Overnutrition and diabetes
Studies from Chennai (Ramachandran, 2005) show that increasing BMI brings an increased risk of diabetes in both men and women, and a steep increase when BMI rises beyond 23 (Figure 62). There is a progressive increase in prevalence of diabetes with increasing waist-to-hip ratio (WHR) in both men and women (Figure 63). Indians have higher body fat per BMI than Caucasians (Figure 64). The associations between abdominal obesity and the metabolic syndrome of hypertension, dyslipedaemia, insulin resistance and diabetes have been well documented. Comparison of the insulin resistance and insulin response of Indians and United Kingdom citizens showed that both fasting and two-hour insulin levels are lower in Indians in rural areas and in Caucasians in the United Kingdom; urban Indians and Indians residing in the United Kingdom have substantially higher fasting and two-hour insulin levels, indicating insulin resistance (Figure 65). Data from the affluent urban population show that the prevalence of insulin resistance is high in children and young adults, as well as adults (Yagnik, 1998).
Risk for diabetes associated with increasing BMI
Diabetes and WHRs
Source: Ramachandran, 2005.
Comparison of body fat (percentage) and BMI in Indians and Caucasians
Source: Ramachandran, 2005.
Insulin resistance/serum insulin responses in Indians and Caucasians
Source: Ramachandran, 2005.
Overnutrition and hypertension
NFI carried out studies to explore the relationships between overnutrition and hypertension in people from different income groups working at a government institution (NFI, 2004). A larger proportion of subjects had high WHR (50.3 percent) than BMI > 25 (30.8 percent). The higher the BMI and WHR, the higher were the prevalence rates of hypertension in both men and women (Figure 66). The prevalence of high blood pressure in the normal and overweight subjects was higher when WHR was high.
Prevalence of high blood pressure by income group and BMI
Source: NFI, 2004.
Serum cholesterol and triglycerides in men were significantly higher in subjects with BMI > 25, and increased significantly with increasing BMI and WHR in both men and women (Figures 67 and 68). Most cholesterol levels greater than 180 mg percent and most blood sugar levels of 140 mg percent were seen in subjects with high BMI and WHR.
Effect of BMI on biochemical parameters
Source: NFI, 2004.
Effect of WHR on biochemical parameters
Source: NFI, 2004. WHR I Males < 0.93, Females < 0.81; WHR II Males 0.93-1.00, Females 0.81-0.89; WHR III Males >1.00, Females >0.89.
Linkages between obesity and diabetes and CVD
The susceptibility of urban Indians to central adiposity has been highlighted in all studies. All studies in India show that central obesity is more strongly associated with glucose intolerance than generalized obesity is. A cluster of risk factors have been demonstrated to be associated with central obesity. These include glucose intolerance, general obesity, hyperinsulinaemia, hypertriglyceridaemia and hypertension, all of which are important risk factors for IHD. Recent studies comparing body fat topography in migrant Asians with that of Caucasians have also reported a higher WHR, with hyperglycaemia, elevated plasma insulin concentrations, altered blood lipids and increased risk of coronary heart disease in Indians.
Indians are at higher risk of metabolic syndrome, with type-2, diabetes, dyslipedaemia, hypertension and CVD (Ramachandran, Snehlata and Vijay, 2004). Data from Chennai provide information on glucose tolerance and different CVD risk factors (Figure 69). These data indicate that the risk of glucose intolerance and diabetes increases with age, BMI, WHR, blood cholesterol (> 209 mg/dl) and triglyceride level (> 165 mg/dl). Cardiovascular risk is lowest in people with normal glucose tolerance and highest in those with diabetes.
Glucose intolerance and CVD risk factors
Source: Ramachandran et al., 2004.
Comparison of newly diagnosed non-insulin-dependent diabetes mellitus patients at KEM hospital, Pune with migrant Indian and Caucasian patients in the United Kingdom showed the following:
Diabetic patients in India are about a decade younger at diagnosis (20 percent are under 35 and 50 percent under 40 years of age).
Obesity (using BMI as the criterion) is less common, but central obesity (increased WHR) is a very striking feature in Indian patients. The highest glucose concentrations were found in subjects who were generally thin but centrally obese.
Hypercholesterolaemia is uncommon (5 percent), but plasma triglycerides and non-esterified fatty acids are significantly elevated in Indian patients with IGT or diabetes compared with those who have normal glucose tolerance (NGT).
Both IGT and diabetic patients show higher fasting hyperinsulinaemia than NGT subjects do, but post-glucose plasma immunoreactive insulin (IRI) concentrations are diminished in diabetic patients. Plasma IRI concentrations show an inverted U-shaped distribution in relation to plasma glucose concentration, suggesting that insulin resistance and compensatory hyperinsulinaemia precede diabetes. Even NGT Indians are substantially more hyperinsulinaemic and insulin-resistant than Caucasians.
In Indians the cardiovascular risk factors (obesity, central obesity, hypertension, high plasma triglycerides and elevated non-esterified fatty acids) are increased in diabetic patients and also in those with IGT, a condition that precedes diabetes by many years. Electrocardiographic changes suggestive of IHD were associated with older age, higher blood pressure, higher plasma triglycerides and immunoreactive insulin concentrations. Cardiovascular risk factors were all related to plasma insulin levels and seem to occur as part of the complex metabolic profile called the insulin resistance syndrome, the metabolic syndrome or Syndrome X.
In 1950, India faced two major nutritional problems. One was the threat of famine and the resultant acute starvation caused by low agricultural production and the lack of an appropriate food distribution system. The other was chronic energy deficiency caused by:
poor utilization of available facilities because of low literacy and lack of awareness.
The country adopted a multisectoral, multipronged strategy to combat these problems and improve the nutritional status of the population (Box 5). Successive five-year plans laid down the policies and strategies for achieving these goals.
Box 5. Initiatives to improve the nutritional status of the population, 1950 to 1990
· Increasing food production:
building buffer stocks.
· Food supplementation to address the special needs of vulnerable groups, the Integrated Child Development Services (ICDS) and midday meals.
· Nutrition education, especially through the Food and Nutrition Board (FNB) and ICDS.
· Efforts of the health sector to tackle:
Source: Planning Commission, 2002.
Progress achieved in seven five-year plans was reviewed in 1991/1992. It was obvious that the threat of famine has disappeared and there has been a significant decline in severe forms of undernutrition. However, mild and moderate undernutrition and micronutrient deficiencies were widespread. India prepared and adopted the National Nutrition Policy in 1993 (DWCD, 1993). This policy advocated a comprehensive intersectoral strategy involving 14 sectors (which directly or indirectly affect the dietary intake and nutritional status of the population) in combating the multifaceted problem of undernutrition and improving the nutritional status of all sections of society. The policy sought to strike a balance between short-term direct nutrition interventions and long-term institutional/structural changes to create an enabling environment and the necessary conditions for improving nutritional and health status. It also set goals to be achieved in each sector by 2000. A National Plan of Action (DWDC, 1995) was drawn up and approved in 1995. In order to achieve intersectoral coordination at the highest level, a National Nutrition Council was formed with the Prime Minister as chairperson and the Planning Commission as the Secretariat. The council was to act as the national forum for policy and strategy formulation, review performance and suggest mid-course corrections. A similar set-up was envisaged for the state level. An interdepartmental coordination committee under the Department of Women and Child Development (DWCD) was to coordinate and review the implementation of nutrition programmes.
Review of the situation in 2000/2001 prior to formulation of the Tenth Five-Year Plan (Planning Commission, 2002) showed that although undernutrition and micronutrient deficiencies continue to be major public health problems, overnutrition and obesity are also emerging as a major problem in many states. In response to this, the Tenth Five-Year Plan envisaged a paradigm shift:
from household food security and freedom from hunger to nutrition security for the family and the individual;
from untargeted food supplementation to screening of all the people in vulnerable groups, identification of those with various grades of undernutrition and appropriate management;
from ad hoc unfocused interventions addressing the prevention of overnutrition to the promotion of appropriate lifestyles and dietary intakes for the prevention and management of overnutrition and obesity.
The plan gave high priority to the effective implementation of focused and comprehensive interventions aimed at improving the nutritional and health status of individuals. It was emphasized that the increased outlays to combat the dual nutrition burden should result in improved outcomes and outputs in terms of reducing both under- and overnutrition. In view of the massive interstate differences, the Tenth Five-Year Plan laid down state-specific goals based on the current nutritional status and investment provided for the sector in the state plan. The national goals conform to the Millennium Development Goals and, although ambitious, may be achievable through improved coverage, quality and content of nutrition-related services.
Data suggest that there has not been much change in the predominantly cereal-based dietary intake in India over the last three decades, except among affluent segments of the population. In spite of increasing per capita income and reduced poverty, dietary diversity is seen mainly among the affluent. Undernutrition rates remain high; starting before birth, they are aggravated throughout infancy by poor infant feeding practices and perpetuated in childhood by poor intra-family distribution of food and poor access to health care. There has been a substantial reduction in severe undernutrition, most of which is due to improved access to health care. India can achieve substantial improvement in nutritional status through health and nutrition education and improved access to health and nutrition services.
Prevention of intrauterine growth retardation through antenatal care, and early detection and correction of undernutrition so that children attain appropriate weight for height are essential to promoting linear growth; they can be achieved through the effective implementation of ongoing intervention programmes utilizing the available infrastructure.
Low intakes of vegetables and fruit, poor bioavailability of iron and limited use of iodized salt are responsible for micronutrient deficiencies being major public health problems even today. Dietary diversification, better coverage under the national anaemia control programme, massive-dose vitamin A administration and universal access to iodized, and later iron and iodine-fortified, salt are some of the interventions that could help the country to achieve rapid reductions in micronutrient deficiencies.
Over the last decade, there has been a progressive increase in overnutrition. Reduced physical activity is the major factor behind this. In affluent urban segments, increased energy intake from fats, refined cereals and sugar, combined with simultaneous reductions in physical activity have contributed to steep increases in overnutrition in all age groups. Nutrition education on healthy dietary patterns containing plenty of fruit and vegetables, maintenance of energy balance through regulation of dietary intake, and increasing energy expenditure through physical activity as part of the daily routine will promote muscle and bone health and prevent the development of adiposity in all age groups. Such information can be passed on to large segments of the urban upper- and middle-income groups through the media (television, Internet) that this segment has access to.
Indians appear to have a predisposition for adiposity - especially abdominal - insulin resistance and diabetes, hyper-triglyceridaemia and CVD. This predisposition could be genetic or environmental, and can manifest itself at birth, in childhood, during adolescence and in adult life. It is never too early for Indians to start practising healthy lifestyle and dietary habits.
It therefore seems that India could combat the dual nutrition burden through efficient implementation of time-tested, effective and inexpensive interventions to achieve significant reductions in both over- and undernutrition and their adverse health consequences within the next two decades.
Bhargava, S.K., Sachdev, H.P., Fall, H.D., Osmond, C., Lakshmy, R., Barker, D.J.P., Biswas, S.K.D., Ramji, S., Prabhakaran, D. & Reddy, K.S. 2004. Relation of serial changes in childhood body mass index to impaired glucose tolerance in young adulthood. New Eng. J. Med., 350: 865-875.
Department of Education. 2002. Selected educational statistics 2000-01. New Delhi, Government of India.
DWCD. 1993. National Nutritional Policy. Government of India, New Delhi, Department of Women and Child Development (DWCD).
DWCD. 1995/1996. Indian Nutrition Profile. Government of India, New Delhi.
Gopinath, N., Chadha, S.L., Sood, A.K., Shekhawat, S., Bindra, S.P.S. & Tandon, R. 1994. Epidemiological study of hypertension in young (15 to 24 years) Delhi urban population. Ind. J. Med. Res., 99: 32-37.
Government of India. 2003. Economic Survey of India 2003-04. New Delhi.
Gupta, R., Gupta, V.P. & Ahluwalia, N.S. 1994. Educational status, coronary heart disease, and coronary risk factor prevalence in a rural population of India. Br. Med. J., 309: 1332-1336.
ICMR. 1989. Nutrient requirements and recommended dietary allowances for Indians. New Delhi.
ICMR. 1990 to 2005. Reports of the National Cancer Registry Programme 1990 to 2005. New Delhi, Indian Council of Medical Research (ICMR).
ICMR. 2004a. Micronutrient profile of Indian population. New Delhi.
ICMR. 2004b. Assessment of burden of non-communicable diseases. New Delhi.
IIPS. 1992/1993. National Family Health Survey 1. International Institute of Population Sciences (IIPS). Mumbai.
IIPS. 1998/1999. National Family Health Survey 2. Mumbai.
Ministry of Agriculture. 2000. National Agriculture Policy. New Delhi, Government of India.
Ministry of Agriculture. 2002a. Agriculture statistics at a glance 2002. New Delhi, Government of India.
Ministry of Agriculture. 2002b. Report of Department of Economics and Statistics 2002. New Delhi, Government of India.
Ministry of Family and Health Welfare. 1998/1999. Reproductive and Child Health 1. New Delhi, Government of India.
Ministry of Family and Health Welfare. 2002. Reproductive and Child Health 2. New Delhi, Government of India.
Ministry of Family and Health Welfare. 2002/2003. District-Level Household Survey. New Delhi, Government of India.
Ministry of Family and Health Welfare. 2004. District-Level Household Survey 2002-03. New Delhi, Government of India.
National Urban Diabetes Survey. 2001. Diabetologia., 44(9): 1094-1101.
NFI. 2004. Twenty-Five Years Report 1980 to 2005. New Delhi, Nutrition Foundation of India (NFI).
NIN. 2004. Nutritive value of Indian foods. Hyderabad, National Institute of Nutrition (NIN).
NNMB. 1979 to 2002. NNMB reports. Hyderabad, National Nutrition Monitoring Bureau (NNMB), National Institute of Nutrition.
NNMB. 2000. NNMB report. Hyderabad, National Institute of Nutrition.
NNMB. 2001. NNMB report. Hyderabad, National Institute of Nutrition.
NNMB. 2002. NNMB micronutrient survey. Hyderabad, National Institute of Nutrition.
NSSO. 1975 to 2000. Reports of NSSO. New Delhi, National Sample Survey Organization (NSSO), Department of Statistics, Government of India.
Planning Commission. 2002. Tenth Five-Year Plan. New Delhi, Government of India.
Planning Commission. 2004. Annual Plan 2003-04. New Delhi, Government of India.
Ramachandran, A. 2005. Epidemiology of diabetes in India - three decades of research. J. Assoc. Phy. India, 53: 34-38.
Ramachandran, A., Snehlata, C. & Vijay, V. 2004. Low risk threshold for acquired diabetogenic factors in Asian Indians. Diab. Res. Clin. Prac., 65: 189-195.
Ramachandran, P. 1989. Nutrition in pregnancy. In C. Gopalan and Suminder Kaur, eds. Women and nutrition in India. Special Publication No. 5. New Delhi, NFI.
Reddy, K.S. 1998. The emerging epidemiology of cardiovascular diseases in India. In P. Shetty and C. Gopalan, eds. Diet, nutrition and chronic disease: An Asian perspective, pp. 50-54. London, Smith-Gordon and Co.
RGI. 1951 to 2001. Report of census 1951-2001. New Delhi, Registrar General of India (RGI).
RGI. 1971 to 2000. Reports of sample registration system. New Delhi.
RGI. 1996. Population projections 1996-2016. New Delhi.
RGI. 2002. Bulletin of sample registration system. New Delhi.
Salt Department. 2003/2004. Annual Reports - 2003-04. New Delhi, Government of India.
UNDP. 2003. Human Development Report. New York, United Nations Development Programme (UNDP).
Wasuja, M. & Siddhu, A. 2003. Decade-wise alterations in energy expenditure and energy status of affluent women (30 to 88 years) - A cross-sectional study. New Delhi, Delhi University. (Ph.D. thesis)
World Bank. 1993. World Development Report. New York.
Yagnik, C.S. 1998. Diabetes in Indians: small at birth or big as adults or both? In P. Shetty and C. Gopalan, eds. Diet, nutrition and chronic disease: An Asian perspective, pp. 43-46. London, Smith-Gordon and Co.
Yeole. 2001. Cancer in India in 2001. (Ph.D. thesis)