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LETTER |
The author is with the Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan.
Correspondence: Requests for reprints should be sent to Debra Nanan, BAppSc, MPH, Department of Community Health Sciences, The Aga Khan University, PO Box 3500 Stadium Road, Karachi 74800, Pakistan (e-mail: debra.nanan{at}aku.edu).
It was encouraging to see the report by Pappas et al. on the health status of the Pakistani population.1 However, the results presented in Tables 1 and 2 of their article may underestimate the potential burden of noncommunicable diseases in Pakistan, in particular that of overweight and obesity. The authors use body mass index (BMI) values of 
25 and 30 to define overweight and obesity, respectively. Current recommendations for the Asia-Pacific region2 define adult overweight at BMI 23 and obesity at BMI 25. There is growing support for the use of lower BMI cutoffs for Asians, especially given their propensity to abdominal obesity.3, 4
If BMI 25 is used to define obesity, a different picture emerges from the National Health Survey of Pakistan. Table 1 would indicate obesity prevalence rates as follows for adults aged 25 to 64 years, moving from low to middle to high socioeconomic status (and rounding to the nearest whole number): for rural areas, 9%, 15%, and 27%; for urban areas, 21%, 27%, and 42%. These figures are alarmingly high for rural and urban areas but especially for urban areas. In Table 2, the authors compare the prevalence of overweight for adults aged 25 to 64 years in the United States and Pakistan. While BMI 25 may be a good indicator of overweight in the US context, BMI 23 may be a better indicator for Pakistanis. If so, Table 2 would indicate a prevalence of obesity in Pakistan for the age group 25 to 64 at 13% for males and 23% for females. These figures are closer to obesity prevalence rates for US adults 20 years and older, especially for females (20% for males, 22% for females).5 Also, use of BMI 23 for overweight would reclassify a proportion of the adult Pakistani population as overweight that was previously considered normal weight. This implies that the health burden from overweight and obesity in Pakistan is currently underestimated.
Nonetheless, the authors have demonstrated, and the revised analysis given above emphasizes, that Pakistan is a country in transition, facing a double burden of disease. As Akhter and Pappas rightly point out in their editorial, the forces of globalization influence health.6 How well countries like Pakistan adjust to changes brought on by increasing industrialization and urbanization will depend to some extent on the level of support it receives from local and international bodies, but also on an internal examination of its priorities.
Footnotes
Letters to the Editor will be reviewed and are published as space permits. By submitting a Letter to the Editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. Letters referring to a recent Journal article should be received within 3 months of the article's appearance. The editors reserve the right to edit and abridge letters and to publish responses.
Text is limited to 400 words and fewer than 10 references. Submit on-line at www.ajph.org, or send a diskette and 3 copies to the editorial office. Both text and references must be typed and double-spaced.
Accepted for publication June 11, 2001.
References
1. Pappas G, Akhtar T, Gergen PJ, Hadden WC, Khan AQ. Health status of the Pakistani population: a health profile and comparison with the United States. Am J Public Health.2001;91:93–98.[Abstract]
2. Regional Office for the Western Pacific (World Health Organization), International Association for the Study of Obesity, International Obesity Task Force. The Asia–Pacific Perspective: Redefining Obesity and Its Treatment. Melbourne, Australia: Health Communications Australia; 2000.
3. Singh RB, Mori H, Chen J, et al. Recommendations for the prevention of coronary artery disease in Asians: a scientific statement of the International College of Nutrition. J Cardiovasc Risk. 1996;3:489–494.[Medline]
4. Seidell JC. Obesity, insulin resistance and diabetes—a worldwide epidemic. Br J Nutr. 2000;83:S5–S8.
5. National Institute of Diabetes and Digestive and Kidney Diseases. Statistics related to overweight and obesity. Available at: http://www.niddk.nih.gov/health/nutrit/pubs/statobes/html. Accessed October 5, 2000.
6. Akhter MN, Pappas G. Health, Pakistan, and globalization. Am J Public Health. 2001;91:13–14.[Medline]
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