Public Health Clinical and Diagnostic Research

Question: Discuss about the Public Health for Clinical and Diagnostic Research. Answer: Introduction The phenomenon of nutrition transition that is being witnessed all over the world caused due to a shift in diets owing to a modern and urban lifestyle and economic development and greater buying power have triggered poor health outcomes. In India, the demography, pattern of food supply and the pattern of food consumption have undergone a change. Associated with this change is an increase in diet related non-communicable diseases, such as obesity and type 2 diabetes. The impact of nutrition transition is visible on all age-groups. The supply of food is now abundant, but policies have not been able to make food available to the poor who continue to remain malnourished. On the other people from higher socioeconomic background suffer from the problem of plenty. The revision of the standards for overweight and obese classification have been revised for South Asians. The result is a high percentage of the population can now be classified as overweight or obese. Food Sufficiency In the 1970s India was still trying to tackle the problem of food shortage. In the late 70s the green revolution had taken place and India became self sufficient in food production (Ramchandran, 2013). In the 40 year period between 1963 and 2003 consumption of oils, sugar and meat has increased. According to the current trends the per capita consumption as determined by the food balance sheets of the FAO the total food intake in terms of calories has not changed much but the intake fats from animal and vegetable sources, sugar and meat has increased. 33% of the urban Indian diet constitutes fats while rural Indians consume 17% of their diet in the form of fats. Between 1975 and 1995, the consumption of cereals fell drastically and was replaced by consumption of protein and fats. This increase can be attributed to a huge increase in the consumption (following ample production) of milk and milk products and animal meat. But all the figures about consumption show a difference between ru ral and urban populations and socioeconomic status also has a considerable impact on the patterns of consumption. 25% of the available fat is consumed by the rural population while 40% of the fat is consumed by the 5% of the population constituted of the urban rich (Shetty, 2002). The Indian population suffers from the 'double burden' of malnutrition. Its population is suffering from underweight and overweight (Kulkarni, Kulkarni, Gaiha, 2013). As the rural population shifts to urban areas their consumption of processed foods increases. The tradition of consuming vegetables and fruits is declining. Intake of fibre Consumption of fibre in the form of fruits and vegetables has not increased much among Indians. Though horticulture has progressed and yields have increased, most of the produce is sold in export markets. This signifies a loss of soil nutrients and micronutrients which could have benefitted the local population. The shift to polished grains and a drop in consumption of coarse cereals such as millets, maize and sorghum has also reduced the intake of fiber. Consumption of fruits and vegetables in India is 149 -152 kg/person/annum has registered a slight increase. In a survey of two cities 265gm/day and less than three servings a day were registered. Consumption of less than five servings a day was reported from the state of Maharashtra by 76% respondents while it was 99% in the state of Tamil Nadu. This could be the reason for micronutrient deficiencies in 70% children and 55% women. 24% of men were also found to be suffering from anaemia. On the supply side India produces 40% of the w orld's mangoes, 30% of banana, sapota, and papaya, and lime. Several states of the country contribute to the overall production of fruits. Though there are some shortfalls in production of fruits and vegetables, due to the short shelf life about 35 % of the produce is lost during post harvest operations that include harvest, limited cold storage facilities, grading and transport. Only 2% of the produce is utilized by the food processing industry. Annual losses are between INR 130 to 140 million (Sachdeva, Sachdev, Sachdeva, 2013). Once the basic needs of procuring energy giving foods are met, households shift to the purchase of fruits, vegetables, milk and other animal foods. In a report on fruit and vegetable consumption in India it has been reported that Indians consume an average of 3.5 servings of fruits and vegetables a day. It is as low as 2.9 servings a day for the age-group from 18-25 years. These values are much lower than the WHO recommended values of 5 servings a day which have now been revised to 7-10 servings day to be able to lead a life free of chronic diseases. Availability and income play an important role in the consumption. Processed food can be an option but the high cost and high taxes keep these out of reach of most people. Levels of consumption also vary depending on whether a person follows Jain diet, a vegetarian, an ovo-lacto-vegetarian or a non-vegetarian. About 89% respondents of a survey were not aware of the 400g a day recommendation of WHO. 50% respondents who were aware the WHO recommendations had received higher education and were more likely to have a post graduate degree. Various reasons were given by consumers that caus ed reduced intake. These include seasonal availability, high cost, inconvenient location of market place, poor quality, lack of space for storage in homes, some believe the nutritional content is low, and some have a strict preference for non-vegetarian or junk food. Several policy recommendations were made as part of the report. Among them was a recommendation to improve retail formats, facilitate transport of perishable fruits, reduce taxes on processed foods and generate awareness among people about the importance of including fruits and vegetables in their diet. Encouragement of Foreign direct investment in retail could make more choices for consumers available at reasonable prices. Traceability back to the produce farms for better adherence to quality and hygiene would ensure higher consumption. Provision of cold storages and refrigeration facilities to prevent spoilage of produce was also recommended. The very high tariffs on imported produce (up to 30%) make imports commercia lly unviable. The implications of shortfalls in consumption are lower intake of phytonutrients/micronutrients which help in prevention of several chronic diseases(Mukherjee, Dutta, Goyal, 2015). The demand supply gap in food has caused inflation in food prices. The percentage of income that a household spends on food has risen since 2008- the year when global food prices saw an inflationary trend. Food inequities in the urban populations include the malnourished and the over-nourished, both groups require sustainable methods of food that scores well nutritionally also. Fat and carbohydrate dense food consumption is also associated with poor nutrition and can lead to obesity, diabetes and related ailments. The policies based around food production in India do not incorporate sustainable food systems in their ambit. The drivers of food economy are stakeholders who have commercialized food production through an emphasis on getting high yields through use of chemicals for farming. In the developing countries like India, the migration of people to urban areas for employment does not translate into economic success, because the jobs are unstable and income is irregular. This leads to malnourishment because the food that they can afford to buy is often lacking in nutrients such as, Vitamin A and iron. Dwindling agricultural land keeps the nutritious and expensive components of diet far from their reach. The triple burden of undernutrition, overnutrition and nutrition deficient in micronutrients are seen in the same community or even household. The obesity epidemic In a survey of women in Delhi, it was found that over a period of 4 years, in women between the ages of 15-49 an increase of 2 points in the BMI was observed. Since a major shift in diet was not observed, most of the weight gain could be attributed to their sedentary lifestyles (Agrawal, Gupta, Mishra, Agrawal, 2013). Another study measured the physical activity among dental health professionals in terms of metabolic equivalents (MET). The MET minutes that measured the intensity of physical activity in third year and final year students and interns and faculty and was625.6, 786.3, 296.5, and 296.5 respectively.22.4% of the third year students were obese while 16.3% of the final year students were obese. 20.4% interns and 40.8 % of the teaching faculty were found to be obese (Singh Purohit, 2012). The changes in availability and consumption of high calorie foods like oils, sugar and meat have not been balanced with an increase in physical activity, leading to an increase in prevalen ce of obesity and higher BMI among the urban population from the higher socioeconomic levels. With its population size of over 120 billion people, the sheer size of the Indian market made it a lucrative business destination for the giant among the food corporations and they made a beeline to target the Indian consumers. The urban and rural populations of India were already undergoing a rapid nutrition transition. From a culture of fresh home-cooked meals to culture of consuming attractively packaged, branded, low-priced, mass produced, marketed and advertised food products. The Indian markets were inundated with packets of high sugar, fat and salt containing foods. The shift to a sedentary lifestyle also saw an increase in incidence of obesity, diabetes and cardiovascular disease. But also registering a quiet and quick decline in health were the figures on obesity and type 2 diabetes. The genetic predisposition and sedentary lifestyles added to the problem. Coupled with this was the prevalence of perinatal under-nutrition and 'catch up' obesity in children laid the foundation of type 2 diabetes in early adulthood. The South Asian population has lower BMI thresholds and cutoffs for waist circumference that are used to decide obesity and abdominal obesity than the Caucasian counterparts (Misra Bhardwaj, 2014). Obesity among children increased from 4.9 to 6.6% in the period between 2004-2006 (Gupta, Shah, Nayyar, Misra, 2013). More people are shifting towards diet that is rich in hydrogenated fats and animal fats. Intake of fiber is low. Activity at the work place and at home and during leisure is much lower than before and reducing expenditure of energy is commonly seen (Popkin B. , 2006). Consumption of processed and fast food In a study that compared consumption of Western-style fast food between low-income and high-group study participants, the likelihood of people from high income groups were more likely to visit fast food restaurants. The people from low income groups were more likely to eat fast food sold by street vendors because it was more affordable. However, both groups understood the importance of home-cooked food in maintaining health (Aloia, et al., 2013). Rapid increases in overweight and obesity are being reported from developing countries s much as from developed countries. The reliance on processed foods, eating away from home, and increase in intake of edible oils and sweetened beverages has caused an increase of obesity globally. (Popkin, Adair, Ng, 2012). In a survey of medical students in an Indian town, it was found that most of them had stressful study routines and frequently consumed fast food and sugar sweetened beverages. 34.5% of the students were either overweight or obese with BMI ˃ 25. Intake of fruits and vegetables was lacking in the diets of more than 20% students and 60%students were unaware about the risks associated with the intake of fast foods (Shah, et al., 2014). Rapid urbanisation, migration of people from rural to urban areas, changing perceptions, higher number of working women, the convenience of processed foods has made a marked shift in the way Indians now consume food. Traditionally, consumption of fresh foods is rapidly shifting to processed, ready to eat meals. A higher number of younger Indians want to try novel foods and their perception of imported foods being better in quality has led to a transition in nutrition (Puttarathnamma, Prakash, Prabhavathi, 2015). Another study points at the preference of young Indians for fast food but they are aware of the fact that home cooked food is nutritionally superior (Goyal Singh, 2007). In a study on obesity and hypertension among adolescent school children in Gangtok, India, 2.04% subjects were found to be obese and 14.5% were overweight. Consumption of fast food, unhealthy snacks and sedentary habits were reasons for high percentage of the overweight children who came from high income fa milies (Kar Khandelwal, 2015). The fast food industry in India is expanding at the rate of 40% every year. The consumption of fast foods by adolescents is indeed alarming. In survey of 300 school going adolescents, it was found that 292 of them regularly visited fast food restaurants. The percentage of the obese and overweight was found to be 13.7 and 2.7, respectively. Most of them were lured by the television commercials and attractive packaging. They were aware of the harmful effects of consuming the high fat, high sugar foods. Children who did not eat fast foods said they did so due to parental advice, harmful effects on health and having fallen ill in the past due to fast food consumption. However, the children who reported eating fast foods had parental influence and fast food consumption was prevalent at home. About 48.3% fast food consumers among the students wanted to quit the habit because they were aware of the associated health hazards, they considered the foods will ca use weight gain, there was pressure from parents to quit and it resulted in waste of money (Joseph, et al., 2015). Big retailers and the food processing industry that sell attractively packaged, high sugar, fat and salt laden foods and raise sales through the television commercials occupy large sections of food shelves in supermarkets. On the other hand public health nutritionists try to raise awareness on the obesogenic environment created by bottled sugary drinks and unhealthy food that have threatened to become the staple diet of young and old alike. Imposition of higher taxes may help reduce sales and cause restricted expansion of retail outlets and create awareness about healthy eating. But this is diametrically opposite to the market economics that guides food processors. Retailers and policy makers are under attack by consumer groups for sale of healthier foodstuffs produced with an eye on green production practices and those that are sensitive to animal welfare. The giants in the food processing industry have also started the idea of contract farming that helps them obtain produce that co nforms to specifications required by the machine-oriented food production methods. On the one hand governments promote the food processing industry to increase food production, supply, industry and employment opportunities and on the other hand there is a need for policy framing and implementation to facilitate a battle against the growing incidence of diet-related non-communicable diseases that increase the health expenses on budgetary requirements. The need to increase investments in the food sector and the need to preserve health of people are at conflict with each other. Increasing food supply through industry is not enough, policy frameworks need space to include the health priorities of populations (Thow McGrady, 2014). Policy on sale of unhealthy food Production and sale of packaged snacks containing high levels of salt has increased the consumption to dangerous levels. 50-60% of edible salt, sugar and fat are used up by the food processing industry in India. The industry has received a massive backing from the government. The public health impact of consumption of the fried, high salt products is currently being overlooked. Just as governments in many governments around the world mull a tax on sugar sweetened beverages to discourage consumption, Indian policy makers also need to deal with the problem of excess consumption of salt, sugar and fat through packaged foods that include ready to eat meals, frozen foods including ice creams, biscuits and snacks (Brownell, et al., 2009). Another study estimates that a 20% tax on palm oil may reduce deaths due to myocardial infarction by 363,000 in the period between 2014-23. Although doing so may force people to shift to other edible oils which could add to food insecurity and continue to pose a health risk (Basu, et al., 2013). It is a tight rope walk for policy makers because taxes on unhealthy food stuffs have to be balanced with economics of food production and availability (Dasgupta, Pillai, Kumar, Arora, 2015). Benefits of vegetarianism Vegetarianism is a big aspect of nutrition in India. According. to the American Dietetic Association well planned vegetarian diets are not only nutritionally adequate but provide additional health benefits to people against chronic diseases(Singh, et al., 2014). In a study that analysed the prevalence of diabetes among vegetarians, lacto-vegetarians and lacto-ovo vegetarians, it was found that 30% lower incidence was observed (Agrawal, Millett, Dhillon, Subramanian, Ebrahim, 2014). Another study found significant cardiovascular health benefits derived from a vegetarian diet in four geographical locations of India (Shridhar, et al., 2014). Risk of type 2 diabetes was found to be lower in vegans, ovo-vegetarians, lacto-vegetarians, and pesco-vegetarians than non-vegetarians (Zaman, Zaman, Arifullah, 2010). Conclusion In conclusion, the relative abundance of food has led to an increase in the consumption of sugar, fat, milk products and animal protein in India. The nutrition transition is more pronounced in urban India, where sedentary lifestyles have added to the growing numbers of obese people who are at a risk of type 2 diabetes. Consumption of fibre has touched a low because the growth in production of fruits and vegetables has not kept up with the requirements of cold storages, refrigeration and most of the produce is lost due to spoilage. Policies need to focus on better retail formats and protect produce with better post harvest technology. Food inflation post the 2008 rise in global food prices has affected the impoverished. The rise of malnutrition is a challenge for the authorities that is becoming difficult to solve. On the other hand the problems of overnutrition and lower than recommended consumption of micronutrients has given rise to problems associated with obesity and mineral defi ciencies. High BMIs and diabetes are the outcome of change in culture. From home-cooked food, people have quickly moved to the consumption of convenient, attractive and unhealthy packaged and processed foods. The government backing to the food processing industry has improved the economics of food production and marketing but the impact on public health has been poor. Policies are needed that raise awareness for consumption of healthy food on the one hand and levy taxes on unhealthy salt, sugar and fat laden food to discourage consumption on the other. The benefits of having a vegetarian population can be realised only when people learn to eat healthy and exercise. References Agrawal, P., Gupta, K., Mishra, V., Agrawal, S. (2013). Effects of sedentary lifestyle and dietary habits on body mass index change among adult women in India: findings from a follow-up study. Ecology of Food and Nutrition, 52(5):387-406. Agrawal, S., Millett, C., Dhillon, P., Subramanian, S., Ebrahim, S. (2014). Type of vegetarian diet, obesity and diabetes in adult Indian population. Journal of Nutrition, 13:89. Aloia, C., Gasevic, D., Yusuf, S., Teo, K., Chockalingam, A., Patro, B., . . . Lear, S. (2013). 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