TODAY non-communicable diseases, or NCDs, pose an indiscriminate threat to the health and lives of people of all ages, from diverse regions and countries. Heart disease, cancer, diabetes and chronic respiratory diseases, once linked only to the more affluent, have now become global, affecting the poor the most. According to World Health Organization (WHO) data released in 2018, NCDs account for the deaths of 41 million people each year, which is equivalent to 71% of all deaths globally.¹

Between 1990 and 2017, there has in fact been a 40% increase in NCDs and 41% decrease in communicable diseases and neonatal disorders. NCDs like cardiovascular diseases (CVDs) and cancers have gone on to adversely impact the progress we have made in reducing mortality from common diseases. The global burden of disability too is driven mainly by NCDs, which caused 80% of disability in 2017. According to the WHO, ‘The threat of NCDs constitutes one of the major challenges for development in the 21st century, undermining social and economic progress throughout the world.’

NCDs account for an estimated 62% of all deaths in India.² As at the global level, NCDs have become leading factors contributing to the total disease burden in India. This burden has in fact increased from 30% in 1990 to 55% in 2016. Diabetes had the highest increase in disease burden at 80% from 1990 to 2016, with ischaemic heart disease (IHD) at 34%. In 2016, three of the five leading individual causes of disease burden in India were non-communicable – ischaemic heart disease and chronic obstructive pulmonary disease (COPD) were the top two causes and stroke was the fifth leading cause.³

The India State-level Disease Burden Initiative, a joint initiative of the Indian Council of Medical Research (ICMR), Public Health Foundation of India (PHFI), and Institute for Health Metrics and Evaluation (IHME), in collaboration with the Ministry of Health and Family Welfare (MoHFW), also revealed findings of major concern in 2018. While we knew that NCDs have been rising across the country, the report revealed that the less developed states of India had the highest rate of increase in ischaemic heart disease and diabetes (with the latter having increased from 26 million in 1990 to 65 million in 2016⁴).

The prevalence of high blood pressure, high cholesterol, high fasting plasma glucose and obesity, which are amongst the major risk factors for ischaemic heart disease, stroke and diabetes, has increased all over India, including rural areas. Additionally, the high exposure to ambient and household air pollution in the less developed northern Indian states is contributing to the high burden of COPD in these states. The case-fatality rate of COPD in these states is twice as high as that in the more developed states.⁵

The outbreak of Covid-19 has further highlighted the risk NCDs pose. Vulnerable populations, particularly those suffering from diabetes, hypertension and heart diseases, are at greater risk of adverse outcomes following the infection.

 

The dominant risk factors contributing to NCDs are behavioural; they relate to unhealthy diets, inadequate physical activity, and exposure to air pollutants, among other causes. The major NCDs related to diet are ischaemic heart disease (heart attack), stroke, diabetes and polycystic ovarian disease (PCOD). Unhealthy diets lacking in micronutrients promote accumulation of fat tissue around internal organs including the viscera (abdominal adiposity). Even people with apparently normal body mass index (BMI) may have higher body fat and abdominal adiposity. Paradoxically, abdominal adiposity, underweight in childhood, and anaemia are all driven by impaired access to healthy diets and lack of micronutrients in the diet.

Both undernourished individuals and overweight or obese individuals may experience micronutrient deficiencies and anaemia. All these forms of malnutrition, including anaemia, are associated with increased risk of diabetes or heart diseases and cancers, potentially negating the progress we have made in increasing average life expectancy.

 

India suffers from many forms of malnutrition – while 35.8% of our under-5 children are underweight and 58.6% anaemic, as many as 18.9% of men and 20.6% of women in India are overweight or obese.⁶ And nearly half of urban adults and a third of rural adults have abdominal adiposity (waist circumference =90 cm for men and =80cm for women) according to the National Nutrition Monitoring Bureau [NNMB] data. Overweight, abdominal adiposity, anaemia and micronutrient deficiencies are associated with inflammation, which is closely linked with metabolic syndrome and type 2 diabetes, both of which increase the risk of developing CVDs. Experts have identified healthy diet and adequate physical activity as the optimum strategy for preventing the development of type 2 diabetes and cardiovascular complications.⁷

The leading risk factors for CVDs (ranked by disability-adjusted life years or DALYs) in every region of the world are of dietary origin and this excludes hypertension, which is categorized separately and has substantial contributory diet-related mechanisms as well.

 

To address food and dietary issues when tackling NCDs, we must start at the very beginning of the lifecycle. Nutrients consumed by women during pregnancy and the diet and activities adopted right after birth go on to impact the physical, metabolic and cognitive health and growth of a newborn. In fact, steps taken at the initiation of the lifecycle continue to influence our health status throughout our lives. When nutrition is under-prioritized by pregnant women or when infants are not provided the right diets, children will be at greater risk of suffering from NCDs in adulthood. In fact, prenatal maternal undernutrition and/or low birthweight make an individual vulnerable to higher body fat, obesity, high blood pressure, heart disease and diabetes later at life. Maternal obesity is also associated with cardiovascular disease and diabetes in both mother and child.⁸

Further, industrialization, urbanization, economic development and market globalization have accelerated rapid changes in diet and lifestyle over the past decade. While standards of living have improved, food availability has expanded and access to services has increased, there have also been significant negative consequences in terms of inappropriate dietary patterns.

The drastic changes our food systems have undergone in the last 50 years have had implications for food security, nutrition and environmental sustainability. By influencing the nutritional quality of foods that are available, affordable and acceptable to consumers, global food system changes have had profound implications on NCDs. The increased availability of inexpensive, high calorie foods, often from staple cereal crops, has reduced hunger for many, but often at the expense of diet diversity, displacing local ingredients. While not everyone has equal access to diverse, micronutrient-rich foods – fresh fruits, vegetables, legumes, pulses, and nuts – foods with salt, sugars, saturated fats, and trans fats have become cheaper and more widely available today. Plus, the global demand for and supply of meat, dairy products, sugar-sweetened drinks and processed and ultra-processed foods has increased dramatically.⁹

 

Today, disease burdens attributable to hypertension, high BMI, high fasting blood glucose, high sodium intake, and low fruit, vegetable, nut and whole grain consumption have all increased significantly.¹⁰ Processed foods high in trans fats, saturated fats, sugar and salt, and sugar-sweetened beverages, are associated with increased risk of hypertension, diabetes, elevated cholesterol and CVD. Increased urbanization and use of motorized transport have contributed to sedentary lifestyles, with detrimental implications for cardiovascular health.¹¹ Additionally, the lack of access to integrated healthcare services for people who suffer from CVDs and other NCDs is a challenge.

Therefore, while addressing NCDs it is critical that we account for the rapidly evolving ecosystem around us. Our diets and lifestyle patterns are increasingly affecting our health status, with heart conditions and diabetes being detected in youth and ageing populations alike. Healthier diets and physical activity must be integrated and prioritized in our daily lives to reverse and prevent such trends. The right diets and consumption of micronutrient rich foods help build healthy immunity, optimize metabolism and resilience against illness.

 

The NCD epidemic is a global phenomenon with worldwide repercussions. NCDs not only cause illness or death, but also lead to a significant financial burden on patients and their families. Economists have expressed concern that NCDs will result in long-term macroeconomic impacts on labour supply, capital accumulation and the gross domestic product (GDP) of countries worldwide, with the consequences most severe in developing countries.¹² A World Economic Forum study also estimated that, in a ‘business as usual’ scenario, low- and middle-income countries could lose $500 billion per year over the period 2011-25 due to NCD morbidity and mortality, amounting to roughly 4% of average GDP.¹³

NCDs also affect the labour market by affecting work participation, productivity, hours worked, job turnover, retirement and career progression. Globally, the labour lost owing to NCD deaths and NCD associated medical costs have reduced the quality and quantity of the labour force and human capital. Unwell workers who remain on the job with reduced performance, employees who are forced to take sick leave, and premature deaths amongst the workforce all add up to major losses. The economic burden of NCDs is already enormous, and is set to grow rapidly. It is estimated that NCDs including mental health conditions would cost the world economy US$ 30 trillion between 2010 and 2030 if steps are not taken to prevent and treat them.¹⁴

 

Scaling-up the prevention and control of NCDs is significantly low-cost when compared to this economic burden, and would provide substantial returns to health and productivity.¹⁵ According to WHO, if low- and lower-middle-income countries put in place the most cost-effective interventions for NCDs by 2030, they will see a return of $7 per person for every $1 invested.¹⁶

Our focus and efforts to tackle obesity and NCDs have not wavered over the years. The Government of India’s response to NCDs has been robust and aligned with the Political Declaration conveyed at the High-level Meeting on Prevention and Control of NCDs at the United Nations General Assembly (UNGA) in 2011 and 2014. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) has been expanded to cover the entire country. The Population-based Screening Initiative for Hypertension, Diabetes and Three Common Cancers has been initiated for structured screening, disease management, referral and follow-up. The integration of services at the district level and beyond has been brought under the umbrella of the National Health Mission. After the World Health Assembly resolution 66.10, India became the first country to define its National NCD Monitoring Framework and committed to 10 targets and 21 indicators to be achieved by 2025.

 

Concerted efforts from experts representing the MoHFW, ICMR, All India Institute of Medical Sciences, and WHO India country office, led to the drafting of the National Multi-sectoral Action Plan for Prevention and Control of Common NCDs (2017-22). The action plan is a national blueprint, providing clear direction on India’s strategies for tackling the growing burden of NCDs within the specific socioeconomic, cultural and health systems contexts of the country.¹⁷

Recognizing the link between appropriate nutrition and NCDs, the Food Safety and Standards Authority of India (FSSAI) launched the Eat Right movement in 2018. With the overall objective of behaviour change, the initiative aims to create awareness and build the capacity of food businesses and citizens on the importance of eating right.¹⁸ The FSSAI’s Thoda Kam campaign engaged celebrities to urge people to reduce their salt, sugar and fat intake. Complementing these ideas, the Fit India movement, launched by the prime minister in 2019, encourages citizens from all age groups to engage in physical activities and provides tools like recipes and stories of transformation.¹⁹ These movements are aligned with the government’s flagship public health programmes such as Poshan Abhiyaan, Anaemia Mukt Bharat, Ayushman Bharat Yojana and Swachh Bharat Mission, and are all aimed at the common goal of addressing rising challenges like NCDs.

 

The ICMR, WHO-India and MoHFW have also initiated a nationwide scale-up of the India Hypertension Control Initiative (IHCI). From a pilot launch in 2017 in 25 districts, the programme has been expanded to 100 districts across India covering all states. The FSSAI proposed a tax and advertisement ban on unhealthy foods in 2017. Similarly, the National Tobacco Control Programme is facilitating reduction of the prevalence of smoking in India. Additionally, the availability of non-polluting cooking fuels for low-income households has increased under the nationwide Pradhan Mantri Ujjwala Yojana scheme.

The government is also establishing 150,000 Health and Wellness Centres (HWCs) across India to provide comprehensive primary health-care services that would help deal with NCDs and injuries along with communicable diseases, as part of Ayushman Bharat. As of February 2019, 10,252 HWCs were operational, with the highest number in Andhra Pradesh, Tamil Nadu, Uttar Pradesh, Karnataka and Kerala. Through these centres, more than 15 million women and men, 30 years of age and above, had been screened for common NCDs. Hypertension and diabetes were identified as some of the most common NCD challenges that India is grappling with.²⁰

 

Even as these efforts continue to be strengthened, India needs to invest in suitable evaluation systems to monitor changing trends in NCDs and their related risk factors. There is a need for a stronger evidence base that can guide research and thereby the formulation and implementation of effective policies. The National Institute of Nutrition, an ICMR institute, and other partners are setting in place mechanisms to ensure that there is more data available on malnutrition in the various states of India, which will help monitor progress. We are planning the reduction of malnutrition in a manner that is suitable for the trends and contexts of each state.

It is important that there be a steady exchange of information and constant communication between technical experts. Greater synergy among scientists working in the fields of health, agriculture and nutrition will promote better knowledge sharing and exchange of innovative interventions.

Healthcare providers must be better equipped for timely detection of NCDs, their underlying factors and linkages. They must ensure constant monitoring, which will lead to early diagnosis and treatment. It is also important to define and underline the range of roles that different providers – nurses, pharmacists, health educators, public health personnel in schools and in the community – play in addressing the linkages between NCDs and malnutrition. They must be equipped with information and trained, as should frontline workers who play a crucial role in the promotion of health literacy and management of NCDs.

 

Various stakeholders and actors will have to combine forces to build stronger community based programmes. Healthcare givers and community workers must share information on best practices with the masses in urban and rural India. More people must understand the critical linkages between breastfeeding and a healthy growth trajectory in an infant, with lower risk of later obesity. School curriculums can also incorporate information on appropriate nutrition practices so that awareness is instilled from early stages. There is a need for adequate monitoring of the community’s understanding of the challenges of NCDs and the extent to which it is implementing change and interventions. This will support the government in assessing its interventions. Focused surveys of the efforts of health personnel and communities can help communicate community needs to the government.

Mass awareness campaigns and educational materials can be designed to promote effective interventions to reduce unhealthy diets that are high in sugars, fats, and sodium (high calorie and low micronutrient diets). There needs to be greater knowledge about the benefits of plant based diets that are high in vegetables and fruits, whole grains, pulses, nuts and seeds, which help to achieve and maintain a healthy weight and blood pressure and reduce the risk of diabetes.²¹

The second component of such campaigns should communicate the need for energy expenditure through physical activity, which will maintain the energy balance equation that determines body weight and decreases the risk of abdominal adiposity. A decrease in energy expenditure due to decreased physical activity is likely to be one of the major factors contributing to the global epidemic of overweight and obesity, especially abdominal adiposity. Physical activity and nutrients share much the same metabolic pathways and they can interact in various ways that influence the risk and pathogenesis of several chronic diseases.²²

 

These measures need to be adopted across age groups to create impact. Civil society organizations can contribute by conceptualizing and disseminating such messages based on evidence. They can also help monitor and assess policies to understand their possible impacts on nutrition and NCDs. Credible voices and experts can form coalitions across organizations to strengthen the Government of India’s mission of creating a mass movement to address malnutrition. The prevention and reduction of NCDs is inextricably linked to the battle against various forms of malnutrition. This is a social and economic responsibility that must be shared and borne by different actors across the country.

 

Footnotes:

1. World Health Organization, ‘Non-Communicable Diseases: Key Facts’, 2018. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

2. World Health Organization, ‘Non-Communicable Diseases (NCD) Country Profiles’, 2018. https://www.who.int/nmh/countries/ind_en.pdf

3. Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation, India: Health of the Nation’s States – The India State Level Disease Burden Initiative, 2017. https://www.healthdata.org/sites/default/files/files/policy_report/2017/India_Health_of_the_Nation%27s_States_Report_2017.pdf

4. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30387-5/fulltext

5. B. Bhargava and V.K. Paul, ‘Informing NCD Control Efforts in India on the Eve of Ayushman Bharat’, The Lancet, 2018. https://doi.org/10.1016/S0140-6736(18)32172-X

6. International Institute of Population Sciences, National Family Health Survey (NFHS-4, 2015-16), 2015-16. http://rchiips.org/nfhs/pdf/NFHS4/India.pdf

7. B. Bostock-Cox, ‘Understanding the Link between Obesity and Diabetes’, Nursing Standard 31(44), 2017. https://journals.rcni.com/nursing-standard/understanding-the-link-between-obesity-and-diabetes-ns.2017.e10106

8. UNICEF, ‘Responding to the Challenge of Non-Communicable Diseases’, United Nations Children’s Fund, 2019. https://www. unicef.org/media/61436/file

9. B. Francesco et al., ‘Transforming the Food System to Fight Non-Communicable Diseases’, BMJ 364(l296), 2019. https://www.bmj.com/content/364/bmj.l296

10. H. Greenberg and R.J. Deckelbaum, ‘Diet and Non-Communicable Diseases: An Urgent Need for New Paradigms’, in M. Eggersdorfer et al. (eds.), Good Nutrition: Perspectives for the 21st Century. Karger, Basel, 2016. https://www.karger.com/Article/Pdf/452379

11. H. Greenberg and R.J. Deckelbaum, 2016, op. cit.

12. D.E. Bloom et al., The Global Economic Burden of Non-Communicable Diseases. World Economic Forum, Geneva, 2011. http://www3.weforum.org/docs/WEF_ Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf

13. World Health Organization, ‘Non-Communicable Diseases: The Slow Motion Disaster’, in Ten Years in Public Health 2007-17, 2017. https://www.who.int/publications/10-year-review/ncd/en/index2.html

14. A. Kastor and S.K. Mohanty, ‘Disease-Specific Out-of-Pocket and Catastrophic Health Expenditure on Hospitalisation in India: Do Indian Households Face Distress Health Financing?’ PloS One 13(5), 2018, e0196106. https://doi.org/10.1371/journal. pone.0196106

15. World Health Organization and United Nations Development Programme, ‘What Ministries of Labour and Employment Need to Know: Non-Communicable Diseases’, 2016. https://www.undp.org/content/dam/undp/library/HIV-AIDS/NCDs/Labour.pdf

16. World Health Organization, ‘Saving Lives, Spending Less: A Strategic Response to Non-Communicable Diseases’, 2018. https://apps.who.int/iris/bitstream/handle/10665/272534/WHO-NMH-NVI-18.8-eng.pdf?ua=1

17. https://main.mohfw.gov.in/sites/default/files/National%20Multisectoral%20Action%20Plan%20%28NMAP%29%20for%20Prevention%20and%20Control% 20of%20Common%20NCDs%20%282017-22%29_1.pdf

18. Food Safety and Standards Authority of India, ‘Eat Right India’. https://fssai.gov.in/cms/eat-right-india.php

19. Ministry of Youth Affairs and Sports, Government of India, Fit India’. http://fitindia.gov.in/

20. Press Information Bureau, ‘More than 10,000 Ayushman Bharat Health and Well-ness Centres Become Operational’, 2019. https://pib.gov.in/newsite/PrintRelease. aspx?relid=188876

21. World Cancer Research Fund International, ‘The Link Between Food, Nutrition, Diet and Non-Communicable Diseases’, 2014. https://www.wcrf.org/sites/default/files/PPA_NCD_Alliance_Nutrition.pdf

22. World Health Organization, ‘Diet, Nutrition and the Prevention of Chronic Diseases: Report of the Joint WHO/FAO Expert Consultation’, WHO Technical Report Series No 916. https://www.who.int/dietphysicalacti-vity/publications/trs916/intro/en/