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By Mayanka Ambade and Nachiket Mor
A study of older (45+) Indian adults recently published in the journal Preventive Medicine finds that while several drivers of cardiovascular disease are present amongst them, a high level of belly fat (“central adiposity”) and physical inactivity are by far the most prevalent. When measured using a WHO benchmark of the waist-hip ratio of greater than 0.90 for men (0.81 for women), 77.2% were found to have excess belly fat (ranging between 95.3% for Chandigarh and 63% for Mizoram), with 73.9% having low levels of physical activity. In sharp contrast, the proportion of overweight and obese individuals, at 17.7% and 6.8% respectively, was much lower. This is an exciting finding because body weight is most strongly linked to total calorie intake and is difficult to change because it needs fundamental changes in food habits. On the other hand, belly fat is much easier to address because it can be reduced through modest levels of daily exercise.
Body weight is most strongly linked to total calorie intake and is difficult to change because it needs fundamental changes in food habits
Belly fat is strongly associated with insulin resistance and is linked to several diseases, such as high blood pressure and diabetes. Insulin resistance refers to a weakened response to increases in insulin levels in the body, and our evolutionary history provides a clue as to its origins. We evolved in an environment with poor food and salt availability and a high risk of attack, injury, and infections. In such an environment during periods of pregnancy, infection/inflammation, and other forms of stress, since the body needed to maintain higher levels of glucose in the blood, insulin resistance proved to be a helpful adaptation. However, when the environment changed to one in which food and salt availability became plentiful, insulin resistance moved from a helpful response essential for our survival to one now linked to severe disease.
People with excessive belly fat who have high blood pressure are more likely to acquire diabetes
Belly fat is now so familiar that it is considered a normal part of ageing. Some cultures even regard it as an attractive physical feature because it is a sign of prosperity or, perhaps, in an evolutionary carryover, of the presence of insulin resistance, historically so crucial for survival. Unfortunately, it is now well understood that belly fat is strongly linked to high blood pressure, high blood sugar, and higher cholesterol levels, the three most important risk factors for cardiovascular disease, even amongst people with normal weights. People with excessive belly fat who have high blood pressure are more likely to acquire diabetes. It may interfere with digestion in their daily lives, resulting in problems like heartburn produced by oesophageal reflux. It hurts sleep quality and can cause lower back pain. Belly fat is associated with an increased risk of developing cancer and clinical depression.
Increasing the prices of sugar and fat, as has been done in many countries, effectively reduces the calories consumed. The political and policy challenges associated with bringing about similar changes in the Indian context are, however, likely to be extremely high and perhaps even insurmountable
To deal with the challenge of belly fat, one must look at its underlying causes. High-calorie intake and inadequate physical exercise are linked to it. However, unlike overall body weight, belly fat has been shown to respond well to even moderate levels of exercise. Exhorting people to eat less and exercise more has rarely been effective. Increasing the prices of sugar and fat, as has been done in many countries, effectively reduces the calories consumed. The political and policy challenges associated with bringing about similar changes in the Indian context are, however, likely to be extremely high and perhaps even insurmountable.
Many cities, including London and New York in developed countries and Addis Ababa in the developing world, have embraced sought to explicitly design their cities to enhance the level of exercise that people can get as a part of their daily routines
To increase the levels of exercise, more parks, while adding an attractive feature to cities, have not been found to be effective. Instead, public transportation systems that require people to walk to and from their residences to get to bus and train stops on smoothly connected, safe, brightly lit, and well-built sidewalks have had a demonstrated effect on the level of exercise that people get daily. Many cities, including London and New York in developed countries and Addis Ababa in the developing world, have embraced this idea and have sought to explicitly design their cities to enhance the level of exercise that people can get as a part of their daily routines.
Within India, while the rates of formal urbanisation, at close to 30%, are still considered low, an analysis of the Night-Lights data obtained by satellites indicates that much of the population already lives in habitations so dense that they would be classified as urban in many countries. As these dense habitations transform into formal cities, they offer an opportunity to build these walking-friendly features into their designs.
The poor state of our health systems makes designing our emerging cities, where most of our people are likely to reside, to be public transport and walking-friendly, even more critical
As these urban areas evolve, even independently of any health benefits that might accrue, they need to invest in public transportation so that the larger populations of the city can move around safely and economically without the need to use private vehicles, which require expensive roads and result in a much higher degree of pollution and road traffic injuries. Building good sidewalks is also essential because otherwise, as tends to happen in most cities currently, pedestrians spill onto roads, resulting in congestion and an increased risk of accidents. Ensuring that these sidewalks link smoothly to the city's public transportation infrastructure becomes the next logical step, which, happily, also has the strong side-effect of reducing belly fat and, as a direct result, the prevalence of cardiovascular disease.
Diseases like diabetes and high blood pressure pose perhaps one of the greatest challenges we’re likely to confront as a country. That, unlike in the developed world, our average calorie consumption and the associated obesity level, at least for now, continue to be relatively low is good news. Additionally, the fact that over 75% of our adults have big bellies and rarely, if ever, do even moderate exercise, while alarming, is also good news because it offers us a way to prevent these debilitating diseases from overwhelming our populations. The poor state of our health systems makes designing our emerging cities, where most of our people are likely to reside, to be public transport and walking-friendly, even more critical.
(Dr Mayanka Ambade is an Assistant Professor at IIT, Mandi. Dr.Nachiket Mor is a Visiting Scientist at The Banyan Academy of Leadership in Mental Health, Chennai)