overweight and obesity in children and adolescents (0-19

Overweight andObesity in Children and Adolescents (0-19 years) in India

Landscape Study, 2020

Overweight andObesity in Children andAdolescents (0-19 years)in India

Landscape Study, 2020

Table of Contents

1.2.

3.

4.

5.

List of Abbreviations .................................................................................................................................. viiForeword .................................................................................................................................................................ixExecutive Summary .......................................................................................................................................xiKey Messages .................................................................................................................................................. xv

Introduction .......................................................................................................................................1

Methods ................................................................................................................................................42.1. Estimating prevalence of overweight and obesity ....................................................4

2.2. Estimating compound annual growth rate (CAGR) for obesity .....................5

2.3. Estimating burden of overweight/obesity .......................................................................5

2.4. Measuring degree of risk ...............................................................................................................5

2.5. Regression models ..............................................................................................................................6

2.6. Regulation, policy and program review ..............................................................................7

2.7. Limitations ..................................................................................................................................................7

Findings .................................................................................................................................................93.1. Who is affected and where? ........................................................................................................9

3.2. Is the situation improving or worsening? ......................................................................13

3.3. What is the degree of risk for overweight and obesity among children and adolescents? .........................................................................................................13

3.4. What are the strategies, policies, and norms to address the obesogenic environment and promote healthy diets and physical activity? ................................................................................................................................22

Discussion ...................................................................................................................................... 294.1. Priority sub-groups for intervention to address obesity among U5, 5 to 10 years and 10 to 19 years ...........................................................................................29

4.2. Strengthening regulatory frameworks for tackling childhood overweight/obesity ...........................................................................................................................29

4.3. Programs with potential to address childhood overweight/obesity ...........................................................................................................................30

4.4. Research needs to improve understanding on overweight/obesity ...........................................................................................................................32

Conclusion ...................................................................................................................................... 33

References ..........................................................................................................................................................34Annexures ............................................................................................................................................................40

vTable of Contents

List of Abbreviations

AIIMS All India Institute of Medical Sciences

aOR Adjusted Odds Ratio

ASHA Accredited Social Health Activist

BAZ BMI for Age z Score

BMI Body Mass Index

BMS Breastmilk Substitute

BPNI Breastfeeding Promotion Network of India

CAGR Compound Annual Growth Rate

CNNS Comprehensive National Nutrition Survey

DHS Demographic Health Survey

FSSAI Food Safety and Standards Authority of India

FOPL Front-of-Pack Labelling

GDM Gestational Diabetes Mellitus

GWG Gestational Weight Gain

GRAPH Global Recommendations on Physical Activity for Health

HDL High Density Lipoprotein

HFSS High in Fat Sugar Salt

HIP Hyperglycemia in Pregnancy

ICDS Integrated Child Development Services

ICMR Indian Council of Medical Research

IDF International Diabetes Federation

IEC Information, Education and Communication

IFA Iron and Folic Acid

GST Goods and Services Tax

IMS Infant Milk Substitute

INCLEN International Clinical Epidemiology Network

IOM Institute of Medicine

IYCF Infant and Young Child Feeding

JSSK Janani Shishu Suraksha Karyakram

LBW Low Birth Weight

LDL Low density lipoprotein

LMIC Low and Middle Income Countries

viiList of Abbreviations

MAA Mother’s Absolute Affection

MDM Mid-day Meal

MoE Ministry of Education

MoHFW Ministry of Health and Family Welfare

MoWCD Ministry of Women and Child Development

NCD Non-Communicable Disease

NFHS National Family Health Survey

NFSA National Food Security Act

OBGYN Obstetrician and Gynecologist

PDS Public Distribution System

PHFI Public Health Foundation of India

PM-JAY Pradhan Mantri Jan Arogya Yoyana

PMMVY Pradhan Mantri Matru Vandana Yojana

RBSK Rashtriya Bal Swatsthya Karyakram

RDA Recommended Dietary Allowance

RKSK Rashtriya Kishore Swasthya Karyakram

SAG Scheme for Adolescent Girls

SD Standard Deviation

SDGs Sustainable Developmental Goals

SSB Sugar-sweetened Beverage

SSFT Sub-scapular Skinfold Thickness

TSFT Triceps Skinfold Thickness

U5 Under Five

UHC Universal Health Coverage

UNICEF United Nations Children’s Fund

WC Waist Circumference

WASH Water, Sanitation and Hygiene

WHA World Health Assembly

WHO World Health Organization

WHZ Weight for Height z Score

WIFS Weekly IFA Supplementation

viii List of Abbreviations

It is my pleasure to share this report on “Overweight and Obesity in Children and Adolescent (0-19 years) in India: Landscape Study, 2020”. The report synthesizes key finding of a landscape study conducted using the pilot landscape analysis tool to review the current situation, obesogenic environment and policy landscape of childhood obesity and overweight, developed by UNICEF and IEG with contributions by colleagues and collaborators from the NITI Aayog, Ministry of Health Family Welfare, World Obesity Federation, World food Programme and the World Health Organization. The report also highlights the existing national programs and policies available, under various ministries of Government of India, for prevention of overweight and obesity in children and adolescents.

As India faces a triple burden of malnutrition, witnessed by continuing prevalence of stunting, wasting and micronutrient deficiency coupled with the rapid increase in childhood overweight and obesity, the present report sheds light on where progress has been made and where challenges remain. Socioeconomic inequalities remain a key cause of malnutrition – both undernutrition and overweight, obesity and other diet-related chronic diseases. This suggests that double duty action needs to be integrated in health programmes and policies that aim to tackle multiple forms of malnutrition through better diet, services and caregiver practices.

This review highlights gaps in the existing evidence and develops policy recommendations emerging from the review of various research studies on food and health systems that focus on intensifying inequalities in nutrition outcomes. The report lays emphasis on policy measures and guidelines such as restricting sale of high fat, sugar and salt (HFSS) foods in and within 50m radius of schools, regulation on the marketing of HFSS foods through mass media advertising, to address childhood overweight and obesity. Additionally, programmes such as school health programs, antenatal care programs and community-based non-communicable disease prevention and control programs have been identified as important platforms for prevention of malnutrition among children through promotion of healthy eating practices and physical activities.

Given the intricacies associated with overweight and obesity among children and adolescents, it is critical to develop multi-sectoral action plan for tackling malnutrition. This task should be supported with adequate investments in data systems for implementation of programmes and tracking of progress in population health. IEG is committed in its support for the government and civil society organisations, in their efforts to develop evidence based policies, programmes and interventions for addressing malnutrition.

I believe this landscape study is an important step in that direction.

Prof. Ajit MishraDirectorInstitute of Economic Growth, Delhi

Foreword

ixForeword

Obesity affects 380 million children and adolescents worldwide. Low- and middle-income countries (LMICs) are emerging hotspots for the obesity epidemic, which threatens to exacerbate the unfinished agenda of tackling undernutrition. If current trends persist, India is likely to contribute 11% of the global burden of child obesity by 2030. Children affected by obesity face life-long risks for non-communicable diseases (NCDs), in addition to adverse physical and psychosocial impacts during childhood. The United Nations Children’s Fund (UNICEF) guidance on prevention of overweight and obesity in children and adolescents summarizes ten risks that increase the likelihood of obesity including risks in prenatal period to late adolescence, as well as those related to obesogenic food and physical activity environments. Addressing these risks as part of a coherent strategy to tackle multiple forms of malnutrition simultaneously requires a holistic approach across the food, health, education, social support and water and sanitation systems. India is a signatory to the World Health Assembly (WHA) 2025 target of halting child overweight but has not yet set national obesity prevention targets for children aged 0-9 years. Double duty actions in the first 1000 days and in school years are recommended; these actions are more or less embedded in India’s national programs, such as Mothers’ Absolute Affection (MAA) program on breastfeeding, home based care for young children by Accredited Social Health Activists (ASHAs), Ayushman Bharat School Health Program and the Food Safety and Standards Authority of India’s (FSSAI’s) Eat Right school campaign. However, some of the specific actions recommended for obesity prevention, such as restrictions on food marketing, have not yet been introduced in India. As the finish line for the WHA 2025 targets is just five years away, this landscape analysis was undertaken to estimate prevalence and burden of overweight and obesity in children and adolescents aged 0-19 years, trends and progress towards the WHA 2025 target, ascertain predictors of overweight and obesity and map policies and programs that have potential to address childhood overweight and obesity as part of India’s continuing efforts to end all forms of malnutrition.

The landscape study was conducted using the pilot landscape analysis tool for childhood overweight and obesity, developed by UNICEF with input from World Health Organization (WHO). The Comprehensive National Nutrition Survey (CNNS), 2016-18 data was used to estimate prevalence and burden of overweight and obesity and to identify predictors of overweight/obesity. This was supplemented by findings from a desk review of papers published in the last decade that were sourced through the U.S. National Library of Medicine database (PubMed) and stakeholder outreach. The Demographic Health Surveys (DHSs) for 2005-06 and 2015-

Executive Summary

Introduction

Methods

xiExecutive Summary

16 were used for calculating Compound Annual Growth Rates (CAGRs) for overweight/obesity in children under five (U5) and NCDRisC data for growth rates of obesity in middle childhood (5 to 9 years) and adolescence (10 to 19 years). Data on sales and consumption of “healthy” and “unhealthy” foods was sourced from Euromonitor and FAOSTAT. Estimates for overweight for children U5 were based on weight-for-height z-scores (WHZs) > +2SD, and estimates for obesity for children aged 5-19 years were based on BMI-for-age z-scores (BAZs) > +2SD. Prevalence estimates of risk factors for childhood obesity were computed. These included 1) maternal risk factors such as maternal overweight/obesity, thinness, excess gestational weight gain (GWG) and hyperglycemia; 2) childhood stunting and infant and young child feeding (IYCF) practices for children under two; and 3) risks related to diets, physical inactivity, micronutrient deficiencies and NCDs for older children/adolescents. Four multi-variate adjusted regression models were generated to identify predictors of overweight/obesity as well as obesity for the age-groups of 5 to 9 years and 10 to 19 years. Mapping of policies from all relevant ministries was undertaken and strategy documents and guidelines sourced from these websites. Strategies, regulations, guidelines and reports were sourced from relevant ministries and stakeholders.

Overweight/Obesity prevalence in children U5 was 1.6% and in adolescents was 5%, affecting over 18 million children and adolescents. CAGR for overweight was 2.5% for children U5, and CAGR for obesity 8% among girls and 13% among boys aged 5-19 years. Currently, overweight and obesity in children and adolescents is concentrated in urban, higher-income groups. However, the pace of increase among adolescents in rural areas (8.3%) was double than that observed in urban areas (4.4%). Pace of increase in urban areas was highest in urban poorest wealth quartile (9.5%). Prevalence of obesity was high (≥10%) in states of Goa, Tamil Nadu and Sikkim for both children aged 5 to 9 years and adolescents. Regional distribution of maternal obesity mirrored that of children (5-9y) and adolescents, with 38 districts identified as hotspots for maternal risks related to obesity. Over 6 million babies were affected by maternal hyperglycemia. Overweight and obesity in India exist alongside other forms of malnutrition; a quarter of children aged 5 to 9 years and 57% adolescents suffering from obesity also had multiple micronutrient deficiencies. Also, 12-13% had pre-diabetes, over 20% had low high-density lipoprotein (HDL) cholesterol levels and 40% had high triglycerides. Adolescents suffering from any chronic disease condition were more likely to be obese [aOR 1.62(1.05,2.50)]. All adolescents except 17-year-old boys failed to meet minimum physical activity requirements. Being 8 to 9 years of age compared with 5 to 7, was associated with higher odds of obesity [aOR 2.44 (1.65,3.62)]. Greater exposure to mass media and

Results

xii Executive Summary

consumption of fried foods ≥ thrice a week also increased odds of obesity [aOR 2.74 (1.04,7.21) and 2.21 (1.25,3.89)]. At a population level, per-capita consumption of confectionery increased by almost 10 times compared with vegetables between 2014-19.

Food based dietary guidelines are available for nine sub-groups between the aged 0-19 years and are the basis for government food procurements for anganwadis and mid-day meals (MDMs) at schools. Universal food supplementation for all pregnant women and breastfeeding mothers and children 6 months to 6 years covers almost a third of the day’s calorie requirements. These programs face implementation hurdles and do not take into consideration the nutritional status of the women and children. Antenatal care programs, too, lack customization for nutrition risks (like counselling on nutrition and physical activity, guidance on weight gain), except for anemia. Regulations on restricting sale of high fat, sugar and salt (HFSS) foods in and within 50 m radius of schools have been drafted and await implementation. Implementation of front-of-pack labelling (FOPL) is also pending. There is no regulation on the marketing of HFSS foods, and they are widely promoted through mass media and children and adolescents are exposed to persuasive promotions. There is currently no nationwide tax on HFFS foods, but India does have experience in levying a “fat-tax” to curtail sales of branded junk foods in Kerala. The school health programs have potential to be a platform to promote healthy food and physical activity but parental engagement and reaching out to non-attendees and out-of-school children require other approaches. The recently launched, community-based NCD prevention and control programs also have the potential to include prevention in children.

India faces a triple burden of malnutrition, witnessed by continuing burden of stunting, wasting and micronutrient deficiencies coupled with the rapid increase in childhood overweight and obesity.

While currently mostly affecting children from a higher income and/or urban background, increases in childhood obesity in India are inequitable with rural and urban low-income populations witnessing the steepest increases.

Halting the rise in childhood obesity in India, while simultaneously tackling other forms of malnutrition, will require action on diets, services and caregiver practices; in particular efforts to improve food environments will be particularly important. Given the ongoing burden of undernutrition and micronutrient deficiencies in India, the response should be double duty, wherever possible.

Conclusion

xiiiExecutive Summary

Adolescent, prenatal and antenatal programs should become more responsive to risk factors of maternal overweight and hyperglycemia. Existing IYCF programmes should be strengthened to ensure they link better with the prevention of overweight and obesity. Supplementary food programmes may need to be reviewed to include healthier choices and nutrition status-based supplementation.

School health programmes for children in India should ensure access to healthy, nutritious and affordable diets (both the quantity and the quality/healthfulness of food eaten) and adequate physical activity; while taking into account the coexistence of multiple micronutrient deficiencies. There is an opportunity to build on school health programs to develop and test a comprehensive screening, management and referral services package for child obesity in geographical hotspots.

Legislation to restrict the sale and promotion of HFSS foods is needed along with expediting implementation of the regulations on restricting HFSS sales in schools and FOPL.

Standards for physical activity should cover pre-school age groups, and monitoring and reporting of physical activity in schools should be included in the ongoing Ministry of Health and Family Welfare’s (MoHFW) school health program.

While there might be limited evidence from India that the taxes have been effective (both Kerala fat tax and National level Goods and Service tax (GST) rate), there is substantial evidence from overseas that such a policy will have an impact if the tax design and enforcement of the taxes are robust.

The National Multisectoral Plan of Action for prevention and control of NCDs lists actions by different ministries to address obesity in adulthood and adolescence. A similar strategy is needed for children (0-9 years). NITI Aayog (India’s policy think tank), relevant ministries, FSSAI, academic institutions, professional associations of obstetricians and gynecologists (OBGYNs) and pediatricians and Indian Council of Medical Research (ICMR) should be engaged on discussion of the policy and research gaps identified through this landscape analysis.

xiv Executive Summary

Key Messages

1. There are over 17 million children aged 5 to 19 years in India who are affected by obesity. If childhood obesity remains unchecked, these numbers will increase to 27 million by 2030.

2. There are no gender differentials in prevalence of overweight and obesity among children U5 y and adolescents.

3. Prevalence of childhood overweight and obesity is consistently higher in urban areas than rural India across all three age-groups. But the pace of increase is higher in rural areas.

4. Similar to other LMICs, in India, prevalence of childhood obesity currently increases gradually with improving economic status. However, in the urban sub-set of adolescents, pace of obesity increase is highest in the lowest wealth quartile.

5. 11 of 28 states in India have high prevalence of childhood obesity either in boys or girls; these states might be considered for piloting and scaling up prevention and management strategies, that can later be rolled out more widely.

6. Multiple micronutrient deficiencies co-exist and are associated with overweight and obesity in children. Chronic disease risks are high among both children and adolescents but more strongly associated with overweight and obesity in adolescents. This suggests that obesity prevention efforts need to be double duty, and aim to tackle multiple forms of malnutrition through better diets, services and caregiver practices.

1. It is highly unlikely that India will meet the WHA 2025 target of no increase in childhood overweight. Among children 5-19 years, from 2005 to 2016, the rate of increase of obesity has been ‘very rapid’, with a CAGR of 13% for boys and 8% for girls.

2. The rate of increase on overweight and obesity is much higher in rural areas than urban. Among adolescent girls 15-19y, the rate of increase in rural areas (8.3%) compared is almost double urban areas (4.4%). In urban areas, the rate of increase is fastest in the lowest wealth quartile (9.5%).

Maternal

1. Overweight affected 1 in 4 mothers of children under five. Concomitantly, 1 in 3 women were underweight.

2. 38 districts with a total population of nearly 11.5 million women emerged as hotspots for targeting interventions for management of obesity in late adolescents (15 to 19y) and young women (20 to 24y).

Who is affected and where?

Is the situation improving or worsening?

What is the prevalence of risk factors associated with overweight and obesity?

xvKey Messages

3. Among obese mothers, evidence from local studies indicate that nearly 30% gain more than the recommended weight during pregnancy, thus, increasing risk of intergenerational transmission of obesity and life-time risk of NCDs in their offspring.

4. Annually, 6 million births are affected by hyperglycaemia in pregnancy (HIP), and around 28.5% women suffer from gestational diabetes mellitus (GDM).

Stunting and IYCF

1. 2 in 5 infants miss out on exclusive breastfeeding in the first six months; a protective factor against obesity in addition to its several other benefits.

2. About 19% babies were born low birth weight (LBW); 35% children U5 were stunted.

Diet and Physical Activity

1. About 77% children reported consuming fast-food atleast on a weekly basis and a similar proportion did not meet daily recommended physical activity requirements.

2. In India, fast-food retail outlets and per-capita sales of vegetable oil, sugar and confectionery witnessed very rapid growth. Sales of confectionery increased almost 10 times faster than pulses in the last five years.

1. India is signatory to WHA target 2025 and has targets on halting increase in obesity among adults and adolescents. However, there are no national targets for obesity for younger children (0-9y). There is scope for retrofitting specific national targets and strategies for obesity management and prevention in national nutrition missions for hotspot states and districts.

2. Double duty actions are integrated in health-sector programs (which deliver the majority of nutrition-specific interventions) but not strategized as both undernutrition and overweight related.

3. Fiscal instruments are used but their impact on sale of “unhealthy foods” is not established (such as GST on aerated and caffeinated beverages and processed packaged foods). Kerala fat-tax (@14.5% in 2016-17) did not impact sales of “unhealthy foods” and offers several lessons for introducing fiscal measures.

4. FSSAI has put forward regulations on sale and promotion of HFSS foods in and near schools, as well as regulations on FOPL (in 2020), however these have not been implemented. There is no regulation restricting marketing of HFSS foods more broadly (e.g., on TV, Internet, public transportation).

What are the policy, institutional and governance mechanisms in place to address obesity?

xvi Key Messages

1. Include overweight and obesity prevention and management in children’s pre-school and school health programs as well as in Poshan Abhiyaan 2.0

– Integrated Child Development Services (ICDS) screening for children under 6 should include both underweight and overweight/obese

– Individualized report and feedback to school children who are either underweight or overweight or obese

– Clinical examination should also include body fat distribution (waist circumference (WC) or skinfold thickness) and screening for NCD risk factors

– Reformulation targets, such as sugar reduction and consideration of long term procurement policies on increasing obesity in food-based programmes needs consideration.

2. Prioritize geographies and sub-groups to customize overweight and obesity prevention and management

– Both urban and rural areas should focus on prevention and management strategies

– A life-cycle approach is needed but school-entry level programs may have higher potential in curbing the increase in obesity prevalence from ages 5 to10 years. Rapid increases are noted in this age-group.

3. Retrofit antenatal care and breastfeeding promotion programs to “healthy” start to life and address implementation challenges

4. Ensure a holistic approach to “healthy” eating and lifestyle is applied, as multiple micronutrient deficiencies and NCD risks co-exist with overweight and obesity in children and adolescents.

5. Include physical activity promotion in pre-school years based on age-appropriate standards. Among older children reporting on physical activity needs to be included through school health programs.

6. Expedite roll-out of school food safety regulations drafted in 2020

– Enforce regulations on restricting sale of HFSS foods and Sugar Sweetened Beverages (SSBs) near schools and FOPL

7. Develop guidelines for regulating sale of HFSS foods and SSBs and promotion including advertising as done for Breast Milk Substitute (BMS) and infant foods under Infant Milk Substitute (IMS) Act with similar actions against violators

– Modify existing regulations from FSSAI to restrict marketing of HFSS foods and SSBs

Recommendations

xviiKey Messages

– Restrict media advertisements of HFSS foods and SSBs targeted towards children

8. Examine domestic and international evidence on the impact of use of fiscal instruments on sales of unhealthy foods, review and conduct modelling exercises in India to obtain a clearer perspective on implementation of fiscal policies.

9. Build on ongoing school health programs by MoHFW (including FSSAI’s Eat Right School):

– Understand which components worked and which can be strengthened in shaping healthier behaviours

– Parent engagement to be tested to ensure healthy eating and physical activity during out-of-school hours especially for 5 to 9y aged children

10. Fat tax policy will have an impact if the tax design and enforcement of the taxes are robust. Reformation of procurement policies (for “do no harm”) in food-based programmes

1. Develop nationally representative estimates for physical activity among pre-school, school aged children and adolescents

2. Undertake in-depth content analysis of food and beverage advertisements on Indian television

3. Undertake in-depth analysis on consumption of Indian fast-food, and quality of diets (in terms of refined flour, dietary fibre, nutrient density, packaged food)

4. Evaluate ban on marketing in schools and implementation of FOPL of packaged foods.

5. Undertake in-depth analyses of social and cultural influences on body weight and lifestyle choices

6. Investigate the impact of fiscal policies (taxation, marketing controls) on overweight and obesity prevention (E.g. Has GST on sweetened beverages impacted sales? Can fat-tax be reintroduced based on lessons from Kerala?)

7. Develop an overarching framework for gap assessment, monitoring and tracking of the programs for management of childhood overweight and obesity

8. Develop reference population estimates on WC and skinfold thickness for children in developing countries

9. More robust longitudinal data collection could provide insights into understanding the risk factors and prevention of childhood obesity.

Research Priorities

xviii Key Messages

Introduction1.

Overweight and obesity is increasing worldwide, affecting 380 million children and adolescents. Globally, the proportion of children in middle childhood (5 to 9 years) and adolescents (10 to 19 years) who are affected by overweight or obesity is estimated at 21% and 17%, respectively (1). The rate of increase in childhood overweight and obesity is disproportionally higher among low-middle income countries (LMICs) than developed countries (2). In South Asia, prevalence of overweight more than tripled from 2000 to 2016 among both children and adolescents (5 to 19 years) (1). In absence of measures to check childhood overweight and obesity, India will be home to over 27 million children and adolescents (5 to 19 years) living with obesity by 2030 and account for 11% of the global burden (3).

Children suffering from obesity are predisposed to high blood pressure, insulin resistance and dyslipidemia (together referred to as the metabolic syndrome). In the longer term, children who are affected by obesity are more likely to remain obese in adulthood and at risk of additional non-communicable disease (NCDs)-related morbidity and mortality even after managing the condition in adulthood (4). Many of the risks of obesity emerge in early years and are best addressed then (5).

The United Nations Children’s Fund (UNICEF) guidance on prevention of overweight and obesity in children and adolescents summarizes ten such risks. These include maternal and paternal overweight as well as maternal undernutrition, inadequate breastfeeding and complementary feeding, unhealthy eating habits in young children and adolescents, obesogenic food and cultural environments, epigenetic changes due to environmental factors and socio-economic status with increased propensity among poorer households (1). These risks have been classified using different frameworks by researchers, one based on modifiability is presented in figure 1.

Addressing these risks requires a holistic approach across food, health, education, social support and water and sanitation systems. Promotion of healthy behaviors consistently across all these systems, alongside implementing appropriate legislations on marketing, labelling and taxation of unhealthy foods is likely to positively impact and sustain these behaviors (6). The wider benefits of optimum nutrition in childhood is not only limited to reduce risk of NCDs in the future but also as improved cognitive and physical capacities in later life, thus better productivity, preventing mental health issues associated with obesity.

1Overweight and Obesity in Children and Adolescents (0–19 years) in India

India is committed to the World Health Assembly (WHA) Global Nutrition target of no increase in childhood overweight (Target 4) and NCD targets including 10% relative reduction in prevalence of insufficient physical activity, 30% relative reduction in mean population intake of salt/sodium and halt the rise of diabetes and obesity by 2025 (7,8). The Ministry of Health and Family Welfare (MoHFW), Government of India launched Ayushman Bharat (also referred to as Pradhan Mantri Jan Arogya Yoyana

Figure 1.1 Conceptual framework describing the etiology of childhood obesity

Source: Ang YN, Wee BS, Poh BK, Ismail MN. Multifactorial influences of child obesity. Current Obesity Reports. 2013; 2:10–22

Intrauterine Factor

Maternal obesityGestational weight gainGestational diabetesIntrauterine evnironmentEpigenetics

Parental Determinants

SmokingWorking schedule

Ethnicity

UNMODIFIABLE MODIFIABLE

Environment Interaction

Childhood Obesity

BMIBody weight

Adiposity

LifestyleChanges

Socioeconomic Status

Family incomeUrban/ruralGross national income

Diet

BreastfeedingEnergy dense foodSweetened beverageFast foodPre-prepared convenience foodBreakfast consumptionAvailability of junk foodSkip mealFood marketing to childrenVitamin-D deficiency

Physical Activity

Sedentary activityLess exerciseAcademic engagementScreen time

Genetics

MonogenicPolygenic

Sleep

DurationObstructive sleep apnea

2 Overweight and Obesity in Children and Adolescents (0–19 years) in India

PM-JAY) in 2018 with the aim to achieve Universal Health Coverage (UHC) and meet the Sustainable Development Goals (SDGs) by 2030. Ayushman Bharat conjugates all ongoing primary health care and school health programs with a focus on comprehensive preventive, palliative and curative health care. It offers the largest financial protection cover through health insurance to vulnerable households and aims to upgrade and up-skill 150,000 primary health care facilities as health and wellness centers by 2022. Screening, prevention and management of NCDs in adults is a sizeable component of holistic health and wellness approach under the scheme (9). Further, through the Food Safety and Standards Authority of India (FSSAI), MoHFW sets standards for regulating the manufacture, storage, distribution, sale and import of foods for human consumption. FSSAI also implements the Eat Right India initiative which aims to improve food safety and healthy eating practices across the life cycle. This initiative also has a dedicated school component (10). These school initiatives by MoHFW complement the Department of School Education’s mid-day meal (MDM) program for primary and middle school students.

UNICEF released program guidance on prevention of overweight and obesity in children and adolescents in 2019 (1). In April 2020, UNICEF developed a pilot landscape analysis tool for childhood overweight and obesity for testing as a complement and preparatory step in building a country program of work on overweight and obesity prevention. The pilot tool describes a five step-by-step approach on how to undertake the landscape analysis including: review of the current situation; review of the obesogenic environment: review of the policy landscape; review of the policy options; and assessment of the policy options.

The Comprehensive National Nutrition Survey (CNNS), 2016-18 provides data on nutritional status of Indian children and adolescents (0-19 years) (11). Data on nutritional status of 5 to 14 years age group is available for the first time from any nationally representative survey. With five years to the WHA targets finish line, data availability for children/adolescents and highest political commitment to act on nutrition, this is an opportune time for India to set national targets and plans towards no increase in childhood overweight/obesity. Thus, a deeper understanding of the status, determinants, policy actions and options on childhood overweight/obesity is much needed.

With this background in mind, the landscape analyses were conducted, with the following specific research questions in mind.

1. Who is affected and where?

2. Is the situation improving or worsening?

3. What is the degree of risk among children and adolescents?

4. What regulation, policies and programs support maternal and early child nutrition to prevent early exposures to obesity risks among under 5s (U5s)?

5. What are the regulations, policies and programs that influence obesogenic environments for children and adolescents (5 to 19 years)?


Methods2.

Children and adolescents were grouped into three categories by age – children U5 years, middle childhood (5 to 9 years) and adolescents (10 to 19 years).

The estimates for prevalence of overweight were drawn from the CNNS 2016-18 report. This survey was conducted by UNICEF in collaboration with Population Council and the MoHFW and was designed to be representative of the 28 states and 2 Union Territories. Data were collected from 112,316 children and adolescents 0-19 years. Of these, a subsample of 103,698 children and adolescents with valid anthropometric measurements was considered for analyses. Sample size for maternal anthropometry data was 33,873. Details of sampling are presented in Annex 1. The indicators and cut-offs used for estimating overweight and obesity for the three age groups are presented in table 2.1. Measures of skinfold thickness – triceps skinfold thickness (TSFT) and sub-scapular skinfold thickness (SSFT) and waist circumference (WC) were included to understand fat distribution which is associated with chronic disease risks (12,13).

2.1. Estimating prevalence of overweight and obesity

Table 2.1 Age-specific indicators and cut-offs for estimating overweight and obesity

Age-specific indicator* Overweight Obesity

WHZ (<5 years) >+2SD >+3SD

BAZ (5 to 19 years) >+1SD >+2SD

*BAZ: BMI for age z score, WHZ: Weight for height z score

Bivariate analysis was conducted to estimate the prevalence of overweight and obesity disaggregated by sex (girl/boy), location (rural/urban), socio-economic status determined by wealth index quintiles and quartiles classification for rural and urban areas, respectively, derived using principal component analysis of household assets, following Demographic Health Survey (DHS) guidelines, religion, caste, mother’s age, education, occupation and nutrition status, father’s education and occupation, access to household toilet facility and geographical regions (north, south, east, west, north-east) and states.

In addition, we reached out to key stakeholders, building on this team’s earlier database on maternal obesity experts, to identify ongoing and complete research on childhood overweight/obesity in India. In addition, peer-reviewed articles were shortlisted through PubMed literature searches using search terms like “overweight/obes*”, “infan*”, “child*”, “adolescen*”, “BMI”, “matern*”, “India”. The objective of this supplementary review was to understand the variations in prevalence of childhood obesity across


2.2. Estimating compound annual growth rate (CAGR) for obesity

2.3. Estimating burden of overweight/obesity

2.4. Measuring degree of risk

specific target groups, such as urban versus rural school-going children. This information revealed the scale of the problem in known high risk groups which national averages masked.

The DHS data from the 2005-06 and 2015-16 rounds were used to estimate 10 year trends in prevalence of overweight/obesity and obesity among children U5 (14,15). The DHS does not cover the age-groups of middle childhood (5 to 9 years) or early adolescence (10 to 14 years). Hence, the NCD RisC database was used to extract India data on overweight/obesity and obesity among children in middle childhood and adolescents for estimating CAGR (16). The WHA 2025 target of no increase in childhood overweight was used as a comparator to determine if India could meet the overweight/obesity targets.

Census of India (2011-2036) projections were used to extrapolate prevalence data and arrive at numbers of children and adolescents affected by overweight/obesity (17). Quantum GIS v.3.6.3 was used to graphically present the distribution of overweight/obesity.

2.4.1. Maternal risk factorsEstimates of 12 variables that are known maternal risk factors for child overweight and obesity were drawn from multiple sources referenced here and in the findings section. The indicators included those of women and more specifically pregnant women, based on data availability were: Maternal overweight/obesity (11), obesity and their trends (11,14,15), maternal thinness (classified using Asian Body Mass Index (BMI) cut-offs) (11), gestational weight gain (GWG) more than recommended (18,19), gestational diabetes mellitus (GDM)/ hyperglycemia in pregnancy (HIP) (20,21), smoking tobacco, alcohol consumption (11), low birth weight (LBW) (<2.5 kg) and high birth weight (>4 kg) (11). Data on the trends in GDM/HIP were sourced but found to be not available for India. The degree of risk was assessed using the classification in the UNICEF pilot landscape analysis tool.

2.4.2. Risk factor among children U5Estimates of 10 variables that are known child risk factors for child overweight and obesity were drawn from multiple sources detailed in the findings section. The indicators were: childhood stunting (height for age z-score <-2 SD) and trends (11,14,15), timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding in ages 12 to 23 months (11), consumption of sweetened beverages, consumption of fruits and vegetables, trends in sales of breastmilk substitutes (BMS) and commercial infant foods (22). The degree of risk was assessed using the classification in the UNICEF pilot landscape analysis tool.

2.4.3. Diet related risk factors in middle childhood and adolescence A detailed analysis of daily consumption of all food groups as per national dietary guidelines was conducted for children in middle childhood


and adolescence (23). Daily consumption of sugars, fats and oils and consumption of fried foods, junk foods, sweetened beverages for at least 3 days in a week were also analyzed (11). Estimates of 12 variables of diet related risk factors were drawn from multiple sources referenced here and in the findings section. The variables were: consumption of sweetened beverages (11), confectionery and junk foods for at least 3 days in a week (11,24,25), CAGR for sales of sugar, confectionery, pulses, vegetables (26) and retail outlets of leading fast food chains (27), exposure to advertisements of high fats, salt and sugar foods (HFSS) through television (28,29), schools providing food complying with national standards and access to drinking water in schools and households. The degree of risk was assessed using the classification in the UNICEF pilot landscape analysis tool. There were seven other variables recommended in the UNICEF landscape analysis tool that could not be included in our analysis for lack of data. These were: CAGR for oils/oil seeds and sweetened beverages, schools providing sweetened beverages and HFSS foods through vending machines, schools accepting endorsements from fast-food chains, proportion of relief foods meeting dietary guideline requirements compared to total relief foods and value of subsidized food meeting dietary guideline requirements compared to total subsidized food.

In this section, prevalence of anemia, individual and multiple micronutrient deficiencies (iron, folate, vitamin B12, vitamin A, vitamin D, zinc) and any chronic condition or its precursor (pre-diabetes or high HbA1c, hypertension, high total cholesterol, high low density lipoprotein (LDL), low high density lipoprotein (HDL), high triglycerides, high serum creatinine) were also estimated (11).

2.4.4. Physical activity and air pollution related risk factors in middle childhood and adolescence and in women?The UNICEF landscape analysis tool included 20 indicators to measure risks related to physical activity and one on air pollution. Data was available on 12 indicators of physical activity: insufficient physical activity, trends and gender differentials, active transport to school (walking or cycling in last 7 days), physical activity options in schools, screen time >3 hours per day, insufficient duration of sleep (<8 hours), walking and cycling tracks access and ownership of cars and bicycles (30,31,32). Ambient air pollution related death rate per 100,000 population was the only indicator related to air pollution risk (33).

Multivariate logistic regression was undertaken to determine the association of selected variables with overweight/obesity and obesity in children and adolescents using data from CNNS. Four adjusted models, two for each of the age groups of 5 to 9 years and 10 to 19 years were generated. One of the two models generated associations with overweight/obesity and second only obesity. The variables included in the model were: age (5-7y and 8-9y, 10-14y and 15-19y), sex (male/female), residence (rural/urban), religion (Hindu/Muslim/Christian/Sikh/others), caste/tribe (scheduled caste/scheduled tribe/other backward castes/others), wealth

2.5. Regression models


quintile, region (north, south, east, west, north-east), mother’s education, father’s occupation, currently in school, exposure to mass media (low/medium/high), internet access, access to household sanitation facility, diet (consumption of >=5 food groups daily, consumption of unhealthy food groups >= 3 times a week including fried foods, junk foods, sweets or confectionery (Indian sweets, chocolates, candies, desserts) and aerated drinks) and co-morbidities (anemia or any micronutrient deficiency (out of the six deficiencies studied– iron, folate, zinc, vitamin A, B12 and D) and any chronic condition (presence of any one of the risk factors of NCDs – pre-diabetes or high HbA1c, hypertension, high total cholesterol, high LDL cholesterol, low HDL cholesterol, high triglycerides, high serum creatinine)). To account for the effect of inflammation on iron and vitamin A status, cases with high inflammation (C-reative protein CRP>5mg/l) were excluded from the analyses. We present adjusted odds ratios (aORs) and 95% CIs and considered two-tailed p values of <0.05 for a significant difference.

All analyses were conducted using Stata v.15.1. Prevalence statistics and regression models accounted for the multi-stage cluster sampling design and survey weights specific to biomarker data.

Government of India websites of MoHFW (including FSSAI), Ministry of Law and Justice, Ministry of Rural Development, Ministry of Urban Development and Ministry of Women and Child Development (MoWCD), were accessed to map all relevant regulations, policies and programs documents. A targeted stakeholder outreach was undertaken to solicit further information on the status of policies, regulations and programs from agencies responsible for managing and/or reviewing government programs or research on childhood nutrition as well as those impacting obesogenic environments. FSSAI representatives were reached to understand status of labelling and marketing of foods both healthy and those high in HFSS and Breastfeeding Promotion Network of India (BPNI) for status of implementation of Infant Milk Substitutes (IMS), Feeding Bottles and Infant Foods (Regulation of production, supply and distribution) Act, 1992, Amended 2003 (IMS Act) (34). Several medical colleges and research agencies/institutes were contacted including All India Institute of Medical Sciences (AIIMS), Global Child Nutrition Foundation, International Clinical Epidemiology Network (INCLEN), Madras Diabetes Research Foundation & Dr Mohan’s Diabetes Specialties Centre, Public Health Foundation of India (PHFI) and St. Johns Research Institute and Medical College. Documents sourced from all these stakeholders were purposively reviewed to answer questions listed in the UNICEF landscape analysis tool.

The standard reference population for ascertaining overweight/obesity using body fat distribution (i.e. WC and skin fold thickness) include children/adolescents from developed countries and thus need to be interpreted with caution when applying on Indian dataset (12,13). We have used these indicators to present estimates on body fat distribution and not that of overweight/obesity. Despite using a mixed methods approach

2.7. Limitations

2.6. Regulation, policy and program review


and reaching out to several stakeholders, 13% (21 of 156) data/information needs remained unanswered. These included critical data on diet and physical activity related risk factors for 5 to 19 years aged children/adolescents, evidence on social norms that might promote overweight or obesity in children/adolescents and factors influencing physical activity patterns. Further, estimates on maternal risk factors like excess GWG and GDM as well as physical activity in middle childhood and adolescence were drawn from local studies rather than nationally representative surveys. The CAGR for sales of BMS and infant foods could not be calculated per capita due to lack of age-specific Census of India population estimates for infants and young children. The degrees of risk cut-offs for variables known to be associated with overweight/obesity provided in the landscaping tools were not always backed by evidence based public health significance levels. While we did apply these cut-offs, but we also undertook regression analysis to determine the strength of the association of these indicators with both overweight/obesity and obesity as described in section 2.5. We studied growth rates of large fast-food chains in India, however growth of local brands, Indian street food consumption could have also be considered, for which we found limited information.


Findings3.

The prevalence of overweight/obesity increased with each stage of life cycle from birth to adolescence. It ranged from 1.6% in youngest age group (<5 years) to 4.8% among adolescents. About 2 million children U5 years, 4.6 million children in middle childhood and 12 million adolescents were either overweight or obese in 2016-18. Levels of obesity were negligible among children U5 years and remained low at around 1% in older age-groups (Figure 3.1).

Younger children (0-4 years) have a higher proportion of those with higher than normal range of body fat based on SSFT and TSFT than older children and adolescents (Table 3.1). This contrasts the findings of a higher prevalence overweight/obesity in children/adolescents (5 to 19 years) compared with these younger children (0-4 years) (Figure 3.1).

3.1. Who is affected and where?

Figure 3.1 Prevalence of overweight/obesity and obesity among children and adolescents, India, CNNS 2016-18

Table 3.1 Distribution of SSFT, TSFT and WC in children and adolescents, CNNS 2016-18 (%)

Indicator 0–4 years 5–9 years 10–19 years

+1SD +2SD +3SD +1SD +2SD +3SD +1SD +2SD +3SD

SSFT 12.6 1.8 0.2 7.5 0.8 0.0 5.8 0.1 0.0

TSFT 7.3 1.0 0.1 1.9 0.2 0.0 3.6 0.1 0.0

WC NA NA NA 1.5 0.2 0.0 1.7 0.1 0.0

Overweight/obesity Obesity


There were no gender differentials in prevalence of overweight/obesity among children U5 years and adolescents (Figure 3.2). Prevalence of childhood overweight/obesity was consistently higher in urban areas than rural India across all three age-groups and increased with increasing wealth quintile (Figure 3.2). After controlling for other variables, children living in urban areas had higher odds of obesity than those in rural areas in middle childhood (aOR 2.17[1.24, 4.23]), but not adolescence (Annex 2 and 3). Additionally, being 8 to 9 years of age compared with 5 to 7, increased the odds of both overweight (aOR 2.44[1.65, 3.62] and obesity (aOR 1.87[1.02, 3.43]) (Annex 2).

Figure 3.2 Prevalence of overweight/obesity by sex, location and wealth quintile, India, CNNS 2016-18

Despite the very low prevalence of overweight/obesity in children U5, one state (Nagaland) had a high prevalence (9% to <15%) among boys in this age group (Figure 3.3). Among boys in middle childhood, six states (Kerala, Manipur, Mizoram, Nagaland, Tripura, Sikkim) had a high prevalence and Goa very high (≥15%). Among girls in middle childhood, two states (Goa, Tamil Nadu) had a high prevalence of overweight/obesity, and Nagaland had a very high prevalence (Figure 3.4). Among adolescent boys, the prevalence was high in four states- Delhi, Goa, Punjab and Tamil Nadu. Among adolescent girls too, the four states of Andhra Pradesh, Arunachal Pradesh, Delhi and Sikkim had high prevalence while Tamil Nadu had very high prevalence (Figure 3.5). The geographic distribution of overweight/obesity was similar for boys and girls in each age group.

State-wide variations in childhood overweight and obesity


Box 1Findings on the prevalence of childhood overweight/obesity fromresearch studies across diverse Indian settings

Through web searches and stakeholder outreach, 23 studies on the prevalence of child or adolescent overweight/obesity that were published within the last decade were identified (Annex 4). Of these, 21 were school based, and one each in a health facility and a community setting. The geographic spread was across 11 states with three multi-centric studies. Only three studies included children in rural areas. Sample sizes ranged from 84 to 20,000 and child ages from newborn to 19 years. The highest prevalence of overweight/obesity at 37% was reported in a study from Vadodra, Gujarat, in adolescents aged 10-18 years (Pathak et al, 2018) (35), followed by 27% and 24% in studies from north-eastern state of Assam in children 10-14 years (Saikia et al, 2018) and Sikkim in adolescents 11-19 years (Kar et al, 2015), respectively (36,37). The lowest reported prevalence was around 4% from a study in Odisha (Mishra et al, 2017) (38). In studies that purposively selected middle to high-income settings, the prevalence of childhood obesity exceeded 20% (Kuriyan et al, 2012, ages 10-19 years; Jagadesan et al, 2014; Misra A, 2011, ages 8-18 years) (39,40,41). Irrespective of age, the prevalence of obesity among children in rural areas was lower than 5% (Ganie at al, 2017, Pillai R, 2018, ages 6-18 years) (42,43). The urban and rural estimates of overweight/obesity in childhood and adolescence drawn from CNNS were much lower than those reported in these studies.

Figure 3.3 State-wise prevalence of overweight/obesity in children U5, India, CNNS 2016-18

Very low: <2.5% Low: 2.5% to 5% Medium: 5% to <10% High: 10% to <15% Very high: >=15% No data

Boys Girls


Figure 3.4 State-wise prevalence of overweight/obesity in middle childhood (5 to 9 years), India, CNNS 2016-18


Boys Girls

Figure 3.5 State-wise prevalence of overweight/obesity in adolescents (10 to 19 years), India, CNNS 2016-18


Boys Girls


3.2. Is the situation improving or worsening?

The prevalence of child overweight and obesity is relatively low in India, but the situation is worsening. The rate of increase of overweight was relatively slower among children U5 but still rapid at 2.4% (National Family Health Survey (NFHS) 2005-06 and 2015-16). Consequently, India is highly unlikely to meet the WHA 2025 target of no increase in childhood overweight. Additionally, according to estimates from the World Obesity Federation, the rate of increase of obesity is ‘very rapid’ among children in middle childhood and adolescents with a CAGR of 13% for boys and 8% for girls.

The disaggregated CAGR for urban and rural areas revealed a very rapid pace of increase for obesity among adolescent girls in both settings, but it was particularly rapid for rural areas (Table 3.2a); the increase in overweight/obesity among children U5 was also more rapid in rural areas (Table 3.2b). Within the adolescent urban sub-set, children in the lowest wealth quartile had the highest CAGR (9.5%). However, this was not observed among children U5.

3.3.1. Maternal risk factorsFour of six maternal factors for overweight and obesity in childhood for which risk categorization was available were classified as high risk (thinness, LBW, GWG higher than recommended, GDM/HIP) and two as moderate risk (obesity, smoking). Overweight/obesity affected one in four mothers of children U5 and 15% suffered from obesity. At a CAGR of 11% from 2005-06 to 2015-16, the increase in levels of maternal obesity was very rapid. Concomitantly, almost one in three mothers were thin. Local studies indicated that almost 30% mothers living with obesity gained more than recommended weight during pregnancy as per Institute of Medicine (IOM) classification (18). Data on GWG in thin and obese mothers was inconsistent across two studies with the proportion of thin women gaining more than recommended gestational weight similar to obese mothers in one study (19) and much lower in another study (18). Almost one in five newborns were LBW while 4% weighed more than 4 kgs at birth (11). Prevalence of GDM and HIP was alarmingly high based on local studies as well as the International Diabetes Federation (IDF) (Table 3.3). The Federation report also claimed 6 million newborns were affected by HIP annually in India (20).

3.3. What is the degree of risk for overweight and obesity among children and adolescents?

Table 3.2a 10 yr CAGR for obesity among adolescent girls (15 to 19 years) by wealth quartiles (NFHS 2005-06 and 2015-16)

Urban Rural Total

Wealth quartile NFHS-3 NFHS-4 10 yr

CAGR NFHS-3 NFHS-4 10 yr CAGR NFHS-3 NFHS-4 10 yr

CAGR

Quarter 1 1.7 4.3 9.5 0.7 1.1 4.3 0.8 1.3 5.0

Quarter 2 3.3 6.6 7.2 0.9 2.1 8.7 1.1 2.9 10.2

Quarter 3 6.0 9.2 4.4 1.2 3.3 10.7 2.3 5.6 9.3

Quarter 4 9.1 10.5 1.4 2.5 6.0 9.2 5.8 8.8 4.3

Total 4.8 7.3 4.4 1.3 2.9 8.3 2.4 4.3 6.0


Table 3.3 Prevalence of maternal risk factors for overweight or obesity in children

Risk factor Mothers of children U5 (15-49 years) %

Risk category Data source

Maternal overweight* BMI ≥25kg/m2 25.2 NA CNNS 2016-18 (11)Maternal obesity* BMI ≥30 kg/m2 15.3 Moderate

Trends in prevalence of maternal overweight (CAGR)

5.5 NA NFHS-3 (2005-06) (14) and CNNS (2016-18)(11)

Trends in prevalence of maternal obesity (CAGR)

11.4 Very rapid growth

Thin 28.0 High CNNS 2016-18 (11)

GWG more than recommended Subnational data: 18Chennai, Tamil Nadu (N=2728 pregnant women)Thin: 3.3 HighNormal: 7.1Overweight: 8.7Obese: 28.5 19Raipur, Chhattisgarh N = 1000 pregnant womenThin: 26.6Obese: 29.4

GDM 28.5 206.5 -16.3 High 16 studies

(2011 to 2020)

HIP 18.9 21

Tobacco smoking 6.3 Moderate CNNS 2016-18 (11)

Alcohol consumption 0.8 NALow birth weight (<2.5kg) 18.8 HighHigh birth weight (>4kg) 4.2 NA

* Estimates for maternal overweight and obesity includes all mothers of children under-5 surveyed in CNNS, aged 15-49 years

Table 3.2b 10 yr CAGR for overweight/obesity among children U5 by wealth quartiles (NFHS 2005-06 and 2015-16)

Urban Rural Total

Wealth quartile NFHS-3 NFHS-4 10 yr

CAGR NFHS-3 NFHS-4 10 yr CAGR NFHS-3 NFHS-4 10 yr

CAGR

Quarter 1 3.0 2.2 -3.1 1.4 1.9 2.6 1.4 1.9 3.1

Quarter 2 2.5 2.8 1.0 1.5 1.8 2.2 1.7 1.9 1.1

Quarter 3 3.1 3.5 1.3 1.4 2.2 4.5 1.8 2.4 2.9

Quarter 4 3.1 4.1 2.8 2.2 2.7 2.2 2.8 3.5 2.3

Total 2.9 3.1 0.7 1.6 2.1 2.8 1.9 2.4 2.4


By juxtaposing district level estimates of moderate to high prevalence of obesity among girls in late adolescence (15 to 19 y) and among young women (20 to 29 y), 38 hot-spot districts for priority action were identified (Figure 3.6).

3.3.2. Risk factors among children U5Indian children were at very high risk of being stunted. Nearly 35% children U5 were stunted in 2016-1018 but the situation improved from 2005-06 to 2015-16 with a negative CAGR. Children were at a relatively low risk of obesity resulting from inappropriate breastfeeding practices as over half were breastfed within an hour of birth and similar proportion exclusively breastfed. However, there was a very rapid growth in sales of both BMS and commercial complementary foods in the last five years, indicating an adverse trend in Infant and Young Child Feeding (IYCF) practices. Diversity in complementary foods was a concern with less than half infants and young children consuming no fruits or vegetables in the day preceding survey, while 14% had a beverage with added sugar (Table 3.4).

Figure 3.6 Districts with both a moderate prevalence of obesity in 15-19 years old girls and moderate-high prevalence of obesity in 20-29 years old women, NFHS-4 2015-16


Table 3.4 Prevalence of risk factors for obesity in children U5 years

Indicators Children U5 (%) Risk category Data source

Children U5 stunted 34.7 Very high CNNS 2016-18 (11)

Trends in stunting prevalence (CAGR) -2.6 Decline CNNS 2016-18 (11) and NFHS-3

Breastfeeding initiated within an hour of birth (0-23 months)

56.6 Moderate CNNS 2016-18 (11)

Infants 0-5 months exclusively breastfed 58.0 Moderate CNNS 2016-18 (11)

Children 12–23 months who were breastfed the previous day

27.5 NA CNNS 2016-18 (11)

Infants/ children 6–23 months who consumed a sugar-sweetened beverage during the previous day

14.0 NA

Children 6–23 months who did not consume any vegetables or fruits during the previous day

42.9 NA

Trends in sales of BMS (CAGR 2013-19) 3 Very rapid growth

Euromonitor 2013-2019 (22)

Trends in sales of commercial complementary foods (CAGR 2013-19)

9.2

Figure 3.7 Prevalence of micronutrient deficiencies and anemia among children U5 who were affected by overweight/obesity, CNNS 2016-18

Two in five children affected by overweight/obesity had multiple micronutrient deficiencies (Figure 3.7). Iron deficiency was the most common, followed by zinc deficiency. Anemia affected 34% of children.


3.3.3. Diet related risk factors in middle childhood and adolescence (5 to 19 years)Diets of children and adolescents were low in pulses, fruits and vegetables with only one in four or five children consuming these daily. Daily consumption of eggs and meats was less than 5% and overall, only 10% to 13% had foods from at least five food groups daily (Figure 3.8).

Population trends in per-capita consumption of sugars and vegetable oils from 2005 to 2014 witnessed rapid and very rapid growth, respectively (26). Risks from consumption of HFSS foods at least three times a week was high in these age groups (Table 3.8). Among children (5 to 9 years) the odds of being overweight/obese were more than twice among

Figure 3.8 Dietary intake of children (5 to 9 years) and adolescents (10-19 years) who were affected by overweight or obesity (in percent)


Table 3.5 Dietary risk factors for obesity in school age children and adolescents (5-19 years)

Risk factor Children (5-9 years) %

Adolescents (10-19 years) % Risk category Data source

Consuming ‘aerated drinks’ >= 3times/week

2.3 4.1 Low

CNNS 2016-18 (11)Consuming ‘sweets’* >=3 times/week 4.8 5.1 Low

Schools with safe drinking water 94.0 95.7 Low CNNS 2016-18 (11)

Households with safe drinking water 91.0 91.1 Low CNNS 2016-18 (11)

Schools providing food that complies with national standards (%)

1.13 million schools covered, and 115.9 million (55.7%) children enrolled, out of 208 million children and adolescents aged 6-13 years (2016-17 data)

N/A MDM annual report (2016-17)

Children’s exposure to HFSS food and beverage marketing in TV programs

Misleading food advertisements: 60% of all advertisements

HFSS foods advertisement: 90% of misleading advertisements(TV, magazines, newspaper)

HFSS foods advertisement: 87% (TV)

High 28

29

CAGR for per capita consumption of energy-dense processed foods: sugar

1.2 Rapid growth OECD- FAO 2005-14 (26)

CAGR for per capita sales of energy-dense processed foods: confectionery

9.9 Very rapid growth

Euromonitor (2013-19). Population, Census projections

CAGR for stores owned by the 3-leading fast-food chains in the country

Dominos: 20McDonalds: 7KFC: -1

Very rapid growth

Market reports and media (2013-16)

CAGR for per-capita sales of traditional lower-energy healthier foods: vegetables

-0.6 Moderate decline

Euromonitor (2013-19). Population, Census projections

CAGR for per-capita sales of traditional lower-energy healthier foods: pulses

1.1 Rapid growth

Ate a fast-food meal, such as McDonalds, Fried Chicken, or Burger King

Age: 13-17y, N: 813021 (23.6 boys and 18.6 girls)(≥3 times a week)

Age: 9 to 17y, N: 13,24776.5 (any fast-food meal)12 ((≥2 times a week)

Age: adolescents 13-14y, N:270,00050 (1-2 times per week)13 (≥3 times a week)

High

24

25

44

* Indian sweets, chocolates, candies, desserts


those consuming fried foods at least three times a week compared to those not consuming fried foods (aOR 2.21 [1.25,3.89]) (Annex 2). Local surveys revealed children were exposed to misleading and high volume of advertisements promoting HFSS during children programs and on channels preferentially viewed by children. In the last five years fast-food retail outlets and per-capita sales of confectionery witnessed very rapid growth. At the same time, the growth rate in per-capita sales of pulses was one-tenth that of confectionery and negative for vegetables (Table 3.5). Schools provided options for supplementing diets with the MDM program reaching over half of the children aged 6 to 13 years. Children and adolescents also had almost universal access to drinking water in schools.

Among the micronutrients deficiencies investigated, children (5 to 9 years) and adolescents who were overweight/obese most commonly suffered

Figure 3.9 Prevalence of micronutrient deficiencies and anemia and risk factors for NCDs among children (5 to 9 years) and adolescents who were affected by overweight/obesity, CNNS (in percent)


from folate deficiency; 57% adolescents and over a quarter of children in middle childhood had multiple micronutrient deficiencies >= 2 ( of the six micronutrient deficiencies studied) (Figure 3.9). Among children, anemia or any micronutrient deficiency doubled the odds of overweight/obesity [aOR 2.13 (1.32,3.43))] (Annex 2). About 12%-13% children and adolescents had pre-diabetes. Forty percent children and 25% adolescents, respectively, had high triglycerides (Figure 3.10). Adolescents with any NCD risk were more likely to be overweight/obese than those with no NCD risk [aOR 1.62 (1.05,2.50)] (Annex 3).

3.3.4. Physical activity and air pollution related risk factors in middle childhood and adolescence (5 to 19 years)Available data from national surveys and local studies was primarily for adolescents and they had high risk of being physically inactive, having access to screens in bedroom and less sleep time (Table 3.6).

Table 3.6 Physical activity and air pollution related risk factors for obesity among adolescents

Risk factor Adolescents (10-19 years) %

Risk category Data source

Fail to meet the Global Recommendations on Physical Activity for Health (GRPAH)

73.9 (N= 7744, 11 to 17y, National survey, WHO)

High 32

CAGR for physical activity -0.24 Decline 32

Walked or rode a bike to school during past 7 days

48.2 Moderate

CNNS 2016-18 (11)Experience organized physical activity, as part of routine school timetable

8.3 High

Spent ≥ 2 hrs watching television, playing computer games or engaged in other sitting activities during a typical day

30.8% (N= 13,274, 9 to 17y, 24 states)

Low 25

TV or other screen in their bedroom 85.2 (N= 109, 3 to 11y, OPD medical college, New Delhi)

High 31

Routinely having <8 hours sleep per night 85.8 Boys 84.0% Girls: 88.1% (N= 7744, 11 to 17y, National survey)

High 24

Communities/ municipalities that report they have infrastructure (e.g., sidewalks, trails, paths, bike lanes) specifically designed to promote physical activity, as % of all communities

Chennai, Tamil Nadu: Well-maintained pavements: 30 Bicycle lanes: 11 Pedestrian crosswalks: 26

High 45

Ambient air pollution attributable death rate (per 100,000 population)

89.9 High 33


Nearly three-fourth of adolescents (11 to 17 years) did not meet recommended standards for physical activity and over 80% did not sleep for at least 8 hours (32). In another nationally representative survey, over 30% children/ adolescents (9 to 17 years) had a daily screen time of 2 or more hours (25).

The CNNS 2016-18 provides age specific data for physical activity and screen time for adolescent girls and boys (Figure 3.10 and 3.11). Except for 17 years aged boys, adolescents did not meet minimum physical activity requirements at any age. Girls had lower physical activity levels than boys and the duration of their daily physical activity decreased with age. However, screen time was comparable among girls and boys (average 1.4 hours) and increased gradually from 10 to 19 years of age.

Figure 3.10 Average number of hours spent in different domains of physical activity by adolescent girls, CNNS 2016-18

Figure 3.11 Average number of hours spent in different domains of physical activity by adolescent boys, CNNS 2016-18

Travel time

Leisure time

Screen time

Outdoor physical activity time

Sitting time

Travel time

Leisure time

Screen time

Outdoor physical activity time

Sitting time


3.4. What are the strategies, policies, and norms to address the obesogenic environment and promote healthy diets and physical activity?

India has set national targets on halting the rise of overweight and obesity among adolescents and adults by 2025 but there are no targets for children aged 0 to 9 years (46). However, India is signatory to the WHA 2025 target of no increase in childhood overweight and it remains an issue of interest in parliamentary discussions (7). Many double duty actions that impact both undernutrition and overweight/obesity are embedded in health programs targeting infants, children and adolescents and will be discussed in the following sections. A review of health, food security, agriculture, urban and rural development and water, sanitation and hygiene (WASH) systems in India unveil various factors affecting the food environment for children and their families (Table 3.7).

Table 3.7 Overview of factors affecting obesogenic environments across agriculture, health, food security, financing and WASH systems

Factors and systems Status

Availability of healthy foods, lifestyle needs

Agriculture Production Horticulture department provides range of subsidies on cultivation of fruits, vegetables, spices, bee keeping https://rkvy.nic.in/static/schemes/Horticuluture.html

Supply chain (Storage and transport subsidy)

In early 2020, government announced 50% subsidy for storing and transporting fruit and vegetables to prevent post-harvest losses and distress sale by farmers

Food security Public distribution system

All families living below poverty line (BPL) or extremely poor are entitled to subsidized food grains (up to 35kg per household) through fair price shops located in the neighborhood. Sugar is also subsidized. Having a BPL card (or priority card) is mandatory to avail the entitlement. https://pdsportal.nic.in/main.aspx

Nutri-livelihoods Small scale farmers especially women farmers are supported in developing Agri-nutrition livelihoods to ensure household food security under DAY-National Rural Livelihoods Mission. http://mksp.gov.in/images/Compendium_of_Farm_LH_Advisories_Ver_2.4_Mar_2020.pdf

WASH Water supply Coverage of improved drinking-water source was nearly 90% in 2015-16. However, water supply does not meet quality standards as per local research studies. https://pubmed.ncbi.nlm.nih.gov/24759242/

Urban development

Open spaces/ leisure activity areas

Smart Cities Mission launched in 2016 prioritized 8 cities for development of cycle and walking paths. 11 cities were prioritized for developing open spaces and recreational parks. http://mohua.gov.in/cms/smart-cities.php

Finance Taxation All aerated and caffeinated beverages are taxed 28% as per Goods and Services Tax (GST) and 12% CESS. Tax. Processed packaged foods also attract a GST of 12%. No differentiation according to sugar content and taxes applied for public health reasons.Kerala experimented with fat tax (14.5%) in 2016 levied on all multinational fast-food chains. However, it was reported to have had limited impact on reducing junk food consumption and among other reasons, discontinued in a year (47) (Refer box 2).


Factors and systems Status

Promotion of healthy foods and lifestyle

Health Food based dietary guidelines

ICMR-NIN Dietary guidelines for Indians, 2011 provide RDAs and food-based options for balanced diet throughout the life cycle including infants, young children and adolescents. The age groups from 0-19 y for which RDAs are defined are: 0-6 months, 6-12 months, 1-3 years, 4-6 years, 7-9 years, 10-12 years, 13-15 years and 16-17 years. Older adolescents have same RDAs as adults (15).Under FSSAI’s Eat Right India campaign - Salt intake is recommended at ≤5g/day. Reduction in sugar, fat and no trans-fat consumption is also promoted. https://eatrightindia.gov.in/EatRightIndia/reduction-fat-sugar-salt.jsp

Labelling Food Safety and Standards (Packaging and Labelling) Regulations, 2011 requires nutrient labels per 100g of product and serving size.Revised guidelines requiring mandatory front-of-pack labels for all pre-packaged foods were drafted in 2018 but not in use yet. Requirements include:— declare nutritional information such as calories (energy), saturated

fat, trans-fat, added sugar and sodium per serve on the front of the pack

— label high fat, sugar and salt content levels with “red-colour-coding”NO menu labelling requirements currently in place for restaurants and catering agencies.

Reformulation of processed foods

Strong commercial interests in reformulating foods. Reformulation ranges from fortification with vitamins and minerals to removing additives, reducing sugar, fats and allergens. No clear government policy on the same exist. https://foodindustry.asia/documentdownload.axd?documentresourceid=31781

School food environment

Draft regulations restricting sale of HFSS foods in schools are available and detailed in following section

Marketing (retail/mass media)

The Consumer Protection Act 2019 penalizes misleading advertisements, however, remains ineffective in regulating HFSS foods and SSBs.

Physical activity National target is set at reducing insufficient physical activity by 10% by 2025 among adolescents and adults.Yoga is actively promoted by the government through events on International Yoga day (21 June) and year-long activities. There is a dedicated website on yoga with resources and online registration option for trainers. https://yoga.ayush.gov.in/yoga/. Physical activity class/sports is also encouraged as part of most school curriculum

Decision making (Individual/household)

AwarenessSocial norms

Limited evidence

3.4.1. Preventing early exposures to obesogenic environments: regulation, policy and programs

Regulation

National Food Security Act (NFSA), 2013: Pregnant women and lactating mothers are entitled to supplementary food through anganwadi centres under the NFSA, 2013 (49). As per nutritional norms, the supplement should provide 600 kcal energy and 18-20 g protein; however, many


Box 2Lessons from implementationof Kerala fat-tax (2016-17)

Over a third of women and a quarter of men in Kerala are overweight. The prevalence of type 2 diabetes is double the national average (8%) and hypercholesterolemia is over 60% among women and 50% in men. Almost 75% of the disease burden in Kerala is due to NCDs. Over 50% children 5 to 9 years are overweight/obese and, the risk of diabetes in adolescents is triple the national average (11). Kerala was among the first states in India to adopt NCD prevention program in 2010. After elections in 2016, the new government prioritized public health reforms making NCD prevention and control a central pillar, including the introduction of a fat-tax at 14.5% on “unhealthy foods”. Restaurant chains such as Kentucky Fried Chicken, Pizza Hut, Dominos, Chic King, French Fried Chicken, Southern Fried Chicken, and McDonald’s were the primary targets of the new policy. The intent of the fat-tax was 1) to increase awareness about and disincentivize consumption of “unhealthy foods” and 2) generate revenue for state government for promoting healthy traditional foods. The tax was targeted at selected manufacturers rather than “unhealthy foods”and anecdotal reports suggested that use of fat-tax revenue was challenging to track. With the launch of the uniform Goods and Service Tax (GST), all state taxes were annulled in 2017 leading to roll-back of the fat-tax. Nonetheless, the fat-tax triggered a national policy discourse on “unhealthy foods”. Some of the main lessons learned include that the introduction of such a tax in future should be based on evidence-based guidelines on type of foods to be included (e.g. a nutrient profile model), tax rationalization and monitoring framework to track use of tax revenue. (Summarized from reference 48)

variants have been developed (Table 3.8). The one-full meal programs of Aarogya Laxmi, Anna Amrutha Hastham, Mathrupoorna and Mahatri Jatan Yojana cover almost half the calorie requirements for the day (Table 3.8). The Act also includes entitlements for all children from 6 month to 6 years of age. Among children aged 3 to 6 years the supplement is provided as a hot cooked food that should provide nearly half of the day’s energy requirements (500 Kcal) and 60-90% of the protein needs (12-15g). Undernourished children are entitled to double ration. This Act helps protect nutrition sufficiency in prenatal and early years. Recommended Dietary Allowances (RDA) for essential nutrients and dietary guidelines for nine age-groups from ages 0 to 19 y are available and form the basis for government food procurement policies for anganwadis and MDMs at schools (described in following section).

Maternity Benefit Act (1961), Maternity (Amendment) Bill (2017): In the formal sector, women are entitled to 26 weeks of paid maternity leave under the Maternity Benefit Act (1961), Maternity (Amendment) Bill (2017) (50). The mother can use this time for child care and exclusive breastfeeding which should continue till child is 6 months of age.

IMS Amended Act, 2003: This Act protects early and exclusive breastfeeding of infants less than 6 months and continued breastfeeding till child is 2 years of age (34). It bans the promotion of BMS, feeding bottles and infant foods through advertisements, direct contact and


Table 3.8 Supplementary food variants across states for pregnant women and lactating mothers, India

Name (State) Composition Energy (Kcal)

Protein (g)

Fats (g)

Amounts/100g

1. Amrutham Nutrimix (Kerala)

Wheat, Soya chunks, Bengal gram, Groundnut, Sugar

391 16.14 69.47

2. PWLMAG (Kerala) Wheat, White rice, Raggi, Bengal gram, Green gram, Soya chunks

501 23.3 5.9

3. Shakti Nutrimix (West Bengal)

Rice, Wheat, Whole gram (chana), Groundnut, Sugar

402 10.4 5.3

4. Chhatua (Odisha) Wheat, Roasted channa, Groundnut, Sugar 303 11.7 5.68

5. Complementary food containing Amylase activity (Tamil Nadu)

Wheat, Ragi, Bengal gram, Dhal flour 330 8.99 1.58

6. Fortified Sukhadi Premix (Maharashtra/Gujarat)

Whole wheat flour, Defatted soya flour, Edible oil, Jaggery, Groundnut

463 15.06 23.14

7. Fortified Sheera Premix (Maharashtra/Gujarat)

Atta, Full fatted, Soya flour, Green gram, Sugar, Edible oil, Groundnut

455 16.52 27.8

8. Fortified Upma Premix (Maharashtra/Gujarat)

Whole wheat flour, Full fatted soya, Green gram, Edible oil, Groundnut, Coconut oil, Sugar

462 11.8 30.42

9. Energy Dense Extruded fortified Halwa premix (Rajasthan)

Whole wheat, Defatted soya bean, Green gram, Edible oil, Sugar, Micronutrients (As per norm)

344 12.65 17.27

10. Arogya Lakshmi, One full meal scheme (Telangana)

Rice, Dal, Vegetables, Milk, Egg, Oil 1192.38 37.04 NA

11. Mathrupoorna, One full meal scheme (Karnataka)

Rice, Dal, Vegetables, Milk, Egg, Oil, Peanut chikki

1342.38 41.04 NA

12. Anna Amrutha Hastham One full meal scheme (Andhra Pradesh)

Rice/wheat/millets, Dhal, Oil, Milk, Vegetables, Condiments

1052.7 32.8 NA

13. Mahatri Jatan Yojana One full meal scheme (Chhattisgarh)

Rice, Soya oil, Mix Dal, Vegetables 914 21 NA

through educational materials. It is monitored through independent monitors and violations are a punishable offence.

BPNI is an independent agency, monitoring and supporting implementation of the IMS Act since 1995. In compliance with the Act, Government of India promotes recommended breastfeeding practices of early initiation, exclusive breastfeeding till infant is six months and continued breastfeeding till 2 years through Mother’s Absolute Affection (MAA) program (53). Its design includes sensitization of sub-state level staff on the Act, to promote adherence in their geographies. However, a recent BPNI observation note indicates weak implementation of the Ten Steps to successful breastfeeding.


Policies and programs

To fulfil the mandate of UHC, MoHFW, launched Ayushman Bharat which integrates all primary health care services including prenatal, delivery and postnatal and pediatric care. The antenatal care program includes most of the globally recommended nutrition interventions such as GWG monitoring, screening for anemia and morbidities such as hypertension, GDM, micronutrient supplementation (Iron and folic acid (IFA) and calcium), deworming, nutrition and lifestyle advice and counseling and referral for high-risk pregnancies. In compliance with the NFSA, 2013, MoWCD through the Integrated Child Development Services (ICDS) scheme provides all pregnant women, lactating mothers and children 6 months to 6 years supplementary foods as per entitlements. In a few states, the one-full meal scheme is also active. The ICDS also monitors and screens children under six years for underweight and wasting. New mothers in post-natal wards receive food under the Janani Shishu Suraksha Karyakram (JSSK) as per nutritional norms prescribed in the guidelines (51). Through the Accredited Social Health Activists (ASHAs) all newborns born at home or those who were not weighed at birth in the facility are weighed and a record maintained. ASHAs undertake extensive follow-up of infants and young children upto 16 months of age and are trained in providing IYCF advice and counselling (52).

Under the Rashtriya Bal Swatsthya Karyakram (RBSK), all children are entitled to screening of 4Ds that is- defects at birth, deficiencies, diseases and development delays or disability (54).

Challenges

There is lack of customization in antenatal care for all women of reproductive age who are at nutritional risk. The antenatal care program delivers a standard package of services with no special service package for pregnancies facing risks from malnutrition other than anemia. Pregnant women on both ends of the malnutrition spectrum that is, thin or severely thin and overweight or obese need special attention. A screening, management, referral programs and post-gestation counselling for them is currently missing. The maternity benefit scheme is applicable to and accessed by less than 1% of all eligible women. A large proportion of women work in informal sector (as farm and construction labourers and domestic helpers to name a few) which is outside the purview of this Act (55). All pregnant women are entitled to cash benefit of INR 5000 under the Pradhan Mantri Matru Vandana Yojana (PMMVY) which though a positive move, is argued to be insufficient to cover the direct and opportunity costs of maternity period in absence of other entitlements. Despite increasing rates of institutional deliveries, timely initiation of breastfeeding continues to be low in India and challenges in implementation of the IMS Act and Ten Steps for successful breastfeeding range from limited staff awareness, reflected in low reported counselling on breastfeeding by mothers and no post-surgical support to those who underwent C-section delivery and lack of systematic reporting on breastfeeding indicators (56). Recent evaluations note that mothers are not aware about their and their children’s supplementary food entitlements; those who avail this service, find the food unsatisfactory in taste; while undernourished children are entitled


to a double ration, food but there is no guidance for children affected by overweight/obesity. Finally, growth monitoring among children is largely focussed on screening and management for underweight and wasting, and not on overweight or obesity. This has percolated from design to trainings and general practice in the field. The lack of standards and guidelines on overweight/obesity for children U5 has resulted in the missed opportunity for screening in ongoing growth monitoring programs. Standards for physical activity and screen time for this age-group are also lacking.

3.4.2. Regulations, policies and programs that influence obesogenic environments for children 5 to 19 yearsRegulation

NFSA, 2013: This Act extends to all children till age 14 years and covers one meal for 200 days (for children in school) providing 450 Kcal (up to 26% of RDA) and protein 12 g (up to 47% of RDA) to children 5 to 9 years and 700 kcal (up to 24% of RDA) and protein 20 g (up to 44% of RDA) to older children (10 to 14 years).

Food Safety and Standards (safe food and healthy diet for school children) Regulations, 2019: MoWCD constituted a working group on “Addressing consumption of HFSS foods and Promotion of Healthy Snacks in Schools of India” in 2015 which recommended actions for six ministries including MoHFW and Ministry of Information and Broadcasting on regulating the sale and promotion of HFSS foods. The salient features of draft school guidelines proposed by FSSAI include restriction on promotion and sale of HFSS foods in and within 50 m radius of school campuses and compliance to dietary recommendations for Indians for any school snacks/meals. It also includes restriction on advertising by HFSS manufactures in school events and endorsement on school use sports gears and other products (59).

Policies and programs

The ICDS covers children under 6 years, after which they come under the ambit of the Ayushman Bharat school health program and MDM program of Government of India. The MDM program covers 1.13 million schools and 115.9 million (55.7%) children of 208 million children and adolescents aged 6-13 years (17,60). The school health program is an amalgamation of ongoing programs of RBSK, Anemia Mukt Bharat – Weekly IFA supplementation (WIFS), National deworming program, Nutrition education and Yoga promotion (61). Thus, services include bi-annual health check-ups and deworming, weekly IFA supplementation under teacher’s supervision, monthly health and nutrition education sessions, regular exercise routines and physical education classes and discussion on child’s health and nutrition status in parent-teacher meeting. Teachers are trained as health and wellness ambassadors to deliver these services. FSSAI’s Eat Right School initiative provides the training and learning resources for health and nutrition education through its integrated curriculum (also referred to as Yellow books). It has an online certification program for teachers which is mandatory for becoming a health and wellness ambassador (10). The Ministry of Youth Affairs and Sports implements the Fit India initiative which includes a school component. Schools can


volunteer for a star rated certification program which encourages having trained physical education teachers, 60 minutes of physical activity program for all students through dedicated teaching time (62). Out-of-school children and adolescents are covered through Rashtriya Kishore Swasthya Karyakram (RKSK) through anganwadis and adolescent friendly health clinics. Adolescent girls are also covered through the ICDS Scheme for Adolescent Girls (SAG) in ~200 districts. The scheme in addition to other health and life skills services includes supplementary food for 300 days (600 kcal and 18-20g protein).

Challenges

Enrolment in primary school is little over 90% and in secondary school about 80% (63). Discounting attendance levels, 1 in 5 adolescents (10 to 14 years) and 1 in 10 children (5 to 9 years) are likely to be out of school and need to be reached through non-school platforms which are either not universal (e.g. SAG) or not very effective as revealed by an evaluation of RKSK (64). School programs like Eat right school, School Health programme under Ayushmaan Bharat and Fit India are relatively new, based on volunteerism and still not completely rolled out in all states. Over time these need to be studied for effectiveness in influencing child behaviors related to foods, physical activity and other lifestyle choices. The longer running school feeding program has varying success across states but quality of food remains a concern both with respect to nutrition compliance to standards recommended under the Food Security Act and microbial and chemical contamination and availability of manpower for conducting the said activities (65,66).


Discussion4.

Overweight and obesity in childhood and adolescence is an emerging public health problem in India. The national (<5%) and urban (<10%) prevalence of overweight/obesity appears relatively low. However, geographic pockets of high prevalence emerged from CNNS state-wide disaggregation of these estimates. Further, local surveys among urban affluent populations reveal there are pockets of high prevalence exceeding 20% among children or adolescents.

As common in most LMICs, the current burden and risks of overweight/obesity are higher in urban areas and in affluent populace (67). However, the pace of increase in overweight/obesity is much higher in rural sub-groups and among poorer urban sub-groups. Unlike other forms of malnutrition (e.g., thinness and anemia), there are no gender differentials in the prevalence of overweight/obesity but the pace of increase is significantly higher among boys aged 5 to 19 years compared with girls. Taking a life-cycle perspective, overweight/obesity first emerges as a problem in 5 to 9 years aged children with a significant increase in prevalence from ages 5 to 7 years to 8 to 9 years. Thus, reaching children in early years with double duty actions is critical to halt increase in overweight/obesity, including broadening the scope of IYCF programmes to include overweight and obesity prevention as a goal. Among children U5 and 5 to 9 years, the problem appears to be more predominant in north-east region of the country. By adolescence, states in south, north and west India also emerge as hotspots for overweight/obesity in addition to north-east.

India has the legal framework to ensure availability of food to all vulnerable populations at subsidized cost and free supplementary foods to all pregnant women, lactating mothers and children 6 months to 14 years. The subsidy on sugar should be reviewed and the item replaced with a “healthier” option such as millets which have already been permitted for distribution at subsidized rate country-wide (68). Food based dietary guidelines provide age-specific nutrient requirements which inform norms for supplementary food programs. However, there are no dietary guidelines for children/adolescents who are overweight or obese. Several other regulations are needed or need to be amended for effectiveness. While the Maternity Benefit Act was amended recently, its scope does not cover the majority of women in the informal sector, denying them access to financial security during the maternity and child care period. The IMS Act protects and promotes breastfeeding but in absence of maternity leave, breastfeeding does not remain a practical option for

4.1. Priority sub-groups for intervention to address obesity among U5, 5 to 10 years and 10 to 19 years

4.2. Strengthening regulatory frameworks for tackling childhood overweight/ obesity


most working women in the informal sector. Over the years, the IMS Act has uncovered and halted violations related to promotion and sales of BMS and baby foods in India but early initiation of breastfeeding or exclusive breastfeeding continue to be low including among in-facility births. Stricter implementation of IMS Act is needed with engagement of obstetricians and gynecologists (OBGYN) and pediatricians through their associations. In 2019, their associations released a joint statement on improving early initiation of breastfeeding after C-section delivery (69). A regulation similar to IMS Act for restricting promotion and sale of HFSS foods is also needed. Children and caregivers are exposed to misleading advertisements on HFSS foods and researchers note that such exposures increase calorie intake (70). Currently the Consumer Protection Act 2019 penalizes misleading advertisements, however, exist of it being effective/ineffective in regulating HFSS foods and sugar-sweetened beverages (SSBs) requires to be examined. Strengthening these existing regulations, along with roll-out of draft regulations on front-of-pack labelling (FOPL) with awareness promotion campaigns will reinforce the messaging on “healthy” and “unhealthy” food. Along with regulations that influence food environment, standards for physical activity starting pre-school are needed. The anganwadi services include informal education for children and adolescents but the curriculum does not currently cover physical activity. Finally, the use of fiscal instruments has been tried in India in the form of fat tax levied at 14.5% on all multinational fast food outlets in the state of Kerala. However, it was discontinued due to several reasons including inability to assess any change in people’s HFSS consumption patterns (47,48). While aerated and caffeinated beverages are taxed at the highest level under GST, the tax is not applied according to sugar or sweetener content and there is no direct evidence on its impact on sales. Further investigation as to the possible impact of taxation on SSBs revealed that if the sales of SSBs continued at the current rate, a 20% taxation on SSBs could potentially reduce overweight and obesity among Indian adults by 3.0% (74).

One of the big misses in addressing childhood overweight/obesity is the lack of national targets that could drive investments and energy to tackling the problem. With no guidance on prevention and management of child overweight and obesity, there is no active monitoring to identify affected children and offer them appropriate services. However, through the life-course, many double duty actions are embedded in the health and food security policies and programs in India. The antenatal care package identifies women gaining more than 3 kg per month after first trimester for further investigation and close monitoring. Irrespective of GWG, screening for GDM is undertaken for all pregnant women in primary health care and treated in accordance with the national guidelines. National guidelines on GDM management included up to 30% calorie restriction among obese pregnant women under medical supervision (71). However, the ICDS food supplementation program is universal and not targeted to needs of either thin or overweight/obese pregnant women. Currently, primary health care services do not routinely provide diet and lifestyle counselling that is tailored to the specific needs of thin, overweight or obese pregnant

4.3. Programs with potential to address childhood overweight/ obesity


women. States in southern India, Andhra Pradesh and Telangana, with relatively higher number of hotspot districts for overweight/obesity among women in reproductive age-group have piloted one-full meal scheme which provides half the day’s calorie to all eligible pregnant women without any modifications based on GWG. Implementation of one full meal scheme in obesity hot-spot districts could revisit the food assistance formulation/criteria after screening for pre-pregnancy weight status and GWG. The anganwadi workers and ASHAs both are available in the community to undertake child growth monitoring and offer customized advice or referral. Invariably the growth monitoring program focusses on screening children with acute undernutrition and referral to nutrition rehabilitation centers with no specific actions for those found overweight or obese. The RBSK program includes screening of children and adolescents for 30 conditions but does not include overweight or obesity. Through its mobile clinics, there is an opportunity to increase awareness about the issue and providing some information and counselling on diet and lifestyle modification to affected children/adolescents. The ICDS offers extra supplementary food to children found undernourished however, there are no recommended actions for children affected by overweight/obesity. FSSAI’s Eat Right School campaign fills the gap on awareness generation for older children and adolescents through dedicated curriculum on safe and healthy eating, physical activity and hygiene promotion. The curriculum includes age-appropriate resources like games for messaging on these behaviors in an easy to remember ways for children aged 5 to 9 years and 10 to 14 years. While this program also does not have specific actions for children affected by malnutrition, there is scope to develop and test a comprehensive nutrition assessment, screening and counselling or referral service package. BMI charts for both girls and boys are available which can be used to facilitate screening. Among those found affected, assessment on body fat distribution should also be included as Indian children are more sensitive to adverse metabolic effects of obesity at lower percentage body fat than Caucasians (72). At present there are no national established benchmarks for body fat distribution to identify those at risk. Multiple micronutrient deficiencies co-exist with overweight/obesity in children. WIFS covers iron and folic acid supplementation along with promotion of diets and hygiene behaviors to prevent anemia. However, children and adolescents are also deficient in other micronutrients like vitamin B12, vitamin D and zinc which need to be consumed through diet and exposure to sunlight, in absence of supplementation programs. Messaging on eating diverse diet and undertaking sports activities in daylight hours are included in FSSAI’s curriculum and need to be widely advocated. The Fit India program is an initiative to promote physical activity in children, adolescents and young people and is much needed considering the high levels on physical activity insufficiency. It’s still in nascent stage but needs to be closely monitored to improve both in and out-of-school sports and recreation activities. Finally, under Ayushman Bharat, Government of India has introduced community screening of NCDs through ASHAs but its prioritized for adults aged 30 years or above. Considering the high prevalence of NCD risks in adolescents, those with family history or overweight/obesity should also be selective screened for NCDs.


In the course of this analysis, several research gaps emerged. As overweight/obesity is perceived as an urban and high-income group problem, much of the local research is from urban affluent regions and there are very few to no insights on rural and slum dwellers lifestyle and diets which may be fueling the rapid increase in these sub-groups. Also, much of the research was found to focus on prevalence estimates and evaluation of obesity prevention or management interventions. There is limited understanding on drivers of overweight and obesity in the Indian context, social issues and cultural influences like gender differences, cooking and feeding practices with respect to overweight/obesity in children and adolescents. The reference standards for WC and skin-fold measurement cut-offs are based on children from developed countries. A more representative standard is needed to screen children from LMICs on these parameters. Population Council in India is in process of developing country-specific reference standards for WC. While India adopted the WHO standards for physical activity for children older than 5 years, there are no standards for younger children. These standards are needed to base any recommendations on duration and type of physical activity in this age group. In order to have restriction or ban on HFSS advertising as introduced recently in United Kingdom, evidence on children’s exposure to these across most frequently viewed programs and broadcasting channels is needed (73). With the increasing use of internet by children, the promotion of HFSS through these media, including social media, also need to be investigated to inform the drafting of an effective regulation. The fiscal instruments to discourage sale of HFSS foods have not been tested in India, with the exception of Kerala where it was briefly implemented. Without such evidence taxation while serving revenue collection does not benefit economy with respect to better health of populace. WHO India has completed a review of fiscal regulations on SSBs as well as regulations around sale and promotion of HFSS foods and recommendations have been drafted. Finally, a complete service package inclusive of nutrition assessment and customized services needs to be tested for operational feasibility in a high burden district before roll-out. In addition, a monitoring and evaluation framework for the same needs to be established by embedding the most relevant indicators in MoHFW and Ministry of Education’s (MoE) health information management system.

4.4. Research needs to improve understanding on overweight/ obesity


Conclusion5.

Overweight/obesity in children and adolescents is a silent epidemic in India. The relatively low current prevalence of child and adolescent overweight or obesity are misleading as the problem is rapidly escalating and more so in rural and urban poor sub-groups. Risk factors in early life, including poor maternal nutrition status, high prevalence of LBW and stunting and poor IYCF practices are widely prevalent. These same risk factors that drive undernutrition and now also driving overweight and obesity. Modifiable factors like unhealthy diets, co-existence of micronutrient deficiencies and NCD risks influence overweight/obesity in middle childhood and adolescence in addition to location and wealth. Insufficiency of physical activity is high in middle childhood and adolescence, along with longer than recommended screen time and exposure to misleading HFSS foods advertisements. At population level, in the last five years, consumption of HFSS foods and beverages like confectionery increased at almost ten times higher rate than vegetables. Legislation similar to IMS Act is needed to restrict sale and promotion of HFSS foods along with expediting roll-out of the two draft regulations on restricting HFSS sales in schools and FOPL. Lessons from implementation of fiscal instruments for addressing obesity should be considered before introducing any taxation or subsidy policy. Standards for physical activity should cover pre-school age group and monitoring and reporting of physical activity in schools streamlined through ongoing MoHFW’s school health program. The current hot-spot districts and states should be the starting point for a comprehensive screening, management and referral strategy for addressing the problem of overweight and obesity in children and adolescents. These services should build on ongoing national school health program and FSSAI’s Eat Right School initiative. Universal complementary feeding and food supplementation, especially in hotspot districts and states should be re-thought and a nutrition-status based approach to supplementation tested with the caution that targeting of a welfare scheme may not be well received in the community. The Public Distribution System (PDS) should provide healthier options of subsidized food instead of distributing sugar. The problem of child and adolescent obesity needs to be addressed through a coordinated approach across several ministries as enlisted in the National Multi-Sectoral Action Plan for Prevention and Control of NCDs. There are several research needs have been identified through the landscape analysis which may be taken up after consensus of all stakeholders preferably anchored by NITI Aayog (India’s policy think tank), bringing together relevant Ministries, FSSAI, academic institutions, professional associations of OBGYN and pediatricians and ICMR.


References

1. UNICEF. UNICEF programming guidance: Prevention of overweight and obesity in children and adolescents. New York: UNICEF, 2019.

2. World Health Organization. Consideration of the evidence on childhood obesity for the Commission on Ending Childhood Obesity: report of the ad hoc working group on science and evidence for ending childhood obesity, Geneva, Switzerland. 2016. ISBN 978 92 4 156533 2

3. World Obesity Federation. Atlas of childhood obesity. 2019. Compiled by Lobstein T and Brinsden H.

4. Kelsey MM, Zaepfel A, Bjornstad P, Nadeau KJ. Age-related consequences of childhood obesity. Gerontology. 2014;60:222–8.

5. WHO. Consideration of the evidence on childhood obesity for the Commission on Ending Childhood Obesity: report of the Ad hoc Working Group on Science and Evidence for Ending Childhood Obesity. Geneva: World Health Organization, 2016.

6. Lobstein T, Jackson-Leach R, Moodie M et al. Child and adolescent obesity: part of a bigger picture. Lancet 2015; 385: 2510–20.

7. WHO. Global nutrition targets 2025: Policy Brief Series. https://www.who.int/nutrition/publications/globaltargets2025_policybrief_overview/en/

8. WHO. Non-communicable diseases: campaign for action- meeting the targets. https://www.who.int/beat-ncds/take-action/targets/en/

9. Ministry of Health and Family Welfare, Government of India. Ayushman Bharat- Health and Wellness Centres. https://ab-hwc.nhp.gov.in/home/aboutus

10. Food Safety and Standardas Authority of India, Government of India. Eat Right School. https://fssai.gov.in/eatrightschool/

11. Ministry of Health and Family Welfare, Government of India. Comprehensive National Nutrition Survey. India 2016-18

12. WHO. Waist circumference and Waist-hip ratio report of a WHO expert consultation Geneva, 8-11 December 2008. Geneva, WHO, 2011.

13. de Onis, Onyango MAW, Borghi E, Siyam A, Nishida C and Seikmann J. Development of a WHO growth reference for school-aged children and adolescents. Bulletin of the World Health Organization 2007; 85:660-667.

14. International Institute for Population Sciences (IIPS) and Macro International. 2005–06. National Family Health Survey (NFHS-3), 2005–06: India Report

15. International Institute for Population Sciences (IIPS) and Macro International. 2015–16. National Family Health Survey (NFHS-4), 2015–16: India Report


16. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017; 390: 2627–42.

17. Ministry of Health and Family Welfare, Government of India. National Commission on Population. Population projections for 2011-2036. Report of the technical group on population projections. 2019. https://nhm.gov.in/New_Updates_2018/Report_Population_Projection_2019.pdf

18. Bhavadharini B, Anjana RM, Deepa M, et al. Gestational Weight Gain and Pregnancy Outcomes in Relation to Body Mass Index in Asian Indian Women. Indian J Endocrinol Metab. 2017;21(4):588-593. doi:10.4103/ijem.IJEM_557_16

19. Agarwal S and Singh A. Obesity or underweight-What is worse in pregnancy? Journal of Obstetrics and Gynecology 2016 Dec; 66(6): 448–452.

20. International Diabetes Federation. IDF Diabetes Atlas. Ninth edition,2019.

21. Nielsen KK et al. Risk Factors for Hyperglycaemia in Pregnancy in Tamil Nadu, India. PloS ONE. 2016, 11;3 e0151311. 18 Mar. 2016, doi:10.1371/journal.pone.0151311

22. Euromonitor sales data, India. 2013-19.

23. ICMR and National Institute of Nutrition. Dietary Guidelines for Indians. 2011

24. WHO Global School based Health Survey 2007 (GSHS)

25. Centre for Scienc e and Environment, 2017 survey (knowyourdiets). “Availability of junk food is changing children’s diet in India” Published in Down to Earth. https://www.downtoearth.org.in/news/health/spoilt-for-choice-58417

26. OECD-FAO Agriculture outlook 2015. https://www.oecd-ilibrary.org/agriculture-and-food/oecd-fao-agricultural-outlook-2015/sugar-projections-consumption-per-capita_agr_outlook-2015-table135-en

27. Revenue growth data from market reports and media (2013-16)

28. Kaushal N, Dudeja P. Food advertisements boon or bane: A prevalence study of misleading food advertisements in India. J Child Obes. 2017, 2 (4); 17. doi:10.21767/2572-5394.100039

29. Thangiah V et al. A comparative analysis of television food advertisements aimed at adults and children in India.Int J Innov Res Sci Eng. 2014; 2(6): 476-83.


30. 2018 India Report Card on Physical Activity for children and youth

31. Mukherjee SB, Gupta Y, Aneja S. Study of television viewing habits in children. Indian J Pediatr. 2014;81(11):1221-1224. doi:10.1007/s12098-014-1398-3

32. Guthold R, Stevens GA, Riley LM, Bull FC. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants. Lancet Child Adolesc Health. 2020;4(1):23-35. doi:10.1016/S2352-4642(19)30323-2

33. India State-Level Disease Burden Initiative Air Pollution Collaborators. The impact of air pollution on deaths, disease burden, and life expectancy across the states of India: the Global Burden of Disease Study 2017. Lancet Planet Health. 2019;3(1):e26-e39. doi:10.1016/S2542-5196(18)30261-4

34. Ministry of Law and Justice. Government of India. Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of production, supply and distribution) Amendment Act, 2003. The Gazette of India. https://wcd.nic.in/sites/default/files/IMSamendact2003.pdf

35. Pathak S, Modi P, Labana U et al. Prevalence of obesity among urban and rural school going adolescents of Vadodara, India: a comparative study. International Journal of Contemporary Pediatrics. 2018. 5(4). https://www.ijpediatrics.com/index.php/ijcp/article/view/1792

36. Saikia D, Ahmed SJ, Saikia H et al. Body mass index and body fat percentage in assessing obesity: An analytical study among the adolescents of Dibrugarh, Assam. Indian Journal of Public Health. 2018; 62 (4): 277-281.

37. Kar S, Khandelwal B. Fast foods and physical inactivity are risk factors for obesity and hypertension among adolescent school children in east district of Sikkim, India. 2015; 6(2): 356-359.

38. Mishra AK, Acharya HP. Factors influencing obesity among school-going children in Sambalpur district of Odisha. Journal of Medical Society. 2017; 30(3): 169-173.

39. Kuriyan R, Thomas T, Sumithra S, Lokesh DP, Sheth NR, Joy R, Bhat S, Kurpad AV. Potential factors related to waist circumference in urban South Indian children. Indian Pediatric. 2012;49(2):124-8

40. Jagadesan S, Harish R, Miranda P et al. Prevalence of overweight and obesity among school children and adolescents in Chennai. Indian Pediatr. 2014 Jul;51(7):544-9.

41. Misra A, Shah P, Goel K et al. The high burden of obesity and abdominal obesity in urban Indian schoolchildren: a multicentric study of 38,296 children. Ann Nutr Metab. 2011;58(3):203-11.


42. Ganie MA, Bhat GA, Wani I, Rashid A. Prevalence, risk factors and consequences of overweight and obesity among schoolchildren: A cross-sectional study in Kashmir, India. Journal of Pediatric Endocrinology and Metabolism. 2017;30(2): 203-209.

43. Pillai R. Modelling studies for “Whole of Society” framework to monitor cardio-metabolic risk among children (6 to 18 years). 2018. PhD Thesis, University of Verona, Italy. http://inclentrust.org/inclen/wp-content/uploads/6_D2_Rakesh-Pillai_Thesis_03_Mar_18.pdf

44. Braithwaite I, Stewart AW, Hancox RJ, et al. Fast-food consumption and body mass index in children and adolescents: an international cross-sectional study. BMJ Open. 2014;4(12):e005813.

45. Adlakha D, Hipp JA, Brownson RC. Adaptation and Evaluation of the Neighborhood Environment Walkability Scale in India (NEWS-India). Int J Environ Res Public Health. 2016;13(4):401.

46. Ministry of Health and Family Welfare, Government of India. National multisectoral action plan for prevention and control of common non-communicable diseases (2017-2022). October 2017. https://main.mohfw.gov.in/sites/default/files/National%20Multisectoral%20Action%20Plan%20%28NMAP%29%20for%20Prevention%20and%20Control%20of%20Common%20NCDs%20%282017-22%29_1.pdf

47. Shekhar M, Popkin B. Human Development Perspectives. Obesity-Health and economic consequences of an impending global challenges. The World Bank. 2020

48. The World Bank Group. The “fat-tax” in Kerala state, India: A Case study. Global Delivery Inititaive. Know-how that works. August 2019.

49. Ministry of Law and Justice. Government of India. The National Food Security Act, 2013. The Gazette of India. http://www.egazette.nic.in/WriteReadData/2013/E_29_2013_429.pdf

50. Ministry of Law and Justice. Government of India. The Maternity Benefit (Amendment) Act, 2017. The Gazette of India. http://egazette.nic.in/writereaddata/2017/175036.pdf

51. Ministry of Health and Family Welfare. Government of India. Janani Shishu Suraksha Karyakram. Dietary norms. Operational Guidelines for State Health Managers to be followed in Public Health Facilities. https://www.nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/MH/Guidelines/JSSK_Final_English.pdf

52. Ministry of Health and Family Welfare, Government of India. Operational guidelines. Home based care for young child. Strengthening Health and Nutrition through home visits. 2018.


53. Ministry of Health and Family Welfare. Government of India. Mothers Absolute Affection. Programme for promotion of breastfeeding. Operational guidelines 2016. https://www.nhm.gov.in/MAA/Operational_Guidelines.pdf

54. Ministry of Health and Family Welfare, Government of India. Operational guidelines. Rashtriya Bal Swasthya Karyakram. Child health screening and early intervention services under National Rural Health Mission. 2013.

55. Rajagopalan S and Tabarrok A. Premature Imitation and India’s Flailing State. The Independent Review. 2019; 24 (2):165–186. https://www.independent.org/pdf/tir/tir_24_2_01_rajagopalan.pdf

56. BPNI. Elements of ‘MAA’ Programme, the ‘Ten Steps’ and the Current Status/Gaps. January 2020. https://www.bpni.org/wp-content/uploads/2020/03/elemtns-of-MAA-Programme.pdf

57. Talati KN, Nimbalkar S, Pathak A, Patel D. Take home rations in ICDS Programme: Opportunities for integration with health system for improved utilization via Mamta Card and E-Mamta. BMJ Glob Health 2016;1(Suppl 1):A2 –A43

58. Arthi M, Narayan KA, Surendrar R, Lokeshmaran A. Quality assessment of nutritional component of Integrated Child Development Services provided in rural Puducherry. International Journal of Medical Science and Public Health. 2018, 7(5): 338-341

59. Ministry of Health and Family welfare (Food Safety and Standards Authority of India), Government of India. Draft Food Safety and Standards (Safe food and healthy diet for school children) Regulations, 2019. https://www.fssai.gov.in/upload/uploadfiles/files/Draft_Notification_School_Children_04_11_2019.pdf

60. Ministry of Human Resource Development, Government of India. http://mdm.nic.in/mdm_website/

61. Ministry of Health and Family welfare and Ministry of Human Resource Development, Government of India. Operational Guidelines on School Health Programme under Ayushman Bharat. Health and wellness ambassadors partnering to build a strong future. 2018.

62. Ministry of Youth Affairs and Sports, Government of India. Fit India school registration. https://fitindia.gov.in/fit-india-school-registration/

63. Ministry of Human Resource Development, Government of India. Unified District Information System for Education (UDISE). http://dashboard.udiseplus.gov.in/#!/

64. Desai, S. 2017. Adolescent health: Priorities and opportunities for Rashtriya Kishor Swasthya Karyakram (RKSK) in Uttar Pradesh. Policy


Brief. New Delhi: Population Council. https://www.popcouncil.org/uploads/pdfs/2017PGY_UDAYA-RKSKPolicyBriefUP.pdf

65. Deodhar SY, Mahandiratta S, Ramani KV, Mavalankar D. An evaluation of mid-day meal scheme. Journal of Indian School of Political Economy. 2010; 22(1-4): 33-48

66. Government of Haryana. India. Evaluation of mid-day meal scheme. Evaluation study no. 143. http://esaharyana.gov.in/Portals/0/mdm.pdf

67. Popkin BM, Adair L, Ng S. Global nutrition transition and the pandemic of obesity in developing countries. Nutrition Reviews. 2012; 70(1): 3-21.

68. Raju S, Rampal P, Bhavani Rv et al. Introduction of Millets into the Public Distribution System: Lessons from Karnataka. Review of Agrarian Studies. 2018; 8(2). http://ras.org.in/introduction_of_millets_into_the_public_distribution_system

69. Shastri D. 56th National Conference of Indian Academy of Pediatrics. 5-10 February, 2019. Mumbai. Presidential Address. Indian Pediatrics. 2019; 56: 185-187.

70. Russell SJ, Croker H, Viner RM. The effect of screen advertising on children’s dietary intake: A systematic review and meta-analysis. Obes Rev. 2019;20(4):554-568.

71. Ministry of Health and Family Welfare, Government of India. Technical and operational guidelines on diagnosis and management of Gestational Diabetes Management. 2018.

72. Whincup PH, Gilg JA, Papacosta O, Seymour C, Miller GJ, Alberti KG, Cook DG. Early evidence of ethnic differences in cardiovascular risk: cross sectional comparison of British South Asian and white children. BMJ. 2002 Mar 16; 324(7338):635.

73. Rogers C. Government rolls out junk food ad ban. Marketing Week. 27 July, 2020. https://www.marketingweek.com/government-junk-food-ad-ban-coronavirus/

74. Basu S, Vellakkal S, Agrawal S, Stuckler D, Popkin B, Ebrahim S. Averting obesity and type 2 diabetes in India through sugar-sweetened beverage taxation: an economic-epidemiologic modeling study. PLoS Med. 2014 Jan 7;11(1):e1001582.


Annexures

Annexure 1: Sampling flow chart for CNNS based analysis

Mothers of children under 5 years(15-49 years)

(n=38,060)

Adolescents (10-19 years)

(n=35,856)

Valid anthropometry data

(n=31,940)

Valid data on covariates and

biomarkers(n=4593)


(n=33,873)

CNNS 2016-18 (0-19 years)

Children (0-4 years) (n=38,060)


(n=35,327)

Valid data on covariates

(n=26,161)

Children (5-9 years) (n=38,405)

Missinganthropometry




Missing covariates

Missing covariates and biomarkers

Missing covariates and biomarkers


(n=36,431)

Valid data on covariates and

biomarkers(n=4404)


Annexure 2: Association between overweight and obesity with selected characteristics in children 5-9 years, CNNS 2016-18

Children (5-9 years)

Predictors/Risk factors Overweight/Obese

aOR (95% CI)Obese

aOR (95% CI)

n = 4404

Sociodemographics

Age 5-7 years (ref) 1.00 [1.00,1.00] 1 [1.00,1.00] 8-9 years 2.44*** [1.65,3.62] 1.87* [1.02,3.43]Sex Male (ref) 1.00 [1.00,1.00] 1 [1.00,1.00] Female 0.81 [0.55,1.18] 0.55 [0.28,1.08]Residence Rural (ref) 1.00 [1.00,1.00] 1 [1.00,1.00] Urban 1.16 [0.75,1.79] 2.17* [1.12,4.23]Religion Hindu (ref) 1.00 [1.00,1.00] 1 [1.00,1.00] Muslim 0.73 [0.39,1.39] 0.71 [0.23,2.18] Christian 1.30 [0.47,3.62] 0.39 [0.12,1.26] Sikh 1.00 [0.37,2.69] 0.29 [0.04,2.32] Others 1.12 [0.19,6.54] 4.07 [0.46,36.40]Caste/Tribe Scheduled Caste 0.71 [0.36,1.42] 0.41 [0.13,1.22] Scheduled Tribe 0.46 [0.17,1.24] 0.56 [0.11,2.99] Other Backward Class 0.62 [0.35,1.09] 0.50* [0.25,0.98] Other (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Currently in school Yes 1.70 [0.83,3.48] 0.44 [0.11,1.83] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Wealth Quintile Quintile 1 (poorest) (ref) 1.00 [1.00,1.00] 1 [1.00,1.00] Quintile 2 (poorer) 1.32 [0.15,11.45] 0.27 [0.02,4.72] Quintile 3 (middle) 4.77 [0.67,34.08] 17.24* [1.67,178.11] Quintile 4 (richer) 3.33 [0.46,24.27] 8.82 [0.80,96.65] Quintile 5 (richest) 6.02 [0.77,47.03] 22.20* [1.88,261.67]Mother’s Education No schooling 0.26 [0.03,2.14] 1.11 [0.10,11.92] Primary 0.53 [0.26,1.05] 0.3 [0.09,1.02] Secondary 0.49**[0.31,0.79] 0.75 [0.34,1.65] Higher (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Father’s Occupation Working in Agricultural sector 1.00 [1.00,1.00] 1 [1.00,1.00] Working in non-agricultural Sector 1.43 [0.74,2.77] 1.69 [0.47,6.15]Region North 1.41 [0.64,3.13] Central (ref) 1.00 [1.00,1.00]


East 1.79 [0.73,4.36] NA North-East 8.44*** [3.29,21.62] West 2.71 [1.00,7.37] South 2.39* [1.16,4.94]Environmental Factors

Access to Improved Sanitation1

Yes 0.91 [0.49,1.70] 0.54 [0.17,1.77] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Mass Media Exposure2

Low (ref) 1.00 [1.00,1.00] 1 [1.00,1.00] Medium 1.74*[1.12,2.71] 1.11 [0.57,2.18] High 1.06 [0.49,2.29] 2.53 [0.95,6.69]Access to Mobile/Internet Yes 0.64 [0.39,1.05] 0.76 [0.29,2.01] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Dietary Factors

Consumption of >=5 food groups daily Yes 2.58**[1.46,4.55] 0.58 [0.29,1.15] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Consumption of unhealthy food groups (>= 3 times/week) Fried food Yes 2.21**[1.25,3.89] 0.43 [0.18,1.01] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Junk food Yes 0.93 [0.42,2.06] 2.07 [0.65,6.58] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Sweets Yes 0.78 [0.43,1.40] 1.03 [0.42,2.55] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Aerated drinks Yes 1.16 [0.46,2.90] 1.02 [0.20,5.36] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]ComorbiditiesAnemia or any micronutrient deficiency3

Yes 2.13** [1.32,3.43] 1.67 [0.81,3.46] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Any NCD risk4 Yes 0.97 [0.62,1.51] 1.09 [0.58,2.03] No (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]

NA: Not applicable. Variable on “region” was omitted from the model for obesity due to small sample size. * p<0.05, ** p<0.01, *** p<0.001 1 Improved sanitation includes flush or pour toilet, piped sewer system, septic tank, pit latrine, and VIP toilet, pit latrine with

slab, composting toilets. 2 Mass media includes watching television, listening to the radio and reading newspaper/magazine. Low level was defined

as adolescents who were not exposed to any form of mass media at all, or less than once a week. Medium level was defined as adolescents who had media exposure at least once a week, and high level as adolescents who had media exposure almost every day.

3 Any micronutrient deficiency includes any one of six deficiencies- iron, folate, zinc, vitamins B12, A and D. 4 Any NCD risk includes any one of the risk factors of NCDs- high HbA1C, high total cholesterol, high LDL, low HDL, high

triglycerides, or high serum creatinine.


Annexure 3: Association between overweight and obesity with selected characteristics in adolescents 10-19 years, CNNS 2016-18

Children (10-19 years)

Predictors/Risk factors Overweight/Obese

aOR (95% CI)Obese

aOR (95% CI)

n = 4593

Sociodemographics

Age 10-14 years (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] 15-19 years 0.86 [0.52,1.44] 0.50 [0.20,1.23]Sex Male (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Female 1.00 [0.65,1.53] 0.75[0.36,1.57]Residence Rural (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Urban 0.94 [0.53,1.69] 0.80[0.32,1.97]Religion Hindu (ref) 1.00[1.00,1.00] 1.00 [1.00,1.00] Muslim 1.20 [0.65,2.21] 2.01 [0.81,5.01] Christian 0.65[0.08,5.17] 3.74 [0.20,70.53] Sikh 2.78** [1.31,5.93] 3.60 [0.93,13.97] Others 0.15***[0.05,0.42] 0.10* [0.01,0.75]Caste/Tribe Scheduled Caste 1.12 [0.60,2.11] 1.1 [0.42,3.20] Scheduled Tribe 0.91 [0.37,2.21] 1.13 [0.22,5.81] Other Backward Class 0.98 [0.56,1.74] 1.52 [0.59,3.93] Other (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Currently in school Yes 1.70 [0.83,3.48] 0.74 [0.28,1.92] No 1.00 [1.00,1.00] 1.00 [1.00,1.00]Wealth Quintile Quintile 1 (poorest) (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Quintile 2 (poorer) 2.12 [0.65,6.86] 0.04*[0.00,0.61] Quintile 3 (middle) 5.21** [1.68,16.15] 5.60 [0.73,43.23] Quintile 4 (richer) 6.41**[2.05,20.05] 7.95*[1.14,55.72] Quintile 5 (richest) 8.82*** [2.62,29.68] 7.41 [0.92,59.87]Mother’s Education No schooling 0.67 [0.29,1.53] 0.72 [0.19,2.67] Primary 0.67 [0.31,1.45] 0.64 [0.19,2.19] Secondary 1.13 [0.61,2.10] 0.55 [0.19,1.58] Higher (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Father’s Occupation Unemployed (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00] Working in non-agricultural Sector 0.61 [0.12,3.17] 0.23 [0.02,2.70] Working in Agricultural sector 0.55 [0.11,2.72] 0.22 [0.02,2.12]Region North 3.88** [1.48,10.13] 4.39 [1.00,19.35]


Central (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]East 6.07*** [2.25,16.39] 3.51 [0.87,14.10]North-East 8.87*** [2.71,28.98] 7.20 [0.67,77.82]West 7.98** [2.18,29.25] 23.09*** [4.51,118.35]South 7.44*** [2.79,19.82] 7.68* [1.53,38.39]Environmental Factors

Access to Improved Sanitation1

Yes 0.92 [0.49,1.73] 0.83 [0.32,2.11]No 1.00 [1.00,1.00] 1.00 [1.00,1.00]Mass Media Exposure2

Low (ref) 1.00 [1.00,1.00] 1.00 [1.00,1.00]Medium 0.93 [0.55,1.58] 0.64 [0.21,1.97]High 0.99 [0.49,1.98] 1.91 [0.72,5.09]Access to Mobile/InternetYes 1.52 [0.93,2.49] 1.24 [0.47,3.28]No 1.00 [1.00,1.00] 1.00 [1.00,1.00]Dietary Factors

Consumption of >=5 food groups dailyYes 0.86 [0.43,1.71] 3.13 [0.97,10.16]No 1.00 [1.00,1.00] 1.00 [1.00,1.00]Consumption of unhealthy food groups (>= 3 times/week) Fried food Yes 1.08 [0.61,1.91] 0.86 [0.31,2.42] No 1.00 [1.00,1.00] 1.00 [1.00,1.00] Junk food Yes 0.88 [0.43,1.80] 0.64 [0.20,2.07] No 1.00 [1.00,1.00] 1.00 [1.00,1.00] Sweets Yes 1.18 [0.59,2.35] 1.45 [0.29,7.19] No 1.00 [1.00,1.00] 1.00 [1.00,1.00] Aerated drinks Yes 1.13 [0.43,2.98] 1.12 [0.07,17.52] No 1.00 [1.00,1.00] 1.00 [1.00,1.00]ComorbiditiesAnemia or any micronutrient deficiency3

Yes 0.54 [0.28,1.04] 1.11 [0.33,3.76] No 1.00 [1.00,1.00] 1.00 [1.00,1.00]Any NCD risk4 Yes 1.62* [1.05,2.50] 1.62 [0.77,3.41] No 1.00 [1.00,1.00] 1.00 [1.00,1.00]

* p<0.05, ** p<0.01, *** p<0.001 1 Improved sanitation includes flush or pour toilet, piped sewer system, septic tank, pit latrine, and VIP toilet, pit latrine with

slab, composting toilets. 2 Mass media includes watching television, listening to the radio and reading newspaper/magazine. Low level was defined

as adolescents who were not exposed to any form of mass media at all, or less than once a week. Medium level was defined as adolescents who had media exposure at least once a week, and high level as adolescents who had media exposure almost every day.

3 Any micronutrient deficiency includes any one of six deficiencies- iron, folate, zinc, vitamins B12, A and D. 4 Any NCD risk includes any one of the risk factors of NCDs- high HbA1C, high total cholesterol, high LDL, low HDL, high

triglycerides, or high serum creatinine.


Annexure 4: Prevalence estimates of childhood overweight and obesity from research in India

S. No.

Author and Year

Location Study Design

Sampling and Sample Size

Study Duration

Prevalence

1. Gautum S and Jeong H, 2019

Udupi, Karnataka (Schools)

Cross-sectional study

Sample size: 1185School selection: All students in secondary level (classes 8-10, age 12-16 years) in each school listed. Scholl list stratified as government, private aided and private unaided schools. 9 schools selected using simple random samplingStudent selection: Proportionate allocation technique based on the number of students in each stratum

6 months (March to August 2012)

Overweight/obese: 10.8%Obesity: 6.2%Boys: 11.0% and 7.1%Girls: 10.6% and 5.4%(Definition: BAZ +1SD and +2SD, WHO )

2. Babu et al, 2019

Bangalore, Karnataka (Hospital)

Cohort study

Sample size: 1120 pregnant womenSelection: Pregnant women ≥18 years, in their second trimester (within 36 gestational weeks) visiting and planning to deliver in three public hospitals with their residence in the nearby study area

2 years and 10 months (between April 2016 and February 2019)

14.6% newborns had SFT >85th percentile and were large for gestational age (n=163/1120). Proportion with adiposity was higher among those born to obese mothers (25.7% vs 13.5%) and mothers with GDM (23.9% vs 12.7%) compared with normal weight and non-GDM mothers

3. Mohan et al, 2019

Ludhiana, Punjab (Schools)


Sample size: 1959 (1110 rural and 849 urban) School selection: Of 1864 schools 317 were in the urban and 1547 in the rural areas. Schools were selected by simple random sampling , considering the population proportion to sample sizeStudent selection: Using stratified sampling adolescents aged 11–17 years in each school were selected, considering each class as strata and equally dividing the required sample size for that school among all the classes

16 months (15 March 2016 and 31 July 2017)

Rural schools: 2.7%Urban schools: 11.0%(Definition: BMI classification as per the Indian Academy of Paediatrics-IAP growth charts, 2015)


S. No.

Author and Year



Study Duration

Prevalence

4. Pillai et al, 2018

New Delhi, Shillong, (Meghalaya), Hyderabad (Andhra Pradesh)(Schools)


Sample size: 3900 children (1950 boys and 1950 girls)School selection: List of private and government schools in urban and rural areas obtained from the District Collector/District Officer.Student selection: both school-going boys and girls between the age group 6 years to 18 years 364 days were selected. Eligible children were selected for the study was selected randomly based on the eligibility criteria

NA Boys: 8.4% overweight and 4.9% obeseGirls: 10.6% overweight and 3.9% obese(Definition: IAP Growth charts, 2015)

5. Pathak et al 2018

Vadodara, Gujarat(Schools)


Sample size: 224 (106 rural and 118 urban school).School selection: NAStudent Selection: School going children of adolescent age group (10 to 18 years of age)

3 months (September to November 2016)

Overweight/obese: 37.8%Obese: 17.6%(Definition: Overweight 85th to <95th percentile and Obese ≥95th percentile Centers for Disease Control-CDC 2000.)

6. Saikia et al 2018

Dibrugarh, Assam (School)


Sample size: 1096 (estimated 1200, almost equal number of boys and girls)School selection: <20 yearly enrolment and those with only senior classes were excluded. Of 109 schools, 38 were excluded. Of remaining 18 were randomly selected.Student selection: 20 students randomly selected from each class (grades 5th to 9th; 10 to 14 years).

1 year (May 2015 to April 2016)

Boys: Overweight/ obese 30.2%, Obese 8.8%Girls: Overweight/obese 31.1%, Obese 11.6%(Definition: BAZ +1SD to < +2SD and +2SD, WHO 2007)

7. Ganie et al 2017

Jammu and Kashmir(Schools in five districts)


Sample Size: 2024 (870 boys and 1154 girls)School selection: 7 schools randomly selected on the basis of location (urban vs. rural), availability of permission by the heads of the institutions and the type of schools (private vs. government).

1 year and 9 months (September 2011 to June 2013)

Overweight/obese: 11.3%Obese: 4.6%(Definition: CDC 2000)


S. No.

Author and Year



Study Duration

Prevalence

Student selection: Stratified random sampling to select students of ages 6 to 18 years

8. Mishra et al 2017

Sambalpur, Odisha(Schools)


Sample size: 300 School selection: A list of all government and private schools in Sambalpur town was prepared; from each category, randomly 5 schools were chosen. In the selected school out of the total number of sections for each age group, randomly one section was selected.Student selection: Students were selected by systematic random sampling from the attendance register. 15 students from each age group irrespective of sex were selected and thirty students from each school were selected for the study

12 months (2012–2013)

Overweight/obesity: 9.6%Obesity: 3.3%(Definition: The International Obesity Task Force-IOTF, 2004)

9. Arora et al 2017

Pune, Maharashtra (School)


Sample size: 1652School selection: The total schools in Pune city were listed and out of them 10 schools randomly selected.Student selection: From the selected 10 schools students from class 7th to class 10th (12 to 15 years) were selected for study. 40 students of each class were selected using simple random sampling.

Not mentioned

Boys: 6.4% overweight, 5.2% obeseGirls: 5.9% overweight, 4.3% obese(Definition: CDC,2000)

10. Arora et al 2017

Ahmedabad, Gujarat(Schools)


Sample size: 373 (217 boys and 156 girls) School selection: Four schools were selected by stratified random samplingStudent selection: Students between 13 to 17 years were included in the study.

Not mentioned

Overweight/obese: 11.7%Obesity: 2.9%(Definition: CDC, 2000)


S. No.

Author and Year



Study Duration

Prevalence

11. Amarnath et al 2017

Belgaum, Karnataka(Schools)


Sample size: 600School selection: Eight schools were selected, with 2 schools representing each of the 4 zones of the city, from the list of 92 schoolsStudent selection: Total of 75 children from each school in the age group of 10 to 15 years studying in 6 to 10th standard (15 children from each class) were selected by systemic random sampling.

12 months (January 2010- December 2010)

Overweight/obesity: 18.8%Obesity: 7.5%(Definition: IOTF, 2004)

12. Choudhury et al, 2017

Kolkata, West Bengal (Schools)


Sample size: 11000 School selection: Fourteen schools were selected Student selection: All students 8 to 18 years screened and those with systemic disease excluded (1694)

3 years (July 2013 to 2016)

Overweight/obese: 29.4%Obesity: 11.8%(Definition: CDCD, 2000)

13. Gupta 2016

Palwal district, Haryana (Community)


Sample size: 540 childrenSample selection: 9 villages were selected for the study, which were divided into 3 clusters (3 villages in each cluster) based on the criteria of access to the highways and potential for economic development over next five yearsEqual proportion of girls and boys were recruited in all age groups(6 years and 1 day to 18 years and 364 days) (n=303 boys; n=309 girls) across three rural clusters of Palwal district, Haryana using multi-stage random sampling (cluster wise stratified sampling)

1 year (2009-2010)

Boys: Overweight/obesity 7%Girls: Overweight/obesity 4%(Definition: Khadilkar, 2012)

14. Kar et al. 2015

Gangtok, East Sikkim(Schools)


Sample size: 979 School selection: All senior secondary schools including Government schools, medium-fee structured schools and high fee structured schools listed with the education department

5 months (November 1, 2009- April 30, 2010 )

Overweight/obese: 24.3%Obese: 3.78%(Definition: IOTF 2004)


S. No.

Author and Year



Study Duration

Prevalence

of Government of Sikkim were numbered, and 4 of them selected randomly. Student selection: school children (11-19 years) The sample was selected using stratified random sampling from four out of ten senior secondary schools. 245 students were selected from each schools starting from standard VII upwards, and every 3rd roll numbers were selected for the study.

15. Anuradha et al 2015

Tirupati, Andhra Pradesh(Schools)


Sample size: 2258 subjects (1097 boys and 1161 girls) Student selection: students aged 12 to 16 years. The study used multistage random sampling technique to have precise estimates of the population. School Selection: The town consists of 36 municipal wards. Eight wards were picked, and two schools from each ward were randomly selected and children were sampled with probability proportionate to the size.

12 months (2011-12)

Boys: 11.2 % overweight, 4.8% obeseGirls: 10.3 % overweight, 4.8% obese(Definition: CDC 2000)

16. Jagadesan et al 2014

Chennai, Tamil Nadu(Schools)


Sample size: 18,955 childrenSchool selection: Out of the 1384 government and private schools, listed under the Directorate of Education, Chennai, Tamil Nadu, 51 schools were selected by systematic sampling method. The ratio of government to private schools was maintained at 2:3 in keeping with the distribution of the schools in Chennai city.Student selection: In each school, students 6-17 years were randomly selected and screened

2 years (2010-2012)

Overweight/obesity was higher among girls (IOTF: 18%, Khadilkar: 21.3%) compared to boys (IOTF: 16.2%, Khadilkar: 20.7%) and higher among adolescents (IOTF: 18.1%, Khadilkar: 21.2%) compared to children (IOTF: 15.5%, Khadilkar: 20.7%).(Definition: IOTF 2044, Khadilkar 2012)


S. No.

Author and Year



Study Duration

Prevalence

17. Gamit et al 2014

Surat, Gujarat (Schools)


Sample Size: 1079 School and student selection: All adolescents aged 14–16 years willing to participate in the study and studying in one of the seven selected schools and who were present during the time of study conduction.

7 months (January 2013 to August 2013)

Overweight: 10.3%Obesity: 5.9%Boys: 12.4% and 8.2%Girls: 7.2% and 2.7%(Definition: Khadilkar 2012)

18. Ghosh A 2014

Kolkata, West Bengal (Calcutta Childhood Obesity Study)


Sample Size: 1061 School and student selection: Ten schools randomly selected. 100 students from grades 5th to 12th from each school

3 years 3 month (June 2008 to September 2011)

Overweight: 13.3% (8-11 y), 19.1% (12-15y), 18.5% (16-18y)Obesity: 4.1% (8-11 y), 7.6% (12-15y), 5.4% (16-18y)(Definition: Khadilkar 2007)

19. Gulati et al 2013

Four cities Cross-sectional study

Sample Size: 1800 Sample selection: NA (Ages 9 to 18 y)

– Boys: 19.2% (Overweight/obesity)Girls 18.1% (Overweight/obesity)

20. Aravinda-lochanan et al 2012

Chennai, Tamil Nadu(Schools)


Sample Size: 20,000 School selection: Thirteen CBSE schools in Chennai were included Student selection: Students in the age group of (9–13 years) belonging to the high-income group

6 months (October 2010 to April 2011)

Overweight: 14.9%Obesity: 17.2% (Definition: WHO 2007).

21. Misra A et al 2011

Five cities Cross-sectional study

Sample Size: 38, 296 Selection: Students (Ages 8 to 18 years) randomly selected from designated primary sampling units in five cities - New Delhi, Jaipur, Agra (north), Allahabad (central) and Mumbai (west).

August 2006- December 2008

Overweight and obesity14.4% and 2.8% (IOTF 2004)14.5% and 4.8% (CDC 2000)18.5% and 5.3% (WHO 2007)

22. Khadilkar et al 2011

Five zones (north, south, east, west, centre)


Sample Size: 20,243 School selection: Eleven affluent schools purposively selected Student selection: All students 2 to 17 years from ten urban sites across five geographical regions of India (north, south, east, west and central)

June 2007- January 2008

Overweight/obesity 18.2% (IOTF 2004)23.9% (WHO, 2007)


S. No.

Author and Year



Study Duration

Prevalence

23. Kuriyan et al 2012

Bangalore, Karnataka (Schools)


Sample Size: 8444 children; (4707 children aged 3-10 years and 3737 children aged 10-16 years) School selection: Children recruited from 8 urban middle income preschools and schools in Bangalore. The schools were selected by using convenience sampling procedure for operational feasibility.Student selection: Normal healthy children in the age group of 3 to 16 years were selected for the study.

1 year and 5 months (August 2008 to January 2010)

Overweight/obesity 22% (3 to 9y)15% (10 to 19y)

Annexure 5: Completed Worksheets: India

Q1. Does the country have a problem with childhood overweight and obesity? Which sub-groups are affected? Is the problem getting worse or improving?

Suggested Indicators Data Score Rating Scale Source

Overweight: % infants and children under age 5 years classified with overweight

1.6% Very low <2.5% = Very low2.5% to <5% = Low5% to <10% = Medium10% to <15% = High15% or more = Very high

CNNS (2016-18)

Obesity: % older children and adolescents (age 5-9y) classified with obesity

1.3% Very low

Obesity: % older children and adolescents (age 10-19y) classified with obesity

1.1% Very low

Under 5s trend CAGR 2.4% Rapid growth CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth3% or more = very rapid growth

NFHS-3 (2005-06) and NFHS-4 (2015-16)

Older children trend CAGR Boys: 12.5%Girls: 8.4%

Very rapid growth

NCD RisC database (CAGR based on prevalence data from 2006 and 2016)



Overweight in under 5s: subgroups Male: 1.6% Female: 1.5%

Urban: 2.7%Rural: 1.2%

Poorest wealth quintile: 0.8% Richest SES: 2.9%

Genders similar, high wealth quintile higher prevalence than low wealth quintile

CNNS (2016-18)

Obesity in older children (5-9 years): subgroups

Male: 1.8% Female: 0.9%

Urban: 2.8% Rural: 0.9%

Poorest wealth quintile: 0.3% Richest wealth quintile: 3.4%

Boys higher prevalence than girls, high wealth quintile higher prevalence than low wealth quintile

Obesity in older children (10-19 years): subgroups

Male: 1.1%Female: 1.1%

Urban: 2.2% Rural: 0.7%

Poorest SES: 0.1% Richest SES: 3.0%

Genders similar, high wealth quintile higher prevalence than low wealth quintile

Likelihood of meeting overweight targets Under 5s

No data Unknown ‘On course: Good progress’ ’On course: At risk’‘Off course: Some progress’‘Off course: No progress’‘No data’ = unknown

Global Nutrition Report 2020

NCD RisC predictions for older children

0% poor chance of meeting target

>70% = good chance 40% to 70% = moderate chance<40% =poor chance

World Obesity Federation – Childhood Obesity Atlas for India (2019)World Obesity Federation national

childhood obesity risk scores 4/11 Moderate risk <3 = low risk

3 to 6.5 = moderate risk>6.5 = high risk


Q2. Does the country have a problem with childhood overweight and obesity?


% of women in reproductive age group (15-49y), with BMI ≥25kg/m2

15.3% Moderate <10% = low10% to <25% = moderate25% or more = high

CNNS (2016-18)

Female obesity trend CAGR 5.04% Very rapid growth

CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth3% or more = very rapid growth

NFHS-3 (2005-06) and NFHS-4 (2015-16)

% births underweight <2.5kg 18.8% High <5% = low5% to <10% = moderate10% or more = high

CNNS (2016-18)

% women underweight (BMI<18.5 kg/m2)

28% High <5% = low5% to <10% = moderate10% or more = high

CNNS (2016-18)

% of women in sub-groups with BMI ≥25kg/m2

Urban: 29.7%; Rural: 10.9%

Poorest wealth quintile: 3.6%; Richest wealth quintile: 33.8%

Urban higher prevalence than rural, high wealth quintile higher prevalence than low wealth quintile

<10% = low10% to <25% = moderate25% or more = high

CNNS (2016-18)

% pregnancies in which maternal weight gain is above recommended levels.

Study from Chennai, Tamil Nadu: Underweight: 3.3%Normal: 7.1% Overweight: 8.7% Obese: 28.5%

For women with obesity: High

For other sub-groups: Low

<10% = low10% to <25% = moderate25% or more = high

Bhavadharini B et al, 2017

Study from Raipur, Chhattisgarh:Underweight: 26.6%Obese: 29.4%

High <10% = low10% to <25% = moderate25% or more = high

Agrawal S et al 2015

% of pregnant women classified as having GDM

28.5% High <5% = low5% to <10% = moderate10% or more = high

IDF Atlas 9th edition 2019 (modelled estimates from local studies)



Local studies:6.5 -16.3%

Moderate-High <5% = low5% to <10% = moderate10% or more = high

16 Local studies with seven in rural settings, 2011 to 2020 (multiple sources)

% of pregnant women classified as having hyperglycaemia

Study from 3 health centers in Tamil Nadu: 18.9%

High <5% = low5% to <10% = moderate10% or more = high

KK Nielsen, et al. 2016

Trend in GDM CAGR No data CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth3% or more = very rapid growth

% women in reproductive age group tobacco smoking

6.3% Moderate <5% = low5% to <15% = moderate15% or more = high

CNNS (2016-18)

% births >4.0kg 4.2% Moderate <5% = low5% to <10% = moderate10% or more = high

Q3. What is the degree of risk: Under 5s?


% births with breastfeeding initiated (0-23 months)

56.6% Moderate >70% = high 40% to 70% = moderate<40% = low

CNNS (2016-18)

% infants 0-5 months fed exclusively with breastmilk

58% Moderate >70% = high 40% to 70% = moderate<40% =low

CNNS (2016-18)

% Under 5s stunting 34.7% Very high <2.5% = Very low2.5% to <10% = Low10% to <20% = Medium20% to <30% = High>30% = Very high

CNNS (2016-18)

Stunting CAGR -2.6% no growth CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth3% or more = very rapid growth

NFHS-3 (2005-06) and CNNS (2016-18)


Q4a. What is the degree of risk: children aged 5-19? Dietary intake


Consumption of carbonated drinks >= thrice/ week

5-9y: 2.3%10-19y: 4.1%

Low CNNS (2016-18)

Consumption of confectionery > = thrice/per week

5-9y: 4.8%10-19y: 5.1%

Low CNNS (2016-18)


% infants 0-5 months fed exclusively: subgroups

Male: 57.7%Female: 58.4%


Poorest wealth quintile: 60.1%Richest wealth quintile 55.2%

Genders similar, Low wealth quintile higher rates than high wealth quintile

CNNS (2016-18)

% of children aged 12–23 months who were fed with breastmilk during the previous day

27.5% Low >70% = high40% to 70% = moderate<40% = low

CNNS (2016-18)

Trend in BMS sales 3% (between 2014-19)

Very rapid growth

CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth>3% = very rapid growth

Euromonitor (2014-2019)

% stunting: subgroups Male: 35.4%Female: 34.0%


Poorest wealth quintile: 49.2%Richest wealth quintile: 19.4%

Genders similar, Rural higher rate than urban, Low wealth quintile higher rate than high wealth quintile

CNNS (2016-18)

Commercial complementary food sales / infant food sales (in ‘000 tonnes)

43.1 (in 2019) High <0.01kg = low0.01 to 0.5kg = moderate>0.5kg = high

Euromonitor 2019

Trend in complementary food sales CAGR

9.2% Very rapid growth

CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth>3% = very rapid growth

Euromonitor (2014-2019)



Trend in population sugar consumption CAGR

1.2% Rapid growth CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth3% or more = very rapid growth

FAO data from 2005-14, per capita consumption

Trend in population veg oil consumption CAGR

4.3% Very rapid growth

FAO data from 2005-14, per capita food use

Schools complying with national standards

1.13 million schools covered, and 115.9 million (55.7%) children enrolled, out of 208 million children and adolescents aged 6-13 years (2016-17 data)

Poor >90% = good 60% - 90% = moderate<60% = poor

Mid-day meal scheme

% schools with drinking water facilities

5-9y: 94%10-19y: 95.7%

Good >90% = good 60% - 90% = moderate<60% = poor

CNNS (2016-18)

Social support foods meeting FBDGs

Provision of supplementary food through the Integrated Child Development Scheme (ICDS), mid-day meals in schools, food items (rice, wheat, millets) distributed through Targeted Public Distribution System (TPDS) under the National Food Security Act 2013

>90% = good 60% - 90% = moderate<60% = poor

Child exposure to HFSS adverts

N Kaushal et al 2017:Misleading food advertisements: 60%HFSS foods advertisement: 90% of misleading advertisements(TV, magazines, newspaper) Vijayapushpam et al 2015: HFSS foods advertisement: 87% (TV)

Very poor <10% =good10% to 20% = poor>20% = very poor

Kaushal N and Dudeja P, 2017.

Thangiah V et al, 2014.



Sugar beverage trends CAGR No data CAGR<0.5% low or no growth0.5% to <1% = moderate growth1% to <3% = rapid growth3% or more = very rapid growth

Confectionery trends CAGR 9.9% (2014 to 2019) Euromonitor 2019

Fast food stores trend CAGR Dominoes: 20%McDonalds: 7%KFC: -1%

Dominoes and McDonald’s: ‘very rapid growth’

Revenue growth data from market reports and media (2013-16)

Vegetable trends CAGR -0.6% (between 2014-19)

Moderate decline

CAGR3% or more = very rapid growth1% to <3% = rapid growth0.5% to <1% = moderate growth-0.5% to <0.5% little growth or decline-1% to -0.5% = moderate decline< -1% = rapid decline

Euromonitor 2014-19

Pulses trends CAGR 1.1% (between 2014-19)

Rapid growth Euromonitor 2014-19

% children who ate a fast food meal, such as McDonalds, Fried Chicken, or Burger King

WHO Global school based health survey 2007 (age: 13-17y) 21.% (23.6 boys and 18.6% girls) ≥3 times a week

Centre of science and Environment Survey 2017 (age: 9 to 17y) 76.5% (any fast-food)12% ≥2 times a week

Braithwaite I et al 2014 (age: adolescents 13-14y) 50% 1-2 times per week13% ≥3 times a week

Poor to very poor

<10% =good10% to <20% = moderate20% to <30% = poor30% or more = very poor

1. WHO Global School based Health Survey 2007 (GSHS)

2. Centre of Science and Environment Survey 2017 (CSES, nationally representative)

3. Braithwaite I et al, 2014.

% schools offering sugar drinks, HFSS snacks

No data

% households with access to drinking water

5-9y: 91% 10-19y: 91.1%

Good >90% = good 60% to 90% = moderate<60% = poor

CNNS (2016-18)

Pre-schools meeting FBDGs 1.37 million AWCs countrywide

Relief foods meeting FBDGs No data No data

% schools accepting branded sponsorship

No data No data <10% = good10% to 20% = poor>20% = very poor


Q4b. What is the degree of risk: children aged 5-19? Physical activity, sedentary behaviour and screen times


% of children fail to meet GRPAH

73.9% High <40% = low40% to 70% = moderate>70% = high

Guthold R, Stevens GA, Riley LM, Bull FC. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants. Lancet Child Adolesc Health. 2020;4(1):23-35. doi:10.1016/S2352-4642(19)30323-2

Trend in PA CAGR 0.68% Rapid decline CAGR3% or more = very rapid growth1% to <3% = rapid growth0.5% to <1% = moderate growth-0.5% to <0.5% little growth or decline-1% to -0.5% = moderate decline< -1% = rapid decline

Guthold et al 2019 (Global trends in physical activity) – comparison between 2001 and 2016

% children active transport to school

48.2% Moderate <40% = low 40% to 70% = moderate>70% = high

CNNS (2016-18)

% of schools PA in timetable

8.3% Low CNNS (2016-18)

% of children watch screen >3h/day

30.8%- >2 hours screen time per day, Internet for recreation-14.5% >2 hours, 29.8% > 1 hour- , Television viewing-17.7% >2 hours, 42.2% >1 hours

Low <40% = low 40% to 70% = moderate>70% = high

Centre of science and Environment Survey 2017

% of children with TV screen in bedroom

New Delhi: 85.2% High <10% = low10% to 20% = moderate>20% = high

Mukherjee SB et al, 2014

% of children <8 hours sleep per night

85.8% (age: 13-17y) High <10% = low10% to 20% = moderate>20% = high

Global school based health survey, WHO 2007



% of children meet GRPAH: subgroups

Boys: 28.2%; Girls: 23.7%

Boys more active than girls

% of children active >2 hours a day.

49% (6-19 years) spent at least 1 hour in active play 45% boys and 26% girls played for more than one hour daily

Moderate >70% = high40% to 70% = moderate<40% = low

2018 India Report Card on Physical Activity for children and youth% of children outdoors

>2 hours a day.

% of parents meet GRPAH

No data

% of children own a bicycle

No data

% of population owning bicycle

No data

Trends in cycle ownership CAGR

No data

Trail walks and cycle lanes

Chennai, Tamil Nadu: 30% reported well-maintained pavements11% reported having bicycle lanes26% pedestrian crosswalks

Low >70% = high40% to 70% = moderate<40% = low

Adlakha D et al, 2016

Trends in cycle routes CAGR

No data

% of population owning cars

~4% Low <40% [or <40/100] [or 4/100] = low40% to 70% [40-70/100] [4-7/100] = moderate>70% [>70/100] [>7/100] = high

CNNS (2016-18)

Trend in car ownership CAGR

No data

Trend in sedentary behaviour CAGR

No data

% children <8 hours sleep: subgroups

85.8% total (84% boys and 88% girls)

High <10% = low10% to 20% = moderate>20% = high

Global school-based health survey, WHO 2007

Ambient air pollution death rate (per 100,000 population)

89.9(1.24 million)

Very poor <20 = good 20 to <50 = moderate50 to <80 = poor80 or more very poor

GBD 2017, India State-Level Disease Burden Initiative Air Pollution Collaborators


Annexure 6: Sharing and learning: Suggestions from stakeholder consultations on report findingsPost completion of the draft report, top line findings were shared with government and non-government stakeholders through seven online consultations. Suggestions from these consultations are presented below.

Stakeholders Suggested recommendations

MoHFW School Health ProgrammeDr. Zoya Rizvi

1. Key messages on prevention of overweight/obesity to be included in national and state resource group trainings (they train health and wellness ambassadors at schools)

2. RBSK has mobile clinics- scope to include simple interventions (like a growth chart with important messages for child/adolescent nutrition displayed)

3. NCD risks screening for school children may be tested in better governed states with hotspots

4. Advocacy with the National Urban Health Mission for outreach in slums/vulnerable pockets with out-of-school children (develop information sheets for urban areas which could be shared with State trainers/officials)

5. Development of IEC materials for specialized counselling of at-risk children and adolescents

6. Before and after evaluation of existing programs in hotspots identified through the landscape analysis

7. Submission of list of research needs identified through the landscape analysis to ICMR

FSSAI Dr. Inoshi Sharma Dr. Rubeena Shaheen

1. Parent engagement to be tested both one-to-one through schools as well as impact of mass media

2. Expedite roll out of regulation on restricting sale and promotion of HFSS foods in and near schools and on front-of-pack labelling

3. Generate evidence on advertising on HFSS foods to inform draft regulation on banning/restricting promotion

4. (PHFI undertaking review of HFSS advertising in north India)

NITI Aayog Dr. Neena Bhatia Dr. Supreet Kaur

1. Further details on sales of HFSS foods in India could be added to the analysis2. Pre-COVID and post-COVID distinction on consumption of healthy food,

increase in sales of unhealthy food could be undertaken3. NITI Aayog is developing the POSHAN Plus strategy, where national targets

are being revisited. Request was made to partner in developing a joint policy document.

CNNS-NCD Policy Group(22 stakeholders led by Dr. HPS Sachdev and WHO)

1. Population Council has initiated work on reference population estimates on waist circumference and skinfold thickness for children in India

2. Dr. Anand Krishnan and his team at CCM-AIIMS can be engaged for deriving nationally representative estimates for indoor and outdoor physical activity among pre-school, school-aged children and adolescents.

3. WHO has conducted two studies on marketing and taxation of unhealthy food in India

IFPRI1. Dr. Purnima Menon 2. Dr. Phuong Hong3. Dr. Samuel Scott4. Dr. Rashmi Avula5. Dr. Mohammad Fahim

1. Framing of “Childhood Obesity”- conceptual framework to be included2. Inequity analysis for fast-food consumption among children and adolescents

in India could be conducted from CNNS3. Inclusion of definition of “fast food” in the context of India – kind of food

products covered, what brands4. Sales and growth of national food chains like Haldirams, Bikanerwala etc

could be studied.5. Inclusion of price of food, sales and consumption data from FAOSTAT on

some food items could be considered6. Recommendations for multifaceted interventions, spanning homes, schools,

other community spaces could be included


Stakeholders Suggested recommendations

Net-Profan1. Dr. Rebecca Raj,

Professor and Head, Division of Nutrition, St Johns Medical College and St Johns Research Institute.

2. Ms. Roshan Kore, Dietician at Obesity clinic at the SRCC Children’s hospital managed by Narayana Health, Mumbai.

3. Dr. Nimali Singh, Associate Professor, Department of Home Science, University of Rajasthan.

4. Ms. Anita Jatana, Chief Dietician, Indraprastha Apollo Hospital, Delhi and President IDA -Delhi Chapter

5. Dr. Bani Aeri, Assistant Professor, Institute of Home Economics, DU.

6. Dr. Upasna Seth, Associate Professor, Aditi Mahavidhlaya, DU.

7. Dr. Hema Divakar, Co-chair FIGO.

1. Adolescents, food intake and mental health- are obese adolescents more depressed or are depressed adolescents obese? It would be useful to see this relation.

2. Studying the Sibling effect- is this higher in upper or lower wealth quartiles/quintiles?

3. St. John’s Research Institute also has data on waist circumference for children and adolescents 3-18 years, and data on healthy and unhealthy Indian snacks – could be studied further.

4. Need include Indian fast foods as in terms of calories and they are higher in calories than Domino’s Pizza. Additionally quality of foods in terms of refined flours/ fiber, nutrient density/ calorie density and freshness / stale/ packaged/ prepared/ use of preservatives should be studied.

5. Focus is needed on school wellness programs and check what is being sold in canteens and sensitize administration through maybe a government circular on laying restrictions on unhealthy food to be sold at premises.

6. Schools should promote one hour of physical activity in school hours, the curriculum needs to be revisited for the same.

7. Food affordability is a myth as the big companies are coming up with chotu (small) packs of everything, here FSSAI could play a regulatory role in curtailing salt, simple sugars and trans fats.

8. Food labelling are not upto the Codex guidelines, here also FSSAI has to play a big role in regulation.

9. The teachers and peers play a big role in regulating food behaviours besides family, sensitizing them is of utmost importance so that habit formation takes place in the school itself.

1. Public Health Foundation of India

2. Dr. GVS Murthy 3. Dr. Giridhar R Babu4. Dr. Monika Arora 5. Ms. Shalini Bassi 6. Dr. Jyoti Sharma 7. Dr. Sandra Albert

1. Further study on Indian fast foods and snacks is needed. 2. Follow up studies regarding waist circumference, skinfold thickness, physical

activity measurements could be conceptualized for PHFI’s MASTI cohort.3. Comparison between obese, non-obese and undernourished could be

explored.4. PHFI can engage in further studies on exploring the link between depression,

sibling effect and obesity from the CNNS data.


Arjan de Wagt, UNICEF India Country Office, New DelhiVani Sethi, UNICEF India Country Office, New DelhiPraween Agarwal, UNICEF India Country Office, New DelhiRobert Johnston, UNICEF India Country Office, New Delhi Harriet Torlesse, Regional Office for South AsiaBernadette Gutmann, Regional Office for South AsiaJo Jewel, UNICEF New York

Tim Lobstein

Arti BhanotAnwesha Lahiri

William Joe, Assistant Professor Tashi Choedon, Research Fellow Giridhar Babu (Public Health Foundation of India, Bangalore)Monika Arora (Public Health Foundation of India, New Delhi)Shalini Bassi (Public Health Foundation of India, New Delhi)Fiona Sing (University of Aukland) Food Safety and Standards Authority of IndiaInoshi SharmaRubeena Shaheen

Adolescent Health DivisionZoya Rizvi

Rachita Gupta

Shariqua Yunus

UNICEF

World Obesity Federation

Independent Consultants

Institute of Economic Growth

WHO India

WFP

Information and/ Review Support

Ministry of Health and Family Welfare

List of Contributors