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Chubby And Affluent: India’s New Face of Malnutrition

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By Charu Bahri, IndiaSpend.com:

Broadening girths are expanding India’s battle against malnutrition, a new Indian study has revealed, setting off a host of so-called lifestyle ailments.

This is happening as India fights a losing battle with the bulge, hosting as it does the third-most number of obese people in the world, 61 million and growing.

Malnutrition is commonly associated with emaciated, undernourished people, not with being obese or overweight—or over-nourished, as it is called in dietary parlance.

Actually, the ‘over’ in over-nourished relates only to calories, or energy intake. Getting those excessive calories from fat- and sugar-rich, nutrient-poor foods can lead to significant micronutrient deficiencies in obese people, said Carlyne Remedios, senior nutritionist, Centre for Obesity and Digestive Surgery, Mumbai and co-author of the study published in August 2015 in the journal Obesity Surgery.

Of 2,740 people with a Body Mass Index (BMI) more than 30 kg/m2, the cut off for obesity, forming the study group, 43% suffered from iron deficiency, 56.7% from vitamin B12 deficiency, 11% from calcium deficiency, 35% from vitamin D3 deficiency and 10% from protein deficiency.

Micronutrient Deficiencies In Obese People In India
Micronutrient Deficiency in obese people (%) Deficiency in general population (%)
Iron 43 60-80
Vitamin B12 57 35-75
Calcium 11 8-40.6
Vitamin D3 35 44-90

A new US study has arrived at a similar conclusion as Remedios. One in five obese patients of that study had insufficient levels of three or more of these micronutrients: vitamin A, vitamin B12, vitamin D, vitamin E, iron, folate (vitamin B9) and thiamine (vitamin B1).

Clearly, abundance of food and nutrition are not synonymous.

Overweight Indians: Growing Almost As Fast As Malnourishment Is Contained

India’s new face of malnourishment is likely to belong to the urban and affluent, those who can afford to choose their diet.

Three times more obese and overweight people live in urban areas than in rural areas, as per the National Family Health Survey III. Their numbers are growing almost as fast as the number of undernourished Indians is being contained.

Consider:

  • In 1990, 23.7% of India’s population was undernourished while 15.8% was over-nourished.
    Today, 15.2% of the population is undernourished while 22% is over-nourished.
overweightobese

Source: World Health Organisation Obesity & Overweight data.

 

undernourished

Source: Food and Agriculture Organization

Diets Gone Awry Are Broadening India’s Girth

A 28-year-old man, 5 feet 4 inches tall, weighed 100 kg. His diet was overloaded with bad carbohydrates and bad fats, and low in protein. Severely obese, he complained of persistent body ache and pain in the thighs and around the knees. His vitamin B12 levels were low.

Investigations showed that the patient was suffering from vitamin D deficiency and high uric acid, findings that are “typical of overweight people”, said the consulting doctor Anil Arora, head of unit and lead consultant, Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, Delhi.

A 13 year-old girl, 5 feet 4 inches tall, weighed 114 kg. She consulted a dietician for a weight-loss programme.

“Dietary assessment revealed she ate no vegetables, just high-fat and high-carbohydrate foods and a lot of meat, mostly chicken. Overall, her intake of calcium, iron and other micronutrients was low,” said Sherin Verghese, manager, dietetics, Malabar Institute of Medical Sciences, Kozhikode.

Blood tests showed the young teen to be borderline diabetic, despite her young age.

Research and the experience of dieticians across the country trace a clear correlation between faulty diets and excess weight.

A 2010 study in Gujarat compared the daily diet of overweight people and normal weight people. Overweight people were consuming almost 10% more grams of oil per day and 20% fewer grams of vegetables.

In a 2013 survey focussed on women conducted in Delhi, obese women identified fried food as the leading cause for their condition, while overweight women attributed excess weight to overeating.

Most overweight and obese people consume a surfeit of energy-dense foods rich in saturated fats and simple sugars“, said Karishma Chawla, Mumbai-based nutritionist and founder, Eat Rite 24×7, a nutrition consultancy, “We call them empty calories for being nutrient poor.”

To add to this, metabolic changes associated with obesity can compromise the absorption of micronutrients from food.

Technically, obesity is a kind of inflammation, which research has shown impairs iron absorption or iron utilisation.

A recent Indian study at St. John’s Research Institute in Bengaluru showed that obese women face an increased risk of iron deficiency, and they also absorb less dietary iron.

Research is yet to fully confirm but we believe that adipose (fat) impedes the utilisation of micronutrients—iron and potentially other micronutrients—by the tissues,” said Remedios.

From Fatness To Disease—Via Micronutrient Deficiencies

Raised BMI is a major risk factor for non-communicable diseases such as heart disease and stroke, the leading cause of death in 2012, diabetes, musculoskeletal disorders and some cancers—endometrial, breast, and colon, according to the World Health Organisation.

Less commonly reported is the association between obesity, nutritional deficiencies and disease.

A US study has traced a link between obesity, diabetes and deficiencies of vitamin D, chromium, vitamin B7 (biotin), vitamin B1 (thiamine) and vitamin C.

A 2012 study of 1,765 North Indians diabetics, pegged the overall vitamin D deficiency rate at 76%. It identified progressively worse deficiency in those with higher BMI: 65% in those with BMI less than 23kg/m, 75% in those with BMI 23-27.5 kg/m and 81% in those with BMI greater than 27.5 kg/m.

This is highly plausible.

Overweight people are at higher risk of developing vitamin D deficiency because the vitamin is fat-soluble, which means it gets stored or ‘locked up’, so to speak, in fat cells, with less available to the body for use,” said Seema Gulati, head of the Nutrition Research Group, Center for Nutrition & Metabolic Research (C-NET).

Conversely, when fat people lose weight, their serum vitamin D level may increase, said Gulati.

Lower vitamin B12 and folic acid levels are characteristic of hypertensive overweight and obese people as compared to hypertensive people of normal weight, according to a 2009 study in Mumbai. Even among people with normal blood pressure, those who were overweight or obese had lower vitamin B12 and folic acid levels than those of normal weight.

Why Watching Your Weight Is The Only Way Out—And Why It Is So Hard

Obesity can shave off up to eight and a half years of an adult male’s lifespan and six years of an adult female’s lifespan. Obese people also lose two to four times more healthy life years than a person of normal weight.

While that is reason enough to lose weight, shedding kilograms isn’t so easy.

In the last 33 years, no country has significantly reduced obesity, according to the Global Burden of Disease Study 2013.

With the prevalence of overweight people in India estimated to increase to 27.8% by 2030, and with the most population growth expected to occur in urban India where obesity is expanding the fastest, experts said public policy should focus on malnutrition at the other end of the spectrum—that presents its own challenges because in India, over- and under-nutrition are not simply a problem of the rich or the poor.

“Often, over- and under-nutrition overlap and coexist in the same household even in rural and periurban areas as a result of ‘urbanicity’,” said Sutapa Agrawal, epidemiologist, Public Health Foundation of India.

Dual burden households make public health interventions tricky.

Strategies to address under-nutrition—such as increasing household food supplies—could contradict obesity curtailment programmes while interventions to address obesity—like recommendations of a low fat diet—may adversely effect any underweight members, said Agrawal.

So what is the best way forward?

Catch them young before the fat creeps on: create awareness in children through school education programmes that simultaneously address both types of malnutrition, she said.

This article was originally published on IndiaSpend.com, a data-driven and public-interest journalism non-profit.

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An ambassador and trained facilitator under Eco Femme (a social enterprise working towards menstrual health in south India), Sanjina is also an active member of the MHM Collective- India and Menstrual Health Alliance- India. She has conducted Menstrual Health sessions in multiple government schools adopted by Rotary District 3240 as part of their WinS project in rural Bengal. She has also delivered training of trainers on SRHR, gender, sexuality and Menstruation for Tomorrow’s Foundation, Vikramshila Education Resource Society, Nirdhan trust and Micro Finance, Tollygunj Women In Need, Paint It Red in Kolkata.

Now as an MH Fellow with YKA, she’s expanding her impressive scope of work further by launching a campaign to facilitate the process of ensuring better menstrual health and SRH services for women residing in correctional homes in West Bengal. The campaign will entail an independent study to take stalk of the present conditions of MHM in correctional homes across the state and use its findings to build public support and political will to take the necessary action.

Saurabh has been associated with YKA as a user and has consistently been writing on the issue MHM and its intersectionality with other issues in the society. Now as an MHM Fellow with YKA, he’s launched the Right to Period campaign, which aims to ensure proper execution of MHM guidelines in Delhi’s schools.

The long-term aim of the campaign is to develop an open culture where menstruation is not treated as a taboo. The campaign also seeks to hold the schools accountable for their responsibilities as an important component in the implementation of MHM policies by making adequate sanitation infrastructure and knowledge of MHM available in school premises.

Read more about his campaign.

Harshita is a psychologist and works to support people with mental health issues, particularly adolescents who are survivors of violence. Associated with the Azadi Foundation in UP, Harshita became an MHM Fellow with YKA, with the aim of promoting better menstrual health.

Her campaign #MeriMarzi aims to promote menstrual health and wellness, hygiene and facilities for female sex workers in UP. She says, “Knowledge about natural body processes is a very basic human right. And for individuals whose occupation is providing sexual services, it becomes even more important.”

Meri Marzi aims to ensure sensitised, non-discriminatory health workers for the needs of female sex workers in the Suraksha Clinics under the UPSACS (Uttar Pradesh State AIDS Control Society) program by creating more dialogues and garnering public support for the cause of sex workers’ menstrual rights. The campaign will also ensure interventions with sex workers to clear misconceptions around overall hygiene management to ensure that results flow both ways.

Read more about her campaign.

MH Fellow Sabna comes with significant experience working with a range of development issues. A co-founder of Project Sakhi Saheli, which aims to combat period poverty and break menstrual taboos, Sabna has, in the past, worked on the issue of menstruation in urban slums of Delhi with women and adolescent girls. She and her team also released MenstraBook, with menstrastories and organised Menstra Tlk in the Delhi School of Social Work to create more conversations on menstruation.

With YKA MHM Fellow Vineet, Sabna launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society. As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Read more about her campaign. 

A student from Delhi School of Social work, Vineet is a part of Project Sakhi Saheli, an initiative by the students of Delhi school of Social Work to create awareness on Menstrual Health and combat Period Poverty. Along with MHM Action Fellow Sabna, Vineet launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society.

As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Find out more about the campaign here.

A native of Bhagalpur district – Bihar, Shalini Jha believes in equal rights for all genders and wants to work for a gender-equal and just society. In the past she’s had a year-long association as a community leader with Haiyya: Organise for Action’s Health Over Stigma campaign. She’s pursuing a Master’s in Literature with Ambedkar University, Delhi and as an MHM Fellow with YKA, recently launched ‘Project अल्हड़ (Alharh)’.

She says, “Bihar is ranked the lowest in India’s SDG Index 2019 for India. Hygienic and comfortable menstruation is a basic human right and sustainable development cannot be ensured if menstruators are deprived of their basic rights.” Project अल्हड़ (Alharh) aims to create a robust sensitised community in Bhagalpur to collectively spread awareness, break the taboo, debunk myths and initiate fearless conversations around menstruation. The campaign aims to reach at least 6000 adolescent girls from government and private schools in Baghalpur district in 2020.

Read more about the campaign here.

A psychologist and co-founder of a mental health NGO called Customize Cognition, Ritika forayed into the space of menstrual health and hygiene, sexual and reproductive healthcare and rights and gender equality as an MHM Fellow with YKA. She says, “The experience of working on MHM/SRHR and gender equality has been an enriching and eye-opening experience. I have learned what’s beneath the surface of the issue, be it awareness, lack of resources or disregard for trans men, who also menstruate.”

The Transmen-ses campaign aims to tackle the issue of silence and disregard for trans men’s menstruation needs, by mobilising gender sensitive health professionals and gender neutral restrooms in Lucknow.

Read more about the campaign here.

A Computer Science engineer by education, Nitisha started her career in the corporate sector, before realising she wanted to work in the development and social justice space. Since then, she has worked with Teach For India and Care India and is from the founding batch of Indian School of Development Management (ISDM), a one of its kind organisation creating leaders for the development sector through its experiential learning post graduate program.

As a Youth Ki Awaaz Menstrual Health Fellow, Nitisha has started Let’s Talk Period, a campaign to mobilise young people to switch to sustainable period products. She says, “80 lakh women in Delhi use non-biodegradable sanitary products, generate 3000 tonnes of menstrual waste, that takes 500-800 years to decompose; which in turn contributes to the health issues of all menstruators, increased burden of waste management on the city and harmful living environment for all citizens.

Let’s Talk Period aims to change this by

Find out more about her campaign here.

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

A Gender Rights Activist working with the tribal and marginalized communities in india, Srilekha is a PhD scholar working on understanding body and sexuality among tribal girls, to fill the gaps in research around indigenous women and their stories. Srilekha has worked extensively at the grassroots level with community based organisations, through several advocacy initiatives around Gender, Mental Health, Menstrual Hygiene and Sexual and Reproductive Health Rights (SRHR) for the indigenous in Jharkhand, over the last 6 years.

Srilekha has also contributed to sustainable livelihood projects and legal aid programs for survivors of sex trafficking. She has been conducting research based programs on maternal health, mental health, gender based violence, sex and sexuality. Her interest lies in conducting workshops for young people on life skills, feminism, gender and sexuality, trauma, resilience and interpersonal relationships.

A Guwahati-based college student pursuing her Masters in Tata Institute of Social Sciences, Bidisha started the #BleedwithDignity campaign on the technology platform Change.org, demanding that the Government of Assam install
biodegradable sanitary pad vending machines in all government schools across the state. Her petition on Change.org has already gathered support from over 90000 people and continues to grow.

Bidisha was selected in Change.org’s flagship program ‘She Creates Change’ having run successful online advocacy
campaigns, which were widely recognised. Through the #BleedwithDignity campaign; she organised and celebrated World Menstrual Hygiene Day, 2019 in Guwahati, Assam by hosting a wall mural by collaborating with local organisations. The initiative was widely covered by national and local media, and the mural was later inaugurated by the event’s chief guest Commissioner of Guwahati Municipal Corporation (GMC) Debeswar Malakar, IAS.

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