Research Article
Changing Perspectives of Tribal Health in the Context of Increasing Lifestyle Diseases in India
Gautam Kumar Kshatriya*
Department Of Anthropology, University Of Delhi, Delhi 110007, India
*Corresponding author: Gautam Kumar Kshatriya, Department Of Anthropology, University Of Delhi, Delhi 110007, India, E-mail: g26_51@yahoo.co.in
Article Information: Submission: 07/06/2014; Accepted: 19/06/2014; Published: 24/06/2014
Abstract
The total Scheduled Tribe population of India stands at 104,281,034 as per 2011 census and accounts for 8.6 per cent of the total population of the
country. In spite of the concerted efforts by the Government of India, the tribal population groups are lagging behind Indian National population in most of
the demographic and social and economic indicators. Similarly, a large number of these tribal groups also show prevailing dismal health conditions. The
major focus of various studies related to health issues among tribal populations of India has been on malnutrition or under nutrition. Like all other developing
countries, large scale urbanization/modernization has been taking place in India with effective changes in the lifestyles leading to appreciable increase in the
prevalence of chronic metabolic conditions like cardio vascular diseases (CVD), diabetes, metabolic syndromes. The benefits of development in education,
health and income generation have resulted in a significant amount of mainstreaming of Indian tribes. A number of tribal groups are capitalizing on economic
opportunities that are available to them, with a desire to acquiring a better life style with modern life comforts. And thus many of the tribal populations of India
are becoming susceptible to various metabolic risk factors that may be related to their dietary profile and physical activity. Therefore, it is worth investigating
the changing perspectives of health among the tribes of India in the context of increasing life style disease in India. Precisely for this reason present paper
highlights not only the prevalence of under nutrition and malnutrition among the Indian tribes, but, also tries to implicate the association of age, sex and
Body Mass Index (BMI) with the different metabolic health risk factors using data among six tribes in Birbhum district of West Bengal and Mayurbhanj district
of Odisha, India. Results of the present study indicate that young tribal males are showing increasing tendency towards growing body weight, against the
traditional wisdom, which in turn has been found to be strongly associated with metabolic risk factors. Tribal females are in more danger of developing
metabolic risks at lower BMI, irrespective of age, clearly indicating an increasing tendency towards a double burden of disease among the Indian tribal
populations. Therefore, this changing pattern of health among Indian tribes needs to be addressed immediately before the situation becomes too alarming.
Introduction
The Constitution of India recognizes the indigenous tribal groups
or Adivasis or Janjatis as a special category and has designated them
as the Scheduled Tribes. Mahatma Gandhi called the tribal people
as Girijan. [1] Article 366 (25) defined STs as “such tribes or tribal
communities or parts of or groups within such tribes or tribal
communities as are deemed under Article 342 to be STs for the
purpose of this constitution”. [2] Article 342 prescribes procedure
to be followed in the matter of the specification of STs. The Indian
constitution has recognized nearly 700 types of tribal population
groups as Schedule Tribes. The total ST population of India stands
at 104,281,034 as per 2011 census and accounts for 8.6% of the total
population of the country [3]. The decadal population growth between
census years 1981 to 1991 in respect of tribal population has been
higher (31.64%) than that of entire population (23.51%). Similarly during census years 1991 to 2001 it has been 24.45% against the
growth rate of 22.66% for the entire population [4,5]. As per the latest
census data, the change in decadal growth of ST population during
2001-2011 is 23.7% [3,5]. As compared to the sex ratio for the overall
population (933 females per 1000 males) the sex ratio among STs is
more favorable, at 977 females per 1000 males [5]. This trend (990
females per 1000 males; Census 2011) also continued with respect
to overall population of India (940 females per 1000 males; Census
2011). The literacy rate among the STs has increased from 29.62% to
47.10% during the period from 1991 to 2001 and it is 63.1% by 2009-
10 [6] (NSS 66th round Report no 543, 2009-10). The infant mortality
(62.1; NFHS 2005-06), under 5 mortality (95.7; NFHS 2005-06) and
% of children under weight (55.9) in respect of STs is higher than
that of the overall population as well as of other disadvantaged socioeconomic groups [7].
The main concentration of tribal population is in central India
and in north-eastern states. However tribals are present in all states
and Union Territories except Haryana, Punjab, Delhi, Pondicherry
and Chandigarh. The states of Madhya Pradesh, Maharashtra,
Gujarat, Rajasthan, Orissa, Bihar, West Bengal and Andhra Pradesh
account for around 83% of the total tribal population of India. The
tribal population of India inhabits widely varying ecological and
geo-climatic conditions (hilly, forest, desert regions etc) in different
concentration and with different socio-economic background. Tribal
groups are homogenous, culturally firm, have developed strong
magico-religious health care system and they wish to survive and live
in their own style [8].
The economic practices in everyday life of tribal society is highly
diverge which further varies from one tribal group to other. Many
tribal populations of eastern, southern and central India (Chola
Naikan, Juang, Birhor, Kadar, Chenchu, Hill Khadia and Makadia)
and the Andaman islanders are efficient food gatherers and hunters.
There are many tribal populations of north eastern, central and eastern
region (Khasi, Naga, Kutia Kondha, Korwa, Saora, Hill Muria, etc.)
who still practice shifting cultivation. There are settled agriculturists
(Bhil, Mina, Santal, Munda, Oraon etc.) at par with other peasant
communities in many parts of Madhya Pradesh, Gujarat, Rajasthan,
Maharashtra, Bihar, West Bengal and Orissa. And there are urban
industrial workers as well [9].
The differential access to outer world between tribal groups is
remarkably different. On one hand there are Jarwas with virtually no
contact with modern societies, on the other hand there are tribal
industrial workers in Ranchi, Jamshedpur, Bacheli (Bastar), Rourkela,
Bhilai etc. According to 2001 census 44.70% of the ST population were
cultivators, 36.9% agricultural labourers, 2.1% household industry
workers and 16.3% were other occupation workers. Thus about
81.6% of the main workers from these communities were engaged in
primary sector activities.
It is generally agreed upon that the health status of tribal
population of India is poor [10-16]. The widespread poverty,
illiteracy, malnutrition, problems of potable water, sanitary and living
conditions, poor maternal and child health services and practices,
ineffective coverage of national health and nutritional services,
communication facilities, prevalence of genetico-environmental
disorders, have been traced out in several studies as possible
contributing factors for the dismal health conditions prevailing
among the tribal population of India. Unfortunately not many tribes
are studied comprehensively for assessing the health status and its
associated determinants.
Nutritional Status and Maternal and Child Health
Nutrition status of individuals and general health condition
indicates the socio-economic condition prevalent the society. The
pattern of health and nutrition problems of the tribal population
of India is highly varied.. Nutritional problems of various tribal
communities located at various stages of development are full of
obscurities and very little scientific information on their dietary habits
and nutritional status are available due to lack of systematic and
comprehensive research investigations. Malnutrition is a common health issue in tribal areas and has greatly affected the general physique
of the population. Malnutrition lowers the ability to resist infection,
leading to chronic illness and in the post weaning period leads to
permanent brain impairment. Good nutrition is required throughout
life and is particularly vital for women to continue to remain in good
health and to do everyday household work. Nutritional anemia is a
major problem for women in India and more so in the rural and tribal
belt. Maternal malnutrition is predominantly a serious health problem
among the tribal women especially for those who have closely spaced
multiple pregnancies. Such health condition also reflects the complex
socio-economic factors that have serious bearing on their health. The
nutritional status of pregnant women is also crucial for the infants’
chances of survival and subsequent growth and development. It
directly influences the reproductive performance of the women and
the birth weight of their children. Nutrition also affects lactation and
breast feeding which are key elements in the health of infants and
young children and a contributory factor in birth spacing.
Dietary Habit:
Dietary habit of most of the tribes in India is not satisfactory.
Tribal diets are generally grossly deficient in calcium, Vitamin A,
Vitamin C, riboflavin and animal proteins. Diets of south Indian
tribes, in general and Kerala in particular, are grossly deficient
even in respect of calories and total proteins. Studies carried out at
National Institute of Nutrition (1971) and Planning Commission
of India (Sixth five year plan, Government of India) reported a high
protein calories malnutrition along the rice eating belts. Surveys
on the nutritional deficiencies [17] among the tribals show a high
incidence of goiter, angular stomatitis among the Mompas of Assam
and Vitamin A deficiency among the Onges. A high incidence of
malnutrition was observed [12,18,19] in some PTGs like Bondas in
Koraput and in such other groups in Phulbani, and Sundergarh
district of Orissa and also among Bhil, Garasia of Rajasthan, Padar,
Rabari and Charan of Gujarat [15].Pulses, milk and milk products and other animal products
which were the main sources of protein are lacking in the diets of
tribal women of Trivandrum district, Kerala [20]. Deficits of calcium
in the diets of pregnant and lactating tribal women of western and
central India were reported by [21]. Detailed clinical examination of
the Kannikar tribal women showed that anaemia (90%), vitamin A
deficiency (30%) and niacin deficiency (10%) were prevalent among
these tribal women [20].
[22] ICMR bulletin (1996) documents high prevalence of goiter
and intestinal parasites in Baigas of Baigachak area of Mandla district
of Madhya Pradesh. RMRC Jabalpur reported incidence of Goitre as
11.6% among Bharias children below 5 years in Potal Kot valley in
Chindwara district of M.P. Study among Pauri Bhuniyas of Orissa [23]
showed that 52 women as against 17 men in a sample of 268 persons
suffered from diseases related to malnutrition. Historically it has been
observed that male and female individuals in tribal populations are
undernourished. Study among Kondhs, a major tribe in central
India has shown that over 55% of them consume less than 2000
calories per day [24] and most of them as little as 1700 calories [25]
compared to the ICMR stipulated requirement of 2400 calories.
Health care practices:
Findings from studies among tribal groups in Bastar district
shows maternal and childcare is largely neglected [26]. Proper and
preventive health practices like immunization and vaccination of
expectant mothers as well as new borns was largely absent. From
inception to termination of pregnancy, no specific nutritious diet is
consumed by women. The consumption of iron, calcium and vitamins
during pregnancy is poor. More than 90% of deliveries are conducted
at home attended by elderly ladies of the household. In addition a lot
of females suffer from ill health due to pregnancy and childbirth in
the absence of well defined concept of health consciousness.As far as the child care is concerned, both rural and tribal
illiterate mothers are observed to breast feed their babies. But most
of them adopt harmful practices of discarding of colostrum, delaying
the initiation of breast feeding and delaying the introduction of
supplementary foods. Vaccination and immunization of infants
and children have been inadequate among the tribal groups. Since
the personal hygiene is very poor, the under 5 children are the worst
sufferers and most vulnerable to infections.
Life style Diseases:
It is true that the major focus of various studies related to health
issues in tribal areas is on malnutrition. However, in the present
context, it has become absolutely essential to conceptualize such
studies which lay emphasis on assessment of the health status of
various tribal groups with respect to obesity, metabolic measures,
dietary profile and physical activity. Like all other developing
countries, large scale urbanization/ modernization has been taking
place in India with effective changes in lifestyles including food habits
and decreased physical activity attributable to evolving circumstances
of chronic conditions, for example dyslipidaemia, diabetes etc. Even
the tribal groups are subjected to such changes. The benefits of
development in education, health and income generation has resulted
in a significant amount of their mainstreaming. A number of tribal
groups are capitalizing on opportunities that are available to them,
with a desire to acquiring a better life style with modern life comforts.
In this process of acculturation their food habits are likely to undergo
substantial changes and so does the level of their physical activity.
Thus, in the present circumstances many of the tribal populations are
becoming susceptible to various metabolic risk factors that may be
related to their dietary profile and physical activity, and therefore, it is
worth investigating the prevalence of obesity and metabolic measure
and their association with dietary fatty acids among the adult males
and females of the tribal groups of different geographic regions. The
investigation of this nature, therefore, will help to understand the
magnitude and the intensity of problems related with obesity and
metabolic measures and their relationship with dietary profile in
culturally heterogeneous groups of different geographical regions of
India.There are however, few studies available on Indian population
that take into consideration dietary fatty acid profiles and their
associated risk with cardiovascular diseases, obesity and metabolic
disorders. The propensity to coronary heart disease (CHD) is
known to be high in people of Asian Indian origin [27,28]. There is evidence that Indian women may be worse of than men in many
aspects of risk for CHD [29]. Some risk factors for atherosclerosis
are particularly high among South Asians. These include high plasma
triglyceride (TG), increased level of total cholesterol (TC) and high
density lipoproteins (HDL) ratio (TC:HDL), type 2 diabetes mellitus
(T2DM), central or visceral obesity [30-32]. The Indian subcontinent
is characterized by cultural heterogeneity which results in differences
in food consumptions amongst the different communities across
the Indian Diaspora [32,33]. This diversity in food consumptions is
intriguing one and is unequivocally a potential risk factor for growing
catastrophe from many chronic conditions such as dyslipidaemia
in Asian Indians. Among Asian Indians one of the highest levels of
Lipoprotein was observed and correlated to CHD [34,37]. People in
this part of the world often use Vanaspati, a kind of hydrogenated oil.
This contains more than 50% Trans fatty acid [35]. An observation
on north Indian slum dwellers had reported that high oral intake of
Trans fatty acid increases LDL and lowered HDL level in circulation.
In addition Trans fatty acid also elevated the level of lipoprotein (a),
an independent risk factor for CHD. About 50% of Asian Indians are
vegetarians but their lipoprotein levels and rates of diabetes and CHD
are no different from those of non vegetarians owing to contaminated
vegetarianism, in which vegetarians manage to consume excessive
amounts of saturated and trans fatty acids [36]. Here it is in the fitness
of the case to state that most Asian Indians are lacto-ovo-vegetarians
unlike western vegetarians [37]. In the midst of altering lifestyles and
abundant use of Vanaspati to prepare foods, intake of trans fatty acid
is likely to increase further in the Asian Indians [31,32].
Most importantly, in Asian populations mortality and morbidity
from chronic diseases (eg. CHD) is occurring in people with lower
body mass index and thus they tend to accumulate intra-abdominal
or visceral fat without developing generalized obesity, i.e. BMI or %
body fat [38,39]. The metabolic syndrome that has been defined as
the constellation of CHD risk factors is associated with striking
tendency to central obesity in south Asians although they are no
more overweight than European or Americans [40,41]. People of
South Asian origin (e.g. Indians) have more centralized obesity for
a given level of BMI compared to Caucasians [42]. The prevalence of
T2DM and/or Dyslipidaemia are high for Asian Indians both in India
[43-46] and abroad [28,47-50]. It seems reasonable to argue that
dietary management including dietary guidelines would be useful
to retard the growing incidence of Diabetes in Indian population
[51]. In yet another study it has been argued that while dealing with
Dyslipidaemic Asian Indians, clinicians should consider obesity
measures, metabolic profiles and dietary fatty acids simultaneously to
better comprehend the condition [52].
Further, a number of studies have also been undertaken on Indian
populations and Asian Indians in relation to obesity, BMI, pattern of
subcutaneous fat, physical activity and ageing, and also some studies
have reported associated social, cultural and behavioral variables with
obesity measures [53-57].
Thus, studies related to health in transitional scenario among
these culturally heterogeneous vast majority of tribal groups of India
need immediate attention. More so, not only because of diversity in
food consumption but also due to the changes, which are coming up due to acculturation which have also affected their life style including
food habits due to modernism and has made them vulnerable to those
non communicable diseases, which were not common among them.
Precisely for these reasons we also recently undertook a study to
understand the association of age, sex and Body Mass Index (BMI)
with the different metabolic health risk factors; among six tribes
in Birbhum district of West Bengal and Mayurbhanj district of
Odisha, in the eastern part of India. Of the total 1,434 subjects in the
study; 705 were adult tribal males and 729 were adult tribal females
belonging to the age group between 20 to 60 years. We investigated
various aspects of BMI with respect to selected risk factors among
the males and females of indigenous population groups in the age
categories of ≤40 years and >40 years old. It was observed that a
considerable proportion of the studied population was suffering from
the stress of under nutrition. It is interesting to note that with the
stress of under nutrition they are also susceptible to hypertension.
It was also observed that in the pre-hypertensive risk category, the
overall prevalence was more pronounced between the two age group
categories. It is to be noted that tribal males in the ≤40 years old age
group were found to be in more danger of developing metabolic risks
like hypertension as compared to older males (>40 years old). Sesso et
al have shown in their study that MAP (Mean Arterial Pressure) may
be strongly associated with CVD (Coronary Vascular Disease) risk in
younger men [68]. Dyer et al observed that the steady component of
BP (highly correlated with MAP) was strongly associated with CVD
risk in their four Chicago epidemiological studies [69].
Our study shows that male individuals with BMI ≥25 kg/m2 are in a stronger association with hyper-normal MAP in both the ≤40 years and >40 years old age groups. However, younger males (≤40 years old) show strongest association with hypertensive MAP, as well as with hypertensive BP (Blood Pressure). We also found >40 years old tribal males were more likely to develop different metabolic risks when they had a low BMI status. The overall tribal male population with raised BMI was two or more than two times likely to develop metabolic risks. Role of increased BMI in contributing towards CVD risks among indigenous Indian populations (Nicobarese tribe) has been reported previously [70].
With respect to the tribal females, it was found that the prevalence
of the selected metabolic variables was higher than in the males,
in both the age groups. Schall, in her meta-analysis on traditional
and tribal societies has shown that older women are at double risk
of hypertension than older men [71]. However, the selected risk
measures among the females in the present study showed significant
association with low BMI, which explains the high under nutrition
stress among the females in both the younger as well as the older
age group. Dettwyler in his study among rural populations of Mali
showed that under nutrition among adult populations is due to
under nutrition stress during childhood, a low protein diet and hard
physical labour [72]. In the present study it can be inferred that the
high prevalence of hypertension among females with low BMI in the
middle or older age groups might be due to low BMI status during the
early years. The present results with respect to association between
high blood sugar and low BMI correspond to previous studies
showing the association between low BMI and glucose intolerance indicative of high glucose load [73-76]. The mean SBP (Systolic Blood
Pressure) and DBP (Diastolic Blood Pressure) with respect to all the
selected metabolic risks are much higher among the tribal females
than their male counterparts. A similar result has been observed in
another previous study involving tribal populations [77].
Previous studies [70,78-81] among indigenous populations in
India show that hypertension has a positive correlation with raised
BMI which further exacerbates with growing age. In this study, we
found that BMI is a strong facilitator of hypertension among tribal
males in general and among younger males in particular. We also
found that individuals with BMI ≥25 kg/m2 showed a strong
association with hypertensive BP and hypertensive MAP along with
hypertensive SBP and hypertensive DBP.
So, as per the findings of this study, individual BP parameters like
MAP, SBP and DBP can be considered to plot cardiovascular risks,
particularly in younger tribal populations. Increased age is a decisive
factor for increased hypertensive risk. Irrespective of age, a raised
BMI puts at risk the cardiovascular health of younger males. This has
also been observed in other Indian tribal groups [82,83]. Stini in his
hypothesis proposed that variation due to environmental stresses is
reflected more among males [84]. In the tribal women, low BMI is
highly prevalent, irrespective of age group, along with high prevalence
percentage of hypertension; making the association between raised
BMI non-significant with respect to most of the metabolic indicators
of hypertension. Such a trend is observable both in younger as well as
older females.
Conclusion
Previous studies among indigenous Indian populations have
shown an association of under nutrition and anaemia with high
BP [80]. Studies have also shown that malnutrition [85,86] and
particularly under nutrition [87-90] influences the immune system
negatively which may further lead to causation of disease conditions
[91]. Results of the present study indicate that young tribal males are
showing increasing tendency towards growing body weight, against
the traditional wisdom, which in turn has been found to be strongly
associated with metabolic risk factors. Tribal females are in more
danger of developing metabolic risks at lower BMI, irrespective of
age. So the present status of health suggests an increasing tendency
towards a double burden of disease among the Indian tribal
populations. Therefore, health of these indigenous population groups
needs to be looked into holistically, so that timely intervention can be
made against this silent epidemic. And finally there is a need to move
away from the traditional wisdom that non-communicable diseases
specially the Coronary Heart Diseases are not the component of
tribal morbidity. On the contrary one can visualize changing pattern
of tribal health as a part of distinct life style changes, which needs to
be addressed immediately before the situation becomes too alarming.
Acknowledgements
Author is thankful to Indian Council of Medical Research for
financial support to the study of “Prevalence of obesity and selected
risk factors among the tribes of India”, from where author has utilized
a part of results.
References
6. Ministry of Statistics and Programming, Government of India. 2009-10. NSS
66th round: Report no 543.