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Obese and hungry: Tackling two seemingly opposing public health concerns in India

Stanford Health Policy core faculty member works across Stanford and around the globe to identify promising intervention approaches

Obesity is a well-documented problem in developed countries, and Stanford Health Policy researchers have conducted a series of studies on the topic-including one observing its impact on America's lower-income workers and another study assessing parental effects on childhood obesity in the United States.

 "From a public health perspective I don't think that we can focus solely on undernutrition or on obesity. Both are important. Their interplay produces complex policy challenges."
- Jeremy Goldhaber-Fiebert

But SHP core faculty member Jeremy Goldhaber-Fiebert is turning to an unexpected location to conduct his own obesity research. He has teamed up with colleagues from across campus and worldwide to better understand India's dual health burden of undernutrition and obesity. 

"In these places where both undernutrition and obesity are intermingling, the story becomes complicated and the challenges unique," Goldhaber-Fiebert, also an Assistant Professor of Medicine at Stanford School of Medicine, said.  "The image that many people have of India is dominated by the series of pictures we've received for the last 20 years of poorly nourished people. But  obesity and diabetes are increasingly prevalent,   affecting cities and rural areas; northern and southern regions in different ways."

As India's middle class has expanded, the nation's public health concerns have shifted. Obesity rates have risen, coinciding with a surge in diabetes. The number of Indians with type 2 diabetes is expected to double by 2030 to nearly 80 million (Wild, S, et al. "Global Prevalence of Diabetes," Diabetes Care 27:5, p1051, June 2004). Meanwhile, according to the World Bank, 43 percent of children in India are underweight.

A chronic condition, type 2 diabetes is characterized by high levels of glucose in the blood.  People who have type 2 diabetes are at much greater risk of health problems, including those of the eyes, kidneys, and cardiovascular system. The American Heart Association estimates that almost three-quarters of type 2 diabetics die from some form of heart or bloody vessel disease. And a person's risk of stroke increases more than two-fold within the first five years of being treated for type 2 diabetes.

Public health strategy

Goldhaber-Fiebert is interested in how this rise in India's type 2 diabetes rate will affect the country of 1.1 billion, and wants to better understand how best to attempt a public health strategy that addresses both individuals who are undernourished, and those who are obese and at greater risk for type 2 diabetes. He is joined in his research by colleagues across disciplines and around the globe:  epidemiologists in India and across Stanford-- SHP Core Faculty Paul Wise, a pediatrician, Assistant Professor of  Environmental Earth System Science David Lobell, Deputy Director of the Food Security and the Environment Program Walter P. Falcon and Assistant Professor of Statistics Bala Rajaratnam. The group is benefiting from a Woods Institute Environmental Venture Project grant for interdisciplinary research aimed at understanding the practical implications of climate change, food production, and nutrition for human health.

Bringing his own expertise in mathematical modeling, Goldhaber-Fiebert is working with the group to consider the patterns of future illness and death due to undernutrition and obesity. They are interested in how economic and demographic changes will impact these trends. Ultimately, broadly delivered nutrition policies will have to contend with addressing these issues without exacerbating either one.

Global implications

While their research is focused in India now, it has broad implications for the many other nations that face the undernutrition/obesity dual burden. For example, Goldhaber-Fiebert and Karen Eggleston, Shorenstein APARC fellow, have published on type 2 diabetes topics in India and China and are currently working together to examine the analogous issues discussed here in the context of China.

 "From a public health perspective I don't think that we can focus solely on undernutrition or on obesity," Goldhaber-Fiebert said. "Both are important. Their interplay produces complex policy challenges."

Goldhaber-Fiebert explained that research has found that some Indian families have undernourished and obese members living side-by-side.  Other studies have shown that public health initiatives aimed at addressing undernutrition-for example food programs-end up providing food to older children who are not undernourished. Similarly, efforts to curb obesity might risk inadvertently harming undernourished citizens.

"The next couple years of our research is going to be largely about how to address both at once," Goldhaber-Fiebert said. "In recent trips to India, we've started conversations with local policymakers and NGOs actively involved in these issues."