exlverimmtar *socehre

EXPERIMENTAL PROCEDURE
The methodology adopted for the present study entitled "Prevalence
of obesity among different age groups and body composition among
adults in Ernakulam district, Kerala" consisted of the following phases;

Phase I Prevalence of overweight and obesity among different

age groups
Phase II Study the epidemiological factors of obesity among
adults
Phase III Assessment of anthropometric measures and body
composition among adults
Phase IV Determination of biochemical profile of adults
Phase V Evaluation of the knowledge, and practices of subjects
regarding obesity and impact of intervention in adults
Phase VI Statistical analysis and interpretation

A. PHASE I - PREVALENCE OF OVERWEIGHT AND OBESITY AMONG

DIFFERENT AGE GROUPS

1. Selection of Locale

Ernakulam district of Kerala State was selected as the locale for the
study. Kerala is a small state located in the southwestern tip of Indian
peninsula and came into existence in its present form in November 1956
when state boundaries were demarcated on the basis of language.
However, for Kerala two of its boundaries by co-incidence are natural ones.
On the Eastern side is the Western Ghats and the western boundary is the
Arabian Sea. These diverse physical characteristics of the state led to the
natural classification of its 38,863sq.km into three regions: high land
(the Ghat region), low land (western coastal region) and midland (the area
between the high and the low land). The Kerala state map indicating the
geographical location of Ernakulam district is depicted in Figure 3.

35
 Experimental Procedure

According to Shetty (2002), a major feature of the developmental

transition in India is the rapid urbanisation and the large shifts in population
from rural to urban areas. The consequences of internal migration and
urbanisation in India could be staggering but the problem is likely to be highly
variable in different states, given the variations in urban populations between
the different states in India and their differential rates of urbanization.
The India Social Development Report by the Council for Social Development
(2008), ranked Kerala first in social development in the rural areas and
second in the urban areas among the states in India. According to the Report
of the National Commission on Macroeconomics and Health, Ministry of
Health and Family Welfare, Government of India (2005), the state is reported
to have the lowest rural-urban inequalities in public health status. The state is
also ranked top on the basis of Human Development Index.

Figure 3

KAsA4.,
.....73
PCJLMEWAL
... .3.

.i!
a.. \

K.A14 4.41 U R
_r--1 .:j .),:. -P 2 -, WA1014100,
NA 0
i
..r !LI111671
: :4
0
t
ra
:101
44AiAmmomit)
MA LA P P FLA pp, Litc KA 0

'74.2
THIPI UR

I0U
E RAIMOIA L-45.14j, pAntAv-.

KE11'7AY

A LA PPUZ A. ti
9

K IL Lilb M

0 0 ta-ric In-r CACI&J IL4Arrre R mi

THIRUV A 131.1 RA M

* •-nacre c rrout_ 11111 RUN

NOT TO SCALE

MAP OF KERALA STATE

36
 Experimental Procedure

Rural areas in Kerala and Ernakulam in particular, are slowly merging

with urban areas to become semi urban areas, adopting lifestyle changes
spurred on by economic development with no distinct characteristic features
typical of a rural area. Hence, in the absence of typical rural areas, the
present study was conducted in the two major social demarcative areas of
Ernakulam district - the urban and coastal areas.

Urban Area

In the Census of India 2001, an urban area is defined as all statutory

places with a municipality, corporation, cantonment board or notified town
area committee etc; a place satisfying the following three criteria
simultaneously; a minimum population of 5,000; at least 75 per cent of male
working population engaged in non-agricultural pursuits and a density of
population of at least 400 per sq km (1,000 per sq. mile).

Areas coming within Cochin (Ernakulam) Corporation and municipality

limits namely Kadavanthara, Edapally and Panampilly Nagar were selected
for the study.

Coastal Area

Total population living within 100 kilometers of the coastline is termed

as the coastal population. The average population density in coastal areas is
about 80 persons per square kilometer. The stretch of coastal area from Vypin
to Njarakkal in Ernakulam district was selected for the present study.

FIGURE 4

SCENE FROM THE COASTAL AREA, ERNAKULAM

37
 Experimental Procedure

2. Selection of Subjects

A total of 8576 subjects comprising of 4167 from coastal areas and

4409 from urban areas constituting four age groups namely preschool
(2 - 5 years), school going (6 - 12years), adolescents (13-19 years) and adults
(20-60 years) both male and female were selected.

The subjects from the coastal area were selected from Vypin and
Njarakkal consisting of 600 and 340 households out of which 440 households
and 300 households respectively were selected at random.

Adults from the urban areas were selected from 3031 households in
Kadavanthara, 2407 households in Edapally and 1747 households in
Panampilly Nagar. A total of 250 households were selected from
Kadavanthara, 350 from Edapally and 400 from Panampilly Nagar, by random
sampling.

Individuals from each household fulfiling the criteria (age) for inclusion
were considered for the study. Total number of subjects from each age group
included for the study are given below.

Preschool children (2 - 5years)

A total of 2051 children in the 2 to 5 year age group consisting of 1026

from the coastal area and 1025 from the urban area comprised the preschool
subjects.

School Going children (6 - 12 years)

A total of 2130 children, between the age group of 6 and 12 years

consisting of 1044 from the coastal area and 1086 from the urban area were
the school going subjects included in the study.

Adolescents (13- 19 years)

A group of 2381 boys and girls consisting of 1098 from the coastal and
1283 from the urban area formed the adolescent subjects.

Adults (20-60 years)

A total of 2014 adults (957 and 1057 from the coastal and urban areas
respectively) were included in the study.

38
 Experimental Procedure

Distribution of subjects based on area, age and gender is presented in

Table I.

TABLE I
DISTRIBUTION OF SUBJECTS BY AREA, AGE AND GENDER

Coastal Urban Total

(n=4167) (n=4409) N=8576
Age Group
Male Male Female Female Coastal Urban

Preschool
560 519 506 466 1026 1025
(1-5 yrs)

School going
600 567 477 486 1086 1044
(6-12 yrs)

Adolescent
586 648 635 512 1098 1283
(13-19 yrs)

Adult (20-60yr5) 360 456 601 597 957 1057

Total 2106 2190 2219 2061 4167 4409

3. Conduct of Prevalence Study

Prevalence considers all the current cases old and new cases existing
at a given point of time or over a period of time. Prevalence helps to estimate
the magnitude of under nutrition or over nutrition in the community and
identifies potential high risk populations which are useful for planning control
measures (Laxmaiah, 2011). In this case, comparison was made among the
different age groups from preschool to adults to determine the age at which
the highest prevalence of obesity occurs, between male and female and
among coastal and urban areas to identify the at risk population groups.
Prevalence or cross sectional survey method was used to assess the extent
of prevalence of overweight and obesity among the different age groups in the
coastal and urban areas. According to Rao (2010), cross sectional or
prevalence studies involve large samples and are typically collected at one
point of time by personal administration or mailed questionnaires within a
short period. The large sample size couple with the control of "freezing" all
respondent information at a specific time makes the cross-sectional approach
to data collection a very useful and widely used method.

39
 Experimental Procedure

The steps of the survey included taking anthropometric measurements

of all the subjects and then categorizing them based on BMI cut off values
appropriate to the age group, to determine the prevalence of overweight and
obesity.

a. Anthropometric measurements

The term anthropometry refers to comparative measurements of the

body. Anthropometric measurements are used in nutritional assessments.
Those that are used to assess growth and development in children, and
adolescents include height and weight. Individual measurements are usually
compared to reference standards on a growth chart. Anthropometric
measurements used for adults usually include height, weight, BMI, waist-to-
hip ratio, and percentage of body fat. These measures are then compared to
reference standards to assess weight status and the risk for various diseases.

For the prevalence study, anthropometric measurements namely

height and weight of all the 8576 subjects were recorded.

i. Height and weight measurements

Height and weight measurements of all the subjects were recorded.

Height

Height is useful in determining the nutritional status. The height of an

individual is influenced by both genetic (hereditary) and environmental factors.
Height is affected only by long term nutritional deprivation and is considered
as an index of chronic long duration malnutrition (Bamji, 2007).

A measuring tape was used to measure the height. The subject was
made to stand erect looking straight on a leveled surface without shoes, with
heels together and toes apart touching the wall. The point of contact of the
head was then marked with a scale held perpendicular and the reading noted
with an accuracy of 0.1cm graduation (Plate 1).

40
 Experimental Procedure

Weight

Body weight is the most widely used and the simplest reproducible
anthropometric measurement for the evaluation of nutritional status.
It is sensitive to even small changes in nutritional status. Body weight
indicates the body mass and is a composite of all body constituents like water,
minerals, fat, protein, bone etc.

The subject was asked to stand straight with feet placed on a

calibrated weighing scale adjusted to zero. The scale was set to zero before
each measurement and weight was recorded to the nearest 0.5kg. The weight
was measured with the subject wearing minimum clothes and without
footwear.

ii. Body Mass Index (BMI)

The Body Mass Index (BMI) is defined as the weight in kilograms

divided by the square of the height in meters (kg/m2). BMI was calculated
from the following equation:

Weight (kg)
BMI (kg/m2) =
Height (m 2 )

Thus BMI was computed from the height and weight measurements recorded.

4. Classification of Subjects into Various Nutritional Classes Based on

Body Mass Index (BMI)

The subjects were then classified based on their Body Mass Index
(BMI) as underweight, normal, overweight and obese. Adult BMI increases
very slowly with age, so age-independent cut-off points can be used to grade
fatness. In children, however, BMI changes substantially with age, rising
steeply in infancy, falling during the preschool years and then again during
adolescence and early adulthood. For this reason, child BMI needs to be
assessed using age-related reference curves (WHO, 2000).

41
 Experimental Procedure

a. Classification of preschool, school going and adolescents by BMI

BMI-for-age and gender specific centiles is recommended as the best

method for screening overweight and underweight in children and adolescents
from 2 to 20 years of age. BMI-for-age compares well with both weight-for-
stature measurements and measures of body fat and hence is a screening
tool that may lead to further assessment to diagnose a specific health
condition. The most widely used growth reference, recommended by WHO for
international use is the CDC growth charts based on well off populations from
USA (Appendix la and Ib).

Recently, new BMI standards in children using a large internationally

representative sample from six different countries (not India), with widely
differing prevalence rates for obesity have been published. Age- and sex-
specific BMI cut-off points for defining overweight and obesity in children have
been derived by identifying percentiles in children analogous to adult BMIs of
25 kg/m2 and 30 kg/m2, respectively. These are referred to as IOTF cutoff
points and are now recommended as standards for international comparison
of data.

In the present study, children were classified and compared using both
CDC and IOTF standards.

i. Centre for Disease Control (CDC) percentile growth charts (2000)

The CDC Growth Charts, developed by the National Center for Health
Statistics (NCHS) consist of the BMI -for-age charts which gives age and
gender specific centiles. BMI values are plotted on the chart and the
corresponding centile value noted. There are several advantages to using
BMI-for-age as a screening tool for overweight and underweight. BMI-for-age
is the only indicator that allows plotting a measure of weight and height with
age on the same chart. Age and stage of sexual maturation are highly related
to body fatness. Another advantage is that BMI-for-age is the measure that is
consistent with the adult index. Hence BMI can be used continuously from
two years of age to adulthood. This is important since BMI in childhood is a
determinant of adult BMI.

42
 Experimental Procedure

The following are the cut offs used by CDC to differentiate between the
different nutritional classes.

Classification of BMI based on CDC growth charts (2000)

Category BMI

Underweight < 5th percentile

Normal >5th percentile and<85th percentile

Overweight >85th percentile and <95th percentile

Obese >95th percentile

ii. International Obesity Task Force (IOTF) cut off values

(Cole et al., 2006)

These are internationally acceptable definitions for child overweight

and obesity which are age and sex specific cut off points for BMI, using
dataset specific centiles linked to adult cut off points for the 2 - 18 age group.
The IOTF cut offs are less arbitrary and provide internationally comparable
prevalence rates of overweight and obesity in children. The International
criteria are higher than the CDC growth charts. CDC is based on a mix of
newer and older American data; older data has less fatness resulting in a
lower line on the chart.

b. Classification of Adult BMI

After the cessation of linear growth around 21 years, weight for height
indicates muscle-fat mass in the adult body. BMI provides a reasonable
indication of the nutritional status of adults and has a good correlation with
fatness. It may be used as an indicator of health risk. It is a simple index that
provides a reasonable indication of the nutritional status of adults. BMI is
commonly used as it provides the most useful population-level measure of
overweight and obesity as it is the same for both sexes and for all ages of
adults (WHO, 2004). It may also be used as an indicator of health risk.
The adult subjects were classified using two BMI cut offs as indicated below.

43
 Experimental Procedure

Cut off values for BMI given by James et al (1988)

Classification of overweight and obesity by James et al (1988) is given below.

BMI Classification
< 19.9 Underweight
20-24.9 Normal
25-29.9 Overweight
> 30 Obese

Potential Public Health Action Points for Asians as given by

WHO (2000)

There was an increasing concern that the International BMI cut off
points for overweight and obesity might substantially underestimate health
risks, in particular in some Asian populations because of differences in body
composition, fat distribution and associated health risks at a given BMI level
among Asians compared with other populations. The 2002 WHO Expert
Consultation concluded that Asians generally have a higher percentage of
body fat than do Caucasians of the same age, sex and BMI. In addition, the
proportion of Asians with risk factors for type II diabetes and cardiovascular
disease is substantial even below the existing BMI cut off point of 25kg/m2 for
defining overweight. Therefore, Asian populations might have higher risk at
lower BMI levels. Hence potential public health action points for Asian Indians
suggested is given below.

<18.5 Chronic Energy Deficiency

18.5 - 23 Normal
23 - 27 Overweight
27 Obesity

Using the appropriate classification for the different age groups, the
subjects were classified into underweight, normal, overweight or obese
category and the area wise and age wise prevalence of overweight and
obesity noted. The results of the prevalence study is summarized in Table I.

44
 Experimental Procedure

TABLE II
PREVALENCE OF OVERWEIGHT AND OBESITY AMONG ALL AGE
GROUPS

Coastal Urban Total

Age Male Female Male Female Coastal
Urban %
Group
OW OB OW OB OW OB OW OB OW OB OW OB

Preschool 1.4 1.6 2.5 1.5 3.5 2.7 3.3 2.3 3.9 3.1 6.8 5
(2-5 yrs)
(560 (466) ( 519) (506) (1026) (1025)

School 2.1 1.0 1.6 1.4 5.4 3.4 4.4 3.7 3.7 2.4 9.8 7.1
going
(6-12 yrs) (600) (486) ( 567) ( 477) ( 1086) ( 1044)

31 1.0 3.5 1.5 5.3 1.7 4.7 1.5 6.6 2.5 10.0 3.2
Adolescent .
(13-19 yrs) (586) (512) ( 648) ( 635) ( 1098) (1283)

Adult 7.2 1.7 15.9 4.7 16• 2.6 20.2 4.4 23.1 6.4 36.5 7.0
(20-60 yrs)
(360) (597) ( 456) ( 601 ) ( 957) (1057 )

Total 2106 2061 2190 2219 4167 4409

*No. in parenthesis indicates total number of subjects
OW- Overweight OB-Obese

The results of the survey conducted among the different age groups in

the coastal and urban areas indicated that the prevalence of overweight and

obesity was highest among adults in the urban and coastal area, hence this
group was considered for further study and intervention.

B. PHASE II- STUDY THE EPIDEMIOLOGICAL FACTORS OF OBESITY

AMONG ADULTS

Epidemiology is the study of the occurrence and determinants of

diseases in human populations. According to the WHO (2004), recent

epidemiological trends in obesity indicate that the primary cause of the

problem of obesity lies in environmental and behavioural changes apart from

the underlying genetic factor. Hence in the present study, the incidence and

extent to which the risk factors of obesity are present among the subjects

were determined. The major factors studied were socio-economic, genetic,

45
 Experimental Procedure

weight variables, physical activity pattern and dietary pattern. Metabolic

disorders, present in the subjects were also determined. The incidence of
epidemiological factors and metabolic disorders with a change in BMI and
area wise differences were compared. Frequency of food intake and twenty
four hour dietary recall was assessed. Physical Activity Ratio was computed
from the physical activity recall proforma and Energy expenditure determined
using the ICMR prediction equations (2010). From the energy intake and
expenditure, energy balance was computed.

A total of 904 adults comprised the study population inclusive of all

obese adults (135), a substantial number of overweight (369) and an equal
proportion of normal adults (400) both males and females in coastal and
urban areas from the survey conducted in Phase I.

1. Formulation of Interview Schedule

A pretested interview schedule (Appendix II) was developed for the

study. According to Kothari (2004), the interview method of collecting data
involves presentation of oral-verbal stimuli and reply in terms of oral verbal
responses. The interview schedule was administered to each of the subjects
to elicit information on socio-demographic profile, genetic predisposition,
physical activity pattern, dietary intake and medical profile. Frequency of food
intake and twenty four hour dietary recall were determined. Physical activity
pattern was recorded using the 24 hour activity record.

Socio-demographic profile

The socio-economic factors like religion and its variation with BMI and
between the coastal and urban area were determined.

Weight correlates

Details such as the age of onset of obesity in the overweight and obese
subjects, incidence of childhood obesity, birth weight etc was determined.

Genetic predisposition

Information on the family history of overweight and obesity present

among the subjects were elicited.

46
 Experimental Procedure

Physical Activity Pattern

Routine exercise pattern followed by the subjects, type of exercise and

duration, duration of work, duration of leisure, type of leisure activity, all of
which influence energy expenditure of the subjects were determined.

Metabolic disorders present among the subjects

The pattern of incidence of metabolic disorders associated with

obesity such as diabetes, the various cardiovascular diseases such as
hypertension, hyperlipidemia, angina, musculo skeletal, gynaecological,
hypothyroidism in the subjects were compared between BMI and area.

Other factors related to Obesity

Other risk factors of obesity such as incidence of stress, mode of

conveyance used, alcohol and smoking in men were assessed.

Dietary Pattern

Dietary pattern followed by the subjects included information such as

type of diet, snacking pattern, consumption of fast foods, food out, frequency
of consumption, type and quantity of fats etc.

Food Frequency Questionnaire (FFQ)

Food frequency was determined using the Food Frequency

Questionnaire (FFQ). It is the most commonly used method in epidemiological
studies to assess the diet in relation to chronic diseases. The goals of diet
assessment are to obtain a measure of usual rather than current diet.
The consumption of a particular food by an individual is estimated using FFQ
wherein frequency of intake of food items in major food groups like cereals
(wheat and rice), pulses, nuts and oil seeds, green leafy vegetables, other
vegetables, roots and tubers, fruits, milk and milk products, flesh foods, fats
and oils by the subject is noted, to assess dietary consumption pattern.

2. Dietary Intake

To assess the dietary intake and adequacy of the diet consumed, the
24 hour recall method of survey was adopted using the 24 hour oral

47
 Experimental Procedure

questionnaire. The intake of food items were quantified using the

standardized cups developed by National Institute. This method is used to
collect data on the diet history of the subject i.e. raw food equivalent of the
cooked food was determined what he/she had eaten during last 24-hours.
Conversion of the cooked amount into the raw amount would be done using
standardized techniques. From this the intake of energy, macronutrients,
micronutrients for individuals was calculated using the Nutritive value of Indian
foods (ICMR, 2010) and compared with RDA.

3. Computation of Energy Balance

The regulation of body weight is dependent on a balance between

nutrient intake and utilization, apart from other factors. Energy balance was
computed from the difference between Energy Intake and Total Energy
Expenditure.

a. Assessment of Total Daily Energy Expenditure (TDEE)

Energy expenditure is calculated by factorial approach (adopted by

FAO/WHO/UNU). From body weight, the subjects' basal metabolism is
predicted, to which energy spent during the activities of the day are related as
the PAL value.

TEE = Predicted BMR x PAL

Step I: Computation of Basal Metabolic Rate (BMR)

BMR contributes to 50 to 70 per cent of energy expenditure of an

individual. Recent measurements of BMR in adult Indians have shown that
BMR of Indians is lower by five per cent as compared to the reported BMR in
developed countries. The FAO / WHO / UNU Consultations have given
prediction equations for computing BMR from the body weights.
These equations have been modified to use for Indian adults, taking into
consideration the lower BMR of Indians (Shetty et al., 2002).

In the present study, BMR was calculated using ICMR prediction

equation for Indian adults (2010). The equations for the (18-60 age group) are
given below.

48
 Experimental Procedure

Equation for predicting BMR of Indian adult from body weights

(ICMR, 2010)

Male Age (yrs)

18-30 14.5 x body weight (Kg) + 645
30-60 10.9 x body weight (Kg ) +833
>60 12.8 x body weight (Kg) + 463
Female
18-30 14.0 x body weight (Kg) + 471
30-60 8.3 x body weight (Kg) + 788
>60 10.0 x body weight (Kg) + 565

Step 2 : Energy cost of BMR

The amount of time spent on different physical activity is highly

variable. Physical activity accounts for 30 to 40 per cent of the total daily
energy expenditure. The physical activity pattern was recorded by using
standardized 24 hour physical activity recall proforma developed by
Satyanarayana et al (1989). Each subject was asked to recall his or her
physical activity for 24 hours prior to the measurement. In physical activity
proforma, 24 hours have been divided into 48 slots of 30 min each.
Time spent for various physical activities by the subjects were graded into
various intensity zones namely light, moderate and heavy activity. For the
whole day, the activities were summed up in each category of light, moderate
and heavy. The energy cost of BMR sleep hours was also considered.
PAL values for different categories of work for Indians as proposed by ICMR
(2010) is given below and was used to compute Physical Activity Level.

Sedentary work 1.53

Moderate work 1.8
Heavy work 2.3

Energy cost of activities was calculated as a multiple of BMR per

minute, also referred to as the Physical Activity Ratio (PAR), and the 24 - hour
energy requirement was expressed as a multiple of BMR per 24 hours by
using the Physical Activity Level (PAL) value.

49
 Experimental Procedure

PAR = Energy cost of an individual activity per minute

= Energy cost of BMR per minute

PAL = Total PAR hours/ Total time

Total Energy Expenditure (TEE) = Predicted BMR x PAL

b. Energy Balance

From the energy intake and Total Energy Expenditure (TEE), the
energy balance of the adults was calculated using the formula.

Energy Balance = Energy intake - Energy expenditure

The difference between the two indicated the energy balance of the
subjects. A positive energy balance is a risk factor for weight gain and vice
versa.

C. PHASE III - ASSESSMENT OF ANTHROPOMETRIC MEASURES AND

BODY COMPOSITION AMONG ADULTS

Body composition reflects the overall nutritional status of an individual.

It depicts the percentage of various components of the total body weight of an
individual. A two compartment model of body composition divides the body
into a fat component and fat-free (lean) component. Body fat is the most
variable component in the body and consists of essential fat and storage fat.
Lean tissue includes muscles, bones, skin, and body organs.

The indirect measures for assessing body composition include

anthropometric measurements and bioelectric impedance. The body
composition measures assessed by anthropometry were waist circumference,
hip circumference (from which the Waist Hip Ratio (WHR) was computed) and
mid upper arm circumference (MUAC) using measuring tape. Skin fold
Thickness (SFT) at four sites namely triceps, biceps, sub scapular and supra
iliac was measured using Harpenden skinfold calipers to determine the
subcutaneous fat.

Body fat per cent, visceral fat, muscle mass and body water were
determined using Tanita Body Fat Analyzer which works on the principle of
Bioelectric Impedance Analysis (BIA).

50
 Experimental Procedure

1. Assessment of Anthropometric Measures

Measurements such as waist circumference, hip circumference, and
mid upper arm circumference (MUAC) were assessed.

Waist circumference
The measurement of waist circumference provides information about
the distribution of body fat and is a measure of risk for conditions such as
Coronary Heart Disease (CHD). Increased waist circumference is also
associated with metabolic syndrome.

The subject was asked to stand straight and waist circumference was
measured to the nearest 0.1 cm horizontally midway between lower rib cage
and iliac crest using a fibre glass tape (Plate 1). Adult men with waist
circumference ?102cm and adult women with .? 88cm considered as having
abdominal obesity. The Asian cut-offs for the same is 90cms and 80cms
respectively.

Hip Circumference
Hip circumference was measured to the nearest 0.1 cm at the greatest
horizontal circumference below the iliac crest at the level of greater
trochanter.

Waist Hip Ratio (WHR)

The waist to hip ratio is an indicator of central obesity. Excess body fat
in the abdominal area has been closely linked to an increased risk for
diabetes, cardiovascular disease and stroke. The Waist Hip Ratio is computed
Waist circumference in ems
using the formula
Hip circumference in ems

Adult men with WHR of 0.95 and women with 0.80 are considered

as having central obesity.

d. Skinfold measurement

Fat stored at different sites plays different

physiological roles. Amount of subcutaneous fat on
trunk correlates more strongly with the risk of
diabetes mellitus and cardiovascular disease than r.
the fat on the extremities. Using Harpenden skinfold caliper the skinfold

51
 Experimental Procedure

measurements were measured at four sites in the body viz - triceps, biceps,
subscapular and suprailiac. Readings were taken to the nearest mm. and
compared with standards. Average of three measurements were taken.

The skin fold measured consisted of double layer of skin and

subcutaneous fat and left side of the body was chosen for measurements.
With the left arm of the subject hanging loosely in a relaxed state, the biceps
skin fold was measured as the thickness of a vertical fold on the front of the
upper arm approximately over the middle of the biceps muscle and the
reading was noted within two to three seconds as the subcutaneous fat gets
compressed if calipers is kept for longer period.

The measurement of triceps was made on the dorsal side at the

midpoint where mid upper arm circumference is measured. The skinfold is
picked up between the thumb and the forefinger about 1cm above the
midpoint. The tips of the skinfold caliper should be applied at the midpoint at a
depth equal to the skinfold. The subscapular fat fold is measured just below
the lateral angle of the left scapula by picking up with the thumb and fore
finger in a line running approximately 45° to the spine, in the natural line of
skin cleavage. The skinfold was lifted just above the anterior superior iliac
spine on the left side in the mid auxiliary line and the readings were recorded
with the fold being lifted to follow the natural diagonal line at this point to
measure supra iliac skinfold.

Body fat percentage was calculated from the sum of four skinfolds
(triceps, biceps, supra iliac and sub scapula. For a given skinfold, the amount
of body fat was determined. The density of the total body depends on the ratio
of fat mass to free fat mass. Body density is calculated using linear regression
equation by the formulae (Durnin & Wormersely, 1974)

Body density = C- (m x log (sum of all skinfolds)

Where C and m values vary with the age and gender of the population.
Once the body density is determined, body fat can be calculated using Siri's
equation:

Fai percentage = [(4.95/body density - 4.5) x 100]

52
 Experimental Procedure

e. Mid Upper Arm Circumference (MUAC)

Measurements of MUAC give an indication of skeletal muscle or

somatic protein stores. The mid point between the tip of acromion of scapula
and the tip of the oleocranon process of the ulna (fore- arm bone) with the
arm flexed at the elbow is marked with a marker pen. Now the arm should
hang freely and the fibre glass tape is gently, but firmly placed embracing the
arm, without exerting too much pressure on the soft tissues. The reading is
taken to the nearest mm while the tape is still in position. The average MUAC
is about 32 ± 5 cm for men and 28 ± 6 cm for women (Morley, 2007).

2. Assessment of Body Composition Parameters

Body composition parameters such as per cent of body

fat, body water, muscle mass, BMR and visceral fat were
assessed using the Tanita Body Fat Analyser (model-UM076)
which works on the principle of Bioelectrical Impedance
Analysis (BIA) (Plate I). Electrical impedance is a newer
method used for body composition assessment and is relatively simple, quick,
and noninvasive. BIA measures the opposition of body tissues to the flow of a
small (<1mA) high frequency low amplitude alternating current. This
procedure involves sending a very small current through the body (800 ❑A at
50 kHz), which is unable to be felt and measuring its resistance. The
underlying theory to this procedure is based on the subject's height and
his/her resistance to a current. Lean tissue offers less resistance to a current
as it contains more water and electrolytes than adipose tissue. Impedance is
inversely proportional to body water volume.

a. Body fat percentage

Fat distribution in and around the body varies with age, sex,
physiological, nutritional and health status and ethnicity. It is an estimate of
the fraction of the total body mass that is adipose tissue, as opposed to lean
body mass (muscle, bone, organ tissue, blood etc.). Adipose tissue is
distributed over a large number of sites in the body. Subcutaneous fat
constitutes the body's main store of energy reserves. Close association has

53
ANTHROPOMETRIC AND BODY COMPOSITION MEASUREMENTS

HEIGHT MEASURMENT

BODY COMPOSITION USING TANITA

WAIST CIRCUMFERENCE
BODY FAT ANALYZER

Plate 1

54
 Experimental Procedure

been observed between fatness and calorie reserves and between

muscularity and protein status. This relationship can be used as a tool for
assessing the gross nutritional status of persons at specific stages of life.
The body fat per cent of the subjects obtained from the impedance method
were compared with standard values.

Body fat (kg) calculated from body weight

Using the body fat per cent, the amount of body fat in kg can be
derived using the following equation;

Body fat (kg) = Body weight (kg) x fat%

100

Fat Free Mass (FFM)/Lean Body Mass

Lean body mass constitutes the weight of muscle, bone, ligaments,

tendons and internal organs. Since there is some essential fat in bone marrow
and internal organs, the lean body mass includes a small percentage of
essential fat. People who do regular physical activity have a larger percentage
of lean body weight. With the body weight of the subjects and body fat known,
the FFM can be calculated using the formula;

Fat Free Mass/Lean Body Mass = Body weight (kg) - Body fat (kg)

Muscle Mass

A person with a higher amount of body fat will have a lower muscle
mass. The amount of muscle mass is higher in men than in women.

Body Water

The higher the fat, the lower the water content, hence ideally a higher
level of hydration is a healthy sign for a normal individual. The normal rate of
water in the body varies from 40 -60 per cent. Hydration levels are generally
higher among men than women (60% and 55%).

Visceral Fat

Fat accumulation predominant in the intra-abdominal cavity is termed

as visceral fat; indicative of abdominal obesity and is a major risk factor.
A value of visceral fat above 10 is indicative of a high risk.
55
 Experimental Procedure

D. PHASE IV - DETERMINATION OF BIOCHEMICAL PROFILE OF

ADULTS

Among the 904 subjects, a total of 236 adults constituting 116 in the
coastal and 120 in the urban area, comprising of 56 males (20 normal,
20 overweight and 16 obese) and 60 females (20 each of normal, overweight
and obese) in coastal area were selected for the biochemical assessment.
Likewise, 60 male and female each in urban area including 20 normal,
20 overweight and 20 obese were included. The subjects were selected
based on their willingness to participate and co-operate in this invasive
technique. Fasting blood glucose, lipid profile consisting of total cholesterol,
triglycerides, HDL-cholesterol, LDL cholesterol and VLDL cholesterol were
assessed.

Blood Sample Collection

Totally 5m1 of blood was collected (Plate 2) in fluoride tube (1m1) and
serum plain tube (4m1). The supernatant was separated by using the
centrifuge at 3000 rpm for 10 minutes and the supernatant was transferred
into vial tubes and stored at -20°C until analysis. The vial tubes were screw
capped tightly The methods used for assessing the biochemical profile
are given below.

Fasting blood glucose

The American Diabetes Association (ADA) uses fasting blood glucose

level for screening, because it is faster, more acceptable to patients and less
expensive than other screening tests. The fasting plasma glucose level is
also more reproducible than the oral Glucose Tolerance Test (GTT) and
varies less between patients (Bhaskarachary et al, 2010). Fasting blood
glucose was measured by GOD-PAP method.

Lipid Profile

Lipid profile namely Total Cholesterol, Low Density Lipoprotein(LDL),

High Density Lipoprotein(HDL), Very Low Density Lipoprotein(VLDL) and
Triglyceride were measured by GPO - POD method.

56
 Experimental Procedure

d. Blood pressure

Blood pressure of the subjects was determined using the

sphygmomanometer (Plate 2).

Variations in the above biochemical indices with BMI, gender, age,

area and religion among the selected subjects were noted.

1. Prevalence of Metabolic Syndrome (Syndrome X)

Metabolic syndrome is a condition characterized by insulin resistance,

dyslipidemia, abdominal obesity and hypertension, that is associated with a
high risk of type 2 diabetes mellitus (T2DM) and CVD (Grundy, 2008). Obesity
is a key etiological factor in the development of metabolic syndrome (Kahn
and Flier, 2009). According to Grundy, in most countries, about 20 to 30% of
the adult populations have the syndrome. At least three organizations have
recommended clinical criteria for the diagnosis of the metabolic syndrome.
Their criteria are similar in many aspects, but they also reveal fundamental
differences in positioning of the predominant causes of the syndrome.
The most common are the US National Cholesterol Education Program Adult
Treatment Panel III (2001) criteria and the more recent International Diabetes
Federation Criteria (2006).

The US National Cholesterol Education Program Adult Treatment

Panel III, NCEP ATP III (2001) requires at least any three of the following:

Central obesity: Waist circumference 102 cm or 40 inches (male),

?. 88 cm or 36 inches(female)
Dyslipidemia: Triglycerides mmol/L(150 mg/dl)
HDL-Cholesterol 40 mg/dL (male),
50 mg/dL (female)
Blood pressure 130/85 mmHg
Fasting plasma glucose 6.1 mmol/L (110 mg/dl)

57
ASSESSMENT OF BIOCHEMICAL PARAMETERS

Checking blood pressure

Plate 2

58
 Experimental Procedure

The American Heart Association/National Heart, Lung, and Blood

Institute in their latest scientific statement have recommended using the
NCEP, ATP III definition with lower cut-off point for defining abdominal obesity
for ethnic groups who are more insulin resistance (in case of Indians >80cm
and >90cm among female and male respectively) and prone to develop T2DM
and also lower cut-off point for diagnosis of IFG (>100 mg/dl) known as
modified definition of NCEP, ATP III (Grundy et a/., 2005).

The IDF consensus worldwide definition of the metabolic syndrome

(2006) is Central obesity (defined as waist circumference with ethnicity
specific values in case of Indians >80cm and >90cm among female and male
respectively) and any two of the following:

Raised triglycerides > 150 mg/dL (1.7 mmol/L), or

specific treatment for this lipid
abnormality.
Reduced HDL cholesterol < 40 mg/dL (1.03 mmol/L) in
males,
< 50 mg/dL (1.29 mmol/L) in
females,
Raised blood pressure- systolic BP > 130 or >85 mm Hg, or
treatment of previously
Diastolic BP diagnosed hypertension.

Raised fasting plasma glucose (FPG) >100 mg/dL (5.6 mmol/L), or

previously diagnosed type 2
diabetes.
If BMI is >30 kg/m2, central obesity can
be assumed and waist
circumference does not need to
be measured.

In the study, the occurrence of metabolic syndrome in the 236 subjects

were determined as per the NCEP ATP (III) criteria, the Modified NCEP ATP
(III) criteria and the IDF (2006) guidelines and the prevalence compared age
wise, area wise and gender wise. The presence and extent of risk factors
contributing to metabolic syndrome present among the subjects were
determined.

59
 Experimental Procedure

E. PHASE V - EVALUATION OF THE KNOWLEDGE AND PRACTICES OF

SUBJECTS REGARDING OBESITY AND IMPACT OF
INTERVENTION IN ADULTS

Prevalence of obesity and the metabolic syndrome has shown a rapid

rise in developing countries in the past few decades and has led to increased
risk of CVD and consequent morbidity and mortality. Health interventions
required to prevent or reduce the morbidity or mortality need to be addressed
in both children and adults. Interventions should be aimed at increasing the
physical activity along with healthier food patterns and health education.
Successful community based intervention programs have been reported in
developed countries, and a similar approach is required in developing
countries (Misra and Khurana, 2008).

In the present study, a Nutrition and Health Education program was

conducted for the 236 subjects both in the coastal and urban areas for a
period of 120 days (four months). Appropriate nutritional aids were developed
suitable to the target group and nutrition education imparted. Impact of
intervention was determined from the pre and post intervention score using a
checklist and change in weight and BMI noted.

1. Assessing Knowledge and Practices of Subjects

The knowledge and practices of the subjects were assessed by

administering a checklist consisting of a set of 20 questions (Appendix III).
The knowledge about the dietary practices followed, awareness and practices
towards obesity were determined. This constitutes the pre- intervention
knowledge score.

a. Development of educational aids

Educational intervention involved nutrition and health education in

general apart from imparting educating the stake holders on general dietary
guidelines and obesity. Nutrition education aids developed included pamphlet,
posters, charts, handouts, flip charts, booklet in English and the regional
language (Malayalam) and electronic package. These educational aids
contained information regarding the significance of the problem of overweight
and obesity, its causative factors, consequences and practical guidelines to

60
 Experimental Procedure

prevent its onset or control its further continuance (increased physical and
dietary management). Taking into consideration the epidemiological risk
factors of obesity inherent in the target groups as evidenced from Phase II, Ill
and IV, the education module was prepared so as to address relevant issues
and concerns particular to the target age group and area. Behaviour
modification was addressed taking into consideration the time limit, economic
constraints, prevailing cultural and regional influences so as to advocate a
more realistic and practical approach.

Development and demonstration of low calorie, high fibre recipes

As part of the intervention program twenty high fibre recipes were

developed and demonstrated. These recipes were developed taking into
account easy availability of the ingredients, low cost (for the coastal
population), ease of preparation and palatability to increase the acceptability
of the recipes by the target group. Recipes suitable to both the coastal and
urban group were developed based on their varied food preferences.
Commonly used ingredients were plantain stem, colocasia leaf, tapioca, oats,
fish (staple food of the coastal group) green leafy vegetables and the like to
prepare dishes such as stuffed puttu, stuffed chappathi, tapioca upma, oats
soup, plantain stem salad, dieter's pizza, punch, summer salad etc.
The recipes were standardised and demonstrated to the target group.

During the education program, three to four recipes were demonstrated

in one session and three demonstrations were conducted per month. Further,
the investigator conducted informal meetings with women to know the
feasibility of preparing such recipes and its relevance to reduction in body
weight and enhancing the micronutrient availability. Among the 20 recipes
demonstrated, the most preferred recipes were tomato drink, cool amla,
vegetable soup, oats soup, chick pea salad, plantain stem salad, chicken
dumpling, plantain kabab, colocasia patra, stuffed chappathi and stuffed puttu.
Plate 3 shows some of the recipes developed.

Development of booklet and electronic package

A recipe booklet was developed which is given in Appendix 4.

An electronic package containing information on obesity regarding

61
 Experimental Procedure

prevalence, risk factors, consequences, prevention and control (behavior and

lifestyle modification), and dietary management was prepared (Appendix 5).

Conduct of the education program

Using the developed visual aids appropriate to

the area, a series of nutrition education classes were
given to the subjects in both areas taking into
consideration the availability of time and other
constraints of the subjects. Recipes were Date - 22-, 24- December 2010
26- - 31' December 2010
demonstrated involving the participants also for better
understanding and involvement. Individual diet counseling in case of
overweight and obese subjects whenever necessary was resorted to. Regular
monitoring and counselling of the subjects informally in groups and
individually was followed (Plate 4).

Impact of Intervention

Impact of intervention was assessed by the following two methods.

Post intervention scores

Evaluation of the efficacy of the education program was obtained by

giving the same checklist used at the beginning of the study to determine
post-intervention impact of the education program on the subjects after the
four month period. These scores constituted the post-intervention score. The
mean of the scores were computed and the mean difference (increase) in the
pre and post intervention scores determined the increase in knowledge and
awareness of the subjects.

Change in mean body weight and BMI

Height and weight measures of the subjects before intervention were

recorded at the start of the program and finally at the end of the four month
period. The mean difference between the initial and final weight was
determined and hence variation in BMI determined.

62
 RECIPES DEVELOPED

Oats soup

Chicken dumpling

Stuffed puttu

Plate 3

63
 NUTRITION EDUCATION

EDUCATION MATERIALS DEVELOPED AND EDUCATION IN PROGRESS

INDIVIDUAL DIET COUNSELLING

TALK ON OBESITY USING POWERPOINT INFORMAL DIET COUNSELLING

Plate 4

64
 Experimental Procedure

The research design and methodology adopted in the present study

was approved by the Human Ethical Committee of Avinashilingam Deemed
University, Coimbatore.

E. PHASE VI - STATISTICAL ANALYSIS AND INTERPRETATION OF

DATA

The data was consolidated and tabulated and subjected to statistical

analysis with appropriate tools using the SPSS 16.0 version. The following
were the statistical tests applied in the different phases.

Phase I
Descriptive statistics (mean and standard deviation) was used to
represent the basic distribution of BMI (overall, area wise, age wise
and gender wise).

Karl Pearson's chi-square correlation was used to determine the

degree of linear relationship between two or more variables. In the
study, relationships between age, area, gender and religion with
increase in BMI were analysed.

Chi-square analysis was also used to determine whether differences in

the prevalence of overweight and obesity in adults comparing WHO
and Asian Pacific cut off levels is significant.

Correspondence analysis was done to explore the relationship

between nutritional status and age class.

Logistic regression was applied to understand the risk of overweight or

obesity due to variables such as gender, area, religion and age.

Phase II
Descriptive statistics (mean and standard deviation) was used to
represent the basic distribution of anthropometric and body
composition parameters.

Karl Pearson's chi-square correlation analysis was used to determine

the relationship between the epidemiological factors of obesity (socio-
economic, physical activity, dietary, weight variables, genetic,

65
 Experimental Procedure

metabolic disorders) among the different BMI classes, area and

gender.

Correspondence analysis to explore the relationship between

occupation and nutritional status.

Factor analysis was applied to determine among the various risk

factors, the most influential factors of obesity.

Phase III
Descriptive statistics (mean and standard deviation) was used to
represent the basic distribution of the anthropometric and body
composition parameters

One way ANOVA to interpret intra group variations; to compare for

significant differences in the mean of anthropometric and body
composition parameters between normal, overweight and obese
subjects, between age, gender and area.

Pearson's chi-square test was also used to determine the type and
degree of association (correlation) between anthropometric and body
composition parameters among normal, overweight and obese
subjects.

Regression was used to model the change in BMI with respect to

changes in certain anthropometric and body composition parameters.

Phase IV
Descriptive statistics (mean and standard deviation) was used to
represent the basic distribution of the biochemical parameters

One way ANOVA to interpret intra group variations; to compare for

significant differences in the mean biochemical parameters between
normal, overweight and obese subjects, between age, gender and
area.

Phase V
Paired t- test to determine the significance of the impact of nutrition
education using pre and post intervention scores and change in BMI.

The research design of the study is depicted in Figure 5.

66
 FIGURE 5

Selected Area
Ernakulam District, Kerala State

Urban Area (U)

Coastal Area (C) (Panampilly Nagar, Kadavanthara,
(Vypin, Njarakkal) Edapally)
(749 households) (1000 households)

Selected subjects Selected subjects

4409 4167

Total subjects
N=8576

Preschool School going

Adolescent Adult
n=2051 n=2130 n=2381 n=2014
o(\ si(\
1026 (C) 1025 (U) 1086 (C) 1044 (U) 1098 (C) 1283 (U) 957 (C) 1057 (U)

PHASE I

PREVALENCE OF OVERWEIGHT AND OBESITY USING BMI (N=8576)

Pre school, school-going, adolescents - BMI centiles CDC, IOTF

Adults - BMI cut offs (WHO, Asia Pacific)
Selected adults (N=904)

PHASE II

ASSESSMENT OF EPIDEMIOLOGICAL FACTORS OF OBESITY

Formulation of Interview Schedule

Socio demographic Metabolic Dietary factors Energy intake

disorders Diet pattern
Weight correlates ► PAR
Food frequency BMR
Genetic Predisposition
questionnaire
Physical activity pattern
► 24 hour dietary recall ► Energy expenditure
Physical activity recall Mean food intake ► Energy balance
Mean nutrient intake

RESEARCH DESIGN

67
PHASE III
ASSESSMENT OF ANTHROPOMETRIC MEASURES
AND BODY COMPOSITION (N=904)

Anthropometric Body composition

Waist circumference Using Tanita Body Fat Analyzer
Hip circumference WHR
Body Fat %
MUAC Visceral Fat
Skinfold thickness (using harpenden Muscle Mass
caliper) biceps, triceps, subscapular,
Body water
suprailliac
Fat Free Mass
Body fat (kg) Calculated
PHASE IV

DETERMINATION OF BIOCHEMICAL PARAMETERS (n=236)

Coastal (N=116) Urban (N=120)

Male (n=56) Female (n=60) Male (n=56) Female (n=60)

/N A/\&
N OW OB N OW OB N OW OB N OW OB
20 20 16 20 20 20 20 20 20 20 20 20

Fasting Lipid profile Blood Metabolic syndrome

blood Total Cholesterol pressure NCEP ATP (III) Criteria
glucose Triglycerides IDF criteria
LDL Cholesterol
HDL Cholesterol
VLDL Cholesterol
PHASE V

EVALUATION OF KNOWLEDGE AND PRACTICES OF SUBJECTS

REGARDING OBESITY AND IMPACT OF INTERVENTION

Development of Recipe Nutrition Impact of

education materials development education intervention
Electronic f Demonstration z- Knowledge and
package practices

PHASE VI
STATISTICAL INTERPRETATION OF DATA

Chi square
z Correspondence Analysis
Logistic Regression
z- Factor Analysis
One way ANOVA
.e Paired t test
68
Validation of Data

Measurements of height and weight for prevalence study on obesity

was carried out on 8576 subjects over a one year period by the investigator
with the help of an assistant to record the data. Further the data on body
composition using Tanita Body Fat Analyser and skin fold measurements on
474 urban adults and 430 coastal adults were done by the investigator. With
the • help of a male assistant trained earlier in the technique, skin fold (four
sites), waist and hip measurements were taken among adult men.
Epidemiological factors, body composition measures and biochemical
analysis were carried out over a one year period. Education was given for a
four month period. Since the researcher herself took anthropometric and body
composition measurements in both urban and coastal areas, there was no
probability of bias in data collection.

The interview schedule used for collection of epidemiological data was

pretested on a sub sample of the study subjects for validation. Data obtained
from Tanita Body Fat Analyser was validated for body composition
measurements by comparing body fat obtained from body fat analyser and
using skin fold calipers with 5 per cent variability and using standardized
procedures.

Limitation of Methodology

The present study involves the use of the basic model of Tanita Body
Fat Analyser. The investigator did not have access to the compartmental
model of Body Composition Analyser which would have given a more detailed
picture of body composition.