Obesity In The Indian Urban 'Middle Class' C. Gopalan developments is the rising prevalence of overweight and obesity in the middle class. Our efforts must now be di- rected to control this basic problem which has far-reaching public health implications. By the turn of the century nearly 35 per cent of India's population will be living in urban areas. The corre- sponding figure for 1950 was no more than 16 per cent. Steady urban mi- gration has been an important fea- ture of the ongoing developmental transition not just in India, but in all developing countries as well. Thus, Asia's urban population is expected to exceed 1,242 million by 2000 AD, more than a five-fold increase from 226 million in 1950. This process of urbanisation is expected to continue in the decades to follow. Urbanisation involves changes in occupation patterns, life-styles, family structures and value systems. These changes are reflected in changes in dietary practices and in the levels of physical activity. In the urban popu- lation of India, refined wheat and rice have virtually displaced coarse grains and millets as the staple cereal, re- sulting in a substantial reduction in fibre content in the diet and, possi- bly, also the content of micronutri- ents such as vitamin B-complex, zinc and chromium, etc. As the popula- tion ascends the socio-economic scale, cereal intake declines and intakes of sugar and fats generally increase. Convenience foods and fast foods find increasing acceptance, especially in the context of globalisation. While the rural population is mainly engaged in agricultural occupations involving manual labour and a fairly high level of physical activity, urban occupations (except those of some of the urban slum dwellers) are gen- erally of the 'skilled' and 'semi-skilled' categories that tend to favour seden- tary life-styles. Bicycles, generally used in earlier years by the staff for com- muting from their homes to offices, are now being rapidly displaced by motorbikes and cars - not only in India but in China and other Asian cities as well. Thus, it has been re- ported that nearly 10,000 automo- biles are being added to the automo- bile fleet in Delhi every month! Apart from cutting down on physical exer- cise, this change is contributing to significant aggravation of the prob- lem of air pollution in the cities. While a third of India's popula- tion still falls below the poverty line, there has been a steady growth of the relatively affluent urban middle class, now estimated to number over 200 million. A good proportion of this middle class is constituted by those who have achieved affluence within a life- time. This number is expected to in- crease in the coming decades. The changes in dietary prac- tices, physical activity levels and life- styles associated with rising afflu- ence induced by developmental tran- sition mentioned above contribute to the increasing prevalence of over- weight/obesity. Earlier issues of this Bulletin had drawn attention to the disturbing escalations in the preva- lence of chronic degenerative dis- eases1 - especially coronory heart disease, diabetes (NIDDM) and the changing profile of cancers in the urban populations. The underlying feature common to these disturbing THE NFl STUDY The Nutrition Foundation of In- dia has just completed a study of the prevalence of obesity in urban Delhi. The study was supported by the In- dian Council of Medical Research (ICMR) and was carried out with the active cooperation and participation of Dr S. Padmavati from the National Heart Institute of Delhi. Detailed sta- tistical analysis of the data was car- ried out by Dr Visweswara Rao of the National Institute of Nutrition (N IN). The results of the study are being published separately in a Scientific Report of the Foundation. In this pa- per, some salient observations emerg- ing from the study are briefly discussed. In view of wide disparities with respect to diet, physical activity and life-styles in general, as between the 'middle class' and the poor in India, 'average' figures of prevalence of obesity have no meaning and do not provide any leads for corrective ac- tion. The study, therefore, made an attempt to capture fairly representa- tive segments of the middle class CONTENTS • Obesity In The Indian Urban 'Middle Class' - C. Gopalan • Fruit And Vegetable Production In India 5 - G.L. Kaul
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Obesity In The Indian Urban 'Middle Class'
C. Gopalan
developments is the rising prevalenceof overweight and obesity in the middleclass. Our efforts must now be directed to control this basic problemwhich has far-reaching public healthimplications.
By the turn of the century nearly35 per cent of India's population willbe living in urban areas. The corresponding figure for 1950 was no morethan 16 per cent. Steady urban migration has been an important feature of the ongoing developmentaltransition not just in India, but in alldeveloping countries as well. Thus,Asia's urban population is expectedto exceed 1,242 million by 2000 AD,more than a five-fold increase from226 million in 1950. This process ofurbanisation is expected to continuein the decades to follow.
Urbanisation involves changesin occupation patterns, life-styles, familystructures and value systems. Thesechanges are reflected in changes indietary practices and in the levels ofphysical activity. In the urban population of India, refined wheat and ricehave virtually displaced coarse grainsand millets as the staple cereal, resulting in a substantial reduction infibre content in the diet and, possibly, also the content of micronutrients such as vitamin B-complex, zincand chromium, etc. As the population ascends the socio-economic scale,cereal intake declines and intakes of
sugar and fats generally increase.Convenience foods and fast foodsfind increasing acceptance, especiallyin the context of globalisation.
While the rural population is mainlyengaged in agricultural occupationsinvolving manual labour and a fairlyhigh level of physical activity, urbanoccupations (except those of someof the urban slum dwellers) are gen-
erally of the 'skilled' and 'semi-skilled'categories that tend to favour sedentary life-styles. Bicycles, generally usedin earlier years by the staff for commuting from their homes to offices,are now being rapidly displaced bymotorbikes and cars - not only inIndia but in China and other Asiancities as well. Thus, it has been reported that nearly 10,000 automobiles are being added to the automobile fleet in Delhi every month! Apartfrom cutting down on physical exercise, this change is contributing tosignificant aggravation of the problem of air pollution in the cities.
While a third of India's population still falls below the poverty line,there has been a steady growth of therelatively affluent urban middle class,now estimated to number over 200million. A good proportion of this middleclass is constituted by those whohave achieved affluence within a lifetime. This number is expected to increase in the coming decades.
The changes in dietary practices, physical activity levels and lifestyles associated with rising affluence induced by developmental transition mentioned above contribute tothe increasing prevalence of overweight/obesity. Earlier issues of thisBulletin had drawn attention to thedisturbing escalations in the prevalence of chronic degenerative diseases1 - especially coronory heartdisease, diabetes (NIDDM) and thechanging profile of cancers in theurban populations. The underlyingfeature common to these disturbing
THE NFl STUDY
The Nutrition Foundation of In
dia has just completed a study of theprevalence of obesity in urban Delhi.The study was supported by the Indian Council of Medical Research(ICMR) and was carried out with theactive cooperation and participationof Dr S. Padmavati from the NationalHeart Institute of Delhi. Detailed statistical analysis of the data was carried out by Dr Visweswara Rao of theNational Institute of Nutrition (NIN).The results of the study are beingpublished separately in a ScientificReport of the Foundation. In this paper, some salient observations emerging from the study are brieflydiscussed.
In view of wide disparities withrespect to diet, physical activity andlife-styles in general, as between the'middle class' and the poor in India,'average' figures of prevalence ofobesity have no meaning and do notprovide any leads for corrective action. The study, therefore, made anattempt to capture fairly representative segments of the middle class
CONTENTS
• Obesity In The IndianUrban 'Middle Class'- C. Gopalan
• Fruit And VegetableProduction In India 5- G.L. Kaul
TABLE 1Percentage prevalence of overweight(BMI 25 +) in urban adults bysocia-economic status
Economic status
Prevalence %
Males
Females
Middle Class 1. High
32.2a50.0'
(118)
(142)
2. Middle
16.2b30.3b
(142)
(33)
3. Low
7.0e27.8b
(86)
(18)
Slum (poor)
1.0d4.0e
(218)
(250)
a,b,e,d p <0.05
( ) sample sizeSex differences are significant in all(p<0.05)Source: NFl studies, 1997
and of the poor in urban Delhi. It wascarried out in two locations: 1. A largeoffice establishment employing several hundred people, drawn largelyfrom what may be termed the 'middleclass' consisting of officers (high-income), clerks (middle income) andpeons/attendants (low-income); and2. A slum in Delhi inhabited mostly bypoor, unorganised labour, the slumbeing typical of numerous others inDelhi and its environs.
The investigations included
anthropometery, blood pressure recordings, assessment of diets andlevels of physical activity. In a subsample of (1) above, ECGs and estimations of serum lipid profile, seruminsulin and sugar levels were alsocarried out. Internationally acceptedyardsticks for the assessment of theprevalence of overweight, obesity andabdominal obesity were employed asfollows: Body Mass Index (BMI): Weight(kgs)/HeighF (metres); Overweight:BMI between 25 and 30; Obesity:BMI>30; Abdominal Obesity: Waist!Hip Circumference (WHR) >1.0 inmales and >0,85 in females.
PREVALENCE OF OVERWEIGHT
The striking difference in theprevalence of overweight between themiddle class and the slum dwellers isobvious from the data in Table 1 whichclearly show how, with the ascent inthe socio-economic scale, the overweight problem worsens. Thus, asagainst the prevalence rate of overweight of 1 per cent for males and 4per cent for females in the slums, thecorresponding figures for the highincome group among the middle classwere 32.2 per cent and 50 per cent.More females than males have beenfound to be overweight in all agegroups in both locations.
Table 2 presents the distribution of all subjects of the middle classaccording to the BMI in two age groups.It will be seen that the prevalence ofoverweight/obesity is higher in theage group >40 years. The preva-
lence of obesity (BMI>30) is about 3per cent in males and about 14 percent in females above 40 years.
The prevalence rates of obesityobserved in the NFl study in urbanDelhi are generally in line with observations reported by Visweswara Raoet a/2, except that the rates among thehigh-income group in the NFl studyare somewhat higher. Thus, VisweswaraRao et al had reported a prevalencerate of 23.9 per cent in urban malesand 36.3 per cent in urban females ofthe high socio-economic group ascompared to 0.8 per cent in ruralmales and 2.2 per cent in rural females. The NNMB report of 19963,
covering nine Indian states, reporteda prevalence rate of overweight of 3.6per cent in rural males and 6.6 percent in rural females. These figuresare somewhat higher than those figures reported by Visweswara Rao,but they are still far less than thoseobserved for any section of the urbanmiddle class.
The prevalence of overweight!obesity in the urban middle class asrevealed from the data of the NFlstudy is less than what has beenreported for Europe' or the USA'- Thus,in the UK, 50 per cent men have beenreported to be overweight as against32 per cent in the high Indian socioeonomic group investigated here; 15per cent of men and 16.5 per cent ofwomen in Europe have been reportedto be obese (BMI>30) as against 3per cent of males and 14 per cent offemales above 40 years in India. The
TABLE 2BMI and WHR levels in two age groupsAge Group
8MIWHR
(Vrs)
NumberLess than 1818.0 - 24.9925.0 - 29.9930 andLess than1/0.85 andabove
corresponding figures for obesity inthe USA are 19.7 per cent and 24.7per cent.
The relatively low figures foroverweight/obesity in the Indian urban middle class, however, shouldnot lead to complacence. The special features pertaining to the Indianpopulation have to be taken into account in drawing conclusions basedon international comparisons of overallprevalence rates of obesity. Thedistribution of excessive fat in thebody may be an important factor whichmay determine the implication of agiven order of obesity. Abdominaladipocytes are metabolically different from those in other locations andabdominal adiposity may carry a moresinister significance than generalobesity. Indeed, the possibility thatIndians may be genetically more proneto develop abdominal adiposity needsto be considered. Furthermore, the
TABLE 4% of subjects with high WHR(abdominal obesity) by grades of BMI
Details
Grades% (with highof BMI
WHR)
Males
Females
(>1.0)
(>0.85)
Under- nourished
<18.51.81.75
Normal
18.5-2517.820.0
Overweight /obese
>2568.158.0
TABLE 5Prevalence rates (percentage) of highBP by grades of BMI and WHRBMI
WHR*% with high BP
Males
Females
<18.5
Low1.90.0High
0.00.018.5-25.0
Low9.81.7
High
12.510.8>25
Low15.05.4High
31.115.6
* Note: Those having systolic and diastolicblood pressure of more than 140 and 85respectively are taken as having high bloodpressureHigh: > 1.0 in males and >0.85 in femalesLow:<1.0 males and <0.85 in females
possibility of some sections of theIndian population being more susceptible to the deleterious effects ofoverweight because of genetic predisposition or because of undernutrition (including intra-uterine) in earlylife needs to be kept in mind, If this is
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the case, the yardsticks for identification of overweight (BMI>25) andobesity (BMI >30) may need revisionin the case of Indian (and Asian)subjects.
ABDOMINAL OBESITY
The prevalence of abdominal adiposity in the subjects of the NFl study(Tables 2 and 3) was higher than theprevalence of overweight/obesity(BMI>25).
When all subjects of the middleclass were considered together (seeTable 2), abdominal adiposity wasfound in 34.9 per cent of males and49.7 per cent of females; the figuresfor general overweight (BMI>25) were19.6 per cent in males and 44.5 percent in females. Abdominal obesity,thus, did not always go hand in handwith overweight/obesity. Abdominalobesity was found in 68.1 per cent ofmales with overweight (BMI>25) and58 per cent of females (Table 4). Inthese subjects, greater the grade ofBMI, the greater was the abdominaladiposity. It was noteworthy that nearly
a third of overweight males and morethan 40 per cent of the overweightfemales did not show abdominal obesity. On the other hand, nearly 19 percent of non-overweight male subjectswith BMI<25 and 22 per cent femalesshowed abdominal obesity (Table 4).
These data will show that in Indian subjects, abdominal obesityfrequently, but not always, coexistswith general overweight/obesity. Abdominal obesity could be present inthe absence of general overweight/obesity also. Abdominal obesity wouldthus appear to be different with respect to its pathogenesis and possible implications. The presence ofabdominal obesity aggravates the deleterious effects arising from generaloverweight/obesity alone. It will beseen from the data in Table 5 that thesuperimposition of abdominal obesity had brought about a two-fold increase in the prevalence rate of highblood pressure in males and a threefold increase in females.
Careful analysis of bio-chemical findings of the study (Table 6)showed that higher the tertile valuesof BMI, higher were the mean valuesfor cholesterol, triglycerides, bloodsugar, LDL, VLDL and blood pressure. Similarly, with an increase inthe tertile values of WHR, there was asignificant increase in the mean values of blood pressure, cholesteroland triglycerides. In subjects suffering the additive effects of high BMIand distorted WHR, the values weresig nificantly worse. These observations serve to underline the centralrole of overweight/obesity and theadditive deleterious effects of abdominal obesity in the pathogenesis ofdisordered lipid and carbohydrate metabolism, leading to coronary heartdisease and diabetes mellitus (NIDDM).
DISCUSSION
It would appear from the datapresented above that nearly a third ofmales, and more than half of females,belonging to what may be termed the'upper middle class' in India are currently overweight (BMI >25). The prevalence of abdominal obesity in thisgroup is even higher. Assuming thatthe 'upper middle class' in India numbers around 100 million (half the numberof middle class), it may be computedthat there are roughly 40 to 50 millionoverweight subjects belonging to theupper middle class in the country
today. If present trends continue, thesituation can get worse even within adecade, and overweight could emergeas the single most important publichealth problem in adults. Overweight/obesity may not be considered a specific 'disease' but it is certainly the'mother' of important degenerativediseases in adult life. Prevention andcontrol of this problem must, therefore, claim priority attention.
A possible genetic basis behindAsians being prone to abdominalobesity was suggested by observations of McKeigue et a(6, who hadreported that Asian migrants exhibited greater proneness to syndromeX, characterised by higher levels ofBMI, prevalence of abdominal obesity, blood pressure, serum cholesterol and triglycerides. Bhatnagar eta(7 had shown in the Asian migrantsthe presence of increased Lp (a) levels which may imply diminished tolerance to trans-fatty acids and greaterproneness to disordered lipid metabolism. On the other hand, Barkeret a(8 had suggested a possible etiologic role of foetal undernutrition inthe proneness to syndrome X in adultlife. If Barker's hypothesis is right, itmay be argued that escalation in theprevalence of abdominal obesity is atransient phenomenon confined to ageneration of those born in poverty,with low birth-weights but who hadacquired affluence with all its attendentdeleterious effects in adult life. Withthe control of low birth-weights, future generations may be spared; butat this stage, this can only be aspeculation.
Genetic predisposition can findexpression only if potentiating factors such as dietary errors and lack ofregular physical excercise are operative. This should be obvious from the
near-absence of overweight/obesity/abdominal obesity in the slums andrural populations. Diets in India, andindeed in South Asia, are predominantly based on cereals - wheat orrice - unlike Europe or North America.Much of the excessive dietary energyin overweight/obese South Asian subjects is, therefore, derived from carbohydrates unlike in Europe. It hasbeen computed that as much as 20per cent of the ingested carbohydrate (including starch and non-starchpolysaccarides) may be mal absorbedin the small bowel and may passbeyond the caecum to the colon to beacted upon by microbial flora and
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converted into short chain fatty acids- acetic, propionic and butyric acids- which are wholly absorbed9-.2• There-fore, the possible role of excessivecarbohydrates in Indian diets, in theelevation of serum triglycerides (andabdominal obesity) would also require consideration.
It is, however, reasonable to expect that irrespective of the nature ofbasic predisposing factor(s) dietarydiscipline and regular physical excerciseshould be able to contain the problemof overweight/obesity.
The need for according highpriority to control the rising prevalence of overweight/obesity/abdominal obesity, especially, in the urbanmiddle class, must be appreciated.The problem could get worse in thedecades to follow. The most prudentand cost effective way of controllingthe disturbing escalation of CHD andNIDDM in Indian urban populationwould obviously consist in combating the problem of overweight in them.
Apart from dietary errors andexcesses, lack of regular physicalexcercise in the urban middle classwith sedentary occupations, is a major underlying factor. In an earlierissue of the Bulletin, Shetty13 had discussed the importance of physicalactivity in the control of CHD andNIDDM. The beneficial harmonal effects of physical excercise and especially its role in combating insulinresistance, a feature associated withabdominal obesity, are now betterunderstood.
The answer to the problem ofobesity is not to be found in the numerous 'instant slimming' centres thatare springing up in the mega cities ofIndia. The undesirable effects of drastic
weight reduction or of weight cyclingare now being recognised.
Among the positive strategiesthat can be adopted to retard theescalation of obesity in urban Indians could be the following:
• An intensive programme of healtheducation through the media, on theproblem of overweight/obesity, designed to promote healthy dietary practices and regular physical excercise.
• The provision of facilities for dietary counselling and short periodsof daily physical excercise/training inlarge establishments (public/privatesector) employing large number of