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Last year, NIN through NNMB and ICMR conducted a nutritional study on chronic non-communicable diseases (NCDs) that evaluated hypertension, diabetes and dyslipidemia in urban population of 16 Indian states. Dr R Hemalatha, Director, NIN  reveals outcomes of the research report

What are the key findings of the research report on Urban Nutrition Data of India 2017?

Considering that India’s nutrition transition has been rapid in the last few decades, it was thought necessary to look into the nutritional status of the urban population especially because most of our earlier surveys through the National Nutrition Monitoring Bureau (NNMB) were among rural areas. The last few decades are marked by phenomenal changes with liberalisation, job opportunities, urban areas have been swelling with population and also there have been phenomenal lifestyle and dietary changes that have occurred. Gone are the days when India was thought to be the home for only undernourished people, but today, we are confronting a paradox in which we have undernutrition and overweight/ obesity and associated non-communicable diseases co-existing. From double burden of malnutrition (undernutrition and overnutrition), we are now confronting the triple burden where the micronutrient deficiencies are seen both in undernourished and overweight/ obese population. All these necessitated a study to see what the current nutritional situation is like.

What role has ICMR and National Institute of Nutrition (NIN) played in bringing out the research report?

This study was implemented by National Institute of Nutrition (NIN) through National Nutrition Monitoring Bureau (NNMB) units located in different districts. Financial support was provided by Indian council of Medical Research (ICMR).

In this comprehensive study, nutritional status, chronic non-communicable diseases (NCDs) such as hypertension and diabetes, and dyslipidemia were evaluated in urban population of 16 states of India. The results showed high frequency of hypertension and diabetes, and high cholesterol levels in one fifth of the urban population. Of the 16 states studied, Kerala has the highest numbers of men (46.6 per cent) and women (38 per cent) with hypertension followed by Assam; while Puducherry has the highest numbers of men (42 per cent ) and women (30 per cent) with diabetes, followed by New Delhi (36 per cent). Relatively lower numbers of men (28 per cent) in Madhya Pradesh and women (21 per cent) in Andaman and Nicobar Islands have hypertension; and again, Madhya Pradesh men (17 per cent) and women (13 per cent) recorded the lowest level of diabetes. Income was directly associated with hypertension and diabetes in both men and women.

As for overweight people, a whopping one half of urban men (52 per cent) and women (59 per cent) are overweight (BMI=23) or obese(BMI=28) with Asian cutoffs.While the highest number of overweight and obesity among men was observed in Rajasthan (63 per cent) and Puducherry (62 per cent), Tamilnadu recorded highest number of women (69per cent) with overweight and obesity after Puducherry (74 per cent).As per the global cutoffs (BMI =25), 34 per cent men and 44 per cent women are overweight or obese.

Nearly a fifth of the pre-schoolers living in the same regions are undernourished (17 per cent, low weight for age) and stunted (20 per cent, low height for age). While, more children are stunted in Uttar Pradesh (40.8 per cent), Puducherry recorded the lowest prevalence of stunting (11.6 per cent). Even though low birth weight (LBW) prevalence is relatively low at an average of 16.4 per cent, ranging from 10 per cent to 30 per cent , stunting persisted at an average of 28.7 per cent, ranging from 11.6 per cent to 40.8 per cent in preschool children. Infant and young child feeding practices were poor in these regions with only 50 per cent complying with early initiation of breast feeding and 34 per cent following timely initiation of complementary feeding at six months of age.

Although 82 per cent of urban households have sanitary latrines and around 85 per cent have access to protected drinking water, we still have nearly a fifth of all urban population who do not have access to these basic requirements.

Which diseases are more prevalent in urban areas?

As we can see from the urban data, NCDs like Hypertension, Diabetes and Cardiovasular dieseas are on the rise. The India State-level disease burden initiative, in which also draws from the Urban Survey data, estimated a 36 per cent reduction in Disability Adjusted Life Years (DALYs) in India, from 1990 to 2016, suggesting an overall decrease in disease burden due to infectious diseases, maternal and neonatal and nutritional disorders in India. At the same time, DALYs due to NCDs are going up rapidly. It is indeed a cause of concern. Despite reduction in maternal, neonatal and nutritional disorders, child and maternal malnutrition still topped the five leading risk factors for DALYs in 2016, the others being air pollution, dietary risks, high systolic blood pressure, and high fasting plasma glucose. While deaths due to diarrhoeal diseases lower respiratory infections and tuberculosis decreased, deaths due to ischaemic heart disease (heart attack) and diabetes increased significantly as per the State-level Disease Burden. Epidemiological transition is occurring with increase in diseases due to NCDs such as diabetes, ischemic heart disease, stroke, cancers etc; with infectious diseases, and maternal, neonatal and nutritional disorders continuing to be public health problems.

Will this trend be soon visible in rural areas and in which states?

Some regional studies in India have reported NCDs as the leading cause of death even in rural India. Projection estimates from the WHO have shown that by the year 2030, CVDs (ischemic heart disease, stroke) will emerge as the main cause of death (36 per cent) in India. And majority of deaths in India are premature with substantial loss of lives during the productive years adding to economic loss to the country.

Why men in urban areas suffer more than women from hypertension?

Comparatively, more men have hypertension than women due to biological factors like hormone- estrogen, which is protective in women. Additionally, behavioural factors such as increased smoking, alcoholism among men may also contribute to a higher prevalence of hypertension.

Tell us about NIN’s role in formulating strategies to promote food safety and streamlining regulatory mechanisms?

NIN- ICMR, ministry of health and family welfare, works closely with ministry of women and child development (WCD) and Food Safety Standards Authority of India (FSSAI). Most of the nutrition programmes in the country are supported by NIN- ICMR research findings. Diet and nutrition related regulations are also guided by NIN- ICMR research findings. The Dietary Allowances for Indians are recommended by NIN-ICMR and are revised from time to time depending on what India is eating and latest research findings. In this centenary year, we are planning to soon revise the Recommended Dietary Allowance (RDAs) which were last recommended in 2011. In addition, NIN constantly has been evaluating various nutrition programmes and providing advice to state governments. In fact some of our district-level studies have mapped undernutrition among children and have provided valuable inputs for state governments like Madhya Pradesh, Gujarat etc., to plan targeted interventions.

What is inborn metabolic disorder? Has there been a progress so far to control it?

In contrast, Inborn errors of metabolism (phenylketonuria, maple syrup urine disease, glycogen storage disease, lipid storage disease etc) are rare genetic disorders in which the body is not able to utilise the food to derive energy. These disorders are generally linked with defects in specific enzymes needed for digestion and metabolism of food. Foods that are not metabolised into energy can build up in the body and cause a wide range of symptoms. Several inborn errors of metabolism cause developmental delays or other medical problems and can be life threatening.

These disorders are due to genetic abnormalities and therefore difficult to control.

Why new born screening is not mandatory in India? How do we make it mandatory in our country?

Hypertension, diabetes and obesity cannot be detected at birth. These are lifestyle diseases (diet and physical activity) and can be prevented by making smart choices in food and by resorting to regular physical activity.

New born screening for IEM is available, primarily in metros, but given the multitude of possible mutations underlying inborn errors of metabolism, it is not possible to recognise all inborn errors of metabolism by neonatal screening. However, screening for congenital hypothyroidism and deafness may be prioritised due to grave consequences if these conditions are left untreated and proven benefits with appropriate and timely treatment. But this needs a lot of manpower and funds, but we can aim to get there soon.

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