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Type 2 Diabetes and the Double Burden of Malnutrition in Rural South India: a Mixed- Methods Examination of a Public Health Crisis

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Type 2 Diabetes and the Double Burden of Malnutrition in Rural South India: a Mixed- Methods Examination of a Public Health Crisis Type 2 diabetes and the double burden of malnutrition in rural south India: A mixed- methods examination of a public health crisis by Matthew Little A Thesis Presented to The University of Guelph In partial fulfillment of requirements for the degree of Doctor of Philosophy in Population Medicine and International Development Studies Guelph, Ontario, Canada © Matthew Little, May, 2017 ABSTRACT TYPE 2 DIABETES AND THE DOUBLE BURDEN OF MALNUTRITION IN RURAL SOUTH INDIA: A MIXED-METHODS EXAMINATION OF A PUBLIC HEALTH CRISIS Matthew Little Advisors: Dr. Cate Dewey Dr. Sally Humphries India is experiencing a nutrition transition characterized by shifting diets and physical activity patterns that are driving increased prevalence of obesity, type 2 diabetes, and the double burden of malnutrition (defined as co-occurring under- and over-nutrition). The objective of this research was to describe and determine factors associated with these phenomena in rural Tamil Nadu, India using a mixed methods (qualitative and quantitative) study design. In-depth interviews (n=61+54) and focus groups (n=8) assessed perceptions of diabetes, nutrition, and the local food environment. Randomly selected adults (n=753) participated in a socio- demographic survey, food frequency questionnaire, and bio-metric measurements (waist/hip circumference ratio [WHR], body mass index [BMI], blood hemoglobin, and oral glucose tolerance test). Age- and sex-standardized prevalences of health outcomes were: overweight, 34%; pre-diabetes, 9.5%; type 2 diabetes, 10.8%; underweight, 23%; and anemia, 47%. Prevalence of co-morbid anemia plus overweight was 22.6% in women and 12.0% in men, while prevalence of co-morbid anemia plus diabetes was 5.6% of men and women. Multivariable linear and logistic regressions were used to identify factors associated with health outcomes at p<0.05. Factors [odds ratios] associated with obesity included physical activity [0.8], wealth index [1.1], high caste [4.6], rurality index [0.4], and tobacco use [0.2]. Factors [ORs] associated with diabetes included physical activity [0.8], BMI [1.9], WHR [1.6], high caste [2.4], rurality index [0.8], and tobacco use [2.8]. Factors [ORs] associated with co-morbid anemia and overweight included female sex [2.3], rurality index [0.7], high caste [0.7], wealth index [1.1], livestock ownership [0.5], and meat intake [0.8]. Factors [ORs] associated with co- morbid anemia and diabetes included age [1.1], rurality index [0.8], family history of diabetes [4.9], and BMI [2.1]. Local explanatory models of diabetes cited “poor diet”, “tension”, and “tradition” (family history). Illness narratives described “fear” and “loss of control” upon diagnosis with diabetes. Food environment characteristics affecting food choices and consumption included individual factors (age, gender), socio-economic factors (wealth, caste, religion), access to government entitlements, occupation, and media exposure. Results shed light on public health issues in rural India and carry implications for policy, practice, and future research. 3 ACKNOWLEDGEMENTS As my PhD studies come to a close, I am grateful for the support and guidance of many individuals. First and foremost, I am forever indebted to my PhD committee members for their willingness to provide supervisory, methodological, logistical, and financial support. Thank you to my co-supervisor Dr. Sally Humphries, who agreed to supervise an undergraduate independent study in Guatemala all those years ago, and who introduced me to the joys and challenges of international development and global health research. Without Dr. Humphries’ support, supervision, and encouragement, I would never have entered a PhD program at the University of Guelph. Sally, your strong commitment to community engagement, humility, and integrity shaped and bettered my research, and I will carry these principles with me into my research career. Thank you as well to Dr. Cate Dewey, my co-supervisor in Population Medicine, whose empathy, insight, and unending curiosity constantly reminded me of the value of global health research and permitted me to overcome numerous challenges. Cate, I am so grateful to have you as a mentor, and for all your patient support and guidance. I am amazed and impressed at your dedication to developing meaningful relationships with all your students. Most importantly, thank you Sally and Cate for being good friends throughout the research and writing process, and for sharing many laughs along the way. Thanks as well to Dr. Kirit Patel, who was an excellent and empathetic leader of the overarching project, “Revalorizing small millets in rainfed regions of south Asia” (RESMISA). Kirit, your knowledge of the Indian context, your insights into the complexities of conducting research in India, and your persistent enthusiasm were invaluable to the success of my research. I know that my year spent conducting research in rural Tamil Nadu would never have been possible without your support, strong community relationships, and constant encouragement. iv RESMISA was a large and complex international development research project, and I am grateful to the investigators and partner organizations for their willingness to support my research objectives and assist with logistics and methods. Thank you to the Development of Humane Action (DHAN) Foundation for acting as a partner organization. Specifically, M. Karthikeyan in the Krishnagiri office and V. Vediyappan and M. Suresh in the Anchetty field office provided extensive support, from hiring research assistants to finding housing. Thank you as well to Ms. Sudha Vasudevan, Dr. Mohan, and their team of researchers at the Madras Diabetes Research Foundation for permitting me to use their validated food frequency questionnaire. I owe many thanks to the research assistants, without whom I would never have been able to buy a motorcycle, let alone seek clearances from local authorities, conduct interviews, obtain and process blood samples, and overcome the myriad of daily challenges that arise during fieldwork. T. Madhe Gowda, I may have recently missed your wedding, but I hope to visit your new family someday. Your support, assistance, and most of all, your friendship, were crucial to our success. You were more a partner than an assistant, and I truly hope that you achieve all the crazy dreams you have. N. Kodhai Priya and Priscilla Dhanapal, I still barely believe you accepted jobs as nutrition researchers with a strange Canadian you had never met, but I will be forever grateful for your enthusiasm, proficiency, and empathy. Dr. Vikas Kumar, I am sorry we never visited Himachal Pradesh, but I am glad we lived together in Anchetty and you taught me how to cook butter chicken “just like mom makes”. The entire research team appreciated your wisdom, professionalism, and constant comic relief. Finally, R. Rajesh, you stepped in as a nurse when you were most needed and saved the project, and for that I will be forever grateful. You also drove me to Krishnagiri multiple times, took care of me when I was v ill, and gave me a tetanus shot when I walked into a piece of rusty sheet metal. Your support, assistance, and friendship will always be remembered. Finally, thank you to many of the friends in Anchetty that made me feel welcome, including Vahijahn, Shankara, Suresh, and Vasanth. Special thanks are owed to Gopi, who made the best chai in Tamil Nadu and was always willing to beat me in a game of chess. Most importantly, thank you to all of the fascinating individuals participated in the qualitative and quantitative studies. Many participants will be remembered for their charisma, generosity, and willingness to share their fascinating stories. I am very grateful for the numerous institutions and organizations that provided financial support for this work. I was honored to receive a Vanier Canada Graduate Scholarship and a Michael Smith Foreign Study Supplement through the Canadian Institutes for Health Research (CIHR), a Doctoral Research Award through the International Development Research Centre, and an Ontario Veterinary College Incoming Student Scholarship. I received additional financial support by RESMISA funds through the Canadian International Food Security Research Fund, provided by IDRC and the Department of Foreign Affairs, Trade, and Development (DFATD, formerly the Canadian International Development Agency and now Global Affairs Canada). Many thanks are owed to faculty, staff, and peers at the University of Guelph. Dr. Sherilee Harper, you have been a mentor and an inspiration. Dr. Craig Johnston, Dr. David Pearl, and Dr. Jason Coe, many thanks for providing support and encouragement at various stages of my PhD work. Sally Maclachlan and Linda Kraemer, thank you for all your assistance in navigating the logistical and financial challenges of work in India, and I forgive you for taking three years to realize that Warren Dodd (now Dr. Dodd) and I were, in fact, different vi people. And Warren, I owe you a major debt of gratitude for your companionship throughout our PhD studies, especially during our first trip to Anchetty. Congratulations on your impressive dissertation - I am awestruck by your dedication to community engagement and global health research, and I look forward to a lifelong friendship. I have a strong community of friends and family who have been sources of inspiration and reprieve throughout this journey. Thanks are owed to my parents, Bob and Betsy, who offered endless encouragement over the past five years. Special thanks as well to my brother Kevin and friends Sean Gallagher and Matt Smider, who were always up for an adventure when I needed a break. And finally, thank you Holly, you taught me the value of finding balance in life, and continually inspire me to seize the day, no matter where we wake up. vii STATEMENT OF WORK STUDY DESIGN: The research presented in this dissertation was a component of a large, interdisciplinary international development research project titled “Revalorizing Small Millets in the Rainfed Regions of South Asia” (RESMISA).
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