Bursting at the seams

Recently, a 16-year-old boy, 95 kg, had a heart attack. Another 14-year-old, weighing 82 kg, has premature coronary artery disease and hypertension. They live in India’s bustling metros, and twice a week, order lunch and dinner on a food aggregator app. Just two examples picked from a hundred such. 

That India is facing an obesity epidemic is increasingly obvious now with a monumental rise in metabolic diseases — often a consequence of obesity. India’s 1.3 billion, it seems, are weighed down by many stuffing their faces, and inadvertently snuffing out their lives even as malnutrition remains a stinging problem. “In the past five years, child obesity has increased drastically, and physical activity is down. Children in metros and small towns are habituated to order on food aggregator apps, at least twice or thrice a week, if not more. India is third on the global obesity index,” warns Dr Suparna Mukherjee, head of the clinical nutrition department at the Narayana Institute of Cardiac Science, Bengaluru.

Pune-based Dr Jayshree Todkar, a metabolic and bariatric surgeon, points to an India where “The youngest population under 25 would soon be the most obese.”

A Lancet study found that 12.5 million children (7.3 million boys and 5.2 million girls) in India, aged between five and 19 were grossly overweight in 2022 (up from 0.4 million in 1990). Female obesity prevalence has increased sharply. A generation tucking into all manner of food, thanks to lack of stringent laws, rampant food aggregators, faulty advertising and nuclear-working families, which hardly allow the luxury of fresh meals, and a lackadaisical government combined with lax food safety, has led to a click-happy fat populace. Intervention is crucial. The study said, “In India, 4 in 10 women have a waist circumference higher than the prescribed cut-off mark for abdominal obesity. Prevalence was found to be 40 per cent in women and 12 per cent in men. Five to six out of 10 women between the ages of 30-49 are abdominally obese. Incidence is higher in the elderly, city dwellers, wealthy and non-vegetarians.”

Luke Coutinho, an integrative lifestyle expert, believes the problem lies in the lack of awareness. “The culprit is poor lifestyle choices with junk, processed and all the wrong sorts of foods available even in schools and colleges. Sleep deprivation, stress, environmental effects and a food chain with pesticides, and contaminants, all have a direct impact on obesity.”

Obesity is directly associated with multiple noncommunicable diseases (NCDs) such as type 2 diabetes, cardiovascular disease, and certain types of cancer, according to WHO. Shockingly, abdominal obesity is also on the rise in rural areas as well as in small towns. The rise in NCDs is a direct indication of the obesogenic environment in the country. “Overall, 15 states and UTs have a national average rate of 6 per cent; unhealthy diets comprising processed foods, added sugars, salt, saturated fats and transfats all contribute,” says Rahi Kanwa, a policy expert.

The portly fat cell awaits the onslaught of carbohydrates, sugars, and saturated fats. According to Shiva Subramanian, CEO of Connect Ventures, dedicated towards health, performance and sustainability, remarks, “Persistent inflammation of any kind is the first sign of fat accumulation which eventually leads to obesity.”

Visceral fat is the biggest danger — a silent precursor to disease. Dr Peter Attia, Canadian-American author and physician, speaks about the need to reduce visceral fat in his book Outlive. When one eats excess carbs or sugars, the overload is converted into fat in a process called lipogenesis. Thus, obesity starts at a metabolic level, and the beginnings of metabolic disease show up as high cholesterol, diabetes, fatty liver disease, cardiac issues, stroke, and high blood pressure — all indicators of a diet and lifestyle gone grossly wrong. “Visceral fat is directly related to diet. Indians have a carb-heavy diet. My recommendation is clamp down strongly — there are too many prediabetics and diabetics today — the government has to formulate laws, as well as teach children in schools and colleges and corporates to ensure healthy food and habits,” interjects Luke Coutinho.

Spewing anger and hate on social media promotes depression and helplessness, feels Coutinho. “That is when people turn to emotional eating. Our extremely sedentary lives — people sitting more than moving, and those moving concentrating on cardio rather than bodyweight training and building lean muscle, have to change. A holistic exercise programme is crucial. Obesity is not just about diet and exercise, it is about stress, sleep, emotional wellness, environment and laws.” 

Metabolic disease

“Obesity is a metabolic problem. The intracellular starvation of energy versus the extracellular abundance is the paradox of obesity,” Dr Todkar says, comparing the obesity epidemic to that of diabetes, another silent killer on the loose in India.

Diseases are also being treated as islands. Organ dysfunction and toxicity of energy, both invite metabolic diseases and impact vascular health, she adds, “That is why all the organs from the brain to the feet are impacted. Let us start paying attention to the root cause — genetically Indians have obesogenic and diabetogenic precursors,” Dr Todkar explains.

Don’t ignore sleep

A vastly ignored determinant is good sleep. “Sleep deprivation is a huge issue — it lowers immunity, heightens inflammation and increases the risk of cognitive brain disorders. A sleep-deprived individual automatically craves junk food, it’s a vicious cycle,” Coutinho adds. Dr Todkar, alarmed at the high rise in cardiovascular-related fatalities says, “The rise is nearly 200 per cent, age is younger, attacks more severe. We have to introspect on what is going wrong.”

Lack of nutrition literacy

A crucial aspect of understanding what is going wrong lies in the lack of nutrition literacy in India. “We may be educated and literate, but the big question is, are we nutrition literate?” asks Rahi, emphasising, “Data reveals, shockingly, that the average consumer thinks only 3 to 8 seconds before buying a product or reading the ‘back-of- the-pack label,’ time which goes in checking ‘the best before date,’ and MRP. A growing consensus is that Front-of-Pack Nutrition Labelling (FOPNL) ought to be made mandatory for nutrients of concern. “Do you think the average Indian consumer is educated enough to scan for nutrients in 3 to 8 seconds?” she asks. In a culture where looking lean and toned is a calling card, no one is looking deeper. “Weight is inflammation. Let’s address why inflammation occurs — let us not look at aesthetics and vanity. Those on extreme diets with pressure on physicality, please stop. Every time one goes on an extreme diet, they inadvertently multiply fat cells,” alerts Subramanian. “Why are we so inflamed as a society, and storing fat? Is it stress, environment, or genetics? High cortisol makes the body think it is under attack, thus it stores fat as a reserve — obesity is a different conversation for different people.” Women have a larger proportion of body fat mass, with oestrogen playing an effective role in the distribution of fat, and protection against abdominal fat. The loss of oestrogens after menopause makes women vulnerable. “We need to look at obesity from different lenses, environmental, microplastics, radiation, lifestyle, cellular, and geographic. One size does not fit all,” he adds.

Fat chance

Is it time India had a fat tax? Kerala first implemented it in 2016, proposing a 14.5 per cent ‘fat tax’ on burgers, pizzas and other junk food in branded restaurants. Did it work? It reduced the consumption of fast foods. Yet, its efficacy is dependent on research, social context, and unfortunately, political will (against lobbies). “Tax aerated drinks. All schools and colleges should have a ban on junk and processed food. Stop Bollywood and sports champions from advertising unhealthy products. Have stringent laws when it comes to contamination of food, and check food label accuracy,” offers Coutinho. “People have a right to know if the food they are eating is unhealthy. Let us move towards whole grains — millets, local fruits, vegetables and grains, but with stringent quality checks,” he adds.

Screen early, read labels

Early screening could be a game-changer. “Mandatory screening from childhood to adulthood, in organised and unorganised sectors, will address the hidden effects of what we eat. A nationwide health action plan has become vital. Screening programmes should be conducted yearly for the 20-plus age group onwards,” stresses Dr Todkar. “We campaigned against HIV, why can’t we work against unhealthy food? A strong political will and government understanding of scientific policy is necessary. Unfortunately, no one seems to be working towards this.” A check on ads and marketing will also go a long way. Often, packaged and processed foods entice children. For instance, high-sugar chocolate, and high-salt processed chips come with a gift. “We need to strictly monitor and regulate these underhand practices,” says Dr Mukherjee. Much of the nutrition information is lost in translation. Perhaps it is time to add advisories on entertainment apps? “When I binge on Netflix, I tend to eat more junk. Streaming sites need to have advisories on health. They might not deter an individual but at least may make him uncomfortable reaching out for that next sugar-loaded toffee,” says Anandita Kar, an IT professional.

Children of a stressor generation

The increase in obesity in children is distressing. “Rising obesity in children invites early metabolic syndromes — hypertension, diabetes, fatty liver, thyroid...no organ in the body is immune. We have to save our child or we will have a country that has a young and sick population,” warns Dr Todkar.

Graded physical activity is the first step. “Save the children — train them, make sports and physical activity mandatory for two hours daily,” says Rahi. “We should ask ourselves what we have done to our children — tremendous stress, lack of exercise, and a flawed education system are all weighing them down. We are a survival economy and parents don’t have time. Thus, the nutrient density of food has lowered too,” adds Subramanian.

“I had a patient, a 13-year-old boy who is obese, had developed hypertension. It’s terrifying. Clarity in awareness campaigns is required. Jargon about saturated fats and sugars won’t help much,” says Dr Mukherjee, adding that it is time we thought up actual solutions instead of lifestyle hacks. “Obesity clinics may offer you macro solutions. But it is time for micro.”

The obesity pill is coming

An ostensible “magic bullet” to get thin fast, Ozempic and Mounjaro are all the rage in the countries that have approved their sale and use — essentially the US and many countries in Europe. These drugs are not yet commercially available in India although many Indians, including certain influencers, captivated by their purported effects, are already rooting for these drugs. Recently, an expert committee of the Central Drugs Standard Control Organisation (CDSCO) gave their approval to the drug tirzepatide, which is the active ingredient in several obesity-treating medicines. A final approval and review is pending, post which drug manufacturers can launch the product in the Indian market. "These drugs mimic the naturally occurring incretin hormone. As hormone levels rise, the molecules travel to the brain, telling it you're full. It slows digestion by increasing the time it takes for food to leave the body, which is similar to the effect of bariatric surgery,” explains Dr Todkar, cautioning that these drugs should only be taken on prescription, under supervision and after assessment of a clinician.

“As a doctor, I feel sad when we speak of obesity in terms of shape and inches. Obesity is a deeper disease. Short-term solutions are not sustainable. The medicines are not enough to address obesity — behavioural change, diet restrictions and physical activity should follow.”

A farm-to-fork approach

Dr (Prof) Vishal Rao, Dean, Centre of Academics and Research, HCG and surgical oncologist, says: “Food has become a carcinogen. This is the result of instant gratification and a vulture-like capitalistic approach. In the next 10 years, more people will die of eating. Our primary objective today must be food safety. We should collectively work towards a farm-to-plate approach, have regulatory policies in place and be active, not passive, about food licensing and testing."