A STUDY ON DISEASE BURDEN ASSOCIATED WITH ABNORMAL WEIGHT IN SOUTH INDIAN POPULATION

Page5485 Indo American Journal of Pharmaceutical Research, 2014 ISSN NO: 2231-6876 A STUDY ON DISEASE BURDEN ASSOCIATED WITH ABNORMAL WEIGHT IN SOUTH INDIAN POPULATION Sangram Vurumadla*, Sagar Koona, Bhanu Chander Lakkarasu, Venkateshwarlu Konuru Department of Pharmacy Practice, St. Peter s Institute of Pharmaceutical Sciences, Hanamkonda, Warangal, Telangana, India,506001. ARTICLE INFO Article history Received 19/11/2014 Available online 30/11/2014 Keywords Disease Burden, Overweight, Body Mass Index. ABSTRACT Objective: The current study was performed with an aim to determine the disease burden associated with underweight overweight, obesity class-1 and obesity class-2 individuals and to determine disease burden of hypertension, type 2-diabetes milletus, coronary heart disease, osteoarthritis, hypothyroidism, and other co-morbidities in abnormal weight individuals. Methodology: It was a comparative study carried for nine months from January 2014 to September 2014. The study was conducted in south India in selected districts of Telangana such as Hyderabad, Karimnagar, Khammam and Medak. The survey protocol included a home interview and a standardized physical examination in the subject s home and personal interviews. Based on BMI, subjects were distributed into weight status categories according to NHLBI&WHO classification. Patients with various comorbidities were recorded and noted in different status categories. Results: A total 2600 population was enrolled in the study. In total population 1136 (43.69%) were healthy population and 1464 (56.30%) were disease population. In healthy population 84(70.00%), 751(69.52%), 236(33.90%), 226 (27.39%) were underweight, normal weight, overweight, obesity respectively. In disease population 36 (30.00%), 369 (38.48%), 460 (66.09%), 599(72.60%) were underweight, normal weight, overweight and obese respectively. Conclusion: Our study concludes that Disease burden has been elevated two folds with overweight and three folds with obesity in disease population as compared to healthy population overweight and obesity weight status categories. Disease burden is directly proportional to weight status i.e. with increasing body weight disease burden was found to be elevated in our study. Corresponding author Sangram Vurumadla Assistant Professor, Department of Pharmacy practice, St. Peter s College of Pharmaceutical sciences, Warangal, Telangana, India-506001 Email id: sangram.vuru@gmail.com Please cite this article in press as Sangram Vurumadla et al. A Study on Disease Burden associated with Abnormal Weight in South Indian Population. Indo American Journal of Pharm Research.2014:4(11). Copy right 2014 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Page5486 INTRODUCTION Overweight and obesity are leading risks for international deaths. Around 3.4 million adults die annually as a result of being overweight or fat [1]. The foremost normally used measure for overweight and obesity is Body Mass Index (BMI) - an easy index to classify overweight and obese in adults. It is outlined as the weight in kilograms divided by the sq. of the height in meters (kg/m2). According to World Health Organization, overweight and obese are outlined as BMI larger than or up to 25 is overweight and BMI larger than or up to 30 is obese [2]. Main reasons for being fat and overweight are lack of energy balance, inactive life setting, environment, genes and case history, health conditions like inactive thyroid (hypothyroidism), and various hormonal imbalance syndromes. Medicines like corticosteroids, anti-depressants and anti epileptics can also cause overweight and fat. Emotional Factors like anger, stress and boring could cause excess eating in some individuals results in weight gain and leads to overweight or obese [3]. Overweight and obese people are at exaggerated risk for several diseases and health conditions like high blood pressure, Dyslipidemia, diabetes milletus, coronary cardiovascular disease, stroke, bladder sickness, arthritis, apnea, respiratory problems and a few cancers. The chance for these non-communicable diseases increases with the rise in BMI [4]. Need of our study India is one among the biggest countries in the world. There's a necessity to form in-depth study on overweight and obesity in people, as they are most liable to develop diseases and need to address the issue of abnormal weight in people as major problem at national level [5]. This study summarizes the characteristics of illness burden related to abnormal weight various cities of Telangana in south India and also fulfils the gap in literature because it forms the area in specific study. The study provides an outline of illness burden related to varied weight classes present in WHO classification [2] of overweight and obesity. The objectives of our study was to work out on the disease burden related to under-weight, overweight, obesity class-1 and obesity class-2 people and to determine disease burden of high blood pressure, diabetes milletus, coronary cardiovascular disease, osteo-arthritis, hypothyroidism and other co-morbidities in abnormal weight people. METHODOLOGY The study was conducted in various districts of Telangana like Hyderabad, Karimnagar, Khammam, Medak and Nizamabad. Study criteria included only those individuals above 20 years and confined to south Indian population. Pregnant women and persons who were suffering from any major physical or mental disability were excluded from the study. Study Procedure: The survey protocol enclosed a home interview and a homogenous physical examination within the subject s home and private interviews. In each setting, weight and height were measured with standardized instruments and procedures. Then BMI was calculated by means of BMI formula. Then based on BMI, subjects were distributed as per weight status categories according to NHLBI and WHO [5]. BMI=Body weight (Kg s)/ (height in meters 2 ) Overweight and Obesity Criteria : The present study uses the National Heart, Lung and Blood Institute s definitions for the cut off points between overweight and obesity and between obese and its category levels. Using a reference class of BMI 18.5 to 24.9 kg/m 2 (termed normal weight); the four categories are shown in table 1, that additionally lists the World Health Organization s cut off points [2,5,6]. Both organizations use identical classes with the exception of the BMI vary of 25.0 to 29.9 kg/m2 category: World Health Organization calls it pre-obese and National Heart, Lung, and Blood Institute calls it overweight. Both organizations take into account persons with a BMI of between 25.0 and 29.9 kg/m2 to be overweight. Table 1: Classification of Weight status based on BMI. NHLBI Terminology BMI, kg/m2, Range WHO Classification Underweight <18.5 Underweight Normal 18.5-24.9 Normal Overweight 25.0-30.0 Overweight Obesity class 1 30.0-34.9 Obesity class 1 Obesity class 2 35.0-39.9 Obesity class 2 Obesity class 3 >40.0 Obesity class 3 Health condition of individuals On the basis of previous studies [5,6,7], We had chosen only those health conditions for which excess weight is a long time risk and where sample size was adequate. The health conditions included were high blood pressure, cholesterol levels, type 2 DM, coronary heart disease (CHD), and osteo-arthritis. Hypertension was deemed present only if subjects reported that a doctor had told them that they had high blood pressure or hypertension. Type-2 DM was outlined solely by self-reports of diagnosed disease. Subjects were categorised as having high blood cholesterol levels if they have reported that doctor had told them such a diagnosis of

Page5487 CHD based on history of getting a heart attack. Coronary heart disease in individuals was recorded based on self-report of doctor identification. Osteo arthritis was considered present for subjects who had ever been told by their doctor that they had OA condition. RESULTS In this study, a total of 2600 patients were studied during a period of seven months. Among total population enrolled 1136 (43.69%) individuals were healthy population and 1464 (56.30%) individuals were disease population. Among healthy population, 702 (61.79%) individuals were males, 434 (38.20%) individuals were females. Among disease population, 845 (57.71%) individuals were males and 619 (42.28%) individuals were females as shown in Figure 1. Figure 1: Gender distribution in total population In healthy population 84 (70.00%) individuals were underweight, 751 (69.52%) individuals were normal weight, 236 (33.90%) individuals were normal weight and 226 (27.39%) individuals were obese. In disease population 36 (30.00%) individuals were underweight, 369 (38.48%) individuals were normal weight, 460 (66.09%) individuals with overweight and 599 (72.60%) individuals were obese. Data is shown in table 2 and Figure 2. Table 2: Study subjects distribution according to weight status category in total population (WHO classification). Weight status category {BMI (Kg/m 2 )} Total. No. (2600) Healthy population (1136) (43.69%) Disease population (1464) (56.30%) Underweight 120 (4.61%) 84 (70.00%) 36 (30.00%) Normal weight 959 (59.26%) 590 (69.52%) 369 (38.48%) Overweight 696 (27.92%) 236 (33.90%) 460 (66.09%) Obesity class-1 422 (16.23%) 118 (27.96%) 304 (72.03%) Obesity class-2 403 (15.5%) 108 (26.79%) 295 (73.20%)

Page5488 Fig 2: Study subjects distribution according to weight status category in total population. Out of 1464 disease population in the study, 245 (16.73%) individuals were suffering with hypertension, 67 (4.57%) individuals with diabetes milletus, 261 (17.82%) individuals with diabetes milletus and hypertension, 30 (2.04%) individuals with coronary artery disease, 94 (6.42%) individuals with osteo-arthritis, 22 (1.50%) individuals with hypothyroidism, 320 (21.85%) individuals with two diseases (any of the above) and 425 (29.03%) individuals with more than two diseases( more than two of the above) as shown in table 3 and figure 3. Table 3: Distribution of individuals with various diseases in diseased individuals. Disease condition Number of Individuals (Percentage) Hypertension 245 (16.73%) Diabetes Milletus 67 (4.57%) Diabetes Milletus with Hypertension 261 (17.82%) Coronary Artery disease 30 (2.04%) Osteo arthritis 94 (6.42%) Hypothyroidism 22 (1.50%) Two diseases (any two of the above) 320 (21.85%) More than two diseases (More than two of the above) 425 (29.03%) Figure 3: Distribution of individuals with various diseases in diseased individuals.

Page5489 Table 4: Disease burden in individuals according to weight status category. Weight status category Hypertension patients Diabetes patients DM+HTN Patients Underweight 07 (2.85%) 02 (2.9%) 07(2.68%) Normal weight 72 (29.38%) 16 (23.88%) 67(25.66%) Overweight 73 (29.79%) 18 (26.86%) 87 (33.33%) Obesity 93 (37.95%) 31 (46.26%) 100 (38.31%) It is evident from the data given in Table 4 and Figure 4 that hypertension burden is higher in obese patients i.e., 93 (37.95%) inviduals. Hypertension is also seen in 73 (29.79%) overweight individuals and 72 (29.38%) normal weight status category patients. Type 2-diabetes milletus disease burden is higher in obesity patients in 31 (46.26%) individuals followed by 18 (26.86%) overweight individuals and 16 (23.88%) normal weight status category patients as shown in table 4 and figure 5. In patients with both hypertension and type-2 diabetes milletus, disease burden were almost equal in overweight (33.33%) and obesity (38.31%) individuals, and was higher comparing with normal weight status category (25.66%) as shown in Table 4 and figure 6. Figure 4: Disease burden of hypertension in individuals according to weight status category. Figure 5: Disease burden of Type 2 Diabetes Miletus in individuals according to weight status category.

Page5490 Figure 6: Disease burden of both HTN with DM in individuals according to weight status category. Table 5: Disease burden in individuals according to weight status category. Weight status category Coronary Artery disease Osteo-Arthritis Hypothyroidism Underweight 05 (16.66%) 00 00 Normal weight 7 (23.33%) 18 (19.14%) 03 (13.63%) Overweight 08 (26.66%) 24 (25.23%) 08 (36.36%) Obesity 10 (33.33%) 52 (55.31%) 11 (50.00%) Table 5 and figure 7 show that coronary artery disease patients, disease burden is higher in obese patients in 10 (33.33%) inviduals. This disease condition is also seen in 08 (26.66%) overweight individuals and 7 (23.33%) normal weight status category patients. Osteo-arthritis disease burden is higher in obesity patients in 52 (55.31%) individuals followed by 24 (25.23%) overweight individuals and 18 (19.14%) normal weight status category patients as shown in table 5 and figure 8. In patients with hypothyroidism, disease burden was high among obese individuals (50%) followed by overweight (36.36%) and normal weight individuals (13.63%) as shown in table 5 and figure 9. Figure 7: Disease burden of coronary heart disease in individuals according to weight status category.

Page5491 Figure 8: Disease burden of osteoarthritis in individuals according to weight status category. Figure 9: Disease burden of hypothyroidism in individuals according to weight status category. Table 6: Disease burden in individuals according to weight status category. Weight status category Inviduals with any two diseases (any two mentioned above) Individuals with more than two diseases mentioned above Underweight 08 (2.35%) 07 (1.57%) Normal weight 96 (30.00%) 90 (21.17%) Overweight 98 (30.62%) 144 (33.88%) Obesity 118 (36.87%) 186 (43.76%) Table 6 and figure 10 shows that disease burden of any two diseases were higher in obesity patients in 118 (36.87%) inviduals. This condition is also seen in 98 (30.62%) overweight individuals and 96 (30.00%) normal weight status category patients as shown in table 6 and figure 10. 186 (43.76%) obese individuals were with more than two diseases followed by 144 (33.88%) individuals overweight and 90 (21.17%) individuals with normal weight as shown in table 6 and figure 11.

Page5492 Figure 10: Disease burden of any two diseases in individuals according to weight status category. Figure 11: disease burden of more than two diseases in individuals according to weight status category. DISCUSSION In this study, we predicted a relationship between overweight and obese category levels and morbidity in an up to date sample of adults. We observed a considerable prevalence of chronic health conditions in association with elevated BMI for each gender and also associations of weight status with health outcomes didn't differ between the people of various areas. The Prevalence ratios usually augmented with increasing weight and for several co-morbidities, the prevalence ratios were considerably elevated even for the overweight category (BMI, 25.0-29.9 kg/m2). The information here in this study reflect the burden of disease related to overweight and obese within the South Indian population aged twenty five years and older. In present study disease population was compared with healthy population which revealed that disease burden was found to be decreased in underweight people (healthy 70.00%, disease 30.00%) and normal weight people (healthy 69.52%, disease 38.48%). Disease burden was found to be increased by two folds in overweight people (healthy 33.90%, disease 66.09%), three folds in obesity class-1 people (healthy 27.96%,disease 72.03%) and three folds in obesity class-2 people (healthy 26.79%, disease 73.20%) when compared with healthy population. This indicates disease burden increases with increased body weight. A study conducted by Aviva Must, et al [5] found that the persons who have a body mass index of 25 kg/m2 or greater are more prevalent of having 2 or more health conditions increased with weight status category which found similar to our study.

Page5493 Out of 1464 disease population in present study, most of the individuals were with various co-morbidities like having 2 or more disease conditions (29.03%) followed by individuals with any two diseases (21.85%), diabetes milletus and hypertension (17.82%), only hypertension (16.73%), osteo-arthritis (6.42%), only diabetes milletus (4.57%), coronary artery disease (2.04%) and hypothyroidism (1.50%) which is similar to findings of Katherin M, et al [8]. Our study shows that in hypertension patients, disease burden was higher in obesity patients (37.95%) and almost equal in overweight patients and normal weight status category (29.38%) patients. A study conducted by S Goya Wannamethee, et al [9] also revealed that prevalence of hypertension increased with increasing degrees of overweight/obesity and Men in the normal weight range (18.5 24.9 kg/m2) had the lowest prevalence of ill health. Our study results were similar to Goya study that disease burden of hypertension increased with increasing degrees of overweight, obesity, the normal weight range men had lowest disease burden. In type 2 diabetes patients, disease burden was found to be higher in obesity patients (46.26%) than overweight patients (26.86%) and normal weight status category patients (23.88%). A study conducted by Ali H Mokdad, et al [10] found that overweight and obesity were significantly associated with diabetes which was in concordance with our study. We observed particularly strong associations for overweight (33.33%) and obesity (38.31%) with type 2 DM and hypertension comparing with normal weight status category (25.66%) consistent with the findings of several large cohort studies based on non-representative populations. [11, 12] In Osteo arthritis patients, disease burden was higher in obesity patients i.e. almost three folds (55.31%) compared to normal weight status patients. Disease burden was also found to be more in overweight patients (25.23%) comparing to normal weight status category (19.14%). A study conducted by David T Felson, et al [13] found that obesity precedes and increases the risk of osteoarthritis and his study results found that osteo-arthritis effects in women (72.34%) than men (38.29%). In both men and women comparing to normal weight (male-33.33%, female-66.66%) overweight (45.83%) and obesity class-2 (80.00%) has higher disease burden in men and women respectively. Our results were consistent with the findings of David study. In hypothyroidism patients, disease burden was found elevated four folds in obesity patients (50.00%) almost three folds higher in overweight patients (36.36%) when compared to normal weight status category (13.36%) patients. Our results were consistent with findings of Abhyuday Verma, et al [14] and Thomas Reiner [15] who also found that more patients with thyroid dysfunction were of overweight (44.44%) and obese (80.00%) category. In Coronary heart disease patients, disease burden was higher in obesity patients (33.33%) and overweight patients (26.66%) comparing to normal weight individuals (23.33%). A study was also conducted by Ancel Keys, et al [16] and Willett WC, et al [17] concluded that excessive incidence of coronary heart disease was associated with overweight and obesity which was in concordance with our study. In Patients with two diseases (co-morbidities other than hypertension with type 2 DM) disease burden was higher in obesity individuals (36.87%) comparing to normal weight individuals (30.00%) and is almost equal in overweight (30.62%) and normal weight status category (30.00%). In patients with more than two diseases, disease burden was found to be double in obesity (43.76%) individuals, higher in overweight individuals (33.88%) comparing with normal weight individuals (21.17%) which similar to the findings of the study by Aviva Must, et al [5]. The prevalence of having 2 or more health conditions increased with weight status category both sexes. CONCLUSION From our study it can be concluded that overweight and obesity are strongly associated with several major health risk factors. Disease burden has been elevated two folds in overweight and three folds in obesity class-1, class-2 weight status categories when compared with healthy individuals weight status category. This data clearly suggests that there is increased morbidity frequently with elevated BMI even in those patients in the overweight category. A general pattern of increasing prevalence of disease conditions with increasing overweight and obesity is consistent for all of the health conditions considered. Half of south Indian adults considered having diseases. The prevalence of obesity-related co morbidities emphasizes the need for concerted efforts to prevent and treat obesity rather than just its associated co-morbidities. REFERENCES 1. World Health Organization. Obesity and overweight facts [Internet]. Geneva, Switzerland. August 2014. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/index.html (14 November 2014). 2. World Health Organization. BMI Classification, Global Database on Body Mass Index. [Internet]. Geneva, Switzerland. August 8 2014. Available from; http://apps.who.int/bmi/index.jsp?intropage=intro_3.html. (14 November 2014). 3. National Heart Lung Blood institute. Overweight and Obesity causes in Adults [Internet]. July 13 2012. Available from: http://www.nhlbi.nih.gov/health/health topics/topics/obe/causes.html. (12 November 2014). 4. National Heart Lung Blood institute. Health Risks of Overweight and obesity [Internet]. July 13 2012;]. Available from: http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks.html. (14 November 2014). 5. Must, A., Spadano, J., Coakley, E. H., Field, A. E., Colditz, G., & Dietz, W. H., The disease burden associated with overweight and obesity, JAMA : The Journal of the American Medical Association 1999; 282, 1523 1529. doi:10.1001/jama.282.16.1523. 6. Adams, K. F., Schatzkin, A., Harris, T. B., Kipnis, V., Mouw, T., Ballard-Barbash, R., Leitzmann, M. F., Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old, The New England Journal of Medicine 2006; 355, 763 778. doi: 10.1056/NEJMoa055643 7. Flegal, K. M., Williamson, D. F., Pamuk, E. R., & Rosenberg, H. M., Estimating deaths attributable to obesity in the United States, American Journal of Public Health 2004. doi:10.2105/ajph.94.9.1486

Page5494 8. Flegal, K. M., Graubard, B. I., Williamson, D. F., & Gail, M. H., Cause-specific excess deaths associated with underweight, overweight, and obesity, JAMA : The Journal of the American Medical Association 2007; 298, 2028 2037. doi:10.1097/01.ogx.0000305202.93507.2a 9. Goya Wannamethee, S., Gerald Shaper, A., Whincup, P. H., & Walker, M., Overweight and obesity and the burden of disease and disability in elderly men, International Journal of Obesity and Related Metabolic Disorders : Journal of the International Association for the Study of Obesity 2004, 28; 1374 1382. doi:10.1038/sj.ijo.0802775 10. Mokdad, A. H., Ford, E. S., Bowman, B. A., Dietz, W. H., Vinicor, F., Bales, V. S., & Marks, J. S., Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001, JAMA : The Journal of the American Medical Association 2003; 289, 76 79. doi:10.1001/jama.289.1.76. 11. Hanson, R. L., Narayan, K. M. V, McCance, D. R., Pettitt, D. J., Jacobsson, L. T. H., Bennett, P. H., & Knowler, W. C., Original articles: Rate of weight gain, weight fluctuation, and incidence of NIDDM, Diabetes 1995; 44, 261 266. doi:10.2337/diabetes.44.3.261 12. Colditz, G. A., Willett, W. C., Rotnitzky, A., & Manson, J. E., Weight gain as a risk factor for clinical diabetes mellitus in women, Annals of Internal Medicine 1995; 122, 481 486. doi: 10.1059/0003-4819-122-7-199504010-00001 13. Marks, R., Ghanagaraja, S., & Ghassemi, M., Ultrasound for Osteo-arthritis of the Knee: A systematic review, Physiotherapy 2000; 86, 452 463. 14. Verma, A., Jayaraman, M., Kumar, H. K. V. S., & Modi, K. D., Hypothyroidism and obesity, Saudi Medical Journal 2008; 29, 1135 1138. 15. Reinehr, T., Obesity and thyroid function. Molecular and Cellular Endocrinology 2010. doi:10.1016/j.mce.2009.06.005 16. Ancel keys, Christ Aravanis, Henry Black B, Coronary heart disease: overweight and obesity risk factors., Ann intern Med 1972; 77(1):165.26. 17. Willett, W. C., Manson, J. E., Stampfer, M. J., Colditz, G. A., Rosner, B., Speizer, F. E., & Hennekens, C. H., Weight, weight change, and coronary heart disease in women. Risk within the normal weight range, JAMA 1995; 273, 461 465. 54878478451141141