Sage Journals: Discover world-class research

Abstract

Obesity is a chronic relapsing disease with rising prevalence in South Asia because of the changing economic and social landscape and transition in lifestyle. The issues in obesity management are unique to South Asians because of the characteristic ‘thin-fat’ phenotype, diet with high carbohydrate and low protein contents, issues with availability, affordability and approval status of various anti-obesity drugs and various social and cultural aspects unique to this population. In this article, we have reviewed literature sourced from India and South Asia pertaining to obesity and addressed the steps for a comprehensive and streamlined approach for the management of obesity in this part of the world.

Keywords

Adiposity body mass index metabolic syndrome nutrition & dietetics obesity waist circumference waist hip ratio

Obesity is a chronic disease with a high potential for relapse. In order to emphasise this fact, the term ‘Adiposity Based Chronic Disease’ (ABCD)^[1] was coined by the American Association of Clinical Endocrinology (AACE) to refer to obesity. There is a tremendous rise in prevalence of obesity in South Asia in the recent decades, and various factors contribute to it, like rapid rate of urbanisation, sedentary lifestyle and change in food habits especially among the younger population. According to the World Obesity Atlas 2024, the global estimate of people with BMI ≥ 25 kg/m² was 2.2 billion in 2020, of which 335 million were from the South East Asia region. This burden is projected to increase to 3.3 billion worldwide in 2035, out of which 607.57 million will be from the South East Asia region only. Looking at the data available from 2000 to 2016, all the South Asian countries are among the top 20 countries worldwide for the most rapid increase in the proportion of adults living with high BMI.^[2] The diagnosis and management of obesity should be curated for the South Asian context. This review enumerates the unique challenges in diagnosis and management of obesity in South Asia.

Parameters Indicating Obesity

The BMI cutoffs for defining overweight and obesity are lower in the Asian population as compared to international cutoffs due to the concept of thin fat phenotype with higher visceral fat for the same BMI in South Asians as compared to the Caucasian population [Table 1].^[3] South Asians have higher insulin resistance and cardiometabolic risk at lower BMIs.^[4-6]

Table 1.

Cut points of various indicators for overweight and obesity^[7,8]

	WHO International Guidelines^[9,10]	The Asia-Pacific Perspective: Redefining Obesity and Its Treatment^[11]	ESI Obesity Guidelines^[8]	IDF Consensus^[12]
Overweight BMI (kg/m²)	25.0	23.0	23–24.9	–
Obese BMI (kg/m²)	Class I: 30.0 Class II: 35.0 Class III: ≥40.0	Class I: 25.0 Class II: ≥30.0	Grade I: 25–29.9 Grade II: 30–34.9 Grade III: >35	–
Excess risk waist circumference (cm)	Increased risk: 80(women)/94(men) Higher risk: 88(women)/102(men)	80(women)/90(men)	80(women)/90(men)	80(women)/90(men)
Waist-hip ratio	>0.9 for men >0.85 for women	–	0.9 for men 0.8 for women
Body fat percentage	–	–	>25% for men >30% for women

Note: BMI: Body mass index, IDF: International Diabetes Federation, WHO: World Health Organisation, ESI: Endocrine Society of India.

Assessment of Patients with Obesity

As obesity is a multifaceted chronic disease with multiple complications and associated comorbidities, the evaluation for the same should be broad enough to address to all such aspects. Numerous guidelines have stressed the significance of employing detailed clinical staging systems like the Edmonton Obesity Staging System (EOSS) alongside evaluating the aetiology of obesity and assessing associated comorbidities.

The EOSS is a comprehensive clinical staging system which takes into account the risk factors related to obesity, physical and psychological symptoms and functional limitations for disease staging.^[13] This staging system not only helps in predicting mortality but also in designing a plan for the treatment of obesity as well. People with obesity (PwO) who have BMI >23 kg/m² or WC > 80 cm for women and >90 cm for men should undergo the EOSS staging system for staging and planning therapeutic interventions.^[14]

A comprehensive comorbidity and complications assessment should be done in PwO [Table 2].

Table 2.

Co-morbidities and complications related to obesity

Metabolic	T2DM, Prediabetes, Dyslipidaemia
Cardiovascular	Hypertension, atherosclerosis, coronary artery disease
Mechanical/musculo-skeletal	Osteoarthritis, degenerative disc disease, slipped capital femoral epiphysis in children, plantar fasciitis
Gastrointestinal	GERD, cholelithiasis, MASLD
Reproductive	PCOS, male hypogonadism, female infertility, pregnancy complications
Respiratory	Obstructive sleep apnoea, Asthma
Urological	Stress incontinence
Psychological	Depression, poor body image
Oncological	Increase risk of endometrial, breast, ovarian, prostate, pancreatic, hepatocellular and colon cancer

Note: T2DM: Type 2 diabetes mellitus, GERD: Gastro-oesophageal reflux disease, MASLD: Metabolic dysfunction-associated steatotic liver disease, PCOS: Polycystic ovarian syndrome.

Treatment of Obesity

The goals of obesity management should be aimed at prevention of further weight gain, reducing weight and maintenance of the lower body weight achieved. Along with weight loss, treatment should be targeted to improving metabolic health, developing a positive body image, addressing comorbidities and overall, well-being. Achieving a weight loss of 5%-10% within six months is a practical target and offers several metabolic benefits [Table 3].^[15]

Table 3.

Body mass index (BMI) thresholds for obesity management in the South Asian population^[8]

Body Mass Index	Lifestyle Modification, Behavioural Therapy	Pharmacotherapy	Bariatric Surgery
23–24.9 (overweight)	+	−	−
25–26.9 (Grade I)	+	+ (with co-morbidities)	−
27–29.9 (Grade I)	+	+	−
30–34.9 (Grade II)	+	+	+ (with co-morbidities)
≥37.5 (Grade III)	+	+	+

Lifestyle Modification

Lifestyle modification combines dietary modifications, physical activity and behavioural therapy. It is the first rung in the ladder of obesity management.

Diet in Obesity

In planning a diet for obesity, the goal should be to lower overall calorie intake while maintaining adequate nutritional value. The patient’s cultural culinary habits, personal choices, affordability, compatibility with other co-morbidities and potential to continue over a prolonged time period need to be considered while designing a diet plan. The patient needs to be educated about unhealthy foods and food habits. A food diary or journal would be useful to track daily meals, and hence avoid eating at irregular intervals, frequent snacking or skipping meals.

The dietary modification with calorie restriction, modification of macronutrient composition and portion control are required for a long-term effective weight loss. South Asian population have a characteristic macronutrient distribution with high carbohydrate and low protein content compared to the western diet. This is responsible for the typical thin fat Indian phenotype with sarcopenic obesity.^[8]

Calorie restriction can be started by restricting >500 kcal per day, targeting 0.5 kg-1 kg of weight loss per week or 8%-10% weight loss over six months’ time.

Physical Exercise

Studies have shown that South Asian people are physically less active^[16,17] compared to the western population and also their participation in recreational activities is uncommon, especially among women and elderly^[18,19] which in turn contributes to the increased prevalence of obesity in this subset of population. Regular physical exercise not only helps in weight loss but also has other benefits like improvement in cardiometabolic risk factors, improvement in body image, mood disorders and reduction of dementia and cognitive decline.^[20-23]

Aerobic exercise of moderate intensity of ≥150 min/week done in three to five daily sessions per week not only helps in modest weight loss, but also in reducing visceral fat^[24] and in maintenance of weight after weight loss.^[25] Resistance training is recommended two to three times a week in patients undergoing weight loss therapy, which includes single-set exercises that involve major muscle groups, as it helps promote weight loss and maintain fat-free muscle mass.^[26-29] Escalating to 300 minutes a week of moderate-intensity, or 150 minutes a week of vigorous-intensity aerobic physical activity can have probable benefit given the dose response relationship between physical activity and health.

However, while prescribing an exercise regimen for any patient, his/her age, physical status, disability, co-morbidities and motivation to adhere to the regimen must be considered. It is recommended that patients with co-morbidities undergo a pre-participation medical consultation before starting an exercise regimen.

Pharmacotherapy in Obesity

Pharmacotherapy is recommended for individuals with a BMI greater than 27 kg/m² or for those with a BMI over 25 kg/m² who have one or more associated comorbidities like Type 2 diabetes, hypertension, dyslipidaemia, obstructive sleep apnoea, etc. or at lower BMIs for individuals who are unable to exercise.

The most commonly used drugs in South Asia for obesity are orlistat, liraglutide and phentermine. However, Orlistat is the only approved drug for pharmacotherapy of obesity in India.

After starting the drug, it is advisable that the patients are monitored once monthly for three months, followed by once in three months thereafter. A drug is considered ineffective and can be discontinued if it fails in reducing the body weight by 5% in adults.^[30] It should be kept in mind that pharmacotherapy should always be used as an adjunct to lifestyle modification and never alone. Short term pharmacotherapy has not proven to reduce long term complications of obesity and there is often weight regain when the drug is stopped [Table 4].^[31-33]

Table 4.

Pharmacotherapeutic options for obesity^[7,8,30]

Medications	Class/Mechanism of Action	Dose	%weight Loss from Baseline^[7,8,30]	Adverse Effects	Contraindications/Warnings
Orlistat	Lipase inhibitor	120 mg PO thrice daily before food	4.6%–10.2% v/s 1.6%–6.6% with placebo [Studies ranging from 12 to 24 months]	• Steatorrhea • Faecal incontinence • Abdominal pain • Oily spotting • Fat-soluble vitamin deficiency	Warnings: • Oxalate nephrolithiasis • Cholelithiasis • Hepatic failure (rare) • Decreased absorption of cyclosporine, thyroid hormones, antiepileptic drugs Contraindications: • Pregnancy • Hypersensitivity to drug • Malabsorption syndromes • Cholestasis • Pregnancy and breastfeeding
Liraglutide (3 mg)	Glucagon like peptide 1 receptor agonist	Start with 0.6 mg SC QD and uptitrate by 0.6 mg weekly till a dose of 3 mg is reached while monitoring for side effects.	6.0%–8.0% v/s 0.2%–2.6% with placebo [Studies of 56 weeks duration]	• Nausea • Vomiting • Dyspepsia • Bloating • Abdominal distension • Diarrhoea • Constipation • Increased heart rate • Hypoglycaemia • Headache • Dizziness • Fatigue	Warnings: • Injection site reactions • Pancreatitis • Cholelithiasis • Acute cholecystitis • Tachycardia • Acute kidney injury • Chronic kidney disease • Suicidal ideation/behaviour Contraindications: • Personal/family history of medullary thyroid carcinoma or multiple endocrine neoplasia 2 • Pregnancy and breastfeeding
Phentermine/topiramate	Phentermine-Norepinephrine releasing drug Topiramate- GABA receptor modulation	Starting dose: 3.75/23 mg PO QD for two weeks. From day 15 increase to 7.5/46 mg PO QD, continue for 12 weeks. After 12 weeks if patient has not lost at least 3% of baseline body weight, increase to 11.25/69 mg for 14 days, followed by an increase to 15/92 mg (maximum dose). After 12 weeks on maximum dose, if weight loss is <5% of baseline, then the drug can be stopped.	7.8%–9.3% (7.5/46 mg dose) 10.5%–12.1% (15/92 mg dose) 1.2%–2.5% (placebo) [Studies of 108 weeks duration]	• Headache • Paraesthesia • Dizziness • Insomnia • Xerostomia • Dysgeusia • Depression • Anxiety • Cognitive impairment CV safety not established	Warnings: • Metabolic acidosis • Impairment of cognition • Tachycardia • Renal calculi • Hypokalaemia • Mood disorders Contraindications: • Glaucoma • Monoamine oxidase inhibitor use • Hyperthyroidism • Pregnancy & breastfeeding
Semaglutide 2.4 mg (injectable)	Glucagon like peptide 1 receptor agonist	Titrate every four weeks. Start with 0.25 mg SC QW, then subsequently increase to 0.5 mg, 1 mg, 1.7 mg and finally 2.4 mg SC QW as tolerated by the patient.	16.9% v/s 2.4% (placebo) [over 68 weeks]	• Nausea • Vomiting • Abdominal distension • Constipation • Diarrhoea • Headache • Gastroesophageal reflux disease • Dizziness	Warnings: • Injection site reactions • Pancreatitis • Cholelithiasis • Acute cholecystitis • Tachycardia • Acute kidney injury • Chronic kidney disease • Suicidal behaviour/ideation Contraindications: • Personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia 2 • Pregnancy and breastfeeding
Naltrexone /Bupropion	Naltrexone-mu-opioid receptor antagonist Bupropion-dopamine and norepinephrine reuptake inhibitor	One tablet: 8/90 mg (8 mg naltrexone/90 mg bupropion) Week 1: 1 tablet PO QAM Week 2: 1 tab PO QAM & 1 tab PO QHS Week 3: 2 tab PO QAM & 1 tab PO QHS Week 4: 2 tab PO QAM & 2 tab PO QHS Maximum dose: 32 mg naltrexone, 360 mg bupropion (2 tablets BID)	5.0%–6.4% v/s 1.2%–1.8% (placebo) [Studies of 56 weeks duration]	• Nausea • Vomiting • Constipation • Diarrhoea • Dry mouth • Dizziness • Anxiety • Insomnia	Warnings: • Suicidal thoughts • Neuropsychiatric symptoms • Seizures • Hypertension and tachycardia • Liver toxicity Contraindications: • Uncontrolled hypertension • Seizure disorder • Eating disorders due to seizure risk • Chronic opioid drug use • Abrupt alcohol discontinuation • Monoamine oxidase inhibitor use • Pregnancy & breastfeeding

Newer Drugs

Several newer molecules have shown promising results for obesity management in phase 2 and phase 3 trials, which are going to be available in the market in the near future [Table 5].

Table 5.

Newer drugs under development

Drug	Mechanism of Action	Clinical Trial	Results
Tirzepatide	Glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist	Phase III (SURMOUNT 1 trial)^[34]	At 72 weeks, the mean percentage change in body weight was −15.0% with 5 mg weekly dose, −19.5% with 10 mg dose and −20.9% with 15 mg dose
Oral semaglutide	Glucagon-like peptide-1 receptor agonist	Phase III (OASIS 1 trial)^[35]	At the end of week 68, the mean percentage change in weight was −15.1% with a 50-mg dose
Retatrutide	Glucose-dependent insulinotropic polypeptide, glucagon-like peptide 1, and glucagon receptor agonist	Phase II^[36]	Least squares mean percentage change in body weight was as high as −17.9 at the end of 24 weeks and −24.2 at the end of 48 weeks
CagriSema (cagrilintide 2•4 mg + semaglutide 2.4 mg)	Amylin analogue and glucagon-like peptide-1 receptor agonist	Phase II^[37]	At week 32, the estimated mean change from baseline was −15.6%
Survodutide	Glucagon receptor-glucagon-like peptide-1 receptor dual agonist	Phase II^[38]	At week 46, mean changes in bodyweight from baseline were −6.2% with 0.6 mg; −12.5% with 2.4 mg; −13.2% with 3.6 mg and −14.9% with 4.8 mg dose
Orforglipron	Nonpeptide glucagon-like peptide-1 (GLP-1) receptor agonist	Phase II^[39]	At week 36, the estimated mean change from baseline in body weight was −9.4% with the 12-mg, −12.5% with 24-mg, −13.5% with 36-mg and −14.7% with 45-mg dose
Ecnoglutide	Long-acting glucagon-like peptide-1 analogue	Phase II^[40]	The least square mean body weight reduction at the end of 26 weeks was −11.5% with 1.2 mg, 11.2% with 1.8 mg and −14.7% with 2.4 mg dose

Certain drugs have been approved for use in monogenic/syndromic obesity like setmelanotide and metreleptin.

Setmelanotide, a melanocortin 4 receptor (MC4R) agonist, is FDA-approved for treating obesity in adults and children over six years old caused by deficiencies in proopiomelanocortin (POMC), proprotein convertase subtilisin/kexin type 1 (PCSK1) or leptin receptor (LEPR). It has also received supplemental indication for obesity associated with Bardet-Biedl Syndrome.

A leptin analogue, metreleptin has been approved for management of obesity and other complications of leptin deficiency in patients with congenital or acquired generalised lipodystrophy.

Bariatric Surgery

Bariatric surgery predominantly involves three kinds of procedures: restrictive procedures, malabsorptive procedures and combined procedures. Restrictive procedures involve reducing the gastric volume and increasing satiety with smaller portions of food. Malabsorptive procedures include changing the path of the gastrointestinal tract via resections and anastomoses to cause malabsorption and combined procedures involve elements of both.

Restrictive procedures: Laparoscopic adjustable gastric banding, vertical sleeve gastrectomy, vertical band gastroplasty and intragastric balloon.

Malabsorptive procedures: Jejuno-ileal bypass, bilio-pancreatic diversion with duodenal switch.

Combined procedures: Roux-en-Y Gastric Bypass (RYGBP)

The indications for bariatric surgery according to western guidelines are BMI ≥ 40 kg/m² or BMI ≥ 35 kg/m² with at least one obesity related complication/comorbidity. For South Asians, indications for surgery are as mentioned in Table 6.

Table 6.

Indications for bariatric surgery

BMI (kg/m²) Cut Offs for Bariatric Surgery	IFO-APC^[41]	DSS-II^[42]	ESI^[8]
Recommended irrespective of co-morbidities	≥35	≥37.5	≥37.5
Recommended with co-morbidities	≥30^a	≥32.5^c	≥32.5
Can be considered	≥27.5^b	≥27.5	-

Notes: IFO-APC: International Federation for the Surgery of Obesity and metabolic disorders - Asia Pacific Chapter; DSS-II: 2nd Diabetes Surgery Summit; ESI: Endocrine Society of India.

^aT2DM or metabolic syndrome not adequately controlled by lifestyle alterations and medical treatment.

^bInadequately controlled T2DM/metabolic syndrome.

^cT2DM with poor glycaemic control.

The amount of weight loss after bariatric surgery depends on the type of surgery done. Gastric bypass, gastric band and sleeve gastrectomy lead to loss of 14–20, 8–12 and 10–18 units of BMI respectively.^[43,44] Apart from weight loss, studies have also shown remission of T2DM^[45,46] and improvement in dyslipidaemia and decrease in systolic blood pressure with bariatric surgery.^[47,48] However, surgery may not be suitable for all populations and is contraindicated in patients with reduced life expectancy, substance abuse, untreated schizophrenia and a history of non-adherence to previous medical care. Post surgery patients may require permanent dietary modifications or micronutrient supplementation and should be counselled before surgery about such consequences.

Follow-up and Maintenance of Weight Loss

As mentioned earlier, obesity is a chronic relapsing illness and despite initial weight loss, regain of weight is common and patients need to be educated regarding this fact. It is important to give realistic targets and expectations in order to prevent disappointment and loss of motivation to adhere to lifestyle modifications and treatment. While designing a dietary plan or exercise regimen for a patient, care should be taken that it is done in such a way that the patient has maximum adherence to the prescribed treatment regimens. Follow up visits to be scheduled at least every three months. A multidisciplinary team should be involved in the follow-up care of the patient, which addresses different domains like diet, exercise, pharmacotherapy and psychological support. At each visit, weight measurement to be done and investigations as needed for co-morbidities/for assessing metabolic health. Caregivers should emphasise adherence to diet and exercise at every visit and educate the patients on pharmacotherapy that medications are used as an adjunct to lifestyle modifications and not alone.

Current Concepts in Obesity Definition

Most guidelines rely on excess adiposity alone, mostly measured by BMI in defining obesity as a disease. However, there are several limitations to this approach:

Preserved health can exist in the face of increased adiposity.

BMI alone does not provide any information on the health of the individual.

BMI can underestimate (e.g., elderly, South Asians, etc.) or overestimate (e.g., Athletes) adiposity leading to underdiagnosis or overdiagnosis respectively.^[49,50]

A disease is defined as a distinct pathophysiology that can cause alterations in a single organ or multiple organs. Excess adiposity alone does not satisfy this definition.

Therefore, terms like preclinical and clinical obesity have been recommended in the recent consensus guidelines by F. Robino et al. to address these limitations.^[50] Clinical obesity includes alterations in the functions of organs directly caused by excess adiposity and is categorised as a chronic illness, whereas preclinical obesity is characterised by excess adiposity without major signs/symptoms of organ dysfunction due to obesity and is categorised as a physical phenotype and not as a disease.

The recommendations further suggest that a person with increased BMI should be confirmed for having excess adiposity by other anthropometric measurements or by direct body fat measurement. Once confirmed, the next step is to categorise him/her into preclinical or clinical obesity. Clinical obesity is managed like any other chronic disease with evidence-based treatment. Patients with preclinical obesity need regular monitoring for appearance of clinical obesity or other adiposity related diseases, while sometimes requiring treatment when the risk of developing clinical obesity is high or when reducing obesity can help in managing other diseases (certain cancers, transplantation, orthopaedic surgeries, etc.).

Conclusion

With the booming economy, development and urbanisation in South Asia, there is an increased prevalence of sedentary lifestyle, fast food consumption and psychological stress contributing to obesity. Promotion of a healthy lifestyle and eating habits at the level of individual, family, school or workplace and the community as a whole should be encouraged to prevent obesity. Education of the public to recognise obesity as a chronic illness, which if untreated can lead to several health hazards and requires long-term follow-up and care is the need of the hour. Designing an individualised treatment plan, patient education and ensuring adherence to treatment are key elements of management of obesity.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Institutional Ethical Committee Approval Number

Not applicable.

Credit author statement

Sambit Das and Amogh Chappalagavi: Conceptualisation, data collection and analysis, literature search, manuscript writing, editing and final approval.

Arun Kumar Choudhury, Dayanidhi Meher, Devadarshini Sahoo, Sandeep Kumar Sahu and Sheenam Gupta: literature search, data collection and analysis, editing and supervision.

Data availability

Not applicable.

Use of artificial intelligence

There was no use of artificial intelligence in preparing this manuscript.

References

Mechanick

, Hurley

, Garvey

. Adiposity-based chronic disease as a new diagnostic term: the American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement. Endocr Pract. 2017;23(3):372–8. doi:10.4158/EP161688.PS

World Obesity Federation. World Obesity Atlas 2024. London: World Obesity Federation, 2024. https://data.worldobesity.org/publications/?cat=22

World Health Organization. The Asia Pacific perspective: redefining obesity and its treatment. 2000. https://apps.who.int/iris/handle/10665/206936. Accessed October 2021 .

Deurenberg-Yap

, Chew

, Lin

, . Relationships between indices of obesity and its co-morbidities in multi-ethnic Singapore. Int J Obes Relat Metab Disord. 2001;25(10):1554–62. doi:10.1038/sj.ijo.0801739

Lin

, Lee

, Chen

, . Optimal cut-off values for obesity: using simple anthropometric indices to predict cardiovascular risk factors in Taiwan. Int J Obes Relat Metab Disord. 2002;26(9):1232–8. doi:10.1038/sj.ijo.0802040

Ntuk

, Gill

, Mackay

, . Ethnic-specific obesity cutoffs for diabetes risk: cross-sectional study of 490,288 UK biobank participants. Diabetes Care. 2014;37(9):2500–7. doi:10.2337/dc13-2966.

Tham

, Abdul

Ghani R

, Cua

, . Obesity in South and Southeast Asia—a new consensus on care and management. Obes Rev. 2023;24(2):e13520. doi:10.1111/obr.13520

S V M, Nitin

, Sambit

, Nishant

, Sanjay

; on behalf of Endocrine Society of India. ESI clinical practice guidelines for the evaluation and management of obesity in India. Indian J Endocrinol Metab. 2022;26(4):295–318. doi:10.4103/2230-8210.356236

WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363(9403):157–63.

10.

World Health Organization. Preventing and managing the global epidemic. WHO Technical Report Series 894. 2000.

11.

World Health Organization. The Asia Pacific perspective: redefining obesity and its treatment. 2000. https://apps.who.int/iris/handle/10665/206936.

12.

Alberti

, Zimmet

, Shaw

. Metabolic syndrome—a new world wide definition. A consensus statement from the international diabetes federation. Diabet Med. 2006;23(5):469–80.

13.

Sharma

, Kushner

. A proposed clinical staging system for obesity. Int J Obes (Lond). 2009;33(3):289–95.

14.

Deshpande

, Kapoor

, Dalal

, . Consensus on current landscape and treatment trends of obesity in India for primary care physicians. J Assoc Physicians India. 2023;71(10):69–77. doi:10.59556/japi.71.0349

15.

Jensen

, Ryan

, Apovian

, . 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. Circulation. 2014;129(25_suppl_2):S102–38.

16.

Hayes

, White

, Unwin

, . Patterns of physical activity and relationship with risk markers for cardiovascular disease and diabetes in Indian, Pakistani, Bangladeshi and European adults in a UK population. J Public Health Med. 2002;24(3):170–8.

17.

Trinh

, Nguyen

, Dibley

, . The prevalence and correlates of physical inactivity among adults in Ho Chi Minh City. BMC Public Health. 2008;8(1):204. doi:10.1186/1471-2458-8-204

18.

Win

, Yen

, Tan

, . Patterns of physical activity and sedentary behavior in a representative sample of a multi-ethnic South-East Asian population: a cross-sectional study. BMC Public Health. 2015;15(1):318. doi:10.1186/s12889-015-1668-7

19.

Johnson

MRD

. Perceptions of barriers to healthy physical activity among Asian communities. Sports Educ Society. 2010;5:51–70.

20.

Shaw

, Gennat

, O’Rourke

, . Exercise for overweight or obesity. Cochrane Database Syst Rev. 2006;2010(4):Cd003817. doi:10.1002/14651858.CD003817.pub3

21.

Warburton

, Nicol

, Bredin

. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801–9. doi:10.1503/cmaj.051351

22.

Pedersen

. Body mass index-independent effect of fitness and physical activity for all-cause mortality. Scand J Med Sci Sports. 2007;17(3):196–204. doi:10.1111/j.16000838.2006.00626.x

23.

World Health Organization. Risk reduction of cognitive decline and dementia: WHO guidelines. 2019. https://www.who.int/publications/i/item/9789241550543

24.

Vissers

, Hens

, Taeymans

, . The effect of exercise on visceral adipose tissue in overweight adults: a systematic review and meta-analysis. PLoS ONE. 2013;8(2):e56415. doi:10.1371/journal.pone.0056415

25.

Jakicic

, Clark

, Coleman

, . American College of Sports Medicine position stand. Appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2001;33(12):2145–56. doi:10.1097/00005768-200112000-00026.

26.

Schwingshackl

, Dias

, Strasser

, . Impact of different training modalities on anthropometric and metabolic characteristics in overweight/obese subjects: a systematic review and network metaanalysis. PLoS ONE. 2013;8(12):e82853. doi:10.1371/journal.pone.0082853

27.

Villareal

, Chode

, Parimi

, . Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med. 2011;364(13):1218–29. doi:10.1056/NEJMoa1008234

28.

Borg

, Kukkonen-Harjula

, Fogelholm

, . Effects of walking or resistance training on weight loss maintenance in obese, middle-aged men: a randomized trial. Int J Obes Relat Metab Disord. 2002;26(5):676–83. doi:10.1038/sj.ijo.0801962

29.

Schmitz

, Jensen

, Kugler

, . Strength training for obesity prevention in midlife women. Int J Obes Relat Metab Disord. 2003;27(3):326333. doi:10.1038/sj.ijo.0802198

30.

Garvey

, Mechanick

, Brett

, . 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. doi:10.4158/EP161365.GL

31.

Davies

, Bergenstal

, Bode

, . Efficacy of liraglutide for weight loss among patients with type 2 diabetes: the SCALE diabetes randomized clinical trial [published correction appears in JAMA. 2016 Jan 5;315(1):90. doi:10.1001/jama.2015.17311]. JAMA. 2015;314(7):687–99. doi: 10.1001/jama.2015.9676

32.

le Roux

, Astrup

, Fujioka

, . 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial. Lancet. 2017;389(10077):1399–409. doi:10.1016/S01406736(17)30069-7

33.

Sjöström

, Rissanen

, Andersen

, . Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. Eur Multicentre Orlistat Study Group Lancet. 1998;352(9123):167–72. doi:10.1016/S0140-6736(97)11509-4

34.

Jastreboff

, Aronne

, Ahmad

, . Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205–16. doi:10.1056/NEJMoa2206038

35.

Knop

, Aroda

, do Vale

, . Oral semaglutide 50 mg taken once per day in adults with overweight or obesity (OASIS 1): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2023;402(10403):705–19. doi:10.1016/S0140-6736(23)01185-6

36.

Jastreboff

, Kaplan

, Frías

, . Triple-hormone-receptor agonist retatrutide for obesity—a phase 2 trial. N Engl J Med. 2023;389(6):514–26. doi:10.1056/NEJMoa2301972

37.

Frias

, Deenadayalan

, Erichsen

, . Efficacy and safety of co-administered once-weekly cagrilintide 2•4 mg with once-weekly semaglutide 2.4 mg in type 2 diabetes: a multicentre, randomised, double-blind, active-controlled, phase 2 trial. Lancet. 2023;402(10403):720–30. doi:10.1016/S0140-6736(23)01163-7

38.

le Roux

, Steen

, Lucas

, Startseva

, Unseld

, Hennige

. Glucagon and GLP-1 receptor dual agonist survodutide for obesity: a randomised, double-blind, placebo-controlled, dose-finding phase 2 trial. Lancet Diabetes Endocrinol. 2024;12(3):162–73. doi:10.1016/S2213-8587(23)00356-X

39.

Wharton

, Blevins

, Connery

, . Daily oral GLP-1 receptor agonist orforglipron for adults with obesity. N Engl J Med. 2023;389(10):877–88. doi:10.1056/NEJMoa2302392

40.

Zhu

, Li

, Zheng

, . 79-LB: An open-label, active-controlled phase 2 evaluation of novel GLP-1 analog ecnoglutide in adults with obesity. Diabetes. 2023;72(Suppl 1):79-LB. doi:10.2337/db23-79-LB

41.

Kasama

, Mui

, Lee

, . IFSO-APC consensus statements 2011. Obes Surg. 2012;22(5):677–84. doi:10.1007/s11695-012-0610-7

42.

Rubino

, Nathan

, Eckel

, . Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care. 2016;39(6): 861–77. doi:10.2337/dc16-0236

43.

Bhasker

, Prasad

, Raj

, . Trends and progress of bariatric and metabolic surgery in India. Updates Surg. 2020;72:743‑9.

44.

Lee

, Almalki

. Recent advancements in bariatric/metabolic surgery. Ann Gastroenterol Surg. 2017;1:171–9.

45.

Chang

, Chao

, Chen

, . The effects of bariatric surgery on renal, neurological, and ophthalmic complications in patients with type 2 diabetes: the Taiwan Diabesity Study. Obes Surg. 2021; 31(1):117–26.

46.

Mingrone

, Panunzi

, De Gaetano

, . Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2021;397(10271):293–304.

47.

Aminian

, Zajichek

, Arterburn

, . Association of metabolic surgery with major adverse cardiovascular outcomes in patients with type 2 diabetes and obesity. JAMA. 2019;322(13):1271–82.

48.

Ikramuddin

, Korner

, Lee

, . Lifestyle intervention and medical management with vs without Roux-en-Y gastric bypass and control of hemoglobin A1c, LDL cholesterol, and systolic blood pressure at 5 years in the diabetes surgery study. JAMA. 2018;319(3):266–78.

49.

Misra

, Vikram

, Ghosh

, Ranjan

, Gulati

; India Obesity Commission Members. Revised definition of obesity in Asian Indians living in India. Diabetes Metab Syndr. Published online January 15, 2025. doi:10.1016/j.dsx.2024.102989

50.

Rubino

, Cummings

, Eckel

, . Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. Published online January 9, 2025. doi:10.1016/S2213-8587(24)00316-4

Obesity Management in South Asian Context

Abstract

Keywords

Parameters Indicating Obesity

Assessment of Patients with Obesity

Treatment of Obesity

Lifestyle Modification

Diet in Obesity

Physical Exercise

Pharmacotherapy in Obesity

Newer Drugs

Bariatric Surgery

Follow-up and Maintenance of Weight Loss

Current Concepts in Obesity Definition

Conclusion

Footnotes

Declaration of conflicting interests

Funding

Institutional Ethical Committee Approval Number

Credit author statement

Data availability

Use of artificial intelligence

References