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Indian Pediatr 2011;48:
763-764 |
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How Should Pediatricians in India Address
Behavior Patterns Associated With Childhood Obesity? |
Jonathan Wells
Professor of Anthropology and Pediatric Nutrition,
Childhood Nutrition Research Centre, UCL Institute of Child Health, 30
Guilford Street, London WC1N 1EH, UK.
Email: [email protected]
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T he nutritional transition is well
underway in India, reflected both in rapid economic development, and in an
epidemic of type 2 diabetes and cardiovascular disease [1]. Rapid
increases in children’s adiposity, referred to by Kuriyan and colleagues
[2] in their article published in this issue of Indian Pediatrics,
indicate powerful exposure of the youngest age groups to these winds of
change.
The study of several thousand children makes several
important contributions to understanding why children’s waist girths are
increasing [2]. Various behaviors were implicated, with one thing in
common: they all relate to ‘modernity’ – new foods in the Indian diet, new
ways of eating, new leisure habits such as TV viewing. These behaviors are
not brand new; rather they are recently arrived and spreading across the
population in a way that can be likened to a ‘cultural virus.’ Even the
parental contribution to children’s adiposity identified by the authors
may involve more than genotype. Trans-generational effects may involve
non-genetic impacts of parental lifestyle (eg: diet during pregnancy) on
the next generation [3].
The discipline of medicine consolidated in the late 19 th
century under the influence of germ theory, to deal with biological
pathogens. The aims were clear: diagnose the illness, identify the disease
agent, and find its weak point so as to eliminate exposure, decrease
transmission, or treat the symptoms. Given adequate funding, medicine does
this very effectively. Rates of infectious disease today arguably track
financial indicators much more strongly than local ecological conditions.
Social factors also make a major contribution to health through living
conditions, acting through physiological mechanisms such as diet, or
exposure to pollution or physical injury. Again, financial indicators are
fundamental, malnutrition goes hand in hand with poverty, and economic
development is seemingly a panacea for all these ills.
And so it is; albeit with a profound cost. Economic
development does indeed enable progress in specific public health arenas,
and many middle-income countries have seen an impressive reduction in
rates of childhood malnutrition and infectious disease [4]. But as
nutrition ‘improves’, why do people get fatter rather than taller?
The current mode of economic development brings with it
a whole range of new disease vectors, and the medical community is still
struggling to understand and adjust. Indeed the ‘dual burden’ – the
simultaneous presence of both undernutrition and overnutrition in
communities, even within families – makes it seemingly impossible to
address both at the same time.
These new disease vectors are very different to those
familiar to clinicians. They spread at the speed of TV transmission rather
than on the wings of the mosquito, they can infect entire schools or
neighborhoods with a few well-targeted billboards, and they co-opt their
human hosts into passive submission through clever marketing practices.
Despite frequent reference to ‘market choice’, modern capitalism makes its
profits primarily by making people’s choices for them [5], and so-called
‘emerging market’ countries such as India are increasingly where those
profits are being made.
How should clinicians, and especially pediatricians,
respond? The experience of western countries is not encouraging.
Governments are unwilling to regulate adequately the commercial interests
that substantially boost their tax revenues. But with tens of millions of
diabetics in India already, you can’t afford to copy our dismal inertia.
The food industrial complex is arguably currently more
dangerous to human health than any single biological pathogen. When I was
last in India, in November, I visited a new supermarket to review the
kinds of foods being sold in such outlets. The shelves were stacked with
sweets, biscuits, ready-made foods and sugary drinks. The individual
products may not all be new, and I confess to personal past experience
with several Indian brands of soft drinks. But in this kind of
supermarket, it is impossible to escape sugar. It is in almost
every product, sweet or savory. Evidence increasingly suggests that sugar
(sucrose) is more harmful to health than fat, due to its profound effects
on insulin metabolism [6,7]. And sugar has long been one the fastest and
most lucrative routes to profit on planet earth, hence its locus at the
heart of economic development worldwide.
It would be easy to assume that the disease vectors of
modernization are therefore foods, perhaps in particular those containing
sugar. This would be a mistake, like identifying Plasmodium as the
cause of malaria but missing the role of the mosquito. The real disease
vectors are the strategies and power that characterize the food and
leisure industries [5] that make it increasingly difficult for the
majority of people to avoid unhealthy foods and lifestyles. The obesogenic
behaviors identified by Kuriyan and colleagues are being powerfully shaped
by these commercial interests.
I believe that pediatricians need to treat the food
industrial complex like a disease, a deadly disease, if you are to have
any chance of success in tackling the Indian diabetes epidemic. You’ll
need different skills to those conventional in the clinic or laboratory.
And it may be uncomfortable and challenging. Corporate strategy is likely
to be an unpleasant sight when analyzed under the microscope. You need to
ask some very tough questions. And here is one for starters. Why were some
of the biscuits in that supermarket, containing 72.3 g carbohydrate per
100g, including 27.3 g sugar, marketed by the same company that in 2005
entered the Indian diabetes therapeutic arena with the launch of two
drugs, Windia and Windamet?
Competing interests: None stated.
Funding: None.
References
1. Misra A, Khurana L. The metabolic syndrome in South
Asians: epidemiology, determinants, and prevention. Metab Syndr Relat
Disord. 2009;7:497-514.
2. Kuriyan R, Thomas T, Lokesh DP, Sheth
NR, Mahendra A, Joy R, et al. Waist circumference and waist for
height percentiles in urban south Indian children Aged 3-16 Years. Indian
Pediatr. 2011;48:765-71.
3. Wells JC. The thrifty phenotype as an adaptive
maternal effect. Biol Rev Camb Philos Soc. 2007;82:143-72.
4. Uauy R, Kain J. The epidemiological transition: need
to incorporate obesity prevention into nutrition programmes. Public Health
Nutr. 2002;5:223-9.
5. Baudrillard J. The Consumer Society: Myths and
Structures. Los Angeles: Sage Publications; 1970/1998.
6. Lustig RH. The ‘skinny’ on childhood obesity: how
our western environment starves kids’ brains. Pediatr Ann.
2006;35:898-907.
7. Taubes G. The Diet Delusion. London: Vermillion; 2008.
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