Obesity Prevalence in Nepal: Public Health Challenges in a Low-Income Nation during an Alarming Worldwide Trend

The future toll of the obesity epidemic will likely hit hardest in low- and middle-income countries. Ongoing urbanization promotes risk factors including sedentary lifestyle and fat- and sugar-laden diets. Low-income countries like Nepal experience a double disease burden: infectious diseases as well as rising incidence of noncommunicable diseases (e.g., cardiovascular disease and diabetes mellitus) frequently characterized by obesity. Nepal currently directs efforts towards curing disease but pays little attention to preventive actions. This article highlights obesity prevalence in Nepal, delineates the challenges identified by our pilot study (including low health literacy rates), and suggests strategies to overcome this trend.


Overweight and Obesity-A Worldwide Accelerating Public Health Problem
Current worldwide estimates suggest that one billion people are overweight or obese, and the World Health Organization (WHO) predicts that number will increase 1.5-fold by 2015 [1]. As early as 1997, an expert committee convened by the WHO signalled that the rising trend of overweight and obesity represented an imminent global threat and a rapidly growing public health problem [2]; that prediction has exceeded expectations. Many countries, most notably the US and UK, have experienced dramatically escalating obesity rates during the last two decades, rates that will continue to rise in the future [3].
The worldwide obesity rate increased from 2.3% to 19.6% between 1990 and 2000 [4]. In the Pacific Islands, the Middle East, and China, obesity has increased at least threefold since 1980 [5], and the Western Pacific Islands of Nauru and Tonga top the region with an adult obesity rate of around 90% [1]. Almost 75% of adults in Barbados, Mexico, Turkey, and Argentina are overweight.

Increasing Prevalence of Obesity in Low-and Middle-Income Countries
Contradicting popular belief, obesity has become commonplace in many low-and middle-income countries, and the prevalence of cardiovascular risk factors including obesity has increased in such countries, particularly in South Asia [6]. This paper bases its definition of low-and middle-income countries on the World Health Report 2008 [7]. The International Day for Evaluation of Abdominal Obesity Study reported that South Asians have the highest prevalence of abdominal obesity [8]. Likewise, a comparative study of obesity prevalence determined a high obesity burden in India and Pakistan, especially in women [9]. Moreover, obesity increased in women in other South Asian countries, including Nepal and Bangladesh, between 1996 and 2006 (from 1.6% to 10% and from 2.7% to 8.9%, respectively) [10].
Mirroring the trend already established by developed countries, the obesity epidemic in low-and middle-income countries now encompasses young children and adolescents. The WHO estimates that obesity prevalence in children in such countries increased 28% in only two years [11]. For example, a study from New Delhi shows that the prevalence of childhood obesity increased from 16% to 24% between 2002 and 2007 [12]. Cardiovascular risk factors such as hypertension occur commonly in obese children compared to normal weight children [13]. eight of the world's 10 highest mountains, including Mount Everest. Much of Nepal's population resides in the fertile and humid south. In 2007, Nepal's adult literacy rate was 57% and life expectancy was 64 years [15].

Altered Lifestyle through Demographic Changes
Despite rapidly increasing urbanization (4.9% per year), about 90% of Nepal's inhabitants live in rural areas [14]. Two of every five Nepalese live below the absolute poverty line, and half of all people in rural Nepal are poor [14]. Similar to many other low-and middle-income countries, Nepal is currently experiencing significant lifestyle changes that spring from various social and demographic changes-an "epidemiological transition" that includes urbanization and migration. Insurgency and political instability drive migration. Moreover, high unemployment and underemployment (17.4% and 32.3%, respectively) compel people to choose between remaining in a vicious circle of poverty or migrating to seek better livelihood opportunities both within and outside the country [14].
Nepal's increasing trend toward urbanization presents large health challenges, whose consequences are at an early stage. As diets rich in fibre and complex carbohydrates shift toward diets that include more sugars and fats, the urbanization process precipitates greatly increased levels of lifestyle-related risk factors. Changing dietary habits can shift a society's disease pattern from infectious, communicable diseases' dominance towards a status of double-disease burden with increasing prevalence of obesity and noncommunicable diseases (NCDs).

Disease Burden and the Rise of Noncommunicable Disease
The burden of NCDs such as cardiovascular disease (CVD), diabetes, cancer, and chronic obstructive pulmonary disease is on the rise in low-and middle-income countries [16]. The WHO Global Burden of Disease Study projected that CVD will increase by 55% in low-and middle-income countries between 1990 and 2020 [17]. CVD is currently the leading cause of morbidity, mortality, and disability in the South Asian region, which is home to more than 20% of the world's population [18]. Nepal, India, Pakistan, Sri-Lanka, and Bangladesh contribute most to the worldwide CVD burden [19][20][21]. Indeed, CVD affects individuals in this region 10 years earlier than the average individual in the west [22]. Early occurrence of myocardial infarction is more common because cardio-protective factors (e.g., exercise, fruit, and vegetable intake) are lower and harmful factors (e.g., diabetes and tobacco use) are common among native South Asians [21].
Nepal was among 52 countries that participated in the global INTERHEART study [23], which investigated risk factors for acute myocardial infarction. Similar to other countries, biological and behavioural risk factors such as high blood pressure, low fruit and vegetable intake and high body mass index (BMI) figure importantly in the Nepalese population. According to WHO estimates, cerebrovascular diseases account for 107.5/100,000 deaths in Nepal (age-standardised death rate) with a total DALY rate of 543/100,000.

Few Studies Address Obesity
A few population-based studies have focused on obesity in Nepal, including both national and regional surveys. The national surveys were part of the broader National Family Health Surveys that included only female respondents and provided policymakers with information regarding family planning, mortality, maternal and child health, nutrition, and knowledge of sexually transmitted diseases such as HIV/AIDS [24]. These surveys did not specifically cover health issues related to obesity and NCDs. Furthermore, the lack of periodic surveys means that little data pertaining to NCDs are available. Although audits from central tertiary care hospitals are sometimes available, they do not represent the national scenario. Nevertheless, some cross-sectional studies on hypertension and coronary heart disease have shown that overweight individuals have marginally higher risks for these conditions compared to those with normal weight [odds ratio for hypertension: 1.39 (1.03-1.87); odds ratio for coronary heart disease: 1.15 (0.12-11.00)] [25,26]. A study in urban Kathmandu showed a high prevalence of diabetes (19%) but did not investigate any association with obesity [27].
The first nationally representative study of both genders was conducted in 2007 [28]. The Nepal Non-Communicable Diseases Risk Factor Survey, which included 15 of 75 districts and represented all five administrative regions and three ecological regions, estimated the prevalence of overweight at about 7% and the prevalence of obesity at around 1.7% ( Figure 1  The first obesity study (in 1983) used Broca's Index, a formula for calculating ideal body weight [29]. Other regional studies conducted since 2000 have shown a prevalence of overweight (between 20% and 34%), but prevalence of obesity varied widely (0.4% to 10.14%; Table 1). Differing methodologies, sample sizes, and varying study accuracy probably explain these high estimates compared to relevant national prevalence rates. Due to varying methods and locations, not all studies mentioned in Table 1 are directly comparable. However, the two nationally representative surveys ( Figure 2) yield a comparison of the prevalence of overweight and obesity among females [28,30].  While data from these studies show a marginal increment in the prevalence of overweight in the females between 2001 and 2007, establishing any trend clearly will require periodic follow-ups to the nationally representative samples.

General and Central Obesity in the Nepalese Population
The 2007 NCD Risk Factor survey estimated average male waist circumference in Nepal at 74.9 cm (95% confidence interval: 73.7-76.1 cm); in females, it was 70.3 cm (68.9-71.8 cm) [28]. The study did not consider hip measurements. Nevertheless, the 2005 Dharan study reported a prevalence of both general and central obesity in 1,000 males ( Table 2) [33]. At the waist-hip ratio cut-off (>0.90 cm), high levels of central obesity (between 40% and 60%) occur across different demographic groups and exceed those for general obesity, as indicated by BMI, in the same population. Thus, the trait of abdominal adipose deposition despite normal BMI, as reported in other South Asian populations [35], may also be common in the Nepalese population.

Obesity and Demographic Variations Including Gender and Ethnicity
Obesity rates were higher in women who participated in the 2003 and 2007 risk factor studies compared to men ( Figure 1 and Table 1) [28]. Although this gender difference requires further investigation, possible reasons include a relatively sedentary lifestyle, which is estimated to be 90% prevalent among urban women in Kathmandu.
To date, few studies in Nepal have compared obesity rates across different demographic strata, but a 2005 study in 1,000 males of Dharan [33] allows some comparison ( Table 2). Although exact contributions of physical activity and diet cannot be ruled out, obesity associated significantly with occupation, socioeconomic status (SES), and ethnicity.
Earlier work recognized a varying relationship between SES and obesity in countries at different levels of development [36]. In the Dharan study, the positive correlation between SES and obesity is typical of low-income countries and opposite to the trend in high-income Western countries [37]. However, a recent review reported that an inverse relation between SES and obesity is no longer exclusive to developed countries [38]. Countries undergoing rapid economic growth (e.g., China) also face this change. Due to sluggish economic growth, Nepal may have to wait for a similar trend. Longitudinal studies will be instrumental in detecting such changes [39].
The Dharan study highlights the varied prevalence of overweight and obesity in different ethnic clusters ( Table 2) [33]. Ethnically different population groups may display varied risks for insulin resistance and obesity. Thus, Singapore residents of Indian origin exhibit higher risk for impaired glucose tolerance than residents of Chinese origin [40]. In the UK, impaired glucose tolerance occurs more commonly among individuals of South Asian origin than Europeans or African-Caribbeans [41]. Compared to Chinese individuals, the risk imposed by obesity appears to increase at lower BMI in Indians. The relationship between insulin resistance, obesity, and diabetes does not appear to be uniform for all ethnic groups, and some studies have reported ethnic differences in diabetes symptoms [42].
Nepal was populated from both the north and the south, and little ethnic intermixing occurs in the rural environments. Therefore, genetic differences between the groups remain intact and are likely to be large. Urbanization in Nepal has been linked with increased occurrence of type 2 diabetes [43]. Genetic diversity and frequent migration, predominantly from rural to urban areas, poses continuous health challenges and complicates the design of preventive measures.

Obesity and Urbanization
In 1998, Smith [31] compared the BMI of urban and rural Sherpa women. Sherpas are an ethnic group that lives primarily in high mountains; they are famous worldwide for their mountaineering skills. Sherpa women in urban regions exhibit higher body weight and BMI compared to their rural counterparts, likely due to decreased energy expenditure that accompanies higher income, motor transportation, and domestic help.
A cross-sectional survey among government employees in five urban Nepalese districts linked lifestyle to obesity; one third of the employees were overweight or obese [34]. Increased age, marital status, higher education, greater job responsibilities, increased alcohol consumption, and motorized transport all associate significantly with obesity. Taken together, these studies suggest that urbanization is the major driving force behind obesity in Nepal.

Insufficient Focus on Noncommunicable Diseases
The figures presented above show that obesity data collected in Nepal has been insufficient and dissimilar in terms of study size and methodologies. Furthermore, the data do not consider the diversity of demographic variations (e.g., ethnicity). Because national data have become available only recently, establishing a definite obesity pattern is not yet possible. Lack of sufficient data can hamper advocacy for policies related to NCDs and their risk factors.
Surveillance mechanisms provide another potential source of data. In Nepal, the surveillance mechanism remains at an incipient stage and focuses mostly on communicable disease control. For example, Nepal's national health programmes include surveillance components for poliomyelitis (Acute Flaccid Paralysis Surveillance) [44]. The Early Warning and Reporting System provides broader sentinel surveillance for other childhood diseases (e.g., measles and neonatal tetanus) as well as endemic diseases (e.g., malaria and visceral leishmaniasis).
Without national health programmes for NCDs, Nepal has no surveillance programmes for them. The absence of longitudinal tracking systems makes it difficult to determine a definite answer on the status of risk factors. Nepal's Health Management Information System does not ordinarily report risk factors, making it difficult to estimate the possible burden of such factors.
An appropriate demographic surveillance site for tracking noncommunicable risk factors would provide a good start for obtaining quality data. Inclusion of noncommunicable components in the overall health system should definitely be the ultimate goal.

Inadequate Health Literacy
Another important issue regarding obesity in Nepal involves the knowledge and attitude that people have towards weight and obesity. Traditionally, Nepalese consider overweight and a big belly as signs of wealth and prosperity. Although no study has investigated this outlook aspect of obesity in detail, the civil servants' study in five districts offers a hint [34]. The number of study participants who thought that obesity results from either "fatty foods" or "a genetic disorder" was almost equal. Respondents perceived that "those who have money do not have to work hard, can eat their favourite food and have drinks which ultimately lead to overweight." More than half of them believe that "overweight people tend to be lazier and they are unable to maintain their daily activities as their physical structure does not allow them to perform the task efficiently." Interestingly, although respondents possessed a good understanding of the importance of regular exercise, they were unable to translate such knowledge into actual practice [34].
Our pilot study in Duwakot Village of Bhaktapur district showed a similar lack of understanding and inability to apply knowledge. We investigated community knowledge of risk factors among 106 respondents between 18 and 70 years of age, recruited from individuals visiting patients in the local Community Hospital run by Kathmandu Medical College, and included both genders. Only about half of the participants linked obesity to heart disease (Figure 3), and most did not know the symptoms of high blood pressure, diabetes mellitus, or dyslipidemia. Other studies confirm this lack of knowledge about hypertension [45] and diabetes [46]. Figure 3. Knowledge on the Risk Factors for Heart Disease. Data from our pilot study investigating the knowledge of the community towards risk factors among 106 respondents in Duwakot Village of Bhaktapur district in Nepal. The numbers indicate the percentage of the participants who correctly identified a particular biological condition or behaviour as a risk factor of heart disease.

Gap between Researchers and Community
As in many parts of the world, the gap between researchers and policy makers and between researchers and the public has hindered appropriate policy formulation in Nepal. Successful evidence-based health policies can be developed only through research-based policy formulation based on need and utilization. Our pilot study on cardiovascular health literacy at Duwakot suggests this scenario (Figure 3). It is important to bridge these gaps. One approach would encourage health researchers to actively involve the community in their research. This is challenging because researchers may feel uncomfortable with such a scenario [47]. Community-based participatory research efficiently bridges between scientists and the community through shared knowledge and experiences, suggesting that capacity building occurs not only in the community but also among researchers in a given study. The community participates in the selection of the best possible research methods that balance both research rigor and community needs. Good evidence suggests that this approach is useful, although still limited in its use [48].

Cure-Centered Public Health Policy and Programmes
Nepal's health policy prioritizes infectious diseases as well as child and maternal health. This approach is reasonable because infectious diseases, including diarrhoea and respiratory tract infections, remain the major causes of childhood mortality [44]. Similarly, malaria, tuberculosis, HIV/AIDS, and swine flu remain a major focus of disease control. Because the maternal mortality ratio in Nepal (281 per 10,000 live births) is among the highest in the world, the reproductive health sector requires further attention [24]. Conversely, the NCD policy formulated in the mid-1990s has not been productive and is basically non-existent today.

Unorganized Noncommunicable Diseases' Prevention Strategies
Thus far, Nepalese efforts to contain NCDs have been sparse and patched together, too often directed only towards the curative aspects of disease. Consequently, secondary and tertiary preventive approaches receive more attention than primary prevention. Lacking any community data and evidence-based interventions, preventive programs do not function well in Nepal [49]. Nepal finds it difficult to consider treatment aspects for the growing number of NCD cases and to address rising costs [50].
Exacerbating this scenario, the national health system in Nepal does not usually cover treatment of NCDs, and health insurance packages developed by individual governmental or private organizations provide only partial coverage. Therefore, health insurance systems exist only for those who are able to pay [50]. Since obesity and NCDs afflict rich and poor alike, this is a major drawback [38,51,52].

Possibilities and Suggested Future Directions
Knowing the consequences of obesity and its impact on morbidity and mortality, Nepal must take stronger steps towards prevention. Initiating this action and slowing the rise of NCDs, including obesity, requires a cross-disciplinary approach [53]. Such an approach across different sections of a community, integrated management of the risk factors, and provision of essential public health services [54] should provide an excellent starting point that can be implemented in the context of Nepal.

Prioritize Health Education
Health literacy, capacity building, and empowerment can all increase community awareness of the challenges posed by obesity and NCDs. Further, education of medical professionals and the creation of supportive environments for obese individuals may encourage healthy living. Health education is an important cornerstone of this approach. Indeed, health is best promoted by increasing individual health literacy. Unless individuals become literate about health, we cannot expect changes in individual behaviour. Literacy is even more important regarding NCDs because the risk factors are usually behaviour-related.
Although particularly challenging in rural areas, it is evident that the improvement of health literacy should be a priority. Several low-and middle-income countries have successfully controlled malaria through community health education, requiring only minor local adaptations of the training material [55]. This approach could be useful as Nepal strives to improve health literacy about NCDs and obesity.
Since television and radio are popular among the Nepalese people, these media could be harnessed to provide general health education and information. Special public campaigns could complement general health education with simple messages directed at average citizens, thus circumventing literacy issues.
School curricula should include heart health-related topics that teach children the causality and consequences of obesity. To counteract the increasing trend of Nepalese adolescents and children remaining indoors, physical activity must be encouraged both at school and at home. Moreover, reversing the already entrenched habit of consuming junk food will require an integrated and massive effort across all levels of society.
Educating workers and employees about healthy lifestyles and providing opportunities for such education is another area that has not received attention to date. In a situation where even basic occupational safety has been neglected, a culture that promotes health activities appears to be a long distant dream.
There is also a need to re-direct health workers towards the risk approach for NCDs. Because the primary health care system does not currently address NCDs, little is done at the grass roots level. Thus, although the disease has already progressed into clinical complications, most health management is performed by a handful of specialists at the central level and in tertiary centres.

Modify the Increasingly Obesogenic Environment
Approaches to obesity prevention should be based on helping people change their lifestyles and modifying the obesogenic environment. Countries like the US, UK, and Australia have developed several strategies (e.g., modifying building design to encourage the use of stairs, making neighbourhoods more walkable, promoting active transport by an integrated network of footpaths and bicycle lanes, improving food labelling to help consumers make informed choices, and increasing healthy foods in schools and work cafeterias) [56][57][58]. Some of these strategies could inspire similar implementation in Nepal.
Another efficient approach could involve banning advertisements for unhealthy junk food and increasing taxes on these foods and beverages. The WHO has asked its member states to establish strategies that promote responsible marketing of food and beverages to children [59]. Several European countries have established legal and self-regulatory activities that address the ban on advertisements that encourage unhealthy dietary practices in children. In 2006, the Australian Democrats sought a complete ban on food and drink advertising during children's television programmes [59]. Some estimates suggest that a one penny-per-ounce excise tax on sugared beverages might reduce consumption by 13% [60]. In Nepal, however, such bans or tax exercises appear to be a distant possibility.
We view as positive that Nepal has recently drafted a health policy for NCDs. The draft encompasses different preventive, curative, and administrative aspects of NCD control. It stresses the importance of establishing a surveillance system for NCD risk factors, capacity building, and strengthening the existing health system to incorporate NCDs. Strategies to counteract obesity include taxing junk food and adding health-related educational materials to the school curricula. However encouraging; it is still a long way from policy to practical reality.

Improve Health Management
Because information technology significantly shortens the time lag in transporting health information and health consultation [61], the current poverty of information presents a serious obstacle for health professionals in the developing world. Networking health resources in low-income communities is certainly more time-and cost-effective in the short term than attempting to build hospitals or health clinics in each locality. Low-cost telecommunication networks enable doctors to "visit" patients in remote locations, thereby strengthening preventive health care [61].
Several countries that already apply Internet-and telephone-based medical provisions show promising results. A prospective study of Internet-based remote counseling, which included participants from Europe, North America, and Australia, showed that both rural and urban areas benefit from combining such infrastructure with conventional practice [62]. This is promising for countries like Nepal, where a large part of the population resides in rural areas. Telemedical care and monitoring efficiently manages type 1 diabetes in children and adolescents [63] as well as NCDs [64]. The feasibility of applying Internet and tele-technology to control NCDs and their risk factors, including obesity, in a low-income country like Nepal requires further exploration.

Increase Access to Drugs and Health Care
High acquisition costs for drugs to treat NCDs keep them beyond the reach of many people in low-income countries like Nepal. Non-affordability is one reason that patients in Nepal choose self-treatment over drugs prescribed by a health professional [65]. One high-potential area in Nepal involves the application of traditional medicines such as Ayurveda. Research on widely popular alternative therapies such as herbs and meditation techniques such as yoga can open gateways for their scientific use alongside western medicine.
Nepal should also develop a concrete negotiating strategy within the World Trade Organization and collaborate with other low-income countries. It must work towards fully capitalizing the flexibilities offered by the agreement on Trade Related Aspects of Intellectual Property Rights and produce less expensive drugs [66]. A national focus on research and development in the pharmaceutical sector would strengthen the capacity of domestic pharmaceutical companies to manufacture new and more effective drugs and also effectively capitalize on the vast amounts of medicinal plants that grow naturally in Nepal [66].
Socioeconomic conditions in Nepal, a rural, agricultural economy with low human development and endemic poverty, make the health sector a priority for sustained economic development [50]. Besides offering greater social protection to the poor and other vulnerable groups against high cost of ill health, health insurance provides an important mechanism for bridging the health-financing gap in Nepal [66].

Preventive Measures beyond the Already Affected
The WHO's global projections on obesity represent a substantial challenge for preventive measures. It is important to not limit efforts solely to children and adults whose BMI is already high, but also develop strategies aimed at preventive public health measures that affect the entire society. In this context, Nepal could adopt the goals of Healthy People 2010 [67], which include increasing the quality and length of healthy life and eliminating health disparities. Other focus areas (e.g., nutrition and overweight, physical activity and fitness, educational and community-based programs, and public health infrastructure) may be important players in tackling the growing obesity epidemic.
The American Heart Association issued a scientific statement that details the essential features needed to address one goal of "Healthy People 2010" (i.e., reducing heart disease, stroke, and their risk factors by 25% by 2010). Similar to the WHO STEPwise approach, a key element involves standardizing data. Nepal could use this statement as a guideline for establishing a surveillance system to manage obesity and CVD. Similarly, many of the suggested public health responses for promoting cardiovascular health in low-and middle-income countries should provide efficient means of blunting the obesity epidemic.

Establish Health Demographic Surveillance Sites
Another strategy would establish health demographic surveillance sites (HDSS) that provide regular monitoring and health surveillance of every individual in a selected area. HDSS data can profile disease burden by systematically and longitudinally collecting information from well-defined populations [68]. The validity of data is crucial, and the resulting information must be useful. The WHO STEPwise approach provides an option for risk factor surveillance [69]. Designed as a three-step manual for NCD surveillance, STEPwise uses standardized instruments and protocols to collect information that can be compared over time and across locations. In low-and middle-income countries, HDSS sites could provide information on a range of health-related outcomes (e.g., cause of death; health systems coverage, particularly regarding vaccination rates, and health service utilization); and, in some cases, growth and nutrition. Such population-level data are especially important when: (i) the quality and accessibility of health services are poor, (ii) record-keeping systems are underdeveloped, (iii) deaths occur outside of the health system and go unrecorded, or (iv) cultural interpretations of disease in more traditional societies present communities with a competing array of alternative providers [56]. Therefore, it is important that we develop such HDSS systems in Nepal to aim for better community health.

Community Involvement in Research Efforts
Curbing obesity in Nepal will require community-level interventions and participation at all levels of society [70]. Many lessons from community-based NCD intervention studies in high-income countries could be applied in low-income settings [71]. The knowledge gained in various CVD programmes can also be applied to NCD and obesity because the risk factors are largely the same. The model developed by the Diabetes Today program could involve community members in obesity prevention [72]. The ongoing Nizwa Healthy Lifestyle Project in Oman suggests community-based initiatives for NCD prevention that could be transferred to the Nepali context [73]. Importantly, components that produce efficient NCD prevention programs include health education and media campaigns, health service interventions that include primary health workers, collaborations between various sectors of the community, and close collaboration between communities and national programs [71].
The WHO has recognized the multi-setting approach. A 2007 resolution by the WHO Regional Committee for South-East Asia acknowledged the need for action by applying "...health promotion and disease prevention strategies to minimize the risk of NCDs at each stage of life and the complementarities of a 'population-based' and 'individual-centred' intervention in achieving this" [74]. Suitable infrastructure, appropriate funding mechanisms, and extensive integration of preventive and control efforts will enable achievement of these goals. Multisectoral, multidisciplinary, and multilevel collaborations must be promoted. WHO plans to follow-up with its member states in 2010.

Increase Awareness of Research Funding Bodies
High-income countries have conducted extensive research on risk factors including obesity, CVD, and diabetes for more than 50 years. Longitudinal studies generate the most useful results. However, the applicability of such results in other geographical, social, and economic contexts has not been widely investigated. It is likely that there are substantial limitations in their transferability.
Unfortunately, most research and funding efforts in low-and middle-income settings are limited to communicable diseases, ignoring not only the imminent threat of obesity and NCDs but also the double-disease burden experienced by such countries. It is crucial that funding bodies recognize the global responsibility of directing supporting research to vulnerable populations in low-and mediumincome settings, and focus on what lies ahead-a rapid increase in obesity and its related complications in a region that contains a large percentage of the world's population.

Conclusions
The long onset of obesity and its clinical complications creates many preventive opportunities in low-and middle-income countries, which could benefit from the experience of other parts of the world. Factors that contribute to obesity are well known [75]. While fighting the menace of communicable diseases, Nepal has largely neglected the problem of NCDs such as CVDs and cardiovascular risk factors such as obesity. To date, only two population-based national studies have focused on these issues. Lacking proper surveillance systems and appropriate policies, the burden of NCDs and their risk factors has silently foundered in the background even while they rapidly emerge as important public health problems.
Low-income settings like Nepal must overcome many obstacles. The largest hurdle likely involves redirecting already scarce health resources, both financial and human, towards the growing trend of obesity. In Nepal, many competing interests are related to infectious diseases and maternal/perinatal health. In addition, Nepal's low literacy rate impedes health literacy and awareness of ongoing trends in the general population. The most efficient strategy would likely combine collaboration between governmental representatives, medical doctors, health workers, and communities.
We must not limit ourselves to cataloguing the ongoing epidemic with increasing precision but rather focus our efforts on active intervention. The major challenges in Nepal are the absence of a substantive public health infrastructure to address the emerging need for NCD prevention and control, and overemphasis on curative care rather than prevention.