demographic_dynamics_and_the_changing_faces_of.4
demographic_dynamics_and_the_changing_faces_of.4
1
Department of Aims and Objective: The development of a nation depends on well-nourished
Abstract
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Community and Family individuals. A country’s economic independence also depends on adequate food
Medicine, AIIMS, supply for all sections of its population and the proper selection of the right kinds
Bibinagar, Hyderabad,
of food, called nutritional literacy. This review will show the transition of dietary
Telangana, 2Department
of Community and selection and practices across India over the last two decades and its impact on
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Family Medicine, AIIMS, health. Materials and Methods: We conducted a literature search to review the
Bhubaneswar, Odisha, India evidence of the last two decades. The literature search was done using the PubMed
search engine and the MeSH words “Nutrition Literacy, Dietary Practices, Diet
Transition, Nutrition transition, India and Food pattern.” Evidence from the
last two decades was collectively reviewed, and observations on the transition
in nutrition literacy were summated. Results: The literature search revealed 18
articles, out of which 13 articles were included in this review based on inclusion–
exclusion criteria. Nine were review articles, and five were cross-sectional studies.
The studies done over the last two decades on nutrition culture revealed that
most of the studies related to transition have been done during the second decade
of the twenty-first century. Most have found that the shift has been happening
more among the urban poor and rural rich people. Indian diets have diversified
and shifted away from cereals towards processed food. Conclusion: It was found
that there is a shift in feeding preferences in diet-deprived sections in India. The
findings are similar in rural and urban areas where the poor fall prey to the food
fads, make poor nutrition choices, and gradually develop chronic ailments. Such
a transition over the years clearly shows that a malnourished child, having faulty
feeding practices, becomes prey to the triple burden of hidden hunger, lack of
nutrition, and repercussions of chronic non-communicable diseases, including
Received : 05-08-22
Revised : 12-07-23
dental ailments.
Accepted : 22-07-23
Published : 30-08-23
Keywords: Demography, dental problems, India, nutrition literacy, transition
© 2023 Journal of International Society of Preventive and Community Dentistry | Published by Wolters Kluwer ‑ Medknow 299
Bhatia, et al.: Changing faces of nutrition literacy among communities in India
of food scarcity, nutritional deficiencies, deprivation, India and Food pattern.” Original articles, reviews,
famines, malnutrition, and droughts have stood the case reports, multicentric studies, technical reports
tests of time. The national programs of our country for or any other historical articles in English medical
nutrition have always served the purpose of confronting journals among all age groups were included from
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the dearth and pitfalls, but they still need to superintend 2000 to 2020 over 20 years. Any other paper not fitting
the insidious genesis.[4] into the ambit of our objective and outcome, whether
abstracts, duplicate, retracted publications, interviews,
In the late twentieth century, as countries grappled
editorials, directory, research support, controlled trials,
with the challenges of combating infectious diseases,
education handouts or any newspaper articles beyond
there was not enough awareness and understanding
the duration, were excluded. The search strategies were
of the impending complexities and fatal consequences
repeat checked by two other reviewers using the peer
caused by widespread food insecurity and chronic
review checklist and a similar process was followed for
undernutrition. The Green Revolution fatigue initiated
data charting. The key findings were tabulated.
a consequential retaliation, wherein the household
food security improved and severe manifestations
Results
of malnutrition depleted due to better access to
health care. However, there was limited awareness The literature search revealed 18 articles, out of which
of their right to choose proper food as well as reflect 13 articles were included in this review based on
upon the concept of “Hidden Hunger,” which arose inclusion–exclusion criteria. Nine were review articles,
out of micronutrient deficiencies.[5,6] India has also and five were cross-sectional studies as mentioned in
encountered a steep and steady upsurge in urban Table 1. Most of the studies have been done on children
migration in the last two decades. Besides offering and adolescents. The studies done over the last two
job opportunities and rogue living conditions, the decades on nutrition culture revealed that most of the
migration also offered a shift in their feeding patterns, studies related to transition have been done during
resulting in a dual burden. Along with chains of the second decade of the twenty-first century. Most
poverty, obesity rates began to rise. The young of them have found that the shift has been happening
population in India must be leveraged by investing more among the urban communities. The urban poor,
more in access to nutritious diets, healthy promoting however, have been showing greater increases in their
lifestyles, making them more nutrition literate and rate of transition as well as nutrition literacy. In rural
providing a sanitary environment.[4-7] areas, it is the rural rich who are affected. Hidden
hunger is relevant across all strata due to micronutrient
This nutritional transition was paradoxical since deficiency. In addition, the studies also revealed that
those who had experienced calorie deprivation and dietary patterns are changing globally towards more
faltering growth in early childhood due to poverty and intake of simple refined carbohydrates, fats and lower
deprivation, subsequently, with better access to food intake of complex carbohydrates and the consumption
and low physical activity, fell prey to non-communicable of processed food is increasing, causing overweight,
diseases, oral health problems, and obesity. Nutrition malnutrition, comorbidities and obesity.[6] Sugar
literacy empowers individuals to make informed consumption is decreasing in urban but increasing
choices about their diet that support general and oral in rural areas.[7-9] Obesity increased in middle-income
health. Barker’s hypothesis linking low birth weights families, probably among those who moved up the scale
and early nutritional deprivation with obesity in from deprivation. The most commonly consumed food
adulthood and accompanying metabolic disorders was refined grains.[10,11] In overweight states (Kerala,
focuses the spotlight on the crucial importance of a Punjab, Delhi) obesity problem expanded from urban
“life-cycle approach” to nutrition.[1] This review will rich to urban poor; the rise was higher among the urban
show the transition of dietary selection practices and Poor. Among the urban rich, married women are mostly
nutrition literacy across India over the last two decades affected.[12] Consuming more energy-dense food is
and its impact on health. causing diet-related non-communicable diseases.[10,13-15]
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Bhatia, et al.: Changing faces of nutrition literacy among communities in India
regional trends, 1993 to consumption diversified and shifted away from cereals and more attention since it’ll
2012[8] towards milk, processed food-heavy diets. increase burden of
oxidative stress injury
Nutrition transition and 2017 4-stage 19% overweight. Risk factors associated: skipping Regional preventive
obesity among teenagers systematic breakfast, fast food consumption, extra salt, and strategy
and young adults in South search watching TV while eating (teenagers).
Asia.[2]
Impact of nutrition 2017 Series review Dietary patterns are changing globally towards Create stringent
transition and resulting more intake of simple refined carbohydrates and mandates and
morbidities on fats and a lower intake of complex carbohydrates. awareness.
economic and human Upsurge in co-morbidities arising from nutrition Explore healthier diet
development.[6] transition. Massive impact on the Indian Economy options.
Development and 2017 NT–FFQ Concordance for eating while watching TV, Need to quantify the
evaluation of nutrition survey frequent snacks, red meat, fried ready-to-eat food. nutrition transition
transition-FFQ in South (Adolescents) and put a check.
India.[7]
Association between full 2017 Cross-sectional The most common full-service and fast-food Further research
service and fast-food population- restaurants were Indian Savory (57%), followed by is needed to
restaurant density, dietary based sweet shops (26%) and Western (14%). The most explore association
intake and overweight/ common consumption was refined grains; most prospectively.
obesity among adults in customers were obese, alcoholic, and had moderate
Delhi, India.[11] physical activity.
Going global: Indian 2016 Cross-sectional Consumed more energy-dense food. Private school Promote diversity
adolescents’ eating Survey using students took up traditional expensive foods (dairy, and health fullness
patterns.[13] FFQ homemade sweets and added fats) more than public of global food by
school students who ate more traditional (tea, considering the
coffee, eggs) and mixed food (snack, street food) preferences.
Overweight prevalence 2015 Secondary In overweight states (Kerala, Punjab, Delhi) obesity Design state and
among Indian women by data analysis problem expanded from Urban rich to Urban poor; SE strata-specific
place of residence and the rise was higher among the Urban Poor. For approaches to
SES: Contrasting patterns underweight states (Bihar, MP, Odisha), obesity arresting the rapid
from “underweight states” is spreading more among the urban rich among growth
& “Overweight states” of married women.
India.[12]
Food choices and 2015 Nutrition 42% of underweight children belonged to Class 1 Most commonly
consequences for the calculation families. Most of the overweight children belonged associated with
nutritional status: Insights software to Class 2. In Class 3 families, there were normal- maternal education,
into nutrition transition in weight children. Underweight children came from and so this needs to
a hospital community[10] poorer households. There was increased obesity in improve.
middle-income families, probably among those who
moved up the scale from deprivation.
Nutrition transition in 2015 Review and India is facing—diet-related non-communicable Multi-sectoral
India: Secular trends in literature diseases and widespread undernutrition leading to a preventive approach
dietary intake and their search socioeconomic burden. The transition has resulted early childhood
relationship to diet-related in a 7% decrease in energy from carbohydrates and approach across life
non-communicable a 6% increase in fats. Resulting in adverse perinatal cycle
diseases.[10] events, LBW, Metabolic syndromes and early
childhood catch-up growth.
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Bhatia, et al.: Changing faces of nutrition literacy among communities in India
Table 1: Continued
Title Year Methodology Major findings Specific
recommendation
The adherence of 2010 Packaged 52% displayed information based on energy, The majority need
packaged food products products protein, sugar, fat, meeting the minimum to meet the labelling
in Hyderabad, India assessed requirements of FSSAI. But only 27% met the guidelines. These
with nutritional labelling minimum criteria as per Codex. It also needs warrants review.
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and adolescents’ diets in 2013 in dietary to consume eggs (+32%), and milk (+12%). No for healthy diets.
low- and middle-income diversity (DD) marked gender disparity or Urban-rural differences, Global context-
countries: a cross-cohort but regional predilection within the nation is specific policies to
comparison.[9] present. Sugar consumption decreased in urban but avert negative health
increased in rural areas. Increased animal-source consequences.
food like eggs and milk is associated with increased
per capita income (adolescents).
Trends in diet, nutritional 2001 Review Adult-onset diabetes is more common in –
status, and diet-related India. Projections were that India’s Costs for
noncommunicable Undernutrition would decline initially but would
diseases in China and rapidly increase for both under and overnutrition
India: the economic by 2025.
costs of the nutrition
transition.[15]
Figure 1: Comparison of Nutritional status of tribal communities, India. *NFHS = National Family Health Survey, ST = scheduled tribe
Figure 1 shows the trend of nutrition status and how it Assam, also have greater numbers of rural tribals below
has decreased for stunting, wasting and underweight in poverty line as compared to the urban tribals. The
India, but the tribal community still has a higher burden literacy rates of tribals from Odisha, MP, and Andhra
to get the better of. India’s stunting rates have made a Pradesh, however, are comparable, but the literacy rates
10% downward shift over 10 years, whereas, those for for Assam and Himachal Pradesh tribals are too high.
wasting have shown an increase (19%–21%), and that Interestingly, the forest areas in regions of MP and UP
of underweight has decreased from 42.5% to 35.7%. tribal areas have depleted maximum, and it is here that
The overall figures for tribal communities show higher the rates of crime and atrocities toward the tribal people
figures as compared to national statistics, although, the are also found to be the highest. This shows that forest
specific ranges for wasting, stunting and underweight land area, atrocities, poverty, education, and nutrition
categories have shown slight decrease, over the 10-year status are relatable.[17,18]
period of assessment.[16,17]
As in Figure 2, the comparison shows that States with Discussion
a higher percent of tribal population such as Andhra Nutrition during the earlier years of the first decade of
Pradesh, Madhya Pradesh, Odisha, Rajasthan, and the twenty-first century mostly indulged with setbacks
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Figure 2: A state-wise comparison of demography and nutritional problems among the tribal communities in India
of undernutrition. Nutrition patterns for both strata consumption of energy-dense, processed foods, known
showed a clear picture among adolescents in schools. as the nutrition transition.[9,10,19,20] The convergence
Students from higher strata mostly went for a non- and the transposition in diets are more pronounced for
vegetarian diet, fried junk food, aerated sugary drinks, adolescent or young adult groups since they are most
or energy-dense refined packaged food items.[7-9] They exposed to and influenced by the food environment
frequently visited restaurants and also preferred factors, advertisements, or promotions. It happened
incessant snacks. The canteen visits, snacking, fast more commonly in developed megacities earlier
food joints, etc., all hatched a habitual pattern that because the noted changes in the diet diversity patterns
the students from lower/middle strata started going or composition also reflect the extent of influence of
around with. They, however, could prefer street food, the global economic forces on food systems, which
locally branded packaged items or homemade energy- penetrates the metropolitan cities first. In simple
dense foods; based on their levels of affordability words, the more global trading or global economic
or family norms. Omitting the tiffin from homes or forces a city is exposed to, the faster the transition of
morning breakfast had become a regular thing. The the dietary benchmark.[9]
frequency of snacking in school canteens or the food
vendors outside schools had become the fad that all A study done on 641 students from Class IX and XI
students, irrespective of their family status, wished in the urban and rural schools of Chandigarh in 2001
to follow.[13] Indian diets have steadily diversified revealed that snacking was a well-established trend set
and shifted from cereals to milk and processed food. up across all classes of society. Although it was more
The findings of studies done during the second affordable among the higher socio-economic class, it was
decade suggested that urban poor have been showing rampant across all strata (Table 1S). Traits among rural
greater increases in their rate of transition as well adolescents showed that most of them were vegetarian,
as nutrition literacy. Increased incidence of obesity did not bring tiffin to schools, avoid morning breakfast,
observed in middle-income families, probably among and prefer eating food outside. A mere 15% brought
those who moved up the scale from deprivation. healthy foods in their tiffin snacks. Approximately
Exposure to early undernutrition followed by being one-third of the students practiced fasting on special
overweight increases the risk of non-communicable days. On the other hand, most of the urban adolescents
disease.[5,10] Similar studies show a widespread shift were vegetarian, but the number was less than rural
from communicable to non-communicable diseases adolescents. Most of the urban students preferred junk
concentrated in low- and middle-income countries food and regular snacks. Very few students practiced
and accompanied by a global trend toward increased fasting. The family traits, anthropometric assessments,
Journal of International Society of Preventive and Community Dentistry ¦ Volume 13 ¦ Issue 4 ¦ July-August 2023 303
Bhatia, et al.: Changing faces of nutrition literacy among communities in India
and knowledge about diet and obesity is mentioned in approach will improve utilization of the existing
Table 1S. Considering the knowledge of students, it governmental policies.[25-27] Another case study done
was found that 93% of rural adolescents were unaware on Indian population related to urbanization and
of balance diets as compared to 88% in urban areas. eating practices also suggests that nutrition transition
However, more urban adolescents knew about obesity is more in urban population than in rural population.
and its repercussions.[21] They found that urban residents spend more on
processed food and prefer eating outside food.[28] The
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among approximately 4000 households by a cross- The rise in overweight or micronutrient deficiency
sectional-based survey conducted during the second steadily started increasing among all masses of
decade of the twenty-first century. A comparison population. This triple burden would not only cripple
of the study findings shows that rural tribals have our existing economy but would also juxtapose a
a greater population of tribals, are less literate, and future, where our adolescents of today would turn out
belong majorly to Below Poverty Line and low Socio- to be a demographic burden upon our nation with high
economic strata with very less average per capita incidences of diabetes, hypertension, or other metabolic
income. On the other hand, the urban tribals had syndromes. Furthermore, the studies have shown
lesser forest coverage, better road and communication, association of diet with periodontal inflammation and
depended more on junk food, and had a higher risk of incidence of dental caries. Micronutrient deficiency has
non-communicable diseases. The random blood sugar, also been linked with periodontitis.[29-31] However, with
triglycerides and cholesterol values were much higher the rise in multiple facets of the nutrition problems,
among the urban tribals as compared to the rural and more specifically relating to obesity and dental
tribals [Figure 1S].[22] The tribal urbans were mostly problems, the recommendations and education, needs
migrants who initially spent life in deficiency, but to be started early during school days. Studies have
gradually started managing their survival. They are no shown a positive association between obesity and
longer earning just hand to mouth. So, these sections primary dentition caries. It’s no more how much you
of urban poor start spending just enough income can take; rather, it depends more on how better it can
on the whims and fads of their children. As a result, be digested and how promptly we can choose the best
they feed upon based on peer trends, advertisements dietary options.[29,32,33]
or options at local shops. Similar studies have
Concepts of balance diet, Recommended Dietary
mentioned that such instances of overweight after
Allowances—RDA and Food standardizations need
an initial period spent in deficiency results in greater
to be more stringent. Fasting, which used to be curbed
harm, thereby, predisposing more to the jaws of triple
entirely, can be considered an option with proper
burden. Much of the household trends depends on the
guidance. Workplaces also need to modulate the culture,
level of literacy of mothers. So, we can well speculate
enhance nutrition literacy, and provide mandatory
that these mothers originally from poor backgrounds
breaks for some physical activity. For those urban
may tend to overcompensate, so that their children
poor, who toil hard and binge eat energy-dense food
do not suffer the deprivations they suffered in their
at the end of the day, the government should provide
childhood.[10,18] It also appears that this section is
mandatory food breaks and items at workplaces and
mostly busy with their work and their basic priorities
ensure they are consumed. The major limitation of
are education of their kids and material possession.
the study is the need for more evidence. The online
They enjoy food which are usually local non-branded
literature search was limited to only one database. It is
and packaged. We have insufficient data in India which
essential to review existing rich sources of information
can actually scrutinize the standards of these food
before planning future research prospects.
items.[23,24] According to NHFS data, there is higher
prevalence of stunting and wasting among triable Conclusion
community [Figure 1]. The dilemma of our fight
against these intertwined problems needs a strategic It was found that there is a shift in feeding preferences
and region-specific response with particular focus on in diet-deprived sections in India. The findings are
vulnerable groups, who are already encountering their similar in rural and urban areas where the poor fall
own levels of hardships. Using region specific dialects, prey to the food fads, make poor nutrition choices, and
hooking around success stories and a demand driven gradually develop chronic ailments in the future. The
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Bhatia, et al.: Changing faces of nutrition literacy among communities in India
shift has been happening more among the urban poor transition-FFQ for adolescents in South India. Public Health
and rural rich. The transition toward more energy- Nutr 2017;20:1162-72.
8. Tak M, Shankar B, Kadiyala S. Dietary transition in India:
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non-communicable diseases, obesity, and dental 2019;40:254-70.
problems. Our study findings suggest that children in 9. Aurino E, Fernandes M, Penny ME. The nutrition
their development years need to focus more on mindful transition and adolescents’ diets in low- and middle-income
eating to prevent non-communicable chronic diseases. countries: A cross-cohort comparison. Public Health Nutr
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2017;20:72-81.
Yester years’ recommendations mostly served the
10. Piple J, Gora R, Purbiya P, Puliyel A, Chugh P, Bahl P, et al.
purpose of improving upon maternal literacy, advice Food choices and consequences for the nutritional status:
on diet consumption and enhancing policies. Insights into nutrition transition in a hospital community.
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25. Narayanan R, Panda AK, Nithya DJ, Bhavani RV. Dialogue Egyptian school children (A cross-sectional study). Front
as a tool of nutrition literacy in an agricultural intervention Public Health 2022;10:953545.
programme in Odisha, India. CABI Agric Biosci 2022;3:28. 30. Li W, Shang Q, Yang D, Peng J, Zhao H, Xu H, et al. Abnormal
26. Liao LL, Lai IJ, Chang LC. Nutrition literacy is associated micronutrient intake is associated with the risk of periodontitis:
with healthy-eating behavior among college students in Taiwan. A dose–response association study based on NHANES 2009–
Health Educ J 2019;78:756-69. 2014. Nutrients 2022;14:2466.
27. Rochman C, Nasrudin D, Helsy I, Hermita N, Darmalaksana W. 31. Mackenbach JD, Ibouanga EL, van der Veen MH, Ziesemer KA,
Nutrition literacy program for improving public wellness. J Phys Pinho MG. Relation between the food environment and oral
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29. Mahmoud SA, El Moshy S, Rady D, Radwan IA, Abbass MMS, 33. Li S, Zhu Y, Zeng M, Li Z, Zeng H, Shi Z, et al. Association between
Al Jawaldeh A. The effect of unhealthy dietary habits on the nutrition literacy and overweight/obesity of adolescents: A cross–
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306 Journal of International Society of Preventive and Community Dentistry ¦ Volume 13 ¦ Issue 4 ¦ July-August 2023
Bhatia, et al.: Changing faces of nutrition literacy among communities in India
Supplementary Data
Table 1S: Findings from Nutritional Assessment among Adolescents in government Schools of Rural and Urban
Chandigarh, 2001
Variables Parameters Frequencies (Percentage)
Rural (n = 180) Urban (n = 147)
Family Traits Housewife Mothers 171 (95%) 125 (85%)
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Figure 1S: Comparison of patterns among Rural and Urban Tribes in Odisha, 2019