What India's obesity problem has to do with its malnourished pregnant women

One in every 50 children in India is obese, according to a new study from the Imperial College London and the World Health Organization. This burgeoning problem might be due not only to children’s access to junk food and to sedentary lifestyles but may be traced back to when they were being carried in-utero by undernourished mothers.

India’s obesity problem has been rather recent and India still has among the lowest rates of obesity in the world. But it is a disease that may be growing fast.

“The prevalence of obesity was estimated at close to zero for girls and boys in 1975, so the proportional rise has been large,” said Dr James Bentham from Imperial College London and one of the authors of the study. “A problem that was rare 40 years ago is now affecting approximately one in 50 children in India.”

Bentham and his team pooled 2,416 population based studies to estimate the trend of underweight, overweight and obesity across 200 countries, including India, between 1975 and 2016. The findings were published in The Lancet and released this week.

India has long had a problem of undernutrition among its children linked to poverty and lack of access to nutritious food. Even in 2016, the study shows, 22% of the girls and 30% of the boys in the country were moderately or severely underweight. This prevalence was the highest among the countries surveyed in the study.

But doctors and public health researchers are now seeing both overweight and underweight children in the same poor communities, where families have the same limited of access to food and health services. Anthropologist Sushma Shende who works with a non-governmental organisation SNEHA said that the double burden of malnutrition – undernutrition in some children and obesity in others – is evident in some of the slums of Mumbai.

The Barker hypothesis

According to Dr A Laxmaiah, head, division of community studies, National Institute of Nutrition in Hyderabad, undernutrition and obesity are linked by maternal malnutrition.

“Poor nutrition especially during intra-uterine life and in early childhood may cause stunting but may lead to overweight and obesity in later life,” said Laxmaiah who was also a part of the study.

Laxmaiah’s observations are partly based on the Barker hypothesis. The hypothesis proposed in 1990 by British epidemiologist David Barker states that “intrauterine growth retardation, low birth weight, and premature birth have a causal relationship to the origins of hypertension, coronary heart disease, and non-insulin-dependent diabetes, in middle age.”

This, Barker argues, is because that individuals who do not get adequate nutrition in-utero and who are later have regular or excess calorie intake are more likely to become overweight as adults and more thus prone to these obesity-linked disorders.

“This hypothesis says that if the infant is suffered nutritionally during intra-uterine life and then has a chance to grow through adolescence, then if in adulthood he gets plenty of food (calories), his vital organs cannot utilise these calories leading to deposition of excess energy in the form of fat in various parts of the body,” Laxmaiah explained.

According to the fourth round of the National Family Health Survey conducted in 2014-’15, about 23% of women in India are undernourished with Body Mass Indices of BMIs below normal. Among pregnant women between the ages of 15 and 49, about 50% are anaemic, anaemia being one of the most prevalent nutritional deficiencies globally.

Dr Alka Jadhav, professor of paediatrics department, Lokmanya Tilak Municipal Medical College in Mumbai, also agrees that the Barker hypothesis might explain India’ double malnutrition– undernutrition and obesity – problem.

“An undernourished mother gives birth to an undernourished child,” said Jadhav. “In the bargain of correcting undernutrition rapidly, [supplying calories in large quantities] can lead to overnutrition, which is what Barker’s hypothesis states. But, it is difficult to prove.”

The junk food problem

Jadhav runs an obesity clinic at the municipality hospital, which she set up because children from poor backgrounds were routinely being diagnosed with obesity- linked hypertension and diabetes. “We surveyed two schools where most children come from modest backgrounds and found that at least 10% of the children were obese,” she said.

The journey from undernutrition to obesity for a child may be speeded up by the intake of unsuitable food. Jadhav pointed out that children who are undernourished prenatally or as infants catch up and grow like other healthy children if given proper nutrition in the first two years of life.

“But, the problem is energy dense food high on calories and sugar is given to children and they become obese,” she said. “The act of adding energy-dense food like cheese and peanut butter in sandwiches can lead to fat deposition.”

The Lancet study also concludes that “nutrient-poor, energy-dense foods can lead to stunted growth along with weight gain in children, adolescents, and adults, resulting in higher BMI and worse health outcomes throughout the life course.”

This is compounded by the environments in which children grow where they lack physical exercise.

Even though malnutrition in India has been falling, it has not been falling fast enough. “The pace of decrease is about 0.7% in every year,” said Laxmaiah. “This should be increased to 1.25% to achieve some of the nutritional goals set for 2035,”