The Other Epidemic

February 27, 2014

By Joanna Mackenzie

A recent article from the Times of India, featured in our Global Food Ethics Project Newsfeed, highlighted the growing diabetes epidemic in India. Typically thought of as a disease of affluence, diabetes disproportionately affects South Asians, both poor and rich.

Diabetes in India is estimated to affect 65 million people, approximately 5.2% of India’s 1.2 billion population, with an additional 77.2 million people considered to have pre-diabetes. Moreover, India faces a huge burden of malnutrition, with more than 230 million, or 21% of the population, considered undernourished.

India, like many developing countries is faced with the challenge of addressing disease related to both poverty and affluence.

The diabetes epidemic in India has widespread economic implications as well. Diabetes most commonly affects working-age adults, potentially hindering the growth of India’s workforce and also costing the Indian government hundreds of billions of dollars in health care costs.

Some of the drivers of the diabetes epidemic in India are similar to those found around the globe: urbanization, a transition in diet from traditional foods to calorically dense processed foods and decreased physical activity.

However, research has shown that South Asians may be more susceptible to diabetes at lower body mass index than Europeans possibly due to fetal adaptations that occur when a mother is undernourished. Individuals born into a starvation environment are at increased risk for developing metabolic diseases when placed in an obesogenic environment, such as that described above.

It has also been noted that, although diabetes is most commonly associated with wealth, the urban poor in India’s slums are also affected by diabetes due to high availability of junk food in these areas.

The connection between early stunting and increased risk for obesity is an example of the compounding effects of multiple disadvantages that fall disproportionally on the poorest members of society with long-lasting, pervasive effects over the course of a lifetime and even generations. Preventing such compounding effects and combatting those effects when they occur are arguably urgent obligations of social justice.

Although there is still a justice-based argument for tackling obesity in developed countries, given the demographic distribution of this health condition, in developing countries the case for a justice-based policy is even stronger. According to the International Diabetes federation, 80% of the 382 million people who have diabetes worldwide live in low and middle-income countries.

Chronic disease is no longer a concern only of rich, developed countries. Instead it is increasingly burdening the world’s most disadvantaged, those who have the least access to healthcare and high burdens of infectious disease and malnutrition.

Developing countries have tight budgets and face many equally urgent demands. How should a country, such as India, prioritize limited resources? India’s current food and agricultural policies focus on creating economic growth, preventing starvation and price stabilization — all legitimate goals. On the other hand, incorporating chronic disease prevention into agricultural policies may be an effective way to halt the diabetes epidemic. For instance, Dr. Anura V Kurpad, president of the Nutrition Society of India, argues that the Indian government’s comprehensive plan to combat diabetes needs to include food policies to promote the production of healthier food staples, such as millet and pulses instead of sugarcane.

Dr. Kurpad’s belief that the nutritional value of foods and their impact on long term health, not just their economic value, should be a major consideration in designing agricultural policies is revolutionary. Advancing policies that support the production and distribution of foods with high nutrient density, or high nutritional value per calorie, could address the diabetes epidemic at its nutritional roots, by targeting both malnutrition and obesity.

Joanna Mackenzie is a Registered Dietitian and Research Assistant for the Global Food Ethics Project at the Johns Hopkins Berman Institute of Bioethics.  She is also working towards obtaining an MSPH in Health Education and Communication from the Department of Health, Behavior and Society at Johns Hopkins Bloomberg School of Public Health. She received a B.S. in Nutrition Science from Russell Sage College in 2010.  Prior to coming to Hopkins, Joanna was a Public Health Nutritionist for the New York State Child and Adult Care Food Program. Previous work included using nutrition interventions to enhance the quality of life of HIV/AIDS populations in upstate New York.

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