India’s epidemiological transition

See Transcript


Coming up on Harvard Chan: This Week in Health…India’s rapid epidemiological transition.

{***Lindsay Jaacks Soundbite***}
(We now have higher prevalence of diabetes in urban areas of India than in people who migrate from India to the U.S. In the past, you used to migrate to the U.S. and have a higher risk of diabetes because we have this obesogenic environment here. Now, it seems that if you migrate to the U.S. there is some protection from diabetes.)

In this week’s episode: A massive new study finds high rates of diabetes and hypertension in India.

We’ll speak to experts about what could be driving this trend-and how health systems in India and around the world must adapt to address the growing threat from non-communicable diseases.


Hello and welcome to Harvard Chan: This Week in Health. It’s Thursday, March 8, 2018. I’m Noah Leavitt.

In this week’s episode we’re taking a closer look at the growing threat posed by non-communicable diseases worldwide.

Non-communicable diseases-or NCDs-are conditions like heart disease, hypertension, diabetes, or cancer.

According to the WHO, NCDs kill about 40 million people each year-with 80% occurring in low- and middle-income countries.

And that’s an important point. NCDs are often perceived as a problem for high-income nations, but as the world rapidly develops and urbanizes, more countries are grappling with these chronic diseases.

This shift will put a strain on health systems-many of which simultaneously face substantial burdens of infectious diseases and poor maternal and child health.

That includes India-which was the focus of a massive new study we’ll be talking about today.

Researchers in the Department of Global Health and Population collected data from a nationally representative sample of more than 1.3 million people and found high rates of diabetes and hypertension across the country.

Overall, prevalence of diabetes was 6.1% among women and 6.5% among men; for hypertension, prevalence was 20.0% among women and 24.5% among men.

Researchers say the findings highlight what they call India’s “rapid epidemiological transition.”

And we’ll be taking a look at this research in three parts.

First-we’ll be looking at the findings itself, then we’ll broaden things out a bit to explain what an epidemiological transition actually is-and look at some of the potential drivers of NCDs in India and elsewhere, and then finally the big picture view: how should we redesign health systems so they’re able to address these chronic conditions.

And while the findings from India showed overall high prevalence of diabetes and hypertension, Pascal Geldsetzer, a third-year doctoral student and one of the paper’s authors, told us that rates varied widely among India’s states.

{***Pascal Geldsetzer Soundbite***}
(One unit we looked at was the state level, because many had system functions in India are organized at the state level, so it made sense to use data as a geographic unit. And here we saw that the crude prevalence of diabetes, for example, varied from 3.2% to 19.9%, and for hypertension from 18.0% to 41.6%. So, there’s a huge amount of variation between the different states in India. And I think it just shows how heterogeneous a country India really is. And you can almost think of it as a continent with different countries, rather than as a country with different states, I think.)


And Geldsetzer says that these state-level variations are really important because they can help inform how a government might respond to no communicable diseases.

{***Pascal Geldsetzer***}
(So, I think this geographic variation can certainly inform where you would want to implement certain programs in a scenario of limited resources, and you can’t afford implementing a program everywhere in India. You might well prioritize those states that have the highest prevalence of diabetes and hypertension for instance. And then apart from that, obviously, you can try targeting by age group and rural versus urban areas also to some extent. But really we saw high prevalence of these conditions throughout the population groups. And that really would go more than in the direction of population policies where you’re really trying to not just targeted at the specific population groups, but at the entire population, like sugar taxes for example, just as one example, the sort of policies that would affect the entire population.)

In order to effectively target interventions to address diabetes and hypertension it’s critical to understand what’s driving high rates of these conditions.

And that’s what we’re going to focus on in the second part of our podcast.

We spoke to Lindsay Jaacks, another author of this study, and an assistant professor in the Department of Global Health and Population.

We spoke to her shortly after she returned from a month-long trip to India, where she led a course that focused on fieldwork related to non-communicable diseases.

And she helped put what we’re seeing in India in perspective.

{***Lindsay Jaacks Soundbite***}
(We now have a higher prevalence of diabetes in urban areas in India than in people who migrate from India to the US. So, in the past, you used to migrate to the US and have a higher risk of diabetes, because we have this obesogenic environment here. Now, it seems that if you migrate to the US, there there’s some protection from diabetes. Which suggests that in urban areas of India, Chennai and Delhi specifically where this data is coming from where this was analyzed, there’s some exposure that really increasing people’s risks. And I think that part of the equation is environmental exposures. The environmental exposures in Delhi and Shania and other parts of India are so much higher than what we see in the US now. And I think that trying to understand and quantify that risk is of great interest. And I think that we need that to actually have strong policies in place and government support for those policies and enforcement of those policies to move forward on this. And again, I really don’t think that we can address the diabetes epidemic without addressing environmental exposures.)


We’ll be talking more about environmental exposures in a few minutes.

But first, as we mentioned at the beginning of this episode, researchers say these findings highlight the nature of India’s rapid epidemiological transition. And so I asked Jaacks to explain what that means. And then we’ll dive into more of my conversation with her about the factors driving high rates of NCDs in India and elsewhere.

LINDSAY JAACKS: The epi transition is one of the mainstays of global health and demography, I would say. It’s basically the transition from what we consider the classic global health issues of high maternal mortality, high under-five mortality from things like acute respiratory infections and diarrheal diseases. And in the neonatal period, first 28 days of life, high mortality in that area. And kind of as we’ve addressed that through development and public health, global health interventions, we’ve seen a decline in mortality in that age group and an increase in life expectancy. And so, people are dying at older ages and from different diseases. And that’s why NCDs, the non-communicable diseases are increasingly of interest in global health.
NOAH LEAVITT: And I mean, India is not unique in this sense. It’s a sign that we’re seeing in a lot of countries now, right?

LINDSAY JAACKS: Yep, yep. I have not seen a country yet that is not undergoing this transition. India is really interesting because it’s, well, A, because it’s such a big country, but also because the transition has happened very, very quickly. So, about a month ago now, I guess, one of the largest collaborations ever that’s been part of the global burden of disease project to this India collaborators for the global burden of disease, published a paper in The Lancet actually on the epidemiological transition in India. And it was the first state by state quantification of the epi transition. And they found in 15 years, every state has fully transitioned to having the majority of deaths be from NCDs rather than the classical maternal and child health and communicable diseases.

NOAH LEAVITT: And so, for the global health communities, is this just kind of– I don’t know if surprising is the right word, but is it kind of forcing people in global health to maybe rethink the way their kind of approaching these countries, because it is shifting from like you said, maternal mortality, et cetera, to maybe these longer-term diseases like diabetes and hypertension.

LINDSAY JAACKS: I think it’s definitely shifting the way that we think about health systems for example and what health systems need to be able to provide to citizens. I think that because– so this transition is occurring, but it doesn’t mean that those communicable diseases and maternal and child mortality are not issues. They still are issues, and in a country like India, the numbers are still very high in absolute terms for those diseases. So, I don’t think that everyone in global health should all of a sudden start studying NCDs because there is this un-left agenda of communicable diseases. And there still are high rates of under-five mortality and maternal mortality that I think we need to continue to address, same thing with under-nutrition. And as climate change is occurring I think while we’ve seen this epi transition occur with climate change, we could see ourselves going back to having higher rates of under-nutrition because of food insecurity that may arise from shifts in the climate that lead to lower food production.
So, I don’t think that we should abandon those traditional global health issues, but I do think that we need to start to think about and NCDs, and we do see that in the Harvard School of Public Health, more and more people are starting to study that including students and faculty.

NOAH LEAVITT: And so, I know this most recent study found kind of higher rates of diabetes and hypertension across the board in India. But there was also– I talked about this with Pascal– that there was also this really interesting variation kind of depending on my state and geographic region. So, I guess, what are some of the takeaways from those findings that there are higher rates across the board, but also these kinds of really significant variations?

LINDSAY JAACKS: Most states in India are bigger than most countries in Europe. Which is such an interesting thing to talk about. As you know I just got back from this field trip where we had 11 masters students from Harvard traveling around India and talking about NCDs. And we’re in Madhya Pradesh, which I think the population is like 79 million, and they have 22 certified mental health workers, psychologists. So, it’s just like bigger than most European countries, but has fewer mental health practitioners than Brookline. So, it’s a very interesting country in that way, because it’s so huge. And I think we all struggle to really comprehend how big India actually is. And the health care system in India, because it’s so big, is run at the state level. And so, I think a lot of the state-wide variation that we see in all health outcomes is stemming partially from the state level health care system implementation. And we see more self-gradients or more broader regional gradients, and some of that may relate to more historical and cultural differences that you see from north India to south India. And that leads to differences in dietary intake, differences in social demographic indicators. And so, I think there are a lot of things that are contributing. And I don’t think we’ll figure out what specific things are explaining all of the variation that we see. But because it is at the state level in terms of health systems, working with state level governments will be critical for addressing the numbers that we see across states and getting those numbers to states, especially the ones that have high prevalence of diabetes and hypertension will be critical.

NOAH LEAVITT: And you can imagine a few minutes ago, this idea of making sure health systems are prepared to deal with increasing rates of NCD. So, I guess in the case of India where so much is run at the state level, like what would that look like in terms of strengthening health system to better manage, respond NCDs.

LINDSAY JAACKS: Yeah, the number one thing is increased investment. The Indian government right now is investing, I think it’s only 2.5% maybe of GDP, maybe not even, certainly under 5% of GDP compared to say 20% in the US. So, there’s just not much money going into the health system and health care in India. And so, I think that that’s really an area where we just have to have more investment and more money going into the health system.

NOAH LEAVITT: And so, I know a lot of your focus is on nutrition and also kind of interventions to address diabetes and hypertension. So, is there anything from the findings from this recent paper that maybe might inform what our future interventions look like? Do we have a sense of what can work to prevent diabetes and hypertension in a country like India?

LINDSAY JAACKS: I think this paper in particular for me is informative for trying to understand which groups need to be targeted for these sorts of interventions. Unfortunately, we found that the prevalence is high across almost all of the socio demographic groups that we looked at. So that suggests that the classic community-based interventions in high risk individuals may, I think they’re important, but I think higher level policies that influence food systems, environmental exposures, these are going to be much more important in India, because the risk is so high across all of the groups that we looked at in all adults. And so those kinds of things would look like taxes on highly processed foods that are high in sugar, not just sugar sweetened beverages, but also, I think more traditional highly processed Indian sweets, which we find are much more prevalent than sugar sweetened beverages actually, which is a bit different than Latin America where we see much higher sugar sweetened beverages. So, taxes on soda are much more effective in Latin America than I think they’ll be in India. Though that will change over time as the epidemiological transition continues. I think that policies that encourage consumption of whole wheat in the north, so whole wheat breads in the north, and high fiber rice, not necessarily brown rice, but higher fiber streams of rice, which some of my colleagues at MDRF, the Madras Diabetes Research Foundation are working on developing. So, breeding high fiber white rice so that it’s more palatable to diabetes patients, but also has a lower glycemic index, is of interest. So, I think that there are some innovative approaches that can kind of lead to healthier population level dietary patterns that could be useful in the long run in terms of preventing across all of these different socio demographic groups. And then of course, environmental exposures, which is a huge, huge health risk in India right now. And just increasing at a pace that we just have never seen from air pollution, which has been linked to cardiometabolic risk, especially hypertension and stroke to pesticide exposures, which are strongly linked to endocrine disruption and diabetes risk. So, I think that without addressing all of these exposures, we won’t see any dent in future risk of diabetes and hypertension, because these things are not going down and there aren’t any policies that are being implemented to address them right now.

NOAH LEAVITT: Seems like there’s more that can be done from the nutrition side, like you said, the partnerships of agriculture, but from the environmental exposure side, it seems like it’s much more dependent on a policy response. So, I mean, where do where do things stand in India, for example? I imagine what you’re seeing in India is probably somewhat similar to what we’re seeing in China, so where do things stand in that regard?

LINDSAY JAACKS: Yeah, the environmental policy is again, it’s highly variable and seems to be at the state level right now. So, when we talk about things like pesticides, for example, there are some states in southern India that have adopted pretty strong bans on things like DDT, but then there are states like West Bengal that are still spraying DDT twice a year. So, you know I think it’s again probably going to be at the state level. There’s one state where we’re trying to start up an organic versus conventional farmer cohort, because the state is really advocating for organic agriculture. And so that’s a beacon of hope potentially if these pesticides are associated with cardiometabolic risk. And we hope to collect some hard data on whether or not that’s true. So again, at the state level, China is very different. You don’t see this. There is a state to state variation in China, but it’s a very strong central government. And so, you don’t see in terms of policies such big variation across states in policy implementation. And they’ve done a really good job so far of addressing a lot of these environmental exposures. So, things like when we look at breast milk samples, which is kind of this way to monitor pesticide levels. We’ve seen steady declines actually in China for many of the pesticides that have been looked at, whereas in India, it’s flat. So, I think China is making progress on a lot of these environmental exposures. And as we’ve all seen in the news, they’re actually driving the agenda when it comes to climate change.


That was Lindsay Jaacks talking about the factors behind NCDs in India-and also potential interventions to address things like diabetes and hypertension.
But as she discussed, India’s health system is not currently equipped to deal with chronic diseases like diabetes or hypertension.

So, how should health systems be redesigned to address these new challenges?

For that, we got some insight from Rifat Atun, the senior author of this India study and professor of global health systems at the Harvard Chan School.

And he says this research-as we mentioned a large, nationally representative study of more than 1.3 million people-offers important lessons for policymakers.

RIFAT ATUN: I think this study is a perfect example of the dangers of using averages. Averages in countries like India are completely meaningless because the country is so rich in terms of culture, diversity is something to be celebrated of course. But when it comes to health, we also see this diversity. And having a general policy for a condition like diabetes or for hypertension is completely meaningless. So, the findings really stress the importance of having precise measurements that are granular at the state level, or even the case of India, at district level, because districts are also fairly large in terms of population. So, one can develop highly targeted policies in parts of the country that are in different stages of epidemiological transition. And the prevalence levels vary two, three, four-fold in different states, among different states.

NOAH LEAVITT: Because these states are all maybe in different levels of economic transition as well, is one of the challenges in implementing an intervention also taking into account that this state might be in a more advanced economic state than this state? So is that part of the challenges adapting an intervention to what it maybe is possible from a resource perspective.

RIFAT ATUN: Absolutely. It’s a really excellent point. So, I think there are two consolations here. One is the stage of transition, secondly, the capabilities that exist. It may be that states that are further down the transition have greater capability in terms of health system resources, or their application to address the problems. But they need to be applied to be effective. In the states that may be less economically well developed, where the prevalence might be lower, there’s an opportunity in the sense that these states will economically grow, but there’s an opportunity to invest in prevention and target policies to ensure that with the economy transition, we can actually maybe bend the curve in terms of the increase and the prevalence of incidence and prevalence of diabetes and hypertension. So, one has to take into account the resource capabilities in the stage of development, and also how these resources can be used. So, in less well developed areas, there’s going to be more resources needed, but they need to be the right resources up applied to the right people.

NOAH LEAVITT: I know in the past we’ve talked about a separate paper looking at diabetes in sub-Saharan Africa. I remember in that conversation, one of the things we talked about was the idea of strengthening primary health systems is so important for NCDs. It’s that something that still holds in a country as large as India that if you can strengthen that front line primary health care system, you can make an impact on not just diagnosing diabetes, but then also treating it, working towards prevention, all those things?

RIFAT ATUN: Absolutely. Primary care in its broader sense is critically important in managing diabetes and hypertension and other chronic conditions along the whole care continuum in terms of health education, having appropriate interventions to ensure that people are not affected. And then the screening and then diagnosis, treatment, and then effective management, effective control of those who are in treatment. And given that the numbers are so large, that has to happen on the primary care level. Once the primary care is where continuative care can be provided, ongoing care can be provided for these conditions. Many of these people will have multiple conditions. So, diabetes and hypertension plus one other, so there’s multi morbidity. So, having primary care that can focus on the person as opposed to just a disease is critically important in managing chronic illness.

NOAH LEAVITT: And is that also important too because I mean, even as NCDs rise, there is still going to be other issues, maternal and newborn health, all of these kinds of persistent issues as well. So is that part of the, is that why it’s also important to get to focus on the person so that your doctor is looking at NCDs that you can kind manage all of these health issues at the same time, I guess balance all the different priorities.

RIFAT ATUN: The whole principle of primary care is to have individually focused the services, health services, and health care services. And this is important for antenatal care, but also for chronic disease, also for children’s illnesses. Across all conditions, primary care is key to provide the first contact, to provide a comprehensive set of interventions, to provide continuity, but also coordinate the patient’s journey within primary care, but also among different health specialists, but also across different levels. So that individuals are indeed referred to hospital when they’re needed, and much of the care can take part in primary and at the community level.


Improving primary care is an important first step, but addressing NCDs on a broad international scale will require more research to better understand the factors driving these conditions, as well as the barriers to diagnosis and treatment.

That’s why the Department of Global Health and Population launched its Project on Access to Care for Cardiometabolic Diseases or HPACC.

Atun explained that the group will be taking a broad, holistic view of NCDs-gathering data from dozens of countries.

{***Rifat Atun Soundbite***}
(I think the difference of the group is that it’s focused on cardiovascular disease, but also across many countries. But also speaking to us important questions on the variation. To really get to sort of understand how these conditions vary within and among countries. As we’ve seen India, averages are not terribly meaningful. Then once we’re able to demonstrate variation, then ask the questions, why are we seeing this variation? Is it related to socioeconomic status, is it related to geography, is it related to transition, nutritional transitional or is it economic transition to try and understand the root causes of this variation. And then develop target policies in health systems, but beyond. Especially with diabetes and other kind of multiple conditions, one has to think of multi-sectoral interventions. For example, low nutrition value but high calorie foods, for example, introducing taxes to reduce utilization of such sort of beverages and foodstuffs that are clearly a very, that have adverse effect on individuals.
So the group is looking at the issues as a whole all the way from nutrition systems to health systems and the global systems in relation to sort of commercial products that are being provided.)


And Lindsay Jaacks, who you heard from earlier, says this group and the data it gathers, will help researchers answer really fundamental questions about individual experiences with NCDs and also with health systems.

{***Lindsay Jaacks Soundbite***}
(One of the things I’m increasingly interested in, especially after this past month that I spent in India is trying to understand why individuals, especially individuals in rural, low income countries– and this is probably true everywhere, but this is just the example that I have from this past trip– people don’t want to know that they have diabetes or hypertension.
They know that sugar and tension are out there. When you talk to them about this, if you talk to your taxi driver in India, they know about sugar, they know about tension, they don’t want to know that they have it. And so, it’s very interesting, because when we talk about these huge screening programs that the Indian government is rolling out, that’s great. But if people aren’t going to show up because they don’t want to know, then this is a different kind of problem.
And so, I’m increasingly interested in trying to understand what’s behind that, and how can we change that, and how can we make people feel empowered so that when they figure out that diagnosis, they realize that they can change, and that even lifestyle changes without you know Western these Western medications, which seems to be what people don’t want to be taking every day. Without that, which is lifestyle changes, and adoption of healthy traditional diets for example, reducing stress and increasing physical activity. These pretty basic lifestyle changes can actually prevent risk very significantly. And there’s strong evidence for that from many different countries. So, trying to shift people’s perception in that way I think is a really interesting area that no one is really exploring right now. But in the future, I think that HPACC and other platforms would be a great place to explore those sorts of questions.)


Thank you to Pascal Geldsetzer, Lindsay Jaacks, and Rifat Atun for sharing their insights on NCDs in India and globally.
If you want to learn more about their work-or HPACC, their new research collaborative, we’ll have more information on our website,

A reminder that if you’re a new listener you can always find this podcast on iTunes, Soundcloud, Stitcher, and Spotify.

March 8, 2018 — A large new study of more than 1.3 million people finds high rates of diabetes and hypertension in India. We’ll speak to experts about what could be driving this trend—and how health systems in India and around the world must adapt to address the growing threat from noncommunicable diseases. You’ll hear from Pascal Geldsetzer, a third-year doctoral student in the Department of Global Health and Population, Lindsay Jaacks, assistant professor of global health, and Rifat Atun, professor of global health systems.

Learn more about the new Harvard Chan research collaborative, GHP Project on Access to Care for Cardiometabolic Diseases (HPACC), which aims to address the significant unmet need for care of diabetes, hypertension, and other conditions in low- and middle-income countries.

You can subscribe to this podcast by visiting iTunes, listen to it by following us on Soundcloud, and stream it on the Stitcher app or on Spotify.