were having a better understanding with respect to certain diseases which were happening because of the obesity like we were having a better pathophysiological understanding in diabetes and hypertension but lesser with respect to obesity. But often there has been you know landmark you know changes which has happened how we understand obesity and we have you know we know pathophysiology of the obesity in better detail and there has been advent of you know newer drugs for obesity management. So, in fact GLP, the creatinine group of drugs they are the you know breakthrough and we all of you would have heard like GLP one receptor agonist we have semaglutide which can be given injectable once a weekly. Now, these drugs are available in India and also we have a GLP glucagon like peptide one agonist and GIP gluca insulotropic peptide one agonist combination of these which is called a dual agonist kyrgiphtide which again is available in India and these agents have shown in the trials that is about 50 to 22 percent of weight loss can happen with them. So, that is a huge weight loss in fact we are comparing these drugs to metabolic surgery means they are having a result akin to the bariatric surgeries. So, these are the new molecules which are come up very promising and getting a good results but yes the data with respect to the safety in the real terms is coming up and yes as for whatever limited experience we have in our practice they are translating into the lot of you know benefit with respect to weight reduction. And now the you know the research community have realized that obesity is a huge problem and that is why there is a lot of research which is happening. In fact, now there is a GLP plus GIP plus glucagon triple agonist which is about to come which has cleared the you know late advance at stages of their trial and it has also demonstrated about 22 to 24 percent of weight loss and which is oral molecule which is about to come. So, basically there is a lot of research which is coming up and in coming over half one or one and a half years we are about to witness a large number of molecules which would be available for the medical management of obesity but most of them would be based on their you know GLP, GIP or glucagon based mechanisms because they are translated for signal to weight loss. So, now with lifestyle if we are motivated and if we are willing to treat obesity and manage obesity. So, not only life like definitely we would be like doing the lifestyle but yes there are good molecules, pharmacological interventions are also available which can be great reinforcement in our management strategies. And yes definitely so they have been recent advances in endoscopic bariatric surgeries like intra-gastic bile balloons, endoscopic sleep gastric to me also but then as I told you because of these available of these in creatine or glup GLP group of drugs they are better employed and they are giving a good result in practical scenarios. So, thank you even commander Sandeep for that comprehensive and insightful discussion on obesity. So, we have beautifully highlighted how obesity is not merely a disorder of excess weight but a complex interplay of hormonal genetics and environmental determinants requiring a holistic and sustained approach to prevention and management. From the importance of early lifestyle interventions and dietary restructuring to neo-pharmacological agents like GLP1 receptor agonists and dual in creatine therapies and finally the role of multidisciplinary care. Today's conversation underscores that effective obesity management demands both medical precision and compassionate long-term engagement. As clinicians and educators our responsibility extends beyond treatment to awareness, prevention and promoting healthier lifestyles among our patients and community. We hope our listeners found this discussion thought-provoking and practical. Thank you once again to our expert wing commander Sandeep Kumar for sharing his expertise and to all our listeners for joining us today. Until next time stay healthy, stay active and keep learning. Jai Hind. (upbeat music)