Amidst scarce access to healthcare, the tribal communities in Jammu and Kashmir have a huge burden of under-nutrition, vitamin deficiency, hypertension, diabetes mellitus, and thyroid disorders, a study conducted by doctors has revealed.
According to the study published in various national and international peer-reviewed journals, a copy of which has been also accessed by Greater Kashmir reveals that the demographic particulars of Gujar-Bakarwals are most dominant along the mountainous regions of Jammu and Kashmir regions.
“Their housing, sanitation, nutrition, accessibility, affordability and accessibility of health care facilities are very low and sub-optimal than other sections of the population,” Professor of Endocrinology and Metabolism, Sheri-Institute of Medical Sciences, Soura, Srinagar, Dr Muhammad Ashraf Ganaie, the lead author of many of these publications told Greater Kashmir.
Overall socio-demographic profile
DrGanaie, who is a member of the Nationwide ICMR Task Force for Universal Health Coverage (UHC) on Tribal population and also Sub-Dean, Research and Head, the Department of Clinical Research, SKIMS, said that behavioural risk factors including tobacco use, salt tea, smoke exposure, poor housing conditions coupled with physical, social and health care barriers complicate the scenario. “Our study focused on the socio-economic and demographic profile among the tribal population of Kashmir; their major risk factors for some non-communicable diseases (NCDs). The study was conducted on a community approach based cross-sectional survey undertaken in selected districts of Jammu and Kashmir.” DrGanie said. The study supported by the research grant to Sheri Kashmir Institute of Medical, Sciences, Srinagar from the Department of Science and Technology GOI, was co-authored by DrAnjumFazili, DrArif Habib, Dr Sheikh DrAbid Ali, DrDrAafia Rashid, DrRabiya Rashid. The study said that around 94.3% of the tribal population fell under low-income groups with an annual income of Rs. 25000 per year. Only 37.1% of subjects were educated. 61.0% of tribal subjects lack access to pure drinking water and proper sanitation. Interestingly, 63-66% of the population was younger with a high prevalence of smoking among both males and females (33.3% males and 7.3%, respectively).
“There is widespread poverty, illiteracy, and lack of basic amenities among the tribal people which makes it imperative to address these concerns to improve the socioeconomic disparities and health indices of the marginalized population,” the study said.
Prevalence of Vitamin Deficiency
“Vitamin deficiency (VD) is highly prevalent among Kashmiri tribals with 66% having VDD,14.71% having insufficient and only 19.3% having sufficient serum 25(OH)D levels despite their good sun exposure. This results in stunting of children due to rickets and poor bone mass in adults predisposing them to high prevalence of fracture. Poor nutrition including low calcium intake may be a contributing factor. Although the magnitude of the deficiency seems to be lower as compared to the general Indian population, these preliminary findings are likely to pave the way for vitamin D supplementation in this population,” DrGanaie informed.
The study carried out as a collaborative effort between AIIMS New Delhi and Sheri Kashmir Institute of Medical, Sciences, Srinagar funded by Science and Technology GOI, was co-authored by DrsVishnubhatlaSreenivas; Lakshmy R, Irfan Robbani, Sobia Nisar, Bashir Charoo, Ashraf Bhat, Majid Gania and TabassumParvez. They informed that during this cross-sectional investigation, a total of 1732 apparently healthy tribal participants (786 males and 946 females) were sampled from five districts of Kashmir valley by using the probability proportional to size method. Serum 25-hydroxy vitamin D (25(OH)D) levels were classified as per the Endocrine Society (ES) and assessed in relation to various demographic characteristics such as age, sex, education, smoking, sun exposure, body mass index and physical activity. “VDD was equally prevalent in male and female participants. Serum 25(OH)D levels correlated positively with serum calcium, and phosphorus and negatively with serum alkaline phosphatase. Also, gender, sun exposure, altitude, physical activity, and BMI did not seem to contribute significantly to VDD risk,” the doctors, quoting the study, revealed.
Prevalence of Hypertension
According to the study, the prevalence of hypertension is increasing among all ethnic groups across the globe with only a handful of studies from India addressing the prevalence of hypertension among tribal populations.
“In view of the paucity of data, this study was aimed at estimating the prevalence of hypertension and associated risk factors among the tribal population of Kashmir, India,” the study revealed. Dr. Ganaie informed that in this regard, the cross-sectional survey included 6808 tribals aged 20 years (5695 Gujjars and 1113 Bakarwals) from five randomly selected districts of Kashmir. “Modified WHO-STEPS surveillance questionnaire was used to collect relevant data. Hypertension was defined by the Joint National Committee on prevention, detection, evaluation and treatment of hypertension (JNC 8) criteria,” he informed.
The study published in the Indian Journal of Medical Research, the official journal of ICMR reveals that the participants belonging to different age groups were examined and the overall prevalence of hypertension (95% confidence interval (CI)] was 41.4% (39.9-42.9%) In men, 46.7% (44.1-49.1%); women, 37.9% (35.9-39.9%)behaviorallence of prehypertension (95% CI) in the study was 35 per cent (33.7-36.6%). Higher age, passive smoking, family history and obesity were significantly associated with hypertension.
“Gujjar and Bakarwal tribes of Jammu and Kashmir showed a high prevalence of hypertension and prehypertension. Hence, urgent policies and reforms are needed to tackle this silent epidemic and further studies focusing on community-based interventions must be considered,” DrGanie recommended in the study.
Prevalence of Diabetes and Pre-Diabetes: Lessons For Future
Considering a surge in the incidence of Diabetes mellitus (DM) across all ethnic groups and lack of any representative data from the tribal communities of Jammu and Kashmir, the present study aimed to assess the prevalence of DM and prediabetes in them.
Among NCDs, although diabetes prevalence has been reported to be less (1.26 %), which is somewhat like that of Europeans, the magnitude of prediabetes was very high (15%) despite the low magnitude of obesity (8%).
“Considering the fact that prediabetes has high odds of progressing to full-fledged diabetes, we have uncovered a window of opportunity to urgently administer various lifestyle measures to prevent the epidemic of diabetes,” said DrGanaie the lead author of the study published in the international journal Diabetes Research and Clinical Practice 2020. Notably, the ratio of diabetes in the general population is already the highest on the globe in India.
DrGanaie, who is also president, M.P PCOS Society, National Coordinator PCOS Task Force and editor of the Diabetes and Obesity Journal, informed that smoking and inadequate consumption of meals were prevalent. “There is an urgent need to address behavioural risk factors such as smoking and skipping meals through primary prevention. There is scarce data on the prevalence of thyroid disorders and urinary iodine status among tribal populations of India, with no reported data from Kashmir valley.”
Status of Thyroid and Iodine deficiency Disorders
DrGanaie said that in order to estimate the prevalence of thyroid disorders and evaluate urinary iodine concentration (UIC) and thyroid autoantibody status among Gujjar and Bakerwal tribes of Kashmir valley located in the Sub Himalayan belt a zone popularly known as Endemic area, this cross-sectional study was undertaken. Adult tribal subjects using multistage cluster sampling from 5 out of 22 districts of Jammu and Kashmir (J&K) were recruited using a predesigned questionnaire. Clinical examination included anthropometry (height, weight, waist circumference), blood pressure measurement, and relevant general physical examination focusing on goitre palpation, while laboratory assessment included estimation of serum thyroid hormone levels, antithyroid peroxidase antibody (anti-TPO Ab), and urinary iodine concentration. “Goiter was detected in 6.8%, while 33.2% of subjects had some form of thyroid dysfunction (including 24.1% subclinical and 6.8% overt hypothyroidism). Subclinical and overt hyperthyroidism were observed in 1.3 and 0.9% of cases, respectively. Anti-TPO Ab was elevated in 13.6%, while the median interquartile range (IQR)] for UIC was 154.50 (135) microgm/L [156.13 (134) microgm/L in men and 147.26 (136) microgm/L in women].” UIC is still low despite the iodized salt being available to all.
“These novel data on iodine and thyroid status among a tribal population of India generally inhabiting remote sub-Himalayan belts demonstrate a high prevalence of subclinical hypothyroidism with persistent iodine deficiency. These preliminary data may warrant large well-designed studies to carry out a comprehensive assessment of the problem in this high-risk and marginalized population,” DrGanaie led team recommended.
Pertinently, Indigenous people all over the world are historically subjugated and socially disadvantaged, which is explicitly and implicitly affecting their life expectancy and health status. They usually live within geographically distinct territories; tend to maintain distinct social, economic, and political institutions within their territories; and self-identify as indigenous or tribal. India has the second largest tribal population in the world with a total of 84.33 million scheduled tribes, constituting 8.6% of the population of the country.
Notably, Jammu and Kashmir have a substantial proportion of the tribal population and constitute 11.9% of the total population. Gujjar tribe is the largest tribe in J&K. Gujjars are not original inhabitants of J&K but started their migration in the 9th and 10th century from plain areas such as Gujarat, Kathiawad, and Jodhpur where they have been even in power while Bakarwal is a nomadic pastoral tribe known for livestock farming as the main source of livelihood and is the second largest tribe in the Union territory. The combined population of the Gujjar and Bakarwal communities is around 1093852 constituting 69% of the total tribal population of J&K.
According to a study by Nutrition India Info, since 1947, post-India’s independence, multiple government policies and programmes sought to develop tribal communities by focusing on their livelihood, education and health.
Despite several decades of special treatment, even today, tribal peoples continue to be the most undernourished segment of Indian society.
The latest available data reveals that 4.7 million tribal children of India suffer from chronic nutrition deprivation affecting their survival, growth, learning, performance in school and productivity as adults.
About 40 per cent of under-five tribal children in India are stunted, and 16 per cent of them are severely stunted. Tribal children have higher levels of undernutrition compared to children of socially and economically advanced sections.