Prevalence of overweight and obesity and associated demographic and health factors in India: Findings from Comprehensive National Nutrition Survey (CNNS)

BACKGROUND

Childhood obesity (5-9 years) in India is likely to contribute 11% to the global burden by 2030.

METHODS

Data from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018) was used to assess the prevalence and key associated factors of overweight and obesity. Multivariable logistic regression models were applied to identify potential determinants associated with being overweight and obese.

RESULTS

Overweight prevalence (including obesity) varied from 1.6% (0-4 years) to 4.8% (10-19 years). The majority of states reported a higher proportion of adolescents overweight and obese, than younger age group 5-9 years. A significantly higher prevalence of children and adolescents with obesity was reported in higher wealth quintiles and residents of urban areas. The prevalence of overweight and obesity and associated demographic and health factors in India included: the presence of NCD risk factor (adolescents: 1.68, 95% CI [1.31-2.14]), micronutrient deficiency (5-9 years children: 1.72, 95% CI [1.30-2.28]), mother's education (5-9 years children: 4.84, 95% CI [2.92-8.03]; adolescents: 2.17, 95% CI [1.42-3.32]), wealth (adolescents: 1.92, 95% CI [1.16-3.19]), place of residence (5-9 years children: 1.68, 95% CI [1.39-2.03]; adolescents: 1.39, 95% CI [1.16-1.66]), child age (5-9 years children: 1.64, 95% CI [1.40-1.93], and screen-time (adolescents: 1.63, 95% CI [1.22-2.19].

CONCLUSION

The findings set out policy and research recommendations to pave the path for curtailing the increasing prevalence of overweight and obesity and achieving the World Health Assembly's Global Nutrition target of 'no increase in childhood overweight (Target 4) by 2025'.

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia.

Integrating nutrition and mental health screening, risk identification and management in prenatal health programs in India

Pregnancy is a period of major physiologic, hormonal, and psychological change, increasing the risk of nutritional deficiencies and mental disorders. Mental disorders and malnutrition are associated with adverse pregnancy and child outcomes, with potential long-standing impact. Common mental disorders during pregnancy are more prevalent in low- and middle-income countries (LMICs). In India, studies suggest the prevalence of depression is 9.8%-36.7% and of anxiety is 55.7%. India has seen some promising developments in recent years such as increased coverage of the District Mental Health Program; integration of maternal mental health into the Reproductive and Child Health Program in Kerala; and the Mental Health Care Act 2017. However, mental health screening and management protocols have not yet been established and integrated into routine prenatal care in India. A five-action maternal nutrition algorithm was developed and tested for the Ministry of Health and Family Welfare, aiming to strengthen nutrition services for pregnant women in routine prenatal care facilities. In this paper, we present opportunities and challenges for integration of maternal nutrition and mental health screening and a management protocol at routine prenatal care in India, discuss evidence-based interventions in other LMICs including India, and make recommendations for public healthcare providers.

Population estimates and determinants of severe maternal thinness in India

OBJECTIVE

To examine prevalence, risk factors, and consequences of maternal severe thinness in India.

METHODS

This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India.

RESULTS

Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness.

CONCLUSION

This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations.

Screening and management options for severe thinness during pregnancy in India

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

Screening and Management of Maternal Malnutrition in Nutritional Rehabilitation Centers as a Routine Service: A Feasibility Study in Kalawati Saran Children Hospital, New Delhi

Background:

In India, Nutrition Rehabilitation Centers (NRCs) established at public health facilities provide residential medical nutrition therapy for severe acute malnutrition (SAM) children with complications. A large proportion of their mothers are also malnourished. NRCs do not provide services to such mothers as part of routine practice. However, technical algorithm for delivering Maternal Nutrition (MN) services in facility settings is available.

Objectives:

To test the practical feasibility of layering the MN services in NRC as a routine service.

Methods:

The MN services were delivered by a nutrition counselor using a triage approach (assess, classify, supplement/counsel/treat). All mothers received diet, micronutrients, and group counseling, those at nutritional risk received individual counseling and SAM mothers also received catch-up diet during their stay. Program data were collected from mothers during January 1 to August 31, 2019 at the NRC in Kalawati Saran Children Hospital. To gain operational insights, a structured interview with nutrition counselor was conducted.

Results:

Out of 168 mothers, 8% were found to be pregnant and 89% were at nutrition or medical risk. The prevalence of short stature was 18%, severe/thin 21%, overweight/obese 34%, and anemic 72%. Feedback from the nutrition counselor indicated no operational challenges, however, further efforts to ensure that mothers keep coming back for follow-up visits is needed.

Conclusion:

The findings indicated that existing staffs were able to deliver the MN services within the time, cost, and regime of the routine NRC. This paper provides four recommendations for layering the MN services in NRCs.

Tipping the Scales: Population Estimates and Risk Factors for Severe Thinness, Thinness, Overweight and Obesity Among Pregnant Women and Mothers in India

Objectives

Thinness and overweight/obesity are prevalent among women of reproductive age in India but there is limited evidence on the burden and predictors of this during pregnancy and post-partum. We estimated prevalence and risk factors for thinness and overweight among pregnant and recently delivered women (RDW).

Methods

We used India's National Family Health Survey (2015–2016), including 16,153 pregnant women &lt;20 weeks of gestation and 19,430 RDW of 2–6-month-old infants. All women were classified as severe thin (ST), thin (TH), overweight (OV) or obese (OB) (body mass index, BMI &lt;16, &lt;18.5, ≥23 and ≥25 kg/m2, respectively), using cutoffs for Asian populations. Logistic regression was used to examine associated factors (including socio-demography, hygiene and sanitation, antenatal health services and diet) with those outcomes.

Results

Barely 40% of women were of normal BMI. ST, TH, OV/OB and OB were seen in 2%, 20%, 25% and 13% respectively among pregnant women, and for RDW, they were 2%, 21%, 24% and 13%. Factors associated with a lower odds of ST and TH among pregnant women and RDW included higher wealth quintile (adjusted odds ratios, AORs ranging from 0.58–0.63 for highest quintile), higher education (AORs: 0.64–0.81), age group ≥25 y (AORs: 0.58–0.83), and improved toilet facility (AOR 0.81). Multiparous pregnant women had higher odds of TH compared to primiparas (AORs: 1.24–1.31). Factors associated with OV and OB among pregnant women and RDW were belonging in higher socio-economic group (AORs: 1.34–1.53), higher wealth quintile (AORs: 1.56–8.49), age group ≥25 y (AORs: 2.73–5.09), urban residence (AOR 1.16–1.36), and having higher education (AORs: 1.44–1.60). Among RDW, receiving supplementary food and health and nutrition education increased odds of TH (AORs: 1.15) and reduced odds of OV and OB (AORs: 0.83–0.87), but this is likely attributable to selection bias in program use.

Conclusions

TN and OV/OB affect 1 in 5 pregnant women and 1 in 4 RDW in India. Socio-economic factors, sanitation, parity, education and age influence TN and OV/OB. Better diet and physical activity estimates are needed to understand OV and OB in this population. Given the high burden of both forms of malnutrition, a policy focus on healthy weight gain is essential.

Funding Sources

UNICEF; Bill & Melinda Gates Foundation (via POSHAN).