Minutes of the 3rd NTBN Meeting - | NITI Aayog

NA/SW 1 - 1 6 (26) t 20 17-WC DNlTlAayog

WCD DivisionNlTlAayog

Sansad MargNew Delhi-110001Dated: 08.05.2019

OFFICE MEMORANDUM

Subject Minutes of the Third Meeting of the National Technical Board onNutrition held on 12.04.2019.

The undersigned is directed to enclose a copy of the Minutes of the Meeting onthe above cited subject held under the Chairpersonship of Dr. V. K. Pau!, Member, NlTlAayog on 12.04.2019.

p lil6bDr R.V.P Singh

SRO

To,

Al! Participants

Page 1 of 9

MINUTES OF THE THIRD MEETING OF NATIONAL TECHNICAL BOARD

ON NUTRITIONHELD ON 12.04.2019 AT NITI AAYOG

A Scientific Consultation on Childhood and Adolescent Overweight-Obesity in

India

The Third Meeting of the National Technical Board on Nutrition (NTBN) was held

under the Chairpersonship of Dr. V.K. Paul, Member, on 12.04.2019 at NITI Aayog. The list

of the participants is attached (Annexure 1).All the non-official members signed a No-

Conflict of Interest undertaking provided by NITI Aayog.

2. Director (Women and Child Division), NITI Aayog, welcomed all the participants.

She brought to note that the present meeting has been convened as a scientific consultation to

discuss the issue of childhood and adolescent overweight-obesity (O-O) in India. She

informed the group that relevant experts on the subject have been invited to make

presentations on the burden of the problem, its key determinants and the evidence on

effective preventive strategies to discuss the way forward for India on this issue.

3. Dr. V. K. Paul, Member (Health and Nutrition), NITI Aayog opened the Consultation

by stating that it is important that the young population of the country is healthy and well-

nourished for India to be able to reap the demographic dividend and achieve high

productivity and economic growth. Government and academic circles have been concerned

about the problem of undernutrition in India and major efforts are being made to combat this

through POSHAN Abhiyaan. However, given the epidemiological transition that India is

going through, another important problem that confronts us is over-nutrition (overweight and

obesity; O-O). Childhood and adolescent O-O is an important area of concern, as it is a

precursor to adult O-O and non-communicable diseases (NCDs). He briefly referred to the

increasing burden of childhood and adolescent O-O in India with the more developed States

showing a high prevalence with indications that metabolic problems like pre-diabetes at early

age might be on the rise. This has huge cost implications for India in the coming years.

However, most action in India is presently around NCDs, primarily targeted to the adult

population and there are no specific policy or programmatic provisions to address the menace

of rising childhood and adolescent O-O.

4. Thereafter, invited experts, Dr Viswanathan Mohan (Madras Diabetes Research

Foundation, India) and Dr. Prabhakaran Dorairaj (Public Health Foundation of India) made

presentations on the burden of the problem, its key determinants and potential preventive

strategies. The detailed presentations are attached as Annexure 2.

After the presentations, Dr Paul opened the topic for group discussion.

5. Dr Paul initiated the discussion by enquiring if there is any strong evidence of a

package of interventions on reducing childhood and adolescent O-O that the Government

Page 2 of 9

may confidently take up and expect that it will decrease the incidence/prevalence of the

problem. Dr. Dorairaj mentioned that evidence is available from cities like Denmark, New

York, and California which have shown a decline in O-O profile of population following a

ban on the trans-fats.

6. Dr. Bhan stated that O-O is a complex, multi-dimensional and multi-sectoral problem

and it is important that we act on it now. He recommended that a national level cross-sectoral

body/structure with diverse stakeholders be created which is primarily action-oriented.This

body/structure should comprise both Government and non-Government partners and include

various related Ministries, administrators, program managers, academicians, researchers and

other experts who can get together and get things done. The group needs to identify work

priorities in each sub-area for e.g., regulatory policies required, formulation of healthcare and

programmatic guidelines, defining research priorities etc.

7. Dr. Toteja from Indian Council of Medical Research (ICMR) highlighted that on the

recommendation of Ministry of Health and Family Welfare (MoHFW), ICMR has taken up a

study to analyse consumption of foods high in fat, salt and sugar. This study covers 16

locations of India and has a sample size of 17000 households and 3.5 lakh population. Data is

also being collected on anthropometry, blood pressure and lipid profile. Data of this study is

likely to be available by the end of this year.

8. Director General (DG), Indian Council for Agriculture Research stated that social as

well as policy action required to tackle this issue. Restrict high energy diets in schools,

hospitals and other public settings. Make physical activity mandatory in schools and

introduce good diets, for e.g., the Kendriya Vidyalayas in MP have started agri-nutri gardens

involving students and some States are promoting millets in the diet.

He also informed that India produces more fruits and vegetables than cereals and

pulses but the issue is with storage and the supply chain is a big concern. Effective strategy is

required to involve food processing industries to explore healthy ways to process and store

the fresh fruits and vegetables.

9. Dr Pradeep Saxena, Additional DG, MoHFW brought to note that already a National

Program for Control of NCDs which has been launched by the MoHFW, the National

Programme for Prevention and Control of Cancer, Diabetes, Cardio-vascular diseases and

Stroke (NPCDCS), which includes all relevant stakeholders and has intervention components

like school based activities etc. He suggested that relevant existing interventions may be

strengthened under the same program if required. Any programme on obesity and overweight

can be strengthened by linking with this program.

10. Dr. Prema Ramachandran, Director, Nutrition Foundation of India highlighted the

increasing pace of overweight and obesity from 1990 to 2015.Until two decades ago, Indians

had adequate physical activity in domestic, occupational and transport domains. Over the last

two decades, physical activity in daily chores had declined. She stressed that the aspirational

Page 3 of 9

districts should be a major area of focus and we should ensure that the growth of

undernourished children should be promoted in a manner that they do not end up becoming

overweight/obese as adults.

11. Dr Sila Deb from MoHFW stated that the Government is undertaking several

activities in the domain of NCDs and also engaging with FSAAI on some aspects of obesity.

She said that a multi-stakeholder action is required and inputs from the Consultation can be

used to develop a strategy document to help Ministry take cohesive action.

12. Dr. Rajesh Kumar, Joint Secretary, MoWCD, highlighted that a mass movement like

‘Jan Andolan’ is required for creating awareness to reduce obesity, for e.g., a “Walk India”

campaign.

13. Secretary, Ministry of Woman and Child Development (MoWCD) concurred with all

the previous suggestions made by the group. He agreed that physical activity among children

has reduced over the years and it needs to be promoted, especially in schools. He further

recommended that mass movement to create awareness about obesity and overweight is

important and community needs to be involved for the same. He concurred with the

importance of providing nutritious, healthy and well balanced meals under ICDS and MDM

programs. He explained that advisories have already been issued to State Governments to

promote healthy diets but this needs to be strengthened through community sensitisation.

14. Dr. Rubeena Shaheen from FSSAI explained that food regulation is the most

important area, and standards of food have already been developed by FSSAI. She mentioned

that regulation on packet labelling has already been notified, presently on call for comments,

that on display of nutritional information in food is at the final notification stage, reduction of

trans fat from 5% to less than (no more than) 2% is by 2022 is targeted and the promotion of

healthy food in schools is in the draft notification stage.

She also informed the group about other related FSSAI initiatives like the Eat Right

Movementlaunched on 10th July 2018 which built on two broad pillars of 'Eat Healthy' and

'Eat Safe' in which several food businesses pledged to decrease salt and trans-fat in their

preparations. FSSAI is focusing on reducing the daily intake of sugar, salt and fat with its

campaign called ‘Aaj se thoda kam’. FSSAI also initiated Swasth Bharat Yatra, a pan India

campaign to create awareness on the importance of being healthy. Lastly, to address

malnutrition and micronutrient deficiency, FSSAI places a lot of focus on food fortification.

She recommended that these initiatives need to be sustainable and focus on education policy

is crucial.

15. Dr Vandana Jain, Paediatric Endocrinologist from AIIMS, Delhi highlighted the need

to focus on education policy – the stress on education shifts the focus from physical activity –

this is the case with teachers and students alike so both need to be informed and counselled.

Another area of major focus is the advertisements on television. She drew comparison

between the industry policies in the domains of tobacco industry where these harmful

Page 4 of 9

products are advertised as being “cool” to the younger generation, the same is the case with

sweetened beverages like cola chips etc. where the children and parents believe that if

something is on TV it must be right and feel denied or deprived of a privileged if parents

refuse to provide these to the children. Further strengthening of the “coolness” and the

“righteousness” beliefs of these ads by celebrity endorsements was flagged as an issue of

concern.

16. Dr Prabhakaran Dorariraj summarised the proposed interventions in four domains:

regulatory, multi-disciplinary interventions addressing the upstream environmental

determinants, behaviour change through smart marketing and advertising and context

specific, culturally appropriate/sensitive, equity promoting, and evidence-based messaging

with multi stakeholder involvement.

17. Mr. K.M.S Khalsa, Deputy Secretary, Department of Food and Public Distribution

(DoFPD) informed that the role of DoFPD is limited to allocation of food grain under PDS.

However, in order to address the problem of micronutrient deficiency and the RDA gap,

DoFPD is promoting distribution of fortified commodity as well and has recently launched a

centrally sponsored pilot scheme on rice fortification. The Department is also exploring the

possibility to distribute additional food grain as current distribution meets 40% of the

requirement to meet the gap of 60%.

18.Some other points emanating from the discussion are as follows:

Periodic monitoring of standard measures is required to understand the O-O trends in

various age groups.

Accessibility and affordability of healthy foods is an important area to explore and to

work on. Promotion of healthy diet is important both for under- and over-nutrition.

Indians eat too much of carbohydrates and the primarily cereals being given through

the Public Distribution System (PDS) are rice and wheat. These should be

supplemented with healthier foods which have more protein, and are rich in

antioxidants and micronutrients.

Strong policy framework is required for promotion of healthy diets and lifestyle in

schools. Supply of junk food should be restricted around schools areas and physical

exercise should be encouraged.

Policy directions should be given to private schools to provide nutritious meals.

Education and awareness of mothers about the importance of child nutrition and how

to provide healthy nutritious diets to their children is crucial.

Role of AYUSH in prevention of childhood and adolescent O-O should be explored.

Fast developing urban cities where the adverse food and nutrition (availability and

price of fresh fruits and vegetables) and physical activity environment (walkways,

parks etc.) is pushing an epidemic of overweight and obesity should be tackled by

specific focus on urban areas.

Data on the dietary practices of Indians needs to be collected and analysed to be able

respond to the changing trends through timely intervention.

Page 5 of 9

19.The following recommendations were made in the Meeting:

i. Define a monitoring framework for childhood and adolescent O-O in India,

including the standard indicators to be measured, methodology (how, at what level-

national/state/district/sub-district, and how often- yearly/ 3-yearly/ other), and the

targets to be achieved with timelines.

(Action: NITI Aayog)

ii. Regulatory policies required at various levels to specifically tackle childhood and

adolescent O-O need to be identified. These should include fiscal (taxation on

unhealthy foods like those high in trans-fats, salt and sugar etc.) and others (e.g.,

those related to advertising and marketing of various unhealthy products like palm

oil, junk foods etc.) to promote healthy and discourage the use of unhealthy diet and

practices.

(Action: FSSAI, NITI Aayog)

iii. Schools, colleges and universities are a major battleground and promotion of healthy

diets is very important. Norms for food provision in and around schools, colleges

and universities should be defined as well as those for physical activity. An

awareness program/training on the issue should be included and provided to the

teachers and students alike.

(Action: MoHRD, MoHFW, FSSAI)

iv. The nutritional composition of the food being provided as part of the Mid-Day Meal

Program should be examined for optimality of macro- and micronutrients such that it

protects against undernutrition but does not predispose to over nutrition.

(Action: MoHRD)

v. The nutritional composition of the food being provided as part of the ICDS program

should be examined for optimality of optimality of macro- and micronutrients such

that it protects against undernutrition but does not predispose to over nutrition.

(Action: MoWCD)

vi. Standardised messages to create awareness about the issue should be created for

mass media (TV, Radio, Social media etc.) need to be developed and an event may

be organised to disseminate these messages.

(Action: MoWCD, MoHFW and FSSAI)

vii. AYUSH and Yoga need to be promoted aggressively for wellness including O-O

prevention among school children and adolescents, along with increased physical

activity and sports participation.

(Action: Ministry of AYUSH, Ministry of Youth Affairs and Sports, and

MoHRD)

Page 6 of 9

viii. Explore the need to conduct a national level survey on “What India eats and why?”

to document the dietary practices of specific age groups, especially children and

adolescents, with the aim to identify the critical periods and opportunities for

effective interventions.

(Action: ICMR-NIN)

ix. Millets, jowar, ragi, bajra and bio-fortified crops should be promoted through the

PDS, and a diversified, well balanced diet (calories, proteins as well as

micronutrients) should be promoted as part of ICDS and MDM schemes and in

various other public schemes.

(Action: Department of Food, MoWCD, MoHRD)

x. Like the “White Revolution” and the “Green Revolution”, there is now a need for

“Fruit and Vegetable Revolution”. Measures should be taken to increase the

production of fruits and vegetables and improve their access and consumption. An

effective strategy should be developed for efficient processing and storage of fresh

fruits and vegetables.

(Action: Ministry of Agriculture and Farmers Welfare)

xi. Draft a comprehensive position paper on the issue of childhood and adolescent O-O

including a situational analysis, potential solutions and the way forward for

country’s policy and programmatic response including all the issues highlighted

above.

(Action: NITI Aayog)

The Meeting ended with a vote of thanks to all participants.

******

Page 7 of 9

Annexure 1: List of participants

Sr

No

Name and Organisation Email Contact

1 Dr. J.H Panwal

Jt. Technical Adviser,

MoWCD

[email protected] 9711995999

2 Dr. R M Tandon

IMA


3 Dr. Prerna Kohli [email protected] 9811862338

4 Dr. Rachita Gupta [email protected] 9958097016

5 Dr. A Vamsi Krishna [email protected] 9650153253

6 Dr. Pradeep Saxena

Add DDG, MoHFW


7 Dr. Prabhakaran Dorairaj [email protected] 9810118696

8 Dr. D.K Yadava

Rep DG, ICAR


9 Dr. Rubeena Shaheen

Director (FSSAI)


10 Dr. M.K Bhan [email protected] -

11 N. K Arora 9818110376

12 Dr. Vandana Jain

Professor, AIIMS


13 Dr. Hemlatha

Director, NIN

[email protected] -

14 Dr. Rajkumar Bhandari [email protected] 9930680444

15 Prof Meenakshi Mehan [email protected]

m, [email protected]

9227770218

16 Geeta Trilok Kumar [email protected]

m, [email protected]

9650559995

17 Nita Bhandari [email protected] 9899144127

18 Prof Sangeeta Yadav [email protected] 9968604307

19 Anoop Misra [email protected] 9811153997

20 Dr. Sila Deb [email protected] 9868843430

21 K.M.S Khalsa [email protected] 23383046

22 Anuja Agarwala [email protected] 9873164643

23 Prema Ramachandran [email protected] 9891485605

mailto:[email protected]





Page 8 of 9

24 Mohan Gupta [email protected] 9822718745

25 Dr. Uma V Manjappara [email protected] 9379664585

26 DGS Toteja [email protected] 9868368875

27 Shalini Gupta MoWCD [email protected]

28 Kriti Chugh, Asst Director,

FSSAI


29 Dr. V Mohan MDRF [email protected] 9840097370

30 Dr. Ajay Gambhir

[email protected]

om

98115 57085

31 Dr. VK Paul

Member, NITI Aayog

[email protected] -

32 Ms. Anamika Singh

Director, NITI Aayog

[email protected] -

33 Dr RVP Singh

Sr. Research Officer, NITI

Aayog

[email protected] -

34 Dr. Supreet Kaur

Sr. Consultant, NITI Aayog


35 Dr. Shuchita Gupta

Consultant, NITI Aayog


36 Ms. Khushboo Saiyed

Young Professional, NITI

Aayog


37 Ms. Vedeika Shekhar

Young Professional, NITI

Aayog


``







Page 9 of 9

Annexure-2

1. Presentation by Dr. Viswanathan Mohan

2. Presentation by Dr. Prabhakaran Dorairaj

Dr.V.Mohan., MD., Ph.D., D.Sc., D.Sc (Hon. Causa),

FRCP (London, Edinburgh, Glasgow & Ireland), FNASc., FASc., FNA, FACE, FTWAS, MACP

PRESIDENT & DIRECTOR

MADRAS DIABETES RESEARCH

FOUNDATION,

SIRUSERI, CHENNAI

CHAIRMANDR.MOHAN’S DIABETES SPECIALITIES

CENTRE,

GOPALAPURAM, CHENNAI

WHO COLLABORATING CENTRE FOR

NONCOMMUNICABLE DISEASES

ICMR CENTRE FOR ADVANCED

RESEARCH ON DIABETES IDF CENTRE OF EXCELLENCE

IN DIABETES CARE

Problem statement : Burden and risk factors of childhood and adolescent overweight and

obesity in India

The term ‘overweight’ refers to excess body weight for a

particular height whereas the term ‘obesity’ is used

to define excess body fat.

Overweight and obesity primarily happen either due to

excess calorie intake or insufficient physical activity or

both.

Furthermore, various genetic, behavioural, and

environmental factors play a role in its pathogenesis.

Definitions

Ranjani H, Mehreen TS, Pradeepa R, Anjana RM, Garg R, Anand K, Mohan V. Indian J Med Res. 2016;143:160–74.

PROBLEM STATEMENT

The prevalence of obesity in adolescents and children

has risen to alarming levels globally, and this has

serious public health consequences.

Sedentary lifestyle and consumption of calorie-dense

foods of low nutritional value are believed to be two

of the most important etiological factors responsible for

escalating rates of childhood obesity in developing

nations like India.

Ranjani H, Pradeepa R, Mehreen TS, Anjana RM,, Anand K, Garg R Mohan V.

Indian J Endocr Metab. 2014;18:17–25.

Childhood obesity is a forerunner of metabolic

syndrome, poor physical health, mental disorders,

respiratory problems and glucose intolerance, all of

which can track into adulthood

Developing countries like India have a unique problem

of ‘double burden’ wherein at one end of the spectrum

we have obesity in children and adolescents while at

the other end we have malnutrition and underweight.

WHY IS IT IMPORTANT ?

So, what is the burden of

childhood overweight and

obesity in India ?

Results: Prevalence data from 52 studies conducted in 16 of the 28 States in India

were included in analysis. The median value for the combined prevalence of

childhood and adolescent obesity showed that it was higher in north, compared to

south India. The pooled data after 2010 estimated a combined prevalence of

19.3 per cent of childhood overweight and obesity which was a significant increase

from the earlier prevalence of 16.3 per cent reported in 2001-2005.

Flow chart indicative of the review process


Map of India indicating prevalence of childhood obesity in

various States and cities


Values in parentheses are prevalence in

percentages

HIMACHAL PRADESH

UTTARAKHAND

HARYANA

GOA

JHARKHAND

ARUNACHAL

PRADESH

TRIPURA

MEGHALAYA

ASSAM

SIKKIM

BIHAR

MADHYA PRADESH

ORISSA

ANDHRA PRADESH

MAHARASHTRA

CHATTISGARH(8.4)

TAMIL NADU

UTTAR

PRADESHRAJASTHAN (3.7)

KARNATAKA

GUJARAT

WEST

BENGAL

KERALA

(1.3-4.9)

JAMMU &

KASHMIR

PUNJAB

(2.4-11.1)

Srinagar (25)

Udipi (2.6)

Jaipur (5.5 - 10.1)

Mangalore (1.4)

Mysore (0.8 - 8.8)

Pune (5.7)

Wardha (1.2)

Ahmedabad (1.4)

Baroda (2.2)

Surat (6.5 – 26.3)

Indore (14.9)

Chandigarh

Chennai (0.6 –11.6)Puducherry (2.1)

Delhi (5.3 - 29)Meerut (8.1)

Bangalore (4.3)

Bhubaneswar (14.5)

Karimnagar (11.9)Hyderabad (1.3)

Kolkata (2.5 – 6.1)

MANIPUR (3.4 - 4.1)

NAGALAND (2.5)

MIZORAM

Allahabad

Bankura (4.0)

Agra

Raipur LEGEND

PAN India Study 1

STATE-with prevalence data

STATE- without prevalence data

City

PAN India Study 2

Mumbai

# PAN India Study 1

prevalence= 10.3;

PAN India Study 2

prevalence= 6.3

Childhood (1 – 12 years) obesity trends in India

S.

N

o.

Author Year Region Age

group

(years)

Sample

size (n)

Methods/

cutpoints^

Overweight Prevalence

(%)

Obesity Prevalence (%)

Overall Boys Girls Overall Boys Girls

1 Monga S 2004 New Delhi,

NI

7-9 1238 11.3 ‡ 6.2 - - 8.2 - -

2 Sidhu et al 2006 Punjab, NI 6-11 1000 IOTF-Cole

et al*

- 12.2 14.3 - 5.9 6.3

3 Bose et al 2007 Kolkata, EI 6-9 431♀ IOTF-Cole

et al*

- - 17.6 - - 5.1

4 Kumar et al 2008 Mangalore,

SI

2-5 425 WHO cut

points*

4.5 - - 1.4 - -

5 Wang et al 2009 National

NFHS-1

(1992-93)

<4 25584 WHO * - - - 1.6 - -

National

NFHS-2

(1998-99)

1-5 - - - - 1.6 - -

National

NFHS-3

(2005-06)

<5 46655 - - - 1.5 - -

National

NNMB

2000-01

1-5 28392 Gomez et al * - 5.7 8.2 - 0.4 1.2

National

NNMB

2005-06

1-5 32642 Must et al * 7.8 10.9 0.8 1.8

6 Dhingra et al 2011 Srinagar, NI 7-11 128 WHO * - - - 25 - -

7 Preetam et al 2012 Puducherry,

SI

6-12 12685 CDC growth

charts

4.4 4.2 4.6 2.1 2.0 2.3


Adolescent (10 – 18 years) obesity trends in India

S.

N

o.


group (years)

Sample

size (n)

Methods/

cutpoints^


(%)



1 Gupta et al 1998 Jaipur,

NI13-17 237 WHO* - - - 10.1 - -

2 Kapil et a 2002 New Delhi, NI

10-16 870 IOTF-Cole

et al*

24.7 23.1 27.7 7.4 8.3 5.5

3 Ramachandran

et al

2002 Chennai,

SI

13-18 4700 IOTF-Cole

et al*

- 17.8 15.8 3.6 2.9

4 Subramanyam,

et al

2003 Chennai,

SI

10-15 707

(1981)

IOTF-Cole

et al*

9.6 - - 5.9 - -

610

(1998)

9.7 - - 6.2 - -

5 Chhatwal et al 2004 Punjab,

NI9-15 2008 WHO* 14.2 15.7 12.9 11.1a 12.4 9.9

6 Mohan et al 2004 Punjab,

NI11-17 3326 IOTF-Cole

et al*

11.6

(U)

- - 2.4 (U) - -

4.7 (R) - - 3.6 (R) - -

7 Khadilkar &

Khadilkar

2004 Pune,

WI10-15 1228♂ IOTF-Cole

et al*

19.9 19.9 - 5.7 5.7 -

8 Sidhu et al 2005 Punjab,

NI10-15 640 Must et al*c 10.9 9.9 12 5.6 5.0 6.3

9 Gupta et al 2006 Jaipur,

NI

11-17 1224 ♀

(1997)

IOTF-Cole

et al*

10.9 - 10.9 5.5 - 5.5

915 ♀

(2003)

10.5 - 10.5 6.7 - 6.7

10 Kaneria et al 2006 RajasthanNI

12-17 268 IOTF-Cole

et al*

3.25 - - 3.73 - -



S.

N

o.


group (years)

Sample

size (n)

Methods/

cutpoints^


(%)



11 Iyer, et al 2006 Baroda,

WI12-18 5329 IOTF-Cole

et al*

8.5 8.0 9.0 1.5 1.4 1.7

12 Singh et al 2006 New

Delhi, NI


charts

- - - - 18.6 16.5

13 Sood et al 2007 BangaloreSI

9-18 794♀ IOTF-Cole

et al*

13.1 - 13.1 4.3 - 4.3

14 Rao et al 2007 Pune,

WI9-16 2223 IOTF-Cole

et al*

- 27.5 20.9 - - -

15 Laxmaiah et al2007

Hyderabad,

SI12-17 1208

IOTF-Cole

et al*- 6.1 8.2 - 1.6 1.0

16 Global school

based student

health survey

(CBSE)

2007 - 13-15 8130 WHO* 10.8 11.6 9.7 2.1 2.5 1.5

17 Unnithan &

Syamakumari

2008 Kerala,

SI10-15 3886 IOTF-Cole

et al*

17.7 - - 5.0 - -

18 Aggarwal

et al

2008 Punjab,

NI12-18 1000 Rosner et al* 12.7 - - 3.4 - -

19 Bharati et al 2008 Wardha 10-17 2555 CDC growth

charts

3.1 - - 1.2 - -

20 Goyal et al 2010 Ahmedabad, WI

12-18 5664 IOTF-Cole

et al*

- 14.3 9.2 - 2.9 1.5


Contd…


S.

N

o.


group (years)

Sample

size (n)

Methods/

cutpoints^


(%)



21 Jain et al. 2010 Meerut, NI 10-16 2785 EHPA* - 18.4 19.7 - 10.8 5.3

22 Gupta et al 2011 New Delhi,

NI

14-17 3493

(2006)

Pandey et al* 24.2 - - 9.8 - -

4908

(2009)

25.2 - - 11.7 - -

23 Saraswathi

et al

2011 Mysore,

SI

13-17 1439(U) WHO* - - - 8.8 (U) 7.7

(U)

10.4

(U)

750(R) - - - 0.8 (R) 0.5

(R)

1.0

(R)

24 Kumar et al 2011 Udipi Dist., SI

12-15 500 WHO* 3.0 - - 2.6 - -

25 Kumar et al 2012 Surat,

WI

13♀ 277 IAP* - - 12.6 - - 6.5

14♀ 271 - - 13.3 - - 6.6

15♀ 215 - - 14.0 - - 6.7

26 Jain et al 2012 Chattisgarh

,

EI


charts

- - 23.8 - - 8.4

27 Alok et al 2012 Surat, WI 14-16 213 (U) IOTF-Cole et

al*

26.3 27.4 24.9 14.6 14.3 15.0

176 (R) 25.8 25.6 26.2 12.8 11.2 14.1

28 Gupta et al 2013 Bankura, EI 10-≥18 452 WHO* 7.7 8.9 6.3 4.0 4.0 3.9


Contd…

Childhood & adolescent obesity trends in India (Studies inclusive of

both age groups)

S.

N

o.


group (years)

Sample

size (n)

Methods/

cutpoints^


(%)



1 Gupta & Ahmad 1990 New Delhi, NI

5-15 3861 >2.26 ‡ - - - - 8 7

2 Chatterjee P 2002 New Delhi, NI

4-18 5000 IOTF-Cole et

al*

29.0 - - 6.0 - -

3 Marwaha et al 2006 Delhi, NI 5-18 21485 IOTF-Cole et

al*

- 16.8 19 - 5.6 5.0

4 Sharma et al 2007 Delhi, NI 4-17 4000 IOTF-Cole et

al*

22 - - 6.0 - -

5 Raj et al 2007 Kerala, SI 5-16 24842

(2003)

CDC growth

charts*

4.9* 5.4 4.6 1.3* 1.7 0.9

20263

(2005)6.6* * 7.3 5.9 1.9* 2.5 1.3

6 Kaur et al 2008 Delhi, NI 5-18 16595 IOTF-Cole et

al*

2.7 (LI)

6.5 (MI)

15.3 (HI)

- - 0.1 (LI)

0.6(MI)

6.8 (HI)

29.0 (P)

11.3 (G)

- -

Must et al * 2.4 (LI)

4.9 (MI)

13.1 (HI)

- - 1.2 (LI)

2.5 (MI)

9.3 (HI)

- -

7 Premanath et al 2010 Mysore, SI 5-16 43152 Agarwal

Charts*

8.5 8.8 8.2 3.4 3.7 3



both age groups)

S.

N

o.


group (years)

Sample

size (n)

Methods/

cutpoints^


(%)



8 Khadilkar et al 2011 Delhi &

Chandigarh,NI,

Kolkata, EI, Chennai,

Bangalore,

Hyderabad, SI,

Mumbai,

Pune, Baroda, WI,

Raipur, CI


al*

14.9 15.2 14.4 4.7 5.4 3.9

WHO* 11.1 10.8 11.4 15.9 18.4 12.8

9 Misra et al 2011 New Delhi,

Jaipur,

Agra,

Allahabad, NI,

Mumbai, WI


al*

14.4 - - 2.8 - -

CDC 14.5 - - 4.8 - -

WHO* 18.5 - - 5.3 - -

Pandey et al* 21.1 - - 12.3 - -

10 Patnaik et al 2011 Bhuba-

neswar, EI

5-15 468 CDC* 14.1 - - 14.5 - -

11 Ghosh 2011 Kolkata, EI 8-12 753 IOTF-Cole et

al*

9.4 - - 6.1 - -

13-15 9.7 - - 5.3 - -

16-18 10 - - 5.4 - -


Contd…


both age groups)


Contd…

S.

N

o.


group (years)

Sample

size (n)

Methods/

cutpoints^


(%)



12 Chakraborty

et al

2012 Kolkata, EI 5-8 271 CDC* 14.4 - - 5.2 - -

9-12 381 22.6 - - 0 - -

13-18 327 17.1 - - 2.5 - -

13 Singh & Devi 2012 Manipur, NEI 6-12 192 IOTF-Cole

et al*

- - - - 1.6 5.2

14 Longkumer 2012 Nagaland,

NEI

13-18 192 IOTF-Cole

et al*

- - - - 3.1 5.0

8-15 571 2.3 2.1 2.5 - - -

15 Siddiqui &

Bose

2012 Indore, CI 7-14 2158 IOTF-Cole

et al*

- - - 15.0 6.8 8.2

16 Sonya et al 2013 Chennai, SI 6-11 8025 IOTF-Cole

et al*

- 16.2 (P)

1.6

(G)

13.7 (P)

2.6

(G)

- 4.2 (P)

0.3

(G)

3.9 (P)

0.4 (G)

Khadilkar

et al *

- 23.2 (P)

3.6

(

G

)

23.2 (P)

5.7

(G)

- 11.6 (P)

0.8

(G)

11.5 (P)

1.1 (G)


al*

- 17.9 (P)

3.6

(G)

19.2 (P)

4.1

(G)

- 4.6 (P)

0.4

(G)

4.6 (P)

1.1 (G)

17 Adinatesh &

Prashant 32

2013 Karimnagar,

SI

10-16 892 Agarwal

Charts*

11.9 - - 2.7 - -

OVERWEIGHT, OBESITY AND COMBINED TRENDS IN INDIAN

CHILDREN AND ADOLESCENTS (1981-2013)

OVERWEIGHT OBESITY

COMBINED TRENDS

Ranjani H, Mehreen TS, Pradeepa R,

Anjana RM, Garg R, Anand K,

Mohan V. Indian J Med

Res. 2016;143:160–74.

Indian J Endocr Metab. 2014;18:17–25.

Childhood Obesity - Complex condition with multiple

causes & consequences

Ranjani H, Pradeepa R, Mehreen TS, Anjana RM,, Anand K, Garg R Mohan V. Indian J Endocr Metab. 2014;18:17–25.

Obesity

Socio Economic Status

Physical Inactivity/ Sedentary

Activity

Built Environment

Genetic/AntenatalFactors

Unhealthy diets

CAUSES

EFFECTS

Insulin Resistance &

Type 2 Diabetes

Polycystic Ovarian

Syndrome (PCOS)

Cardio Vascular

Diseases (CVD)

Obstructive Sleep

Apnea (OSA)

Psychosocial

Problems

Children (Basel). 2017;4

Panuganti P, Mehreen TS, Anjana RM, Mohan V, Mayer-Davis E, Ranjani H. Children (Basel). 2017;4

Emergent themes from the study


Theme Common Outcomes Rationale

Difficulty in

Distinguishing

between a

non‐

communicable

and infectious

disease

among

government

school students

Misinterpretation of

unhealthy

habits as lifestyle

behaviors

causing diabetes.

Government school

students often come from

low‐income families, who

may struggle to think past

their immediate needs

(such as clean water and

hygiene), and better

comprehend the message

of the intervention

program.

GOVERNMENT SCHOOL STUDENTS

Emergent themes from the study



Misinterpretation

of a costly

activity or meal

as a healthy habit

among private

school students

Private school

students often

suggest eating at

restaurants and

riding cars as healthy

lifestyle modifications

to prevent diabetes.

They may mistakenly

associate wealth with

a healthy lifestyle,

and perceive certain

unhealthy behaviors

to be healthy.

Private school students

come from higher income

families, who can afford

high‐calorie restaurant

food, television sets,

video games, and other

pleasures correlated with

unhealthy eating and

Physical inactivity

Contd…

PRIVATE SCHOOL STUDENTS



Lack of

awareness of

physical activity

and increased

emphasis on

dietary behaviors

among both

private and

government

school students

When asked to

identify unhealthy

lifestyle behaviors

related to diabetes,

more students

correctly listed

improper eating habits

rather than physical

inactivity or sedentary

behaviors. Also, many

students listed

studying as a

healthy lifestyle

behavior to help

prevent diabetes, even

though it is

a sedentary behavior.

It appears that children

are unaware of how the

built environment

influences both

their energy intake and

energy expenditure.

Certain barriers to

exercise include

Inadequate places to

exercise, or a desire to

avoid pollution outdoors.

Familial pressure to

succeed in school may

also cause children

to disregard studying as a

sedentary behavior

Contd…Emergent themes from the study

GOVERNMENT & PRIVATE SCHOOL STUDENTS

MVPABoys

(mins/day)

Girls

(mins/day)

Overall

(mins/day)

Overall a 33.9 * 18.3 26.3

School day b 35.1 * 19.5 27.5

During School c 14.5 * 7.6 11.1

Non School day d 32.7 * 16.3 24.8

p<0.001 when compared to females

SUMMARY OF PHYSICAL ACTIVITY (PA)

FINDINGS FROM ‘BE ACTIV INDIA’ STUDY

a Based on accelerometry, total week, at least 4 days with at least 8 hour of wear time

b Based on accelerometry. at least 3 school days with 8 hours of wear time

c Based on accelerometry, at least 3 school days with 50% of wear time during ‘school hours’

d Based on accelerometry. at least 1 non-school day with 8 hours of wear time

Anjana RM, Abishamala K, Ranjani H, Pradeepa R, Mohan V, et al. 2019 (Under publication)

GRADING RUBRIC

THE 2018 INDIA REPORT CARDINC – Insufficient data

Population based approach to prevention: Evidence

on effective preventive strategies

D Prabhakaran DM, FRCP, FNAScDirector, Center for Chronic Condition and Injuries and Vice President PublicHealth Foundation of IndiaDirector, Centre for Chronic Disease ControlProfessor, London School of Hygeine and Tropical Medicine, London, UK

Addressing Childhood obesity: Introductory thoughts

• Early life influences important particularly maternal and early child nutrition

• Upstream determinants of obesity

• Several complexities including syndemicity in addressing obesity

• So far population approaches largely focused on health education with individual as the target

• Systems and integrated platforms need to be in focus

Low birth weight and its CVD consequences

Rebound Adiposity

Hypertension

Coronary heart disease

Type II Diabetes, Insulin resistance

Stroke

Proof :

Finland

UK

Dutch hunger Cohort

Pelotas ( Brazil)

Guatemala

India

> 100 publications

Age (years)

302826242220181614121086420

Me

an

Z S

co

re

.4

.3

.2

.1

-.0

-.1

-.2

-.3

IGT/IFG/DM

low 120 min glucose

Cohort mean

Those who went on to develop DM became “obese relative to themselves

BMI in subjects with IGT/IFG/DM (red line) andlowest quartile of 120 min glucose (green line)

New Delhi Birth Cohort (NDBC)

Prevalence of dysglycemia (IGT/DM): inversely

related to weight and BMI at 1 y of age

Highest prevalence of IGT/DM: subjects who

were in the lowest third of the group with

respect to BMI at 2y and highest at age 12y.

An increase of 1SD in BMI between 2-12y of

age: associated with an OR of IGT/DM of 1.36

Bhargava et al, NEJM 2004;350:865

Prevalence and Incidence of Obesity between Kindergarten and Eighth Grade.

Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999, a representative prospective cohort of 7738 participants who were in kindergarten in 1998 in the United States; follow up 50000+ person years

Cunningham SA et al,N Engl J Med 2014:370:403-411

Can nutritional interventions improve non health ( educational/SES) and positively

impact health outcomes

Do interventions to improve birth weight change the adverse relationship with CVD ?

The Bradford Hill criteria ?

• A randomized controlled trial to study the impact of foodsupplementation(ICDS) in pregnancy on the birth weightof the offspring.

• Initial trial : 1987-1990- National Institute of Nutrition

Result: Significant increase in birth weight in the intervention arm compared to the control group.

• Follow up survey: 2003-2005- Kinra et al.Outcome measures –

Height -14 mm taller Insulin resistance -20 % lower HOMA score Arterial stiffness – 3.3 % lower AI Adiposity- similar body composition Blood pressures – no strong evidence Lipids – no strong evidence

•

Hyderabad Nutrition Trial

The Guatemalan Trial

• A randomized controlled trial to study the effects of intra –uterine and pre-school nutrition on physical growth and mental development.

• Key Findings: Improved offspring birth weights Improved offspring length independent of birth

weight and socioeconomic statusIncreased growth rates in children< 3yearsGreater stature (body size) and fat-free mass,

especially in femalesDecreased infant mortality rates

Enhanced intellectual performance in adulthoodLower fasting blood glucose, lower systolic blood

pressure, and a lower triglyceride level in adulthood.

Increased work capacity and human capital formation in

adolescents and adults.

COMMUNITYLOCALITY

Agriculture/Gardens/

Local markets

Health Care

PublicSafety

PublicTransport

Manufactured/Imported

Food

Sanitation

Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999: http://www.iotf.org

POPULATION

%

OBESE

AND

OVER--WEIGHT

WORK/SCHOOL /HOME

SchoolFood &Activity

Infections

Labour

Worksite Food & Activity

LeisureActivity/Facilities

Family &Home

INDIVIDUAL

EnergyExpenditure

Food intake :

Nutrient density

SOCIETAL POLICIES AND PROCESSES INFLUENCING THE POPULATION PREVALENCE OF OBESITY

NATIONAL/ REGIONAL

Education

Food & Nutrition

Urbanization

Health

Social security

Transport

Media &Culture

Nationalperspective

INTERNATIONAL FACTORS

Development

Globalizationof

markets

Media programs

& advertising

Supporting more effective policy

to prevent cancer and other NCDs

Identifying policy actions to promote fruit intake in the

Pacific Islands

Source: Snowdon et al 2009

Addressing Childhood obesity what have we learnt so far

• Physical activity and nutrition have been the focus of interventions

• Review of 12 studies ( 6 community and 6 clinic based studies) • All community studies based on some school level intervention

• Modest benefit in terms of weight reduction

Education alone appears insufficient at the community level.

Personal and Environmental Changes Needed For Behaviour Change

PATHWAY TO HEALTH PROMOTION

Knowledge I know

Motivation I want

Skills I can

I Act

Perform

Personally

Reach & Teach

(Involve Others)

It is possible

Enabling Environment

Public Health Interventions Needed for Obesity

PUBLIC HEALTH

INTERVENTIONS

Policy Interventions Educational Interventions

Enabling Environment Health Beliefs and Behaviours

(Financial, Social, Physical) (Community; Individual)

DesiredChange

In addition should address the new and emerging areas

Known and emerging interventions in Childhood

Obesity

Emerging

1. Microbiome2. Air pollution3. Organic pollutants4. Epigenetic

modifications

The Syndemic approach: Climate change , food security, undernutrition,

SES

The systems approach

Non personal policy measures aimed at individual nutrients

Societal drivers(governance, policies,

economics, norms)

Common systems drivers

(food, transport, land use, urban design)

The Great Syndemic: Obesity, undernutrition, and

climate change

Undernutrition

Climate Change

Obesity

(DOHaD)

(Food insecurity)

?

>

Envi

ron

men

ts

Be

hav

iou

rs

Syndemic: two or more diseases that interact in time and place, negatively affect each other and have common economic, societal, or enivironmental drivers

Walkability index of Delhi

Congestion Index

Connectivity IndexExposure Index

Safety IndexComfort Index

Walkability

A Systems Perspective Can Help Guide Effective

Policies For Agriculture, Food And Nutrition

18

Food supply

Food marketing

Food transformation

and retail

Food demandFood

choices

Non Personal Policy Intervention

Restrictions on promotional marketing

Policies to increase Availability and affordability

Promoting and subsidizing free and healthy food

Providing Infrastructure e.g. open play area, safe walking and cycling route

Tax or levy on sugar-sweetened beverages:

Implementation of tax on SSB in Mexico resulted in a decline of purchase of SSB by 6.3% on average in 2014 and 2015 (even more than predicted) and water purchase increased by 16.2%.

Purchases of sugary drinks decreased due to the tax, particularly among lower-income groups, while purchases for untaxed beverages increased. (Colchero et al., 2017)

Front-of-pack labelling:

• Chile: Since June 2016, packaged food must bear a black-and-white warning label inside a stop sign if it exceeds defined limits of calories, saturated fat, sugar and sodium.

Non Personal Policy Intervention: Examples

• Modeling studies have shown considerable benefits by

imposition of taxes on tobacco, palm oil, and sugar-sweetened

beverages in India.

• 20% tax on SSBs is estimated to reduce overweight and obesity

prevalence by 3% and the incidence of type 2 diabetes mellitus by

2% (Basu et al., 2014).

• 20% tax on palm oil purchases could potentially avert

approximately 363,000 deaths from MI and strokes over a period of 10 years (Basu et al., 2013).

What would be the impact of non-personal policy interventions in India?

• Offering healthy food in cafeteria

• Fresh Fruit and vegetable at subsidized rate

• Limiting Availability and Marketing of Packed food

School food environment

• Nutritional and Physical education

Education & school health checkups

• Banning certain products or forms of retail

• In 2005, France extended a ban on vending machines in primary schools and secondary schools. The ban decreased the frequency of morning snacks and reduced sugar intake from these snacks by 10 grams.

Restricting the marketing of food and non-alcoholic beverages

Safe walking and cycling route to school

Physical activity in curriculum

School-based Interventions

School Meal Programme may need modification

India: The School Lunch Program in India (SLP) or Mid-Day Meal Scheme is the largest food and nutrition assistance program feeding millions of children every day.

Provides every child in every Government and Government assisted Primary Schools (1-V) with a prepared mid day meal with a minimum nutritive contentof 300 calories and 8–12 grams of protein each day of school for a minimum of 200 days

Emphasis largely on calories . Need for dietary diversity, whole grain foods , fruits and so on as an aspirational target

School Meal Programme

United Kingdom: Focuses on providing balanced diets

They lunch provides:• high-quality meat, poultry or oily fish• fruit and vegetables• bread, other cereals and potatoes

There can’t be:• drinks with added sugar, crisps, chocolate or sweets in school meals and

vending machines• more than 2 portions of deep-fried, battered or breaded food a week

The Neighbourhood School Concept can improve physical activity

• Nearest primary/upper primary school within walking distance from the child’s residence.

• The concept relates to availability of a school within safe and accessible distance from the habitation where a child lives.

• The Act defines the limits as 1 km walking distance from the habitation of a child at the primary level (class 1 to 5) and within 3km walking distance for upper primary level (class 6 to 8).

• This idea has been implemented such countries as the erstwhile Soviet Union, Cuba, the US, the UK and China.

Physical Activity Recommendation By WHO For Children Aged 5 To 17 Years

For children and young people of this age group, physical activity includes play, games, sports, transportation, recreation, physical

education or planned exercise, in the context of family, school, and community activities

Children and young people aged 5–17 years old should accumulate at least 60 minutes of moderate to vigorous intensity physical activity daily

Physical activity of amounts greater than 60 minutes daily will provide additional health benefits

Most of daily physical activity should be aerobic. Vigorous-intensity activities should be incorporated, including those that strengthen muscle and bone, at least 3 times per week

Lancet series recommendations on urban design and

transport for health

• Make neighbourhoods safe, attractive, destination accessible, and with green spaces and parks

• equitable distribution of employment across cities, creating jobs and residences close within commutable distances.

• Schools, educational institutes, and homes should be located away from high-traffic routes.

• change patterns of land use to increase density withmixed land-use in very low-density cities and todecrease density in high-density urban areas• Policies are also needed to protect and support agriculture

in urban and peri-urban settingsLancet, 2016, Goenka, Andersen

New metrics are needed to measure diet quality and sufficiency, as well as food system efficiency and sustainability. Improvements are needed in five key areas:

•Improving data on actual food intake (currently lacking in most countries of the world)

•Agreement on how to measure diet quality

•Metrics that measure women’s roles in defining dietary choices

•Metrics to measure the food environment within which diet choices are made

•Metrics to measure the health of food systems overall.

Acknowledgement : KS Reddy

Addressing data gaps in diet and food systems needs new approaches

What are the policy questions?

• How can policy support food production systems to minimize risks and enhance the supply of more diverse foods in the diet;

• Promote efficiency, including waste minimization, along the entire food value chain to meet higher food demand and enhanced resource use, while achieving dietary diversification

• Focus domestic research and investments on mitigating climate-related food system shocks and volatility, and adapting those systems to longer-terms stresses;

• Establish robust social protection programmes that stabilize and enhance consumer purchasing power, thereby protecting their diets and nutrition in the face of supply shocks;

What is needed?

• Comprehensive and integrated understandings of links between environment, food systems and health

• Novel analytical interdisciplinary approaches to interrogate data from multiple sectors

• Shared understanding of policy environments for co-development of policy options, scenario analysis and policy uptake

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