DHANVANTARI ORATION - 2012
|Year : 2012 | Volume
| Issue : 2 | Page : 71-78
Nexus of poverty, energy balance and health
Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
|Date of Submission||15-Mar-2012|
|Date of Acceptance||19-Mar-2012|
|Date of Web Publication||12-May-2012|
C P Mishra
Professor and Head, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi- 221 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Since the inception of planning process in India, health planning was an integral component of socio-economic planning. Recommendations of several committees, policy documents and Millennium development goals were instrumental in development of impressive health infrastructure. Several anti-poverty and employment generation programmes were instituted to remove poverty. Spectacular achievements took place in terms of maternal and child health indicators and expectancy of life at birth. However, communicable diseases and undernutrition remain cause of serious concern and non-communicable diseases are imposing unprecedented challenge to planners and policy makers. Estimates of poverty based on different criteria point that it has remained a sustained problem in the country and emphasizes on revisiting anti-poverty programmes, economic policies and social reforms. Poverty affects purchasing power and thereby, food consumption. Energy intake data has inherent limitations. It must be assessed in terms of energy expenditure. Energy balance has been least explored area of research. The studies conducted in three different representative population group of Eastern Uttar Pradesh revealed that 69.63% rural adolescent girls (10-19 years), 79.9% rural reproductive age group females and 62.3% rural geriatric subjects were in negative energy balance. Negative energy balance was significantly less in adolescent girls belonging to high SES (51.37%), having main occupation of family as business (55.3%), and highest per capita income group (57.1%) with respect to their corresponding sub-categories. In case of rural reproductive age groups, this was maximum (93.0%) in SC/ST category and least (65.7%) in upper caste group. In case of geriatric group, higher adjusted Odd's Ratio for negative energy balance for subjects not cared by family members (AOR 23.43, CI 3.93-139.56), not kept money (AOR 5.27, CI 1.58-17.56), belonging to lower and upper middle SES by Udai Pareekh Classification (AOR 3.73, CI 1.22-11.41), with lowest per capita income (AOR 15.14, CI 2.44-94.14) and in age group >80 years (AOR 5.76, CI 1.03-32.39). Of those in negative energy balance, 70.21% rural adolescent girls and 7 out of 10 geriatric subjects (activity based) were victims of CED. Extent of undernutrition and CED in rural reproductive age group females were more in those caste groups where energy deficit was also of higher magnitude. Energy balance must be visualized giving due consideration to the importance of exercise on human health. The evidence thus generated needs to be translated to the masses based on principles of translational research.
Keywords: Chronic energy deficiency, energy balance, poverty, translational research
|How to cite this article:|
Mishra C P. Nexus of poverty, energy balance and health. Indian J Community Med 2012;37:71-8
| Introduction|| |
After about 200 years of colonial rule marked by a number of challenges and calamities, India won its independence in 1947 through the sustained efforts of social, spiritual, religious and political leaders of the 19 th and early 20 th century. People had to undergo great social and economic hardships; millions had to suffer oppression and humiliation. When freedom came, the nation was confronted with the wounds of partition, widespread poverty and diseases, and to compound it all, lack of resources for providing the basic amenities. 
Health planning was considered as an integral component of national socio-economic planning. In fact, there was no dearth of men and women of talent, ability and wisdom who took up the challenge and gave a lead to the country through planned five years social and economic developmental plans.
Recommendations of committees under the chairmanship of Sir Joseph Bhore (1946), Mudaliar (1962), Chadha (1963), Mukherji (1965 and 1966), Jungalwalla (1975), Kartar Singh (1973), Srivastava (1975) and the report of the Working Group (1981) of Health For All by 2000 AD served as basis for national health planning in India. National Health Policy (1983), National Nutrition Policy (1993), The Calcutta Declaration of Public Health (1999), National Population Policy (2000), Millennium Development Goals (2000) and National Health Policy (2002) provided policy framework for health development culminating in the most ambitious National Rural Health Mission of Government of India in 2005. The People's Charter for Health (2000) and Health Vision 2020 India document under Chairmanship of Dr. A.P.J. Abdul Kalam added newer facets in the planning process of the country. 'India 2020' with the vision of transforming the nation into a developed country identified five areas for integrated action to double the growth rate of GDP for the realization of the vision. These areas are agriculture and food processing, infrastructure with reliable and quality electric power including solar farming, providing urban amenities in rural areas and interlinking rivers, education and health care, and information and communication technology and critical technologies and strategic industries.
Realizing poverty as the root cause of many evils Government of India started several [Table 1] anti-poverty and employment generation programmes. 
Although our achievements have been spectacular in terms of maternal and child health indicators , and expectancy of life at birth, our failures are still greater. The problem of communicable diseases and under-nutrition remain cause of serious concern and non communicable diseases are imposing unprecedented challenge  to planners and policy makers. Nothing has been more elusive than the concept of poverty.
| Dimensions and Measurements of Poverty|| |
It is too difficult to define and measure poverty in precise terms. It depicts a situation where people live under sub-human condition.  Most of the people of today's world or past have or had no problem in understanding the general meaning of the word 'poverty'. It is a multi-dimensional phenomenon and refers to deprivation or inequality which can be considered as two faces of the same coin. All the definitions of poverty take in to cognigence standard level of reference such as "custom of the country" or "minimal acceptable way of life in the member state" or the "minimum standard of living" [Table 2].
Poverty can be viewed from three angles: (a) relative monetary poverty or scarcity of resources as compared with population averages; (b) poverty measured through physical indicators and (c) subjective poverty. 
Poverty must be regarded as general form of relative deprivation which is the effect of mal-distribution of resources. Needs which are unmet can be defined satisfactorily only in terms of relative to society in which they are found or expressed. Distinction hitherto made between absolute and relative poverty, between basic and cultural needs are argued to be unreal upon analysis. 
Kurian (1978) stressed that poverty may be considered as deprivation but not only deprivation. He conceptualized poverty as a socio economic phenomenon whereby the resources available to a society are used to satisfy the 'wants' of few while many do not have their basic needs met. 
Adiseshih (1990) has enumerated four essential features of deprivation viz. (a) deprivation of basic necessities of life- food, clothing and housing from which all other accompanying deprivation flow, educational and intellectual deprivation, cultural and moral deprivation, in what anthropologists have come to call the culture of poverty. (b) Deprivation means being deprived of what one is entitled to e.g. a descent standard of life (c) Varying intensity of deprivation e.g. poorest of the poor, very poor and poor and (d) Deprivation of many due to abundance of few.  According to UN poverty refers to human conditions with sustained and chronic deprivations of resources, capabilities, choices, security and power required for the enjoyment of an adequate standard of living and other civil, cultural, economic, political and social rights. It is inability to gratify physiological (survival, safety, security) and social (autonomy, independence and self actualization) needs. Whatever may be the conceptual problem, poverty is a curse on humanity. Its continued existence does reflect the incapacity of the man to vanish it and it is indeed shameful that humanity despite its great achievement in the field of science and technology has so far failed to remove it from the surface of the earth. Thus, no other task needs a high priority than of reducing poverty.
No one indicator can fully capture the numerous facets of poverty among which are low average consumption and wages, inadequate nutritional intake, vulnerability to various diseases, low literacy rate and gender related disadvantages. However, poverty line is single summary index for encapsulating trends and patterns of poverty and framing issues in this regard.  Poverty line refers to the threshold of the level of indicators below which people are called poor and above which are considered non poor. For the sake of simplicity, monetary indicators are usually preferred as they provide the one dimensional synthesis of this plural phenomenon. For measurement of poverty one may select a number of resources say 'n' and the level of each individual can be represented as an 'n' dimensional vector, each of component measuring the position of the individual with regard to each of the selected resources. Using different criteria, estimates of poverty in India have been made [Table 3].
The problem in using poverty line is that it makes worth while for the policy makers seeking credits for achievements in "garibi hatao". Pushing them a little higher up brings rich dividends in terms of this poverty measure while the credit for pushing up even poorer people is likely to be zero on this measure unless they are pushed up quite a bit. The proportion of people below poverty line does not tell how poor the poor are. Considering this issue, a large number of researchers have developed measures of poverty in the form of various indices of poverty viz. Sen's Index, Thorn's Index, Takeyama Index and Kekawani Index. 
| India's economic policies and social reforms|| |
India had started out in 1950s with high growth rates, openness to trade and investment, a promotional state, social expenditure awareness and macro stability but ended in 1980s with low growth rates, closure to trade and investment, a license- obsessed, restrictive state (License Raj), inability to sustain social expenditures and macro stability, indeed crisis.  Poverty has decreased significantly since reforms were started in the 1980s. , The labyrinthine bureaucracy often led to absurd restrictions - up to 80 agencies had to be satisfied before a firm could be granted a license to produce and the state would decide what was produced, how much, at what price and what sources of capital were used.  Economic reforms initiated in the early 1990s are responsible for the collapse of rural economies and the agrarian crisis currently underway with resultant wave of farm suicides in Indian rural population from 1997 to 2007.  Some government schemes such as the Mid-day Meal Scheme and the NREGA have been partially successful in providing a lifeline for the rural economy and curbing the further rise of poverty. Social reforms and the implementation of reservations in employment and benefits have been responsible for steady rise in empowerment of Dalits. However, casteism is still widespread in rural areas and continues to segregate Dalits. They constitute the bulk of poor and unemployed. Caste is still a major determinant of socio economic status of rural households. 
In spite of green, blue and white revolutions in India, our achievements in nutritional front have been not up to the mark. About 49 percent of the world's underweight children, 34 percent of the world's stunted children and 46 percent of the world's wasted children, live in India.  Food security has been major developmental objective of India since the beginning of the planning. India achieves self sufficiency in 1970s and has sustained it since then. But their achievements of food grain security at national level did not percolate down to the households and level of chronic food insecurity is still high.  As per NFHS-2 and NFHS-3 there has been marginal changes in malnutrition and chronic energy deficiency in women over a period of seven years. , While poverty is often the underlined cause of malnutrition in children, the superior economic growth experienced by South Asian Countries compared to those in Sub Saharan Africa has not translated in to superior nutritional status for South Asian children.
Initiatives to alleviate poverty helped to eliminate famines and cut absolute poverty by more than half. According to a new UN Millennium Development Goals Report, as many as 320 million people in India and China are expected to come out of extreme poverty in the next four years, while India's poverty rate is projected to drop to 22% in 2015. However, 2011 Global Hunger Index (GHI) Report ranked India 45th, amongst leading countries with hunger situation. 
Massive parallel economy in the form of black (hidden) money stashed in overseas tax havens and under utilization of foreign aid have also contributed to the slow pace of poverty alleviation in India. ,, Indian economy has grown steadily over the last two decades, its growth has been uneven when comparing different social groups, economic groups, geographic regions, and rural and urban areas. , Between 1999 and 2008, the annualized growth rates for Gujarat (8.8%), Haryana (8.7%), or Delhi (7.4%) were much higher than for Bihar (5.1%), Uttar Pradesh (4.4%), or Madhya Pradesh (3.5%). 
Corruption is the main cause of poverty in India. High population growth rate is considered as symptom rather than cause of poverty by demographers. While services and industry have grown at double digit figures, agriculture growth rate has dropped from 4.8% to 2%. About sixty percent of the population depends on agriculture whereas the contribution of agriculture to the GDP is about eighteen percent.  The surplus of labor in agriculture has caused many people to not have jobs. Farmers are a large vote bank and use their votes to resist reallocation of land for higher-income industrial projects. Poverty affects purchasing power and thereby food consumption.
| Methodological Issues in Computation of Energy Intake and Expenditure|| |
Adequacy of food is judged against the yardstick of recommended dietary allowances (RDA). In defining the RDA for specific nutrients, it is assumed that the requirements of all nutrients are adequately met. RDA is applicable only in this condition to a healthy normal population living under normal conditions. It aims at meeting the requirements of all individuals in population. Generally mean ± 2 SD is chosen to define RDA (safe level of intake). This approach is not used in case of energy. Since excess energy intake is as undesirable as inadequate intake, only the average intake requirement is defined as RDA. Ideal energy requirement is the level of energy intake from food that balances energy expenditure when the individual has a body size and composition and level of physical activity, consistent with long-term good health, also allowing for maintenance of economically essential and socially desirable activity. Energy requirement must be assessed in terms of energy expenditure rather than in terms of energy intake. , It is not essential that man should be in energy balance on a day-to-day basis. However, over a period of a week or a fortnight, he can be in energy balance, that is, his daily energy expenditure and daily energy intake averaged over this period should be in a state of balance. An analysis of energy intake data is not helpful because (a) it is possible to have a grossly inadequate intake by individuals who, in the face of maintaining normal obligatory energy expenditure, respond by weight loss so that they become substantially underweight as in underdeveloped and developing countries; (b) energy intake far above the energy expenditure is harmful leading to overweight and obesity and is associated with chronic disorders as in populations of affluent countries; (c) recommended dietary intake for energy is intended for a healthy, well nourished and active population. It needs to be recognised that RDA is not meant to be used as standard to determine whether or not individual requirements have been met. It does not imply that an individual who has an intake below the RDA is necessarily at risk, since there will be several individuals in the population whose requirements will be well below the RDA. This point must be kept in mind while applying RDA at the individual level. For this purpose probability approach may have to be used. Energy requirements are based on factorial and activity break-up approach. Energy requirements of Indian adult man were computed using both Indian and Western data. Available data on BMR of Indians were used for computing the energy cost of sleep. Activity component from different daily activities was however, computed from Western data. Physical activity level (PAL) and physical activity ratio (PAR) are used for these computations.
PAL = Total PAR-hours / Total time
Where, PAR= Energy cost of an activity pre minute / Energy cost of basal metabolism pre minute
The energy expenditure for specific tasks when expressed as ratio of BMR as PAR values is similar in men and women and individuals with different body weights and ages. Expressing daily energy requirements in terms of PAL values would automatically take care of the problem of lower BMR of certain population groups such as Indians.
The principle of using the PAL values for computing daily energy requirement has been followed by the FAO/WHO/UNU Expert Consultation in 2001. However, this expert consultation has used two other principles (a) Individually calibrated heart rate monitoring (HRM) method, and (b) Doubly Labelled Water (DLW) technique. Daily energy expenditure of adults depends on their occupational activity, sleep and non-occupational activity, each typically for eight hours in a day. FAO/WHO/UNU have adopted factorial method to estimate the energy requirements of adults. It largely depends upon the body weight, from which the subjects' basal metabolism is predicted, and then to which energy spent during the activities of the day are related, as the PAL value. Therefore, TEE = Predicted BMR x PAL.
PAR values for some activities and equations for predicting BMR by FAO/WHO/UNO (1985) and ICMR (1989) serve as basis for factorial computation of energy expenditure of adult Indian population (ICMR 1990 and 2010). ,
| Negative Energy Balance and Their Correlates|| |
Rural adolescent girls
Although several studies have been undertaken on dietary intake of adolescent girls, studies on their energy expenditure and thereby energy balance are practically non-existent. In order to explore the extent of negative energy balance and their correlates, a community based cross-sectional study was done on 270 adolescent girls of a rural area of Varanasi.  The study subjects were drawn by appropriate sampling technique. Their energy intake was estimated by 24 hours oral questionnaire method. Estimation of energy expenditure was based on physical activity which was noted by 24 hours activity recall method. Energy expenditure of each study subject was determined by multiplying their BMR and rate of energy expenditure. As much as 69.63% subjects were in negative energy balance. Majority of the subjects belonging to lower (79.37%) and middle (75.19%) socio-economic status (SES) category were in negative energy balance. This was significantly less in subjects belonging to high SES (51.37%), having main occupation of family as business (55.3%) and highest per capita income group (57.1%) with respect to their corresponding sub-categories. Association of negative energy balance with age, caste, highest education in the family, literacy status of the adolescent girls, working status of adolescent girls, literacy status of father, type of family, nature of diet of study subjects, illness at the time of survey were not statistically significant.
Rural reproductive age-group females
A community-based cross-sectional study was conducted on 462 currently married female in the age-group 15-49 years in 360 households to find out the status of energy balance.  Dietary intake was determined by 24 hours recall using standardized utensils. The various activities performed by them in previous 24 hours were assessed by interview technique. Bouchard et al method was used for determination of average physical activity ratio and BMR was computed using ICMR equation. To know the adequacy of energy intake in comparison to energy expenditure, the ratio of energy intake to energy expenditure were computed. Caste has been considered as a major determinant of socio-economic status in rural households. As much as 79.9% study subjects were in negative energy balance. In all caste groups more than three-fifth of the study subjects were in negative energy balance; this was maximum (93.0%) in SC/ST category and least in upper caste group (65.7%). As much as 20.2% study subjects were in positive energy balance. This was maximum in the upper caste group (34.8%).
Rural geriatric subjects
When energy expenditure was estimated on the basis of activities of the study subjects and their multipliers, 62.32% subjects were in negative energy balance.  Majority (84.58%) of the subjects were in the positive energy balance when their energy requirement was assessed on the basis of BMR and its multipliers. Energy balance was more than 100% in 54.9% subjects belonging to other caste category: corresponding value in OBC and SC categories were 41.4% and 0.0% respectively. In comparison to nuclear families (8.3%) positive energy balance was significantly (P<0.01) more in joint family and families categorized as 'others'. In subjects with the family size >6 positive energy balance was to the extent of 40.0% whereas 45.5% subjects with yellow card were in the same status (P<0.01%). With increasing per capita income as well as socio-economic status there had been significant (P<0.01) increase in the positive energy balance of study subjects. Negative energy balance was significantly (P<0.01) more in widow/widower (71.1%), illiterates (69.3%), subjects engaged in labour (75.0%), house work (69.0%) and agriculture work (58.89%) and unemployed (63.2%). Positive energy balance was significantly more (P<0.01) in subjects cared by the family (45.2% versus 10.6%) with decision power (50% versus 27.7%) and kept money with them (48.1% versus 21.4%). Logistic regression analysis revealed higher adjusted odd's ratio (AOR) for negative energy balance for subjects not cared by family members (AOR 23.43, CI 3.93-139.56), not kept money (AOR 5.27, CI 1.58-17.56), belonging to lower and lower-middle (AOR 3.73, CI 1.22-11.41) SES by Udai Pareekh classification, with lowest per capita income (AOR 15.14, CI 2.44-94.14) and in age group >80 years (AOR 5.76, CI 1.03-32.39).
| Linkage Between Negative Energy Balance and Nutritional Health|| |
Nutritional status of rural adolescent girls referred earlier revealed that 70.21% subjects with negative energy balance were victim of chronic energy deficiency.  The study on negative energy balance, under nutrition and chronic energy deficiency in rural reproductive age group female conducted in a district of eastern Uttar Pradesh revealed that the energy deficit was closely associated with their nutritional status. It was evident that extent of under nutrition and chronic energy deficiency were more in those caste groups where energy deficit was also of higher magnitude. The prevalence of CED among females of upper and middle class groups was found to be half of the SC/ST caste groups. 
The study in the geriatric age group revealed that seven out of 10 subjects in negative energy balance (activity based) were victims of chronic energy deficiency. 
It is expected that positive energy balance will lead to adequate nutrition. However, when cross sectional study is done, relationship may not be precise because of seasonal variation in the dietary intake which is in fact governed by availability of food and purchasing power of people. Another factor which may affect nutritional status is the degree of positive and negative energy balance.
Exercise helps to control weight, improve blood circulation, increases flexibility, and lowers blood pressure and blood sugar levels. Further, it also improves emotional well beings, relieves stress, increases energy level, improves balance thereby dangers of falls and improves bone density thereby preventing osteoporosis
There are three distinct stages in the maturation process of any programme viz. conceptual, operational and practice stage. The evidence thus generated needs to be translated to the masses based on the principles of translational research (TR), which refers to the way of thinking about and conducting scientific research to make the results of research applicable to the population under study. Community is our ward and families are our bed: thus, TR is of relevance to our discipline as it takes research from the 'bench to bedside'. However, the classical NIH TR Road Map needs to be operationalized accordingly, more so, in Indian context. There are two Indias in India. One India is the land of privileged class who are totally 'globalized' and 'liberalized', and have no restrain in conspicuous consumption and the display of their wealth and spends thousands of rupees on Valentine's day. The other India, the 'little India' is the land of several hundred millions hungry, sickly, illiterate and typically oppressed people with no productive assets. They are caught in vicious circle: 'poor producing more poors'. Because of enormous backlog of poverty, their future is bleak. Yet, they are singing 'Malhar' in front of their burning huts. Issue of energy balance is applicable in both the cases. We have our future responsibility towards Science, Society and Services to the Mankind and nothing can be more relevant than addressing to the issues related to nexus of poverty, energy balance and health.
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[Table 1], [Table 2], [Table 3]
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