INTRODUCTION:

What are obesity and overweight?

Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair
health.

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify
overweight and obesity in adults. It is defined as a person's weight in kilograms divided by the
square of his height in meters (kg/m2).

Children aged between 5–19 years:

Overweight and obesity are defined as follows for children aged between 5–19 years:

 Overweight is BMI-for-age greater than 1 standard deviation above the WHO Growth
Reference median; and
 Obesity is greater than 2 standard deviations above the WHO Growth Reference median.

 Charts and tables: WHO growth reference for children aged between 5–19 years

-1-
Obesity is a complex disease involving an excessive amount of body fat. Obesity isn't just a
cosmetic concern. It is a medical problem that increases your risk of other diseases and health
problems, such as heart disease, diabetes, high blood pressure and certain cancers.

There are many reasons why some people have difficulty avoiding obesity. Usually, obesity results
from a combination of inherited factors, combined with the environment and personal diet and
exercise choices.

The good news is that even modest weight loss can improve or prevent the health problems
associated with obesity. Dietary changes, increased physical activity and behavior changes can
help you lose weight. Prescription medications and weight-loss procedures are additional options
for treating obesity.

SYMPTOMS:

Obesity is diagnosed when your body mass index (BMI) is 30 or higher. To determine your body
mass index, divide your weight in pounds by your height in inches squared and multiply by 703.
Or divide your weight in kilograms by your height in meters squared.

BMI WEIGHT STATUS

BELOW 18.5 Underweight

BETWEEN 18.5 TO 24.9 Normal

BETWEEN 25 TO 30 Overweight

ABOVE 30 Obesity

-2-
CAUSES:

Although there are genetic, behavioral, metabolic and hormonal influences on body weight,
obesity occurs when you take in more calories than you burn through exercise and normal daily
activities. Your body stores these excess calories as fat.

Most Americans' diets are too high in calories — often from fast food and high-calorie beverages.
People with obesity might eat more calories before feeling full, feel hungry sooner, or eat more
due to stress or anxiety.

-3-
RISK FACTORS:

Obesity usually results from a combination of causes and contributing factors:

Family inheritance and influences

The genes you inherit from your parents may affect the amount of body fat you store, and where
that fat is distributed. Genetics may also play a role in how efficiently your body converts food
into energy, how your body regulates your appetite and how your body burns calories during
exercise.

Obesity tends to run in families. That's not just because of the genes they share. Family members
also tend to share similar eating and activity habits.

Lifestyle choices

 Unhealthy diet. A diet that's high in calories, lacking in fruits and vegetables, full of fast
food, and laden with high-calorie beverages and oversized portions contributes to weight
gain.

-4-
  Liquid calories. People can drink many calories without feeling full, especially calories
from alcohol. Other high-calorie beverages, such as sugared soft drinks, can contribute to
significant weight gain.

 Inactivity. If you have a sedentary lifestyle, you can easily take in more calories every day
than you burn through exercise and routine daily activities. Looking at computer, tablet and
phone screens is a sedentary activity. The number of hours you spend in front of a screen is
highly associated with weight gain.

Certain diseases and medications

In some people, obesity can be traced to a medical cause, such as Prader-Willi syndrome, Cushing
syndrome and other conditions. Medical problems, such as arthritis, also can lead to decreased
activity, which may result in weight gain.

Some medications can lead to weight gain if you don't compensate through diet or activity. These
medications include some antidepressants, anti-seizure medications, diabetes medications,
antipsychotic medications, steroids and beta blockers.

-5-
Social and economic issues

Social and economic factors are linked to obesity. Avoiding obesity is difficult if you don't have
safe areas to walk or exercise. Similarly, you may not have been taught healthy ways of cooking,
or you may not have access to healthier foods. In addition, the people you spend time with may
influence your weight — you're more likely to develop obesity if you have friends or relatives with
obesity.

Age

Obesity can occur at any age, even in young children. But as you age, hormonal changes and a less
active lifestyle increase your risk of obesity. In addition, the amount of muscle in your body tends
to decrease with age. Generally, lower muscle mass leads to a decrease in metabolism. These
changes also reduce calorie needs, and can make it harder to keep off excess weight. If you don't
consciously control what you eat and become more physically active as you age, you'll likely gain
weight.

-6-
Other factors

 Pregnancy. Weight gain is common during pregnancy. Some women find this weight
difficult to lose after the baby is born. This weight gain may contribute to the development
of obesity in women. Breast-feeding may be the best option to lose the weight gained during
pregnancy.

 Quitting smoking. Quitting smoking is often associated with weight gain. And for some, it
can lead to enough weight gain to qualify as obesity. Often, this happens as people use food
to cope with smoking withdrawal. In the long run, however, quitting smoking is still a greater
benefit to your health than is continuing to smoke. Your doctor can help you prevent weight
gain after quitting smoking.

 Lack of sleep. Not getting enough sleep or getting too much sleep can cause changes in
hormones that increase your appetite. You may also crave foods high in calories and
carbohydrates, which can contribute to weight gain.

 Stress. Many external factors that affect your mood and well-being may contribute to
obesity. People often seek more high-calorie food when experiencing stressful situations.

 Micro biome. Your gut bacteria are affected by what you eat and may contribute to weight
gain or difficulty losing weight.

-7-
  Previous attempts to lose weight. Previous attempts of weight loss followed by rapid
weight regain may contribute to further weight gain. This phenomenon, sometimes called
yo-yo dieting, can slow your metabolism.

Even if you have one or more of these risk factors, it doesn't mean that you're destined to develop
obesity. You can counteract most risk factors through diet, physical activity and exercise, and
behavior changes.

Facing a double burden of disease:

Many low- and middle-income countries are now facing a "double burden" of disease.

 While these countries continue to deal with the problems of infectious diseases and under
nutrition, they are also experiencing a rapid upsurge in non-communicable disease risk
factors such as obesity and overweight, particularly in urban settings.
 It is not uncommon to find under nutrition and obesity co-existing within the same country,
the same community and the same household.

Children in low- and middle-income countries are more vulnerable to inadequate pre-natal, infant,
and young child nutrition. At the same time, these children are exposed to high-fat, high-sugar,
high-salt, energy-dense, and micronutrient-poor foods, which tend to be lower in cost but also
lower in nutrient quality. These dietary patterns, in conjunction with lower levels of physical
activity, result in sharp increases in childhood obesity while under nutrition issues remain
unsolved.

-8-
ABSTRACT:
The term overweight refers to excess body weight for a particular height whereas the term obesity
is used to define excess body fat. Overweight and obesity primarily happen either due to excess
calorie intake or insufficient physical activity or both. Furthermore, various genetic, behavioral,
and environmental factors play a role in its pathogenesis. Childhood obesity is a forerunner of
metabolic syndrome, poor physical health, mental disorders, respiratory problems and glucose
intolerance, all of which can track into adulthood. Developing countries like India have a unique
problem of ‘double burden’ wherein at one end of the spectrum we have obesity in children and
adolescents while at the other end we have malnutrition and underweight.

Globally, the prevalence of childhood obesity has risen in recent years. The International
Association for the Study of Obesity (IASO) and International Obesity Task Force (IOTF) estimate
that 200 million school children are either overweight or obese. It is difficult to compare prevalence
rates of childhood obesity in different countries due to several limitations: lack of nationally
representative surveys of school children and paucity of serial measurements over time. Ogden et
al reported that the percentage of obese children in the US (6-11 yr. age group) was 7 per cent in
1980 which increased to 20 per cent by 2008. Parallely, among adolescents (age groups of 12-19
yr.) obesity rates increased from 5 to 18 per cent. Recent figures from the IOTF website showed
prevalence rates of overweight / obesity as 40 per cent in both genders in US. Studies conducted
on childhood obesity suggest that it may be plateauing off in some developed countries, while
steep increases continue to occur in developing countries. However, these trends are not well
documented.

Lower BMI (body mass index) cut-offs of 23 and 25 kg/m2 have been suggested by the World
Health Organization (WHO) and IOTF for Asian Indian adults for overweight and obesity,
respectively. But these are not applicable for children and adolescents. Over the years, there has
been a lack of consensus on the various cut-points or definitions used to classify obesity and
overweight in children and adolescents. This makes it difficult to interpret and compare the global
or national prevalence rates. For children and adolescents, overweight and obesity are usually
defined using age and gender specific norm grams of BMI.

There is lack of national representative data on obesity in children from India with its widely
varying geographical, social and cultural norms. Here we attempt to review available literature on
childhood overweight and obesity from India using the various cut-points used to define childhood

-9-
and adolescent obesity. We also used the published data from India from 1981 to 2013 to plot the
trend in childhood obesity and to look at its key socio-demographic patterns.

METHODS AND MATERIALS:

A review of the studies published in the last three decades between 1980 and 2013 reporting on
prevalence of childhood overweight and obesity (age 1-18 yr.) in India was conducted using a
systematic approach. As the aim was to present the current scenario in this area, we restricted our
search to 1980 and beyond. Literature search was done in available scientific public domains such
as Google Scholar, PubMed, IndMED and Cochrane systematic reviews using key words such as
childhood and adolescent overweight, childhood obesity, epidemiology in India and globally, body
mass index (BMI), trend and prevalence. A combination of MeSH terms and free texts was used
for the search. Cross references from identified articles were also used to expand the coverage.
Also, websites of official agencies such as IOTF, WHO and Centres for Disease Control and
Prevention (CDC) were accessed for related information. The review search initially revealed 612
titles or abstracts. The first two authors critically reviewed the studies to decide if these could be
included based on the criteria detailed in the flow chart indicating the review process (Fig. 1).

- 10 -
Prevalence in the age group of 1-5 yr. were obtained only from national surveys; most studies from
India reported only on under nutrition in this age group. Finally, 52 studies were selected and were
grouped based on the age groups studied and presented as childhood (1-12 yr.), adolescent (10-18
yr.) and childhood and adolescent (studies inclusive of both age groups) obesity trends in India
according to the year in which that study was published. All reported prevalence’s were taken
directly from the study and no recalculations were performed. Due to the lower obesity prevalence
rates in rural or government schools, these were excluded only from the trend analysis (Fig. 2) but
have been reported in the Tables. Thus, to plot the figure demonstrating combined childhood and
adolescent obesity trends, only urban prevalence’s from 42 studies (49 datasets as 7 studies
reported multiple datasets in the form of repeat surveys) from 1981 to 2013 were used and the year
the study was conducted in was considered for analysis; in case, this was not mentioned, the
publication year was included.

- 11 -
- 12 -
Box plots indicating overweight (a), obesity (b) and combined (c) trends in Indian children and
adolescents (1981-2013).

- 13 -
For each time period, the median of the reported values for the individual studies was calculated
along with the quartile limits. Trends for overweight, obesity and combined prevalence in children
and adolescents were calculated and presented using box plots (Fig. 2). The box plot included the
25th and 75th percentiles and data labels plotted were median values with the minimum and
maximum. When multiple cut-offs were used in the same study, only IOTF-Cole et al 2000
criteria were considered to prevent duplication of study data. Also, two outliers were not included
in this trend analysis but shown in Table I. We further looked at the distribution of prevalence of
obesity by sex and area of residence (rural / urban).

Table I
Childhood (1-12 yr) obesity trends in India

Prior to 2001, prevalence studies reported more on obesity (5 studies) rather than overweight
(2 studies) while post-2001, there were almost equal numbers of reported values for both (45 for
obesity versus 41 for overweight). Due to this drop in the sample size and number of studies
conducted, plotting separate trend graphs for children and adolescents did not show a good trend.

- 14 -
Therefore, the results are presented for all 52 studies combined with a total count of 435162
participants. Overweight numbers were available for 43 studies comprising 353738 participants
while obesity numbers were reported for 50 studies with 431262 participants. Both numbers were
available for 42 studies with 351454 participants. The combined prevalence was the sum of the
overweight and obesity prevalence.

RESULTS:
Overall, 52 studies were included based on the defined inclusion and exclusion criteria. The
geographical spread of these studies is shown in Fig. 3. The studies appear to be spread across the
country with 16 of 28 States being covered by at least one survey. Fig. 3 shows the lack of
prevalence data on childhood obesity from many northern and north-eastern States of India.

- 15 -
Cut-points used to define childhood obesity in India

The most commonly used definition for childhood overweight and obesity in India was IOTF-
Cole et al (28 studies) followed by WHO (10 studies) and CDC (8 studies). Others included
Gomez classification, and that of Must et al and Rosner et al India specific cut-points were found
in the Agarwal charts 1992, 2001 [used by Indian Academy of Paediatrics (IAP) for growth
monitoring in children and adolescents], Eliz Health Path for Adolescents and Adults (EHPA),
Pandey et al cut-points for Asian Indian adolescents and the data provided by Khadilkar et al. Of
the 52 studies reported in this review, six studies used multiple cut-points.

Epidemiology of childhood obesity: Indian data

Studies reporting prevalence of childhood and adolescent obesity in India were included as part
of Table I (1-12 yr.), Table II (10-17 yr.) and Table III (combined age group) in accordance to the
year the study was published.

- 16 -
- 17 -
- 18 -
- 19 -
Children (Table I): The key studies are from the National Family Health Surveys (NFHS) and
National Nutrition Monitoring Bureau (NNMB) surveys. These surveys covered under-five
children only. In the older age groups, the study by Preetam et al from Puducherry was the largest.
In under-fives the prevalence of obesity was below 2 per cent in all the studies. In children above
5 yr., the prevalence of obesity varied between 2 to 8 per cent. Overweight rates were around two
times higher and seem to be more in northern and eastern India than in southern India. One study
from Srinagar reported a high prevalence rate of 25 per cent, probably due to the smaller numbers
studied and being from affluent families.

Adolescent (Table II): The largest study in this age group was the Global School Based survey in
2007 on 8130 students. Overall, overweight prevalence varied between 3 to 24.7 per cent and
obesity ranged from 1.5 to 14 per cent in these 28 studies highlighting the wide variability in their
prevalence in India. In most studies, slightly higher prevalence rates were reported in boys,
compared to girls.

Combined (Table III): A total of 17 studies reported prevalence of overweight/obesity in childhood

and adolescence but were combined in such a way that we could not separate the two. The least
prevalence of obesity was reported from Nagaland (2.3%) and the maximum from New Delhi
(29%) and both used the IOTF-Cole et al criteria.

Some socio-demographic differentials

Sex/gender: Khadilkar et al reported on affluent Indian 2 to 17 yr. old children and showed that
the prevalence of overweight and obesity was 18.2 per cent by the IOTF classification while it was
23.9 per cent using WHO cut-points and the prevalence was higher in boys. Chhatwal et
al reported overall prevalences of childhood obesity and overweight in Punjab as 11.1 and 14.2
per cent, respectively and again a higher prevalence in boys (12.4 vs 9.9%, 15.7 vs 12.9%). Sidhu
and colleagues from Amritsar reported overweight in 10 per cent among boys and 12 per cent
among girls and obesity in 5 per cent boys and 6 per cent in girls. Kotian and co-workers reported
that the overall prevalences of overweight and obesity were 9.3 and 5.2 per cent, respectively
among boys and 10.5 and 4.3 per cent among girls, in a semi urban city in Karnataka.

Socio-economic status (SES): Marwaha et al, using IOTF classification showed that among
children in the upper SES the prevalences of overweight and obesity were 17 and 5.6 per cent in
boys and 19 and 5.7 per cent in girls, respectively, whereas in the lower SES the values were

- 20 -
2.7 and 0.4 per cent in boys and 2.1 and 0.5 per cent in girls, respectively. Goyal and
colleagues from Gujarat found the prevalence of obesity to be higher in upper SES group as
compared to the middle SES. A recent study based on 18,955 school children in Chennai, reported
the prevalence of overweight to be 17 per cent while that of obesity was 4.4 per cent among private
school children. Conversely, among the government school children the values were 3.1 and 0.5
per cent, respectively using the Cole cut-points. In another study from Karimnagar, Hyderabad,
the prevalences of overweight and obesity were 11.9 and 2.7 per cent, respectively among 10-16
yr. olds. While obesity was more in higher SES, factors like family size, residence and parent's
education did not contribute to obesity.

Place of residence: In a report from Kerala the prevalence of overweight and obesity among
children was shown to increase in urban as well as rural areas. This study reported high prevalence
of obesity and overweight among boys especially in urban areas whereas underweight was more
common in girls especially in rural areas. Premanath and co-workers from Mysuru surveyed
43,152 school children from private and government schools using Agarwal charts. They reported
the prevalences of obesity, overweight and underweight to be 3.4, 8.5 and 17.2 per cent,
respectively among 5-7 yr. old children with higher prevalence of obesity seen in private schools.
Another study from Mysuru using the WHO cut-points reported obesity prevalence among urban-
rural adolescents to be 9.0 and 0.8 per cent, respectively. A study from Surat, Gujarat, showed an
increase in prevalence of overweight/obesity in urban males aged 14-17 yr. Higher SES was found
to be significant risk factor for obesity.

These data showed that in India, obesity in children was associated with affluence but the exact
prevalence varied based on the definitions used. However, with the rapid epidemiological
transition occurring in large metropolitan cities and peri-urban areas, recent studies have shown a
steady increase in prevalence among government school children.

Trends in prevalence of overweight/obesity

Despite the limitations related to cut-points and definitions, when 42 prevalence studies
(49 datasets) from India were plotted to observe the trends for combined overweight and obesity
in Indian children and adolescents over the last decade, it was seen to be increasing (Fig. 2). The
pooled data after 2010 estimated a combined prevalence of 19.3 per cent of childhood overweight
and obesity which was significantly (two-sample z-test, P<0.01) higher than the earlier prevalence
of 16 per cent reported in 2001(Fig. 2). However, these rates tend to vary widely (as also indicated

- 21 -
by the length of the box plots) depending on the cut points used, the sampling frame and time
period of the survey.

A large variation was noted for combined prevalence (overweight + obesity) values reported from
different studies ranging from 4.3 to 40.9 per cent. If further stratified by the cut-offs used, looking
at studies using IOTF cut-offs, the combined prevalence range was 6.98 to 40.9 per cent. Region-
wise stratification was done on the basis of the region where the studies were performed, excluding
studies that were done across multiple regions. The median value for the combined prevalence
based on the number of studies reported from that particular region showed that the combined
prevalence was higher in north (20.7%, n = 15) compared to south (15.1%, n=16). The combined
obesity prevalence from east India (22.0%, n=4) and west (19.7%, n =8) could not be used to make
a significant conclusion due to the smaller number of studies reported from these areas.

We also looked at studies which have been done in the same area with a time interval to assess the
trends. Subramanyam et al reported on obesity trends in adolescent girls in private schools in
Chennai and showed that in 1981, overweight was present in 9.6 per cent and obesity in 5.9 per
cent of the girls while in 1998, overweight was seen in 9.7 per cent and obesity in 6.2 per cent of
the girls. A similar study from the same city in 2002 showed that among children attending private
schools the prevalence of overweight/obesity had almost doubled - 17.8 per cent in boys and 15.8
per cent in girls. This increase was attributed to changes in lifestyle factors. Gupta et al reported
in girls aged 11-17 yr. an unchanged trend in prevalence of overweight (10.9% in 1997, 10.5% in
2003) and obesity (5.5% in 1997, 6.7% in 2003) based on a population-based birth cohort in New
Delhi. This could be attributed to tracking trends of a cohort study whereas both the studies done
in Chennai were cross-sectional and in a school based setting.

DISCUSSION:
India is a fast growing economy, currently undergoing major epidemiological, nutritional and
demographic transitions. These transitions tend to promote obesity in all age groups. However,
when one looks at the prevalence of obesity alone, there is no clear secular trend. The median
values ranged from 5.5 per cent in 2001-2005 to 4.0 per cent in 2006-2010 and then rose to 4.6 per
cent since 2010. This suggests that the prevalence of obesity has probably been somewhat constant
over the last couple of decades. However, the overweight and combined overweight/obesity
prevalence showed an increasing trend. The prevalence of overweight increased from 9.7 per cent
prior to 2001 to 13.9 per cent in studies reported after 2010. The combined trend followed a similar

- 22 -
pattern increasing from 15.9 per cent prior to 2001 to 16.3 per cent from 2001-2005. The value
then increased to 17.4 per cent in the 2006-2010 period, finally reaching 19.3 per cent in studies
reported after 2010. Hence, there was a trend of increase in overweight among children/adolescents
in India.

The criteria used for diagnosis of obesity in children and adolescents in developing countries like
India have been based on American and European BMI standards. In these standards, the
>85th percentile for overweight and > 95th percentile for obesity have been derived from the data
from National Center for Health Statistics (NCHS) and National Health and Nutrition Examination
Survey (NHANES) in USA or from studies in western European countries where
BMI > 95th percentile corresponds to >130 per cent ideal body weight and BMI of > 30 kg/m2(Ref).
The CDC growth curves have been developed from an apparently overweight population. In an
effort to overcome this drawback, Cole et al used data from several European and Asian countries
to determine childhood BMI cut-points that corresponded to adult BMI of 25 and 30 kg/m2. Many
countries including India use the Cole (2000) criteria. This criterion has also been adopted by the
IOTF. However, two studies conducted in India showed the IOTF reference classified participants
as having a lower weight. Both the studies concluded that the Cole criteria were not suitable for
Indian and South Asian children.

The WHO has been persuading paediatricians and governments all over the world to use the WHO
growth charts for identifying underweight and overweight. de Onis and group thus came up with
the WHO 2007 age and gender specific BMI cut-offs as a global standard. In children selected
from across the globe it was seen that they grew at an astonishingly consistent pattern up to the
age of five years, suggesting that there may not be ethnic differences in the growth pattern of
babies and children. However, it is likely that the WHO cut-off will result in higher overweight
and or obesity rates.

WHO response

Adopted by the World Health Assembly in 2004, the "WHO Global Strategy on Diet, Physical
Activity and Health" describes the actions needed to support healthy diets and regular physical
activity. The Strategy calls upon all stakeholders to take action at global, regional and local levels
to improve diets and physical activity patterns at the population level.

- 23 -
The Political Declaration of the High Level Meeting of the United Nations General Assembly on
the Prevention and Control of Non communicable Diseases of September 2011, recognizes the
critical importance of reducing unhealthy diet and physical inactivity. The political declaration
commits to advancing the implementation of the "WHO Global Strategy on Diet, Physical Activity
and Health", including, where appropriate, through the introduction of policies and actions aimed
at promoting healthy diets and increasing physical activity in the entire population.

WHO has also developed the "Global Action Plan for the Prevention and Control of
Non communicable Diseases 2013-2020" which aims to achieve the commitments of the UN
Political Declaration on Non communicable diseases (NCDs) which was endorsed by Heads of
State and Government in September 2011. The “Global Action Plan” will contribute to progress
on 9 global NCD targets to be attained by 2025, including a 25% relative reduction in premature
mortality from NCDs by 2025 and a halt in the rise of global obesity to match the rates of 2010.

The World Health Assembly welcomed the report of the Commission on Ending Childhood
Obesity (2016) and its 6 recommendations to address the obesogenic environment and critical
periods in the life course to tackle childhood obesity. The implementation plan to guide countries
in taking action to implement the recommendations of the Commission was welcomed by the
World Health Assembly in 2017.

Strengths and limitations of the review

- 24 -
One important limitation of this study was that the trend was plotted using reported prevalence
rates which in turn were calculated using various cut-offs. To better understand and compare
childhood obesity trends, we need age, gender and country or ethnic specific cut-points from age
six onwards to 18 yr. to uniformly define childhood overweight and obesity. Also, overweight and
obesity studies from important States like Haryana, Himachal Pradesh, Uttar hand, Bihar,
Jharkhand and six North-Eastern States could not be found in literature. Data from these States
could have enriched the summary observations. Five studies conducted within the years
1992-2006 provided national estimates for pre-school children but many used varying cut-points
for overweight and obesity. This practical issue of interpreting the various cut-points is a major
obstacle in understanding secular trends in childhood obesity not just in India but also worldwide.
A major strength (which may also be interpreted by some as a limitation) of this study was that we
included all reported overweight/obesity prevalence studies that were accessible through our
comprehensive search strategy. As we aimed to report specifically on data from India we also
included reports available as conference proceedings or in Indian journals (may not be high impact
and indexed). Thus, bearing in mind these limitations, the current available data on childhood
overweight and obesity need to be interpreted with caution.

CONCLUSIONS:
The present analysis shows that overweight and obesity rates in children and adolescents are
increasing not just among the higher socio-economic groups but also in the lower income groups
where underweight still remains a major concern. This suggests the need for a balanced and
sensitive approach addressing economic and nutrition transitions to effectively tackle this double
burden paradox in India.

Recognition is increasing that overweight and obesity are not only problems of individuals, but
also society wide problems of populations. Acting on this recognition will require multifaceted,
population-based changes in the socio environmental variables that influence energy intake and
expenditure. There exist both a pressing need to act on the problem of obesity and a large gap
between the type and amount of evidence needed to act and the type and amount of evidence
available to meet that need. A new framework is necessary to assist researchers and a broad
community of decision makers in generating, identifying, and evaluating the best evidence
available and in summarizing it for use in decision making. This new framework also is important

- 25 -
for researchers attempting to fill important evidence gaps through studies based on questions with
program and policy relevance. However, the methods used and the evidence generated by
traditional research designs do not yield all the types of evidence useful to inform actions aimed
at addressing obesity prevention and other complex public health challenges. An expanded
approach is needed that emphasizes the decision-making process and contextual considerations.

REFERENCES:
1. National Institutes of Health, National Heart, Lung, and Blood Institute. Disease and Conditions
Index: what are overweight and obesity? [accessed on December 8, 2013]. Available
from: http://www.nhlbi.nih.gov/health/health-topics/topics/obe/

2. Centers for Disease Control and Prevention (CDC), Fact sheets. [accessed on November 22,
2013]. Available from: http://www.cdc.gov/healthyyouth/obesity/facts.htm .

3. International Obesity Task Force. [accessed on November 22, 2013]. Available

from: http://www.iaso.org/iotf/obesity/obesitytheglobalepidemic/ for Saudi, Canada, South
Africa, Australia and NZ estimates.

4. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index
in US children and adolescents, 2007-2008. JAMA. 2010;303:242–9. [PubMed] [Google Scholar]

5. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr
Obes. 2006;1:11–25. [PubMed] [Google Scholar]

- 26 -
6. Raj M, Krishna Kumar R. Obesity in children & adolescents. Indian J Med Res. 2010;132:598–
607. [PMC free article] [PubMed] [Google Scholar]

7. Australia: Health Communications Australia; 2000. World Health Organization Western Pacific
Region, International Association for the Study of Obesity, International Obesity Task Force. Asia
Pacific perspective: Redefining obesity and its treatment. [Google Scholar]

8. Geneva: WHO; 1998. [accessed on November 22, 2013]. World Health Organization. Obesity,
preventing and managing the global epidemic. Report of a WHO consultation on obesity.
Available from: http://whqlibdoc.who.int/hq/1998/WHO_NUT_NCD_981_ (p1-158). Pdf.

9. Goyal RK, Shah VN, Saboo BD, Phatak SR, Shah NN, Gohel MC, et al. Prevalence of
overweight and obesity in Indian adolescent school going children: Its relationship with
socioeconomic status and associated lifestyle factors. J Assoc Physicians India. 2010;58:151–
8. [PubMed] [Google Scholar]

10. Laxmaiah A, Nagalla B, Vijayaraghavan K, Nair M. Factors affecting prevalence of

overweight among 12- to 17-year-old urban adolescents in Hyderabad, India. Obesity (Silver
Spring) 2007;15:1384–90. [PubMed] [Google Scholar]

11. Preetam MB, Anil PJ, Zile S, Johnson C, Murugan N, Sandeep A, et al. Study of childhood
obesity among school children aged 6 to 12 years in Union Territory of Puducherry. Indian
J Community Med. 2011;36:45–50. [PMC free article] [PubMed] [Google Scholar]

12. Monga S. Obesity among school children (7-9 years old) in India: Prevalence and related
factors. The 132nd Annual Meeting (November 6-10, 2004) of American Public Health
Association (APHA) [Google Scholar]

13. Sidhu S, Kaur N, Kaur R. Overweight and obesity in affluent school children of Punjab. Ann
Hum Biol. 2006;33:255–9. [PubMed] [Google Scholar]

14. Bose K, Bisai S, Mukhopadhyay A, Bhadra M. Overweight and obesity among affluent
Bengalee schoolgirls of Lake Town, Kolkata, India. Matern Child Nutr. 2007;3:141–
5. [PubMed] [Google Scholar]

- 27 -