Food, Glorious Food

Content from the Brookings Institution India Center is now archived. After seven years of an impactful partnership, as of September 11, 2020, Brookings India is now the Centre for Social and Economic Progress, an independent public policy institution based in India.

Obesity, an epidemic often thought to be exclusive to wealthy countries, is becoming a rapidly growing crisis for India. The National Family Health Survey of 2006 revealed that roughly one in four urban Indians was overweight or obese, and several more recent studies indicate that these numbers are increasing. A new study released by the Registrar General of India indicates that obesity-related diseases have joined malnutrition as leading causes of death in India. Meanwhile, India’s “unacceptably high” levels of child malnutrition are being declared a “national shame” by Prime Minister Manmohan Singh. These simultaneous, yet almost paradoxical epidemics of both obesity and severe malnutrition in the same spaces (households, villages, towns and everything in between) have important implications for public health programmes, economic considerations, and more implicitly, relations of food within a transitional and largely unequal social arena.

An upward sedentarianism
Studies provide quantitative evidence to what is a widespread assumption – over-nutrition is significantly related to socio-economic status with urban, educated, higher socio-economic groups at higher rates of obesity. However, these results do not simply represent a straightforward equation between access and over/under-nutrition. Rather, they indicate a larger transition – in our epidemiological, nutritional and socio-economic structure. The forces of internal migration and urbanisation, changes in patterns of food consumption and physical inactivity are contributing to an increased sedentarianism. The convergence of these forces has led to an almost contradictory, yet perhaps inevitable state of affairs – with high rates of under-nutrition, over-nutrition and inadequate nutrition at a point that demands greater health awareness and targeted health policies.

In a five-city study published in the medical journal Acta Cardiologica, a cross-sectional survey was conducted in 6 to 12 urban streets in different regions of India to find the prevalence of overweight, obesity, under-nutrition and physical activity status in the urban populations. A total of 6,940 subjects aged 25 years and above were randomly selected from the cities of Moradabad, Thiruvananthapuram, Kolkata, Nagpur and Mumbai. The overall prevalence of obesity was 6.8 per cent and of overweight was 33.5 per cent. Sedentary behaviour and the prevalence of obesity were greater in the cities of Mumbai, Thiruvananthapuram and Kolkata, indicating a relationship between more urbanised areas and higher rates of sedentarianism.

Shades of nutrition
The term “malnutrition” refers to a spectrum of imbalanced relationships between the body and nutrients – encompassing excess, lacking or in wrong proportion – as well as implying problems with access and/or absorption. The distinction between bad nutrition and under-nutrition (and its relation to access and sanitation) is under much contestation. For our purposes, bad nutrition (that is, consuming too many of the wrong nutrients and not enough of the right ones) is directly related to consuming too much energy with not enough activity to burn it. Nationally, the consumption pattern of the household seems to be moving away from cereals and pulses to edible oil, dry fruits, beverages and other processed products. This increased fat consumption and decreased protein intake coupled with the marked shift in activity levels from rural to urban lifestyle is a recipe for bad nutrition.

It is evident that with increased family income comes greater dietary diversification – the higher the income, the greater access to diverse forms of nutrients. However, regardless of graded access, data indicate a decrease in calorie and protein intake with an increased fat intake in both rural and urban areas (though to differing degrees across the socio-economic spectrum), resulting in an increase in over-nutrition for the comparatively affluent and bad nutrition for weaker sections.

Due to changes in lifestyle and consequent reduction in energy expenditure, both adults and children are at an increased health risk for several diseases. A study in Indian urban children and adolescents (12 to 19 years) published by the Indian Diabetes Research Foundation (2010) showed that nearly 65 per cent of normal weight subjects also had at least one risk factor. The cardio-metabolic risk factors studied were blood pressure, fasting plasma glucose, HDL-cholesterol, triglycerides, waist circumference and insulin resistance. The percentage of abnormalities increased to 85 per cent in overweight children.

Being obese or overweight is disregarded, amongst some circles, as somewhat of a vanity – an epidemiological variation reserved for the privileged. In a country with abject inequality of access to basic resources, those seemingly with the unhealthy access to too many may be dismissed in public health programmes. However, the immediate and accumulating health risks of a disease no longer limited to the privileged of society demand attention. In his work published in the Public Health Nutrition Journal (2002), Prakash Shetty notes that wide variations in health risks of a population are largely attributable to the epidemiological transition in the economic growth process of a country. During this process, a majority of that population gains reliable access to the basic necessities of life, including adequate food and nutrition. It is evident, then, that disparities in income influence health – the larger the degree of inequality, the lower the life expectancy of the population.

Feeding enough versus feeding correctly
The current challenge of coping with malnutrition and obesity as leading causes of death at the same time begs the question: is there an effective policy response? Besides the deficiency of calories and protein (macronutrients), deficiency of micronutrients (that is, vitamins and minerals) is rampant. Micronutrient deficiency is referred to as “the hidden hunger” since most of the times it is not an obvious killer or crippler, but extracts heavy human and economic cost.

Since obesity is often related to lifestyle and a lack of awareness, a policy approach must be based on prevention – with education, mass communication and regulation, when possible. While the Twelfth Plan vaguely addresses tackling growing obesity rates through better education and communication, widespread implementation must be more rigorous, particularly in schools. However, an essential component of this must be considered: what is the cost of rebalancing nutrients to a healthy equilibrium? With price incentives having led to a domination of cereal production and unhealthy food becoming cheaper, dietary diversification and providing a nutrient-balanced meal may be growing increasingly unaffordable. While my reference to the Dickensian starving orphan (“Food, Glorious Food” being the song of the workhouse boys in Oliver Twist, the musical) in the title of this piece may appear facetious, it is only meant to indicate that while feeding enough is a necessary effort, so is knowing how to feed correctly.

The full piece was originally published here.

Image credit to the opoponax