Obesity is defined as excessive unhealthy accumulation of body fat. India has the third largest obese population in the world after United States of America and China. Prevalence of obesity has reached epidemic proportions in parts of India. In some urban areas, up to a third of the population is either overweight or obese. Childhood and adolescent obesity is also rising rapidly. If this trend continues, certain sections of Indian society may start seeing declining life expectancy in India after many decades of steady progress. Early diagnosis of overweight and obesity may prevent progression to more severe forms associated with complications. In this review, we examine the usefulness of Body Mass Index in diagnosis of obesity in Asian Indian population and the debate surrounding the call for a downward revision of “normal” range in this population.

1.
B
Body mas
ss index: IIs it relev
vant for Inndians?

2. Review Article
Body mass index: Is it relevant for Indians?
Kamal K. Mahawar a,b,*
a
Senior Consultant, Bariatric & Metabolic Surgery, Apollo Obesity and Metabolic Surgery Centre,
Indraprastha Apollo Hospital, New Delhi, India
b
Honorary Consultant Surgeon, Sunderland Royal Hospital, Sunderland SR4 7TP, United Kingdom
a r t i c l e i n f o
Article history:
Received 25 June 2014
Accepted 26 July 2014
Available online xxx
Keywords:
Obesity
Body mass index
Body fat content
a b s t r a c t
Obesity is defined as excessive unhealthy accumulation of body fat. India has the third
largest obese population in the world after United States of America and China. Prevalence
of obesity has reached epidemic proportions in parts of India. In some urban areas, up to a
third of the population is either overweight or obese. Childhood and adolescent obesity is
also rising rapidly. If this trend continues, certain sections of Indian society may start
seeing declining life expectancy in India after many decades of steady progress. Early
diagnosis of overweight and obesity may prevent progression to more severe forms asso-
ciated with complications. In this review, we examine the usefulness of Body Mass Index in
diagnosis of obesity in Asian Indian population and the debate surrounding the call for a
downward revision of “normal” range in this population.
Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Background
Obesity or excessive body fat is associated with poor cardio-
vascular and general health outcomes.1
Accurate identifica-
tion of individuals with an abnormal level of body fat or
adiposity can be challenging, as sophisticated tools for body
fat analysis are not widely available outside specialist obesity
clinics. Body Weight and Body Mass Index (BMI) are the most
commonly used population level surrogate tools to measure
an individual's adiposity. This relationship between adiposity
and BMI is far from a direct correlation and can vary
depending on age (older population has more body fat), sex
(women have more body fat), higher muscle and bone mass
(athletes have less body fat), abdominal obesity (Indian
population), body fat percentage (Indians have higher body fat
percentage) etc.1e3
Currently accepted World Health Organization guidelines
indicate that BMI range of 18.5 kg/m2
e24.99 kg/m2
is normal.
Those with a BMI 25.0 kg/m2
to 29.99 kg/m2
are considered as
overweight and obesity is defined as a BMI of 30.0 kg/m2
[Z].
Several recent studies have however examined continued
relevance of the BMI range between 18.5 kg/m2
e25.0 kg/m2
as
the normal range for the global population. High body fat is an
independent predictor of all cause mortality4
and since In-
dians have more body fat at any given BMI, there has been a
call for downward revision of normal BMI range for Indians.5,6
Furthermore, Indians are more susceptible to the riskier
abdominal (visceral) fat,5,7,8
which is independently associ-
ated with diabetes mellitus,9
metabolic syndrome, and
Abbreviations: BMI, Body Mass Index.
* Apollo Obesity and Metabolic Surgery Centre, Indraprastha Apollo Hospital, New Delhi, India.
E-mail address: kamal_mahawar@hotmail.com.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e4
Please cite this article in press as: Mahawar KK, Body mass index: Is it relevant for Indians?, Apollo Medicine (2014), http://
dx.doi.org/10.1016/j.apme.2014.07.013
http://dx.doi.org/10.1016/j.apme.2014.07.013
0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. cardiovascular disease. BMI is a poor indicator of visceral
adiposity.
We examine the literature surrounding the usefulness of
BMI in identifying population at risk of developing adverse
health consequences as a result of obesity in India in this
review.
2. BMI and mortality
Ideal BMI that results in best health outcomes has been a
matter of considerable debate amongst academicians. Several
recent studies have studied correlation between BMI and
mortality.10e15
Though most studies examining relationship
between BMI and mortality have found lowest mortality
amongst people with BMI 25 kg/m2
, some13e15
have found
overweight (BMI 25 kg/m2
e29.9 kg/m2
) to be associated with
lowest mortality. These studies are usually pooled analysis of a
large number of studies, with very different subject as well as
study characteristics. It is important to understand the limi-
tations of conclusions derived from pooling of such data. These
studies usually generate a lot of hype in media due to the sheer
numbers involved, even though the quality of scientific data in
such pooled analysis of cohort studies is understandably weak.
A recent collaborative analysis10
of baseline BMI versus
mortality in 57 prospective studies with 894,576 participants
(mostly from western Europe and North America) revealed
that the mortality rate was lowest in both sexes in the BMI
range of 22.5 kg/m2
e25.0 kg/m2
and increased proportionately
with any further rise in BMI. Each 5 kg/m2
higher BMI led to
about 30% higher overall mortality. According to this study,
moderate obesity (BMI 30.0 kg/m2
e35 kg/m2
) reduced life ex-
pectancy by about 2e4 years and severe obesity (BMI 40.0 kg/
m2
e45.0 kg/m2
) shortened a person's life by 8e10 years.
Interestingly in this study, the mean BMI was slightly lower in
current smokers than in never-smokers (male 0$3 kg/m2
, fe-
male 0$9 kg/m2
lower), and in regular alcohol users than in
others (male 0$1 kg/m2
, female 1$2 kg/m2
lower).
Similar results were obtained by another study11
where
mortality from any cause was lowest amongst white adults
with a BMI of 22.5 kg/m2
e24.9 kg/m2
. However, the analysis
for those who never smoked showed lowest death rates at a
BMI of 20.0 kg/m2
e25.0 kg/m2
and showed an approximately
linear relationship between BMI and mortality in the range of
BMI 25.0 kg/m2
e40.0 kg/m2
. When the BMI was analyzed as a
continuous variable, the hazard ratio for each 5-unit increase
was 1.31 over the range of 25.0 kg/m2
e49.9 kg/m2
. Authors
concluded that in white adults, overweight and obesity are
associated with increased all cause mortality. Another study
from Taiwan12
found lowest mortality in the group with BMI
22 kg/m2
e26 kg/m2
overall but in BMI 20 kg/m2
e22 kg/m2
ranges after excluding smokers and those with cancers.
In contrast to above observations, Flegal et al13
rather
controversially claimed last year in an article published in
Journal of American Medical Association that overweight (BMI
25 kg/m2
e30 kg/m2
) was associated with significantly lower all
cause mortality relative to normal weight. In this study
though class 2 and 3 obesity was associated with significantly
higher all-cause mortality; class 1 obesity was not and over-
weight was in fact protective.
It is worth knowing that many of these studies fail to
satisfactorily account for confounding variables that are
independently associated with both BMI and early mortality.
The importance of variables like baseline age, female sex, pre-
existing chronic disease, urban residence, higher education,
higher socioeconomic class, better living conditions, better
nutrition, smoking, and significant alcohol consumption in
analyzing relationship between BMI and mortality, is now
widely appreciated.16,17
Lack of proper adjustment for one or
more of these confounding variables may have accounted for
the superior health outcomes seen in overweight patients
(BMI 25.0 kg/m2
e29.9 kg/m2
) in some of these studies. Other
explanations for such counterintuitive beneficial effects of
being overweight may be earlier presentation of obese pa-
tients, higher likelihood of receiving medical treatment,
cardio-protective metabolic effects of increased body fat, and
benefits of higher metabolic reserves.13
In Indian context, overweight and obesity are diseases of
the affluent in the society, who can afford better education
and healthcare, which their poorer counterparts with lower
BMI cannot. For instance, Pednekar et al.18
observed from their
large study of 148,173 men and women in Mumbai that over-
weight men and women (BMI 25.0 kg/m2
e30.0 kg/m2
) had
lowest mortality. These findings are easy to explain when we
find out that the study did not include upper middle class and
upper class people and authors themselves conceded that the
study cohort might not have been representative of Mumbai's
population. Socioeconomic status is known to be a big con-
founding factor in Indian studies.19,20
Lack of association be-
tween BMI 23 kg/m2
and mortality seen in another large rural
study from South Indian state of Kerala,21
could also be
explained by lack of adjustment for socioeconomic status. The
association between socioeconomic status and overweight is
positive in most low and middle-income countries, as the
burden of overweight and obesity has consistently remained
concentrated amongst wealthier populations in these
countries.22e24
3. Correlation between BMI, total body fat,
and visceral fat
Furthermore, limitations of BMI in reflecting total body fat
content and abdominal obesity are widely recognized.16
This
limitation is more pronounced at the lower BMI ranges and for
certain population groups like Indians. BMI cannot differen-
tiate between fat mass and muscle mass and it is now known
that Asians have a higher body fat percentage for a given
BMI.5,7,25
Rush et al.26
confirmed that Asian Indian men and
women with a BMI of 24 and 26 respectively had the same
percentage of body fat as Europeans with a BMI of 30 or Pacific
men and women with a BMI of 34 and 35 respectively. Authors
of this study concluded that Asian Indians have more total
body fat, abdominal fat; and less lean mass, skeletal muscle
mass, and bone mineral than all other ethnic groups.26
In
another study of body fat content in North Indians, Dudeja
et al.25
found that A BMI of 21.5 kg/m2
for males and 19.0 kg/m2
for females had the optimum sensitivity and specificity in
identifying subjects with a high percentage of body fat. A
number of other studies have also suggested that a BMI of
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e42
Please cite this article in press as: Mahawar KK, Body mass index: Is it relevant for Indians?, Apollo Medicine (2014), http://
dx.doi.org/10.1016/j.apme.2014.07.013

4. 22.0 kg/m2
or 23.0 kg/m2
might be ideal for the Asian Indian
population.7,27
Excessive body fat or adiposity is positively associated with
cardiovascular disease. When one studies only cardiovascular
disease related deaths amongst South Asians, unsurprisingly
the lowest rate is seen in individuals with lowest adiposity,
the ones in the BMI range of 15.0e19.9.17
Others have also said
that the control of obesity and greater physical activity are the
most effective strategies for prevention of diabetes and car-
diovascular disease in South Asian people.28
Adiposity is more
important than BMI in determining cardiovascular risk.17,29
This has led to call for wider use of body composition mea-
sures to study the link between adiposity and mortality in
future studies.30
Measuring total body fat is however not easy
in routine clinical practice and tools to do that are beyond the
reach of most clinicians, even in developed countries. There is
hence an urgent need to invent tools for total body fat analysis
that can be made available more widely. Some authors31
have
further suggested that simply calculating body fat content is
also unsatisfactory, as it does not take into account the vari-
ations depending on the height of the individual. They have
proposed calculation of a body fat mass index on the lines of
body mass index, which incorporates the height of the indi-
vidual as well.
Indians are more predisposed to the abdominal or visceral
adiposity and visceral adiposity is independently linked with
diabetes mellitus and metabolic syndrome,5,28
and cardio-
vascular risk.32,33
Not only do Asian Indians have higher
upper-body adiposity and higher visceral fat for a given BMI
when compared with the Western population, but also a
tendency for minor changes in BMI to tilt the metabolic bal-
ance towards hyperglycemia and metabolic syndrome.5,7,8
Risk of diabetes becomes significant at BMI 23 kg/m2
for
urban Indians.7
In an earlier study, same authors had noted an
increasing trend of diabetes with BMI 22 kg/m2
. Beyond CVD
and type 2 diabetes, individuals with metabolic syndrome
seemingly are susceptible to other conditions, notably poly-
cystic ovary syndrome, fatty liver, cholesterol gallstones,
asthma, sleep disturbances, and some forms of cancer.34
BMI
has obvious limitations in measuring abdominal or visceral
adiposity. Waist circumference can be used as a surrogate
marker to measure abdominal obesity. It is indeed known
people with large waist circumferences have excess burden of
ill health.35
It is hence suggested that waist circumference and
waist hip ratio may be better tools for measurement of
abdominal obesity and should be measured more widely in
Indian population.
Relationship between BMI, Total Body Fat, and the riskier
Visceral obesity is far from linear in Indian population. This is
probably why WHO expert consultation36
in 2004 did not
revise the cut-off points for overweight for Asian people. The
consultation though agreed that a large number of Asian
people have a high risk of type 2 diabetes and cardiovascular
disease at BMIs lower than the existing WHO cut-off point for
overweight (or ¼ 25 kg/m2
). They further observed that the
cut-off points for increased risk varies from 22 kg/m2
to 25 kg/
m2
in different Asian populations and for high risk it varies
from 26 kg/m2
to 31 kg/m2
. Even though the consultation did
not recommend altering cut-off values, they did recommend
further potential public health action points at BMIs of 23.0,
27.5, 32.5, and 37.5 kg/m2
.
4. Conclusion
We feel there is a need to look beyond BMI when diagnosing
pathological adiposity or obesity in Indian population. Waist
Circumference and Waist Hip Ratio should be more widely
used and where possible (in specialist clinics), total body fat
content should be studied. Finally, one should take into ac-
count individual's current health and genetic predisposition
before deciding when to intervene.
Conflicts of interest
The author has none to declare.
r e f e r e n c e s
1. Heitmann BL, Erikson H, Ellsinger BM, Mikkelsen KL,
Larsson B. Mortality associated with body fat, fat-free mass
and body mass index among 60-year-old swedish men-a 22-
year follow-up. The study of men born in 1913. Int J Obes Relat
Metab Disord. 2000;24(1):33e37.
2. Prentice AM, Jebb SA. Beyond body mass index. Obes Rev.
2001;2(3):141e147.
3. Pasco JA, Nicholson GC, Brennan SL, Kotowicz MA. Prevalence
of obesity and the relationship between the body mass index
and body fat: cross-sectional, population-based data. PLoS
One. 2012;7(1):e29580.
4. Bigaard J, Frederiksen K, Tjønneland A, et al. Body fat and fat-
free mass and all-cause mortality. Obes Res. 2004
Jul;12(7):1042e1049.
5. Banerji MA, Faridi N, Atluri R, Chaiken RL, Lebovitz HE. Body
composition, visceral fat, leptin, and insulin resistance in
Asian Indian men. J Clin Endocrinol Metab. 1999;84(1):137e144.
6. James WP, Chunming C, Inoue S. Appropriate Asian body
mass indices? Obes Rev. 2002;3(3):139.
7. Snehalatha C, Viswanathan V, Ramachandran A. Cutoff
values for normal anthropometric variables in Asian Indian
adults. Diabetes Care. 2003;26(5):1380e1384.
8. Chandalia M, Abate N, Garg A, Stray-Gundersen J, Grundy SM.
Relationship between generalized and upper body obesity to
insulin resistance in Asian Indian men. J Clin Endocrinol Metab.
1999;84(7):2329e2335.
9. Kanaya AM, Wassel CL, Mathur D, et al. Prevalence and
correlates of diabetes in South Asian Indians in the United
States: findings from the metabolic syndrome and
atherosclerosis in South Asians living in America study and
the multi-ethnic study of atherosclerosis. Metab Syndr Relat
Disord. 2010;8(2):157e164.
10. Prospective Studies Collaboration. Body-mass index and
cause-specific mortality in 900 000 adults: collaborative
analyses of 57 prospective studies. Lancet.
2009;373:1083e1096.
11. Berrington de Gonzalez A, Hartge P, Cerhan JR, et al. Body-
mass index and mortality among 1.46 million white adults. N
Engl J Med. 2010;363:2211e2219.
12. Pan WH, Yeh WT, Chen HJ, et al. The U-shaped relationship
between BMI and all-cause mortality contrasts with a
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e4 3
Please cite this article in press as: Mahawar KK, Body mass index: Is it relevant for Indians?, Apollo Medicine (2014), http://
dx.doi.org/10.1016/j.apme.2014.07.013

5. progressive increase in medical expenditure: a prospective
cohort study. Asia Pac J Clin Nutr. 2012;21(4):577e587.
13. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-
cause mortality with overweight and obesity using standard
body mass index categories: a systematic review and meta-
analysis. J Am Med Assoc. 2013;309(1):71e82.
14. Orpana HM, Berthelot JM, Kaplan MS, Feeny DH, McFarland B,
Ross NA. BMI and mortality: results from a national
longitudinal study of Canadian adults. Obesity (Silver Spring).
2010;18(1):214e218.
15. McGee DL, Diverse Populations Collaboration. Body mass
index and mortality: a meta-analysis based on person-level
data from twenty-six observational studies. Ann Epidemiol.
2005;15(2):87e97.
16. Adams KF, Subramanian SV. Commentary: is the concern
regarding overweight/obesity in India overstated? Int J
Epidemiol. 2008;37(5):1005e1007.
17. Chen Y, Copeland WK, Vedanthan R, et al. Association
between body mass index and cardiovascular disease
mortality in east Asians and South Asians: pooled analysis of
prospective data from the Asia Cohort Consortium. BMJ.
2013;347:f 5446.
18. Pednekar MS, Hakama M, Hebert JR, Gupta PC. Association of
body mass index with all-cause and cause-specific mortality:
findings from a prospective cohort study in Mumbai
(Bombay), India. Int J Epidemiol. 2008;37(3):524e535.
19. Subramanian SV, Perkins JM, Khan KT. Do burdens of
underweight and overweight coexist among lower
socioeconomic groups in India? Am J Clin Nutr.
2009;90(2):369e376.
20. Subramanian SV, Smith GD. Patterns, distribution, and
determinants of under- and overnutrition: a population-
based study of women in India. Am J Clin Nutr.
2006;84(3):633e640.
21. Sauvaget C, Ramadas K, Thomas G, Vinoda J, Thara S,
Sankaranarayanan R. Body mass index, weight change and
mortality risk in a prospective study in India. Int J Epidemiol.
2008;37(5):990e1004.
22. Neuman M, Finlay JE, Davey Smith G, Subramanian SV. The
poor stay thinner: stable socioeconomic gradients in BMI
among women in lower- and middle-income countries. Am J
Clin Nutr. 2011;94(5):1348e1357.
23. Subramanian SV, Perkins JM, €Ozaltin E, Davey Smith G.
Weight of nations: a socioeconomic analysis of women in
low- to middle-income countries. Am J Clin Nutr.
2011;93(2):413e421. http://dx.doi.org/10.3945/ajcn.110.004820.
Epub 2010 Nov 10.
24. Jones-Smith JC, Gordon-Larsen P, Siddiqi A, Popkin BM. Is the
burden of overweight shifting to the poor across the globe?
Time trends among women in 39 low- and middle-income
countries (1991e2008). Int J Obes (Lond). 2012;36(8):1114e1120.
25. Dudeja V, Misra A, Pandey RM, Devina G, Kumar G,
Vikram NK. BMI does not accurately predict overweight in
Asian Indians in Northern India. Br J Nutr. 2001;86(1):105e112.
26. Rush EC, Freitas I, Plank LD. Body size, body composition and
fat distribution: comparative analysis of European, Maori,
Pacific Island and Asian Indian adults. Br J Nutr.
2009;102(4):632e641.
27. World Health Organization. WHO Recommendations: Obesity:
Preventing and Managing the Global Epidemic. Geneva: World
Health Org.; 2000 (Tech. Rep. Ser., no. 894).
28. McKeigue PM, Shah B, Marmot MG. Relation of central obesity
and insulin resistance with high diabetes prevalence and
cardiovascular risk in South Asians. Lancet.
1991;337(8738):382e386.
29. Segal KR, Dunaif A, Gutin B, Albu J, Nyman A, Pi-Sunyer FX.
Body composition, not body weight, is related to
cardiovascular disease risk factors and sex hormone levels in
men. J Clin Invest. 1987;80(4):1050e1055.
30. Allison DB, Faith MS, Heo M, Kotler DP. Hypothesis
concerning the U-shaped relation between body mass index
and mortality. Am J Epidemiol. 1997;146(4):339e349.
31. VanItallie TB, Yang MU, Heymsfield SB, Funk RC, Boileau RA.
Height-normalized indices of the body's fat-free mass and fat
mass: potentially useful indicators of nutritional status. Am J
Clin Nutr. 1990;52(6):953e959.
32. Britton KA, Massaro JM, Murabito JM, Kreger BE, Hoffmann U,
Fox CS. Body fat distribution, incident cardiovascular disease,
cancer, and all-cause mortality. J Am Coll Cardiol.
2013;62(10):921e925.
33. Varghese B, Swamy S, Srilakshmi MA, et al. Visceral adiposity
in young patients with coronary artery disease-a case control
study. Indian Heart J. 2012;64(3):284e289.
34. Ninomiya JK, L'Italien G, Criqui MH, Whyte JL, Gamst A,
Chen RS. Association of the metabolic syndrome with history
of myocardial infarction and stroke in the third national
health and nutrition examination survey. Circulation.
2004;109(1):42e46.
35. Lean ME, Han TS, Seidell JC. Impairment of health and quality
of life in people with large waist circumference. Lancet.
1998;351(9106):853e856.
36. WHO Expert Consultation. Appropriate body-mass index for
Asian populations and its implications for policy and
intervention strategies. Lancet. 2004;363(9403):157e163.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e44
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