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| EDITORIAL |
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| Year : 2019 | Volume
: 63
| Issue : 2 | Page : 91-93 |
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Silent drivers of childhood obesity in India
Sanjay Chaturvedi
Member, Journal Advisory Board, Indian Journal of Public Health, Professor and Head, Department of Community Medicine, University College of Medical Sciences, Delhi, India
| Date of Web Publication | 18-Jun-2019 |
Correspondence Address:
Sanjay Chaturvedi
Member, Journal Advisory Board, Indian Journal of Public Health, Professor and Head, Department of Community Medicine, University College of Medical Sciences, Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.IJPH_155_19
How to cite this article:
Chaturvedi S. Silent drivers of childhood obesity in India. Indian J Public Health 2019;63:91-3 |
A global problem that is unevenly distributed between and within regions is likely to have a complex web of causation. The ongoing pandemic of obesity, especially that of childhood obesity, has emerged as a huge challenge for epidemiologists, program managers, and policy makers world over.[1],[2] The economic implications of childhood overweight and obesity are also enormous. This, combined with the closely associated burden of noncommunicable diseases, is threatening to offset the growth, development, and the “demographic dividend” of India. To deconstruct the complex interplay between multiple factors causing childhood obesity, and to draw a suitably informed framework of its biomedical and socio-environmental determinants, we need a better evidence base from India-specific research. Evidence that is available from studies conducted on Indian participants or the analyses done with Indian context are barely able to draw an outline of further research needs, especially when we include underexplored areas of social capital, media, and market. In such a discourse, the boundaries between “determinants” and “risk drivers” would always be blurred, and it would be safer to restrict our inferences to “risk drivers” instead of going for “determinants.” Rapid cultural, societal, and economic transition leading to health-compromising lifestyle changes have been underscored by several Indian researchers and commentators, but this area is so amorphous that no demonstrable construct is emerging from their narrative. Collective discourse generated from studies conducted in high-income countries and other low and middle income countries also deals with this area by breaking it down to several domains which can be measured and examined for better clarity. At best, the “big picture” of rapid lifestyle transition, local or universal, remains hazy and leads to varied inferences.
Some documented risk drivers of childhood obesity related to food, eating behavior, intake, and feeding practices are as follows: shorter duration of breastfeeding or no breastfeeding; ready availability of calorie-dense food; preference to and increased consumption of sweet and fatty/fried food snacks; skipping the breakfast; and child's food environment at home.[3],[4],[5],[6] Obese and overweight children have been found to have a higher preference for sweet and fatty snacks compared to children with normal weight. One interesting evidence emerging from North Indian urban students is the association of skipped breakfast with overweight, obesity, and other health-compromising behaviors.[6] Food-related risk drivers are also very closely related to social structures; urbanization (urban residence; rural-to-urban migration; and psychological stress in urban settings); increasing affluence; and child-targeted market.[4],[7],[8] For children, prime movers in the domain of social structures are family-related attributes. The correlates emerging through a study conducted in urban school children of central India are father and/or mother involved in service/business; and English medium school (which again may be a proxy for higher economic strata).[9]
Risk drivers associated with physical activity are motorized transport; increasing mechanization of day-to-day activities; and child playing outdoor games for <30 min.[7],[9] Decreased duration of sleep (<8.5 h/day) and increased television viewing (>3 h/day) have also been documented as significant risk drivers. A cultural aspect, which seriously affects physical activities in children, is tremendous societal pressure on academic performance. The child is seen through the lens of competitive scholastic grades and parents are unable to find a way to neutralize this pressure. Moreover, the criticality of recreation, play and physical activity in early childhood development is differently understood in different socio-cultural contexts. To make things worse, 2–3 h are lost in commuting, even with motorized transport. In all this, child's playtime is squeezed or sacrificed. Moreover, something more devastating is happening in the lives of children who, unfortunately, do not go to school.
Last three decades have shown us that television, which came to Indian households as a phenomenal source of information and entertainment, can also be a serious barrier to health promotion. They have also become hidden persuaders for commercial interests of those who own them. Even when they are dealing with health-related issues, they frequently end up promoting a product goaded by some quasi-scientific misinformation. With their near universal reach and traction, the market forces are exerting an overarching influence to sustain this seemingly unidirectional mass movement toward their construct of “modernity.”
India is one of the civilizations with greatest numeric significance globally, and this makes it a huge market of lifestyle products and ideas that are woven around “modernity.” The unprecedented and deliberate marketing targeted at young children, often using children as agents of pester power, are resulting in the commercialization of the “whole of childhood.” This is happening for the first time in history and is yet to be scientifically examined and documented. It can hardly be expected that child-targeted market will seriously question the values of the economic interests from which they derive sustenance. The manufacturers of illness are not highlighted for scrutiny to the same extent, as are the biomedical causalities. The heavy dependence on theories of etiopathology and biomedical prevention will continue to guide the way corporate owned advertising spreads information on health. These theories lead us to question the motives of individual who overuse a product, but not the culture of consumption that is so skillfully marketed. This has radically changed the concept and practice of child rearing and parenting. At the end, it turns everyone into a “happy victim.” Child-targeted advertising, which is being increasingly owned by the leaders of the industry, can hardly be expected to stimulate the type of critical thinking which examines the ethic of consumption that bargains with child's health for private profit.[10],[11]
Context may be a little different, but the lessons learnt from the market and advertising in highly urbanized countries have a relevance to Indian reality as well. Food products having higher compositions of sugar, fat, or a combination of both, have an intrinsically higher motivational power compared to other food products which lack sugar and fat.[12] The sight, smell, and touch of food is also a source of continuous temptation. They stimulate reported hunger and salivation and have a significant positive impact on purchase. Individuals' power to engage in self-control, forego temptation, and choose healthier alternatives is compromised by aggressive advertisement of low-nutrient, high-calorie food items.[13] Increased television viewing leads to a decrease in the consumption of healthy food items due to a lack of presence of these foods in the present advertisement and media space. Increase in package size promotes overeating, and increase in the variety, in and between meals, leads to an overall increase in quantity consumed.[14] On the other hand, an interesting area of intervention is additional taxation on obesogenic food, which has shown positive results at population level.[15]
Younger populations of India are facing “double burden” of under nutrition as well as obesity. Different class strata within same locale, setting, and population group may show a different type of trends, making it a bit complex to design population-based interventions. In spite of the inherent tensions created by an overwhelming coexistence of protein-energy hypoalimentation, we will have to evolve a cogent approach, informed by context specific evidence, to address the rising threat of childhood overweight and obesity. The drivers which are likely to play a role in both, undernutrition as well as obesity, need to be identified, and a “whole of society” approach may be woven around them, while evolving and piloting population-based interventions.[16] Some actionable areas in this regard would include promotion of exclusive breast feeding and home food for children; restriction on fast food in homes and schools; assuring regular breakfast intake; regulating media and child-targeted market to control the promotion of health-compromising food, drinks, and habits; early promotion of moderation in life through Yoga and relaxation techniques in homes and schools; assuring at least an hour a day outdoor physical activity; improving access to build environment that promotes walking, cycling, and other physical activities; assuring >9 h sleep per day; reducing television time; and finding ways to engage in mild physical activity while watching television. Global evidence is increasingly suggesting that sugar is more harmful to health than lipids in diet, and since it is the sugar that provides the most tempting bait to be used by the food industry, market-based interventions will have to keep a watch on sugar as much as on lipids.
The universal factor of “passive obesity” induced by “modern living,” where every generation is heavier than the last needs to be addressed by an exceptionally imaginative and plastic approach. We cannot, and should not, stall the process of modernization and urbanization of human lives. The interventions would aim at minimizing the unhealthy by-products of these overwhelming forces especially that are associated with food habits and physical activity. It would require some game changers in the government, industry, and civil society. Dietary patterns, physical activity, sedentary lifestyle, and sleep time tend to cluster.[17] Evidence generated from One Health analyses also suggests a relationship between owner's and companion pet's overweight and obesity indicating the cardinal importance of shared obesogenic environment.[18] An equally forceful scientific argument is taking us back to our traditional wisdom, where the origin of childhood obesity is found rooted in the first 1000 days of life after conception.[19] Our kids are not “our” kids any more. They are children of their difficult times and are being manhandled by forces of unprecedented change of civilizational magnitude. If we do not act now, obesity and related diseases will desiccate the scarce resources that should have been directed elsewhere.
 References | |  |
| 1. | Campbell MK. Biological, environmental, and social influences on childhood obesity. Pediatr Res 2016;79:205-11.  |
| 2. | Zeiher J, Varnaccia G, Jordan S, Lange C. What are the determinants of childhood obesity? A literature review as part of the project “Nationwide monitoring of childhood obesity determinants”. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016;59:1465-75. |
| 3. | Ahmad QI, Ahmad CB, Ahmad SM. Childhood obesity. Indian J Endocrinol Metab 2010;14:19-25. |
| 4. | Kiranmala N, Das MK, Arora NK. Determinants of childhood obesity: Need for a trans-sectoral convergent approach. Indian J Pediatr 2013;80 Suppl 1:S38-47. |
| 5. | Raj M, Kumar RK. Obesity in children & adolescents. Indian J Med Res 2010;132:598-607. [ PUBMED] [Full text] |
| 6. | Arora M, Nazar GP, Gupta VK, Perry CL, Reddy KS, Stigler MH. Association of breakfast intake with obesity, dietary and physical activity behavior among urban school-aged adolescents in Delhi, India: Results of a cross-sectional study. BMC Public Health 2012;12:881. |
| 7. | Misra A, Khurana L. The metabolic syndrome in South Asians: Epidemiology, determinants, and prevention. Metab Syndr Relat Disord 2009;7:497-514. |
| 8. | Raychaudhuri M, Sanyal D. Childhood obesity: Determinants, evaluation, and prevention. Indian J Endocrinol Metab 2012;16:S192-4. |
| 9. | Bharati DR, Deshmukh PR, Garg BS. Correlates of overweight & obesity among school going children of Wardha city, central India. Indian J Med Res 2008;127:539-43. [ PUBMED] [Full text] |
| 10. | Chaturvedi S, Arora NK, Dasgupta R, Patwari AK. Are we reluctant to talk about cultural determinants? Indian J Med Res 2011;133:361-3. [ PUBMED] [Full text] |
| 11. | Chaturvedi S, Dasgupta R, Kumar A, Garg S, Chaudhury RR. Non-health determinants of health and healthcare in Delhi. Natl Med J India 2011;24:170-5. |
| 12. | Davis C, Patte K, Levitan R, Reid C, Tweed S, Curtis C. From motivation to behaviour: A model of reward sensitivity, overeating, and food preferences in the risk profile for obesity. Appetite 2007;48:12-9. |
| 13. | Wardle J. Eating behaviour and obesity. Obes Rev 2007;8 Suppl 1:73-5. |
| 14. | Khare A, Inman JJ. Habitual behavior in American eating patterns: The role of meal occasions. J Consum Res 2006;32:567-75. |
| 15. | Powell LM, Han E, Chaloupka FJ. Economic contextual factors, food consumption, and obesity among U.S. Adolescents. J Nutr 2010;140:1175-80. |
| 16. | Chaturvedi S, Ramji S, Arora NK, Rewal S, Dasgupta R, Deshmukh V, et al. Time-constrained mother and expanding market: Emerging model of under-nutrition in India. BMC Public Health 2016;16:632. |
| 17. | Aranceta-Bartrina J, Pérez-Rodrigo C. Determinants of childhood obesity: ANIBES study Nutr Hosp 2016;33:339. |
| 18. | Bomberg E, Birch L, Endenburg N, German AJ, Neilson J, Seligman H, et al. The financial costs, behaviour and psychology of obesity: A one health analysis. J Comp Pathol 2017;156:310-25. |
| 19. | Mameli C, Mazzantini S, Zuccotti GV. Nutrition in the first 1000 days: The origin of childhood obesity. Int J Environ Res Public Health 2016;13. pii: E838. |
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