Using appropriate body mass index cut points for overweight and obesity among Asian Americans
Introduction
Overweight/obesity is a global and growing public health problem associated with type 2 diabetes and cardiovascular disease (Manson and Bassuk, 2003, Must et al., 1999). Recent recognition of obesity as a disease by the American Medical Association underscores the importance of appropriate identification and treatment of obesity in clinical settings (American Medical Association, 2013). Body mass index (BMI) is a convenient surrogate measure of body fatness in clinical settings and has strong associations with health risks and mortality across populations. The standard BMI cut points that World Health Organization (WHO) has recommended since 1993 are 25–29.9 kg/m2 for overweight and ≥ 30 kg/m2 for obese, which have been adopted by most countries as the standard overweight/obesity cut points (World Health Organization, 1995).
For the same amount of body fat, age and sex, Asians tend to have a consistently lower BMI by about 2–3 kg/m2 in comparison to Whites, partly due to differences in body build and muscularity (Deurenberg et al., 2002). Moreover, conventional cut points for overweight/obesity do not correspond to similar absolute or relative metabolic risk in all ethnic groups (Pan et al., 2004, Simmons et al., 1991, World Health Organization, 2004, World Health Organization et al., 2000). Based on these shortcomings of the BMI measure in Asian populations, a WHO Expert Consultation panel, using all available data from Asian countries, in 2002 proposed lowering BMI cut points to trigger public health action for Asians, categorizing 23–27.5 kg/m2 as overweight and BMI ≥ 27.5 kg/m2 as obese (World Health Organization, 2004). However, there has been debate on the adoption of Asian specific BMI cut points, particularly in Westernized countries (Low et al., 2009, Pan and Yeh, 2008, Razak et al., 2007, Stevens, 2003).
In the United States (US), Asian Americans have low rates of overweight/obesity defined by the standard BMI cut points compared to non-Hispanic Whites (NHW), African Americans and Hispanics (Bates et al., 2008, Lauderdale and Rathouz, 2000, Ogden et al., 2013, Wang and Beydoun, 2007). Despite a relatively favorable body weight profile, Asian Americans suffer from a disproportionate burden of type 2 diabetes and associated metabolic abnormalities (Karter et al., 2013, King et al., 2012, Lee et al., 2011, Palaniappan et al., 2011). Consistently, type 2 diabetes has been found to develop at a lower BMI in Asians (Chan et al., 2009, Chiu et al., 2011, Karter et al., 2013, Lee et al., 2011, McNeely and Boyko, 2004, Steinbrecher et al., 2012, Wander et al., 2013). The application of the WHO Asian BMI cut points may provide better estimates of health conditions attributable to overweight/obesity using more population-appropriate cut points (Karter et al., 2013, King et al., 2012, Palaniappan et al., 2011) but are currently not recommended as screening guidelines for clinical use (American Diabetes Association, 2013, Moyer, 2012, National Institutes of Health, 1998). Using standard BMI cut points to examine overweight/obesity among Asians American subgroups may underestimate its impact in these populations.
Few studies have examined overweight/obesity in Asian Americans, defined by the WHO Asian BMI cut points, compared to rates seen in other major racial/ethnic groups. We compared the prevalence of overweight/obesity among Asian Americans subgroups using the WHO Asian BMI cut points to its prevalence among NHW, African American and Hispanic respondents, using the standard cut points. We also examined the prevalence of self-reported diabetes among respondents with BMI of 23–24.9 kg/m2 or 27.5–29.9 kg/m2, the two BMI ranges differentially classified by the WHO for Asians and compared to other groups.
Section snippets
Study design and sample
We used publicly available cross-sectional data from the 2009 California Health Interview Survey (CHIS), a population-based random-dial telephone survey of non-institutionalized Californians administered since 2001 by the University of California Los Angeles Center for Health Policy and Research. CHIS was conducted in English, Spanish, Mandarin, Cantonese, Korean and Vietnamese languages. The 2009 survey oversampled Korean and Vietnamese populations. The CHIS uses complex weighting to provide
Results
The 2009 CHIS sample included 45,946 respondents eligible for analysis. Table 1 illustrates weighted unadjusted sociodemographic and health characteristics for each racial/ethnic group.
Among the 6 Asian subgroups, mean BMI was highest among Filipinos (25.5 kg/m2), but this was lower than the means for the NHW, African Americans and Hispanic groups. Filipinos also reported the highest prevalence of type 2 diabetes (12.7%) across all groups, while Vietnamese and Chinese had the lowest prevalence
Discussion
Using a population-based representative sample of Asian Americans, we found that the adjusted prevalence of overweight/obesity in Filipinos using the WHO Asian BMI cut points is as high as or higher than traditionally high risk racial/ethnic populations. Over half of surveyed South Asians, Koreans, Japanese and Chinese met WHO Asian BMI criteria for overweight/obesity. Moreover, the prevalence of diabetes was higher among Vietnamese, Koreans, Filipinos and South Asians than NHWs in the BMI
Conclusions
The prevalence of overweight/obesity among Filipinos is the highest among all Asian American groups when using the WHO Asian BMI cut points, exceeds rates seen in NHWs and is comparable to African American and Hispanic populations. Filipinos should be considered as a high priority population for screening, counseling and treatment of overweight/obesity and related conditions. South Asian, Korean, Japanese and Chinese groups also had substantial rates of overweight/obesity and merit
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgments
Jane Jih is supported by a Ruth L. Kirschstein National Research Service Award (T32HP19025).
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