Double Burden of Malnutrition

• The increasing income differences have widened the gap between the rich and poor and thus has put India in a position in which it was not before.
• Malnutrition in India has always been synonymous with undernutrition.
• But obesity among adults is nearly as big a problem in the country as under-nutrition.
• Even as under-nutrition continues to remain extraordinarily high in the poorer parts of the country, obesity has reached endemic levels in some of the richer parts of the country
• Thus the present situation is a perfect example of the paradoxical situation, popularly known as the Double Burden of Malnutrition (DBM).
• A study by medical journal Lancet has raised concern about this double burden of malnutrition in India.
• At the same time, a report was also released by the National Nutrition Monitoring Bureau (NNMB) to understand the current nutritional status of urban population in India.
• India has the second highest number of obese children in the world after China.
• At the same time, India has the highest number of moderately and severely underweight children and adolescents in the world.
• The twin problem of high malnutrition and growing obesity may have a common cause: a high proportion of low birth weight babies in India.
• The stark nutritional divide across the country mirrors the uneven growth and development across the country.

Lancet Report

• According to the Lancet, India has the highest number of moderately and severely underweight children and adolescents in the world.
• In the report, it showed that the prevalence of mild to severe underweight under-20s in India is 22.7% among girls and 30.7% among boys.
• The number of obese children and adolescents rose from 11 million in 1975 to 124 million in 2016 globally.  
• In this trend, India will have more obese than underweight children by 2022.  
• In India deaths due to non-communicable diseases (NCDs) are rising alarmingly.  
• One in 12 deaths can be prevented with 30 minutes of physical activity 5 days a week.

NNMB report of India  

• The states having highest obesity rates are: Rajasthan, Kerala, Gujarat, New Delhi, Tamil Nadu, Puducherry
• Cases of hypertension, high cholesterol levels, diabetes in urban population are rising.
• Kerala has the highest prevalence of hypertension as well as high cholesterol in urban men and women while Puducherry has highest prevalence of diabetes.  
• Only 57% of children between the ages of 1-3 years & 68% of those between 4-6 years consumed adequate amounts of proteins and calories.  
• 34% of men and 44% of women are overweight in India.
• 13% of men & 11% of women are underweight in India.  
• 16% of children were born with low birth weight (LBW) in Urban areas which puts them at risk for infections and even early death.

Impact of Double Burden of Malnutrition

• The double malnutrition trap can be particularly dangerous for India, where urban populations are rising, and where people increasingly face a sedentary lifestyle.
• The World Bank estimated that the annual cost of malnutrition to the world economy is approximately $80 billion.
• The direct cost to the Indian economy is around $10 billion, and the total costs, direct and indirect, at 2-3% of GDP.
• It would affect the working conditions of the people.
• With every case of obesity or malnutrition in children, India is being dragged back in its growth trajectory.
• The government would need to spend more on health sector which may led to affect other welfare programs.
• DBM will put pressure on already fragile health systems in India by posing a high risk of chronic diseases such as cardiovascular diseases, diabetes and some cancers (clubbed together as non-communicable diseases, or NCDs).
• At the same time, we will be losing out on a healthy and well nourished workforce.

Obesity in India

Reasons for Obesity

• Not taking recommended daily intake (RDI) despite improvement in nutritional status  
• Although cereal consumption has reduced in compared to 3 decades ago but intake of fat, sugar and oil have increased.
• 63% of men and 72% of women work for 8 hours per day but they lead a sedentary life.  
• No proper regime of eating, sleeping & doing physical activity is followed.
• Traditional foods are being replaced with packed & processed foods.  
• Only 28% of men & 15% of women exercised in the surveyed states.
• Increasing tobacco & alcohol consumption in men & women.

Issues related to child obesity 

• Identification of obesity – in early years is not done as the obese child is often thought of as a healthy child by parents.  
• Unawareness – about the diet patterns, physical activity habits etc. which leads to developing of an unhealthy environment around children.  
• Increased income and urbanization – leads to a rise in the consumption of foods high in fats, sugar and salt and low physical activity.  
• Poor sleep patterns – It also intensifies the effects of genetic risk for obesity  
• Moderate wasting and stunting – These are also potential risk factors for children becoming overweight or obese.  
• Major risk of NCDs – such as cardiovascular disease, diabetes, premature death, as well as physical and psychological consequences in childhood.  
• Economic cost – The annual cost of treating the consequences of obesity will reach a staggering $13 billion in India and $1.2 trillion globally by 2025.

What Do WHO Guidelines Say:

• Height-weight measurement – The weight-for-height and their nutritional status of all infants and children aged less than 5 years at primary health-care facilities should be determined to enable comparing with WHO child growth standards.  
• Counselling – If identified as overweight, counselling should be provided to parents and caregivers on nutrition, eating habits and physical activity including promotion for breastfeeding.  
• Obesity management plan – If identified as obese, an appropriate management plan should be developed after further assessment by the health worker at the primary health-care level or an adequately trained professional at a referral clinic or local hospital.  
• Focus on prevention – and not on providing formulated supplementary foods on a routine basis to children who are moderately wasted or stunted until there is a more definitive evidence base.  
• Tackle obesogenic environment – By preventing high energy intake and inactive behavior and change the social norms in relation to food and physical activity.
• Improving Public policy formulation such as Hungary does heavy taxation on high salty foods.
• Regulation of marketing and promotion of unhealthy foods particularly those targeted at children that are high in salt, sugar and fat  
• Labelling – the role of positive front of pack and standardized global nutrient labelling on packaged foods may help in promotion of healthy foods and lifestyle.

Malnutrition in India

Reasons for Malnutrition

• Extremely low incomes – Many of the rural poor survive at incomes, which are not more than Rs 30 a day. they are unable to afford even two square meals a day.
• Artificially inflated food prices – The market prices of essential food items are way above actual production costs, primarily on account of supply chain inefficiencies and practices like black marketing, hoarding.
• Lack of storage facility at centre as well as state level is below standard as a result of which almost 40% of fruits/vegetables and 20% of grains get damaged.
• With less food in market .the price goes up and the poor finds it difficult to afford it.
• Neglect of female nutrition – In rural societies, patriarchal norms continues unabated. Thus, young girls, newly married women are overworked and denied access to food, which affects their health and that of their newborns.
• Failure of government sector schemes – Despite massive government interventions through NFSA, PDS, the benefits have not reached the needy due to leakages, corruption and mistargeting of subsidies.

Impact of malnutrition

• Undernourished children have significantly lower chances of survival than children who are well-nourished.
• They are much more prone to serious infections and to die from common childhood illnesses such as diarrhoea, measles, malaria, pneumonia, and HIV and AIDS.
• The risk of death increases with the severity of the undernutrition.
• Nutrition is important to ensure proper brain formation and development, which starts in the womb: development of the brain goes on during early childhood.
• Evidence suggests that children who are stunted often enrol late in school, complete fewer grades and perform less well in school.
• This, in turn, affects their creativity and productivity in later life. Iodine deficiency is known to affect a child’s Intelligence Quotient (IQ) adversely.
• It has also been established that children with deficient growth before age two are at an increased risk of chronic disease as adults, especially if they gain weight rapidly in the later stages of childhood.
• A low birth weight baby, who is stunted and underweight in its infancy and gains weight rapidly in childhood and adult life, is much more prone to chronic conditions such as cardiovascular disease and diabetes.

Steps Government is taking to tackle malnutrition

• Expanded the safety net through ICDS to cover all vulnerable groups (children, adolescent girls, mothers, expectant women).
• Fortify essential foods with appropriate nutrients (e.g., salt with iodine and/or iron).
• Popularise low cost nutritious food.
• Mid-day Meal Programme.
• Ensure food security through increased production of food grains
• Improve dietary pattern by promoting production and increasing per capita availability of nutritionally rich food
• Affecting income transfers (improve purchasing power of landless, rural and urban poor; expand and improve public distribution system)
• Recently Government has launched the National nutrition mission

What more is needed

• Promotion of appropriate infant and young child feeding habits along with timely immunisation.
• Empower women because they are the best caretakers when it comes to nutrition of their children and they know exactly what is the nutritional requirement of the child.
• Use of biotechnology with proper safeguards like fortification of grains and promotion of coarse grains and pulses
• Prevention of anaemia in adolescent girls and pregnant women through nutritional programmes with iron and folic acid and deworming
• Capacity building of anganwadi workers
• Child specific growth monitoring cards
• Introduction of BMI and other index for assessing nutritional status at the anganwadi levels.
• National health and sanitation committees to monitor nutrition programmes by conducting national health and nutrition days

Conclusion

• Tackling obesity benefits the economy and the environment, as healthy and sustainable diets are good for productivity levels and the planet
• While tackling undernutrition through assurance of adequate nutrition (usually interpreted as dietary calories), we need to ensure that it is also about appropriate nutrition (the right balance of nutrients)
• Our policy response has to move from “food security” to “nutrition security”.

There is the need to revisit the existing nutrition action plans to simultaneously address undernutrition and these emerging non-communicable diseases related to obesity

India is fortunate to have these indicators included in the national health surveys, at a disaggregated enough level to initiate local actions to understand and address this major health challenge

These guidelines will support achieving the SDGs, the global targets set by the Comprehensive implementation plan on maternal, infant and young child nutrition, and the Global strategy for women’s, children’s and adolescents’ health 2016–2030.