The Kathmandu Declaration – Obesity in the south Asian region: An exigency statement

Region shoulders more

Background: The South Asian Region shoulders more than its fair share of health-related challenges. While we continue to tackle acute and communicable illness, newer challenges and concerns have emerged. These include the rapidly increasing metabolic and endocrine syndromes such as diabetes, dyslipidemia and obesity. Methods: In the past, SAFES has released the Dhaka Declaration (2015) on gestational diabetes mellitus, and the Colombo Declaration (2019) on prevention of diabetes. The authors from 8 countries have together drafted and agreed this declaration to improve healthcare delivery for the recognition and management of obesity in the region. Results: In this Kathmandu declaration we highlight the urgent need for recognition, evaluation and prevention of obesity in this region. It has described not only the need but also the methods to improve obesity outcomes in the region through advocacy, awareness and addressal. Conclusion: Through its member associations, South Asian Federation of Endocrine Societies (SAFES) works to ensure optimal endocrine health care delivery in South Asia and has worked on the Kathmandu Declaration to improve the obesity pandemic in the region.
The South Asian Region shoulders more than its fair share of healthrelated challenges. While we continue to tackle acute and communicable illness, newer challenges and concerns have emerged. These include the rapidly increasing metabolic and endocrine syndromes such as diabetes, dyslipidemia and obesity. Through its member associations, South Asian Federation of Endocrine Societies (SAFES) works to ensure optimal endocrine health care delivery in South Asia. In the past, SAFES has released the Dhaka Declaration (2015) on gestational diabetes mellitus, and the Colombo Declaration (2019) on prevention of diabetes. In this Kathmandu declaration we highlight the urgent need for recognition, evaluation and prevention of obesity in this region.

Declaration
At Kathmandu, on the 17th day of March 2023, SAFES declares that obesity is a chronic, relapsing multifaceted, multisystemic endocrine disease, which needs timely, and sustained, attention at a clinical as well as public health level. 1 Obesity has multiple cause and contributory factors, and many drivers and determinants. The main abnormality, however, is endocrine in nature, and has been summarized as the Ominous Octet of obesity. 2 Endocrine dysfunction plays a key role in obesity, not only as a culprit (cause or contributory factor), but also as collateral damage (comorbid condition) consequence (complication), or a contrivance for cure (clinical intervention for prevention and treatment). 3 Obesity impacts not only individual, but also family, societal and national health. Within each person living with obesity, it affects not only biophysical, but psychosocial health as well. Virtually every organsystem of the body can be disturbed by obesity. 4,5 Though international health advocates have recognized obesity as an important risk factor for other non-communicable diseases, obesity itself has not been recognized as a disease by all countries. Gradually, however, more and more organizations have labeled obesity as a disease, and rightfully so. SAFES acknowledges the ROOTS framework, developed by World Obesity, which enjoins us to recognize obesity, monitor, prevent and treat it, using a system-based approach, and joins the effort to tackle this pandemic. 5 SAFES member organizations have already published comprehensive national guidelines on the management of obesity. 1 South Asian consensus statements are also available regarding the nutritional management of diabesity. 6 The concept of barocrinology has originated from South Asia, and the Journal of Pakistan Medical Association runs a regular monthly column on the subject. 7 This declaration also highlights and advocates the use of the south Asian definition for the diagnosis of overweight and obesity status in the south Asian countries as endorsed by the world health Organisation. Table 1.

Rationale
The World Obesity Atlas, 2022, predicts that over one billion people will be living with obesity by the year 2030. These include 1 in 5 women, and 1 in 7 men, if a BMI (body mass index) threshold of 30 kg/m 2 is taken. Of the 1028 million people expected to live with obesity, 333 million are expected to have a BMI ≥35 kg/m 2 , and 111 million, a BMI ≥40 kg/m 2 . 8 Obesity has affected different age groups across many South Asian countries. [9][10][11][12] Of the SAFES member countries, India (40 million women, 24 million men) and Pakistan (13 million women and 7 million men) rank in the top 15 countries affected by obesity. Maldives and Bhutan are expected to have the highest prevalence, within South Asia, (18% and 13% in women, 10% and 8% in men) by 2030. It must be noted that these figures are calculated using a generic BMI cut-off of 30 kg/m 2 . The figures will be much higher if the South Asian ethno-specific threshold of 25 kg/m 2 is used to define obesity. Maldives (18%) and Sri Lanka (13%) lead the table when childhood obesity is taken into account. 8 Moreover, abdominal obesity, normal weight obesity and higher ectopic fat has been reported in several SAFES member countries. [13][14][15][16] The world obesity federation has proposed a risk scoring system for each country with respect to obesity in adults and children called the national and childhood obesity risk. The national obesity risk is a composite score based not only accounting for the prevalence of obesity in that country but also taking into considerations about the available therapeutic options, likelihood of meeting the 2025 targets and the average age of onset of childhood obesity. Similarly, a comprehensive childhood obesity risk score has also been proposed. These have been summarized in Table 2 for each of the countries that have participated in the Kathmandu Declaration.
Globally, high BMI is the cause of 21.5% of all disability-adjusted life year (DALYs), and 18% of deaths, that are due to preventable noncommunicable diseases. The corresponding numbers for South East Asia region are 18.2% and 14.7% respectively. Within the SAFES family, Sri Lanka has the highest ALYs that result from high BMI (2443 DALYs/ 100,000 population), followed by India (1511) and Bhutan 1409). 8 Several unique characteristics define the phenotype of obesity in the south Asian region. These include a high fat content despite a low birth weight in a newborn, poor maternal nutrition during pregnancy further coupled with the underlying high risk genetic predispositions. A predominant high carbohydrate intake in the diet has been documented across all south east Asian countries, this has implications on management. It is now recommended to not only prescribe lower calories in patients with overweight (~23 kcal per kg of ideal body weight) and obesity (~25 kcal per kg of ideal body weight) but also suggest that the macronutrient distribution be also regulated in patients from the south Asian region (Carbohydrates -50 to 60%;, proteins -15-20%; and fat -20 to 25%). It has also been proposed that this population has a much lower capacity of subcutaneous fat than the Caucasian population. This tends to get overwhelmed with even initial stages of calorie excess and thus results in a spill over to the visceral tissues. These have been summarized in Fig. 1. [17][18][19][20][21] The economic impact of overweight and obesity was calculated to be 0.8% of India's GDP (USD 23 billion) in 2019, and has been estimated to climb to 2.75% of GDP (USD 479 billion) by the year 2060. Only Maldives (rank 39) and Sri Lanka (rank 40) score better than the global average in terms of preparedness for obesity-NCD management. India follows at rank 99. All other SAFES countries rank below #100. 8,22

SAFES resolves to:
• Highlight the importance and impact of obesity as a multisystemic endocrine syndrome. (ADVOCACY) • Spread awareness about (AWARENESS) -The South Asian thresholds for diagnosis of overweight and obesity  -The various baro-phenotypes of adiposity that are common in South Asia -The therapeutic options, both non-pharmacological and pharmacological, for obesity management • Facilitate adoption of optimal obesity prevention and management strategies (ADDRESSAL)

Activities
To accomplish these objectives, related to advocacy, awareness and addressal of obesity, SAFES will: • Collaborate with international, national organizations engaged in obesity care • Create continuing medical and nursing education programmes on obesity • Carry out public awareness programmes highlighting the importance of obesity prevention and management • Call for enhanced emphasis on obesity prevention in national health programmers • Connect like-minded researchers across South Asia to work together on various facets of obesity care SAFES will encourage its members to focus on the following means of achieving these targets, among others: • Publications in journals • Presentations at conferences and CMEs • Posts and uploads on social media • Public awareness events • Popular opinion about obesity

Conclusion
Through the Kathmandu Declaration, SAFES hopes to draw attention to the obesity epidemic. This should be accompanied by active addressal of this challenge, at both public health and clinical level. Timely and sustained action, in preventive and clinical care, education and research, as well as advocacy and awareness, should help mitigate the adverse effects of obesity on our society.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest
None for all authors.