New Delhi: Even as Indian children continue to grapple with undernutrition, the first ever national nutrition survey of children and adolescents shows a growing risk of non-communicable diseases (NCDs) such as diabetes, hypertension and chronic kidney disease, with many showing early signs of these diseases.
Almost one in 10 children, 5 to 9 years, were pre-diabetic and 1% were already diabetic, according to the government’s Comprehensive National Nutrition Survey (CNNS), released on October 8, 2019. About 5% of children and adolescents, 5-19 years, were overweight, the survey found.
Signs of high cholesterol and triglycerides in children and adolescents–India’s future working-age population–that increases risk for heart disease, stroke and other NCDs puts our growth opportunity from our young population at risk. “[I]f overweight and obesity are not aggressively addressed, the burden of non-communicable disease will exact a terrible cost on the development of India and reduce its contribution to global health and economic progress,” said the CNNS report.
The survey was conducted between 2016 and 2018 by the Ministry of Health And Family Welfare, with the United Nations Children’s Fund and the Population Council of India. It surveyed a sample of 112,000 children in 30 states.
The CNNS is the first survey to give detailed nutrition information of children between 5 and 14 years, and to study overnutrition and markers of NCDs in children. Previous national surveys studied the health status of children upto five years, and of those above 15 years. Other than measuring undernutrition and overnutrition, the survey was also the largest micronutrient survey implemented globally, the CNNS report said.
Reducing undernutrition, increasing overnutrition
One in three (35%) children, younger than five years, were stunted–low height for age; 33% were underweight, one in six (17%) were wasted–low weight for height; and 41% were anaemic, found the CNNS.
The prevalence of undernutrition-related diseases during 2016-18, when this survey was conducted, was lower than it was during the National Family Health Survey of 2015-16, which found that 38.3% of children were stunted, 35.8% were underweight, and 21% were wasted.
“It’s good news for Poshan Abhiyan,” tweeted Alok Kumar, an advisor to the NITI Aayog, the Centre’s policy think-tank, referring to the National Nutrition Mission that aims for a 25% fall in the prevalence of child stunting and a three-percentage-point annual decline in the prevalence of anaemia among women and children under the age of five years of age by 2022.
“We as a society are transitioning,” said Suparna Ghosh Jerath, additional professor of public health and nutrition at the Indian Institute of Public Health (IIPH) in Delhi, who called the findings “alarming”. This means a decrease in undernutrition, but a growing threat of non-communicable diseases and problems of overnutrition “which we cannot ignore”.
About 3% of children, 5-9 years, and 4% of adolescents (10-19 years) had a high level of total cholesterol. About 26% of children, 5-9 years, and 28% of adolescents had low levels of high density lipoprotein–known as good cholesterol as it removes the unhealthy forms of cholesterol from the blood. Having a high level of total cholesterol, and a low level of good cholesterol increases the risk for heart disease.
About a third (34%) of children, 5-9 years, and 16% of adolescents had high triglycerides–a kind of fat found in the bloodstream that is linked to heart disease and stroke. In addition, about 7% of children and adolescents were at risk of chronic kidney disease, and 5% of adolescents had hypertension, found CNNS.
These results are not normal, said R Hemalata, director of the National Institute of Nutrition (NIN) in Hyderabad. “We know it is dangerous.”
“These figures should frighten people–not just policymakers, but also parents–into acting for their children. There is an urgent need to improve diets at home, in schools, in public institutions,” said Purnima Menon, senior research fellow at the International Food Policy Research Institute (IFPRI).
“India is definitely following the trends of other countries–these levels are much higher in Brazil, Mexico and other countries,” Menon said.
India’s nutrition mission ignores overnutrition
The proportion of girls (15-19 years) and women (20-49 years) who were overweight more than doubled from 1.6% to 4.9% and from 11.4% to 24%, respectively, from 1999 to 2016, found a study published in the global journal, Nutrients, as IndiaSpend reported in August 2019.
Globally, the rise in overweight and obese adolscents is larger than the decline in prevalence of low body weight among children, the researchers wrote. “It has been estimated that if post-2000 trends continue unabated, the prevalence of child and adolescent obesity will surpass the prevalence rate of underweight by the year 2022,” they wrote.
There is evidence that undernutrition and excess body weight increasingly co-exist in the same countries, communities and even families.
However, Poshan Abhiyaan, the National Nutrition Mission–India’s flagship programme to reduce malnutrition–focuses only on undernutrition and anaemia and does not mention overnutrition.
We have to address overnutrition in Poshan Abhiyaan as well, said R Hemalata of NIN.
This is not just about individual behaviours–efforts to stem the increase in overweight children requires a range of policy efforts, said Menon of IFPRI. These include “labelling and taxing of unhealthy foods, improving the quality of food in public institutions (how much nutrition are you buying for public money in the government food programme), creating stronger physical activity cultures across the board for everyone–men, women, boys, girls–everywhere,” she said.
Poor dietary diversity in children
Lack of dietary diversity can be blamed for rising obesity, overweight children and high undernutrition, said R Hemalatha. “Lack of dietary diversity means most of the nutrition comes from the same groups of foods which usually is calorie dense.” But these foods are deficient in micronutrients and different kinds of nutrients like amino acids, fatty acids, which are all needed for growth and development, she explained.
Changing diets and consumption of high carbohydrate and high sugar foods have an impact on health–almost one in three (31.4%) children, 5-9 years, and 36% of adolescents, 10-19 years, ate fried foods once a week. Almost 7.6% of 5- to 9-year-olds and one in 10 (10.4%) adolescents, 10-19 years, drank aerated drinks once a week.
Among children and adolescents, the majority consumed dark green leafy vegetables (~90%) and pulses or beans (85%) at least once per week. The consumption of dairy products was less frequent, with two-thirds (~65%) of children and adolescents consuming milk or curd at least once per week.
Fruits, eggs, fish, chicken and meat were consumed least frequently. Among children, 40% consumed fruits, 35% consumed eggs, and 36% consumed fish or chicken or meat. Similarly, among adolescents, only 41% consumed fruits, 35% consumed eggs, and 36% consumed fish or chicken or meat.
The consumption of milk or curd, fruits, eggs, and fish or chicken or meat increased when mothers had more education, and households were richer.
Consumption of diversified diets is not adequate in the rich and the poor, in urban and rural areas. This could be because of a lack of knowledge, said Ghosh Jerath of IIPH. There needs to be more awareness about what foods are nutritious in the community, as well as in frontline workers including anganwadi workers and auxiliary nurse midwives, she added.
Socio-economic status impacts nutrition
Across India, 4% of children, 5-9 years, were overweight–where body mass index for age is one standard deviation higher than it should be–and 1% were obese–when body mass index for age is two standard deviations higher, the survey found.
The highest prevalence of overweight children, 5 to 9 years, was in Goa (14.5%) and Nagaland (14.7%), while the lowest prevalence of overweight children was in Jharkhand and Bihar, where less than 1% were overweight.
A household’s socio-economic status impacts whether a child will be overweight. Only 1% of children from households in the lowest wealth quintile were overweight compared to 9% of children in the highest wealth quintile.
Compared to rural areas, more children in urban areas suffered from obesity. In urban areas, 7.5% of children, 5 to 9 years were overweight, as compared to 2.6% in rural areas. Similarly 9.7% of adolescents from urban areas, 10 to 19 years, were overweight as compared to 3.2% in rural areas.
The least prevalence of overweight and obesity among different social groups was in children belonging to scheduled tribes (ST)–the constitutional term for India’s recognised tribes. About 2.8% of school-going children, and 2.1% of adolescents from ST were overweight and obese as compared to 5.1% of children and 7.1% of adolescents who belonged to ‘other’, implying upper castes.
Also, 2% of children and adolescents had abdominal obesity, as measured by waist circumference-for-age. Indians are more likely to store fat around the abdomen, and this fat increases the risk for non-communicable diseases.