Chris Baker: Child obesity in India? Tell me something I don’t know!

chris_bakerIn recent years an abundance of observational studies have drawn attention to the rising prevalence of child overweight and obesity in India. A recent meta-analysis of studies in South Asia, including 57 datasets from India, concluded that 14% of children and adolescents were overweight, with the more affluent and those in urban areas being at higher risk. Despite this evidence, the publication of prevalence studies continues apace, confirming existing knowledge but providing little to inform a much needed response.

Tackling child obesity requires more than estimates of the number of children at risk and more than a simplistic appreciation of lifestyle determinants (a recent review of risk factors in South Asia points, unsurprisingly, to two well known adversaries: physical inactivity and consumption of energy dense foods). We need qualitative research to understand the specific cultural beliefs and drivers related to these behaviours. Only by incorporating such insights from the ground can we hope to develop interventions that effectively address overweight as it is experienced in India.

Unfortunately, such research is severely lacking. A search of PubMed, PsychInfo, and Google identified only two qualitative studies from the past 15 years on the issue of child overweight in India (one from New Delhi and the other from four Indian cities). These studies were well conducted and provided interesting insights, but there is a need for more work, given the ethnic and socio-economic diversity of India’s population.

The imbalance of quantitative and qualitative work is common in many research areas in India, where skilled qualitative researchers are outnumbered by those focusing on the so called “numbers game.” Qualitative research needs to be valued for its critical role in the design of effective, acceptable interventions. Indian journals should publish more qualitative research and issue specific calls on important topics. A national body for qualitative research is essential to facilitate collaboration within the subject and raise its profile more widely. Such a body could support the professional development of those interested in qualitative methods. Meanwhile, eager researchers can consult published guidance on how to conduct and report qualitative research.

What do we need to know to better tackle child overweight and obesity in India? The following research questions, within three broad categories, offer some starting points but by no means represent an exhaustive list.

Meanings and myths

How is overweight in children understood by different populations in India?

How do the media portray overweight in print, film, and television?

Is overweight perceived as a threat to good health or as an enabler of successful growth and development? What beliefs support prevalent myths in India, including the so called “fat is healthy” argument, observed in a study in Delhi, and the belief that a child will “grow out” of their excess weight—contradicted by evidence that obesity during childhood is likely to continue into adulthood.

Which lifestyle factors, if any, are believed to contribute to overweight? A review of qualitative studies with South Asian populations in the UK identified a widely held belief that lifestyle had minimal impact on health. Such insights have important implications for the framing of behaviour change interventions and their messages.

Identification of overweight

How do Indian parents, health professionals, and children differ when defining “healthy weight?”

Can parents and health professionals recognise overweight or obesity in children? A recent review of recognition studies found that over half of parents underestimate their overweight/obese child’s weight status. Furthermore, a study of GPs and GP trainees in the UK found that health professionals also have difficulty discerning weight status accurately. To date, no such studies (with parents or health professionals) have been conducted in India, but studies of this kind are important to determine the extent to which overweight patients, and therefore opportunities to offer them support, are being overlooked.

Enabling behaviour change

For parents or children who intend to address being overweight:
What influences the decision to lose weight?
Which dietary or lifestyle behaviours are adopted?
How are new habits initiated, encouraged, and maintained?
Which environmental factors are identified as obstacles to success?
Which expert agencies are consulted for support?

These questions, which have yet to be addressed in an Indian context, will help health professionals to provide culturally appropriate care, which acknowledges the specific beliefs and perceptions prevalent in the community.

It is therefore time for a moratorium on prevalence studies of child overweight and obesity in India. These studies are unlikely to challenge existing knowledge of the scale and distribution of the burden of overweight and obesity. Rather, let us divert resources away from the “what” and “who” of child obesity towards the “why” and “how.” These questions require the application of qualitative research methods with families and health professionals to explore the lived experience of being overweight or obese, and the broader social and cultural beliefs related to this growing burden.

Chris Baker is a distance learning tutor at the London School of Hygiene and Tropical Medicine, and is interested in non-communicable diseases and lifestyle change in India.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.