As some readers may recall, last year I was in Beijing to speak on obesity and hypertension management, problems that most non-Chinese readers may not readily associate with China. No doubt, any Western visitor to China may find it hard to spot any Chinese obese men or women, at least by applying our Western definitions of ‘obesity’.
Unfortunately, obesity and related metabolic diseases are alive and kicking across East Asia – which makes the recent rather enthusiastic announcement of Weight Watcher’s interest in growing their Chinese presence understandable.
Thus, according to Weight Watcher’s CEO David Kirchhoff in an interview to the The Wall Street Journal,
“What you see in China is that overnight, there’s this huge middle class that’s emerged: People who have all the money they could need to buy whatever food they want to buy. There are cars all over the place. People are on the Internet, doing lots of things other than being outside. They’re literally eating so much food they don’t know what to do with it. On top of that, you have the one-child policy, you have parents and two sets of grandparents spoiling one kid. Put all those things together, and it’s not surprising that China has one of the fastest growth rates in obesity of any country around.”
So while festive occasions such as New Year celebrations should perhaps not be the time to brood about the potential adverse effects of the many less-than-healthy foods served at the traditional family reunions, the rise of obesity (and related disorders) in the Chinese community may well raise concerns over the coming year.
I, for one, am quite confident that my trip to China last year to discuss obesity, will certainly not have been my last.
Yesterday, on the first day of the 1st Caribbean Obesity Forum, I presented various talks on obesity – its economic implications, its assessment and the need for firmly anchoring obesity treatment in primary care.
Interestingly, several family doctors in the audience raised the interesting issue that here on Barbados (as probably on other islands) many patients are actually quite happy with their weights.
One family physician noted in his presentation the case of an overweight woman, who presented in his practice with diabetes. A few weeks after starting her on metformin, she came back considerably distressed about the fact, that she had now lost a few kilos. He noted that despite explaining out that her diabetes was now under control and her blood pressure had improved, she remained unconvinced about the benefits of being on this treatment. To her, losing weight equated directly with being unhealthy and ‘less sexy’ to her husband.
This topic came up several times during the day, where the issue of how to address obesity related health problems in a culture, where excess weight is considered both physically attractive and a sign of good health – never mind that the Caribbean (as pointed out by other speakers) now has some of the highest diabetes rates in world – I have heard Jamaica referred to as the world capital of foot amputations.
The notion of obesity as a sign of good health of course is not that surprising – especially in countries where malnutrition, infectious diseases, gut parasites, and other ‘wasting’ conditions, are endemic. Being skinny is a sure sign of sickness and weight loss is most alarming.
One discussant reminded me of the African practice of fattening rooms, where brides-to-be would be sequestered and overfed in order to be their ‘best weight’ on their wedding day – the exact opposite of Western societies, where brides wanting to lose weight provide healthy profits for the weight-loss industry.
Obviously, in such a setting, the very idea that excess weight may adversely affect pregnancy outcomes, is clearly a hard sell – as noted by the colleague speaking on the issue of epigenetic programming in utero.
In the discussions, I did point out that while we certainly did not have an issue with women not wanting to lose weight (in fact our challenge is perhaps the opposite – convincing many women that the few extra pounds they would so desperately like to shave off their butts and thighs may actually protect them from diabetes and other health problems), we do have a problem with men trivialising or denying the problem.
These learnings are nevertheless important to me, especially when practicing in a country like Canada, where we see patients with a wide range of ethnic and cultural backgrounds.
As clinicians, let us be aware that when some of our patients appear unconcerned about their weight-realated health problems, they may not simply be unmotivated to consider obesity treatments – they (and their family and friends) may actively oppose and resist them.
But how does this variation in weight perception affect actual weight management behaviours?
This question was addressed by R Dorsey and colleagues from the Centers for Disease Control and Prevention, Hyattsville, MD, USA, in a paper just published in Ethnicity and Disease.
To examine racial/ethnic differences in the relationship between weight perception and weight management behaviors among overweight and obese adults, the investigators examined a nationally representative sample of 11,319 non-Hispanic White, non-Hispanic Black and Mexican American overweight and obese adults from the 1999-2006 National Health and Nutrition Examination Survey (NHANES).
Correct weight perception was positively associated with weight management behavior across all ethinic/racial groups.
However, there were interesting differences in reported weight management behaviours.
Thus, overweight non-Hispanic Blacks with a weight misperception were 30% less likely to have tried to lose weight or to have tried not to gain weight than overweight non-Hispanic Whites with a weight misperception.
Also, among individuals with obesity and a weight misperception, non-Hispanic Blacks were about half as likely to desire to weigh less compared to non-Hispanic Whites.
Thus, while individual with correct weight perception report similar weight concerns and behaviours, there are significant differences amongst those with weight misperceptions cross ethnic/racial groups.
In Canada, where the proportion of hispanic and blacks is far lower than in the US, it would be interesting to see how both weight perception and behaviours differ amongst South Asian and East Asian populations. Obviously, it would also be interesting to see how these issues are relevant to the aboriginal peoples of Canada.
Dorsey RR, Eberhardt MS, & Ogden CL (2010). Racial and ethnic differences in weight management behavior by weight perception status. Ethnicity & disease, 20 (3), 244-50 PMID: 20828097
Yesterday, I attended the annual Spring Meeting of CANNeCTIN (Canadian Network and Centre for Trials Internationally), a national network funded by the CIHR/CFI Clinical Research Initiative program to improve the prevention and treatment of cardiac and vascular diseases and diabetes.
CANNeCTIN is jointly led by Dr. Salim Yusuf, from Hamilton Health Sciences and McMaster University, and Dr. John Cairns, from the University of British Columbia. CANNeCTIN facilitates the development, conduct and leadership of large international clinical trials, registries and epidemiologic studies across Canada and the world.
As it so happens, yesterday, also saw the online publication in Diabetes Care of a paper I was involved in during my time in Hamilton on the ethnic variation of risk factors associated with obesity.
In this paper, we looked at the relationship between body weight (BMI), adipokines, and insulin resistance in 1,176 South Asian, Chinese, Aboriginal, and European Canadians in the SHARE study (Study of Health Assessment and Risk in Ethnic groups).
Adjusted mean adiponectin (a protein secreted by fat cells that improves insulin sensitivity) concentration was significantly higher in Europeans [12.9] and Aboriginals [11.8] compared to South Asians [8.8] and Chinese [8.5].
Serum leptin levels were also significantly higher in South Asians [11.8] and Aboriginals [11.1] compared to Europeans [9.2] and Chinese [8.3].
BMI and waist circumference were inversely associated with adiponectin in every group except the South Asians.
The increase in HOMA-IR (a measure of insulin resistance) for each given decrease in adiponectin was larger among South Asians and Aboriginals compared to Europeans.
Interestingly, a high glycemic index diet was associated with a larger decrease in adiponectin among South Asians and Aboriginals, and a larger increase in HOMA-IR among South Asians relative to other groups.
This study clearly shows that South Asians have the least favourable adipokine profile of the studied ethnic groups, and like the Aboriginal people, display a greater increase in insulin resistance with decreasing levels of adiponectin.
The reasons for these differences are not clear but we are studying possible mechanisms to explain these findings in South Asians in a “molecular” version of this study.
Mente A, Razak F, Blankenberg S, Vuksan V, Davis AD, Miller R, Teo K, Gerstein H, Sharma AM, Yusuf S, Anand SS, & for the SHARE, SHARE-AP investigators (2010). Ethnic variation in adiponectin and leptin levels and their association with adiposity and insulin resistance. Diabetes care PMID: 20413520
To those of us working in the obesity field, the idea that there are people out there, who do not think that being overweight or obese has a negative impact on health may seem surprising. But fact is, not everyone, who carries around extra pounds, believes that this may be negatively affecting their health – according to a new study just published in the Patient Education and Counseling, whether or not patients do, may depend on their race.
In this study, Nefertiti Durant and colleagues from Birmingham, Alabama, USA, examined 1071 overweight (41%) and obese (59%) patients who completed a 2002 Community Health Center (CHC) User survey.
Interestingly, Blacks and Hispanics were half as likely as non-Hispanic Whites to believe weight was damaging to their health despite correction for covariates (SES, etc.).
Furthermore, overweight/obese patients who were told they were overweight by healthcare providers were almost nine times more likely to perceive that weight was damaging to their health compared to those not told.
Thus, the authors conclude, there appear to be great racial/ethnic disparities in the perception that overweight is unhealthy but provider communication may be a powerful tool for helping patients understand that overweight is damaging to health.
I am not aware of Canadian data on this issue – do visible minorities in Canada (e.g. East Asian, South Asian, etc.) perceive overweight to be any less detrimental to their health than White Canadians? Also, are there sex differences in this perception that explain why we so few men present in obesity clinics?