Cross-sectional study

At Shivam Medicare Clinic, Ahmedabad, Gujarat, India, we did a cross-sectional study on 423 patients. The patients were enrolledrandomly. The patient should have any of these comorbid conditions of diabetes, hypertension or obesity. Along with their bloodglucose and lipid parameter, we also measured the overall fat mass including visceral and muscle fat mass of each patient. Bodyfat was measured using Omron^™ Body Composition Monitor. We did a statistical analysis of each clinical parameter like HbA1c,obesity, and high blood pressure and observed their correlation with overall fat, visceral fat and muscle mass

In this Outpatient Department (OPD)-based cross-sectional study, a total of 423 patients were enrolled. Their demographicdetail is shown in Table 1.

As per the analysis, with HbA1c (6.5%), high SBP (>130 mmHg) and high DBP (>80 mmHg); therewas no significant association of visceral fat mass, and the muscle mass was higher than the visceral fat mass.But in obese patients (BMI >30 kg/m²), overall fat mass (body fat - BF) was higher (~36.4%) compared to

other clinical parameters. Even in obese patients, visceral fat mass (~22.7%) and muscle mass (~25.12%) bothwere higher compared to other conditions (Table 2). In T2DM (HbA1c >6.5%) and hypertensive patients, theoverall fat mass is high, including higher muscle mass in comparison to visceral fat (Table 2).

Metabolic conditions like T2DM, hypertension and obesity have become extremely prevalent worldwide today. Theseconditions are associated as risk factors for various cardiovascular diseases (CVD). In these 3 metabolic conditions, the overallfat mass plays a crucial role to assess future CVD risk. A sex-specific threshold of body fat was adopted as 25% for menand 35% for women given by the American Association of Clinical Endocrinologists/American College of Endocrinology(AACE/ACE) guideline (obesity in men ≥25%and women ≥35%).¹¹ Relationship of body fat and metabolic conditions likeobesity is ethnic-specific. Wang D et al. observed that Chinese males had more body fat and a greater degree of central fatdeposition pattern than white males. Even laboratory parameters like blood pressure, fasting glucose and blood lipids suggestthat Chinese men may be more prone to obesity-related risk factors than white men.¹²

Indians tend to have a higher proportion of body fat, especially abdominal fat than white Caucasians, which is veryimportant because of its metabolic implications. As abdominal fat is associated with insulin resistance because of theinflammatory profile of intra-abdominal adipocyte secretions is important and due to that, it has been known that Indians,even from infancy, are more insulin resistant than white Caucasians and a proportionately greater distribution of fat within theabdomen is one possible reason.¹³ In our study of 423 patients, it was observed that average body fat is ~33%, while visceralfat and muscle mass is 14% and 26% respectively; which shows that Indians have higher proportion total body fat and visceralfat compared to the Western population.

Indian diabetics have more body fat compared to the western population. Even visceral and central fat proportion remainsmore compared to non-diabetic patients. In our study, it was observed that patients with high HbA1c (>6.5%) have 33% totalbody fat; which is considered as significantly high compared to the normal population. Even visceral fat proportion was alsohigh (14%); which supports that in Indians visceral and central abdominal fat shows a strong association with type 2 diabetessimilar to the study conducted by Anjana M et al.⁶

Hypertension is such type of metabolic condition which is commonly associated with dyslipidaemia, obesity and T2DM;and one of the most responsible risk factors for CVD like myocardial infarction and stroke. In a study conducted by BhaskarS V et al., had observed that body fat can be a potent marker for risk assessment in hypertensive patients. In an analysis of200 hypertensive patients, the mean body fat mass was found to be 21.7 kg, while the mean percent of body fat was 28.9%,which was much higher than the normal. Various parameters depicting body fat were compared. All of them, namely body fatmass, percent body fat, obesity degree, and VFA were found to be significantly higher in hypertensives as compared to theother group.⁹ In our study hypertensive patients had significantly higher total body fat (33%); irrespective of high systolic ordiastolic blood pressure. Visceral fat mass is also invariably high by 14% in hypertensive patients

Population with a similar BMI will have different body fat level, which is dependent on variable factors like exercise,diet, genetic factors, etc. The Y-Y paradox theory is a reminder of the limitations of BMI as a measure of adiposity acrosspopulations.¹⁴ The percentage of body fat is found to be a better predictor of cardiovascular morbidity and mortality thanBMI, but data is very limited on the Indian population. In our analysis, the mean BMI was found to be very high (28.3 kg/m2) compared to the Asian population cut off level (23 kg/m2).¹⁵ That is the probable reason for having higher total fat massin this study population. Misra P et al. had done one study on Indian obese patients to observe the relationship between bodymass index and percentage of body fat in the rural patients of India.¹⁰ In this study of 388 patients, it was seen that mean fatmass and BF% was 19.2 kg and 33.6%. BMI and BF% were highly correlated among obese, whereas least correlated in theunderweight population. In our cross-sectional study, obese patients were associated with the highest body fat percentage(36.4%) and visceral fat (22.7%); which is higher than average western population fat proportion as well.

Major limitations of this study are its design of the cross-sectional study and small sample size. We need clinical study withan objective to assess long term association of total body fat with metabolic and cardiovascular disease and their outcome andcurrently, we are doing such analysis on the similar patient population. Long term follow-up these patients will provide longterm effect of body fat on metabolic and cardiovascular disease in the Indian population.

Our study concludes that Indian diabetic, hypertensive and obese patients have considerable overall higher body fat andvisceral fat than the White population. High-fat level in the body is a strong indicator for the futuristic development of CVD events and insulin resistance as well. Hence, considering these factors, today India is the global capital of T2DM and othercardiovascular diseases as well, and in the future, it is going to increase.