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October 2001, Vol 91, No. 10 | American Journal of Public Health 1545-1546
© 2001 American Public Health Association

LETTER

AKHTER AND PAPPAS RESPOND

Mohammad Akhter, MD, MPH and Gregory Pappas, MD, PhD

Mohammad N. Akhter is the executive director of the American Public Health Association. Gregory Pappas is with ORC Macro International, Washington, DC.

Correspondence: Requests for reprints should be sent to Mohammad N. Akhter, MD, MPH, American Public Health Association, 800 I St, NW, Washington, DC 20001 (e-mail: mohammad.akhter{at}apha.org).

In her letter, Debra Nanan suggests that Asians are more sensitive to overweight and obesity than Americans. Although the consensus report on the Asian region of the World Health Organization (WHO) that she cites does reach this conclusion, the evidence for this proposition is sparse. In addition to its recommendation on body mass index (BMI) cutpoints, the report on the WHO Asian region also recommends another strategy to illuminate differences between Asian and Western populations—the use of an additional anthropomorphic measure, waist size. The great diversity in Asia argues against cutpoints that imply some sort of biological or genetic uniformity. International cutpoints make for clear comparison and were used in our study for this reason.

Furthermore, the effect of obesity on cardiovascular disease in Asians might be different from the effect in Western populations because these populations are at different stages in a health transition. That is, the effect of obesity on health may not be the same for a population that in childhood was undernourished or exposed to high levels of infectious disease as it is for a population that was provided with adequate childhood nutrition and exposed to low levels of infectious disease. If indeed Pakistanis today are more susceptible to the ill effects of obesity, it may be the unique experience of a generation conditioned by Pakistan's recent economic and health development.

More fundamental than methodology, however, the thrust of Nanan's letter focuses attention on the economically advantaged urban population in Pakistan and digresses from the comparison we were trying to make in our article. Over- and underweight are unequally distributed in both Pakistan and the United States. One quarter of working-aged adults of Pakistan are underweight.

Overnutrition among the privileged and undernutrition among the disadvantaged are related through social, political, and economic forces that connect the fates of citizens of both countries, both well off and poor. Whereas international organizations have committed to reducing poverty, in Pakistan regional conflict, internal political turmoil, and international economic sanctions have forestalled economic development. Public health is also hostage to these global forces, which have driven the Pakistani government into debt at the same time it has been developing nuclear weapons. The people of Pakistan, both over- and underweight, suffer from development that is not directed toward human welfare or governed by an equitable distribution of resources within or between nations.





This Article
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