Obesity is a medical condition that occurs everywhere. According to the World Health Organization, it is almost three times more common worldwide than in 1975.
In the US, nearly 42% of American adults are obese, according to data from the CDC. But it is less common among Asian Americans. Some experts have suggested that the standard definition of obesity — having a BMI of 30 or higher — may not best fit Asian Americans.
In this interview, Jennifer Ng, MD, a board-certified obesity medicine specialist in New York City and chair of the Obesity Medicine Association’s Outreach Committee, discusses how obesity affects Asian Americans and what they need to know about this condition. This interview has been edited for length and clarity.
WebMD: How did you become interested in obesity medicine?
By: When I started practicing medicine, many of the patients I saw had an elevated BMI, and this was true across different socioeconomic classes. I was very surprised. This wasn’t something I was aware of when I was in medical school or residency. Medical training did not equip me to deal with this or tell me how to manage patients. It’s frustrating when you’re trained to be the person who provides the answers and you just don’t have the answers. I wanted to learn more.
WebMD: How do obesity rates within the Asian American community compare to other demographic groups?
By: The obesity rate among Asian Americans is roughly 11%, which is lower compared to many other ethnicities. Under current criteria, a body mass index (BMI) of 25 and above is considered overweight and 30 and above is obese, and that is applied across the board.
But there are concerns that we may not be capturing the full spectrum of the problem because BMI and the standard for measuring obesity and overweight are based on people of European descent.
There are some differences between ethnic groups that we need to take into account. Some guidelines suggest that we may need to consider Asian Americans as overweight and obese at a lower BMI – a BMI of 23 and above for overweight and 25 and above for obese – because there appears to be an increased prevalence of cardiovascular disease and metabolic disease at lower body weight among Asian Americans.
WebMD: Do overweight and obesity rates differ among different subpopulations of Asian Americans?
By: Different subgroups within the Asian community may have different rates of overweight or obesity. For example, Filipino Americans and South Asians tend to have higher rates than East Asians. I will say that things change depending on how long you’ve lived in this country. A higher BMI appears to be associated with living in the United States longer.
WebMD: If we use a standard like BMI that is based on one population of people, such as whites or people of European descent, and then generalize those findings across all populations, what might we be missing?
By: We want to make sure that we don’t apply one standard to everyone, because people are different. People from different ethnic backgrounds face different risks. When we use only one standard, we sometimes underdiagnose or underscreen certain populations, or overdiagnose or overscreen other populations.
WebMD: How does this impact the Asian American population?
By: Many misconceptions exist. I have a lot of Asian Americans who come into my office who don’t think overweight and obesity are an Asian problem because Asian Americans tend to run on the lean side, they don’t have a family history, or they don’t eat a Western diet. They may think they don’t need to exercise or worry about their diet.
Primary care physicians may also be unaware of this and may underdiagnose or underscreen Asian American patients.
WebMD: Why do Asian Americans experience cardiovascular and metabolic disease at a lower BMI compared to other populations?
By: You can get fat in different ways. The size of the fat cell may increase, or the number of fat cells may increase. There is genetic variation in the way people store fat. It appears that, especially in the South Asian community, there is a tendency for fat cell size to increase, which appears to be more problematic than increasing the number of fat cells. The fat becomes ‘diseased’ and begins to produce inflammatory markers and abnormal hormones, which can lead to many of the problems we see in metabolic diseases.
It is thought that within the East Asian and South Asian communities there is an increasing tendency to store fat as visceral fat as well. It is the more dangerous fat that is stored in and around the organs. Our organs are not equipped to store fat, making them dysfunctional. This can lead to more cardiovascular disease, metabolic syndrome, diabetes and cholesterol problems.
For example, storing more fat in the liver leads to inflammation because the fat produces inflammatory markers and interrupts the function of normal liver cells. This can lead to problems metabolizing cholesterol, glucose and fat. If your glucose regulation is disturbed because your liver is not working properly, your pancreas starts to release more and more insulin. That can lead to diabetes, and insulin itself causes fat cells to grow.
WebMD: Besides genetics, what else seems to be driving the overweight and obesity rates among Asian Americans? Do diet and exercise play a role among Asian Americans?
By: Diet and lifestyle certainly play a role, but so do environmental factors. If people work a lot, live far from work, do not have the opportunity to eat healthy and are not physically active, it becomes a problem. The diet that may have worked for them before they moved to America, where they were more active and less sedentary, may not be okay here.
Misconceptions about exercise exist among my patients of Asian descent, especially among the elderly who did not grow up in America. They say, “This is not something that Asian people do. It is too much. It’s too intense.”
WebMD: How do you care for your Asian American patients?
By: Every patient is different. I’m a GP, so when they come to me I assess their overall health, diet and exercise and see where they are. Regardless of BMI or weight, I educate them about healthy eating and exercise.
When I see patients of Asian descent in my office, I am more vigilant. I use the lower BMI criteria to advise my patients and monitor symptoms to consider whether they are at risk for cardiac and metabolic disease. I also use waist circumference to evaluate patients because BMI doesn’t always accurately tell you about body composition. Waist circumference may be a better marker of visceral fat, which is a more concerning risk factor for heart and metabolic disease.
You don’t want to alienate your patient. You want them to come back. I try to meet them where they are, because you can’t bulldoze over them and their culture. I suggest tai chi, a gentle exercise that helps build balance and strengthen muscles, or bodyweight exercises such as carrying the groceries. I suggest trying brown rice or wild rice or reducing the portions. Small changes are better than no changes.
WebMD: What do you want Asian Americans to know? What message do you have for them?
By: My main message is that just because you are thin or within the normal range of the standard BMI criteria does not mean you are not at risk. It is still important to eat healthy, exercise and see your doctor regularly. Many conditions are reversible if you catch them early enough, even if you have a genetic predisposition. There are changes you can make to your diet or lifestyle that could affect obesity and other disease risks.