ESI Clinical Practice Guidelines for the Evaluation and Management of Obesity In India : Indian Journal of Endocrinology and Metabolism

Secondary Logo

Journal Logo

Guidelines

ESI Clinical Practice Guidelines for the Evaluation and Management of Obesity In India

S.V, Madhu1,; Nitin, Kapoor2; Sambit, Das3; Nishant, Raizada4; Sanjay, Kalra4 (on behalf of Endocrine Society of India)

Author Information
Indian Journal of Endocrinology and Metabolism: Jul–Aug 2022 - Volume 26 - Issue 4 - p 295-318
doi: 10.4103/2230-8210.356236
  • Open

Preamble

Obesity is a major health problem that increases the risk of multiple non communicable diseases such as diabetes, hypertension, and cardiovascular diseases. In India, as well as globally, the prevalence of obesity has been increasing rapidly. The management of obesity is complex and often unrewarding with respect to long-term weight loss. The management of obesity requires proper knowledge and training on the part of the health care providers. However, most health care providers either lack the required knowledge or do not feel confident in managing obesity. Considering the severity of the health problem, the Endocrine Society of India (ESI) has come up with clinical practice guidelines to provide guidance to doctors as well as paramedical staff who are interested in managing obesity in their patients.

Methodology

The Executive Committee of the Endocrine Society of India appointed a writing committee for framing the guidelines. The members of the committee were chosen from endocrinologists involved in research as well as clinical care of obesity and related disorders. The writing committee was chaired by the Editor-in-Chief, Indian Journal of Endocrinology and Metabolism. The writing committee met on several occasions and came up with 14 sub-sections under which the guidelines would be formulated. Each member was then allotted one or more subsections in order to search the literature, including all existing literature, and suggest recommendations for that subsection. Each recommendation had two options: (a) Recommended care as the primary recommendation and (b) limited care recommendation for resource-limited settings. The recommendations are numbered as 1.1, 1.2, etc., where the first number indicates the subsection while the second denotes the serial number of the recommendation. The limited care recommendations are denoted by (L) after the recommendation number (such as 1.1 (L)). An abridged version of the document for primary care providers was also made. Once the members had completed the literature search and formulated the recommendations, all the subsections were compiled together and circulated amongst the committee members for their comments. Any corrections or suggestions by the other committee members were incorporated into the document. The chairman of the writing committee approved this draft and forwarded it to the Executive Committee of the ESI. The members of the Executive Committee, consisting of national experts in the field of endocrinology, vetted the document and gave their inputs. After incorporation of these inputs, the draft was uploaded on the official website of ESI and inputs or suggestions were sought from all members of the ESI or any other stakeholder. The inputs were considered for inclusion as per their merit and relevance; the draft was then finalized for publication in the Indian Journal of Endocrinology and Metabolism.

1. INTRODUCTION

1a. Recognition of obesity as a chronic disease

One of the basic challenges to the successful management of obesity is the failure to consider obesity as a disease or chronic disease and as a challenge to modern medicine.

  • First, the concept of obesity as a disease remains controversial, including among many health care workers
  • Once the motivated person with obesity seeks care, expert facilities may not be available in their community.
  • Most physicians in primary care are ill-equipped to deliver the established high-intensity lifestyle treatments that can lead to lasting weight loss and improved health

Defining Obesity:

Obesity is a chronic, relapsing progressive disease defined by excessive adiposity that may impair health.[1]

Abundance of food, low physical activity, and genetics or environmental factors result in a positive energy balance. This excess energy is stored as fat.

American Association of Clinical Endocrinology (AACE) has coined a new term for obesity, i.e., ABCD or Adiposity-Based Chronic Disease, to underline the need to recognize it as a chronic disease.

The management of obesity should follow the approach that is followed for any chronic disease, viz., we need to initiate interventions (medical nutrition therapy, lifestyle changes and behavior modification) and keep titrating these with time in order to achieve our treatment goals.

1b. Need for these clinical practice guidelines in the Indian setting

Several studies have demonstrated a rising prevalence of overweight and obesity in our country over the last one or two decades. More importantly, the prevalence of abdominal obesity rates is also very high and is significant even in those with a normal body mass index (BMI). This thin–fat Indian phenotype is unique to India, which is associated with a higher insulin resistance and a greater risk of cardiometabolic abnormalities. Indians are also genetically predisposed to the metabolic consequences of obesity.

Childhood obesity has also shown a significant rise during this period which is a primary driver of obesity later in adulthood, adding to the already high burden of diabetes and cardiovascular diseases in our country. Also, obesity and overweight rates have varied widely across different states and regions within India. What has been consistently demonstrated has been the largely sedentary nature of Indians, with physical inactivity being highly prevalent in urban areas and among women.

India is a large country and, aside from the rural–urban divide, it is diverse in its lifestyle. There is a significant variation in dietary and physical activity patterns as well as cultural and religious beliefs that can have a huge impact on obesity management.

Obesity management in our country has been a neglected area and has remained unstructured and is, therefore, largely unsuccessful and frustrating to the patient and the physician alike.

Clearly, there is an urgent need for concerted efforts to tackle obesity in our country, if we have to significantly halt the rising burden of cardiometabolic disorders. Thus, there is also an urgent need for structured and evidence-based clinical practice guidelines for the management of obesity that addresses the specific needs of the Indian context, as summarized above, and that can see the emergence of focused obesity care in our country.

Recommendations:

1.1 Obesity should be considered as a chronic disease and not a risk factor.

Limited care recommendations:

1.1(L) Obesity should be considered as a chronic disease and not a risk factor.

2. PREVALENCE OF OBESITY IN INDIA

2a. National data: Prevalence in different states and regions

Overweight and obesity are some of the biggest challenges that are faced by modern medicine today. The prevalence of people living with either overweight or obesity worldwide has almost tripled from 1975 to 2016.[2] In 2016, globally, more than a third of adults were overweight and about 12% obese.[3] This translates to 1.9 billion adults in this age group with overweight and over 650 million with obesity. Childhood and adolescent obesity are also on the rise.

Prevalence of generalized obesity as well as of abdominal obesity were reported to be 20% and 23.7%, respectively, in India by the INDIAB- ICMR investigators in 2015.[4] Obesity rates a decade earlier were 16.5% for men and 14.5% for women,[2] suggesting a 25% increase in this period. The INDIAB-ICMR study also showed that 54.5% of Indians were physically inactive, with those from urban areas (60%) more inactive than their rural (50%) counterparts and women more than men.[5]

More recent studies from different parts of India have reported similar or higher prevalence of obesity and abdominal obesity. The Delhi Urban Diabetes Survey (DUDS) in 2018[6] found alarmingly high rates of both overweight or generalized obesity (79.5% %) and abdominal obesity (71%) in a middle-class urban metro city. Another study from Delhi also detected significantly high rates of overweight or obesity (approximately 60%) and central obesity (70%) among women, while corresponding figures among nurses were over 80%.[7]

A secondary data analysis of the National Family Health Surveys (NHFS) in India using Asia-specific cutoffs found that 34.4% of men and 36.2% of women over the age of 18 years were living with overweight or obesity as of 2015–16.[8] It also documented the rising prevalence of obesity in India from what was observed in NHFS III earlier in 2005–6, both in urban as well as rural areas. Older age, higher education, richest wealth quintile, and living in urban areas were the strongest predictors of being overweight or obese. Factors such as unhealthy diet pattern, sedentary lifestyle, odd and prolonged working hours and stress add to the risk in urban areas. In an earlier study, prevalence rates were shown to increase with age, decreasing physical activity, and higher socioeconomic status.[9]

Regional variation within India

There is significant regional variation within India, and prevalence for generalized and abdominal obesity[4] varies from 11.5% and 16.5% in Jharkhand to 31.5% and 37% in Chandigarh, with Maharashtra (15.6% and 17.3%) and Tamil Nadu (24% and 25.5%) in between. The NHFS IV data also showed considerable regional variation[8]: prevalence of overweight and obesity was highest at over 50%–55% in Kerala, Punjab, Goa, Delhi, Tamil Nadu and Sikkim, while it was the lowest in Jharkhand, Bihar, Chhattisgarh and Madhya Pradesh at 23%–27% in the mainland states and in Assam and Meghalaya in the North East at about 27%–30%.

Obesity prevalence in rural India

Two studies from rural India[1011] show clearly that the prevalence of obesity and central obesity is high even in these communities. Rural parts of western India were reported in 2020 to have a 16.5% prevalence of overweight and 24.6% prevalence of obesity. Abdominal obesity was over 30% in both men and women.[10] Obesity (BMI >25 kg/m2) was found in over 50% of adults in rural Kerala,[11] a third of whom had normal weight obesity.

2b. Prevalence across different age groups: Children, adults, and the elderly

Obesity in children

At least 30% of obesity begins in childhood. Conversely, 50%–80% of obese children become obese adults. The older a child when they remain overweight, the greater is the likelihood that it will persistent in adulthood. Hence it is very important to identify and manage childhood obesity.[12]

Childhood obesity has been on the rise in the last three decades. Most studies among schoolchildren between 1990 and 2010 reported a prevalence of obesity of less than 10% and overweight of 12%–22%. This was regardless of whether the children were from Delhi[13141516] or Chandigarh[17] in the north, Chennai in the south,[9] Pune[18] in the west or Bengal in the east.[19]

More recent studies on childhood obesity clearly show a continuing trend of a rising prevalence of obesity in children. The high burden of obesity and abdominal obesity in urban Indian schoolchildren was confirmed in a large multi-center study from different parts of India[20] and was found to be higher in girls and among adolescents.[21]

Factors implicated in the rise of childhood obesity in India include lifestyle factors such as unhealthy eating patterns, sedentary habits of children, such as watching TV, internet surfing, videogaming and restricted playtime, as well as genetic and constitutional factors, such as early life programing, high rates of Gestational diabetes mellitus (GDM) and familial patterns of eating and exercising behaviors.[12]

Obesity among pre-adolescents and adolescents in India

In Chandigarh in 2020,[22] 9.3% and 4.9% of adolescent schoolchildren were found to be overweight and obese, respectively, but abdominal obesity was far higher at 39.3%. Higher levels of obesity and abdominal obesity are associated with hyperinsulinemia and insulin resistance in Asian Indian children and adolescents.[2324]

Obesity in women in the reproductive age group and after menopause

An analysis of females of reproductive age observed that 22.6% of women were overweight and 10.7% were obese.[25] Obesity rates reported recently in menopausal women aged 40–60 years[26] showed that these were high even in rural areas at about 35.5% overall, of which 26% were overweight and 9.5% obese.

Conclusions

The prevalence of obesity and abdominal obesity is rising to alarming levels, particularly in urban India with rural India fast catching up. High obesity rates among children and adolescents are particularly disturbing and highlight the need for focused attention in this group. The wide variation in prevalence of obesity and overweight across different states of India with a higher potential for obesity-related comorbidities suggest that at a national level particular attention must be paid to these states from a public health point of view.

Recommendations:

2.1 A rapid increase in the prevalence of obesity in India warrants urgent attention of all involved stakeholders to work together toward the prevention and management of obesity.

Limited care recommendations:

2.1 (L) A rapid increase in the prevalence of obesity in India warrants urgent attention of all involved stakeholders to work together toward the prevention and management of obesity.

3. Unique Indian Thin–Fat Phenotype

South Asian ethnicity is known to have a unique phenotype known as the thin–fat obesity, wherein individuals have a significantly higher fat content despite an apparently smaller body frame.[2728] This was first depicted in the famous lancet paper called “The Y-Y Paradox” wherein Dr Yajnik, a physician of Indian origin, had almost double the body fat percentage as compared to Dr Yudkin, a physician of Caucasian origin, who had the exact same BMI.[29] This has been shown in several other studies from India and has been called by different names, such as normal weight obesity, metabolic obesity, skinny fat and thin–fat phenotype. The prevalence of normal weight obesity has been found to be about 15% in Chennai and about 16% in Mumbai.[3031] In another recent study from Kerala, the prevalence among high diabetes risk individuals was found to be about 30% of the population.[11] But the prevalence of diabetes, hypertension and dyslipidemia in individuals with normal weight obesity was found to be similar to those with overt obesity and significantly higher than individuals with normal weight and normal body fat. There is emerging evidence on the impact of lifestyle and other interventions in people with obesity. At present, limited literature is available which suggests that individuals with normal weight obesity are more resistant to improvement but do improve following lifestyle interventions.[32] Emerging data from randomized clinical trials using GLP-1 analogues seem to be effective in reducing weight and improving glycemic control in the subset of patients from the South East Asian region.[33]

Recommendations:

3.1 A significant population in the South Asian setting is noted to have normal weight obesity.

3.2 The cardiometabolic risk in individuals with normal weight obesity is at par with those with an overt phenotype of obesity

3.3 Emerging literature suggests slow but a favorable response to lifestyle intervention in people with normal weight obesity

Limited care recommendations:

3.1 (L) A significant population in the South Asian setting is noted to have normal weight obesity.

3.2 (L) The cardiometabolic risk in individuals with normal weight obesity is at par with those with an overt phenotype of obesity

3.3(L) Emerging literature suggests slow but a favorable response to lifestyle intervention in people with normal weight obesity

4. Diagnosis of Obesity: Identification and Classification

4a. Classification of obesity in adults and children

Several definitions [Table 1] and classifications [Table 2] have been proposed to define obesity in the Indian population.[34]

T1-2
Table 1:
Obesity indicators used to define obesity
T2-2
Table 2:
Criteria for using body mass index (BMI) as a measure of obesity in children and adults

Beyond the above-mentioned conventionally used obesity indicators, several others like waist–height ratio, neck circumference, wrist circumference, etc., have also been proposed or used in the Indian setting. In a study on over 500 subjects from New Delhi, waist circumference and waist–height ratio (WHtR) were the best predictors of metabolic disorders in the north Indian population.[35] WHtR also appeared to be the best predictor of hypertension in both genders, particularly in women. In another population-based study from southern India, waist circumference, waist–height ratio and waist–hip ratio stood as the best predictors of underlying diabetes as opposed to other indicators.[36] Neck circumference of ≥37 cm in males and ≥34 cm in females and the ratio of neck circumference and height has also been shown to be a good predictor of metabolic syndrome in the Indian population.[37] Other studies in India have also validated the use of surrogate measures like Metabolic Score for Visceral Fat (METS-VF) to assess visceral adipose tissue. A METS-VF value of 7.3 was found to have a good sensitivity and reasonable specificity in predicting elevated Visceral adipose tissue (VAT) in this population.[38]

4b Assessment of obesity beyond numbers

Despite, several cut-points, noted for different obesity indicators across several ethnicities, the evaluation of obesity is currently moving away from just evaluating it on the basis of numbers and cut points, but towards incorporating all comorbidities as well. Edmonton Obesity Staging System is an example of such a clinical staging system.[38] This incorporates each of the medical, functional and psychological aspects in the evaluation of obesity and has been endorsed by the recently published clinical practice guidelines by the Canadian Obesity Network.[39] The advantage of using this system against the conventional use of BMI is that it can not only predict mortality in a much efficient way, but can also be used to suggest a plan for management of obesity as well.[40] In the Indian setting, data from a tertiary care centre suggests that 68% of the patient population belongs to the stage 3 and 4.[38] [Table 3].

T3-2
Table 3:
The utility of Edmonton Obesity Staging System in therapeutic decision-making

Recommendations:

4.1 We recommend the use of body fat measurement, when feasible, in addition to other anthropometric parameters (like waist circumference, neck circumference, wrist circumference and BMI) for assessment and follow-up of patients seeking obesity management.

4.2 We recommend the use of more comprehensive clinical staging systems like the Edmonton Obesity Staging System for clinical staging, assessment and management of obesity in current day practice.

Limited care recommendations:

4.1(L) Body mass index (BMI), though convenient, is not the best way to assess obesity in the Indian setting. Centripetal assessment with parameters using waist circumference and waist–hip ratio have been validated and shown to be better predictors in the Indian setting. In limited care settings, if BMI is used, we recommend the use of lower cutoffs of BMI, as mentioned in Table 2, to be used in the Indian setting. Novel methods of obesity assessment like neck circumference, wrist circumference, and body fat assessment are being validated in the Indian settings and could be used if available.

4.2(L) We recommend the use of more comprehensive clinical staging systems like the Edmonton Obesity Staging System for clinical staging, assessment and management of obesity in current day practice.

5. ETIOLOGICAL EVALUATION OF OBESITY

As adapted from the Canadian Obesity Network guidelines, the root cause of obesity needs to be identified in each patient, as only once it is assessed appropriately that it will become possible to target that particular aspect, and thereby not only help weight loss but more importantly, attain long-term weight maintenance.[39]

The three domains that need to be assessed for the etiological evaluation of obesity include causes of slow metabolism, increased dietary intake and limited physical activity. These have been summarized in Table 4.

T4-2
Table 4:
Etiological evaluation of obesity

Though exogenous obesity is common, globally, about 5% of patients with obesity may have an underlying genetic component significantly contributing to obesity. This is likely to be more common in the South Asian region as we still have large pockets of consanguineous marriages that happen in India.[41] In other South Asian countries only three monogenic causes (LEP, LEPR and MC4R mutations) could be attributed to 30% of children with obesity in the presence of consanguinity.[42] The key indications for doing a genetic test in individuals withs severe obesity are summarized in Table 5.

T5-2
Table 5:
Indications of performing a genetic test in a patient with obesity

The treating physician should also rule out secondary causes of obesity and associated endocrinopathies.[43] These have been summarized in the Table 6.

T6-2
Table 6:
Endocrine evaluation in a patient with obesity

Recommendations:

5.1 The key cause of weight gain should be identified in each individual seeking evaluation for obesity. These could be screened under the domains of slow metabolism, limited physical activity and increased caloric intake.

5.2 The endocrinopathies and underlying genetic testing should be asked if indicated.

Limited care recommendations:

5.1 (L) The key cause of weight gain should be identified in each individual seeking evaluation for obesity. These could be screened under the domains of slow metabolism, limited physical activity and increased caloric intake.

6. ASSESSMENT OF COMORBIDITIES

A patient with obesity should be assessed both clinically and biochemically for different comorbidities associated with obesity [Table 7]. These should not be just limited to the metabolic comorbidities but could encompass mechanical and psychological associations as well.[39] These have been summarized in the table. Based on several studies from the Indian subcontinent, these comorbidities are often found equal to or even in more frequency that the western counterparts.

T7-2
Table 7:
Comorbidity assessment in a patient with obesity

The key investigations that should be considered while evaluating a patient with obesity are summarized in Table 8. These are only suggested investigations to be chosen from case-to-case basis and not all tests are required for all patients with obesity.

T8-2
Table 8:
Proposed set of investigations in a patient with obesity

Recommendations:

6.1 A comprehensive assessment of obesity-related comorbidities should be done, including metabolic, mechanical and psychological assessments [Table 7].

6.2 The investigations for a patient with obesity should be customized for a given patient and decided by clinical and social parameters [Table 8].

Limited care recommendations:

6.1(L) A comprehensive clinical assessment of obesity-related comorbidities should be done, including metabolic, mechanical and psychological assessments [Table 7]

6.2(L) Fasting and post prandial blood glucose, creatinine, low density lipoprotein and serum glutamic pyruvic transaminase (SGPT) should be tested in all patients with obesity.

7. TREATMENT OF OBESITY

7a. Realistic goal setting

The realistic goals of weight management should be aimed at

  • Preventing further weight gain
  • Reducing bodyweight
  • Short-term goal: 5–10%, or 0.5 to 1 kg per week of weight loss.
  • Interim goal: Maintenance of reduced weight
  • Long-term goal: Additional weight loss, if desired.
  • Maintenance: The achieved lower bodyweight over long term

The goals and weight loss targets are summarized in Tables 9 and 10. Weight management strategies need to be customized based on patient-centric cut-points [Table 11]. Moreover, in certain populations (such as those with eating disorders, pregnancy, organ failures and those receiving chemotherapy) the targets need to be individualized.[44]

T9-2
Table 9:
Goals for obesity management
T10-2
Table 10:
Weight loss targets based on comorbidities[45]
T11-2
Table 11:
BMI cutoffs for management of obesity in South Asians[47 48]

7b. Dietary changes reduction in energy intake

Definition

Medical nutrition therapy (MNT) is defined as a process and provision of nutritional assessment, counselling, advice (dietary, nutritional and culinary) and follow-up for prevention and/or management of obesity by a qualified or trained health care provider.[34]

Challenges of providing medical nutrition therapy in India[49]:

  • In India, MNT is pay from pocket and is not covered by insurance.
  • Lack of Individualized MNT for obesity (mostly MNT is provided as pre-printed diet charts)
  • Lack of awareness among physicians about the importance of MNT.
  • Less number of trained and registered nutritionists.

Recommendations:

7.1 The three steps for an effective, individualized and patient-centric MNT for obesity include [Figure 1][34]

  • A) Understanding the current dietary practices of the individual and family
  • B) Individualized dietary planning
  • C) Careful follow-up
F1-2
Figure 1:
A step-wise approach to effective MNT

7.2 For better adherence and compliance by the patient, MNT should follow the 7As principles. It should be appropriate, accurate as per the patient’s requirement, easily absorbed, and should be affordable, easily accessible, acceptable and attractive for the patient [Figure 2].[4950]

F2-2
Figure 2:
An approach for MNT

7.3 MNT should be appealing to all five human senses (vision, smell, taste, touch, and hearing) as per the ‘Degustation Pentad’ [Figure 3] proposed by Dr Kalra and colleagues.[51]

F3-2
Figure 3:
Degustation entad

7.4 A hypo-caloric diet with reduced portion size is recommended for people living with overweight or obesity.

7.5 MNT should have the “biomedical triplet” or marco-nutrient (carbohydrate, protein and fat) balance correct and should have recommended micronutrients. The nutrient composition of MNT for weight management has been depicted in Table 12. The plate model can be used to control portion size of different major macronutrients [Figure 4].

T12-2
Table 12:
Nutrient distribution in MNT for weight management
F4-2
Figure 4:
The plate model

7.6 Culinary diversity, economic status and food preferences of the person should be kept in mind.

7.7 Mindful and slow eating, eating only in response to sensation of hunger and avoidance of frequent snacking and skipping of meals are recommended.

7.8 Patients should be encouraged to maintain food diaries and journals. This helps understand food patterns, emotional eating patterns, and patients’ perceptions and behaviors toward food.

7.9 Any eating disorders should be identified and treated on priority through proper education, counselling and pharmacotherapy.

7.10 The prescribed nutrition therapy should be compatible with other comorbidities like diabetes, dyslipidemia, chronic kidney disease, celiac disease and hyperuricemia.

7.11 Indications for formula MNT are limited. However, they can be prescribed in the following circumstances:

  • Patients who have a busy lifestyle, or who are not willing to adhere to a strict diet regime.
  • Macronutrient imbalance in available diet.
  • Limited access to healthy cooking.
  • Those who have difficulty in calculating calories.
  • Those having chewing, swallowing or dextromotor limitations and high glycemic variability

Limited care recommendations:

7.1 (L) The three steps for an effective, individualized and patient-centric MNT for obesity include [Figure 1][34]

  • A) Understanding the current dietary practices of the individual and family
  • B) Individualized dietary planning
  • C) Careful follow-up.

7.2 (L) For better adherence and compliance by the patient, MNT should follow the 7As principle. It should be appropriate, accurate as per the patient’s requirement, easily absorbed, and should be affordable, easily accessible, acceptable and attractive for the patient [Figure 2].[4950]

7.3 (L) MNT should be appealing to all five human senses (vision, smell, taste, touch, and hearing) as per the ‘Degustation Pentad’ [Figure 3] proposed by Dr Kalra and colleagues.[51]

7.4 (L) A hypo-caloric diet with reduced portion size is recommended for people living with overweight or obesity.

7.5 (L) MNT should have the correct balance of the “biomedical triplet” or macronutrients (carbohydrate, protein and fat) and should have the recommended micronutrients. The nutrient composition of MNT for weight management has been depicted in Table 12. The plate model can be used to control portion size of different major macronutrients [Figure 4].

7.6 (L) Culinary diversity, economic status and food preferences of the person should be kept in mind.

7.7(L) Mindful and slow eating, eating only in response to the sensation of hunger and avoidance of frequent snacking and skipping of meals are recommended.

7.8 (L) Patients should be encouraged to maintain food diaries and journals. This helps understand food patterns, emotional eating patterns, and patients’ perceptions and behaviors toward food.

7.9 (L) Any eating disorders should be identified and treated on priority through proper education, counseling and pharmacotherapy.

7.10 (L) The prescribed nutrition therapy should be compatible with other comorbidities like diabetes, dyslipidemia, chronic kidney disease, celiac disease and hyperuricemia.

7c. Increasing physical activity and life style interventions

Definition

Physical activity is defined as any body movement produced by the skeletal muscles that results in energy expenditure beyond resting energy expenditure.

Exercise is referred to as a physical activity that is planned, structured, repetitive and purposeful, aimed at improving or maintaining physical fitness.

Aims of physical activity and exercise[50]:

  • Causes modest weight reduction
  • Preserving fat-free mass and maintaining weight
  • Promotes cardio-respiratory fitness and reduces cardiovascular risk

Recommendations[395152]:

7.12 Physical activity counselling should be an integral part of obesity management. This should include advice on building physical activity in everyday life and supervised, structured exercise program under the guidance of an expert.

7.13 Physical activity must be individualized on the basis of the person’s abilities and comorbidities.

7.14 Structured exercise levels should be gradually stepped up to levels that are safe for the patient.

7.15 Pre-participation medical consultation is recommended for those with chronic conditions or those who are symptomatic.

7.16 Aerobic physical activity (30–60 minutes of moderate to vigorous intensity on most days of the week) will help in

  • Modest amounts of bodyweight and fat loss
  • Reduction in visceral fat and ectopic fat even in the absence of weight loss
  • Weight maintenance and fat-free mass after weight loss
  • Increase cardiorespiratory fitness and mobility

7.17 There is a dose-response relationship between physical activity and health. High-intensity interval training can help increase cardio respiratory fitness, and achieve fat-free muscle mass.

7.18 Adults can increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate-intensity, or 150 minutes a week of vigorous-intensity aerobic physical activity.

7.19 Resistance training may promote weight maintenance or modest increases in muscle mass or fat-free mass and mobility.

7.20 Regular physical activity can improve health-related quality of life, mood disorders (i.e., depression, anxiety) and body image in adults living with overweight or obesity.

7.21 Physical activity can be accumulated throughout the day in blocks as short as 10 minutes. Work-related activity should be encouraged wherever possible.

7.22 Action is needed at the individual, community and societal level to help Indians become more physically active.

Limited care recommendations:

7.11 (L) Physical activity counselling should be an integral part of obesity management. This should include advice on building physical activity in everyday life and supervised, structured exercise program under the guidance of an expert.

7.12 (L) Physical activity must be individualized on the basis of the person’s abilities and comorbidities.

7.13 (L) Structured exercise levels should be gradually stepped up to levels that are safe for the patient.

7.14 (L) Pre-participation medical consultation is recommended for those with chronic conditions or those who are symptomatic.

7.15 (L) Aerobic physical activity (30–60 minutes of moderate to vigorous intensity on most days of the week) will help in

  • Modest amounts of bodyweight and fat loss
  • Reduction in visceral fat and ectopic fat even in the absence of weight loss
  • Weight maintenance and fat free mass after weight loss
  • Increase cardiorespiratory fitness and mobility

7.16 (L) There is a dose-response relationship between physical activity and health. High-intensity interval training can help increase cardio respiratory fitness, and achieve fat-free muscle mass.

7.17 (L) Adults can increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate-intensity, or 150 minutes a week of vigorous-intensity aerobic physical activity.

7.18 (L) Resistance training may promote weight maintenance or modest increases in muscle mass or fat-free mass and mobility.

7.19 (L) Regular physical activity can improve health-related quality of life, mood disorders (i.e., depression, anxiety) and body image in adults living with overweight or obesity.

7.20 (L) Physical activity can be accumulated throughout the day in blocks as short as 10 minutes. Work-related activity should be encouraged wherever possible.

7.21 (L) Action is needed at the individual, community and societal level to help Indians become more physically active.

7d. Medications

Recommendations[395152]:

7.23 Indications: In Asian Indians, pharmacotherapy should be initiated along with lifestyle modifications in individuals with a BMI >27 kg/m2 or in individuals with a BMI >25 kg/m2 with at least one associated comorbid medical condition such as hypertension, dyslipidemia, type 2 diabetes (T2DM), and obstructive sleep apnea. A higher cutoff of BMI >30 kg/m2 or >27 kg/m2 with comorbidities are endorsed by western guidelines.

7.24 Pharmacotherapy is indicated at a lower BMI cutoff in individuals who are unable to exercise. It can increase adherence to behavior change and may improve physical functioning to enhance physical activity.

7.25 Monitoring for weight loss and adverse events of drugs should be done at least monthly for the first three months, then at least every three months.

7.26 Effective response to a pharmacotherapeutic agent has been defined as weight loss of <5% of bodyweight at three months and which can be safely achieved. If found ineffective (i.e., weight loss <5% at three months) or if there are safety or tolerability issues, the medication can be discontinued and alternative medications or treatment approaches may be tried.

7.27 Orlistat is the only approved and available pharmacotherapeutic agent for obesity management in India at present. It is to be used at a dose of 120 mg thrice a day before major meals depending on the tolerance. The various drugs used for obesity management and their approval status in India have been listed in Table 13.

7.28 For management of comorbidities or associated illnesses in a person living with obesity, it is prudent to avoid drugs that can increase weight. Rather, one can preferably choose medications which are weight safe (weight neutral or reducing) [Table 14].

T13-2
Table 13:
Pharmacological options for weight management
T14-2
Table 14:
Selection of drugs for management of associated comorbidities in obesity[53]

Limited care recommendations:

7.22 (L) For management of comorbidities or associated illnesses in a person living with obesity, it is prudent to avoid drugs that can increase weight. Rather, one can preferably choose medications which are weight safe (weight neutral or reducing) [Table 14].

7e. Bariatric surgery and intragastric devices

The indications and contraindications have been quoted in Table 15. As per western guidelines, bariatric surgery is reserved for patients if conventional treatment is not viable and if BMI is: >40 kg/m2; or >35 kg/m2 with comorbidities; or BMI >30 kg/m2 if the patient has comorbid T2DM.[54]

T15-2
Table 15:
Indications met for metabolic surgery

Bariatric surgery involves modification of the digestive system by either decreasing the gastric volume (restriction) or altering the path of the alimentary tract, causing nutrient mal-absorption.[5556]

There are various surgical procedures.

  • Restrictive procedures: Adjustable gastric banding (LAGB) and sleeve gastrectomy,
  • Combined procedures: Roux-en-Y Gastric Bypass (RYGBP),
  • Malabsorptive procedures: Bilio-pancreatic diversions (BPD),
  • Experimental procedures: Ileal interposition and duodeno-jejunal bypass, various implantable pulse generators.

The most common types of bariatric surgeries currently practiced are gastric bypass, adjustable gastric band, and sleeve gastrectomy. The difference between these procedures are mentioned below in Table 16.

T16-2
Table 16:
Various surgical procedures with merits and demerits[55 56]

Recommendations:

7.29 For Asian Indians, bariatric surgery is indicated if BMI is >32.5 kg/m2 with comorbidity, and BMI is >37.5 kg/m2 without comorbidity. The indications and contraindications have been quoted in Table 15.

Limited care recommendations:

7.23 (L) For Asian Indians bariatric, surgery is indicated if BMI is >32.5 kg/m2 with comorbidity, and BMI is >37.5 kg/m2 without comorbidity. The indications and contraindications have been quoted in Table 15. The patients should utilize health insurance coverage for bariatric surgery.

8. COMMUNICATION IN OBESITY MANAGEMENT

Background and evidences

Communication is a fundamental initial step in obesity management. Obtaining consent before starting a discussion on obesity, avoiding stigmatization and motivational interviewing are three components of effective communication.

Health care professionals (HCPs) should not assume that all patients living with obesity will essentially seek consultation for obesity management. A prior consent from the patient is a must for each member of the health care team before initiating a discussion on obesity and weight management issues.[39]

Stigmatization has been noted in different settings for individuals with obesity, starting from the work place, family, friends and public, and also in the media. It is also prevalent among HCPs. Weight bias in the health care set up and public can lead not only to poor compliance and discontinuation of therapy but also various complications like poor self-image, eating disorders, depression and suicidal tendencies. Weight bias can be minimized by self-assessment of health care team by certain tools, like the Implicit Association Test for weight bias.[575859]

Motivational interviewing (MI) is a powerful tool for engaging the patient and the HCPs in a productive conversation for a collaborative goal setting and management strategy.[6061] The core components of MI have been listed below:

  • Respecting autonomy
  • Understanding the patient’s own motivations
  • Active listening
  • Improving confidence of the patient with empathy
  • Open-ended questions, affirmations, reflections, and summaries (OARS).

Recommendations:

8.1 Welcoming the patient without negative judgment and bias.

8.2 Taking consent and asking the patient whether they are ready to discuss about weight-related issues.

8.3 Recognizing obesity as a complex condition with multifactorial etiology and avoiding blaming or stigmatization.

8.4 Avoiding language that may be hurtful to the person with obesity.

8.5 Being empathetic throughout the conversation to maintain a positive, constructive and helpful relationship with the patient.

8.6 Using MI which is a collaborative and non-judgmental discussion method allowing strengthening of the patient’s own motivation and stimulating their involvement toward a behavioral change.

Limited care recommendations:

8.1 (L) Welcoming the patient without negative judgment and bias.

8.2 (L) Obtaining consent and asking the patient whether they are ready to discuss weight-related issues.

8.3 (L) Recognizing obesity as a complex condition with multifactorial etiology and avoiding blaming or stigmatization.

8.4 (L) Avoiding language that may be hurtful to the person with obesity.

8.5 (L) Being empathetic throughout the conversation to maintain a positive, constructive and helpful relationship with the patient.

8.6 (L) Using MI which is a collaborative and non-judgmental discussion method allowing the strengthening of the patient’s own motivation and stimulating their involvement toward a behavioral change.

8.7 (L) Time constraint is a major challenge.

9. FOLLOW-UP OF A PATIENT WITH OBESITY

Strategies to prevent weight gain

Obesity is considered to be a chronic condition with a propensity for relapses.[62] Despite initial success in weight reduction, weight regain is common.[63] Greater than 50% of weight lost is regained within two years of follow-up.[64]

A multidisciplinary team targeting diet, exercise and pharmacotherapy has shown to be effective in preventing weight regain.[65] Adherence to a heathy diet with consumption of planned meals, regulation of portion sizes, avoidance of fast food, increased intake of fruit and vegetables has been noted in individuals who manage to sustain weight loss.[6667] Frequent physical activity, especially brisk walking, has also been associated with weight loss maintenance.[6869] As compared to short-term treatments, prolonged follow-up with health care providers, whether individually or as group sessions, has shown superior results in weight-loss maintenance.[70] Frequent self-weighing is associated with beneficial effects on weight-loss maintenance, irrespective of the underlying weight-loss intervention.[6371] The average weight loss expected with diet, physical activity and behavioral therapy is around 5%–10%, which may be much lower than what patients or physicians expect to see.[7273] Education about the same may help to prevent disappointment with outcomes which are reasonably good. A comparison between the weight loss already achieved by the patient and that documented with similar treatments in literature may improve patient satisfaction with their results. Modest weight loss in the range of 6%–7% bodyweight has been associated with numerous health benefits including reduced risk of diabetes, improvement in cardiovascular risk factors, reduced need for antihypertensive and lipid lowering medications, as well as reduction in hospitalizations.[7475] These health benefits can motivate the patient to continue weight loss efforts despite not seeing major changes in bodyweight. Awareness about the high likelihood of weight regain in obese patients who lose weight can enable the patient to anticipate and make efforts to prevent weight regain.

Relapse prevention training and problem-solving training are behavioral interventions which enable the patient to anticipate high-risk situations, help them identify and counter the lapses and prevent them from giving up.[76]

Recent clinical trials suggest that the GLP-1 agonists may help in long-term weight-loss maintenance when added to the ongoing lifestyle modifications.[7778]

Recommendations:

9.1 A multidisciplinary team that integrates diet, exercise and pharmacotherapy should be involved in follow-up care.

9.2 Patients who have been able to lose weight should be informed that weight regain during follow-up is common.

9.3 Ongoing interaction with the HCP (s) in the period following initial weight loss should be maintained.

9.4 Frequent weighing should be advised in the follow-up period.

9.5 Counselling for long-term weight-loss maintenance should be provided with emphasis on the following points:

  • Realistic expectation for weight loss should be promoted to avoid demoralization and promote adherence.
  • Efforts should be made to enhance patient satisfaction with already achieved outcomes.
  • Heath benefits and reduction of disease risk factors with modest weight loss should be emphasized.
  • Cognitive modifications targeting behavioral fatigue and adoption of realistic behavioral goals is advisable.

9.6 Relapse prevention training and/or problem-solving training should be provided whenever feasible.

9.7 Pharmacotherapy, especially GLP-1 agonists, may be initiated for weight-loss maintenance.

Limited care recommendations:

9.1 (L) The treating physician should reinforce the role of diet and physical activity in weight-loss maintenance.

9.2 (L) Patients who have been able to lose weight should be informed that weight regain during follow-up is common.

9.3 (L) Follow-up visits should be scheduled every three months, if feasible, and should include weight measurement.

9.4 (L) Counseling for long-term weight-loss maintenance should be provided with emphasis on the following points:

  • Realistic expectation for weight loss should be promoted to avoid demoralization and promote adherence.
  • Efforts should be made to enhance patient satisfaction with already achieved outcomes.
  • Heath benefits and reduction of disease risk factors with modest weight loss should be emphasized.

10. MANAGEMENT IN SPECIFIC CONDITIONS

10a. Obesity in children

Healthy eating habits as mentioned in Table 17 are essential in reducing ingested calories and, hence, beneficial in prevention as well as treatment of obesity. Sugar sweetened beverages, fast foods, high-fructose corn syrup, added sugars and foods rich in fats are associated with obesity.[79-81] Similar data has been reported from studies in India, including those from rural areas in Sikkim and Himachal Pradesh.[8283] Skipping breakfast was associated with overweight and obesity in children in Delhi.[84] Self-reported physical activity has shown an association with obesity in 10–14-year-old children in a study from North India.[85] In children, one hour of physical activity has been recommended.[86] Television watching has been associated with obesity in a study from West Bengal.[87] More than two hours of screen time is associated with obesity in both children and parents.[88] Children with obesity may suffer from low self-esteem and report poor quality of life.[89] Adolescents are more likely to suffer from low self-esteem. Lack of support from family and bullying or teasing by peers contributes to low self-esteem and poor quality of life.[90] Depression, anxiety and eating disorders are common and should be addressed concurrently.[91]

T17-2
Table 17:
Healthy eating habits recommended for children with obesity

Pharmacotherapy should be considered only if a formal lifestyle intervention program has not been able to reduce weight gain. Orlistat has been used on obese adolescents, but long-term compliance rates have been poor.[92] Metformin has been used in some studies, but the weight loss has been modest.[93] Liraglutide has shown reduction in BMI when used in obese adolescents in addition to lifestyle intervention.[94] In a small study, liraglutide showed reduction in weight, glycemic parameters and blood pressure in Indian adolescents.[95] Data on other drugs are scanty.

Bariatric surgery is offered to adolescents with BMI >40 kg/m2 or >35 kg/m2 with significant comorbidities, after formal intensive lifestyle modification with or without pharmacotherapy has failed. Other conditions mentioned in Table 18 must also be met. Both vertical sleeve gastrectomy and Roux-en-Y gastric bypass have been performed on adolescents and the weight reduction seems to be comparable.[96] A multidisciplinary team including a surgeon, a pediatric endocrinologist, a nutritionist and a mental health professional should be involved in such cases. Psychological complications can emerge postoperatively.[97] Long-term follow-up for management of nutritional deficiencies and other post-surgical complications is required.[98]

T18-2
Table 18:
Criteria to be fulfilled prior to considering bariatric surgery in children

Recommendations:

10.1 Formal dietary advice should be provided, taking into account the caloric requirement of the patient. Healthy eating habits should be encouraged [Table 17].

10.2 Children should engage in a minimum of 20 minutes of moderate-to-vigorous physical activity daily, with a target of achieving 60 minutes of such activity.

10.3 Non-academic screen time should be restricted to 1–2 hours per day. Healthy sleeping patterns should be encouraged.

10.4 Parents should be educated about the need to develop a conducive atmosphere for weight loss by providing emotional support and avoiding negative comments which may lower self-esteem

10.5 Psychosocial comorbidities should be identified and treated.

10.6 Pharmacotherapy should be initiated only if a trial of formal intensive lifestyle modification including diet and physical activity have not been able to reduce weight gain. Only physicians experienced with the use of such medications in children should prescribe such treatments.

10.7 Bariatric surgery should only be reserved for patients in who fulfill the criteria mentioned in Table 17.

Limited care recommendations:

10.1 (L) Formal dietary advice should be provided taking into account the caloric requirement of the patient. Healthy eating habits should be encouraged [Table 17].

10.2 (L) Children should engage in a minimum of 20 minutes of moderate-to-vigorous physical activity daily with a target of achieving 60 minutes of such activity.

10.3 (L) Non-academic screen time should be restricted to 1–2 hours per day. Healthy sleeping patterns should be encouraged.

10.4 (L) Parents should be educated about the need to develop a conducive atmosphere for weight loss by providing emotional support and avoiding negative comments which may lower self-esteem of the child.

10.5 (L) Psychosocial comorbidities should be identified and treated.

10.6 (L) Patients not improving despite lifestyle measures should be referred to higher centers.

10b. Obesity during pregnancy

Obesity during pregnancy is associated with adverse outcomes for both the mother and the fetus.[99] Wherever feasible, obesity should be diagnosed before conception is planned, and attempts should be made to achieve weight loss prior to conception. Obese women are prone to both folic acid deficiency and neural tube defects in the fetus.[100] Hence, folic acid supplementation should be initiated before conception or as early as possible in the pregnancy.[101] Vitamin D supplementation has been advocated by some guidelines. At the first antenatal visit, height, weight and BMI should be recorded.[102] Weight should be measured subsequently at each antenatal visit. It is currently recommended that gestational weight gain should be limited to 5–9 kilograms.[103] Vaccination for H1N1 has been recommended as H1N1 pneumonia in obese pregnant women is more likely to lead to adverse outcomes.[104]

Nutritional advice to limit gestational weight gain has to be individualized according to the BMI, physical activity and age of the patient.[105] Physical activity is beneficial in limiting gestational weight gain but attention to risk of injury from falls or other accidents is essential.[106] Obese women are at risk of both pregestational as well as gestational diabetes mellitus. Hence, screening with 75 gm Oral glucose tolerance test (OGTT) should be done in early pregnancy as well as at 24–28 weeks of gestation. The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria should be used for diagnosing gestational diabetes mellitus while the ADA/WHO criteria for diabetes mellitus in non-pregnant adults should be used in the first trimester.[107108] Obese women are at an increased risk of pregnancy-induced hypertension, venous thromboembolism and obstructive sleep apnea.[109] Screening for these complications and appropriate management is necessary. Adverse fetal outcomes should be anticipated and managed accordingly.[110] Depression and anxiety are common in obese women with pregnancy and require treatment by a mental health professional.[111]

Recommendations:

10.8 Obesity should be diagnosed wherever possible prior to conception, and advice regarding weight reduction should be provided.

10.9 Before conception, folic acid supplementation should be considered to prevent neural tube defects.

10.10 Height and weight should be recorded at first antenatal visit. BMI should be calculated and these parameters should be documented. Weight should be recorded at each antenatal visit.

10.11 Patients with obesity should be advised to limit gestational weight gain to 5–9 kilograms.

10.12 The risks associated with obesity in pregnancy should be explained to the patient [Table 19].

T19-2
Table 19:
Risks associated with obesity and pregnancy

10.13 Vaccination for H1N1 should be offered to pregnant women with obesity.

10.14 Formal diet advice to limit gestational weight gain along with general information regarding healthy diet should be provided to all patients.

10.15 Moderate physical activity should be prescribed while avoiding risk of fall or injury.

10.16 Screening for gestational diabetes should be conducted in all pregnant women with obesity at the first antenatal visit, and again at 24–28 weeks.

10.17 Screening and appropriate management of complications mentioned in Table 19 should be done as appropriate.

10.18 Mental health problems such as depression and anxiety should be looked for and treated, if present.

Limited care recommendations:

10.7 (L) Obesity should be diagnosed wherever possible prior to conception, and advice regarding weight reduction should be provided.

10.8(L) Before conception, folic acid supplementation should be considered to prevent neural tube defects.

10.9(L) Height and weight should be recorded at first antenatal visit. BMI should be calculated and these parameters should be documented. Weight should be recorded at each antenatal visit.

10.10(L) Patients with obesity should be advised to limit gestational weight gain to 5–9 kilograms.

10.11(L) The risks associated with obesity in pregnancy should be explained to the patient [Table 19].

10.12(L) Vaccination for H1N1 should be offered to pregnant women with obesity.

10.13(L) Formal diet advice to limit gestational weight gain along with general information regarding healthy diet should be provided to all patients

10.14(L) Moderate physical activity should be prescribed while avoiding risk of fall or injury.

10.15(L) Screening for gestational diabetes should be conducted in all pregnant women with obesity at the first antenatal visit and again at 24–28 weeks.

10.16(L) Screening and appropriate management of complications mentioned in Table 19 should be done as appropriate.

10.17(L) Mental health problems such as depression and anxiety should be looked for and treated, if present.

10c. Sarcopenic obesity

Sarcopenic obesity refers to the coexistence of obesity with reduced muscle mass and muscle function.[112113] This is seen more commonly in elderly individuals.[114115] Nutritional intervention and physical activity is the mainstay of treatment. Intentional weight loss along with exercise improve physical function in sarcopenic obese adults.[116] Both aerobic activity as well as resistance training should be undertaken. Resistance training causes greater improvement in functional status probably by stimulating muscle growth.[116117] Calorie restriction is essential to induce weight loss, and chronic calorie restriction does not lead to muscle loss, provided physical activity including resistance training is continued.[118] The daily protein requirement in the elderly has been a matter of debate: while 1.0–1.2 grams of protein per kg bodyweight has been recommended, some data suggest that 0.8 g/kg per day protein is enough to maintain lean body mass and muscle function.[119120] At present, there is inadequate data to support the use of pharmacotherapy and bariatric surgery in sarcopenic obesity.[113] Testosterone is not recommended for use in view of lack of evidence of benefit and risk of adverse effects.[121] There are several novel therapies which are undergoing evaluation, but, at present, data is scanty.

Recommendations:

10.19 Both nutritional intervention as well as physical activity should be employed in the management of sarcopenic obesity.

10.20 The diet should contain adequate amount of protein.

10.21 Physical activity should include resistance training to maintain muscle mass.

10.22 The use of testosterone for sarcopenic obesity is not recommended in the absence of clinical and biochemical evidence of hypogonadism.

10.23 The use of novel therapies like ghrelin analogues, selective androgen receptor modulators, myostatin inhibitors, vitamin K and stem cell therapy is still investigational and is not recommended for clinical use.

Limited care recommendations:

10.18(L) Both nutritional intervention as well as physical activity should be employed in the management of sarcopenic obesity.

10.19 (L) The diet should contain adequate amount of protein.

10.20 (L) Physical activity should include resistance training to maintain muscle mass.

10.21 (L) The use of testosterone for sarcopenic obesity is not recommended in the absence of clinical and biochemical evidence of hypogonadism.

10d. Diabesity

Diabesity refers to the coexistence of T2DM with obesity. The management of diabesity centers on medical nutrition therapy and physical activity. The Indian diet is often rich in carbohydrates and fats, while poor in proteins. It is recommended that a reduction of current carbohydrate intake by 10%–15% along with an increase in current protein intake by 10% (with a maximum of 1 g/kg per day) should be attempted. The intake of visible fat should be minimized.[34] Diabesity adversely affects the quality of life of the patients, and the psychological aspects of diabesity may require treatment.[122] The patients should be educated about diabesity and should be involved in their own care by respecting their decisions and values. Drugs like metformin, sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, which induce weight loss, and DPP-4 inhibitors (weight neutral) should be preferred in the management of hyperglycemia in diabesity.[123] An observational study from India suggests that including two or more drugs from the classes of biguanides, SGLT2 inhibitors, GLP-1 receptor agonists and orlistat may be beneficial in diabesity. Those on two or three drugs had greater weight loss and greater reduction in HbA1c as compared to monotherapy.[124] Bariatric surgery should be considered in patients with diabesity who do not appear to benefit from MNT and appropriate pharmacotherapy. Bariatric surgery has shown good results in both weight reduction as well as glycemic control even in patients without morbid obesity.[125] In fact, remission of diabetes has been observed in a large percentage of patients in several studies.[126127]

Recommendations:

10.24 Medical nutrition therapy (MNT) and advice on physical activity should be provided to all patients with diabesity.

10.25 The MNT for diabesity should include a reduction of carbohydrate intake while maintaining adequate protein intake and a minimization of intake of visible fat.

10.26 The impact of diabesity on quality of life should be taken into account and psychological aspects of the disease should be addressed.

10.27 Patient education about diabetes and obesity should be provided, and shared decision-making should be encouraged to improve motivation

10.28 The drugs which induce weight loss or are weight-neutral should be preferred for glycemic control in diabesity.

10.29 Multidrug therapy with two or more drugs capable of inducing weight loss is advisable, if adequate weight loss has not been achieved with lifestyle intervention and/or monotherapy.

10.30 Bariatric surgery can be considered in patients who are not able to meet glycemic or weight-loss targets despite optimal MNT and pharmacotherapy.[128]

Limited care recommendations:

10.22 (L) MNT and advice on physical activity should be provided to all patients with diabesity.

10.23 (L) The MNT for diabesity should include a reduction of carbohydrate intake while maintaining adequate protein intake and a minimization of intake of visible fat.

10.24 (L) The impact of diabesity on quality of life should be taken into account and psychological aspects of the disease should be addressed.

10.25 (L) Patient education about diabetes and obesity should be provided, and shared decision-making should be encouraged to improve motivation.

10.26 (L) The drugs which induce weight loss or are weight-neutral should be preferred for glycemic control in diabesity.

10.27 (L) Multidrug therapy with two or more drugs capable of inducing weight loss is advisable if adequate weight loss has not been achieved with lifestyle intervention and/or monotherapy.

10.28 (L) Bariatric surgery can be considered in patients who are not able to meet glycemic or weight-loss targets despite optimal MNT and pharmacotherapy.[128]

11. ROLE OF GENETIC TESTING

Obesity is a heterogenous disorder which also has a heritable component. Genetic and syndromic obesity disorders constitute a small portion of pediatric obesity. Most of adult obesity has a polygenic inheritance, with a small percentage of patients suffering from monogenic causes of obesity.[129] Genome-wide association studies have shown that over 900 independent single nucleotide variants (SNVs) are associated with obesity.[130] The fat mass and obesity (FTO) gene is probably the dominant contributor to polygenic obesity. Common variants, especially rs8050136, of the FTO gene have been associated with obesity in the Indian population as well.[131132] Tumor necrosis factor-a (TNF-a) 308G > A polymorphisms and LMNA 1908C > T variant have also been associated with obesity in India.[133134] Polymorphisms of INSIG2 gene have been associated with obesity in North Indian subjects.[135] Polymorphisms of FTO and vitamin D receptor genes may influence the response to weight-loss intervention in Indian patients.[136] However, since many genes and their variants contribute synergistically to the development of obesity, polygenic risk scores are probably superior in predicting obesity risk than individual variants.[137] The clinical utility of these risk scores is still being explored. The behavioral outcomes of genetic testing for obesity are also unclear.[138] At present, the management recommendations of obesity remain uniform for adults with polygenic obesity, and routine testing is not recommended.

Childhood extreme obesity with early onset may be due to genetic conditions associated with developmental delay including Prader–Willi syndrome, Albright hereditary osteodystrophy, Bardet–Biedl syndrome.[139] Other causes which may not cause developmental delay include melanocortin 4 receptor (MC4R) deficiency, Alström syndrome, leptin or leptin receptor deficiency, proopiomelanocortin (POMC) deficiency and proprotein convertase subtilisin/kexin (PCSK-1) deficiency.[140] Genetic testing is advisable in these conditions. Whole exome sequencing has been used to identify novel mutations in Indian patients.[141] Specific treatments for obesity may be available in some of these conditions such as leptin deficiency and Prader–Willi syndrome.[142143]

Recommendations:

11.1 Genetic testing for obesity in adults is not recommended outside of research settings unless other clinical features of genetic obesity syndromes are present.

11.2 Genetic testing is recommended for children who have extreme obesity with an onset before 5 years of age along with clinical features of genetic obesity syndromes and/or family history of extreme obesity.

Limited care recommendations:

11.1 (L) Genetic testing for obesity in adults is not recommended outside of research settings unless other clinical features of genetic obesity syndromes are present.

11.2 (L) Genetic testing is recommended for children who have extreme obesity with an onset before 5 years of age along with clinical features of genetic obesity syndromes and/or family history of extreme obesity.

12. BARRIERS TO OBESITY MANAGEMENT IN THE INDIAN SETTING

Physician education on obesity and its management during their training has been noted to be poor.[144] Personal biases, both explicit and implicit, have been noted in physicians which can affect the delivery of care.[145146] Physicians have reported that their busy schedules may not allow enough time to spend on the care of obesity.[147] Primary and secondary care facilities may not have dieticians, educators and psychologists with expertise regarding management of obesity.

Most patients do not realize that obesity is a chronic relapsing condition which requires lifelong intervention.[65] Patients, and many physicians, feel that the treatment of obesity is limited to losing weight. However, since weight regain is common, strategies to prevent weight regain are essential. Obese individuals may not realize or accept that lifelong changes in diet and physical activity are needed to maintain weight loss.[148] There may be a reluctance to implement long-standing lifestyle alterations. Poor compliance to pharmacological interventions may also be a factor.

The patients belonging to low socioeconomic status may encounter barriers such as higher cost of healthy foods including fruits and vegetable, cheaper and easily available foods that are high in refined carbohydrates, and lack of space for engaging in physical activity.[149] The ability to access health care advice and cost of pharmacotherapy may also be limiting factors. There may be a greater acceptability of obesity in lower socioeconomic strata.[150] As diseases such as tuberculosis, which often manifest with weight loss, are common, at least milder forms of obesity may be inferred as good health.[151] Patients with busy schedules may not find enough time to engage in physical activity. Similarly, lack of time is a deterrent in planning and cooking healthy meals instead of consuming readily available calorie-dense food.[152] Consumption of large amounts of food during social gatherings and festivals is common, and refusal to participate may not be considered positively by family and friends.[153] Similarly social and professional obligations also may mandate consumption of alcohol along with unhealthy foods.[154] Adequate support from family and friends is needed to sustain weight loss and weight maintenance intervention. Obese patients, especially those seeking treatment, are more likely to be having metal health issues including depression, anxiety disorders, eating disorders (binge eating disorders and night eating syndromes) and substance abuse.[155156]

Disrupted or inadequate sleep has been associated with obesity. Obstructive sleep apnea with daytime somnolence may lead to poor physical activity and reduced compliance with other weight loss efforts.[157158] Osteoarthritis of the knee, back pain and chronic generalized pains are associated with obesity. These may reduce the ability as well as the motivation to engage in physical activity as well as other lifestyle modifications.[159] Obesity is associated with cardiovascular diseases as well as dyspnoea.[160] Symptoms like angina, claudication, dyspnea or paralysis due to stroke can impair physical activity.[161] Insulin resistance states like T2DM and polycystic ovary disease are associated with high insulin levels and increased liver and visceral fat. These factors have been associated with a poor response to lifestyle interventions as well as pharmacotherapy.[162] Alcohol consumption may be associated with higher BMI.[163]

Awareness and access to surgical treatments is low.[55164] Fear of complications is also a deterrent. The high cost of pharmacological therapy and the injectable nature of some medications are also barriers to drug treatment.[165]

Recommendations:

12.1 The barriers to obesity management in the Indian setting are listed in Table 20.

T20-2
Table 20:
Barriers of obesity management in the Indian setting

Limited care recommendations:

12.1 (L) The barriers to obesity management in the Indian setting are listed in Table 20.

13. PREVENTION OF OBESITY

Obesity is easier to prevent than to manage. It makes sense, therefore, to focus on obesity prevention. The multifactorial nature of obesity, its causes, clinical features, comorbidities, and complications, however, require a multidimensional approach to its prevention.[34122] Various arms of the government, including political, bureaucratic and technocratic, need to work in cohesion. Ministries should ensure their policies regarding nutrition, health, agriculture, trade and finance are concordant with each other.

Obesity can be tackled at a population level (community level) as well as individual level. While multiple strategies will need to run concurrently, it must be noted that obesity is a community or family disorder, rather than a disease of individuals. This means that individual-based strategies will have limited chance of success, unless they are coupled with sensitization and behavior modification of the family, in particular, and society, in general.[166]

Table 21 lists the various levels of obesity prevention. Population-based strategies are structured as policy direction, policy-making, partnership and policy implementation. A separate heading, “Policy for targeted population,” has been included to highlight the need to focus on childhood obesity. Individual-based intervention is listed under three headings: pragmatic therapy, target and tools. This helps readers conceptualize these approaches and activities.

Recommendations:

13.1 The population-based and individual-based strategies for prevention of obesity are shown in Table 21.

T21-2
Table 21:
Prevention of obesity

Limited care recommendations:

13.1 (L) The population-based and individual-based strategies for prevention of obesity are shown in Table 21.

14. FUTURE DIRECTION AND NEED FOR RESEARCH

As the obesity epidemic grows, so will the need for more information and insight regarding the syndrome. This is especially true for India, which needs local data upon which to base its clinical and public health strategies. While we do have good quality work published by Indian authors, there is a need to promote original research in the country. While original research is the gold standard, one can also perform secondary data analysis of pre-existing published data sets to attain meaningful insights into obesity and its management. Some focus areas for future research are listed in Table 22.

T22-2
Table 22:
Focus areas for future research in obesity

Indian endocrine and metabolic journals should take the lead in promoting obesity as an integral part of endocrinology, by publishing manuscripts related to the field.

Recommendations:

14.1 The focus areas for future research in obesity are listed in Table 22.

Limited care recommendations:

14.1 The focus areas for future research in obesity are listed in Table 22.

REFERENCES

1. Wilding JP, Mooney V, Pile R Should obesity be recognised as a disease? BMJ 2019 366 l4258
2. Puska P, Nishida C, Porter D, Organization WH Obesity and overweight World Health Organization 2003 1–2
3. WHO. World Health Organization Global Health Observatory (GHO) Data. Obesity and Overweight 2016 Available from: https://apps.who.int/gho/data/node.main.A896?lang=en
4. Pradeepa R, Anjana RM, Joshi SR, Bhansali A, Deepa M, Joshi PP, et al Prevalence of generalized &abdominal obesity in urban &rural India--The ICMR-INDIAB Study (Phase-I) [ICMR- NDIAB-3] Indian J Med Res 2015 142 139–50
5. Anjana RM, Pradeepa R, Das AK, Deepa M, Bhansali A, Joshi SR, et al Physical activity and inactivity patterns in India–results from the ICMR-INDIAB study (Phase-1)[ICMR-INDIAB-5] Int J Behav Nutr Phys Act 2014 11 1–11
6. Madhu SV, Sandeep G, Mishra BK, Aslam M High prevalence of diabetes, prediabetes and obesity among residents of East Delhi-The Delhi urban diabetes survey (DUDS) Diabetes Metab Syndr 2018 12 923–7
7. Aslam M, Siddiqui AA, Sandeep G, Madhu SV High prevalence of obesity among nursing personnel working in tertiary care hospital Diabetes Metab Syndr 2018 12 313–6
8. Verma M, Das M, Sharma P, Kapoor N, Kalra S Epidemiology of overweight and obesity in Indian adults-A secondary data analysis of the National Family Health Surveys Diabetes Metab Syndr 2021 15 102166
9. Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Kumar CK, Sheeba L, et al Prevalence of overweight in urban Indian adolescent school children Diabetes Res Clin Pract 2002 57 185–90
10. Kalyan M, Dhore P, Purandare V, Deshpande S, Unnikrishnan AG Obesity and its link to undiagnosed diabetes mellitus and hypertension in rural parts of Western India Indian J Endocrinol Metab 2020 24 155–9
11. Kapoor N, Lotfaliany M, Sathish T, Thankappan KR, Thomas N, Furler J, et al Prevalence of normal weight obesity and its associated cardio-metabolic risk factors-Results from the baseline data of the Kerala Diabetes Prevention Program (KDPP) PLoS One 2020 15 e0237974
12. Bhave S, Bavdekar A, Otiv M IAP National Task Force for childhood prevention of adult diseases:Childhood obesity Indian Pediatr 2004 41 559–75
13. Gupta AK, Ahmad AJ Childhood obesity and hypertension Indian Pediatr 1990 27 333–7
14. Kapil U, Singh P, Pathak P, Dwivedi SN, Bhasin S Prevalence of obesity amongst affluent adolescent school children in Delhi Indian Pediatr 2002 39 449–52
15. Marwaha RK, Tandon N, Singh Y, Aggarwal R, Grewal K, Mani K A study of growth parameters and prevalence of overweight and obesity in school children from Delhi Indian Pediatr 2006 43 943–52
16. Sharma A, Sharma K, Mathur KP Growth pattern and prevalence of obesity in affluent schoolchildren of Delhi Public Health Nutr 2007 10 485–91
17. Sidhu S, Kaur N, Kaur R Overweight and obesity in affluent school children of Punjab Ann Hum Biol 2006 33 255–9
18. Khadilkar VV, Khadilkar AV Prevalence of obesity in affluent school boys in Pune Indian Pediatr 2004 41 857–8
19. Bose K, Bisai S, Mukhopadhyay A, Bhadra M Overweight and obesity among affluent Bengalee schoolgirls of Lake Town, Kolkata, India Matern Child Nutr 2007 3 141–5
20. Misra A, Shah P, Goel K, Hazra DK, Gupta R, Seth P, et al The high burden of obesity and abdominal obesity in urban Indian schoolchildren:A multicentric study of 38,296 children Ann Nutr Metab 2011 58 203–11
21. Jagadesan S, Harish R, Miranda P, Unnikrishnan R, Anjana RM, Mohan V Prevalence of overweight and obesity among school children and adolescents in Chennai Indian Pediatr 2014 51 544–9
22. Solanki DK, Walia R, Gautam A, Misra A, Aggarwal AK, Bhansali A Prevalence of abdominal obesity in non-obese adolescents:A North Indian adolescent study J Pediatr Endocrinol Metab 2020 33 853–8
23. Misra A, Vikram NK, Arya S, Pandey RM, Dhingra V, Chatterjee A, et al High prevalence of insulin resistance in postpubertal Asian Indian children is associated with adverse truncal body fat patterning, abdominal adiposity and excess body fat Int J Obes Relat Metab Disord 2004 28 1217–26
24. Misra A, Madhavan M, Vikram NK, Pandey RM, Dhingra V, Luthra K Simple anthropometric measures identify fasting hyperinsulinemia and clustering of cardiovascular risk factors in Asian Indian adolescents Metabolism 2006 55 1569–73
25. Al Kibria GM, Swasey K, Hasan MZ, Sharmeen A, Day B Prevalence and factors associated with underweight, overweight and obesity among women of reproductive age in India Glob Health Res Policy 2019 4 24
26. Singhania K, Kalhan M, Choudhary P, Kumar T Association of menopausal symptoms with overweight and obesity among rural middle aged women in North India:A population based study J Midlife Health 2020 11 137–43
27. Kapoor N Thin fat obesity:The tropical phenotype of obesity Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, et al Endotext. South Dartmouth (MA) 2000
28. Kapoor N, Furler J, Paul TV, Thomas N, Oldenburg B Normal weight obesity:An underrecognized problem in individuals of South Asian descent Clin Ther 2019 41 1638–42
29. Yajnik CS, Yudkin JS The Y-Y paradox Lancet 2004 363 163
30. Geetha L, Deepa M, Anjana RM, Mohan V Prevalence and clinical profile of metabolic obesity and phenotypic obesity in Asian Indians J Diabetes Sci Technol 2011 5 439–46
31. Hadaye RS, Manapurath RM, Gadapani BP Obesity prevalence and determinants among young adults, with special focus on normal-weight obesity;A cross-sectional study in Mumbai Indian J Community Med 2020 45 358–62
32. Kapoor N, Lotfaliany M, Sathish T, Thankappan KR, Tapp RJ, Thomas N, et al Effect of a peer-led lifestyle intervention on individuals with normal weight obesity:Insights from the Kerala diabetes prevention program Clin Ther 2020 42 1618–24
33. Kalra S, Bhattacharya S, Kapoor N Contemporary classification of glucagon-like peptide 1 receptor agonists (GLP1RAs) Diabetes Ther 2021 12 2133–47
34. Kapoor N, Sahay R, Kalra S, Bajaj S, Dasgupta A, Shrestha D, et al Consensus on medical nutrition therapy for diabesity (CoMeND) in adults:A South Asian perspective Diabetes Metab Syndr Obes 2021 14 1703–28
35. Vikram NK, Latifi AN, Misra A, Luthra K, Bhatt SP, Guleria R, et al Waist-to-height ratio compared to standard obesity measures as predictor of cardiometabolic risk factors in Asian Indians in North India Metab Syndr Relat Disord 2016 14 492–9
36. Kapoor N, Lotfaliany M, Sathish T, Thankappan KR, Thomas N, Furler J, et al Obesity indicators that best predict type 2 diabetes in an Indian population:Insights from the Kerala Diabetes Prevention Program J Nutr Sci 2020 9 e15
37. Verma M, Rajput M, Sahoo SS, Kaur N Neck Circumference:Independent predictor for overweight and obesity in adult population Indian J Community Med 2017 42 209–13
38. Kapoor N, Jiwanmall SA, Nandyal MB, Kattula D, Paravathareddy S, Paul TV, et al Metabolic Score for Visceral Fat (METS-VF) estimation-A novel cost-effective obesity indicator for visceral adipose tissue estimation Diabetes Metab Syndr Obes 2020 13 3261–7
39. Wharton S, Lau DCW, Vallis M, Sharma AM, Biertho L, Campbell-Scherer D, et al Obesity in adults:A clinical practice guideline CMAJ 2020 19 E875–91
40. Kalra S, Kapoor N, Kota S, Das S Person-centred obesity care-techniques, thresholds, tools and targets Eur Endocrinol 2020 16 11–3
41. Kapoor N, Chapla A, Furler J, Paul TV, Harrap S, Oldenburg B, et al Genetics of obesity in consanguineous populations-A road map to provide novel insights in the molecular basis and management of obesity EBioMedicine 2019 40 33–4
42. Saeed S, Bonnefond A, Manzoor J, Shabbir F, Ayesha H, Philippe J, et al Genetic variants in LEP, LEPR, and MC4R explain 30% of severe obesity in children from a consanguineous population Obesity (Silver Spring) 2015 23 1687–95
43. Kalra S, Kapoor N, Bhattacharya S, Aydin H, Coetzee A Barocrinology:The endocrinology of obesity from bench to bedside Med Sci (Basel) 2020 8 51
44. Raynor HA, Champagne CM Position of the Academy of Nutrition and Dietetics:Interventions for the treatment of overweight and obesity in adults J Acad Nutr Diet 2016 116 129–47
45. Garvey WT, Mechanick JI, Brett EM, Garber AJ, Hurley DL, Jastreboff AM, et al American Association Of Clinical Endocrinologists And American College of endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity Endocr Pract 2016 22 Suppl 3 1–203
46. Hannah WN Jr, Harrison SA Effect of weight loss, diet, exercise, and bariatric surgery on nonalcoholic fatty liver disease Clin Liver Dis 2016 20 339–50
47. Misra A, Jayawardena R, Anoop S Obesity in South Asia:Phenotype, morbidities, and mitigation Curr Obes Rep 2019 8 43–52
48. Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, 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 57 163–70
49. Viswanathan V, Krishnan D, Kalra S, Chawla R, Tiwaskar M, Saboo B, et al Insights on medical nutrition therapy for type 2 diabetes mellitus:An Indian perspective Adv Ther 2019 36 520–47
50. Mabire L, Mani R, Liu L, Mulligan H, Baxter D The influence of age, sex and body mass index on the effectiveness of brisk walking for obesity management in adults:A systematic review and meta-analysis J Phys Act Health 2017 14 389–407
51. Yumuk V, Frühbeck G, Oppert JM, Woodward E, Toplak H An EASO position statement on multidisciplinary obesity management in adults Obes Facts 2014 7 96–101
52. Tsigos C, Hainer V, Basdevant A, Finer N, Fried M, Mathus-Vliegen E, et al Management of obesity in adults:European clinical practice guidelines Obes Facts 2008 1 106–16
53. Yumuk V, Tsigos C, Fried M, Schindler K, Busetto L, Micic D, et al European guidelines for obesity management in adults Obes Facts 2015 8 402–24
54. Durrer Schutz D, Busetto L, Dicker D, Farpour-Lambert N, Pryke R, Toplak H, et al European practical and patient-centred guidelines for adult obesity management in primary care Obes Facts 2019 12 40–66
55. Bhasker AG, Prasad A, Raj PP, Wadhawan R, Khaitan M, Agrawal AJ, et al Trends and progress of bariatric and metabolic surgery in India Updates Surg 2020 72 743–9
56. Lee WJ, Almalki O Recent advancements in bariatric/metabolic surgery Ann Gastroenterol Surg 2017 1 171–9
57. Alberga AS, Edache IY, Forhan M, Russell-Mayhew S Weight bias and health care utilization:A scoping review Prim Health Care Res Dev 2019 20 e116
58. Puhl RM, Heuer CA The stigma of obesity:A review and update Obesity (Silver Spring) 2009 17 941–64
59. Bucher Della Torre S, Courvoisier DS, Saldarriaga A, Martin XE, Farpour-Lambert NJ Knowledge, attitudes, representations and declared practices of nurses and physicians about obesity in a university hospital:Training is essential Clin Obes 2018 8 122–30
60. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR Motivational interviewing to improve weight loss in overweight and/or obese patients:A systematic review and meta-analysis of randomized controlled trials Obes Rev 2011 12 709–23
61. Christie D, Channon S The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations:A clinical review Diabetes Obes Metab 2014 16 381–7
62. Orzano AJ, Scott JG Diagnosis and treatment of obesity in adults:An applied evidence-based review J Am Board Fam Pract 2004 17 359–69
63. Wing RR, Phelan S Long-term weight loss maintenance Am J Clin Nutr 2005 82 1 Suppl 222s–5s
64. Anderson JW, Konz EC, Frederich RC, Wood CL Long-term weight-loss maintenance:A meta-analysis of US studies Am J Clin Nutr 2001 74 579–84
65. Kheniser K, Saxon DR, Kashyap SR Long-term weight loss strategies for obesity J Clin Endocrinol Metab 2021 106 1854–66
66. Kruger J, Blanck HM, Gillespie C Dietary and physical activity behaviors among adults successful at weight loss maintenance Int J Behav Nutr Phys Act 2006 3 17
67. Kruger J, Blanck HM, Gillespie C Dietary practices, dining out behavior, and physical activity correlates of weight loss maintenance Prev Chronic Dis 2008 5 A11
68. Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL A self-regulation program for maintenance of weight loss N Engl J Med 2006 355 1563–71
69. Catenacci VA, Ogden LG, Stuht J, Phelan S, Wing RR, Hill JO, et al Physical activity patterns in the National Weight Control Registry Obesity (Silver Spring) 2008 16 153–61
70. Middleton KM, Patidar SM, Perri MG The impact of extended care on the long-term maintenance of weight loss:A systematic review and meta-analysis Obes Rev 2012 13 509–17
71. Vuorinen AL, Helander E, Pietilä J, Korhonen I Frequency of self-weighing and weight change:Cohort study with 10,000 smart scale users J Med Internet Res 2021 23 e25529
72. Foster GD, Wadden TA, Vogt RA, Brewer G What is a reasonable weight loss?Patients'expectations and evaluations of obesity treatment outcomes J Consult Clin Psychol 1997 65 79–85
73. Phelan S, Nallari M, Darroch FE, Wing RR What do physicians recommend to their overweight and obese patients? J Am Board Fam Med 2009 22 115–22
74. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin N Engl J Med 2002 346 393–403
75. Espeland MA, Glick HA, Bertoni A, Brancati FL, Bray GA, Clark JM, et al Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes:The action for health in diabetes Diabetes Care 2014 37 2548–56
76. Perri MG, Nezu AM, McKelvey WF, Shermer RL, Renjilian DA, Viegener BJ Relapse prevention training and problem-solving therapy in the long-term management of obesity J Consult Clin Psychol 2001 69 722–6
77. Rubino D, Abrahamsson N, Davies M, Hesse D, Greenway FL, Jensen C, et al Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance in adults with overweight or obesity:The STEP 4 randomized clinical trial JAMA 2021 325 1414–25
78. Lundgren JR, Janus C, Jensen SBK, Juhl CR, Olsen LM, Christensen RM, et al Healthy weight loss maintenance with exercise, liraglutide, or both combined N Engl J Med 2021 384 1719–30
79. Bray GA, Popkin BM Calorie-sweetened beverages and fructose:What have we learned 10 years later Pediatr Obes 2013 8 242–8
80. Dietz WH Sugar-sweetened beverages, milk intake, and obesity in children and adolescents J Pediatr 2006 148 152–4
81. Zhao Y, Wang L, Xue H, Wang H, Wang Y Fast food consumption and its associations with obesity and hypertension among children:Results from the baseline data of the childhood obesity study in China mega-cities BMC Public Health 2017 17 933
82. Kar S, Khandelwal B Fast foods and physical inactivity are risk factors for obesity and hypertension among adolescent school children in east district of Sikkim, India J Nat Sci Biol Med 2015 6 356–9
83. Gupta A, Kapil U, Singh G Consumption of junk foods by school-aged children in rural Himachal Pradesh, India Indian J Public Health 2018 62 65–7
84. Arora M, Nazar GP, Gupta VK, Perry CL, Reddy KS, Stigler MH Association of breakfast intake with obesity, dietary and physical activity behavior among urban school-aged adolescents in Delhi, India:Results of a cross-sectional study BMC Public Health 2012 12 881
85. Singh DP, Arya A, Kondepudi KK, Bishnoi M, Boparai RK Prevalence and associated factors of overweight/obesity among school going children in Chandigarh, India Child Care Health Dev 2020 46 571–5
86. Butcher K, Sallis JF, Mayer JA, Woodruff S Correlates of physical activity guideline compliance for adolescents in 100 US cities J Adolesc Health 2008 42 360–8
87. Bharati S, Pal M, Shome S, Roy P, Dhara P, Bharati P Influence of socio-economic status and television watching on childhood obesity in Kolkata Homo 2017 68 487–94
88. Steffen LM, Sinaiko AR, Zhou X, Moran A, Jacobs DR Jr, Korenfeld Y, et al Relation of adiposity, television and screen time in offspring to their parents BMC Pediatr 2013 13 133
89. Zeller MH, Modi AC Predictors of health-related quality of life in obese youth Obesity (Silver Spring) 2006 14 122–30
90. Gray WN, Janicke DM, Ingerski LM, Silverstein JH The impact of peer victimization, parent distress and child depression on barrier formation and physical activity in overweight youth J Dev Behav Pediatr 2008 29 26–33
91. Rojas A, Storch EA Psychological complications of obesity Pediatr Ann 2010 39 174–80
92. Czernichow S, Lee CM, Barzi F, Greenfield JR, Baur LA, Chalmers J, et al Efficacy of weight loss drugs on obesity and cardiovascular risk factors in obese adolescents:A meta-analysis of randomized controlled trials Obes Rev 2010 11 150–8
93. McDonagh MS, Selph S, Ozpinar A, Foley C Systematic review of the benefits and risks of metformin in treating obesity in children aged 18 years and younger JAMA Pediatr 2014 168 178–84
94. Kelly AS, Auerbach P, Barrientos-Perez M, Gies I, Hale PM, Marcus C, et al A randomized, controlled trial of liraglutide for adolescents with obesity N Engl J Med 2020 382 2117–28
95. Kochar IS, Sethi A Efficacy and safety of liraglutide in Indian adolescents with obesity Obes Sci Pract 2019 5 251–7
96. Inge TH, Jenkins TM, Zeller M, Dolan L, Daniels SR, Garcia VF, et al Baseline BMI is a strong predictor of nadir BMI after adolescent gastric bypass J Pediatr 2010 156 103–8.e1
97. Olbers T, Gronowitz E, Werling M, Mårlid S, Flodmark CE, Peltonen M, et al Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity:Results from a Swedish Nationwide Study (AMOS) Int J Obes (Lond) 2012 36 1388–95
98. Wasserman H, Inge TH Bariatric surgery in obese adolescents:Opportunities and challenges Pediatr Ann 2014 43 e230–6
99. Guelinckx I, Devlieger R, Beckers K, Vansant G Maternal obesity:Pregnancy complications, gestational weight gain and nutrition Obes Rev Off J Int Assoc Study Obes 2008 9 140–50
100. Rasmussen SA, Chu SY, Kim SY, Schmid CH, Lau J Maternal obesity and risk of neural tube defects:A metaanalysis Am J Obstet Gynecol 2008 198 611–9
101. Mojtabai R Body mass index and serum folate in childbearing age women Eur J Epidemiol 2004 19 1029–36
102. Riley L, Wertz M, McDowell I Obesity in pregnancy:Risks and management Am Fam Physician 2018 97 559–61
103. Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight Gain During Pregnancy: Reexamining the Guidelines Washington (DC) National Academies Press (US) 2009 Available from: http://www.ncbi.nlm.nih.gov/books/NBK32813/ Last accessed on 2021 Oct 04
104. Rasmussen SA, Jamieson DJ Influenza and pregnancy:No time for complacency Obstet Gynecol 2019 133 23–6
105. Kominiarek MA, Rajan P Nutrition recommendations in pregnancy and lactation Med Clin North Am 2016 100 1199–215
106. Dipietro L, Evenson KR, Bloodgood B, Sprow K, Troiano RP, Piercy KL, et al Benefits of physical activity during pregnancy and postpartum:An umbrella review Med Sci Sports Exerc 2019 51 1292–302
107. Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovaridr U, Coustan DR, et al Hyperglycemia and adverse pregnancy outcomes N Engl J Med 2008 358 1991–2002
108. American Diabetes Association. 2. Classification and diagnosis of diabetes:Standards of medical care in diabetes—2021 Diabetes Care 2021 44 S15–33
109. Catalano PM, Shankar K Obesity and pregnancy:Mechanisms of short term and long term adverse consequences for mother and child BMJ 2017 356 j1
110. Dow ML, Szymanski LM Effects of overweight and obesity in pregnancy on health of the offspring Endocrinol Metab Clin North Am 2020 49 251–63
111. Steinig J, Nagl M, Linde K, Zietlow G, Kersting A Antenatal and postnatal depression in women with obesity:A systematic review Arch Womens Ment Health 2017 20 569–85
112. Polyzos SA, Margioris AN Sarcopenic obesity Hormones (Athens) 2018 17 321–31
113. Batsis JA, Villareal DT Sarcopenic obesity in older adults:Aetiology, epidemiology and treatment strategies Nat Rev Endocrinol 2018 14 513–37
114. Bouchonville MF, Villareal DT Sarcopenic obesity:How do we treat it? Curr Opin Endocrinol Diabetes Obes 2013 20 412–9
115. Benton MJ, Whyte MD, Dyal BW Sarcopenic obesity:Strategies for management Am J Nurs 2011 111 38–44
116. Villareal DT, Aguirre L, Gurney AB, Waters DL, Sinacore DR, Colombo E, et al Aerobic or resistance exercise, or both, in dieting obese older adults N Engl J Med 2017 376 1943–55
117. Hsu KJ, Liao CD, Tsai MW, Chen CN Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity:A meta-analysis Nutrients 2019 11 2163
118. Campbell WW, Haub MD, Wolfe RR, Ferrando AA, Sullivan DH, Apolzan JW, et al Resistance training preserves fat-free mass without impacting changes in protein metabolism after weight loss in older women Obesity (Silver Spring) 2009 17 1332–9
119. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al Evidence-based recommendations for optimal dietary protein intake in older people:A position paper from the PROT-AGE Study Group J Am Med Dir Assoc 2013 14 542–59
120. Bhasin S, Apovian CM, Travison TG, Pencina K, Moore LL, Huang G, et al Effect of protein intake on lean body mass in functionally limited older men:A randomized clinical trial JAMA Intern Med 2018 178 530–41
121. Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, et al Testosterone therapy in men with androgen deficiency syndromes:An Endocrine Society clinical practice guideline J Clin Endocrinol Metab 2010 95 2536–59
122. Kalra S, Baruah MP, Sahay R Person centered care in the Second Diabetes Attitudes, Wishes and Needs (DAWN2) study:Inspiration from India Indian J Endocrinol Metab 2014 18 4–6
123. Leitner DR, Frühbeck G, Yumuk V, Schindler K, Micic D, Woodward E, et al Obesity and type 2 diabetes:Two diseases with a need for combined treatment strategies-EASO can lead the way Obes Facts 2017 10 483–92
124. Dutta D, Jaisani R, Khandelwal D, Ghosh S, Malhotra R, Kalra S Role of metformin, sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and orlistat based multidrug therapy in glycemic control, weight loss, and euglycemia in diabesity:A real-world experience Indian J Endocrinol Metab 2019 23 460–7
125. Maggard-Gibbons M, Maglione M, Livhits M, Ewing B, Maher AR, Hu J, et al Bariatric surgery for weight loss and glycemic control in nonmorbidly obese adults with diabetes:A systematic review JAMA 2013 309 2250–61
126. Li Q, Chen L, Yang Z, Ye Z, Huang Y, He M, et al Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index <35 kg/m2 Diabetes Obes Metab 2012 14 262–70
127. Panunzi S, De Gaetano A, Carnicelli A, Mingrone G Predictors of remission of diabetes mellitus in severely obese individuals undergoing bariatric surgery:Do BMI or procedure choice matter?A meta-analysis Ann Surg 2015 261 459–67
128. El Khoury L, Chouillard E, Chahine E, Saikaly E, Debs T, Kassir R Metabolic surgery and diabesity:A systematic review Obes Surg 2018 28 2069–77
129. Stryjecki C, Alyass A, Meyre D Ethnic and population differences in the genetic predisposition to human obesity Obes Rev 2018 19 62–80
130. Yengo L, Sidorenko J, Kemper KE, Zheng Z, Wood AR, Weedon MN, et al Meta-analysis of genome-wide association studies for height and body mass index in ?700000 individuals of European ancestry Hum Mol Genet 2018 27 3641–9
131. Chauhan G, Tabassum R, Mahajan A, Dwivedi OP, Mahendran Y, Kaur I, et al Common variants of FTO and the risk of obesity and type 2 diabetes in Indians J Hum Genet 2011 56 720–6
132. Ramya K, Radha V, Ghosh S, Majumder PP, Mohan V Genetic variations in the FTO gene are associated with type 2 diabetes and obesity in south Indians (CURES-79) Diabetes Technol Ther 2011 13 33–42
133. Sharma M, Misra A, Vikram N, Suryaprakash B, Chhabra S, Garg N, et al Genotype of the LMNA 1908C>T variant is associated with generalized obesity in Asian Indians in North India Clin Endocrinol (Oxf) 2011 75 642–9
134. Sharma M, Vikram NK, Misra A, Bhatt S, Tarique M, Parray HA, et al Assessment of 11-b hydroxysteroid dehydrogenase (11-bHSD1) 4478T>G and tumor necrosis factor-a (TNF-a)-308G>A polymorphisms with obesity and insulin resistance in Asian Indians in North India Mol Biol Rep 2013 40 6261–70
135. Prakash J, Mittal B, Apurva S, Shally A, Pranjal S, Neena S Common genetic variant of insig2 Gene rs7566605 polymorphism is associated with severe obesity in North India Iran Biomed J 2017 21 261–9
136. Gulati S, Misra A, Tiwari R, Sharma M, Pandey RM, Upadhyay AD The influence of polymorphisms of fat mass and obesity (FTO, rs9939609) and vitamin D receptor (VDR, BsmI, TaqI, ApaI, FokI) genes on weight loss by diet and exercise interventions in non-diabetic overweight/obese Asian Indians in North India Eur J Clin Nutr 2020 74 604–12
137. Shabana, Shahid SU, Hasnain S Use of a gene score of multiple low-modest effect size variants can predict the risk of obesity better than the individual SNPs Lipids Health Dis 2018 17 155
138. Lambert SA, Abraham G, Inouye M Towards clinical utility of polygenic risk scores Hum Mol Genet 2019 28 R133–42
139. Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH, et al Pediatric obesity-assessment, treatment, and prevention:An endocrine society clinical practice guideline J Clin Endocrinol Metab 2017 102 709–57
140. Koves IH, Roth C Genetic and syndromic causes of obesity and its management Indian J Pediatr 2018 85 478–85
141. Das Bhowmik A, Gupta N, Dalal A, Kabra M Whole exome sequencing identifies a homozygous nonsense variation in ALMS1 gene in a patient with syndromic obesity Obes Res Clin Pract 2017 11 241–6
142. Dayton K, Miller J Finding treatable genetic obesity:Strategies for success Curr Opin Pediatr 2018 30 526–31
143. Butler MG, Miller JL, Forster JL Prader-Willi syndrome-clinical genetics, diagnosis and treatment approaches:An update Curr Pediatr Rev 2019 15 207–44
144. Forman-Hoffman V, Little A, Wahls T Barriers to obesity management:A pilot study of primary care clinicians BMC Fam Pract 2006 7 35
145. Fitterman-Harris HF, Vander Wal JS Weight bias reduction among first-year medical students:A quasi-randomized, controlled trial Clin Obes 2021 11 e12479
146. McLean ME, McLean LE, McLean-Holden AC, Campbell LF, Horner AM, Kulkarni ML, et al Interphysician weight bias:A cross-sectional observational survey study to guide implicit bias training in the medical workplace Acad Emerg Med 2021 28 1024–34
147. Lim S, Oh B, Lee SH, Kim YH, Ha Y, Kang JH Perceptions, attitudes, behaviors, and barriers to effective obesity care in South Korea:Results from the ACTION-IO study J Obes Metab Syndr 2020 29 133–42
148. van Baak MA, Mariman ECM Dietary strategies for weight loss maintenance Nutrients 2019 11 1916
149. Pavela G, Lewis DW, Locher J, Allison DB Socioeconomic status, risk of obesity, and the importance of Albert J Stunkard. Curr Obes Rep 2016 5 132–9
150. McLaren L Socioeconomic status and obesity Epidemiol Rev 2007 29 29–48
151. Lin HH, Wu CY, Wang CH, Fu H, Lönnroth K, Chang YC, et al Association of obesity, diabetes, and risk of tuberculosis:Two population-based cohorts Clin Infect Dis 2018 66 699–705
152. Virtanen M, Jokela M, Lallukka T, Magnusson Hanson L, Pentti J, Nyberg ST, et al Long working hours and change in body weight:Analysis of individual-participant data from 19 cohort studies Int J Obes (Lond) 2020 44 1368–75
153. Porter JS, Bean MK, Gerke CK, Stern M Psychosocial factors and perspectives on weight gain and barriers to weight loss among adolescents enrolled in obesity treatment J Clin Psychol Med Settings 2010 17 98–102
154. Mauro M, Taylor V, Wharton S, Sharma AM Barriers to obesity treatment Eur J Intern Med 2008 19 173–80
155. Hampel P, Stachow R, Wienert J Mediating effects of mental health problems in a clinical sample of adolescents with obesity Obes Facts 2021 14 471–80
156. Sarwer DB, Polonsky HM The psychosocial burden of obesity Endocrinol Metab Clin North Am 2016 45 677–88
157. Loredo JS, Weng J, Ramos AR, Sotres-Alvarez D, Simonelli G, Talavera GA, et al Sleep patterns and obesity:Hispanic community health study/study of Latinos Sueño Ancillar study Chest 2019 156 348–56
158. Patel SR, Hayes AL, Blackwell T, Evans DS, Ancoli-Israel S, Wing YK, et al The association between sleep patterns and obesity in older adults Int J Obes (Lond) 2014 38 1159–64
159. Bliddal H, Leeds AR, Christensen R Osteoarthritis, obesity and weight loss:Evidence, hypotheses and horizons-A scoping review Obes Rev 2014 15 578–86
160. Bernhardt V, Babb TG Exertional dyspnoea in obesity Eur Respir Rev 2016 25 487–95
161. Koliaki C, Liatis S, Kokkinos A Obesity and cardiovascular disease:Revisiting an old relationship Metabolism 2019 92 98–107
162. Thamer C, Machann J, Stefan N, Haap M, Schäfer S, Brenner S, et al High visceral fat mass and high liver fat are associated with resistance to lifestyle intervention Obesity (Silver Spring) 2007 15 531–8
163. Booranasuksakul U, Singhato A, Rueangsri N, Prasertsri P Association between alcohol consumption and body mass index in university students Asian Pac Isl Nurs J 2019 4 57–65
164. Güler SA, Yılmaz TU, Şimşek T, Yirmibeşoğlu O, Kırnaz S, Utkan NZ, et al Obesity and bariatric surgery awareness in the Kocaeli province, a leading industrial city in Turkey Turk J Surg 2018 34 165–8
165. Anis AH, Zhang W, Bansback N, Guh DP, Amarsi Z, Birmingham CL Obesity and overweight in Canada:An updated cost-of-illness study Obes Rev 2010 11 31–40
166. Kalra S, Arora S, Kapoor N The motivation-opportunity-capability model of behavioural therapy-the vital component of effective patient centric obesity management J Pak Med Assoc 2021 71 1900–1
© 2022 Indian Journal of Endocrinology and Metabolism | Published by Wolters Kluwer – Medknow