Introduction:
Non communicable diseases (NCDs) pose a great burden of morbidity and mortality worldwide. In 2017, World Health Organization (WHO) estimated that NCDs kill 40 million people each year [1]. Lifestyle behaviours such as tobacco use, physical inactivity, unhealthy diet and excessive use of alcohol and also metabolic risk factors like overweight/obesity, all increase the risk of NCDs [1]. Research on physical activity and health pointed that regular physical activity has important health benefits which include lowered blood pressure, reduced body fat and central adiposity, enhanced musculoskeletal health, which in turn decreases the risk of cardiovascular diseases (CVD), obesity and diabetes [2]. The worldwide prevalence of physical inactivity was estimated to be 31.1% [3] and analysis of disease association with physical activity revealed physical inactivity causing 6-10% of NCDs globally [4]. As such, studies on physical activity become important in health promotion and a medium to prevent these diseases.
Presently, India is in a state of demographic and nutritional transition characterized by underlying population growth and increasing burden of chronic diseases [2]. Physical inactivity has been implicated as a modifiable risk factor for CVD, obesity and diabetes [5] and when coupled with unhealthy dietary intake, the disease prevalence increases. Thus, in order to develop effective NCD prevention health strategies, data on activity levels and dietary trends of different populations need to be documented with special reference to the environmental and socio-cultural contexts of each population.
The objective of the present study was to estimate the physical activity levels of a single tribal population based on the adherence to the global recommendations on physical activity for health. The study also aimed to assess the general dietary trends prevailing in this population.
Methods
Participants and Data collection
This is a population based cross sectional study conducted using random sampling method among Bhil tribal population in India. As the present study is a part of a major government funded project, where genetic analysis was a component, the basic criteria for the recruitment of the subjects was the exclusion of up to first cousin. The subjects were recruited from Rajasthan and Delhi (tracing their ancestry from Rajasthan). Prior to the study, a pilot survey was conducted among 100 participants from whom listing was done on physical activities performed in the population of interest and food items consumed. Based on this pilot survey, physical activity questionnaire and food frequency questionnaire (FFQ) were developed. The physical activity questionnaire included different activities performed by the individuals and was categorized into occupational, household, transport and leisure-time domains and evaluated according to the frequency and duration of activities performed in a week. The FFQ included all the food items consumed and was categorized into cereals, pulses, milk and milk products, animal products, oils and fats, and sweet/sugar. Frequency of each food item consumed was recorded.
A total of 258 participants were interviewed for physical activity questionnaire while a total of 222 participants were interviewed for FFQ. Detailed socio-demographic information such as name, age, sex, educational qualification and occupation were obtained. Data on somatometric variables were collected following standard protocol. This study was approved by the Departmental Ethics Committee, Department of Anthropology, University of Delhi. Pre-informed written consent was obtained from each participant prior to data collection.
Physical activity and dietary intake analysis
Physical activity was separated according to their intensities into moderate and vigorous activities based on the metabolic equivalent (MET) of each activity using Ainsworth et al Compendium of Physical Activities (2011) [6]. Individuals that performed at least 150 minutes of weekly physical activity were considered active [7]. This duration was calculated by multiplying the number of days of moderate and vigorous activities performed by the number of minutes per day spent in each activity [8]. The overall dietary intake of the population was estimated by recording the frequency of each food item consumed daily, weekly or monthly/occasionally of each participant.
Somatometric measurement
Weight was measured to the nearest 0.1 kg using a calibrated scale and height was measured using anthropometric rod and was assessed according to the defined WHO guidelines for Asian populations. The body mass index (BMI) was calculated after dividing the weight in kilograms by the square of the height in meters (BMI= weight/height2, kg/m2). Individuals with BMI <18.5 kg/m2 were considered underweight, =18.5 kg/m2 but <23 kg/m2 as normal, =23 kg/m2 but <27.5 kg/m2 as overweight, =27.5 kg/m2 as obese [9]. In this study, overweight and obese categories were considered as one category (overweight/obese) as there were very few numbers of individuals in overweight category.
Statistical analysis
Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) v.20. To compare continuous variables t-test was used where as for categorical variables chi-square test was used. A p-value of <0.05 was considered statistically significant.
Results
A total of 258 individuals were interviewed for assessment of physical activity in the present study (Table 1). Mean age was found to be 42.92 years (IQR; 32-52). There were higher number of females (65.89%) as compared to males (34.11%) and a higher number of individuals were non-literate (72.48%) as compared to literate individuals (27.52%). Housewives, employed, and unemployed individuals constituted 28.68%, 65.89% and 5.43%, respectively.
Table 1: General characteristics of the study population |
Variables |
N (%); N=258 |
Mean age (IQR) |
42.92 (32-52) |
Sex |
Male |
88 (34.11%) |
Female |
170 (65.89%) |
Education |
Non-Literate |
187 (72.48%) |
Literate |
71 (27.52%) |
Occupation |
Housewife |
74 (28.68%) |
Employed |
170 (65.89%) |
Unemployed |
14 (5.43%) |
Physical activity |
Inactive (<150 min.wk-1) |
35 (13.57%) |
Active (=150 min.wk-1) |
223 (86.43%) |
BMI† |
Underweight |
55 (22.00%) |
Normal |
94 (37.60%) |
Overweight/Obese |
101 (40.40%) |
† Missing values= 08 |
The prevalence of individuals reporting at least 150 minutes of weekly physical activity (active individuals) was 86.43% where as individuals performing less than 150 minutes of weekly physical activity (inactive individuals) was 13.57%. In regards to BMI, the prevalence of overweight/obese individuals was found to be higher (40.40%) as compared to normal and underweight individuals (37.60% and 22.00%).
 |
Figure 1: Proportion of individuals that performed at least 150 minutes of weekly physical activity by domain among Bhil tribal population in India |
Domain-wise distribution of individuals that performed at least 150 minutes of weekly physical activity (Figure1) showed that maximum physical activity was found to be in the occupational domain (68.99%) followed by household domain (42.25%), transport domain (35.66) and the least in leisure-time domain (1.94%)
Table 2: Proportion of individuals that performed <150 min.wk-1 and =150 min.wk-1 of physical activity according to socio-demographic and obesity variables |
Variables |
Physical activity |
p-value |
Inactive
(<150 min.wk-1); N (%) |
Active
(=150 min.wk-1); N (%) |
|
Age; Mean (IQR) |
53.34 (41.00-63.00) |
41.28 (32.00-50.00) |
<0.001 |
Sex |
Male |
19 (54.3%) |
69 (30.9%) |
0.007 |
Female |
16 (45.7%) |
154 (69.1%) |
Education |
Non-Literate |
24 (68.6%) |
163 (73.1%) |
0.57 |
Literate |
11 (31.4%) |
60 (26.9%) |
Occupation |
Housewife |
06 (17.1%) |
68 (30.5%) |
<0.001 |
Employed |
22 (62.9%) |
148 (66.4%) |
Unemployed |
07 (20.0%) |
07 (3.1%) |
BMI |
Underweight |
08 (23.5%) |
47 (21.8%) |
0.79 |
Normal |
11 (32.4%) |
83 (38.4%) |
Overweight/Obese |
15 (44.1%) |
86 (39.8%) |
Individuals performing <150 minutes and =150 minutes of weekly physical activity were compared with respect to socio-demographic and obesity variables (Table 2). Mean age was significantly higher among inactive group. Female gender and employed individuals were found to be significantly higher among active group as compared to inactive group (p<0.05). In this population, overweight/obese and underweight individuals were found to be higher among inactive group when compared with active group though the difference was not found to be statistically significant.
The overall dietary intake of the study population (Table 3) revealed that majority of individuals consume wheat flour in the form of chapatti and paratha daily (99.09%). Cereals consumed in the form of rice were also common (11.71% daily and 52.25% weekly). The study revealed that, though majority of individuals consume pulses, vegetables and animal products, but the daily amount of consumption were very low. In this population, consumption of milk and milk products was also found to be low. A very high proportion (96.40%) of the population consumed fats and oils, daily and additionally, the consumption of sweets/sugar and beverages were also high (69.81% and 59.91%, respectively).
Table 3: Overall dietary intake of the study population (N-222) |
Food groups |
No, N (%) |
Yes |
N (%) |
Daily, N (%) |
Weekly, N (%) |
Monthly/Occasionally, N (%) |
Cereals |
Wheat |
- |
222 (100.00%) |
220 (99.09%) |
2 (0.91%) |
- |
Rice |
49 (22.07%) |
173 (77.93%) |
26 (11.71%) |
116 (52.25%) |
31 (13.97%) |
Pulses |
2 (0.91%) |
220 (99.09%) |
33 (14.85%) |
173 (77.93%) |
14 (06.31%) |
Vegetables and Fruits |
Green leafy vegetables |
- |
222 (100.00%) |
19 (08.56%) |
198 (89.19%) |
5 (02.25%) |
Other vegetables |
- |
222 (100.00%) |
22 (09.91%) |
196 (88.29%) |
4 (01.80%) |
Fruits |
42 (18.93%) |
180 (81.07%) |
11 (04.95%) |
25 (11.26%) |
144 (64.86%) |
Milk and milk products
|
Milk |
136 (61.26%) |
86 (38.74%) |
48 (21.62%) |
26 (11.71%) |
12 (05.40%) |
Butter/Cheese |
216 (97.30%) |
12 (02.70%) |
5 (02.25%) |
1 (0.45%) |
6 (02.70%) |
Buttermilk |
120 (54.06%) |
102 (45.94%) |
36 (16.21%) |
60 (27.02%) |
20 (09.00%) |
Animal products
|
Eggs |
61 (27.48%) |
161 (72.52%) |
5 (02.25%) |
35 (15.77%) |
121 (54.50%) |
Mutton |
63 (28.38%) |
159 (71.62%) |
4 (01.80%) |
33 (14.86%) |
122 (54.95%) |
Chicken |
60 (27.03%) |
162 (72.97%) |
5 (02.25%) |
30 (13.51%) |
127 (57.21%) |
Fish |
98 (44.14%) |
124 (55.86%) |
3 (01.35%) |
25 (11.26%) |
96 (43.24%) |
Fats and oils |
- |
222 (100.00%) |
214 (96.40%) |
8 (06.60%) |
- |
Sweet food (Sugar) |
67 (30.19%) |
155 (69.81%) |
3 (01.35%) |
39 (17.56%) |
113 (50.90%) |
Beverages |
89 (40.09%) |
133 (59.91%) |
24 (10.81%) |
32 (14.42%) |
77 (34.68%) |
Discussion
The present study tried to capture the physical activity pattern of a tribal population in India. Much of the studies on physical activity pattern in India are done among heterogeneous populations having different dietary and cultural practices [2,10,11]. To the best of our knowledge, this is the first study that assesses the physical activity pattern among a tribal community in India. As per the WHO recommendations, an individual performing at least 150 minutes of weekly moderate to vigorous physical activity is considered healthy. However, this physical activity recommendation in terms of food intake with respect to calories is not considered. In the studied population, physical activity was found to be very high (86.43%) with respect to individuals attaining the recommended physical activity level. Further, almost 70% of the individuals with high physical activity are found to be under occupational domain. This was similar to the findings in China and Vietnam, where most of time spent in physical activity were in the work domain [12,13]. The present population comprised predominantly of agriculturist and daily wage labourers; 73.1% of the population were non-literate and therefore, were engaged in heavy-work occupations. Hence, these might be some probable reasons for the prevalence of high physically active individuals in this population, especially in the occupational domain.
Results obtained from ICMR-INDIAB study showed that a large percentage of people in India are inactive [14]. A systematic review study reported the overall prevalence of inactivity among Indian population to be between 18.5%-88.4% [15]. The same study reported higher prevalence of inactivity among females as compared to males (17.0%-79.6% vs. 12.7%-66.2%) and higher prevalence of inactivity in urban area as compared to rural area (20.7%-88.7% vs. 6.6%-88.1% [15]. The present study also found the prevalence of physical inactivity to be 13.57% which was much lower than the overall inactivity pattern reported in India. However, males were found to be significantly more inactive as compared to females (54.3% vs. 45.7%). This was in contrast to results as reported under Phase 1 of ICMR-INDIAB study conducted in four regions of India as well as other studies [14,15].
Engaging in regular physical activity presents a number of health benefits and reduces the risk of several chronic diseases [16,17]. Physical activity, which is usually highest during the early adult years, sharply declines as age progresses [18,19]. Similar trend was observed in the present study as well whereby active individuals were found to be significantly higher among lower age group (57.3%). India’s elderly population is rising rapidly and is estimated at 10 crore in 2011, which is projected to reach 20 crore by 2030 [20]. Thus, intervention programs targeting individuals of older age group is important since they can benefit the most from increased physical activity [21].
With such a high prevalence of physical activity levels, the studied population is expected to be almost free from adverse cardiovascular variables such as obesity. As per the available literature, physical inactivity/sedentary lifestyle is reported to be directly associated with general and central obesity [22-24]). In the present studied population, general obesity in terms of overweight/obesity was high (40.40%) while the prevalence of general obesity in India has been reported to be between 11.8% and 31.3% [25] and specifically among tribal population, overweight/or obesity was found to be 12.81% [26]. Thus, an underlying mechanism of unhealthy dietary intake could explain the prevalence of higher percentage of overweight/obese individuals in this population. Major dietary habits that most often have been blamed for overweight or obesity include high dietary fat intake and also a diet that is high in sugar and other carbohydrates having higher glycemic index as compared to those with lower glycemic index [27,28]. The present study revealed an unhealthy dietary trend with high intake of cereals (wheat and rice) and fats and low intake of pulses, dairy products and fruits and vegetables. Similar trends of dietary intake were reported by NNMB and CURES 147 surveys in India [29,30]. Cereals such as wheat and rice have lower dietary fibre and higher glycemic index [31]. A change in dietary pattern -less fibre and more fatty food- was found to be influential in the development of many chronic diseases in different countries [32].
India has been undergoing nutritional transition with dietary addition of fast food and artificial sugars which were not present in the traditional diet of the Bhil tribals[33]. Consequently, a higher proportion of individuals in the present study were also found to consume sweets/sugars and beverages, mostly in the form of sugar-sweetened beverages/juices containing high quantity of artificial sugar. There has been an increasing concern that intake of free sugars – particularly in the form of sugar-sweetened beverages – increases the overall energy intake and may likely reduce the intake of foods containing more nutritionally adequate calories, leading to an unhealthy diet, weight gain and increased risk of NCDs [34,35]. A systematic review and meta-analysis of randomized control trials and cohort study to find the evidence on association between intake of dietary sugars and body weight revealed that increased intake in dietary sugars was associated with significantly greater weight [0.75 kg (95% confidence interval 0.30 to 1.19); p=0.001] at the end of the intervention period by comparison with no increase in sugars intake [36]. Therefore, the imbalance in dietary intake prevailing among the study population is likely to be responsible for the high prevalence of overweight and obese individuals despite their high physically active lifestyle.
Conclusion
This study revealed that a high proportion of the population adhered to the recommended physical activity level of at least 150 minutes of moderate to vigorous weekly physical activity. It also revealed an unhealthy dietary food intake which might be associated with the high prevalence of overweight/obese individuals in this population. Therefore, there arises an urgent need for increasing awareness regarding physical activity (especially of leisure-time) and healthy lifestyle through community specific intervention programmes considering diverse socio-cultural practices in the country. Moreover, national programmes and public policies should be developed and implemented to promote healthy and balanced diet, specifically among rural and tribal communities where physical activity is found to be quite high.
Acknowledgments
The authors would like to acknowledge Prof. P. C. Joshi for constant support during successful implementation of the research project.
Funding: This study was supported by DU-DST PURSE Phase II Grant [RC/2014/7114].
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