Review articles
A Journal of Cardiological Society of India, Kerala
Chapterof Cardiological Society of India, Kerala
A Journal
Nutrition Paradox and the evolving
health crisis in the State of Kerala, India
Sivasankaran S. M.D., D.M.*
Abstract:
The health status of the State of Kerala,
India, was hailed as the best example of 'good health
at low cost', in the late 1980s. Currently, Kerala is
experiencing a high burden of non communicable
diseases at younger age, and is currently the diabetic
capital for India, with static levels of childhood
stunting (25%). This double burden of disorders of
under-nutrition and over-nutrition in the society, 'the
nutrition paradox', in Kerala could be the harbinger
of what is going to happen in India and the rest of the
developing world. The present review aims to
highlight the vicious cycle of low birth weight, over-
nutrition in childhood and adolescence, early onset
risk factors in women, perpetuating low birth weight
and or babies with abnormal intrauterine
programming in their progeny, as the driver of this
nutrition paradox and younger age escalation of non
communicable disease risk factors and diseases. The
two factors which make the developing countries
different from the developing countries are this
younger age escalation of risk factors and the
inability of the anthropometric markers of body
adiposity to predict the risk. Both the features can be
explained by the 'sarcopenia and insulin resistance
seen in abnormally programmed babies at birth'
which is perpetuated in child hood and adolescence,
by insulinogenic nutrition, and declining physical
activity. Adolescence is the last opportunity, to build
the best body composition. Attaining good lean body
mass at peak adolescence especially in women is
*Professor in Cardiology, SCTIMST siva@sctimst.ac.in
14KHJ Kerala Heart Journal
Review
Chapter articles
suggested as the best option to break this vicious
cycle. This could be the cost effective strategy which
developing countries should adopt in the wake of the
United Nations High Level meeting on the
prevention on non communicable diseases.
The nutrition paradox in Kerala.
The picture of an obese mother taking an
undernourished child to the clinic was pictured as the
nutrition paradox by Benjamin Caballero.1 The
Indian State of Kerala illustrates this nutrition
paradox with static prevalence of childhood under-
nutrition and steady increase in obesity in women in
the reproductive age group (Table 1). 2 , 3 The
nutritional status of 25% of children below the age of
three years is stunted and is remaining static over
the last 15 years, where as the overweight/ obesity in
urban women in Kerala has reached 34% in 2006.4
Percentage of babies born with low birth weight
(< 2.5kg) has increased from 17.2% (1992-93) to
24.7% (2005-6) during the same period.5,6 Low birth
weight children, grow up as stunted children and
have high prevalence of insulin resistance, and non
communicable disease risk factors.7,8 This could be a
factor in the exponential increase in the cardio-
metabolic risk factors in women in the reproductive
age group, seen in India.9,10 Obese mothers, maternal
short stature, gestational dysglycemia and
gestational hypertension result in low birth weight in
the offspring.11,12 This increase in maternal (in-utero)
risk factors could be the cause for increasing low
birth weight babies in Kerala. It is equally important
KHJ Kerala Heart Journal
23
 Review articles A Journal of Cardiological Society of India, Kerala Chapter

to note that the prevalence of Low birth weight babies Table 2 summarizes the documented change
are remaining static in other developing countries in calorie consumption and life style related diseases
like Sri Lanka where the epidemiologic transition is reported in various studies from Kerala.
almost in par with Kerala.13,14 Similarly the state of
Andhra Pradesh in India has also registered an Table 2:Per-capita increase in calorie consumption
increase in Low birth weight babies during the NFHS and life-style related diseases
survey periods.12 Low middle income countries have a
Calorie consumption28,29 BMI > 25 in
heavy burden on Low birth weight children as well as Year (Cons: Units/day) rural women DM30 HT
non communicable diseases.15,16 Understanding the Rural Urban as %28
contribution of Low birth weight and nutrition 1961-62 1631 1554 1.5/ U2.3
transition to this chronic disease burden is therefore
crucial. 17,18 1971-72 1610 1658
1972-73 1559 1723
1972-74 1534 1760
selected parameters of nutritional status in
Table 1:
Kerala in National Family Health 1975-79 1978 2.3

1983 1884 2049

Surveys (NFHS).2
1988-93 2140 12.2 3.5 16.731
NFHS -1 NFHS-2 NFHS -3 1993-94 1965 1966 2.4/ U8.2
NUTRITIONAL STAUS (1992-93) (1998-99) (2005-06)
Total Total Total 1996-97 2106 15.8 11.6
TOTALChildren 32.8 28 26.5 1998-99 2231 32
19.5 16.3 3033
<3yrs (stunted %)
Children 13.7 13 15.6 2000-06 201434 199634 30.9 / U44.84 22/ U17.14 36.735
<3yrs (wasted %)
Children: R stands for Rural and U for Urban and the superscript
22.1 21.7 21.2 numbers denote the source of information where information is
<3yrs (underweight %)
available the data denoted rural women (considered being the most
Women(BMI < 18.5 %) - 18.7 12.5 disadvantaged section), Data on hypertension is non stratified.
15-49 yrs of age BMI: body mass index as Kg/m2 DM: Diabetes mellitus, HT:
Women (BMI >= 25 %) hypertension.
- 20.6 34.0
15 – 49 yrs of age Positive energy balance:
Percentage of low birth
weight babies 17.2 16.4 24.7 Kerala being a food deficient state, caught in
globalization easily adopted marketed food products,
like biscuits, chocolates, health drinks, colas, non
vegetarian foods and alcohol.36,37 Per-capita alcohol
Evolution of nutrition paradox in Kerala. consumption is highest in India. Consumption of non-
Kerala is the most advanced Indian state in vegetarian products, eggs, health drinks and
epidemiologic transition.19 This happened over a marketed food products are almost double compared
period of last 30 years in par with globalization.20 In to the rest of Indian states. 36 On an average, calorie
1960's Kerala was the best example of a nutritionally consumption in Kerala increased by more than 500
stunted state, with lowest per-capita calorie Kcals/ person and is by far the highest change
consumption in India.21,22 The health achievements compared to the rest of the states.29,38 Kerala has the
were hailed as good health at low cost, achieved best human wealth index in India, which is double
because of high female literacy and good public the Indian average, based on the availability of 33
distribution system, transformed itself over the next domestic commodities like fridge, grinders, vacuum
30 years into a state of high morbidity due to non cleaners, washing machines, and transport
communicable diseases as illustrated in table 2.4,23,24 It vehicles.39 This has contributed to substantial
has a heavy burden of non communicable disease risk decline in transported related, work related and
factors, like diabetes, hypertension, dyslipidemia, leisure related physical activity. In the absence of
obesity alcohol tobacco consumption and physical direct studies on time trends in physical activity,
inactivity. 4 The age adjusted cardiovascular these could be the best indicators of decline in
mortality in Kerala (490/Lakh) is now as high as that physical activity in Kerala. This positive energy
of Finland in 1970s.25 The driving force of this balance generated by increasing calories
transition is best explained as insulinogenic nutrition consumption and decline in physical activity
characterized by a positive energy balance with constitutes the insulinogenic nutrition which drives
increasing supply on one hand and declining energy the non communicable disease epidemic.26 Few cohort
needs on the other.26,27 follow up studies in India have substantiated the
contribution of epidemiologic transition to the high

KHJ Kerala Heart Journal 15

 A Journal of Cardiological Society of India, Kerala Chapter
prevalence of non communicable disease risk factors
in India.40 This New Delhi Birth cohort started in
1970 followed up till date in an urban middle class
population, showed evolution of metabolic syndrome
in 29% of the individuals, which correlated with
increase in body mass indices in adolescence
onwards. Similar study from south India, observed
both low birth weight and adolescent BMI predicted
adult onset insulin resistance and diabetes.41
This positive energy balance is maximal for
Kerala women, and they are now the heaviest in
India in terms of body mass indices, being next only to
Delhi and Punjab.2, 28 This has adversely affected
women. Among the four behavioral risk factors
driving the affecting the non communicable disease
epidemic both tobacco use and alcohol consumption
are not initiated in women in Kerala during
adolescence and reproductive age group.42 Women in
Kerala are mostly home makers, or house wives and
their labor participation is one of the lowest in India.43
Most of the household work in Kerala is mechanized.
Largest consumer of home appliances such as
washing machine, grinders, and vacuum cleaners is
in the state of Kerala.39 Further the energy cost
infections, and energy cost of maintaining body
temperature is lower in Kerala given the good health
facilities, and tropical climate.44 Kerala women have
the lowest fertility rates below 2 compared to > 2.5 for
the rest of India, over the last two decades which
contributed further saving on calorie cost of
pregnancy and lactation. The cohort follow up study
from New Delhi and Vellore also, women had the
maximal increase in obesity. 40,41
Thus the two behavioral risk factors namely
unhealthy diet and physical inactivity are the driving
forces for the escalation of non communicable disease
risk factors in women in Kerala and is perpetuated
further by the cultural believes which have a gender
dimension in Kerala.45 To mention a few are the
concepts of big is beautiful and healthy, food should
not be wasted, women should cover their body, and
girls after menarche should refrain from out door
activities.
Concept of big is beautiful, is illustrated by
the popular actors, who make their appearance in
television and cinema. Their massive figure leaves a
lasting impact on Kerala people as a target they
should attain, at least with their children. This leads
to process of feeding small children with frequent and
large food portions. Most of the marketed products
and refined Indian rotti, (Paratha) are now favorite
food of Kerala children.37,46 Average salt consumption
in South India, is almost double the recommended
daily allowance.47,48 The left over food in the Kitchen
is additionally consumed by the Kerala women,
because of the persistent thought that food should not
be wasted. Covering the whole body in their
traditional clothes is increasingly becoming popular
16
Review articles
among Kerala women, and is a major hindrance to
physical activity in a tropical climate.49 At least 40%
of body needs to be exposed to 2 hours in the sun to
attain adequate blood levels of vitamin D in India.50
Kerala women now have very low levels of vitamin D
than what is recommended.51 Though the academic
pressure during the adolescent age group is heavy in
both sexes in South India, studies have shown that
girls drop more than the boys in physical activity,
which could be the reflection of the socio- cultural
factors.52
The health status of women in Kerala
The younger age escalation of non communicable
diseases in women was initially observed in hospital
admission reports for myocardial infarction during a
period of 20 years from 1967 to 1987.53 This period
was associated with expansion of medical facilities,
increasing population age and improved knowledge
of the disease. But increase was more marked in
younger age group and more in women where the
female male ratio for admission declined from 23:1 to
9:1. The just completed Kerala Acute Coronary
Syndrome (ACS) Registry also confirmed the same
with majority of the ACS (75%) occurring before the
age of 70years, and a further decline in male female
ratio for admission to 4:1.54,55 In a large community
survey in Kerala, the age adjusted stroke mortality
was double that in United States and Japan and the
gender related decadal delay was absent.56 Loss of
this biological delay in the onset of cardiovascular
diseases in relation to globalization formed the basis
of 'Go Red for Women' Campaign by the American
Heart Association. 57 Breast cancer prevalence in
women in Kerala, as per the regional cancer registry,
has increased over 6 times in the last three decades.58
The epidemiologic transition in Kerala has
adversely affected women's health in the
reproductive age group as well. Kerala women in the
reproductive age group are obese. 2,3,27 The recent NCD
survey in Kerala had a 3.7% prevalence of diabetics
below the age of 30yrs. and all were women.4 The
hypertension survey in children of Kerala had shown
a significant step increase in girls in the adolescent
age group, and it was above the US standards, unlike
boys.59 Survey under the Community Intervention for
Health in adolescent children showed that
prevalence of hypertension in Kerala Girls is higher
than boys.60 The younger age escalation of risk factors
occurring in other sites in India shows an exponential
increase in women in the reproductive age group.9
Gestational diabetes in South India has shown a four
fold increase, from 4 to 16% form late 1990s to 2008.61
Polycystic ovarian disease, which is known marker
for adult onset diabetes and cardiovascular disease,
is now an emerging epidemic(>10%) in adolescent
girls in Kerala.62
KHJ Kerala Heart Journal
 Review articles
The altered nutrition cycle and the genesis of
early life growth perturbation:
The main factors leading to positive energy
balance in women in the reproductive age group in
Kerala as outlined generates a hyper insulinemic
state in them, which is the fore-runner of the cardio-
metabolic risk factors.26 This was encouraged with the
hope to break the vicious cycle of nutrionaly stunted
mother giving birth to low birth weight babies who
then grow up as nutritionally stunted children and
adolescents.21,63 This insulinogenic nutrition turned
out to be counter productive as evidenced by the
exponential increase in cardio-metabolic risk factors
in the women of reproductive age group in the last
three decades (table 2).9 Though the components of
positive energy balance could be universal, the people
of Kerala were more susceptible to this because of the
high prevalence of low birth weight and child hood
stunting and the specific socio-cultural factors
peculiar to women in Kerala. Low birth weight babies
and stunted children have lower body water and
metabolic insult of high calorie diet and postprandial
changes could be higher in them.64,65
Low birth weight babies in India are known to be
sarcopenic.66 Low birth babies have the substrate for
the genesis of non communicable disease risk
factors.67,68 Similarly Low birth weight babies are
insulin resistant.69 Women in India have 10 fold risk
of developing gestational diabetes.70 To what extend
the low birth weight children contribute to this
increased risk is currently unknown, but could be
substantial. Follow up of children born to diabetic
mothers show an earlier development of cardio-
metabolic risk factors in a cohort follow up study from
South India.71 Gestational diabetes mellitus could
also increase the chances of gestational hypertension
and low birth weight babies and cause a variety of
growth perturbations in the offspring.61,72
The increase in maternal obesity, gestational
diabetes, and hypertension are documented factors
for persistence of Low birth weight babies in
Kerala.11,12 This vicious cycle can be perpetuated by a
number of other micronutrient factors also. Vitamin
D, B12 and folic acid are now implicated by community
studies.73,74 Vitamin D synthesis is 6 times lower in
dark skinned people and lack of outdoor physical
activity and social custom of covering the body,
perpetuates this deficiency.75 Further women need 4
times more vitamin D during the reproductive age
group; no wonder vitamin D deficiency in women is
the order of 60% in women in this tropical climate.76
Vitamin D has a major role in the prevention diabetes
and cardio-metabolic risk factors.77
Though there is increasing prevalence of
obesity and non communicable disease risk factors
and diseases, the odds ratio for predicting the risk for
overweight and abdominal girth are only modest in
this population.4 Another population survey in Kerala
KHJ Kerala Heart Journal
A Journal of Cardiological Society of India, Kerala Chapter
also did not show the correlation between BMI and
the adult onset diabetes and cancer.78 Development of
non communicable disease risk factors at lower body
mass indices is a reflection of metabolically
obese normal weight individuals where
sarcopenia and adiposopathy drives the metabolic
abnormalities. 5 4 , 7 9 , 8 0 , 8 1 Three patterns can be
recognized in the relation between diabetes and
obesity.82 Those with appropriate adipocyte response
become obese and then become diabetic in the older
age group, well illustrated by the developed world
where the prevalence of obesity is above 30% with
10% of the population being diabetic. Evolution of
diabetes in the reproductive age group is supposed to
explain the high prevalence of diabetes and obesity in
Pima Indians.82 Maternal dysglycemia activates the
fetal pancreas, which in turn generates macrosomic
babies. This early stimulation of beta cell function
leads to premature beta cell failure. Such children
end up in dysglycemia during their reproductive life
perpetuating early onset of diabetes and macrosomic
babies who then grow up as obese dysglycemic
mothers.70 One the other hand sarcopenia and insulin
resistance drives the epidemic in the developing
world where in the prevalence of hypertension, and
cardiovascular risk factors could precede the
evolution of diabetes and morbid obesity because of
the adiposopathy.83 This dissociation between the
prevalence of hypertension and obesity is now well
illustrated in developed and developing world.83 The
younger age escalation of risk factors in the
reproductive age group can perpetuate itself, to
generate a vicious cycle.25 The early life growth
perturbations, perpetuates younger age escalation of
risk factors, which in turn generates a new set of
children with abnormal programming as shown in
figure 1. Therefore developmental origin of the adult
onset diseases (DOAD) and in-utero risk factors could
be a major driving force for this double burden, now
noted in Kerala over the last 30 years.84 Obesity is the
driving force for the non communicable disease
epidemic in the developed world and could precede
the onset of risk factors and diseases. Earlier onset of
risk factors in developing countries is heralded by in
utero risk factors and sarcopenia, and low birth
weight. Low HDL which is a marker of hyper-
insulinemia and declining physical activity is now
seen in > 50% of adolescents.25 The younger age
escalation of risk factors in women in reproductive
age group has now evolved as the worst subset in
perpetuating this vicious cycle. 25
Sarcopenic adiposity and insulin resistance of
low birth weight babies and stunted children are
perpetuated by lack of outdoor physical activity. Both
the factors which make the developing world distinct,
namely the younger age escalation of risk factors and
failure of adiposity markers to predict the risk factor
and diseases can be explained by the proposed new
nutrition cycle (figure 1).
17
 A Journal of Cardiological Society of India, Kerala Chapter Review articles

New nutrition cycle 2 hours is needed to generate adequate vitamin D

Old nutrition cycle levels in adolescent children.50 This radical change in
High prevalence of lifestyle characterized by physical inactivity which is
Cardiovascular In-utero
Low birth weight
baby
diseases programming Energy dense
enforced at menarche is marked by a step increment
food in blood pressure as noted by the survey done in
children.59Adolescent children should be relieved of
Short mother Younger age onset
the academic tension, and encouraged to take part in

rs et
Stunted child

cto ns
of risk factors

fa o
outdoor sports, and provided a heart healthy diet and

k ge
ris r a
of nge
exercise friendly dress code. Energy dense marketed

u
Stunted

Yo
Lake of physical
adolescent Stress & endothelial
dysfunction
activity foods are highly insulinogenic. 2 6 The hyper-
insulinemia generated by such foods could be worse
for low birth weight babies given their sarcopenia
Figure 1: the nutrition cycle old and new depicted by the and lower body volume.86 Frequent smaller feeds
dark cycles and thin arrows. The lighter circle and short arrows could minimize this hyper-insulinemic metabolic
show the drivers and the dark arrow the final outcome. insult.
The process of breaking the new nutrition
cycle is summarized in figure 2. Achieving the best
60% of the insulin sensitivity in the body is possible body composition at peak adolescence could
generated by skeletal muscle, but loss of muscle mass be the best way to postpone the early onset of cardio-
is an unavoidable accompaniment of aging.85 The metabolic risk factors in Kerala. The Go red for
resultant insulin resistance is aggravated by the women campaign for women initiated by the
endocrine metabolic programming, endothelial American Heart Association and the World Heart
dysfunction, and the insulinogenic nutrition. The Federation seems to be most relevant for Kerala.89
most affected are the children with abnormal in- Energy dense nutrition can not be a universal
utero endocrine programming.86 Improving the lean prescription for malnutrition. It needs to be tailored
muscle mass during child hood and adolescence is the to induce proportionate body growth and
best way to minimize the metabolic derangement and composition. The Vitruvian man outlined by da
postpone the younger age onset of risk factors.25 Vinci centuries ago could represent that idealism.90
Driving force for the current epidemic in Kerala is the
energy dense nutrition and the lack of physical
activity perpetuated by the heavy academic pressure
and the dress code which hinders physical activity in
a tropical climate. The development of metabolic risk
factor in the reproductive age group further Post pone the onset In-utero Reduce food
of risk factor programming energy density
perpetuates the in utero programming maintaining
the vicious cycle.
Strategies for breaking the vicious cycle
Vitamin D, Folate & B12
The behavioral changes which can favorably
reduce these risk factors in the reproductive age
Healthy adults
group are to encourage outdoor physical activity and
th

healthy diet from childhood. 87 It is in this context the

ow
gr

recent high level meeting of the United Nations

te
a

General Assembly on Non Communicable diseases

on

Reduce salt &

rti

gains it relevance to the State of Kerala. 88 Improve physical

o

academic pressure
op

activity
Pr

Strategies for prevention of lifestyle related

diseases are well known, but needs to be targeted to
tackle the components of this vicious cycle.64 The data
from Kerala clearly points to the fact that women in
Kerala form the early victims for the new nutrition
cycle, because of the exponential increase in risk
factors. Risk of Heart attack in women in the younger Figure 2: Line diagram to disrupt the new nutrition cycle.
age group has increased at least 5 times in Kerala Reducing the energy dense food substances and improving
and diabetes at least 4 times in the last three physical activity during childhood and adolescence will
decades.25 Adolescent women in Kerala are neither ensure proportionate growth and health during reproductive
habituated to the use of tobacco nor alcohol. But by age group there by avoiding the abnormal in-utero
social custom, girls are forced to wear clothes programming which lays the foundation for the early age
covering the whole body, and to remain indoors after onset of cardio-metabolic risk factors
adolescence. Exposure of at least 40% of the body for

18 KHJ Kerala Heart Journal

 Review articles
Acknowledgement
“This publication was made possible by grant number 1
D43 HD065249 from the Fogarty International Center and the
Eunice Kennedy Shriver National Institute Of Child Health &
Human Development at the National Institutes of Health.”
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