At the Madras Diabetes Research Foundation, my team’s research project addresses the childhood obesity epidemic two public health problems in a two-phase structure. The name of the study is ORANGE: Obesity Reduction and Awareness and Screening for Noncommunicable Diseases through Group Education (they sure do love their acronyms!)
Phase 1 is a screener for diabetes risk factors in 2,000 randomly selected children from residential colonies in Chennai. Phase 2 of the project is a school-based group education program, teaching ~2,300 6th and 7th grade students about lifestyle modifications (diet and exercise) to prevent diabetes.
Recently I had the opportunity to go on a field visit to learn how this process is executed, first hand.
After a short (but bumpy) ride, my team arrived at one of the randomly selected colonies in Chennai for diabetes screening. It was a narrow lane only suitable for motorcycles, so we parked our car outside the gate. 4 blocks completely occupied each side, 4 floors each, and 4 homes on each floor. Estimating a 4 to 5 person family, my advisor told me 70 households (300 people) lived on this street.
We walked up three flights of uneven stairs and arrived at our first household. Most people kept their front doors open, staring at us. The colony was pretty well knit, so they knew we were outsiders. My advisor explained to neighbors we are from Dr. Mohan’s Diabetes Clinic, and their facial expression shifted from that of confusion to a delighted acceptance.
So I forgot to mention, it’s about 7:30 AM right now on a Saturday but it feels like mid-afternoon. People are running around, catching water at the well, grocery shopping, throwing wet clothes on the clothesline, and preparing for the day. The sun also rises around 5:30 AM, so maybe that’s why people start their day much earlier than I do in the States.
The first door we knocked on was not so active. The lights were still off when a middle-aged man opened the door. After introducing us as research assistants from Dr. Mohan’s, he immediately welcomed us in and brought two plastic chairs for us to sit.
Side note on sitting: Indians here are very keen about sitting. If they ever see a guest standing up, they go out of their way to find a chair (or stool or other sitting material).
“Please, sit ma’am”
He told us to stay while he brought his wife and kids. (Yes! A time to observe their home and take some discreet pictures.)
The entryway opened to a square living room about 8 ft by 8 ft, with a few plastic chair/stools (no couches), a refrigerator, and one of those 90’s computers on a desk in the corner. The computer was covered with a cloth, which seemed to be an old nightgown. It’s pretty dusty around here, so the people really make sure to care for their belongings.
This living room had two other doors: one leading to a similar-sized bedroom, and the other leading to the kitchen (and balcony). The man, presumably the father, entered the bedroom to wake the children. The lights were off inside, but I could make out a few heads lying on the ground. At first, I thought they were having a sleepover of some sort, before realizing they did not own beds.
The father returned, asking us to come back later after the children wake. It did not surprise me they were not ready…people here tend to be on their own schedules, and often late. But I find some sort of peace in that. There is much leisure and less stress to be on time.
We continued to the second household, where everyone was awake, showered, and mom was already cooking lunch (or maybe breakfast). AT 8 AM. Wow. Their home was a cookie cutter model of the first, and the father offered us a seat after we introduced ourselves.
Our first task was to complete anthropometric measurements of both children. We take body measurements such as height, weight, BMI, and waist circumference, to assess for obesity prevalence in these children. Then, the lab technicians perform an OGTT (Oral Glucose Tolerance Test) for the participant. They draw blood while the participant is fasting (no food intake for 10 hours), and give them a sugar water drink (75 grams of glucose dissolved in water). After 1 hour, the technician draws the blood again, and sends both the fasting and the post-prandial blood samples to the lab for testing.
Lab technician drawing blood for the OGTT
During the hour in-between drawing blood samples, my research advisor administers a questionnaire about the child’s lifestyle practices. Since they communicate mostly in Tamil, it was a little difficult for me to follow along. I hoped my three semesters of learning Hindi in college would help out, but many people in Chennai do not know Hindi! I was very surprised, because it is the national language of India.
Mehreen (my grad student research adviser) administering the questionairre (in Tamil)
For the most part, today’s participants reported they generally do not play any sports or other physical activities. One boy mentioned swimming, but only once or twice…A YEAR! Another girl mentioned dance, but not so frequently. I wondered why….they are kids, and kids love to play. It is really important for their health, too. And when we asked about time spent watching TV, texting, or talking on the phone, their faces lit up with a smile. One boy even reported watching 4 hours of TV a day, and 10 hours on weekends—not including the time spent with other electronic devices!
As the questionnaire continued, she began to question about their daily habits in terms of transport and household chores. This is where the answer to my question lies. Most of the children either walk to school, or to and from a bus stop. Their part-time jobs involve heavy lifting and climbing stairs, and household chores like washing clothes and collecting water consumed their time. So perhaps they are getting their physical activity, in a different form than I would expect. Also their colony environment was not suitable or safe for playing outside, which could be another reason for not seeing “football” or “running” in their response. The questionnaire also involved a self-reported portion for food intake, which I could not observe.
Portion Tools (reflecting commonly used Indian plates, glasses, and vessels)
Something else that was peculiar to me, is when we asked about family history regarding diabetes or high blood pressure, the children gave an obvious nod—as if we should have known.
After administering the questionnaire and taking the second blood sample, we made our way back to the first house. The children—or should I say, young adults—were awake. One was 18 and the other was 23. In most parts of India, children attend local colleges and live at home until they are married. This is useful in tracking participants for longitudinal studies such as ORANGE, which last over many years. Additionally, it reduces bias that can result from living away from home.
In this home, the mother offered my advisor and myself a cup of chai. If you’ve read my previous post, refusing food or drink when visiting other’s homes is considered disrespectful, and people tend to become upset. However, I had to refuse because my stomach has not been enjoying the buffalo milk here. At least I learned the phrase for “I’m sorry” in Tamil: Enna mannichudunga.
We did the same OGTT and questionnaire in this household, before making our way back to the office. On our way out, an elderly man stopped us to ask where we were from (and gave us chairs to sit, as always). While we were talking, a man and woman approached us. The man was wearing cargo shorts and a buttondown, while the wife was dressed in an elegant churdidar (a long dressy top and leggings). They both were wearing sunglasses, the man’s head focused on his silver iPhone and the woman’s eyes wandering the surroundings. It was obvious they did not live in this colony, like two shining pearls in the middle of colorful plastic beads. They asked the elderly man for the “address of so-and-so”. After giving directions to the best of his ability, he returned and exclaimed, “Address? There are no addresses here! We are all a community of blocks; there is A block, B block and C block.” I guess he does not like visitors.
So to wrap things up, it was very interesting to learn how the lives of people in this colony are very different from my own. I don’t have to worry about many things, like pumping water from the well, bringing in clothes from the balcony before it rains, or fearing for my safety on the streets. Moreover, it is eye opening to see how such starkly different lifestyles also affect our health, in relation to diabetes and other non-communicable diseases.
The blood samples we took today will be sent to the lab for testing, and the participants who screen for pre-diabetes or diabetes will be brought into Dr. Mohan’s Centre over the next few weeks. More on that next time!