Nutrition transition in South Asia: the emergence of non-communicable chronic diseases

Introduction

Globalization of agrifood has brought about remarkable shifts in diet patterns especially in developing countries. Changes in dietary pattern have shown to be a major underlying factor for increasing prevalence of obesity and associated NCDs. With long standing history of infectious diseases, developing countries are now facing a rising tide of non-communicable diseases which is popularly known as the double burden of malnutrition (Coexistence of over- and undernutrition). This dietary transition is basically characterized by a shift from a diet with a higher proportion of carbohydrate based foods such as cereal grains (rice, wheat, maize), vegetables (leaves, roots, legumes) and low animal products (meat, egg, milk) to one which is lower in carbohydrate and higher in animal-based food with high sugar and caloric content and larger amount of processed food (chocolates, soft drinks). Though dietary and epidemiological transition have been two main foci in the study of nutrition transition, more socio-economic and demographic parameters are now being included in the discipline. The term nutrition transition was first coined by Barry M. Popkin who remains one of the most highly cited researchers in the field of human nutrition (Wahdan, 1996). According to Popkin, the scope of nutrition transition encompasses not merely the dietary and physical aspects, but also many other economic, social and environmental factors that is shaping the landscape of modern living as never before. By virtue of increased participation in global trade, South Asian nations have experienced a period of unprecedented economic growth, higher income level, provision of labor-saving technologies, and a significant reduction in the number of people living in extreme poverty. India, the largest economy in the region, rose to global prominence with its trillion dollar economy and is set to be world’s third largest economy by 2050 (World Bank). Despite the global recession, India’s share in global trade increased to 1.28 per cent in 2011 compared to 0.67 per cent a decade earlier (Mubarak, 2012). Bangladesh has earned the recognition of being the economic miracle of the decade and is likely to surpass Pakistan to become the second largest economy in the region. Economic transition with improvement in household economic status has shown to be associated with increased consumption of animal products and higher prevalence of overweight, obesity and other NCDs (Salter, 2013), and South Asia appears to be no exception in this regard. Since 1990, South Asian countries are experiencing an increasing trend in the prevalence of overweight and obesity (Popkin et al., 2012). India with around 35% total population living on vegetarian diet (Michalak et al., 2012) has experienced a doubling in total poultry meat consumption since 2000 while in Pakistan total meat consumption has increased by 130% during the same period (Tirmizi, 2012). Increased cross-border food trade, advancement in local food technology and in food marketing and processing industry have greatly increased the availability of processed food products even in the remote rural areas where around 70% of the South Asians live. Though chronic dietary (caloric) inadequacy, macronutrient deficiency and infectious diseases are traditionally conceived as the major causes of malnutrition in South Asian countries, the impact of adequate but unhealthy diet along with lifestyle and environmental factors are fast replacing the trend and are becoming the major focus of epidemiologists. Rapid urbanization, access to labor-saving technologies and rise in various non-farm sectors have reduced the need and scope for physical activities to a level a level which is contributing to a sharp rise in the prevalence of overweight and obesity. However, the benefit of economic growth didn’t translate to improved nutritional status for the population at large, a phenomenon which is known as the South Asian enigma (Guha-Khasnobis et al., 2010). More than half of world’s total underweight children live in South Asia [Figure 1]. While malnutrition is the single largest cause of child mortality in the region, childhood obesity is also becoming a public health concern especially in the urban areas (Roux et al., 2008). Thus at one the end of the epidemiological spectrum lies widespread undernutrition, and a rising tide of obesity and associated NCDs on the other. This rising dual burden of disease is posing enormous pressure on the underdeveloped healthcare systems in South Asia and provides an imperative to adopt more mainstreaming and cross-cutting policies in national and regional level.

Figure 1. Shows the percent distribution of underweight children in South Asia and the rest of the world.

Source: Global disease burden 2010 (http://goo.gl/Tp7fS1)

Methodology

This study is based on literature published between 1995 and 2014. A systematic literature review was conducted in April of 2014 in the following electronic databases: PubMed, Embase, The Cochrane Library and Google Scholar; using the following search terms: ‘nutrition transition’, ‘dietary transition’, ‘epidemiological transition’, ‘obesity’, ‘diabetes’, cardiovascular diseases. Main inclusion criteria was relevance to studies in context of following South Asian countries: India, Pakistan, Bangladesh, Nepal and Sri Lanka. Following the preliminary search, the titles and abstracts of the articles were analysed and selected according to their suitability for this review. Both original and review articles were included. Original studies including larger sample sizes and sound methodology, and review articles based on broad set of studies (case-controlled, cross sectional, randomized trials) were given priority in the selection of studies. Owing to scarcity of relevant studies no special exclusion criteria was applied except for availability of full text articles. Additional data were triangulated from various sources mainly from FAO, USDA, WHO, World Bank, and health and nutrition surveys in each countries.

Demographic transition in South Asia

South Asian demography is characterized by declining fertility and mortality rate [Table 1], high population density (seven times the world average), and a large youth segment. It houses around one fifth of global population with less than 4% of global land area and contributing to merely 2% of global income (Jacques, 2008). Total population was 1.65 billion in 2012 of which 31% are located in urban settings. Though most people are living in the rural areas, urbanization is occurring at a great speed [Figure 2]. Three of world’s top ten most populous countries (India, Pakistan, Bangladesh) and four of top ten most populous cities are located in this region (Mumbai, Karachi, Delhi, Dhaka). South Asia has registered remarkable progress towards the Millennium Development Goals (MDGs) [Table 1] and has substantially reduced the rate of premature death and disability from infectious diseases such as polio, pneumonia, diarrhea and many malnutrition related deaths thanks strong government commitment and a steady economic growth. In Bangladesh for example, total infant and child mortality rate has decline respectively by around 60 and 50 per cent since 1980. All countries are experiencing increasing trend life expectancy. India accounts for around 75% of total population in South Asia and contributes to around 80% of regional GDP. India’s population surpassed billion mark in 2001 and is likely to exceed China to become the most populated country by 2050 (Doak et al., 2005; World Bank, 2013). Bangladesh, the most densely populated nation in the world, is the third largest country in South Asia and eighth in the world in terms of total population. Population growth rate declined from 2.1% to 1.4% since 1990s which provides a concrete example of how economic growth is linked with decline in population growth, increased life expectancy and reduced child mortality (Bleich et al., 2011; Basu et al., 2013). The country has made good progress in all areas of human development after a long history of huger, food insecurity and human deprivation. Following decades of internal conflicts, Nepal and Sri Lanka have been able to restore peace and have also achieved great success in health and economic terms. Population growth rate is about 0.7% in Sri Lanka and is the least populated country in the region with a population of 20.33 million in 2012. By virtue of this sharp fall in infant mortality rates, the size of the child and youth segment is also expanding. South Asia already has about a quarter of world’s youth and is also the most youthful sub-region in Asia (32% population are below 14). Though its a good sign for the economy as more people are being able to join the workforce to supply cost-effective labor for the fledgling economy, the demographic transition is actually serving as a double-edged sword as it has also produced a rapid increase in numbers of older people who are more prone to NCDs and largely account for the rapidly increasing NCD burden (Basnyat & Rajapaksa, 2004). Besides that, this huge youth population is also being exposed to the growing obesogenic environment and a multitude of other risk factors of NCDs while striving to create the conditions for sustainable careers and quality living for themselves. Childhood obesity has shown to be associated with an increased risk of NCDs in later years (Ghose et al., 2013). Since aging population bears increased susceptibility to NCDs, the total burden from these diseases may reach a huge proportion in next two decades, if steps are not taken immediately to avert this situation.

Figure 2. Illustrates the trend of urbanization in South Asia.

Pakistan has highest urban population in the region while Nepal has the highest rate of urbanization.

Source: UN Population Database, State of world cities (http://goo.gl/6G7S3h)

Drivers of nutrition and dietary transition and their impact on NCDs

A dietary transition from high starch and low animal food to higher intake of animal based food, higher proportions of edible oils and sweetener are occurring in almost all developing regions. Nutrition transition is occurring as an inevitable outcome of the changes in global food system triggered mainly by increasing income levels, rapid industrialization and urbanization and globalization of agrifood.

Income

Historically, nutrition and dietary transition is found to be associated with a shift from a preindustrial agrarian economy to an industrial economy as seen in the context of developed countries in Europe and North America (Barry, 1999). Industrialized countries have experienced a nutritional and epidemiological transition since the industrial revolution. Reform in economic system brings about changes in food system, and when accompanied by modification in lifestyle habits such as reduced degree physical activity, it contributes to changing disease pattern such as rising prevalence of overweight, obesity and associated NCDs (Doak et al., 2005).

Today, people in developing countries can afford more calories than ever before which is largely attributable to increased disposable income and greater availability of food (Josef et al., 2005). As the demand for food is rising in the aggregate, a major shift is also taking place in the type of food demanded. This shift generally occurs to increased demand for fish, egg, meat and dairy based food, and poor households tend to shift to more animal based diet with the rise in income (Misra & Shrivastava, 2013; Singh et al., 2011). Figure 3 shows that total meat consumption has increased significantly in all South Asian countries over past two decades. Though over 60% of all South Asians still earn less then $1.25 a day, the situation is actually much better compared to three decades back and more and more people are being able to afford these type of food. Per capita GDP growth has seen a dramatic leap since 2001 [Table 2] which has played a catalytic role in increasing the demand for meat, fish, egg, and dairy products (Freedman, 2002). Many researchers attributed the food price inflation of 2007–08 to the rising demand from India and China as the countries are becoming major food importers to meet huge domestic demand (Ghose, 2014).

Figure 3. Shows the trend in total meat consumption trend in South Asia over the past two decades.

Per capita meat consumption rate (shown on the Y-axis) has increased in almost all countries with Sri Lanka having the highest rate. Pakistan has the highest per capita meat consumption and is currently world’s tenth largest consumer of beef.

Source: USDA (http://goo.gl/p0dehO), Thepoultrysite (http://goo.gl/Slh83n)

Table 2. Sectoral share of employment in selected South Asian countries (% of total employment).

	Agriculture		Service
	1985	2005	1985	2005
Bangladesh	57.70	48.10	26.00	37.40
Pakistan	50.60	43.00	28.70	36.60
Sri Lanka	49.30	30.70	27.90	38.40

Source: CIA Factbook (http://goo.gl/SqSOTB)

Table 2 illustrates the shift in percent labour force allocation in selected South Asian countries. Despite being agrarian economies, total employment in agriculture has declined in all countries, while that in service sector has increased.

Globalization and the changing food system

There is a growing evidence that globalization and trade liberalization have played a key role in the dietary and nutrition transition in the developing countries (Ghose et al., 2013; Lim, 2012). With the advent of food biotechnology and the expansion of transnational food corporations (TFCs), global food chain has undergone massive changes in terms of the ways food is grown, processed, stored, transported and consumed. Food mile (The distance that food travels from the place of production) has reached continental scale as a result of improved transportation system and declining trade barriers. Following the Uruguay Round, the average tariff on most goods fell from about 40% in 1947 to 4.7% in 1993 (Paul, 2008). As a consequence, developing countries have enjoyed a huge inflow of processed food products which has remarkably transformed the scenario of food market and people’s food choices. Nutritionists and health researchers around the world are expressing serious concerns as food is being traded the same manner as garments, electronics, and all other products ignoring the long term health and environmental impacts. Historically in South Asia, community food markets have been the main sources of everyday food supply which are mostly locally grown fresh raw foods. The situation has been changing as groceries and super-shops are taking the lead which are usually selling cheap junk foods such as cookies, chips and soft drinks. Even two decades earlier popular processed items were limited to rice cakes, sweetmeats and vegetable/fruit jelly/pickle which are produced using traditional methods mostly by rural households who has no knowledge of artificial food chemicals. However, this culture is on the verge of ruin with the progress of industrialization as these foods are now being manufactured on an industrial scale by food companies which are dependent on a range on food additives. Large supermarkets which are characteristics of affluent societies are now spreading fast across developing regions like South Asia (Reardon et al., 2003). Figure 4 shows the interior of a supermarket in a small town in Nepal teeming with soft drinks, cookies, chips. As a result, children especially in the urban areas are increasingly being exposed a completely new food environment which offers cheap availability of numerous food products which are most often obesogenic and have many potential health hazards.

Figure 4. This photo was taken from a super-shop in Janakpurdham district in Nepal.

Janakpurdham is known for many historical and religious sites and has very little traces of industrialization.

Photo credit: Mr. Sudeep Sharma 

Epidemiological transition in South Asia and the burden of NCDs

Epidemiological transition refers to the shift from acute infectious and deficiency type diseases to chronic non-communicable diseases (NCDs) which reflects changes in the pattern of morbidity and mortality [1, (Doak et al., 2005). In general, this transition occurs through a complex pathway which is influenced by gradual changes in nutritional, demographic and socio-economic parameters (Doak et al., 2005). In industrialized countries, epidemiological transition emerged towards the early 1900s marked by a rising levels of NCDs and a drastic fall in the prevalence infectious disease (Detels, 1997). This rising prevalence NCDs is believed to be an outcome of a complex interplay between a demographic (Stuckler, 2008), socio-economic (Thakur et al., 2011), nutritional, environmental factors along with changes in lifestyle pattern (Popkin et al., 2012). Once known as the diseases of the wealthy western countries, NCDs are fast becoming more threatening in the developing regions such as Latin America and South Asia. Globally, NCDs have become the leading causes of morbidity and mortality (Accounting for 43% of all disease burden in 1999) and is projected overtake that of infectious diseases within a decade (Wagner et al., 2012).

In contrast with developed countries where the disease burden is dominated by NCDs (with lower proportion of infectious diseases), countries in the developing world are facing a double burden of malnutrition (Paul, 2008). Like other developing regions, South Asian countries are also facing a double burden of malnutrition (Haddad et al., 2015) [Figure 5]. In 2000, 44% of the burden of disease in this region measured in disability adjusted life years (DALYs) was attributed to non-communicable diseases (Basnyat & Rajapaksa, 2004). According to WHO guidelines for Asian populations, a third of the South Asian adult population is classified as obese, and 50% as overweight, by 2030 NCDs (T2DM, CVDs, COPD, cancer) and are going to account for 72% of total mortality by 2030 in South Asia (Shariful Islam et al., 2013; Singh et al., 2011). In India, although under-nutrition and micronutrient deficiencies continue to be major public health problems, over-nutrition and obesity are also emerging as a major problem in many states(Kerala, Tamil Nadu). In Bangladesh, NCDs are responsible for almost half of annual mortality and of 41% total disease burden (Bleich et al., 2011).

Figure 5. Illustrates the situation of double burden of malnutrition (DBM) in South Asia.

The proportion of stunting and underweight is higher than rest of the world, while that of overweight is about one-third.

Source: WHO, UNICEF (www.childinfo.org)

South Asians have a higher prevalence of diabetes mellitus than in any other region in the world (Jafar, 2006) and also have an increased susceptibility to cardiovascular disease (CVD). CVD is the largest single cause of mortality in all South Asian countries [Table 2]. In Bangladesh, total mortality from NCDs increased by 68% between 1986 and 2006 while that from communicable diseases rose by 5% during the same period (Ahsan Karar et al., 2009). Bangladesh alone accounts for 40% of all diabetes patients located in least developed countries and the number is increasing by 5–6 percent a year (Ramachandran et al., 2008). An estimated 7 million people are suffering from diabetes in Bangladesh, while the corresponding figure is respective 2 and 1 million for Nepal and Sri Lanka. In Pakistan, about 12.9 million (10% of total population) people are currently living with diabetes which is projected to become 14.5 million in 2025. The scenario of double burden of malnutrition is perhaps most vivid in India than any other place in the world. India has the recognition of housing the highest number of malnourished child in the world yet the number of NCDs is increasing dramatically since 1990. With 30% of all children are born underweight (17% of global total), and 48% of all under-five children are stunted, it also has the second highest prevalence of diabetes (Danaei et al., 2011) and cardiovascular disease in the world (Basu et al., 2013). India diabetic population rose to 63 million (>7% of total adult population) in 2013 which is second only to China (~92 million) and is projected to reach 100 million by 2030. Researchers suggest that demographic, epidemiological and nutrition transition is fueling the NCD epidemic in India particularly in the urban areas (Shetty, 2002).

The economic impacts of NCDs and nutrition transition household and national economy

NCDs are both a determinant and result of poor socio-economic status and exert an important bearing especially on the poor households as they require a long-term treatment (Thakur et al., 2011). The United Nations High Level Meeting in 2011 declared NCDs a major health, economic and development issue and one of the most significant challenges to poverty eradication in developing countries. World Economic Forum (WEF) has also identified NCDs as the second most severe threat to the global economy. According to the projections of WEF, the burden of NCDs will account for as high as $47 trillion by the year 2030 globally (Bloom et al., 2011). NCDs including diabetes are estimated to reduce GDP by up to 5% in many LDCs. Studies have shown that South Asian nations incur about a 5% loss of their annual GDP due to substandard sanitation and hygiene facilities while infections account for 20% of DALYs (Disability Adjusted Life Years) (Basnyat & Rajapaksa, 2004). But no such study has yet been conducted focusing on the costs of NCDs. Main direct costs of NCDs include the fees for hospitalization, transportation, drugs and some indirect costs are loss of work days, absenteeism, reduced workplace productivity (Kankeu et al., 2013). Among children, obesity has a detrimental effect not only on health, but also on their psychological wellness and thus can affect lifetime earnings potential (Roux et al., 2008). In 2005, India experienced the highest loss in potentially productive years of life worldwide (Koh-Banerjee et al., 2003). Out of pocket expenditure for NCDs in India increased from 31.6% in 1995–96 to 47.3 percent in 2004, and hospital stays more than doubled during the same time (Jaime & Lock, 2009). Among the NCDs, diabetes is the most costly and is also a major risk factor for a variety of life-threatening and expensive complications such as heart attack, renal disease, neuropathy, visual impairment (Shariful Islam et al., 2013). NCDs are also responsible for unhealthy aging and increases the burden of medical spending in later years which put huge pressure on savings and household assets. Table 4 presents a list of studies indicating the various socioeconomic and public health impacts of dietary and epidemiological transition.

Tackling the risk factors of NCDs among children

While the burden of NCDs is unquestionably going to multiply in near future, understanding of the risk factors of NCDs is still fairly poor which constitutes a major obstacle for the implementation of effective prevention strategies (Espina et al., 2013). The World Health Organization (WHO) forecasts that in next two decades there will be dramatic changes and transitions in the world's health needs, as a result of epidemiological transition (Ahsan Karar et al., 2009). A multi-sectoral policy approach must be accompanied by the adoption of national and community level nutrition and health programs to tackle this overwhelming burden of NCDs.

Food and nutrition policy

Strategic food policy making to control unhealthy dietary behaviour has been in place in many countries (Rangel, 2013). Bolivia and Montenegro have closed down fast food shops; Hungary and Australia have imposed a surtax on soft drinks, whilst Denmark has increased tax by 25% on ice cream, chocolate and sweets products. Successful implementation of such pricing policies will require strong political will and cooperation from private sectors and civil society. As industrial control on global food systems have become the major driver of nutrition transition, more governmental regulation of food companies must aim to keep the use salt, sugar and other food additives limited according to the WHO guidelines. National food policy must also focus on increasing the access to and affordability of healthy and nutritious food and discourage the consumption of junk food. Food advertisements have a major impact on people’s dietary behaviour especially among school aged children (Barry, 2001; Vineis et al., 2014). Globally, expenditure on food advertisements has almost doubled in real terms since 1980 ($512 billion in 1980 compared to $216 billion in 2004) (Hawkes, 2006). Advertising junk foods targeted at children must be banned or reduced to a minimum. Regulating school meals is also important reducing obesity among school children. What children eat at school is hard to control but banning the sale of certain types of foods are extremely helpful. In 2005, New Jersey and California banned selling junk food and sodas in public schools, and in Ontario the government banned junk food and pop in elementary schools in 2010. In most cities in south Asia, students buy oily snacks, junk foods from school canteen or nearby shops which are both cheap and delicious. Figure 6 shows the items in a super shop near a school Dhaka city. To prevent this, school authorities must develop healthy eating programs and also ban selling junk foods in canteens and in shops.

Figure 6. This photo was taken from a grocery shop nearby a high school in Dhaka city.

The picture shows that a variety of junk foods are made available to school students. Most of these products are sold at extremely cheap prices (> $0.15).

Photo credit: Sharmistha Ghosh 

Conclusions and policy recommendations

South Asian countries are undergoing various types of transitions. The study sheds some light on the impacts of nutrition transition on the emergence of NCDs in South Asia. Its highly predictable that the economic and social costs associated with nutrition transition will be felt more severely in the upcoming decades. Given the emerging epidemic of NCDs, healthcare system in South Asian countries is at a crossroads. More comprehensive studies are required to gain insight on the disease-specific social, demographic and economic determinants of NCDs in order to design more effective approaches to tackle them in the long run. In conclusion, this study proposes the adoption of following policies to address the challenges of nutrition transition and the emergence of NCDs in South Asia:

Limitations of the study

The assessment of the impact of nutrition transition is a rather complex task in the context South Asia due to highly unequal social hierarchies. The impact of recent economic growth has not been even across all societies and is criticized for accelerating income inequality. Evidently, average income is rising and health status is also improving. But the majority of the population is still living below poverty line ($1.25/day) in South Asia and it still remains home to worlds largest proportion of undernourished population. This is a highly paradoxical situation since nutrition transition is expected to have better health outcomes for these historically deprived populations who lack access to sustainable food supply and have no sight of the lifestyle changing technologies. Coexistence of over- and undernutrition is increasing in the same communities which makes it hard to develop strategies for the target population. Surtaxing certain food commodities (Meat and dairy products) might adversely affect food and nutrition security among poor households who spend a bulk of income on food. This situation calls for more comprehensive studies to make more context adjusted food and nutrition policies.