Nutrition survey: Children show early signs of diabetes, high cholesterol.

India has made considerable progress in tackling malnourishment, but more children are showing early signs of diabetes and high cholesterol.

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, five to nine years, were pre-diabetic and 1 per cent were already diabetic, according to the government’s Comprehensive National Nutrition Survey (CNNS), released on October 8, 2019. About 5 per cent of children and adolescents, five-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 five and 14 years, and to study overnutrition and markers of NCDs in children. Previous national surveys studied the health status of children up to 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

One in three (35 per cent) children, younger than five years, were stunted—low height for age; 33 per cent were underweight, one in six (17 per cent) were wasted—low weight for height; and 41 per cent 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 per cent of children were stunted, 35.8 per cent were underweight, and 21 per cent 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 per cent 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 per cent of children, 5-9 years, and 4 per cent of adolescents (10-19 years) had a high level of total cholesterol. About 26 per cent of children, 5-9 years, and 28 per cent 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 per cent) of children, 5-9 years, and 16 per cent 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 per cent of children and adolescents were at risk of chronic kidney disease, and 5 per cent 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.

Ignoring overnutrition

The proportion of girls (15-19 years) and women (20-49 years) who were overweight more than doubled from 1.6 per cent to 4.9 per cent and from 11.4 per cent to 24 per cent, 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 behaviour — 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 per cent) children, five to nine years, and 36 per cent of adolescents, 10-19 years, ate fried foods once a week. Almost 7.6 per cent of five- to nine-year-olds and one in 10 (10.4 per cent) adolescents, 10-19 years, drank aerated drinks once a week.

Among children and adolescents, the majority consumed dark green leafy vegetables (90 per cent) and pulses or beans (85 per cent) at least once per week. The consumption of dairy products was less frequent, with two-thirds (65 per cent) 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 per cent consumed fruits, 35 per cent consumed eggs, and 36 per cent consumed fish or chicken or meat. Similarly, among adolescents, only 41 per cent consumed fruits, 35 per cent consumed eggs, and 36 per cent 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.

Economic status and nutrition

Across India, 4 per cent of children, five-nine years, were overweight—where body mass index for age is one standard deviation higher than it should be — and 1 per cent were obese-— when body mass index for age is two standard deviations higher, the survey found.

The highest prevalence of overweight children, five to nine years, was in Goa (14.5 per cent) and Nagaland (14.7 per cent), while the lowest prevalence of overweight children was in Jharkhand and Bihar, where less than 1 per cent were overweight.

A household’s socio-economic status impacts whether a child will be overweight. Only 1 per cent of children from households in the lowest wealth quintile were overweight compared to 9 per cent of children in the highest wealth quintile.

Compared to rural areas, more children in urban areas suffered from obesity. In urban areas, 7.5 per cent of children, five to nine years were overweight, as compared to 2.6 per cent in rural areas. Similarly 9.7 per cent of adolescents from urban areas, 10 to 19 years, were overweight as compared to 3.2 per cent 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 per cent of school-going children, and 2.1 per cent of adolescents from ST were overweight and obese as compared to 5.1 per cent of children and 7.1 per cent of adolescents who belonged to ‘other’, implying upper castes.

Also, 2 per cent 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.