Critical Analysis Obesity and Diabetes in Rural to Urban Migrants

Question: Discuss about the Obesity and Diabetes in Rural to Urban Migrants. Answer: According to the information provided by WHO BMI over 25 kg/m2 is defined as overweight, and a BMI of over 30 kg/m2 as obese (WHO, 2003). Obesity is a serious problem that can lead to much chronic disease and one such chronic health problem is diabetes. Diabetes and obesity are highly prevalent in developed as well as developing economies. Wide array of research has been done to identify the reason of high prevalence of obesity and diabetes. One such study has been conducted by Ebrahim et al (2010). It is crosses sectional study that that has been designed to identify the relation between the rural to urban migration and development of obesity and diabetes in Indian population. There are many evidences that have been presented by the research studies that support the idea of development of obesity and diabetes due to rural to urban migration (Bowen et al, 2011). Study explains that migration of the rural population towards the urban areas helps in promoting urbanization. However, thi s process of urbanization also includes the risk of obesity and diabetes. The study has focused on testing the hypothesis that rural to urban migrants have higher prevalence of obesity and diabetes in comparison to rural non-migrants. Study also based on the theory or the hypothesis that migrants would have an intermediate prevalence of obesity and diabetes compared with life-long urban and rural dwellers, and that longer time since migration would be associated with a higher prevalence of obesity and of diabetes Ebrahim et al (2010). Study has been designed to find the cardiovascular risks in the factory workers, who have migrated from the rural parts of India. These factories were located in the north, central and south India. Other research studies related to this topic has found that migration of the people from the rural areas to urban areas is linked with the high prevalence of obesity that also works as the driving factor for raising the diabetes epidemic in India (Misra et al, 2001). The study selected for this analysis has used the framework of a cardiovascular risk factor screening study that has been conducted in factories situated in north, central, and south India (Reddy et al, 2006). The researchers have designed the sib-pair comparative study that was conducted in the four different factories located in different parts of India. According to the study of Poznik et al (2006), sib-pair linkage analysis is considered as the popular method for identifying the genes that are responsible for the occurrence of the complex disease. The details of the four factories are Hindustan Aeronautics Ltd situated in Lucknow, Indorama Synthetics Ltd located in Nagpur, Bharat Heavy Electricals Ltd located in Hyderabad and Hindustan Machine Tools Ltd located in Bangalore. Study conducted by Misra et al (2001) has also focused on the northern part of the country for identifying the reasons of high prevalence of diabetes and obesity in the rural to urban migrants living in the poor socio-economic conditions. Some of the significant reasons associated with high prevalence of diabetes and obesity in rural migrant population are associated with socio-economic condition and metabolic characteristics of this population. For the purpose of sampling in the study of Ebrahim et al (2010), the factory workers and their spouses were recruited for the study if they were the rural urban migrants. This sampling was done by using the employer records. For identifying the difference in the health, the researchers also asked the migrants and their spouses to invite their non-migrant sibling of same sex and close to their age, who are still residing in their rural location or the place of origin. The main focus of the study has been on rural to urban migration is very hi gh in India and such population suffer many physical and mental health issues (Albers et al, 2016). Study gave priority to the gender over age, as multiple same sex sibs were available. Sibling pair design is significantly used in comparing the risk factors of the chronic diseases. Study also assessed the factory workers with urban origin and urban dwelling sibs (not working in the factory) through interview, fasting blood samples and examination.25% of the samples were collected from the non-migrant urban population working in these factories. Sib pair comparative analysis was carried out to compare the risk factors associated with obesity, diabetes and cardiovascular diseases. This method of the research informed about the complexities of the sib-pair analysis (Albers et al, 2016). The total number of participants in the study was 6150. 42% of the total participants were women. The strategy of inviting the same sex sibs informed that sibs were being drawn from the 20 different states of India. This strategy also informed about the migration patterns of the factory workforce and t heir partners in India. The results of the study show that response rate was high. Total of 21,662 factory workers and their spouses from all four factories were available for the research. Out of these 15,596 (72%) of the people were found to be still working in these factories, out of which 88% of the people were able to complete the initial assessment conducted for the eligibility criteria. Out of 13,695 people, only 7,594 (55%) people were eligible for the study, because these people had the rural dwelling sibs. 94% of these people agreed to complete the medical examination with their sib. The people, who failed to participate in the study were mainly because of the reason that they sibling were unwilling to travel for the purpose of study and also due to time constraints (harvesting season or exams). The researchers could only obtain the limited data from the initial screening interview. The study could not found any significant differences on the basis of marital status, distance from the rural place of origin, mean age or the migrant status. The results of the study stated that prevalence of the cardiovascular risks was lower in the non-responders (14.8%), while it was higher in the non-consenters (21.1%). However, the cardiovascular risk was higher in responders (19.3%) in comparison to non-responders. Results also showed that fasting blood glucose level were similar in the migrant and urban groups (in men and women), while fasting blood glucose was lower in the rural sibs. Prevalence of diabetes was higher in the urban and migrant group in comparison to rural group. Urban and migrant men and women has the increased odds of diabetes in comparison to rural group. Findings of the study suggests that BMI found in men weakened the association between the place of origin and cardio vascular risks systolic blood pressure but did not reduce the strength of associations with fasting blood glucose, HOMA, or the prevalence of diabetes (Ebrahim et al, 2010). Another study also found high insulin resistance in Asian Migrants and diabetes is four times higher in the rural migrated population (Misra Ganda, 2007). The findings of the study by Ebrahim et al, (2010) supported the hypothesis that there is high prevalence of obesity and diabetes in the rural to urban migrants in comparison to rural non-migrants. However the findings of the study could not support the second and third hypothesis of the study that had mentioned that there is intermediate prevalence in migrants in comparison to urban dwellers and the long time of migrations increase the prevalence risks was not supported by the findings. Therefore the findings of the study demonstrated that rural o urban migration in India is associated with rapid increase in the risk of obesity and diabetes. This has been mainly linked with he changed behaviour that is reduced physical activities, increased alcohol intake. These factors are similar to the urban population as well. Obesity and diabetes are reaching to epidemic level in rural to urban migrant population in India (Bowen et al, 2011). Study also suggested that health promotional activities and interventions targeting migrant population can help in reducing or slowing down the risk of obesity and diabetes. Since, there is rapid urbanization in developing countries, such interventions are important (Misra Ganda, 2007). Since, health and social well-being of the people is determined by various factors, such as demographic pattern, pattern of consuming food, and socio-economic condition, holistic approach for empowering vulnerable population is significant (Kumar Preetha, 2012). For the purpose of study validation and ethical consideration, information of the research was provided to the participants in their local languages (Bowen et al, 2011). Informed Consent of the participants was received through their signed information sheets or obtaining thumb print on sheets (if the participant was illiterate). This study also received the approval from the ethical committee of India, which is All India Institute of Medical Sciences Ethics Committee; reference number A-60/4/8/2004. Field work began in March 2005 and was completed by December 2007. Study also includes the appropriate reasons for the exclusion of the participants from the study, which is important for understanding the biases. Rural to urban migrants undergo the extensive environmental change is caused due to rapid urbanization. This change requires studying the epidemiological transition to be studied. The health related changes in the migrants over the short period of time can provide the better insight to the problem. This will also allow providing the health information of the wide range of population affected by urbanization (Mohan et al, 2008). Therefore, the period of research can significantly affect the selection biases based on the length of the period. Study also focused on the dietary intake of the migrants. The dietary intake of the migrants was assessed with the help of the interviewer-administered semi-quantitative food frequency questionnaire (FFQ). The frequency of the intake of the 184 commonly consumed food items was included in the questionnaire. For maintaining the validity and reliability of the data, subsamples were asked to complete the questionnaire during the period of original data collection. Fat intake was considered as indicator of the dietary change. Since, diet is an important risk factor for the occurrence of obesity and diabetes, the changes in the dietary patter and changes in food indicate can provide effective and reliable cues about the occurrence of obesity and diabetes in migrant population. The results of the study are likely to be affected by confounding because the study could not support the hypothesis that longer time since migration can increase the risk of obesity and diabetes. The time could be an important aspect of determining the level of risk. However, study failed to find this and support this hypothesis (Ebrahim et al, 2010). The results are not likely to be affected by the measurement biases because study used the appropriate measurement tool and framework that has been selected by many other epidemiological studies. The temporal relationship is very significant to be established between the exposure and the outcome (Rothman, Greenland, 2005), as the casual association among the exposure has been studied in detail. Ebrahim et al, (2010) has provided the occurrence of the disease with logical explanation about the exposure to the various factors. The study of Ebrahim et al (2010) has explained the various risk factors and exposures that increase the risk of obesity and diabetes (such as, environmental changes, dietary changes, physical exercise and migration associated difference in blood pressure, lipids, fasting blood glucose, and insulin. The dose response relationship has not been established. However, study provides the strong relationship between the exposure and the outcome. Study provides the difference between the BMI of the male migrant sib group and rural sib group. The findings of the study can be considered as consistent with the evidences provided in the similar studies. Ebrahim et al (2010) found that migrant and urban men and women had 2 fold increased odd of obesity and diabetes. This finding has been consistent with the evidences presented by Varadharajan et al (2013), who conducted the cross sectional survey in the 29 states of India and included 56,498 non-pregnant women, aged 15 to 49 years, and 42,190 men, aged 15 to 54 years (Varadharajan et al, 2013). This study also found that there has been mean increase in the BMI value and also suggested that rural to urban migration population in India have higher odds of obesity in comparison to rural population. The results presented by the study can be considered as reliable in terms of biological evidences. The study of Millett et al (2013) has also included the biological evidences for the similar study design and rural to urban population. Genetic and lifestyle factors are found to be responsible for the occurrence of obesity and diabetes (Lyngdoh et al, 2006). The acquired insulin resistance has been associated with biological and genetic factors that may increase due to the migration process. The sib comparison could b like the twin study, but it is significant for determining the genetic contribution towards the disease. Some biological factors like heritability are not mentioned in the study of Ebrahim et al (2010), which my be significant for determining the genetic variations. Diet has been considered as an important risk factor, therefore, it has also been considered by various other rural-urban migrant studies (Carrillo-Larco et al (2016); He et al (1996); Torun et al (2002). Rural to urban Peru migrant study conducted by Carrillo-Larco et al (2016) examined the ongoing urbanization in the developing countries has contributed to rapid development of obesity. Such increased risk of obesity has been associated with change in food and development of obesogenic environment. Study of Jones et al (2014) obesogenic environment would include several characteristics: improved transit leading to less physical activity related to commuting, a wider access to different kinds of food (healthy, unhealthy and even junk food), wider exposure to fast food and their associated marketing strategies, and different prices between healthy and unhealthy food. The increased risk of obesity in urbanized environment may be high because rural environment have more protective effec t. Therefore the study of Ebrahim et al, (2010) found that risk of obesity and diabetes is less in rural populations. High level of saturated fat and cholesterol intake is found in rural to migrant population in comparison to non-migrant population (Torun et al, 2002). The external validity of the study depends upon the applicability of the study design in the source population. Ebrahim et al (2010) conducted the study in the four different factories of India and carefully selected the rural to urban migrants. Study also include the spouses of the migrants and considered them valuable for the migrant study. This study also found the similar pattern for the obesity and diabetes in men as well as in women migrants. The findings can be applied to the source population as the random selection of the urban participants was also done, but study cannot be generalized o the other rural to urban migrant population, as this study includes a very large sample of the participants. 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