It was 1997. I had just finished MBBS. For a short period, I stayed at home. One day I met Raman Menon and family from the house nearby. It was many years since we met. Raman Menon was in his early seventies. He had made his fortune in the Middle East. That was his ticket to affluence.
“Hello, you have become a doctor now, eh?” He greeted me effusively. He laughed happily and his huge abdomen moved up and down rhythmically like a balloon caught in the wind. His wife stood smiling by his side. She was also very fat.
“You are still very thin. Why is that? Don’t you eat anything while in Medical School?” He asked me. I smiled politely. My BMI was 24. That put me in the upper range of the normal weight. I was not too thin at all.
“You have hardly changed. Other than a few hairs lost, I suppose.” He continued. “Too much cramming and thinking is the reason, I guess?”
“And too much testosterone” I thought. Too many testosterone sensitive hair follicles, to be exact. I didn’t want to explain. It was a painful topic.
“You have put on some weight.” I said.
“Some?” He looked insulted. “I must have gained at least ten kilos since I last saw you” He said proudly.
“I love to eat. Everyone in our family is like that. Otherwise what is the point in being able to afford good food?” He said.
“I have increased blood pressure. Doctor said that I am developing Diabetes also. My parents didn’t have any of these.” He said with satisfaction. “She has both” He indicated his wife.
“My son has diabetes. He is hardly forty.” He said in the same way one would have said he had become a CEO of a big company at that age.
Through most of our history, we were able to eat just enough to survive. After widespread agriculture, complex societies with hierarchies sprang up. Surplus food was available, especially for some people, high in the political and religious hierarchy. Still most of the population did not have the luxury of becoming fat. No wonder that fatness was a thing to be proud of. It still is, in many parts of the world. There are places like Mozambique where there are ‘fatness farms’, there girls are force fed to become fat and attractive. This kind of mindset is present in our country also, in patches. It is stronger among rural, poorer communities.
We need certain standards to grade fatness. Otherwise how can we measure and study it? The WHO has given some ready criteria. It is based on a measurement called ‘body mass index’. It is the value we get if we divide one’s weight in kilograms by the square of the height in metres. The normal range is between 18.5 and 24.9. Above 25 is considered overweight. 30 or above is deemed obesity. Obesity is officially classified as a disease. Any BMI above 35 is severe obesity.
Obesity is associated with diabetes, hypertension, high cholesterol and high triglyceride levels. These are all risk factors for atherosclerosis and consequent coronary artery disease and stroke. Mortality risks have been studied. Large scale American and European studies have shown that the mortality risk is lowest at a BMI of 20 to 25. A BMI above 32 doubles the mortality rate, as shown in a 16 year study in 1995.
Other than the lifestyle diseases mentioned, Obesity increases the risk of certain cancers like breast, non-alcoholic liver disease and osteoarthritis. And the list doesn’t stop there. The most important and direct link is to diabetes, technically called type2 Diabetes Mellitus.
Before the 20th century, obesity was a rare disease. Now, it is an epidemic. It was formally declared as an epidemic by WHO, in 1997. About 10 percent of the world population is estimated to be obese. And it doesn’t include the merely overweight individuals. In the USA, 30 percent are obese. The average BMI of an American is 26. It is in the overweight range. The average BMI in societies that still follow the hunter gatherer lifestyle is between 19 and 21.
India is also following the world trend. The National Family Health Survey data- 2007 show that 5 percent of the population is morbidly obese. The proportion of people, who are overweight, ranges from 15 to 30 percent in various states. Surveys among school children put the figure at 20 to 40 percent, showing that this is an increasing trend.
There are many subtleties to all these, of course. Going into the technical details will be boring. That is not our purpose. But some details are unavoidable:
“Things should be made as simple as possible, but not simpler.”- Albert Einstein.
As I fully agree with this great man, I have to tell you that BMI is not a foolproof method of measuring corpulence. What matters is the fat. Arnold Schwarzenegger in his prime would have had quite a high BMI, because he is bulked up on muscle, not fat. For such an individual, this measurement falls flat as a risk predictor.
To complicate things further, it seems the type of fat matters. The fat around the waist is more dangerous. And according to studies, visceral fat is the most lethal. It is the fat that accumulates around our intestines and liver, contributing to a large waist and a pot belly. We see many men (especially men, rather than women), with normal weight, but a football like belly straining at the belt. This feature is said to be commoner in Indian men. So, it is suggested by many authorities to measure the waist-hip ratio also, in addition to the BMI, to get some more perspective. Fat is a metabolically active tissue. The belly fat is supposed to be more active, secreting hormones and other chemicals that set up a chronic inflammatory state in the body. This is one important way in which it contributes to many diseases.
Does that mean we should forever be watching your weight? Obsession can be harmful, and too much pressure on young women (and men) to stay thin has increased the incidence of diseases like anorexia nervosa, in which patients starve; often to the death. As in most cases, a middle path is appropriate.
What about some studies that say being a little fat is good? Indeed, some do come to that conclusion. But a critical analysis of such studies (Which are a minority) shows that they are flawed to a degree. The commonest problem is not to control for smoking. Many smokers are thin as nicotine is a powerful appetite suppressant. The other flaw is to record the weight of a cross section of people and then assessing then for mortality by following them up over the years. you see- that catches people who are thin due to a serious disease in the net; and the mortality rate is going to be higher.