Obesity: The Indian Perspective

Dr. Anoop Misra Dr. Seema Gulati

Head, Nutrition Research Group National Diabetes, Obesity and Cholesterol Foundation (N-DOC) & Center for Nutrition & Metabolic Research (C-NET) Chief Project Officer Diabetes Foundation (India) C-6/57,Safdarjung Development Area

The Myth

You are talking of obesity, while malnutrition is everywhere

Reality: The Double Jeopardy

Prevalence of overweight/obesity among Adolescents (14-18 yrs), Delhi

Age Gender (yrs)
Male Female Male Female Male Female Male Female

Public Schools Overweight % (N=2593)

29.7 39.6 23.3 39.0 28.0 20.8 27.0 21.6

Age wise prevalence in Public Schools

Government Schools Overweight % (N= 955)

12.9 12.4 11.8 11.0 7.8 9.4 9.4 13.8 11.1

Age wise prevalence in Government Schools

12.7

14

32.6

15

29.9

11.5

16

25.1

8.4

17

25.3 29.0

11.0

Total% (N = 3548)

OVERALL PREVALENCE = 24.2%

Misra et al. Ann Nutr Metab.2011

Prevalence of Childhood Overweight/Obesity

Country/City Global USA/UK Australia India/Chennai India/Delhi India/Delhi Year 2004 2000 1995 2002 2004 2006 Prevalence 10 20 20 22 16 29
Misra et al., 2006

Obesity is Caused by Long-Term Positive Energy Balance

Fat Stores

2% = 2.3 kg in a year

Current Eating Habits

More than 40% of the children eat out once or more in a week 70% children eat chips once or more in a week 38% children eat burgers once or more in a week 48% children eat pizzas once or more in a week 40% eat french fries once or more in a week 60% eat noodles and drink colas once or more in a week Misra et al., Unpublished data, 2008

The Myths

Fat children are healthy. With age baby fat will go away

Reality:
50-70% of obese children will remain obese adults

The Evidence
Obesity
Obesity has reached alarming figures. Current figures in New Delhi indicate that every second person fulfills criteria of obesity or has excess abdominal fat.

The Myths
What will happen if a child is fat. He/she will not have any diseases
Reality:

Diabetes may strike early Polycystic ovaries, excess facial hair and infertility may occur in girls

Once fat, you could develop diabetes and heart disease as early in twenties!!!!

The Evidence
Diabetes
The current load of diabetes in India is expected to increase by 170% in the next 20 years. Our India-US collaborative study indicates that 1 in every 10 person in Delhi is a diabetic and 1 in every 5 Indian in US is a diabetic.

The Myths

Heart Disease starts at old age

Reality:

Hardening and blockage of the arteries starts at 11 years in boys and 15 years in girls

Prevalence of Fibrous Plaques in Young Adults: The Bogalusa Heart Study

120 100 Male Female

Percent (%)

Hardening and blockage of the 40 arteries starts at 11 years in boys 20 and 15 years in girls 0
60 2--10 11--15 16--20 21--25 26--30 31--39 Age

80

Berenson G, Am J Med Sci, 2001

The Evidence
High Blood Pressure
One in three urban Indians have high blood pressure. It is predicted to increase by 60% in next 20 years.

The Myths
A fat child is otherwise healthy

Reality:
28% of urban children have syndrome X, one step away from diabetes and 2 steps away from heart disease

The Evidence
Syndrome X
Nearly 35% of the general population and 1/4th of the adolescents have syndrome X, which predates diabetes and heart disease.

Prevalence of Insulin Resistance (by HOMA-IR) Asian Indian Children (n=396)

80 70 60

Overall Prevalence; Males, 21.8%, Females, 35.8%

Males Females 66.7 58.2 45 47.6

% Prevalence

50 40 30 20 10 0 Normal BMI 20 21.3

16.7

20.4

High BMI

Normal BF

High BF

Misra et al., Int J Obesity, 2004

hs-CRP in Asian Indian Children:

Levels Correlate to Obesity
50 40

% Prevalence

30 20

24 13

25

10 0
All Overweight Obese

Misra et al., Atherosclerosis, 2004

The Recommendation for Saturated Fat

Mean CRP:1.3 mg/L in children (moderate CV risk category) 1% decrease in energy intake by saturated fat:CRP levels decrease by 0.14mg/L Saturated fat intake <7% of energy intake would result in mean CRP level <1mg/L (Low risk for CVD)
Misra et al., Atherosclerosis, 2005

Diet and CRP:

The Myths
A child does not develop high blood pressure or high cholesterol
Reality:

Many children will have high blood pressure and low good cholesterol

The Evidence
Heart Disease The absolute death rate due to heart disease/ shall increase in India from 1.6 million/y in the year 2000 to 2 million in 2010 and 2.6 million by the year 2020, an increase by 61%.

The Myths
A child should enjoy, and eat and relax. Such time will not come again later
Reality:

Parents do not realize, but children are eating junk food all the time.

Consumption of lifestyle foods among Children

Item
Chips/ Pringle Corn Puffs etc. Popcorn Soft Drinks Sherbets Ice-Creams Cakes/muffins Chocolates Fried Food Fast Food (Pizza/burger)

Younger children
67.5 58.6 32.8 30.0 42.3 43.7 34.7 71.3 39.7 22.0

Older Children
66.3 52.4 28.2 41.0 45.6 57.9 31.7 74.7 56.7 30.93
Misra et al. Unpublished data.2011

> 2-3 times a week

The Evidence
High Lipids
1/3rd Indians have high levels of triglycerides (a form of bad cholesterol) and 30-70% have low levels of HDL (good cholesterol).

The Myths
All children are doing required physical activity
Reality:

Time on TV, internet and studies leaves little time for play. Even in pd assigned for physical activity, many do not participate

Willingness to be physically more active

Physical activity Younger Children
9-11 years % (N=600)

Older Children
12-18 years %(N =1200)

Willing Not Willing

67.3 (404) 32.7 (196)

71.0 (852) 28.6 (343)

Do not know

0.4 (5)

Misra et al. Unpublished data.2011

Sedentary Activities among children

Activity more than 60 minutes
TV viewing Book Reading Working on Computer Listening to Music Video Games

Younger children %(N)

70.3 (407) 55.0 (269) 55.6 (163) 30.6 (129) 53.7 (122)

Older children % (N)

84.7 (987) 58.9 (551) 67.9 (477) 47.6 (487) 56.2 (200)
Misra et al. Unpublished data.2011

The Myths
All of us (parents, teachers) teach them correct diet and lifestyle
Reality:

Most do not have correct knowledge or time to educate children. Healthy snacks are not prepared at home. Many parents and teachers are obese themselves! No cohesive intervention program in India

Consumption of lifestyle foods among Mothers

Item Mothers of Younger Children 53.3 31.0 28.7 24.7 42.0 43.4 23.7 47.3 38.8 14.7 Mothers of Older Children 56.7 47.2 35.7 27.8 43.7 48.2 29.16 57.2 37.7 14.8
Misra et al. Unpublished data.2011

> 2-3 times a week Chips/ Pringle Corn Puffs etc. Popcorn Soft Drinks Sherbets Ice-Creams Cakes/muffins Chocolates Fried Food Fast Food

Knowledge Regarding Unhealthy Diet and Diseases among Children

90 80 70 60 50 40 30 20 10 0
er Ov t igh we e yp H

Younger Children

Oldren Children

Percentage

n sio n rt e g Hi hT

ly rig

ce

es id r

ol ter s ole Ch

gh hi

ar ug S

r ea H

se ea is tD

ce an C

Misra et al. Unpublished data.2011

Knowledge Regarding Unhealthy Diet and Diseases among Mothers

90 80 70 60 50 40 30 20 10 0
ns io n be sit y ri de s Tr ig ly ce te O yp er ei gh ta nd H

Yes

No

ho le st e

ig h

H ig h

ve r

ig ht C

H ea

rt

Misra et al. Unpublished data.2011

ise a

ca nc er

su ga r

ro l

se

Relationship Between Food Consumption Pattern of Mother and Children

Correlation analysis was done for food consumption of mothers and children. A very high order correlation was found for the following food items: -cereals -pulses -vegetables -Milk and Milk products -Meat and Poultry -Fruits and fruit juices -Nuts
Misra et al. Unpublished data.2011

10

The Myths
So what if there are metabolic abnormalities or diseases, these can be easily treated
Reality:

Most of these diseases are catastrophic and have complications that cannot be reversed. Most will shorten lifespan

Complications of Obesity
Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataract Coronary heart disease Diabetes Dyslipidemia Hypertension
Severe pancreatitis

Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

Hypertension Depression Heart Diseases

Diabetes

Respiratory Problems Gall Bladder disease Cancer

Obesity and Health risks

Osteoarthritis Optical disorders

Infertility Renal Disease

Stroke

Causes And Prevention

Unhealthy Eating Habits

Erratic eating habits Frequent fast and fried food consumption Excess intake of colas Excess consumption of refined foods Not consuming enough fruits and vegetables

Sedentary Lifestyle
Lack of Physical Activity : 67% children spend less than 1 hour in physical activity

Macronutrient Intake Profile of the Asian Indian Adolescents (Urban)

Macronutrients

Gender Boys Girls Boys Girls Boys Girls Boys Girls

RDA* %energy 10-15%

13-15y (n=254) unit/d 2339498 1905 472 69 19 53 16 316 71 238 53 85 26 77 25 % energy 12 2 11 1 54 7 51 7 32 6 36 6

16-18y (n=543) unit/d 2324 549 1820 421 68 18 50 13 313 77 239 62 84 30 71 21 % energy 12 1 11 2 54 8 53 6 32 7 35 6

p-value 0.856 0.045 0.900 0.001 0.352 0.892 0.681 0.030

Energy (kcal/day) Protein (g/day) Carbohydrate (g/day) Total fat (g/day)

55-65%

15-30%

* Recommended Dietary Allowance (Figures mentioned are Mean SD)

Misra et al., JACN 2009

Health and Nutrition Education Initiatives by Diabetes Foundation (India)

Diabetes Foundation (India) has pioneered in launching Health and Nutrition Education initiatives, the first of their kinds in the whole of South Asia to spread the awareness of Obesity and Diabetes prevention amongst the youth

Diabetes and Obesity Awareness for Children/Adolescents & Adults A 50 city country wide awareness and education program
Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation
March 5, 2011

Objectives
Overall Aim:

To create mass awareness about diabetes and obesity among children and adults and to thus act as change agents for better lifestyles and prevention of diabetes

Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation & Emcure Pharmaceutical (India) Pvt. Ltd

March 5, 2011

Objectives
Specific Objectives
To enhance awareness among school children, and adults about diabetes and obesity through
Lectures on Diabetes: Causes, Consequences, Prevention & Care School Health Camps Public Awareness Campaign:
Public Health Lectures on Diabetes: Causes, Consequences, Prevention and Care Diabetes Health Camps Walk for Awareness about Diabetes Prevention on November 14, 2011 World Diabetes Day Distribution of printed education material to children and adults Message dissemination through media
Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation & Emcure Pharmaceutical (India) Pvt. Ltd
March 5, 2011

Participating Teams

Across 50 cities in India

Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation & Emcure Pharmaceutical (India) Pvt. Ltd

March 5, 2011

Initiatives being implemented in various cities of India

New Delhi Mumbai Jaipur Agra Chandigarh Vadodara Noida Dehradun Allahabad Bangalore Pantnagar Pune Lucknow Bhubaneshwar

MARG (The Path)

Medical education for children/ Adolescents for Realistic prevention of obesity and diabetes and for healthy aGing
A Project of Diabetes Foundation (India) Funded by: World Diabetes Foundation (Denmark)

The initiatives are organizing activities to focus on:

1. 2.

changing the individual (children, family, teachers) changing the environment (school, home)

Information and Educational Material for Children, Parents and Teachers

TEACHER
Trends in Childhood Nutrition and Lifestyle Factors in India
A 6 City Countrywide Project of Diabetes Foundation (India)

CHETNA
Childrens Health Education Through Nutrition and Health Awareness Program
A Project of Diabetes Foundation (India) Funded by: Rotary Club South East (Delhi)

Children attending the lectures on Healthy Living

Teachers participating in a lecture on Healthy Living

Mothers participating in a Focused Group Discussion

Poster Making Competition

Poster Making Competition

Cooking Competition

Skit Competition

Extempore Competition

Quiz Competition

Other Activities
Card Making Collage Making Health Board setup Mask Making Cartoon strip making Poem writing Healthy recipe writing Healthy Tiffin Day

Study
School-based Intervention Trial for Prevention of Childhood Obesity: The MARG Study Objective:
To study the effect of an educative and participatory intervention trial for a period of 6 months on the improvement of knowledge levels, anthropometric measurements, body composition and blood profile of urban adolescents aged 15-17 years.

A Case-Control Community Intervention Trial 101 cases and 108 controls 6 months: July, 2008-January, 2009
Misra et al., Eur J Clin Nutr 2010

Intervention Trial (6 months): Case Control Design 1. Intensive intervention vs. usual intervention 2. Improvements in the following aspects:
a. b. c. d. e. f. g. Knowledge levels Dietary habits Anthropometric measurements Body fat composition Glycemic indicators Insulin levels, CRP levels Lipid profile

Key Activities:

Phase 2: Interventions

Weekly individual counseling of children Lectures Activities: Skits, quiz competition, extempore, focused group discussions Replacing unhealthy food in canteen with healthy alternatives Health camp for parents and teachers Recipe demonstration for healthy Tiffin Skit demonstration by the intervention group in morning assembly on important days like the World Food Day Quiz competition in class Paragraph writing on topics like: Ways in which you can prevent yourself from diabetes and heart disease in the next 5-8 years, healthy alternatives to junk food, planning a days diet for themselves, planning their own tiffins for a week Checking tiffins of younger classes in their school by the intervention group

% Decrease in Consumption Patterns of Energy-Dense Foods

Consumption of Food Articles Sweetened carbonated drinks > 3 times/w Western energy-dense foods (Burgers, pizzas, french fries, noodles) > 3 times/w Chips/ Namkeen/Maggi > 3 times/w Indian energy-dense food > 3 times/w
All differences are statistically significant

Case School 15.4% 9.2% 8.3% 6.3%

Control School 7.9% 1.4% No change 2.2%

Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press

Consumption of Fruits (brought in Tiffin) Case School Baseline Follow-up

*Statistically significant

Control School 29.8% 25.9%

10.1% 40.4%*

Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press

% Change in Time Spent in TV Viewing and Physical Activity

Variables TV Viewing > 2 h/d Physical Activity 30-60 min/d
All differences are statistically significant Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press

Case School 5.2% 9.8 %

Control School 2.4% 3.7%

Pre- and Post Surveys Show significant Increase in Knowledge

80 70 60 50 40 30 20 10 0 Healthy living Junk food Obesity Diet and DM

Knowledge, Attitude and Practice about Nutrition, Obesity and Diabetes:

Pre Post

Shah P, Misra A et al., Br J Nutr 2010

% Change in Anthropometric Parameters

4% 2% 0% -2% -4% -6% -8% -10% -12% -14%

WC

Mid -thigh

SAD

Triceps

Biceps

P< 0.05 in Control SAD P< 0.001 in Case biceps

Case

Control

Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press

% Change in Metabolic Parameters Variable Fasting Glucose HDL-C

*p < 0.001

Case School -4.9%* 2.2%

Control School -2.2% -2.3%

Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press

% Change in Fasting Serum Insulin and CRP

13

47

6.2

CONT.
INT. CONT.

-21.6

Insulin
Misra et al., Unpublished data

Hs-CRP

Summary
Rising childhood obesity in urban India and in other Developing Countries is of great concern, and would fuel the diabetes and the metabolic syndrome epidemics further. Overall, it is more in urban areas (vs. rural), and public schools. Its consequences, insulin resistance, PCOS, hirsutism, type 2 diabetes, subclinical inflammation and hepatic steatosis are now frequently seen in children . Countrywide programs, akin to our program MARG in schoolchildren are urgently needed.

Thank You
seemagulati2007@gmail.com

Thank You