Lata Kajania, who works as a helper at an MCD school in Delhi, busts the myth that obesity is just an urban lifestyle and a classist concern. Or that an existing weight metric is enough to tell you how much fat is sitting and hiding around your organs. The 48-year-old, who weighed 97 kg when she walked into the AIIMS obesity clinic and has dropped 27 kg since, still has a round face and stubborn fat around her middle. Worse, she has developed diabetes, hypertension and osteoporosis because of disproportionate body fat. Her body mass index (BMI) -- a count derived by dividing an adult’s weight by their height in metres squared -- is down to a manageable 26.8. But her waist circumference is way off the mark at 109 cm and waist-to-hip ratio (an index arrived by dividing your waist measurement by your hip measurement) is 1.08. This means she still has to work on her abdominal obesity, with fat coating her stomach, liver and wearing out her muscle mass. This fat triggers inflammation, a precursor to diabetes and heart disease. It is also associated with insulin resistance, which means cells don’t effectively absorb glucose from the bloodstream, resulting in high blood sugar levels. “That’s why,” says Dr Naval Kishore Vikram, professor of medicine, Metabolic Research Group, AIIMS, “obesity has to be redefined for Indians (who have a higher fat mass than other populations) as it is crucial for early detection of related diseases and the development of targetted management strategies.” Lata was a test case in one of the many studies from AIIMS, which has devised fresh guidelines to flatten India’s obesity curve and reduce our burden of chronic illnesses that stem from it. AIIMS worked with the National Diabetes Obesity and Cholesterol Foundation (N-DOC) and Fortis C-DOC Hospital for Diabetes and Allied Sciences to create different obesity markers for Asian Indians. What is the new definition of obesity? The new obesity criteria for Indians now include waist circumference and waist-to-hip ratio. Abdominal obesity is indicated when the waist exceeds 80 cm for women and 90 cm for men. “If these limits are exceeded, individuals should get tested for blood sugar, blood pressure, cholesterol and liver function, as high waist circumference often leads to undetected health issues,” says Dr Anoop Misra, Chairman of Fortis CDOC Hospital for Diabetes, Delhi. The new definition integrates comorbidities — such as diabetes and cardiovascular disease — into the diagnostic process, ensuring that obesity-related health risks are better accounted for and taken care of. It also factors in mobility issues associated with obesity like knee and hip osteoarthritis or shortness of breath during daily activities. The new definition of obesity is also in line with the Lancet Commission’s recent definition of clinical obesity as a chronic illness that alters organ functions regardless of other conditions a person might have. “It can lead to life-altering or life-threatening complications,” the report says. Why Indians need new guidelines Like Lata, Dr Vikram has seen many patients at his obesity clinic with a normal BMI of 23 (the Indian cutoff mark) but with disproportionate belly fat. “As per international classification, anybody with a BMI higher than 25 is overweight, higher than 30 is obese. But this doesn’t tell us anything about the person’s body fat composition, the muscle mass or co-existing clinical problems,” he says. Drawing parallels with a WWE wrestler or an athlete, he says their BMI would be 30 plus because they have lean muscle mass. “If we take BMI as the only measure of their health, they would be categorised as obese. The body fat percentage is what we should be looking at,” he explains. Consider two persons with a BMI of 30. One of them has 20 per cent body fat while the other has 35 per cent. “The latter would be more disease-prone. That’s why the waist circumference and the waist-to-hip ratio are important indices,” he says. Dr Misra feels this breakdown is important for customising weight loss strategies. “We have bifurcated obesity into stages 1 (innocuous) and 2 (troublesome). People who don’t have significant abdominal obesity or associated diseases are classified as Stage 1 and require only diet and lifestyle modifications. Stage 2 patients, however, have high abdominal fat that may lead to diabetes, liver and heart problems, difficulty in walking and breathlessness. They need medication. This leads to focussed therapy without wasting resources,” he says. How stress induces weight gain In 2019, Lata was distraught after losing her 25-year-old son. Grieving over his untimely death, surviving the abuse of an alcoholic husband and not eating during her work hours took a toll on her body. “I would only have tea or water while working,” says Lata, who now lives with her brother in Nehru Nagar. Deprivation meant her hunger pangs would kick in around dinner when she loaded up her plate with both roti and rice. The carb-heavy binge-eating led to quick weight gain. Till there came a time when walking even 500 metres left her exhausted. “I could not sleep at night either as I would be short of breath and wake up intermittently,” she says. On one such night in 2022, her brother rushed her to AIIMS, suspecting an anxiety attack. That’s where the doctors diagnosed her with clinical obesity, hypertension and diabetes. In fact, she displayed most signs of clinical obesity listed by Lancet - Breathlessness, wheezing, sleep apnoea, high triglyceride levels, metabolic dysfunctions, non-alcoholic fatty liver disease, changes in reproductive system, heart failure, chronic fatigue, and knee and joint pain, among others. She even developed osteoporosis. Lata’s case was taken up by Dr Vikram and Dr Piyush Ranjan, additional professor, Department of Medicine AIIMS, who is researching obesity in women. “Most perimenopausal women neglect their health and because of hormonal changes, their bone and muscle mass decrease. This is taken over by fat which they acquire because of a poor diet, sedentary lifestyle and stress that they deal with as they transition to a less active phase in their lives,” he says. The diet plan for controlling obesity Lata was asked to drink toned milk, eat protein-rich food like egg whites, chicken, fish, pulses and seasonal vegetables in portion-controlled plates. “There was a six-month intense regimen that she followed like clockwork. We limited her grain consumption and ensured she had a calorie-deficit and balance diet. She stayed off fried, packaged foods and fruit juices,” says Dr Ranjan. Lata even went through grief counselling sessions. “This mental health support was the reason that I released my pent-up emotions, began to look at life positively and spent time outdoors instead of shutting myself up,” she adds. Diet and physical activity are the baseline, the pillar and the foundation for weight management. “Everything else settles with these,” says Dr Vikram as Lata soaks up some sun to boost her Vitamin D levels.
