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The double burden of ‘malnutrition’: Under-Nutrition & Obesity

Intraindividual double-burden of anthropometric undernutrition and “metabolic obesity” in Indian children: a paradox that needs action

European Journal of Clinical Nutrition volume 75, pages 1205–1217 (2021)Cite this article

Subjects

Abstract

Background

Intra-individual coexistence of anthropometrically defined undernutrition and ‘metabolic obesity’, characterised by presence of at least one abnormal cardiometabolic risk factor, is rarely investigated in young children and adolescents, particularly in Low-and-Middle-Income-Countries undergoing rapid nutrition transition.

Methods

Prevalence of biomarkers of metabolic obesity was related to anthropometric and socio-demographic characteristics in 5–19 years old participants from the population-based Comprehensive National Nutrition Survey in India (2016–2018). The biomarkers, serum lipid-profile (total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides), fasting glucose, and glycosylated hemoglobin (HbA1C), and all jointly were analysed in 22567, 23192, 25962 and 19143 participants, respectively.

Results

Overall (entire dataset), the prevalence of abnormalities was low (4.3–4.5%) for LDL and TC, intermediate for dysglycemia (10.9–16.1%), and high for HDL and triglycerides (21.7–25.8%). Proportions with ≥1 abnormal metabolic obesity biomarker(s) were 56.2% overall, 54.2% in thin (BMI-for-age < −2 SD) and 59.3% in stunted (height-for-age < −2 SD) participants. Comparable prevalence was evident in mild undernutrition (−1 to −2 SD). Clustering of two borderline abnormalities occurred in one-third, warranting active life-style interventions. Metabolic obesity prevalence increased with BMI-for-age. Among those with metabolic obesity, only 9% were overweight/obese (>1 SD BMI-for-age). Among poor participants, triglyceride, glucose and HDL abnormalities were higher.

Conclusions

A paradoxical, counter-intuitive prevalence of metabolic obesity biomarker(s) exists in over half of anthropometrically undernourished and normal-weight Indian children and adolescents. There is a crucial need for commensurate investments to address overnutrition along with undernutrition. Nutritional status should be characterized through additional reliable biomarkers, instead of anthropometry alone.

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Fig. 1
Fig. 2: Presence of metabolic obesity biomarkers in relation to BMI-for-age categories among 5–19 years old children.
Fig. 3: Presence of metabolic obesity biomarkers in relation to BMI-for-age categories among 5–19 years old children.

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Acknowledgements

HSS and AVK are recipients of the Wellcome Trust/Department of Biotechnology India Alliance Clinical/Public Health Research Centre Grant # IA/CRC/19/1/610006. AVK is also supported by the India Alliance through their Margdarshi Fellowship.

Funding

The CNNS was conducted by the Ministry of Health and Family Welfare, Government of India, and the UNICEF, with financial support from the Mittal Foundation. These secondary analyses and paper were not supported by any specific funding.

Data sharing and declaration

The Ministry of Health and Family Welfare (MoHFW), Government of India owns the Comprehensive National Nutrition Survey data. The data used in this paper were released for public use by the MoHFW and United Nations Children Fund, India Country Office. The code book and the analytic code can be made available upon reasonable request to the corresponding author(s).

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Authors and Affiliations

  1. Sitaram Bhartia Institute of Science and Research, New Delhi, India

    Harshpal Singh Sachdev

  2. Population Council, New Delhi, India

    Akash Porwal, Avina Sarna, Rajib Acharya & Sowmya Ramesh

  3. Institute of Liver and Biliary Sciences, New Delhi, India

    Umesh Kapil

  4. St John’s Medical College, Bengaluru, India

    Anura V. Kurpad

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Contributions

HSS conceived the idea, guided the analysis and drafted the manuscript. AP conducted all statistical analyses. AVK provided analytic insight for the National Sample Survey Office dietary consumption data. All authors were involved at every iteration of analyses and drafting, and approved the final paper. All authors had access to raw data.

Corresponding authors

Correspondence to Harshpal Singh Sachdev or Anura V. Kurpad.

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Conflict of interest

HSS designed the draft protocol of the CNNS with consultancy support from the UNICEF, India. HSS, AS, UK and AVK were members of the Technical Advisory Committee of the CNNS, constituted by the Ministry of Health and Family Welfare of the Government of India, to oversee its conduct and analysis. HSS is a member of the World Health Organization Nutrition Guidance Expert Advisory Subgroup on Diet and Health and member of Expert Groups of the Ministry of Health and Family Welfare on Nutrition and Child Health. AS, RA, SR and AP were involved in the CNNS study implementation and main analyses. There were no other conflicts to declare.

Ethical approval

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Population Council’s International Review Board (New York, USA) and ethics committee of Post Graduate Institute of Medical Education and Research (Chandigarh, India). No separate ethical approval was required or taken for this secondary analysis.

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Sachdev, H.S., Porwal, A., Sarna, A. et al. Intraindividual double-burden of anthropometric undernutrition and “metabolic obesity” in Indian children: a paradox that needs action. Eur J Clin Nutr 75, 1205–1217 (2021). https://doi.org/10.1038/s41430-021-00916-3

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