Ann. N.Y. Acad. Sci. ISSN 0077-8923
A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S Issue: Paths of Convergence for Agriculture, Health, and Wealth
Whole-of-society monitoring framework for sugar, salt, and fat consumption and noncommunicable diseases in India Narendra K. Arora,1 Rakesh Pillai,1 Rajib Dasgupta,2 and Priyanka Rani Garg1 1 Clinical Epidemiology, The INCLEN Trust International, New Delhi, India. 2 Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi, India
Address for correspondence: N.K. Arora, INCLEN Institute of Global Health (IIGH), The INCLEN Trust International, F-1/5, Phase 1, Okhla, New Delhi 110020, India. [email protected]
India has experienced a rising prevalence of cardiometabolic risk factors in the past 15 years: the prevalence of diabetes has increased from 5.9% to 9.1%, hypertension from 17.2% to 29.2%, and obesity from 4% to 15%. The increase is among all socioeconomic groups and in urban and rural populations, though the quantum of change varies. A concomitant increase in per capita consumption of sugar from 22 to 55.3 g/day and total fat from 21.2 to 54 g/day was observed, with significant differences between states of high and low human development index (HDI). Per capita consumption of sugar, salt, and fat is consistently and significantly associated with overweight and obesity but variably associated with the occurrence of hypertension and diabetes. Market research shows that approximately 50–60% of total salt, sugar, and fat in Indian markets is procured by bulk purchasers, generally for manufacturing processed food items. This sector of the Indian economy is among the fastest growing, with several policy incentives. It is not clear from most of the data sets whether available information on per capita sugar, salt, and fat consumption has considered the contribution of processed and ready-to-eat food items. The unprecedented changes of rapid urbanization, mechanization, and globalization demand close monitoring of social, developmental, and economic determinants. This paper provides pieces of evidence to justify a whole-of-society (WoS) framework for monitoring the inputs, processes, and behavioral components of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) in India. Keywords: whole-of-society; monitoring framework; sentinel surveillance; multisectoral policies; noncommunicable disease
Introduction Noncommunicable diseases (NCDs) account for more than 62% of the age-standardized burden of disability-adjusted life years (DALYs) in India.1 According to a working group report submitted to the Planning Commission of India for the 12th FiveYear Plan (2012–2017), cardiovascular disease is the top cause of mortality (52%) among all NCDs in both urban (poor and nonpoor) and rural India.2 The World Diabetes Federation identified the prevalence of diabetes in India at about 8% with many additional patients undiagnosed. Regional prevalence was estimated between 5% and 15% of persons aged more than 18 years. In particular, diabetes is increasing rapidly among marginalized and poor
communities in both urban and rural areas.3 Almost 25% of the urban and 10% of the rural adult Indian population is reported to have hypertension. There are wide interstate variations in the prevalence of cardiometabolic risk factors like hypertension, diabetes, and obesity. The highest prevalence of hypertension (18%) but the lowest prevalence of diabetes (2.5%) were reported in Maharashtra, while Punjab recorded the lowest hypertension (0.8%). The hilly states of Sikkim, Himachal Pradesh, Jammu and Kashmir, and Uttarakhand, where people are usually believed to be more physically active, recorded high rates of both diabetes and hypertension.4 In addition, 31.3% of people with diabetes were also hypertensive. Projections from crude incidence rates of total cancers in the country highlight that cancer
doi: 10.1111/nyas.12555 C 2014 New York Academy of Sciences. Ann. N.Y. Acad. Sci. 1331 (2014) 157–173
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cases occur differentially across different geographic regions of the country, and the total burden could go up from 97 million in 2010 to 114 million in 2020.5 There has been fairly rapid industrialization, urbanization, and improved health service–system capacities in both public and private sectors, particularly since the early 1990s. India’s gross domestic product (GDP) growth is among the top five in the global list, the per capita purchasing– power parity (PPP) is somewhere in the middle, and the Gini index is among the lowest.6 Paradoxically, multidimensional poverty indices (MPI) are fairly high, with India ranked 74 among 104 countries.7 The decomposition of the indices for the Indian states and social groups tell a tale of wide variations and inequalities, signifying both transition and vulnerability. Urbanization, mechanization, and globalization have led to unprecedented changes in lifestyle, including physical activity and food habits. Closely intertwined are issues of epidemiologic and nutrition transition and changes in traditional dietary patterns.8,9 The concept of epidemiologic acceleration has been used to signify epidemiologic transition happening in developing countries and transition economies in the absence of improvements in social and economic well-being experienced in advanced economies. Epidemiologic polarization refers to the growing increase in the health inequalities between countries, regions, and social groups; it is the most vulnerable populations that experience excess morbidity and mortality from a variety of causes.10 In Mexico, the situation points to an increase in the proportion of people living in nutrition poverty (pobreza alimentaria), which is distinct in the Mexican classification from poverty of basic needs (pobreza de capacidades) and net poverty (pobreza de patrimonio). Epidemiologic polarization is thus marked by the poorest experiencing the highest death rates owing to both pretransitional diseases, including infections and nutritional disorders, and rising NCDs.11 The phenomenon was demonstrated in the context of Kerala about a decade ago.12 It has also been pointed out that the protracted polarization model is accelerated with rapid urbanization.13 Adverse social determinants, along with diminished physical activity and inappropriate nutrition, are reflected in the increasing prevalence of chronic 158
diseases. In the most proximate sense, increased consumption of energy-dense foods in general and of sugar, salt, and fat in particular are catalyzing the onset of NCDs as well as portending poorer prognosis. Rural–urban migration is the foremost coping strategy to fight chronic poverty, but the new urban environment also makes them individuals vulnerable to impaired glucose tolerance.14,15 Barriers to maintaining customary eating habits in the poor, specifically in migrants, are high food prices, particularly those of protective foods such as fruits and vegetables.16 Packaged foods, produced by both leading and local brands, have infiltrated all segments of the population with innovative (and successful) marketing tactics.17 Women engaged in paid and unpaid work in order to support the household economy can devote less time to cooking and child care, thereby leading to increased consumption of packaged foods by children.18,19 Thus, the country currently suffers multiple burdens of chronic diseases related to epidemiological and nutrition transitioning linked to both individual behaviors and social environments.20 Nutrition transition and NCDs, including cancers, are all tied to a cumulative and accelerated malalignment between human biology and the conditions of modern industrial society. Health-system and public-policy researches need to straddle themes of social determinants, epidemiology, and public policy. Effective publicpolicy formulation and design measures to contain NCDs need real-time information to choose among goals, alternatives, and multisectoral choices obtained through integrating data sets that measure inputs, processes, and outputs.21 Currently, in India, much of the public-health data for NCDs are collected and analyzed from a unidisciplinary clinical and cross-sectional perspective. However, for an effective monitoring and surveillance strategy, convergence initiatives are required for assembling data sets from business, civil society, and academia, in addition to administrative information. The wholeof-society–whole-of-government (WoS–WoG) approach, recommended and proposed by the World Health Organization (WHO) during the pandemic influenza preparedness in 2011, is aptly suited for NCDs as well.22 In the absence of such intersectoral approaches, attaining sustained economic growth and healthy societies will remain a distinct dream.
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Methodology We seek to examine policies, programs, and market dynamics related to sugar, salt, and fat consumption (referred to as sectors as we have adopted a sectoral approach to construct the analyses) in the contemporary Indian context. Policy documents, office memoranda, and short communications, available in the public domain from government departments, were analyzed to identify existing rules and regulations pertaining to sugar, salt, and fat products in India. Key players in the sugar, salt, and fat markets were identified from policy documents, expert committee reports appointed by agencies, and business data from different associations. Market research reports, like KPMG (www.kpmg.com), available for free on the Internet, were also analyzed to identify key players. National and state-level per capita consumption of sugar, salt, and fat products were obtained from National Sample Survey (NSS) reports (66th round conducted in 2009–2010 on household consumption (self-reported) of various goods and services in India, report 541 published in 2012).23 The NSS is a nationwide household survey conducted every year through scientifically designed representative samples to inform policies. Prevalence of major NCDs like diabetes, overweight and obesity, and hypertension during 2009–2010 was collated from population studies published on Pubmed and from a National Nutrition Monitoring Bureau (NNMB) report (2011) published by the National Institute of Nutrition, Hyderabad.24 The NNMB carries out diet and nutrition surveys on a regular basis in rural areas of 10 selected states: Kerala, Tamilnadu, Karnataka, Andhra Pradesh, Maharashtra, Gujarat, Madhya Pradesh, Orissa, West Bengal, and Uttar Pradesh. The dose–response relationships among sugar, salt, and fat per capita consumption and the prevalence of diabetes, overweight and obesity, and hypertension were obtained from the NNMB report. State-wise per capita consumption of sugar, salt, and fat from the 2009–2010 NSS report was compared with corresponding state prevalence rates of diabetes, overweight and obesity, and hypertension available during the same period. States were grouped into high, medium, and low human development indexes (HDIs) to relate rising per capita consumption and NCDs with socioeconomic developments. HDIs, first suggested by the
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United Nations (UN) in 2001 and later amended as inequality-adjusted human development indexes (IHDIs) in 2010, are composite statistics of life expectancy, education, and income measurements for monitoring states for their status of quality of life and human well-being.25 Thus, HDIs provide surrogate estimates of health, nutrition, and epidemiological transitioning in a society. States with HDI above 0.8 (Kerala and Delhi) are defined as developed, while those with HDI between 0.5 and 0.79 are defined as medium-development states. Those states with HDI below 0.5 are considered as minimally developing states.26,27 It is with this perspective that HDIs were used to classify Indian states to compare the changing prevalence of major NCDs. Per capita consumption of salt, sugar, and fat, from the 66th round NSS, were compared in each of the high, medium, and low HDI states. Per capita consumption of salt, sugar, and fat in different social classes and economic groups were compared separately. The results are presented following four themes:28 (1) policies related to sugar, salt, and fat markets in India; (2) key players in sugar, salt, and fat markets; (3) trends in the consumption of sugar, salt, and fats and the changing prevalence of NCDs; and (4) the Indian government’s action plan for NCD surveillance. Results Policies related to sugar, salt, and fat Sugar sector. In India, sugar (and sugarcane) is an essential commodity under the Essential Commodities Act (1955), monitored and controlled by the Department of Food and Public Distribution, under the Ministry of Consumer Affairs. Dual strategies and partial-control mechanisms are adopted by the union (central or federal) government for controlling market prices, fixing statutory minimum price (SMP) in relation with sugar seasons, and to set up fair and remunerative prices (FRP) for sugarcane farmers.29 States also intervene in sugarcane pricing through state-advised prices (SAP) to strengthen their farmers’ interests, leading to perpetual differences in sugar and sugarcane prices between states. Neither the states nor the center adequately reward farmers on the quality of cane supplied, especially with reference to high sugar content and yields.30 Policies related to sugar in India could be grouped under four domains: (1) price support for sugarcane
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administered by central and state governments; (2) the release of levy and free-sale sugar and buffer stocks by the central government; (3) the regulation of the sugar trade by the central government; and (4) market restrictions and storage limitation by the central government. There are 682 functional sugar factories in the country, about half of which are in the cooperative sector. Licensing requirements for new sugar mills were abolished in 1998, helping the industry to grow at an annual rate of around 7%, compared to 3.3% before 1998, and encouraged more private players in the Indian sugar sector, traditionally dominated by cooperatives. The government has imposed a compulsory levy of 10% of produced sugar per factory at a fixed price for every season, which is supplied to all below poverty line (BPL) families through the public distribution system (PDS). Nonlevy sugar is allowed to be sold independently in the market for quantities to be released by the government, as per sugar release order, in every quarter. The statutory minimum price for sugar has increased nearly threefold in the past 10 years; despite which retail sugar prices in India are cheaper compared to other countries. Around 65% of the annual production is consumed by bulk purchasers (e.g., beverage, biscuit, and confectionary manufacturers).31 Furthermore, the government has also approved sugar trade through four national exchanges for global marketing. The Economic Advisory Council to the Prime Minister recommended further deregulation of the sugar sector in 2012.31 Currently, the stockholding limits on wholesale dealers of sugar have been withdrawn. In May 2013, the central government decided to decontrol the sector and encourage state governments to buy levy sugar at market price and to supply it to BPL families at subsidized rates, facilitating more benefits to industrialists. States like Uttar Pradesh, Bihar, Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, and Gujarat, which produce 85% of the total sugar in India, have formulated state-specific schemes and governance structures to provide a conducive environment for millers and farmers. In India, export of sugar, through an Ordinance in 1997, is carried out through the Agricultural and Processed Food Products Export Development Authority (APEDA) under the Ministry of Commerce. The federal government uses sugar import and export as a mechanism to control domestic 160
economy and inflation rates. In its recent order in June 2014, the Government of India raised import duty from 15% to 40%, resulting in an increase of retail price by 1–2 rupees per kg of domestic sugar, ostensibly to help Indian millers to find extra money to pay sugarcane farmers. This is in addition to the government subsidies on raw sugar exports to boost trade outputs. Salt sector. Schedule 7, Item 58 of the Constitution of India regulates manufacturing, supply, and distribution of salt through the Salt Commissioner’s organization under the Ministry of Commerce and Industries, within the Department of Industrial Policy and Promotions.33 The Salt Commissioner’s annual report 2012– 2013 highlights that about 6.2 million metric tons of the overall production of 24.5 million metric tons was iodized salt, of which 95% (5.9 million metric tons) was supplied for household consumption; the rest was exported.34 Out of 6.2 million tons of edible salt, over 60% is procured by bulk purchasers (e.g., sauces, savory, and snacks); much of this is used in the food-processing industry and is made available for human consumption through processed foods. Branded iodized salt accounts for 49.7% of the total salt market and is growing at 4% annually. The government has pursued liberalization in this industry since 1996 to encourage private sector participation for achieving a universal salt-iodization goal. In 2006, the program was amended and the sale of noniodized salt for human use was banned under the Prevention of Food Adulteration (PFA) Act. Currently, there are 807 salt iodization units and 42 refineries in India. Fat sector. Dietary fats are grouped into four categories: (1) monounsaturated fats, present in olives, canola, peanuts, nuts, and seeds; (2) polyunsaturated fats, present in sesame, sunflower, corn, canola, and soybean oils and fish; (3) saturated fats, available in processed foods, hydrogenated oils, fatty meats, dairy products, butter, coconut and palm oils, palm kernels, and cocoa butter; and (4) trans-fats, available in processed foods with hydrogenated vegetable oils, snack foods, fast foods, and ready-made foods. Fat and fatty acid content of foods in India are regulated under the Food Safety and Standards (FSS) Act (2006, later amended in 2011). Various acts like the PFA Act (1954), the Fruit Products Order
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(FPO) (1955), the Meat Products Order (1973), the Vegetable Oil Products Control Order (1947), the Edible Oil Packaging Regulation Order (1988), and the Milk and Milk Products Order (1992) were converged and called the FSS in order to move from a regime of multilevel, multidepartment control to a single line of control for all food items. The Food Safety Standards Authority of India (FSSAI) is the regulatory agency tasked to consolidate various acts and orders related to foods under various ministries and departments.35,36 The Ministry of Health and Family Welfare (MoHFW) is the administrative authority for implementing the FSSAI through its Drugs and Food Quality Control section. Standards under this act can be classified broadly under (1) mandatory product standards, (2) mandatory process standards, (3) licensing and prohibitions, and (4) voluntary product and process standards. The food safety and standards chart specifies the key sources of fat in Indian foods. All edible oils and fat products are mandatorily restricted under Section 4.1.9 of this act from using expressions like “super refined, extra refined, microrefined, double refined, ultra refined, anticholesterol, cholesterol fighter, soothing to heart, cholesterol friendly, saturated fat free” or such expressions that are exaggerations of the quality of the product. Labeling of the contents, including the type of fatty acids, cholesterol, saturated fatty acids, monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), and trans-fats, were made mandatory in 2009 through an ordinance. The act also recommends adding antioxidants in prescribed quantities to all edible oils and fats except for ghee and butter. Antifoaming agents in edible oils and fats for deep fat frying were restricted to a maximum of 10 parts per million (ppm), while reuse of tins and plastic containers for edible oils and fats are controlled. Vegetable oils, particularly edible oils, are regulated under the Directorate of Vanaspati, Vegetable Oils and Fats (DVVOF), an attached office of the Department of Food and Public Distribution, the nodal office solely responsible for coordinated management of vegetable oil markets, adjustments of import duties, and public price controls. This department performs regulatory, developmental, and advisory functions in all matters relating to vegetable oils and vanaspati (hydrogenated oil). It has controlled the export of most of edible oils since
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2008.37 After implementation of the FSSAI in 2011, the DVVOF has been partially governed by the FSSAI, especially on licensing, safety, and standards parameters. In addition to the above-mentioned acts, all edible oils are considered as essential commodities under the Essential Commodities Act (1955). Indians consume 17–18 million metric tons of vegetable oils per year; over 60% is supplied through imports. Around 80% of total edible oils imported in India are palm oil. Palm oils are high in saturated fat. Import of edible oils has more than doubled in the past 15 years (Fig. 1).38 The government has abolished all import duties of crude edible oils, while duties on refined oils have been lowered to 7.5%. In addition, since 2008, to augment the availability of edible oils for poor people, the government has implemented a scheme for the distribution of subsidized imported edible oils to ration card holders. Exports of refined edible oils, except for castor oil, coconut oil, and few minor oils of forest origins have been completely banned since 2008. Export of branded edible oils, up to 5-kg packs, is permitted through the Minimum Export Price. The government collects 4% value-added tax (VAT) on market prices for all edible oils. Quality assurance in oils and fat products. In addition to the FSSAI, the Bureau of Indian Standards (BIS) under the Directorate of Marketing and Inspection in the Ministry of Agriculture has also set specifications for edible oils, oil seeds, and vanaspati products, including physical and chemical testing standards. Under the Ministry of Agriculture, governed by the Agriculture Produce (Grading and Marking) Act (1937), the General Grading and Marking Rules (1988), and the Blended Edible Vegetable Oil Grading and Marking Rules (1991), AGMARK certification is mandatory for all blended edible oil and fat products and spreads marketed in India.39 This is in addition to the FSSAI regulations for mandatory labeling of contents of all packaged and processed foods sold in the Indian market. Information on contents including sugar, fats, dietary fibers, and total energy (in calories) is mandated under this law. Labeling of total trans-fats and saturated fat in percentage by weight is also required by the FSSAI through its 2013 notification.40 The FSSAI has proposed a regulation, currently pending within the government, to control trans-fatty acids
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Quanty (in 100,000 tons) 120 100 80 60 40 20 0
Figure 1. Trends in edible oil imports in India. From Ref. 38.
in partially hydrogenated vegetable oils (PHVOs) at a maximum of 10% and reduce that to 5% in the next 3 years, along with mandatory labeling of the amount of trans-fats in all oils.41 Key players in sugar, salt, and fat markets Sugar sector. The sugar industry in India is controlled largely by the union government, which has steadily introduced liberalization in the sector. Policies related to sugar, including sugarcane support price policies and sugar storage and trade policies, are coordinated through two desk officers in the Department of Food and Public Distribution. In addition, officials from the Food Corporation of India, the Directorate of Sugar, the Union Finance Ministry, and representatives of sugar mill associations play key roles. States holding major stakes, including Uttar Pradesh, Bihar, Maharashtra, Karnataka, Tamil Nadu, and Gujarat, have formed sugar departments in their respective states for implementation and monitoring of various regulations related to sugarcane and sugar. During the past 10–15 years, more than 10 key market players have emerged in India who now influence the dynamics of sugar availability and its pricing.42 Salt sector. Policies in the salt sector are coordinated by the Salt Commissioner’s Office headquartered in Jaipur, Rajasthan, with four regional offices across India.34 The central advisory board and regional advisory boards advise governments on collection of salt cess and other reforms. Salt policies in India are formulated through interdepartmental and multisectoral collaborations. 162
Central and regional advisory boards collect information on salt cess and welfare schemes from private producers and consider their inputs in designing annual policies. The Departments of Health, through the National Iodine Deficiency Disorders Control Programme (NIDDCP), hold a major stake in regulating edible salt availability and quality. The Ministry of Information and Broadcasting conducts information, education, and communication (IEC) campaigns for this program, while human resources are mobilized by the Ministry of Women and Child Development. The Ministry of Food and Civil Supplies, as well as the Indian Railways, facilitates salt movement for the PDS. Insurance regulatory and development authority through insurance agencies provide salt employee welfare schemes like Namak Mazdur Swasth Bima Yojana (NMSBY). Agencies such as the NNMB (within the Indian Council of Medical Research (ICMR)) and the NSSO collect and monitor per capita salt consumption in India through state-level population data. Fat sector. The FSSAI is an arm of the MoHFW and plays a key role in making policies for regulating food products at large and fats and oils in particular. The Ministry of Food Processing Industry (MOFPI) designs policies for promoting food processing units and trade by permitting foreign direct investments (FDI) and many other subsidies in this sector. The BIS, under the Ministry of Agriculture, is responsible for implementing these standards. The FSSAI, the MoHFW, the Public Health Foundation of India (PHFI) (a public–private partnership, structured as an independent foundation),
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the Centre for Chronic Disease Control (CCDC) and the Vanaspati Producers Association are some of the key stakeholders promoting advocacy for reducing trans-fat use in India.43 Officials from the Ministry of Agriculture; the Department of Commerce; Consumer Affairs; the Ministry of Micro, Small and Medium Enterprises (MSME); and representatives of food industries, consumer organizations, and states are also members of the food safety policy team. Scientists from the National Diary Research Institute, the Department of Protein Chemistry, and the Technology and Director General of the ICMR also hold stakes in food policies in India. The Indian edible oil market is controlled by unorganized players, as most vegetable oil purchased by industrial buyers, restaurants, and hotels for frying and baking is sold as loose oil or vanaspati. Currently, there are over 250 vanaspati plants in India. However, changing lifestyles, fragmented market segments, consumer preferences, and intense competition from the brands of multinationals have made branding strategies a prerequisite.44 Tracking NCDs and salt, sugar, and fat markets in India Rising NCDs in India. In India, around 80% of NCD deaths are attributed to four diseases: cardiovascular disease, cancer, respiratory disease, and diabetes.45 Traditional cardiometabolic risk factors like hypertension, overweight and obesity, type 2 diabetes, dyslipidemias, and metabolic syndrome
have reached pandemic proportions; in all age groups and in all geographical regions the relative risk varies with habits, socioeconomic position, and built and spatial environments.46 Trend analysis between 2000 and 2014 confirms the rising national prevalence of type 2 diabetes among adult Indians from 5.9% to 9.1%.3 Hypertension prevalence has increased from 17.2% to 29.2% during the same period, with significant urban–rural differences.47 Prevalence of overweight and obesity has also increased almost fourfold in the past 14 years, from 4% to 15% (Fig. 2).48 India has the second largest population with diabetes in the world, an estimated 60 million in 2013, with many more as yet undiagnosed. International Diabetes Federation (IDF) projections forecast that the toll may cross 75 million by 2025.49 Further, Diabetes India (a national association) reports that diabetes is the second most common cause of adult blindness (after cataracts).50 The NNMB Report (2012) highlights that pooled prevalence of diabetes is 7.8% among men and 6.3% among women; the situation is similar for hypertension. Hypertension is present in 25% of the urban and 10% of the rural population.51 Some studies have reported prevalence as high as 27% in women and 31% in men, with an almost equal proportion of people being prehypertensive.52 This was confirmed in many other Indian studies.53 A Screening India’s Twin Epidemic (SITE) study in 2012 monitoring 15,000 hospital-based patients in different states reported
Trends in per capita, per day consumpon of salt, sugar, and fat products
Trends in the prevalence of NCDs 25
Hypertension3 60 Sugar23 50
15 Obesity48 10 Diabetes93 5
Percapita Consumpon in grams/day
Prevalence in 100,000 Populaon
20
Total Fat23
40 30 20 Salt57
10 0 Around Year 2000
Between Year 2008 & 2010
Aer Year 2013
0 Around year 2000
Between Year 2008 & 2010
Aer year 2013
Figure 2. Nationwide trend in rising NCD prevalence and per capita consumption of salt, sugar, and fats. References are provided as superscript numbers on the various labels.
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a hypertension prevalence of over 50%.54 Crude prevalence of overweight and obesity in men and women in India is 19.8% and 22.7%, respectively. NNMB reports confirm high rates of overweight and obesity in urban and rural areas, higher in women than men in all states and in all social classes except for scheduled tribes (STs). This observation in STs may be due to persistent undernutrition and higher levels of physical activity in adult women owing to cultural division of labor. There appears to be a clear link between the state of development in the region and the prevalence of cardiometabolic risk factors like hypertension, diabetes, and overweight and obesity. The average regional prevalence of diabetes in high and medium HDI states was 12%, while that of low HDI states was 9% (Table 1).55–57 In addition, diabetes is also prevalent in marginalized communities: in scheduled castes (SCs), 6% of men and 5% of women; in STs, 6.6% of men and 5.5% of women; and among the collection of socially and educationally disadvantaged castes designated “other backward class (OBC)” by the Indian government, 8.9% of men and 7.4% of women. Hypertension in high and medium HDI states was 26.5%, compared to 17.9% in low HDI states. A recent study on rural tribal population in south India showed a 10-fold increase (2.8–22%) between 2000 and 2014.58 The prevalence of overweight and obesity in high and medium HDI states is 22.7% while that in low HDI states is 20.8%. Overweight and obesity have affected the socially backward communities as well and vary between 15% and 26% in different parts of the country.59 Rising sugar, salt, and fat consumption in India. In India, per capita consumption of sugar increased from 22 g/day in 2000 to 55.3 g/day in 2010 (Fig. 2),24 while per capita consumption of table salt ranges between 9 and 12 g/day.66 Per capita consumption of total fat was 21.2 g/day in 2000 and increased to 54 g/day in 2010. PHVOs, including palm oils, increased from 1.67 g/day to 2.8 g/day.25 Palm oil is abundantly available in the market, largely imported from Malaysia. Until 2005–2006, palm oil attracted an import duty of over 60%; thereafter the import duty has been reduced to almost zero, for more than one reason.61 Palm oils are high in saturated fat and low in polyunsaturated fat, thus contributing to heart diseases. The WHO advises reduced consumption of palm oil.60 Basu et al. used 164
an economic epidemiologic model to demonstrate that a 20% tax on palm oil purchases would be expected to avert approximately 363,000 deaths from myocardial infarctions and strokes over 2014–2023 in India (a 1.3% reduction in cardiovascular deaths) if people do not substitute other oils for reduced palm oil consumption.61 At the national level, per capita consumption of sugar is now approximately 10 spoons, adding up to 18 kg/year (ICAR, 2011).62 The current global average is about 23 kg per capita per year; ranging from a low of 8 kg/year in Bangladesh to 66 kg/year in Israel. Cumulative domestic purchase of white sugar in India has also increased. India produces 17% of total global sugar, but its share in export is only 4%, signifying high demand in the domestic market.63 Around 26 million metric tons of sugar were released for domestic consumption in 2012–2013, compared to 16.7 million metric tons in 2001–2002. Increased use of sugar could be related to the relatively lower market prices of sugar in India. Sugar is currently sold at a retail price of about 35 rupees/kg (approximately half a U.S. dollar), among the lowest in the world.64 Twenty-six million metric tons of sugar was consumed in India in 2012–2013, as per the Sugar Release Order, Food and Public Distribution. Market research companies (KPMG) reported that up to 55% was procured by bulk purchasers and consumed in confectioneries. Therefore, 11.7 million metric tons were available for household consumption. This works out to 9.37 kg/year (25.7 g/day). Further, 10% of total sugar produced was considered as levy sugar for the PDS. The NSS 2010 round reported per capita consumption of 55.3 g/day; this is based on self-reported data through householdlevel questionnaires. These discrepancies in consumption patterns underscore the need for standardization of assessing intake across surveys and taking into consideration different sources in an objective and explicit manner. Population studies by the ICMR in 1988 in 13 Indian states reported salt consumption at 13.8 g/day;66 recent estimates by an ICMR-INDIAB study report 7.6 ± 3.3 g/day consumption in urban areas, significantly higher than in rural areas (6.8 ± 3.5 g/day).65 Salt consumption reported in the 66th Round of the NSS in 2010 was 8.9 g/person/day,24 which is above the National Institute of Nutrition (NIN) recommended dietary intake (RDI) of
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Table 1. State-wise per capita consumption of sugar, salt, and oils during 2009–2010
Status of HDI High HDI states
State Kerala Delhi
Medium Himachal Pradesh HDI states Goa Punjab Maharashtra Tamil Nadu Haryana Jammu & Kashmir Gujarat Karnataka Low HDI states
West Bengal Uttarakhand Andhra Pradesh Assam Rajasthan Uttar Pradesh Jharkhand Madhya Pradesh Orissa Arunachal Pradesh Bihar Chhattisgarh Manipur Meghalaya
Diabetes (urban)
Hypertension (urban)
14.855 10.356
40.7524 30
Obesity/ overweighta (urban) 2924
22.5 10.323 13.1 10.957 13.757 13.346 3.8 13.8 16.0 11.5 5.7 16.6 8.256 8.6
20.724 33.0524
25.424 20.724
17.924 20.9524
18.924 19.524
16.3824 33.2 24.324 13.0
29.4524
13.724
15.924
10.924 14.324
15.324 26.0524
17.524
57
13.5 4.924 3.224
Sugar (g/day)23
Salt (g/day)23
Edible oil (g/day)23
27.6 23.33
8.9 6.97
17.47 23.00
39.03 32.53 56.97 33.37 19.83 48.23 22.40 32.83 23.87
7.33 9.13 6.30 7.23 10.2 6.87 10.17 6.83 9.13
29.57 24.73 27.37 30.97 20.33 18.97 27.60 33.07 21.37
14.17 33.10 16.07 15.97 38.37 23.6 13.17 26.77 13.47 16.77 10.77 18.10 7.43 16.80
10.8 6.40 10.73 10.03 8.67 6.93 9.03 7.67 11.77 11.17 8.93 10.67 8.87 8.10
19.73 23.57 23.8 15.63 24.07 19.57 17.20 19.6 15.07 14.47 16.63 18.50 9.63 12.73
Note: To compare the per capita consumption of salt, sugar, and fats with the prevalence of diabetes, hypertension, and overweight/obesity in 2009–2010, population-based surveys conducted during this reference period were considered. However, a few multicentric population studies for surveillance published in Pubmed during this reference period were also included. a BMI ࣙ 23 was considered as overweight/obesity (Asian classification).
5 g/person/day.66 The Chennai Urban Rural Epidemiology Study (CURES) also reported mean dietary salt intake as 8.5 g/day; while higher salt intake was associated with older age and higher income.67 The salt manufacturing industry puts the current daily consumption at about 7 g/day on the basis of sales data. However, these estimations are on dietary recalls on household utilization of table salt and do not count added salt in processed foods. Consumption of value-added food that are always high in salt—like pickles, bread products, savory snacks, ketchup, mayonnaise, other
sauces, and breakfast cereals—need to be included in per capita salt estimations. This has to be interpreted in conjunction with the rising annual production of edible salt, from 2.8 million metric tons in 1992–1993 to 6.2 million metric tons in 2013.35 As previously indicated, per capita consumption of total fat is 54 g/day, while consumption of edible vegetable oils was 27.6 g/person/day. This information is based on self-reported data through household-level questionnaires (NSS Report, 2009– 2010). The DVVOF reports 19.8 million metric tons
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Table 2. Dose response of hypertension, overweight/obesity, and diabetes in different risk groups Overweight/obesity (BMI > 23)
Hypertension
Diabetes
Men (%)
Women (%)
Men (%)
Women (%)
Men (%)
Women (%)
Sugar and jaggery
14 g/day
20 7.36,a 22.4 P < 0.05 22.2
20.6 5.32, NS 20.5 22.3
17 41.10, 22.5 P < 0.001 22.1
20.1 80.46, 27.8 P < 0.001 26.6
8.7 8.41, 8.1 P < 0.05 6.5
6.7 6.6 6.5
0.13, NS
Salt
0.5; 18 g/day for both sugar and fats), indicating the association of consumption with environment and economy (Table 1). In contrast, average salt consumption was higher (9.6 g/day) in states with lower HDI (
A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S Issue: Paths of Convergence for Agriculture, Health, and Wealth
Whole-of-society monitoring framework for sugar, salt, and fat consumption and noncommunicable diseases in India Narendra K. Arora,1 Rakesh Pillai,1 Rajib Dasgupta,2 and Priyanka Rani Garg1 1 Clinical Epidemiology, The INCLEN Trust International, New Delhi, India. 2 Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi, India
Address for correspondence: N.K. Arora, INCLEN Institute of Global Health (IIGH), The INCLEN Trust International, F-1/5, Phase 1, Okhla, New Delhi 110020, India. [email protected]
India has experienced a rising prevalence of cardiometabolic risk factors in the past 15 years: the prevalence of diabetes has increased from 5.9% to 9.1%, hypertension from 17.2% to 29.2%, and obesity from 4% to 15%. The increase is among all socioeconomic groups and in urban and rural populations, though the quantum of change varies. A concomitant increase in per capita consumption of sugar from 22 to 55.3 g/day and total fat from 21.2 to 54 g/day was observed, with significant differences between states of high and low human development index (HDI). Per capita consumption of sugar, salt, and fat is consistently and significantly associated with overweight and obesity but variably associated with the occurrence of hypertension and diabetes. Market research shows that approximately 50–60% of total salt, sugar, and fat in Indian markets is procured by bulk purchasers, generally for manufacturing processed food items. This sector of the Indian economy is among the fastest growing, with several policy incentives. It is not clear from most of the data sets whether available information on per capita sugar, salt, and fat consumption has considered the contribution of processed and ready-to-eat food items. The unprecedented changes of rapid urbanization, mechanization, and globalization demand close monitoring of social, developmental, and economic determinants. This paper provides pieces of evidence to justify a whole-of-society (WoS) framework for monitoring the inputs, processes, and behavioral components of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) in India. Keywords: whole-of-society; monitoring framework; sentinel surveillance; multisectoral policies; noncommunicable disease
Introduction Noncommunicable diseases (NCDs) account for more than 62% of the age-standardized burden of disability-adjusted life years (DALYs) in India.1 According to a working group report submitted to the Planning Commission of India for the 12th FiveYear Plan (2012–2017), cardiovascular disease is the top cause of mortality (52%) among all NCDs in both urban (poor and nonpoor) and rural India.2 The World Diabetes Federation identified the prevalence of diabetes in India at about 8% with many additional patients undiagnosed. Regional prevalence was estimated between 5% and 15% of persons aged more than 18 years. In particular, diabetes is increasing rapidly among marginalized and poor
communities in both urban and rural areas.3 Almost 25% of the urban and 10% of the rural adult Indian population is reported to have hypertension. There are wide interstate variations in the prevalence of cardiometabolic risk factors like hypertension, diabetes, and obesity. The highest prevalence of hypertension (18%) but the lowest prevalence of diabetes (2.5%) were reported in Maharashtra, while Punjab recorded the lowest hypertension (0.8%). The hilly states of Sikkim, Himachal Pradesh, Jammu and Kashmir, and Uttarakhand, where people are usually believed to be more physically active, recorded high rates of both diabetes and hypertension.4 In addition, 31.3% of people with diabetes were also hypertensive. Projections from crude incidence rates of total cancers in the country highlight that cancer
doi: 10.1111/nyas.12555 C 2014 New York Academy of Sciences. Ann. N.Y. Acad. Sci. 1331 (2014) 157–173
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cases occur differentially across different geographic regions of the country, and the total burden could go up from 97 million in 2010 to 114 million in 2020.5 There has been fairly rapid industrialization, urbanization, and improved health service–system capacities in both public and private sectors, particularly since the early 1990s. India’s gross domestic product (GDP) growth is among the top five in the global list, the per capita purchasing– power parity (PPP) is somewhere in the middle, and the Gini index is among the lowest.6 Paradoxically, multidimensional poverty indices (MPI) are fairly high, with India ranked 74 among 104 countries.7 The decomposition of the indices for the Indian states and social groups tell a tale of wide variations and inequalities, signifying both transition and vulnerability. Urbanization, mechanization, and globalization have led to unprecedented changes in lifestyle, including physical activity and food habits. Closely intertwined are issues of epidemiologic and nutrition transition and changes in traditional dietary patterns.8,9 The concept of epidemiologic acceleration has been used to signify epidemiologic transition happening in developing countries and transition economies in the absence of improvements in social and economic well-being experienced in advanced economies. Epidemiologic polarization refers to the growing increase in the health inequalities between countries, regions, and social groups; it is the most vulnerable populations that experience excess morbidity and mortality from a variety of causes.10 In Mexico, the situation points to an increase in the proportion of people living in nutrition poverty (pobreza alimentaria), which is distinct in the Mexican classification from poverty of basic needs (pobreza de capacidades) and net poverty (pobreza de patrimonio). Epidemiologic polarization is thus marked by the poorest experiencing the highest death rates owing to both pretransitional diseases, including infections and nutritional disorders, and rising NCDs.11 The phenomenon was demonstrated in the context of Kerala about a decade ago.12 It has also been pointed out that the protracted polarization model is accelerated with rapid urbanization.13 Adverse social determinants, along with diminished physical activity and inappropriate nutrition, are reflected in the increasing prevalence of chronic 158
diseases. In the most proximate sense, increased consumption of energy-dense foods in general and of sugar, salt, and fat in particular are catalyzing the onset of NCDs as well as portending poorer prognosis. Rural–urban migration is the foremost coping strategy to fight chronic poverty, but the new urban environment also makes them individuals vulnerable to impaired glucose tolerance.14,15 Barriers to maintaining customary eating habits in the poor, specifically in migrants, are high food prices, particularly those of protective foods such as fruits and vegetables.16 Packaged foods, produced by both leading and local brands, have infiltrated all segments of the population with innovative (and successful) marketing tactics.17 Women engaged in paid and unpaid work in order to support the household economy can devote less time to cooking and child care, thereby leading to increased consumption of packaged foods by children.18,19 Thus, the country currently suffers multiple burdens of chronic diseases related to epidemiological and nutrition transitioning linked to both individual behaviors and social environments.20 Nutrition transition and NCDs, including cancers, are all tied to a cumulative and accelerated malalignment between human biology and the conditions of modern industrial society. Health-system and public-policy researches need to straddle themes of social determinants, epidemiology, and public policy. Effective publicpolicy formulation and design measures to contain NCDs need real-time information to choose among goals, alternatives, and multisectoral choices obtained through integrating data sets that measure inputs, processes, and outputs.21 Currently, in India, much of the public-health data for NCDs are collected and analyzed from a unidisciplinary clinical and cross-sectional perspective. However, for an effective monitoring and surveillance strategy, convergence initiatives are required for assembling data sets from business, civil society, and academia, in addition to administrative information. The wholeof-society–whole-of-government (WoS–WoG) approach, recommended and proposed by the World Health Organization (WHO) during the pandemic influenza preparedness in 2011, is aptly suited for NCDs as well.22 In the absence of such intersectoral approaches, attaining sustained economic growth and healthy societies will remain a distinct dream.
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Methodology We seek to examine policies, programs, and market dynamics related to sugar, salt, and fat consumption (referred to as sectors as we have adopted a sectoral approach to construct the analyses) in the contemporary Indian context. Policy documents, office memoranda, and short communications, available in the public domain from government departments, were analyzed to identify existing rules and regulations pertaining to sugar, salt, and fat products in India. Key players in the sugar, salt, and fat markets were identified from policy documents, expert committee reports appointed by agencies, and business data from different associations. Market research reports, like KPMG (www.kpmg.com), available for free on the Internet, were also analyzed to identify key players. National and state-level per capita consumption of sugar, salt, and fat products were obtained from National Sample Survey (NSS) reports (66th round conducted in 2009–2010 on household consumption (self-reported) of various goods and services in India, report 541 published in 2012).23 The NSS is a nationwide household survey conducted every year through scientifically designed representative samples to inform policies. Prevalence of major NCDs like diabetes, overweight and obesity, and hypertension during 2009–2010 was collated from population studies published on Pubmed and from a National Nutrition Monitoring Bureau (NNMB) report (2011) published by the National Institute of Nutrition, Hyderabad.24 The NNMB carries out diet and nutrition surveys on a regular basis in rural areas of 10 selected states: Kerala, Tamilnadu, Karnataka, Andhra Pradesh, Maharashtra, Gujarat, Madhya Pradesh, Orissa, West Bengal, and Uttar Pradesh. The dose–response relationships among sugar, salt, and fat per capita consumption and the prevalence of diabetes, overweight and obesity, and hypertension were obtained from the NNMB report. State-wise per capita consumption of sugar, salt, and fat from the 2009–2010 NSS report was compared with corresponding state prevalence rates of diabetes, overweight and obesity, and hypertension available during the same period. States were grouped into high, medium, and low human development indexes (HDIs) to relate rising per capita consumption and NCDs with socioeconomic developments. HDIs, first suggested by the
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United Nations (UN) in 2001 and later amended as inequality-adjusted human development indexes (IHDIs) in 2010, are composite statistics of life expectancy, education, and income measurements for monitoring states for their status of quality of life and human well-being.25 Thus, HDIs provide surrogate estimates of health, nutrition, and epidemiological transitioning in a society. States with HDI above 0.8 (Kerala and Delhi) are defined as developed, while those with HDI between 0.5 and 0.79 are defined as medium-development states. Those states with HDI below 0.5 are considered as minimally developing states.26,27 It is with this perspective that HDIs were used to classify Indian states to compare the changing prevalence of major NCDs. Per capita consumption of salt, sugar, and fat, from the 66th round NSS, were compared in each of the high, medium, and low HDI states. Per capita consumption of salt, sugar, and fat in different social classes and economic groups were compared separately. The results are presented following four themes:28 (1) policies related to sugar, salt, and fat markets in India; (2) key players in sugar, salt, and fat markets; (3) trends in the consumption of sugar, salt, and fats and the changing prevalence of NCDs; and (4) the Indian government’s action plan for NCD surveillance. Results Policies related to sugar, salt, and fat Sugar sector. In India, sugar (and sugarcane) is an essential commodity under the Essential Commodities Act (1955), monitored and controlled by the Department of Food and Public Distribution, under the Ministry of Consumer Affairs. Dual strategies and partial-control mechanisms are adopted by the union (central or federal) government for controlling market prices, fixing statutory minimum price (SMP) in relation with sugar seasons, and to set up fair and remunerative prices (FRP) for sugarcane farmers.29 States also intervene in sugarcane pricing through state-advised prices (SAP) to strengthen their farmers’ interests, leading to perpetual differences in sugar and sugarcane prices between states. Neither the states nor the center adequately reward farmers on the quality of cane supplied, especially with reference to high sugar content and yields.30 Policies related to sugar in India could be grouped under four domains: (1) price support for sugarcane
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administered by central and state governments; (2) the release of levy and free-sale sugar and buffer stocks by the central government; (3) the regulation of the sugar trade by the central government; and (4) market restrictions and storage limitation by the central government. There are 682 functional sugar factories in the country, about half of which are in the cooperative sector. Licensing requirements for new sugar mills were abolished in 1998, helping the industry to grow at an annual rate of around 7%, compared to 3.3% before 1998, and encouraged more private players in the Indian sugar sector, traditionally dominated by cooperatives. The government has imposed a compulsory levy of 10% of produced sugar per factory at a fixed price for every season, which is supplied to all below poverty line (BPL) families through the public distribution system (PDS). Nonlevy sugar is allowed to be sold independently in the market for quantities to be released by the government, as per sugar release order, in every quarter. The statutory minimum price for sugar has increased nearly threefold in the past 10 years; despite which retail sugar prices in India are cheaper compared to other countries. Around 65% of the annual production is consumed by bulk purchasers (e.g., beverage, biscuit, and confectionary manufacturers).31 Furthermore, the government has also approved sugar trade through four national exchanges for global marketing. The Economic Advisory Council to the Prime Minister recommended further deregulation of the sugar sector in 2012.31 Currently, the stockholding limits on wholesale dealers of sugar have been withdrawn. In May 2013, the central government decided to decontrol the sector and encourage state governments to buy levy sugar at market price and to supply it to BPL families at subsidized rates, facilitating more benefits to industrialists. States like Uttar Pradesh, Bihar, Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, and Gujarat, which produce 85% of the total sugar in India, have formulated state-specific schemes and governance structures to provide a conducive environment for millers and farmers. In India, export of sugar, through an Ordinance in 1997, is carried out through the Agricultural and Processed Food Products Export Development Authority (APEDA) under the Ministry of Commerce. The federal government uses sugar import and export as a mechanism to control domestic 160
economy and inflation rates. In its recent order in June 2014, the Government of India raised import duty from 15% to 40%, resulting in an increase of retail price by 1–2 rupees per kg of domestic sugar, ostensibly to help Indian millers to find extra money to pay sugarcane farmers. This is in addition to the government subsidies on raw sugar exports to boost trade outputs. Salt sector. Schedule 7, Item 58 of the Constitution of India regulates manufacturing, supply, and distribution of salt through the Salt Commissioner’s organization under the Ministry of Commerce and Industries, within the Department of Industrial Policy and Promotions.33 The Salt Commissioner’s annual report 2012– 2013 highlights that about 6.2 million metric tons of the overall production of 24.5 million metric tons was iodized salt, of which 95% (5.9 million metric tons) was supplied for household consumption; the rest was exported.34 Out of 6.2 million tons of edible salt, over 60% is procured by bulk purchasers (e.g., sauces, savory, and snacks); much of this is used in the food-processing industry and is made available for human consumption through processed foods. Branded iodized salt accounts for 49.7% of the total salt market and is growing at 4% annually. The government has pursued liberalization in this industry since 1996 to encourage private sector participation for achieving a universal salt-iodization goal. In 2006, the program was amended and the sale of noniodized salt for human use was banned under the Prevention of Food Adulteration (PFA) Act. Currently, there are 807 salt iodization units and 42 refineries in India. Fat sector. Dietary fats are grouped into four categories: (1) monounsaturated fats, present in olives, canola, peanuts, nuts, and seeds; (2) polyunsaturated fats, present in sesame, sunflower, corn, canola, and soybean oils and fish; (3) saturated fats, available in processed foods, hydrogenated oils, fatty meats, dairy products, butter, coconut and palm oils, palm kernels, and cocoa butter; and (4) trans-fats, available in processed foods with hydrogenated vegetable oils, snack foods, fast foods, and ready-made foods. Fat and fatty acid content of foods in India are regulated under the Food Safety and Standards (FSS) Act (2006, later amended in 2011). Various acts like the PFA Act (1954), the Fruit Products Order
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(FPO) (1955), the Meat Products Order (1973), the Vegetable Oil Products Control Order (1947), the Edible Oil Packaging Regulation Order (1988), and the Milk and Milk Products Order (1992) were converged and called the FSS in order to move from a regime of multilevel, multidepartment control to a single line of control for all food items. The Food Safety Standards Authority of India (FSSAI) is the regulatory agency tasked to consolidate various acts and orders related to foods under various ministries and departments.35,36 The Ministry of Health and Family Welfare (MoHFW) is the administrative authority for implementing the FSSAI through its Drugs and Food Quality Control section. Standards under this act can be classified broadly under (1) mandatory product standards, (2) mandatory process standards, (3) licensing and prohibitions, and (4) voluntary product and process standards. The food safety and standards chart specifies the key sources of fat in Indian foods. All edible oils and fat products are mandatorily restricted under Section 4.1.9 of this act from using expressions like “super refined, extra refined, microrefined, double refined, ultra refined, anticholesterol, cholesterol fighter, soothing to heart, cholesterol friendly, saturated fat free” or such expressions that are exaggerations of the quality of the product. Labeling of the contents, including the type of fatty acids, cholesterol, saturated fatty acids, monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), and trans-fats, were made mandatory in 2009 through an ordinance. The act also recommends adding antioxidants in prescribed quantities to all edible oils and fats except for ghee and butter. Antifoaming agents in edible oils and fats for deep fat frying were restricted to a maximum of 10 parts per million (ppm), while reuse of tins and plastic containers for edible oils and fats are controlled. Vegetable oils, particularly edible oils, are regulated under the Directorate of Vanaspati, Vegetable Oils and Fats (DVVOF), an attached office of the Department of Food and Public Distribution, the nodal office solely responsible for coordinated management of vegetable oil markets, adjustments of import duties, and public price controls. This department performs regulatory, developmental, and advisory functions in all matters relating to vegetable oils and vanaspati (hydrogenated oil). It has controlled the export of most of edible oils since
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2008.37 After implementation of the FSSAI in 2011, the DVVOF has been partially governed by the FSSAI, especially on licensing, safety, and standards parameters. In addition to the above-mentioned acts, all edible oils are considered as essential commodities under the Essential Commodities Act (1955). Indians consume 17–18 million metric tons of vegetable oils per year; over 60% is supplied through imports. Around 80% of total edible oils imported in India are palm oil. Palm oils are high in saturated fat. Import of edible oils has more than doubled in the past 15 years (Fig. 1).38 The government has abolished all import duties of crude edible oils, while duties on refined oils have been lowered to 7.5%. In addition, since 2008, to augment the availability of edible oils for poor people, the government has implemented a scheme for the distribution of subsidized imported edible oils to ration card holders. Exports of refined edible oils, except for castor oil, coconut oil, and few minor oils of forest origins have been completely banned since 2008. Export of branded edible oils, up to 5-kg packs, is permitted through the Minimum Export Price. The government collects 4% value-added tax (VAT) on market prices for all edible oils. Quality assurance in oils and fat products. In addition to the FSSAI, the Bureau of Indian Standards (BIS) under the Directorate of Marketing and Inspection in the Ministry of Agriculture has also set specifications for edible oils, oil seeds, and vanaspati products, including physical and chemical testing standards. Under the Ministry of Agriculture, governed by the Agriculture Produce (Grading and Marking) Act (1937), the General Grading and Marking Rules (1988), and the Blended Edible Vegetable Oil Grading and Marking Rules (1991), AGMARK certification is mandatory for all blended edible oil and fat products and spreads marketed in India.39 This is in addition to the FSSAI regulations for mandatory labeling of contents of all packaged and processed foods sold in the Indian market. Information on contents including sugar, fats, dietary fibers, and total energy (in calories) is mandated under this law. Labeling of total trans-fats and saturated fat in percentage by weight is also required by the FSSAI through its 2013 notification.40 The FSSAI has proposed a regulation, currently pending within the government, to control trans-fatty acids
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Quanty (in 100,000 tons) 120 100 80 60 40 20 0
Figure 1. Trends in edible oil imports in India. From Ref. 38.
in partially hydrogenated vegetable oils (PHVOs) at a maximum of 10% and reduce that to 5% in the next 3 years, along with mandatory labeling of the amount of trans-fats in all oils.41 Key players in sugar, salt, and fat markets Sugar sector. The sugar industry in India is controlled largely by the union government, which has steadily introduced liberalization in the sector. Policies related to sugar, including sugarcane support price policies and sugar storage and trade policies, are coordinated through two desk officers in the Department of Food and Public Distribution. In addition, officials from the Food Corporation of India, the Directorate of Sugar, the Union Finance Ministry, and representatives of sugar mill associations play key roles. States holding major stakes, including Uttar Pradesh, Bihar, Maharashtra, Karnataka, Tamil Nadu, and Gujarat, have formed sugar departments in their respective states for implementation and monitoring of various regulations related to sugarcane and sugar. During the past 10–15 years, more than 10 key market players have emerged in India who now influence the dynamics of sugar availability and its pricing.42 Salt sector. Policies in the salt sector are coordinated by the Salt Commissioner’s Office headquartered in Jaipur, Rajasthan, with four regional offices across India.34 The central advisory board and regional advisory boards advise governments on collection of salt cess and other reforms. Salt policies in India are formulated through interdepartmental and multisectoral collaborations. 162
Central and regional advisory boards collect information on salt cess and welfare schemes from private producers and consider their inputs in designing annual policies. The Departments of Health, through the National Iodine Deficiency Disorders Control Programme (NIDDCP), hold a major stake in regulating edible salt availability and quality. The Ministry of Information and Broadcasting conducts information, education, and communication (IEC) campaigns for this program, while human resources are mobilized by the Ministry of Women and Child Development. The Ministry of Food and Civil Supplies, as well as the Indian Railways, facilitates salt movement for the PDS. Insurance regulatory and development authority through insurance agencies provide salt employee welfare schemes like Namak Mazdur Swasth Bima Yojana (NMSBY). Agencies such as the NNMB (within the Indian Council of Medical Research (ICMR)) and the NSSO collect and monitor per capita salt consumption in India through state-level population data. Fat sector. The FSSAI is an arm of the MoHFW and plays a key role in making policies for regulating food products at large and fats and oils in particular. The Ministry of Food Processing Industry (MOFPI) designs policies for promoting food processing units and trade by permitting foreign direct investments (FDI) and many other subsidies in this sector. The BIS, under the Ministry of Agriculture, is responsible for implementing these standards. The FSSAI, the MoHFW, the Public Health Foundation of India (PHFI) (a public–private partnership, structured as an independent foundation),
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the Centre for Chronic Disease Control (CCDC) and the Vanaspati Producers Association are some of the key stakeholders promoting advocacy for reducing trans-fat use in India.43 Officials from the Ministry of Agriculture; the Department of Commerce; Consumer Affairs; the Ministry of Micro, Small and Medium Enterprises (MSME); and representatives of food industries, consumer organizations, and states are also members of the food safety policy team. Scientists from the National Diary Research Institute, the Department of Protein Chemistry, and the Technology and Director General of the ICMR also hold stakes in food policies in India. The Indian edible oil market is controlled by unorganized players, as most vegetable oil purchased by industrial buyers, restaurants, and hotels for frying and baking is sold as loose oil or vanaspati. Currently, there are over 250 vanaspati plants in India. However, changing lifestyles, fragmented market segments, consumer preferences, and intense competition from the brands of multinationals have made branding strategies a prerequisite.44 Tracking NCDs and salt, sugar, and fat markets in India Rising NCDs in India. In India, around 80% of NCD deaths are attributed to four diseases: cardiovascular disease, cancer, respiratory disease, and diabetes.45 Traditional cardiometabolic risk factors like hypertension, overweight and obesity, type 2 diabetes, dyslipidemias, and metabolic syndrome
have reached pandemic proportions; in all age groups and in all geographical regions the relative risk varies with habits, socioeconomic position, and built and spatial environments.46 Trend analysis between 2000 and 2014 confirms the rising national prevalence of type 2 diabetes among adult Indians from 5.9% to 9.1%.3 Hypertension prevalence has increased from 17.2% to 29.2% during the same period, with significant urban–rural differences.47 Prevalence of overweight and obesity has also increased almost fourfold in the past 14 years, from 4% to 15% (Fig. 2).48 India has the second largest population with diabetes in the world, an estimated 60 million in 2013, with many more as yet undiagnosed. International Diabetes Federation (IDF) projections forecast that the toll may cross 75 million by 2025.49 Further, Diabetes India (a national association) reports that diabetes is the second most common cause of adult blindness (after cataracts).50 The NNMB Report (2012) highlights that pooled prevalence of diabetes is 7.8% among men and 6.3% among women; the situation is similar for hypertension. Hypertension is present in 25% of the urban and 10% of the rural population.51 Some studies have reported prevalence as high as 27% in women and 31% in men, with an almost equal proportion of people being prehypertensive.52 This was confirmed in many other Indian studies.53 A Screening India’s Twin Epidemic (SITE) study in 2012 monitoring 15,000 hospital-based patients in different states reported
Trends in per capita, per day consumpon of salt, sugar, and fat products
Trends in the prevalence of NCDs 25
Hypertension3 60 Sugar23 50
15 Obesity48 10 Diabetes93 5
Percapita Consumpon in grams/day
Prevalence in 100,000 Populaon
20
Total Fat23
40 30 20 Salt57
10 0 Around Year 2000
Between Year 2008 & 2010
Aer Year 2013
0 Around year 2000
Between Year 2008 & 2010
Aer year 2013
Figure 2. Nationwide trend in rising NCD prevalence and per capita consumption of salt, sugar, and fats. References are provided as superscript numbers on the various labels.
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a hypertension prevalence of over 50%.54 Crude prevalence of overweight and obesity in men and women in India is 19.8% and 22.7%, respectively. NNMB reports confirm high rates of overweight and obesity in urban and rural areas, higher in women than men in all states and in all social classes except for scheduled tribes (STs). This observation in STs may be due to persistent undernutrition and higher levels of physical activity in adult women owing to cultural division of labor. There appears to be a clear link between the state of development in the region and the prevalence of cardiometabolic risk factors like hypertension, diabetes, and overweight and obesity. The average regional prevalence of diabetes in high and medium HDI states was 12%, while that of low HDI states was 9% (Table 1).55–57 In addition, diabetes is also prevalent in marginalized communities: in scheduled castes (SCs), 6% of men and 5% of women; in STs, 6.6% of men and 5.5% of women; and among the collection of socially and educationally disadvantaged castes designated “other backward class (OBC)” by the Indian government, 8.9% of men and 7.4% of women. Hypertension in high and medium HDI states was 26.5%, compared to 17.9% in low HDI states. A recent study on rural tribal population in south India showed a 10-fold increase (2.8–22%) between 2000 and 2014.58 The prevalence of overweight and obesity in high and medium HDI states is 22.7% while that in low HDI states is 20.8%. Overweight and obesity have affected the socially backward communities as well and vary between 15% and 26% in different parts of the country.59 Rising sugar, salt, and fat consumption in India. In India, per capita consumption of sugar increased from 22 g/day in 2000 to 55.3 g/day in 2010 (Fig. 2),24 while per capita consumption of table salt ranges between 9 and 12 g/day.66 Per capita consumption of total fat was 21.2 g/day in 2000 and increased to 54 g/day in 2010. PHVOs, including palm oils, increased from 1.67 g/day to 2.8 g/day.25 Palm oil is abundantly available in the market, largely imported from Malaysia. Until 2005–2006, palm oil attracted an import duty of over 60%; thereafter the import duty has been reduced to almost zero, for more than one reason.61 Palm oils are high in saturated fat and low in polyunsaturated fat, thus contributing to heart diseases. The WHO advises reduced consumption of palm oil.60 Basu et al. used 164
an economic epidemiologic model to demonstrate that a 20% tax on palm oil purchases would be expected to avert approximately 363,000 deaths from myocardial infarctions and strokes over 2014–2023 in India (a 1.3% reduction in cardiovascular deaths) if people do not substitute other oils for reduced palm oil consumption.61 At the national level, per capita consumption of sugar is now approximately 10 spoons, adding up to 18 kg/year (ICAR, 2011).62 The current global average is about 23 kg per capita per year; ranging from a low of 8 kg/year in Bangladesh to 66 kg/year in Israel. Cumulative domestic purchase of white sugar in India has also increased. India produces 17% of total global sugar, but its share in export is only 4%, signifying high demand in the domestic market.63 Around 26 million metric tons of sugar were released for domestic consumption in 2012–2013, compared to 16.7 million metric tons in 2001–2002. Increased use of sugar could be related to the relatively lower market prices of sugar in India. Sugar is currently sold at a retail price of about 35 rupees/kg (approximately half a U.S. dollar), among the lowest in the world.64 Twenty-six million metric tons of sugar was consumed in India in 2012–2013, as per the Sugar Release Order, Food and Public Distribution. Market research companies (KPMG) reported that up to 55% was procured by bulk purchasers and consumed in confectioneries. Therefore, 11.7 million metric tons were available for household consumption. This works out to 9.37 kg/year (25.7 g/day). Further, 10% of total sugar produced was considered as levy sugar for the PDS. The NSS 2010 round reported per capita consumption of 55.3 g/day; this is based on self-reported data through householdlevel questionnaires. These discrepancies in consumption patterns underscore the need for standardization of assessing intake across surveys and taking into consideration different sources in an objective and explicit manner. Population studies by the ICMR in 1988 in 13 Indian states reported salt consumption at 13.8 g/day;66 recent estimates by an ICMR-INDIAB study report 7.6 ± 3.3 g/day consumption in urban areas, significantly higher than in rural areas (6.8 ± 3.5 g/day).65 Salt consumption reported in the 66th Round of the NSS in 2010 was 8.9 g/person/day,24 which is above the National Institute of Nutrition (NIN) recommended dietary intake (RDI) of
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Table 1. State-wise per capita consumption of sugar, salt, and oils during 2009–2010
Status of HDI High HDI states
State Kerala Delhi
Medium Himachal Pradesh HDI states Goa Punjab Maharashtra Tamil Nadu Haryana Jammu & Kashmir Gujarat Karnataka Low HDI states
West Bengal Uttarakhand Andhra Pradesh Assam Rajasthan Uttar Pradesh Jharkhand Madhya Pradesh Orissa Arunachal Pradesh Bihar Chhattisgarh Manipur Meghalaya
Diabetes (urban)
Hypertension (urban)
14.855 10.356
40.7524 30
Obesity/ overweighta (urban) 2924
22.5 10.323 13.1 10.957 13.757 13.346 3.8 13.8 16.0 11.5 5.7 16.6 8.256 8.6
20.724 33.0524
25.424 20.724
17.924 20.9524
18.924 19.524
16.3824 33.2 24.324 13.0
29.4524
13.724
15.924
10.924 14.324
15.324 26.0524
17.524
57
13.5 4.924 3.224
Sugar (g/day)23
Salt (g/day)23
Edible oil (g/day)23
27.6 23.33
8.9 6.97
17.47 23.00
39.03 32.53 56.97 33.37 19.83 48.23 22.40 32.83 23.87
7.33 9.13 6.30 7.23 10.2 6.87 10.17 6.83 9.13
29.57 24.73 27.37 30.97 20.33 18.97 27.60 33.07 21.37
14.17 33.10 16.07 15.97 38.37 23.6 13.17 26.77 13.47 16.77 10.77 18.10 7.43 16.80
10.8 6.40 10.73 10.03 8.67 6.93 9.03 7.67 11.77 11.17 8.93 10.67 8.87 8.10
19.73 23.57 23.8 15.63 24.07 19.57 17.20 19.6 15.07 14.47 16.63 18.50 9.63 12.73
Note: To compare the per capita consumption of salt, sugar, and fats with the prevalence of diabetes, hypertension, and overweight/obesity in 2009–2010, population-based surveys conducted during this reference period were considered. However, a few multicentric population studies for surveillance published in Pubmed during this reference period were also included. a BMI ࣙ 23 was considered as overweight/obesity (Asian classification).
5 g/person/day.66 The Chennai Urban Rural Epidemiology Study (CURES) also reported mean dietary salt intake as 8.5 g/day; while higher salt intake was associated with older age and higher income.67 The salt manufacturing industry puts the current daily consumption at about 7 g/day on the basis of sales data. However, these estimations are on dietary recalls on household utilization of table salt and do not count added salt in processed foods. Consumption of value-added food that are always high in salt—like pickles, bread products, savory snacks, ketchup, mayonnaise, other
sauces, and breakfast cereals—need to be included in per capita salt estimations. This has to be interpreted in conjunction with the rising annual production of edible salt, from 2.8 million metric tons in 1992–1993 to 6.2 million metric tons in 2013.35 As previously indicated, per capita consumption of total fat is 54 g/day, while consumption of edible vegetable oils was 27.6 g/person/day. This information is based on self-reported data through household-level questionnaires (NSS Report, 2009– 2010). The DVVOF reports 19.8 million metric tons
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Table 2. Dose response of hypertension, overweight/obesity, and diabetes in different risk groups Overweight/obesity (BMI > 23)
Hypertension
Diabetes
Men (%)
Women (%)
Men (%)
Women (%)
Men (%)
Women (%)
Sugar and jaggery
14 g/day
20 7.36,a 22.4 P < 0.05 22.2
20.6 5.32, NS 20.5 22.3
17 41.10, 22.5 P < 0.001 22.1
20.1 80.46, 27.8 P < 0.001 26.6
8.7 8.41, 8.1 P < 0.05 6.5
6.7 6.6 6.5
0.13, NS
Salt
0.5; 18 g/day for both sugar and fats), indicating the association of consumption with environment and economy (Table 1). In contrast, average salt consumption was higher (9.6 g/day) in states with lower HDI (
