ASSESSMENT OF NUTRITIONAL STATUS AMONG

THE MEDICAL STUDENTS OF SHEIKH ZAYED

MEDICAL COLLEGE , RAHIM YAR KHAN

Submitted By
Batch A, 4th Year (2018-2019)
Department of Community Medicine
Sheikh Zayed Medical College, Rahim Yar Khan

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Name of Student :_______________________________
Class Roll Number: ___________________________
University Roll Number:__________________________
Signature of Student: ____________________________
Signature of Supervisor: __________________________

Supervisor
Dr.Hafiz Omer Farooq

DEPARTMENT OF COMMUNITY MEDICINE

SHEIKH ZAYED MEDICAL COLLEGE, RAHIM YAR KHAN

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 BATCH A, 4thYEAR MBBS (2018-2019)

Name Roll No. Name Roll No.

Sareema Momin 235 Shafeeq-Ur-Rehman 306
Amber Tasleem Rana 288 Muhammad Yaqoob Irshad 349
Madeeha Mushtaq 401 Syed Ahtsham Safdar 353
Farwa Malik 402 Anil Kumar 358
Saba Sahar Ashraf 403 Safeer Ahmad 383
Rida Nadeem 404 Salman Ahmad Mazari 501
Maheen Shahid 405 Osama Ashfaq Virk 502
Aamina Mushtaq 406 Muhammad Hasnain Haider 509
Noor Fatima 407 Muhammad Younis 510
Hafsa Soofi 408 Revtash Kumar 618
Iqra Munawar 410
Faiza Batool 411
Hafsa Zahid 262

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 TABLE OF CONTENTS

Sr. no Topics Page no.

1 Abstract 6

2 Introduction 7

3 Objectives 15

4 Methodology 16

5 Results 18

6 Discussion 25

7 Conclusion 27

8 References 28

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 ABSTRACT

• Background: For assessing the nutritional status of the students ,their BMI was found
out.BMI is derived from simple mathematics formula. It aims to estimate whether the
person has a healthy weight by dividing their weight with square of height.
Objective:To assess the nutritional status of medical students of SZMC by calculating
their BMI. Compare the gender-wise distribution of nutritional status. Methodology:
Study Design: Descriptive cross-sectional study design. Study subjects: The study
was carried out among medical students of SZMC from first year M.B.B.S. to final
year M.B.B.S. Place and Duration of study: The data was collected in a period of
about 20 days from 28th January, 2018 to 18th December, 2018 that was carried out
among 1st year to Final year students, both hostellites and day-scholars. Performa was
designed by the students of batch A with the help of Batch Incharge. Before
commencing the data result, informed verbal consent was taken from all study subjects.
All the data was recorded on the performa. The performa contained name, gender, class,
age , weight, height of the medical students and BMI was calculated by the formula..
According to Quetelet’s Index those who have BMI below 18.5 were considered
Underweight , 18.5 – 24.9 were Normal or Healthy Weight , 25.0 – 29.9 were
Overweight and 30.0 and Above were Obese The data was entered on SPSS version
22 and results were preserved as percentage, mean and ± standard deviation. Results:
Mean age of students was 21.1 years with standard deviation of 1.7. Male to female
ratio was 1:1.. 67.3% students were having normal BMI, 12 % were overweight, 2 %
were obese, and 18.7% were underweight. Conclusion: The study concluded that
almost majority of students have normal BMI. Keywords: Nutritional status, BMI

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 INTRODUCTION

Nutritional status is the condition of the body in those respects influenced by the
diet; the levels of nutrients in the body and the ability of those levels to maintain
normal metabolic integrity. Normal nutritional status is managed by balance food
consumption and normal utilization of nutrients.

For adults, general adequacy is assessed by measuring weight and height; the
result is commonly expressed as the body mass index, the ratio of weight (kg) to
height2 (m). Body fat may also be estimated, by measuring skin-fold thickness,
and muscle diameter is also measured.

For children, weight and height for age are compared with standard data for
adequately nourished children. The increase in the circumference of the head
and the development of bones may also be measured.

Status with respect to individual vitamins and minerals is normally determined by

laboratory tests, either measuring the blood and urine concentrations of the
nutrients and their metabolites, or by testing for specific metabolic responses.

Body mass index (BMI) is a number calculated from a person’s weight and height.
BMI is a fairly reliable indicator of body fatness for most people. BMI doesn’t measure
body fat directly, but research has shown that BMI correlates to direct measures of body
fat, such as underwater weighing and dual energy x-ray absorptiometry. 1 BMI can be
considered an alternative for direct measures of body fat. Additionally, BMI is an
inexpensive and easy- to-perform method of screening for weight categories that may
lead to health problems.

BMI is used as a screening tool to identify possible weight problems for adults. A
high BMI can be an indicator of high body fatness. BMI can be used as a screening tool
but is not diagnostic of the body fatness or health of an individual.

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To determine if a high BMI is a health risk, a healthcare provider would need to perform
further assessments. These assessments might include skin fold thickness measurements,
evaluations of diet, physical activity, family history, and other appropriate health
screenings10
BMI can assess obesity and underweight and thus nutritional status of an individual.
.

Factors Associated With the Development of Obesity The exact cause

of obesity is unknown; however, there appears to be a complex relationship
among biologic, psychosocial, and behavioral factors, which include genetic
makeup, socioeconomic status, and cultural influences. Obesity has been linked
to microorganisms, epigenetics, increasing maternal age, greater fecundity, lack
of sleep, endocrine disruptors, pharmaceutical iatrogenesis, and intrauterine and
intergenerational effects. Co morbid conditions and their treatments may also be
a factor in developing obesity. The pathophysiology of obesity is well
understood; however, treatment and prevention have focused on the
psychological and social components of the disease. To date, the best
noninvasive interventions have been in dietary management and behavioral
change. The best outcomes are associated with bariatric surgery. Drug therapy
has limited effectiveness, particularly in children. Genetic testing is applicable for
a small group of these patients. Researchers are still in the process of
integrating basic science data with clinical research and learning how to apply
the results to patient care.

Causes of Obesity
Primary causes:
Genetic causes:
Monogenic disorders Melanocortin- 4
receptor mutation Leptin deficiency
Pro-opiomelanocortin deficiency Syndromes
Secondary causes:
Neurologic: Brain injury, Brain tumor
Consequences of cranial irradiation
Hypothalamic obesity
Endocrine:
Hypothyroidism
Cushing syndrome

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 Growth hormone deficiency
Pseudo-hypoparathyroidism
Psychological:
Depression
Eating disorders
Drug-induced:
Tricyclic antidepressants
Oral contraceptives
Antipsychotics
Anticonvulsants
Glucocorticoids
Sulfonylureas Glitazones
Beta-blockers
It is controversial whether hypothyroidism causes obesity or exacerbates obesity.
Depression is associated with overeating or binging.

Food choices, which are influenced by the home, child care, school, workplace,
and community environments, directly affect the type and amount of caloric
intake. Over the last 100 years, because of technological advances in food
processing, the types of foods consumed have changed. Foods with decreased
fiber and increased fat, simple sugar, salt, and increased calories are more
readily available, and they are typically cheaper than healthier alternatives.
Consumption of these ultra-processed foods has led to a 205-calorie increase in
an individual’s average daily caloric intake since the 1960s. A school-based
study conducted by the CDC reported that two-thirds of high school students
drank some type of sugar-sweetened beverage (e.g., soda, Hawaiian punch,
lemonade, Kool-Aid, other sweetened fruit drinks, iced tea) at least once a day,
and about 22% drank them at least 3 times a day. Male and non-Hispanic black
students ate at a fast food restaurant at least 1 day a week, watched television
more than 2 hours a day, and had a greater chance of consuming sugar-
sweetened beverages at least 3 times a day than other groups studied. Students
less likely to consume those drinks were non-Hispanic or those who were
physically active at least 60 minutes a day for at least 5 days a week. One soda
a day, depending on the size (8 oz to 20 oz), could provide 270 to 690 calories a
day. Consumption of sugar-sweetened beverages is associated with an increase
in the risk of obesity; the risk increases 1.6 times (95% CI, 1.14-2.24; P = .02) for
each additional serving of sugar-sweetened drink consumed daily. Consumption
of energy-dense foods is positively associated with an increase in waist

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circumference and BMI. A 6-year, longitudinal study demonstrated that women
who consumed a diet made up of higher energy-dense foods, consisting of
more servings from grain, meats, and fat groups, had an increase in BMI of 2.5
units, whereas women who consumed lower energy- dense diets, containing
more servings of vegetables and fruit, had an increase in BMI of 0.9 units.

People who have obesity are at increased risk for many diseases and health
conditions, including the following: 10, 17, 18

1. All-causes of death (mortality)

2. High blood pressure (Hypertension)
3. High LDL cholesterol, low HDL cholesterol, or high levels of
triglycerides (Dyslipidemia)
4. Type 2 diabetes
5. Coronary heart disease
6. Stroke
7. Gallbladder disease
8. Gallstones
9. Osteoarthritis (a breakdown of cartilage and bone within a joint)
10. Sleep apnea and breathing problems
11. Chronic inflammation and increased oxidative stress19,20
12. Some cancers (endometrial, breast, colon, kidney, gallbladder, and
liver)
13. Low quality of life
14. Mental illness such as clinical depression, anxiety, and other mental
disorders21,22
15. Body pain and difficulty with physical functioning23
16.Heartburn/esophageal reflux
17. Leg swelling and blood clots
18. Joint pain, back pain, osteoarthritis, and other orthopedic problems
19. Fatty liver disease and/or cirrhosis
20.Shortness of breath
21. Reproductive disorders such as polycystic ovarian syndrome (PCOS)
22.Stress incontinence

On the other end of the spectrum, being underweight has its own causes and
consequences.

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Underweight may be due to genetics,[3][4] metabolism, drug use, lack of food
(frequently due to poverty), eating disorder, or illness (both physical and mental).

Being underweight is associated with certain medical conditions, including:

anorexia, type 1 diabetes,[5] hyperthyroidism,[6] cancer,[7] or tuberculosis.[8]
People with gastrointestinal or liver problems may be unable to absorb nutrients
adequately. People with certain eating disorders can also be underweight due to
lack of nutrients or over exercise.

Underweight might be secondary to or symptomatic of an underlying

disease. Unexplained weight loss may require professional medical
diagnosis.

Underweight can also be a primary causative condition. Severely underweight

individuals may have poor physical stamina and a weak immune system,
leaving them open to infection. According to Robert E. Black of the Johns
Hopkins School of Public Health (JHSPH), "Underweight status ... and
micronutrient deficiencies also cause decreases in immune and non-immune
host defenses, and should be classified as underlying causes of death if
followed by infectious diseases that are the terminal associated causes."[9]
People who are mal-nutritive underweight raise special concerns, as not only
gross caloric intake may be inadequate, but also intake and absorption of other
vital nutrients, especially essential amino acids and micro-nutrients such as
vitamins and minerals can be.

In women, being severely underweight as a result of an eating disorder, or due to

excessive strenuous exercise can result in amenorrhea (absence of
menstruation),[10] infertility and, if gestational weight gain is too low, possible
complications during pregnancy.

Malnourishment can also cause anemia and hair loss.

Being underweight is an established [11] risk factor for osteoporosis, even for
young people. This is seen in individuals suffering from the female athlete triad,
when disordered eating or excessive exercise cause amenorrhea, hormone
changes during an ovulation and it leads to loss of bone mineral density.[12][13]
After the occurrence of first spontaneous fractures the damage is often already
irreversible.

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Although being underweight has been reported to increase mortality at rates
comparable to that seen in morbidly obese people,[14] the effect is much less
drastic when restricted to non-smokers with no history of disease,[15]
suggesting that smoking and disease-related weight loss are the leading causes
of the observed effect.

BMI can be used for population assessment of overweight and obesity.

Because calculation requires only height and weight, it is inexpensive and easy
to use for clinicians and for the general public. BMI can be used as a screening
tool for body fatness but is not diagnostic.

BMI is calculated the same way for both adults and children.
The calculation is based on the following formulas:

Measurement Units Formula and Calculation

Formula: weight (kg) / [height (m)] 2
Kilograms and
With the metric system, the formula for BMI is weight in
meters (or kilograms divided by height in meters squared.
centimeters) Because height is commonly measured in centimeters,
divide height in centimeters by 100 to obtain height in
meters.

Example: Weight = 68 kg, Height = 165 cm (1.65 m)

Calculation: 68 ÷ (1.65) 2 = 24.98

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 Formula: weight (lb) / [height (in)] 2 x 703

Pounds and
Calculate BMI by dividing weight in pounds (lbs) by
inches height in inches (in) squared and multiplying by a
conversion factor of 703.

Example: Weight = 150 lbs, Height = 5’5″ (65″)

Calculation: [150 ÷ (65) 2] x 703 = 24.96

For adults 20 years old and older, BMI is interpreted using standard weight status
categories.
These categories are the same for men and women of all body types and ages.

The standard weight status categories associated with BMI ranges for adults are
shown in the following table.

BMI Weight Status

• Below 18.5 Underweight
• 18.5 – 24.9 Normal or Healthy Weight
• 25.0 – 29.9 Overweight
• 30.0 and Above Obese

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For example, here are the weight ranges, the corresponding BMI ranges, and the weight status
categories for a person who is 5′ 9″.

Height Weight Range BMI Weight Status

124 lbs or less Below 18.5 Underweight
125 lbs to 168 lbs 18.5 to 24.9 Normal or Healthy Weight
5′ 9″
169 lbs to 202 lbs 25.0 to 29.9 Overweight
203 lbs or more 30 or higher Obese

For children and teens, the interpretation of BMI depends upon age and sex.

The correlation between the BMI and body fatness is fairly

strong1,2,3,7, but even if 2 people have the same BMI, their level of
body fatness may differ12.

In general,

• At the same BMI, women tend to have more body fat than men.
• At the same BMI, Blacks have less body fat than do Whites13,14, and Asians
have more body fat than do Whites15
• At the same BMI, older people, on average, tend to have more body
fat than younger adults.
• At the same BMI, athletes have less body fat than do non-athletes.

The accuracy of BMI as an indicator of body fatness also appears to be

higher in persons with higher levels of BMI and body fatness 16. While, a
person with a very high BMI (e.g., 35 kg/m2) is very likely to have high body
fat, a relatively high BMI can be the results of either high body fat or high lean
body mass (muscle and bone). A trained healthcare provider should perform
appropriate health assessments in order to evaluate an individual’s health
status and risks.

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 OBJECTIVES

The objectives of the study were to;

• Assess the nutritional status of medical students of Sheikh Zayed Medical college by
calculating their BMI.
• Compare the gender-wise distribution of nutritional status.

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 METHODOLOGY

Study Design:
Descriptive cross-sectional study design.
Study Population:
Medical students of all MBBS classes of SZMC.
Setting:
The study was carried out among medical students of SZMC from first year M.B.B.S.
to final year M.B.B.S.
Study Duration:
The data was collected in a period of about 20 days from 28 th January, 2018 to 18th
December, 2018.
Sampling Technique:
Convenient sampling technique
Sample Size:
A total of 150 medical students 75 males and 75 females were included in this study.
15 males and 15 females were conveniently selected from each class.
Inclusion Criteria:
All the students from final year M.B.B.S. to first year M.B.B.S. were willing to
participate in the research.
Exclusion Criteria:
Medical students who refused to participate for data collection.
Students busy in exams. All other classes(MIT and DPT) were not included.
Data Collection Method:
Data was collected by a pre-tested Performa. The Performa included information about
the body mass index among the medical students of SZMC. The variables included
were class, gender, height, age, weight and BMI.

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Data Analysis:
Data was analyzed by using SPSS version 22 . The numerical values such as age were
presented as mean standard deviation. Qualitative vaiables like gender were presented
as percentages.
Ethical Approval:
Ethical approval was sought from Institutinal Review Board(IRB). Informed verbal
was taken from every study subject.

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 RESULTS

This study was conducted to assess the knowledge about nutritional status of medical
students of Sheikh Zayed Medical collge Rahim yar Khan.

Table I: Age distribution of subjects

Statistics Age of students in years

Mean 21.12
Median 21
Mode 22
Std. Deviation 1.75
Minimum 16
Maximum 25

Table I shows that the mean age of students was 21.13 years with standard deviation
1.76.

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Table II: Distribution according to class

Table II shows that 15 male and 15 female students were taken from each class which
makes a total of 150 study subjects.

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Table III: Distribution of subjects according to sex

Gender

Frequency Percent
Female 75 50.0

Male 75 50.0
Total 150 100.0

TableIII shows that 50 percent were males and 50percent were females.

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Table IV: Distribution of subjects according to BMI

BMI

Frequency Percent
Underweight 28 18.7

Normal 101 67.3

Overweight 18 12.0
Obese 3 2.0
Total 150 100.0

Table IV shows 67.3 percent of students were normal, 12 percent were overweight , 2
percent were obese 18.7 percent were underweight.

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Figure I: Distribution shown in a pie chart

Figure I shows a decreased incidence of obesity among medical students of SZMC,

RYK.

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Figure II: Distribution of nutritional status in histogram

Figure II shows the histogram of the nutritional status of medical students. 108
students were normal according to study

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Figure III: Distribution of nutritional status among males and females.

Figure III shows that none of the females were obese but an increased rate of
underweight students. Similarly males were more obese than female students.

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 DISCUSSION

In the present study, most students (67.3%) had a normal BMI. A study conducted at Dow
Medical College24 , showed similar results with 59% of students having normal BMI.
Reporting from a Malaysian Medical College, Boo et al. reported that 69% of students had
normal BMI25.In the present study, obesity was only found among 2% of students. A
similar study from Malaysia reported Medical students’ obesity to be around 8% 25. A study
conducted in Karachi at Dow medical college elicited obesity at 3% among public sector
medical students24.
The study done by Lakshmi and Devi26 among the medical students of Tirupati reported
no gender difference. Hamid et al.27 in their study, reported female students being more
overweight among the students of Skims medical college. Abdullah and Mohammad in
their study on medical students of Ribat university, Khartoum, reported obesity to be 9%29.
In our study, the problem of being over-weight among students was 12%. In a study
conducted by Gupta et al.30 among medical students studying in Midnapore medical
college, India, overall prevalence of 17.5% and 3.4% for overweight and obesity
respectively was found. In the current study, underweight students were around 18.7%
according to Boo et al25. In a Malaysian study, 15% of the medical students were
underweight.
This trend was also highlighted by Minhas et al. in a similar study at Dow medical college
Karachi24. The study highlight the fact that obesity is not a major problem among medical
students, But being underweight is coming up as a significant problem in medical students.
Obesity is a medical condition that occurs when a person carries excess weight or body
fat that might affect their health. A BMI 30 or over suggests that a person may have
obesity.
Its types include Class 1 (low risk) obesity, if BMI is 30.4-34.9, Class 2(moderate risk)
obesity, if BMI is 35.0-39.9, Class 3(high risk) obesity, if BMI is equal to or greater than
40.
Risk factors include genetics, junk foods, overeating, certain medications, leptin
resistance etc.
If a person does have obesity and excess weight, this can increase his risk of developing
a number of health conditions including metabolic syndromes, diabetes mellitus, heart
problems, arthritis and some types of cancers.
In the present study, most students (67.3%) had a normal BMI. A study conducted at
24

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Dow Medical College ,showed similar results with 59% of students having normal BMI.
Reporting from a Malaysian Medical College, Boo et al. reported that 69% of students
25
.I n
had normal BMI the present study, obesity was only found among 2% of students. A
25.

similar study from Malaysia reported Medical students’ obesity to be around 8% A

study conducted in Karachi at Dow medical college elicited obesity at 3% among public
24
sector medical students .
26
The study done by Lakshmi and Devi among the medical students of Tirupati reported
27
no gender difference. Hamid et al. in their study, reported female students being more
overweight among the students of Skims medical college. Abdullah and Mohammad in
their study on medical students of Ribat university, Khartoum, reported obesity to be
29
9% . In our study, the problem of being over-weight among students was 12%. In a
30
study conducted by Gupta et al. among medical students studying in Midnapore
medical college, India, overall prevalence of 17.5% and 3.4% for overweight and obesity
respectively was found.
25
In the current study, underweight students were around 18.7% according to Boo et al .
In a Malaysian study, 15% of the medical students were underweight.
This trend was also highlighted by Minhas et al. in a similar study at Dow medical college
24
Karachi . The study highlight the fact that obesity is not a major problem among
medical students, But being underweight is coming up as a significant problem in
medical students.

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 CONCLUSION

This study concludes that most of the medical students were having normal BMI while one
third students were either over-weight or under-weight.
Moreover, the trend of obesity was found more among males as compared to females for
which modifications in their life styles i.e. exercise is suggested while for under-weight
balanced diet is adviseds for their healthy life

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 References

1. Garrow, J.S. & Webster, J., . Quetelet’s index (W/H2) as a measure of fatness.
Int. J. Obes., 9(2), pp.147–153.
2. Freedman, D.S., Horlick, M. & Berenson, G.S., 2013. A comparison of the
Slaughter skinfold-thickness equations and BMI in predicting body fatness
and cardiovascular disease risk factor levels in children. Am. J. Clin. Nutr.,
98(6), pp.1417–24.
3. Wohlfahrt-Veje, C. et al., 2014. Body fat throughout childhood in 2647
healthy Danish children: agreement of BMI, waist circumference, skinfolds
with dual X-ray absorptiometry. Eur. J. Clin. Nutr., 68(6), pp.664–70.
4. Steinberger, J. et al., 2005. Comparison of body fatness measurements by BMI
and skinfolds vs dual energy X-ray absorptiometry and their relation to
cardiovascular risk factors in adolescents. Int. J. Obes., 29(11), pp.1346–1352.
5. Sun, Q. et al., 2010. Comparison of dual-energy x-ray absorptiometric and
anthropometric measures of adiposity in relation to adiposity-related biologic
factors. Am. J. Epidemiol., 172(12), pp.1442–1454.
6. Lawlor, D.A. et al., 2010. Association between general and central adiposity
in childhood, and change in these, with cardiovascular risk factors in
adolescence: prospective cohort study. BMJ, 341, p.c6224.
7. Flegal, K.M. &Graubard, B.I., 2009. Estimates of excess deaths associated
with body mass index and other anthropometric variables. Am. J. Clin. Nutr.,
89(4), pp.1213–1219.
8. Freedman, D.S. et al., 2009. Relation of body mass index and skinfold
thicknesses to cardiovascular disease risk factors in children: the Bogalusa
Heart Study. Am. J. Clin. Nutr., 90(1), pp.210–216.
9. Willett, K. et al., 2006. Comparison of bioelectrical impedance and BMI in
predicting obesity-related medical conditions. Obes. (Silver Spring), 14(3),
pp.480–490.
10. NHLBI. 2013. Managing Overweight and Obesity in Adults: Systematic
Evidence Review from the Obesity Expert Panel[PDF – 5.98MB]
11. Kuczmarski, R.J. et al., 2002. 2000 CDC Growth Charts for the United States:
methods and development. Vital Health Stat. 11., 11(246), pp.1–190.
12. Prentice, A.M. &Jebb, S.A., 2001. Beyond body mass index. Obes. Rev., 2(3),
pp.141–7.
13. Wagner, D.R. & Heyward, V.H., 2000. Measures of body composition in
blacks and whites: a comparative review. Am. J. Clin. Nutr., 71(6), pp.1392–
1402.
14. Flegal, K.M. et al., 2010. High adiposity and high body mass index-for-age in
US children and adolescents overall and by race-ethnic group. Am. J. Clin.
Nutr., 91(4), pp.1020–6.
15. Barba, C. et al., 2004. Appropriate body-mass index for Asian populations and
its implications for policy and intervention strategies. Lancet, 363(9403),
pp.157–163.
16. Bray, G.A. et al., 2001. Evaluation of body fat in fatter and leaner 10-y-old
African American and white children: the Baton Rouge Children’s Study. Am.
J. Clin. Nutr., 73(4), pp.687–702.

Page 28
17. Clinical Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults
18. Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L.
Body-mass index and risk of 22 specific cancers: a population-based cohort
study of 5•24 million UK adults. Lancet. 2014 Aug 30;384(9945):755-65. doi:
10.1016/S0140-6736(14)60892-8. Epub 2014 Aug 13.
19. Engstrom G, Hedblad B, Stavenow L, Lind P, Janzon L and Lingarde F.
Inflammation- sensitive plasma proteins are associated with future weight
gain. Diabetes. Aug 2003; 52(08): 2097-101.
20. Marseglia L, Manti S, D’Angelo G, Nicotera A, Parisi E, DiRosa G, Gitto E,
Arrigo T. Oxidative stress in obesity: a critical component in human diseases.
International Journal of Molecular Sciences. Dec 2014; 16(1):378-400.
21. Kasen, Stephanie, et al. “Obesity and psychopathology in women: a three
decade prospective study.” International Journal of Obesity 32.3 (2008): 558-
566.
22. Luppino, Floriana S., et al. “Overweight, obesity, and depression: a systematic
review and meta-analysis of longitudinal studies.” Archives of general
psychiatry 67.3 (2010): 220-229.
23. Han, T. S., et al. “Quality of life in relation to overweight and body fat
distribution.” American Journal of Public Health 88.12 (1998): 1814-1820.

24. Aziz J, Siddiqui NA, Siddiqui IA, Omair A. Relation of body mass index with
lipid profile and blood pressure in young healthy students at Ziauddin Medical
University. J Ayub Med Coll Abbottabad 2003;15:57-59.

25. Minhas HT, Anis D, Jawaid A, Naeem H, Naz M, Zuberi BF. Estimation of
body mass index in students of a public sector medical college in Pakistan.
Pak J Med Sci 2010;26(4):918-22.

26. Lakshmi Y, Devi BV. A study of body mass index among medical
students in a tertiary care teaching hospital. IOSR J Dent Med Sci (IOSR-
JDMS) 2015;14(3):14–7.

27. Hamid S, Rashid AF, Najeeb Q. Estimation of body mass index (BMI) in
first year medical students of Skims Medical College, Bemina. Int J Sci Res
2015;4(1):2654–7

28. Gupta S, Ray1 TG, Saha I. Overweight, Obesity and Influence of Stress on
Body Weight Among Undergraduate Medical Students. Ind J Comm Med.
2009; 34(3): 255-7.

29. "Health Survey for England: The Health of Children and Young
People".Archive2.official-documents.co.uk.

Page 29
30. Gupta S, Ray TG, Saha I. Overweight, obesity and influence of stress on body
weight among undergraduate medical students. Indian J Community Med
2009;34:255-7.

31. Skelton JA, Irby MB, Grzywacz JG, Miller G. Etiologies of obesity in
children: nature and nurture. Pediatr Clin North Am.2011;58(6):1333-1354,
ix. doi: 10.1016/j.pcl.2011.09.006.
32. McAllister EJ1, Dhurandhar NV, Keith SW, et al. Ten puta-tive contributors
to the obesity epidemic. Crit Rev Food Sci Nutr.2009;49(10):868-913. doi:
10.1080/10408390903372599.

33. Apovian CM, Aronne LJ, Bessesen DH, et al; Endocrine Society.
Pharmacological management of obesity: an Endocrine Society clinical
practice guideline. J Clin Endocrinol Metab. 2015;100(2):342-362. doi:
10.1210/jc.2014-3415.
34. Skelton JA, DeMattia L, Miller L, Olivier M. Obesity and its therapy: from
genes to community action. Pediatr Clin North Am.2006;53(4):777-794.

35. Crino M, Sacks G, Vandevijvere S, Swinburn B, Neal B. The influence on

population weight gain and obesity of the macronu-trient composition and
energy density of the food supply. CurrObes Rep. 2015;4(1):1-10. doi:
10.1007/s13679-014-0134-7

36. Park S, Blanck HM, Sherry B, Brener N, O’Toole T. Factors associated with
sugar-sweetened beverage intake among United States high school students.
J Nutr. 2012;142(2):306-312. doi: 10.3945/jn.111.148536.

37. Ludwig DS, Peterson KE, Gortmaker SL. Relation between con-sumption of
sugar-sweetened drinks and childhood obesity: a pro-spective, observational
analysis. Lancet. 2001;357(9255):505-508.

38. Du H, van der A DL, Ginder V, et al. Dietary energy density in relation to
subsequent changes of weight and waist circumference in European men and
women. PLoS ONE. 2009;4(4):e5339.
doi:10.1371/journal.pone.0005339.21. Savage JS, Marini M, Birch LL.
Dietary energy density predicts 3•"Body Shape 'Is Down to Genes'". Indian
Express. Retrieved October 23, 2010.

39. "Unexplained Weight Loss - Reasons, Symptoms & Causes". Retrieved 2017-
11-28.

Page 30
40. Milas, Kresimira. "Hyperthyroidism Symptoms - Signs and symptoms caused
by excessive amounts of thyroid hormones". Endocrine Web. Retrieved 24
September 2012.0

41. "Signs and Symptoms of Cancer". American Cancer Society. Retrieved

24 September 2012.

42. Hira, S. K.; H. L. Dupont; D. N. Lanjewar; Y. N. Dholakia (1998). "Severe

weight loss: the predominant clinical presentation of tuberculosis in patients
with HIV infection in India". National Medical Journal of India. 11 (6):
256–258. PMID 10083790.women’s weight change over 6 y. Am J Clin
Nutr.

43. Gjesdal; Halse, JI; Eide, GE; Brun, JG; Tell, GS (2008). "Impact of lean
mass and fat mass on bone mineral density: the Hordaland Health Study".
Maturitas. 59 (2): 191–200. doi:10.1016/j.maturitas.2007.11.1245. Nattiv;
Agostini, R; Drinkwater, B; Yeager, KK (1994). "The female athlete triad.
The inter-relatedness of disordered eating, amenorrhea, and osteoporosis".
Clinics in Sports Medicine. 13 (2): 405–18. PMID 8013041.
44. Wilson; Wolman, RL (1994). "Osteoporosis and fracture complications in an
amenorrhoeic athlete". British Journal of Rheumatology. 33 (5): 480–1.
doi:10.1093/rheumatology/33.5.480. PMID 8173855.
45. Waaler HT. (1984). "Height, weight and mortality. The Norwegian
experience". Acta Med Scand Suppl. 215 (679): 1–56. doi:10.1111/j.0954-
6820.1984.tb12901.x. PMID 6585126.
46. Body Weight and Mortality:What is the optimum weight for a longer life?.
47. Zeratsky, Katherine (23 August 2011). "Underweight? See how to add
pounds healthfully". Nutrition and healthy eating. Mayo Clinic. Retrieved 19
March 2012.
48. 17"Healthy Weight Gain". Children's Hospital Boston, Center for Young
Women's Health. Retrieved October 23, 2010.002

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