Widening Waistline: Rising Burden of Obesity in India

Obesity is one of the most important problems, affecting one billion people globally, and 2.8 million deaths worldwide are attributable to the various health effects of obesity and overweight. The global prevalence of obesity is around 14% and is expected to rise to 24% by 2035.[1] Approximately 39% of the global adult population was classified as overweight with a body mass index (BMI) of 25–29.9 kg/m2 or obese (BMI > 29.9 kg/m2). In India and the Asia Pacific regions, a lower BMI criterion for overweight (BMI 23–24.9 kg/m2) and obesity (>25 kg/m2) is recommended.[2] Globally, the prevalence of obesity increased among women from 6.4% in 1975 to 14.9% in 2014 and from 3.2% to 10.8% among men in the same period. In India, the prevalence of overweight and obesity increased from 8.4% to 15.5% among women between 1998 and 2015, and the prevalence of obesity increased from 2.2% to 5.1% during the same period. These rates are projected to triple by 2040, with the prevalence of overweight and obesity reaching to 30.1% and 9.5%, respectively.[3] This increased prevalence of obesity is expected to be driven by the rural and elderly populations. The National Family Health Study 5 (NFHS -5) data from 2019 to 2021 show that overall weighted prevalence of obesity and overweight in male and female study participants was 44.02% and 41.16%, respectively, whereas the similar figures from NFHS-4 (between 2015 and 2016) were 37.71% and 36.14% for men and women, respectively.[4] Most states in northern, southern, and western India showed an increasing prevalence, whereas some states in central and eastern India showed lower prevalence. The increasing trends of overweight and obesity in the young population aged 18–49 years, as seen from these two studies, are mainly responsible for the increase in noncommunicable diseases such as type 2 diabetes mellitus, hypertension, hyperlipidemia, and coronary artery diseases in young people. These trends reflect the global trend of increasing obesity. The ICMR-INDIAB study, a large cross-sectional population-based survey conducted in 31 states and union territories of India, has revealed a prevalence of general obesity at 28.6% and abdominal obesity at 39.5%, as well as an overall increase in the prevalence of diabetes and other metabolic noncommunicable diseases.[5] The trend of rising prevalence of obesity is also seen in children and adolescents in India. The World Obesity Atlas, published in 2024, estimates that as of 2020, there are 33 million children in India with overweight or obesity, which translates to a prevalence of 9% among children below the age of 20 years and by 2035, this number is expected to be around 83 million with a prevalence of 24%.[6] The rapid uptick is primarily driven by socioeconomic changes, including improved wealth, urbanization, and lifestyle shifts (less physical labor, more sedentary work), which have markedly increased calorie intake and obesity over just a few years. THE DIETARY CULPRITS: A DEPARTURE FROM TRADITION The primary driver of this escalating crisis is a profound shift in dietary habits. The traditional Indian diet, rich in fibre, whole grains, legumes, and vegetables, is being systematically replaced by a modern, energy-dense diet. A high intake of refined carbohydrates, unhealthy fats, processed foods, and sugar-sweetened beverages (SSBs) characterizes this “Indianized” Western diet.[7] Over the past one to two decades, dietary patterns have undergone significant shifts. Indians are now consuming more energy-dense processed foods, sweets, and fats, at the expense of whole grains and vegetables. Urban and rural diets often include SSBs (such as soft drinks), packaged snacks, fried street foods, and refined grains. One review found that “diets have diversified and shifted away from cereals towards processed food.” with refined grains remaining staples and a greater intake of snacks, sweets, and oils. Overall, dietary changes reflect a “global nutrition transition:” More simple sugars, saturated fats, and processed foods, and fewer complex carbohydrates and fibre.[8] In contrast, the typical Western diet includes a high intake of red and processed meats, sugary drinks, ultraprocessed fast foods, refined grains, and high sugar cereals. In India, emerging data suggest a similar trend: An increase in red meat and poultry consumption associated with obesity and central adiposity. SSB consumption is increasing in India and is a significant risk factor for obesity in young adults. Modeling studies have shown that taxing SSB could significantly affect weight gain, and rural men would benefit the most from the SSB tax.[9] The urban lifestyle, characterized by sedentary work and increased screen time, contributes to the problem, and rural areas are also being affected as these foods penetrate rural markets. Studies have shown that a shift in dietary patterns is occurring more frequently among the urban poor and the rural affluent. Many commercial determinants, such as aggressive marketing and targeted advertisements, have enabled food manufacturing giants to penetrate rural areas in low- and middle-income countries (LMIC), including India. With no further growth expected in high-income countries, the consumption of “unhealthy” food has increased rapidly in LMIC countries.[10] In this issue of the APIK Journal of Internal Medicine, Bala et al. have published their study on the prevalence, determinants, and impact of junk food consumption on body weight in a cohort of 409 college students of Hyderabad, Telangana, India. Using a questionnaire-based cross-sectional study, the authors noted that nearly 46% of the study participants (mean age 20.52 ± 1.65 years) consumed junk food more than three times a week. The food included fast food, sweets, sugary juices and drinks, as well as salty processed foods. Only 2% of the studied population reported not consuming junk food. It is worth noting that 20.2% of the students included in the study were overweight or obese, underscoring the growing problem of obesity in urban India. Although the authors found an increase in BMI with increased intake of junk food, this was not statistically significant. As the study had a small sample size of 409 and was cross-sectional and observational, the authors were unable to demonstrate a clear positive relationship between junk food consumption and obesity.[11] RISING OBESITY AND A CALL FOR ACTION Obesity is linked to several serious comorbidities, such as type 2 diabetes, hypertension, cardiovascular disease, and certain cancers, which are responsible for over 3.4 million deaths worldwide. The annual economic burden of obesity in India stands at $23.2 billion, which equals 1.7% of the country’s GDP, and without adequate measures, this could rise to $440 billion by 2060; direct medical expenses account for about 32% of these costs, whereas the remaining 68% arise from indirect factors such as absenteeism, reduced productivity, and premature mortality. Obesity also leads to psychological challenges stemming from social stigma, resulting in mental health issues and unhealthy behaviors, and it can disrupt family life by affecting dynamics, educational opportunities, and healthcare access. The condition increases healthcare spending and puts additional pressure on national health systems, ultimately limiting economic growth and reducing life expectancy.[12] Overall, obesity poses a multifaceted challenge to India’s public health, necessitating urgent interventions in screening, treatment, and awareness programs to mitigate its impact. Addressing the growing burden of obesity in India necessitates a multifaceted approach, encompassing public awareness, promoting healthy lifestyles, and implementing policy interventions. Key strategies include promoting a healthy lifestyle, encouraging a balanced diet that includes whole grains, fruits, and vegetables while reducing consumption of high-sugar, high-sodium, and high-fat foods. In addition, promoting physical activity, engaging in outdoor activities, and engaging in regular exercise are also important. Nationwide campaigns to raise awareness about the health issues associated with obesity and the importance of adopting healthy habits are essential. There are several good initiatives of the Government of India, such as Fit India, Eat Right, Khelo India, Aaj Se Thoda Kam campaign, Poshan 2.0, Repurpose used cooking Oil, which are aimed at promoting good eating habits and improving physical activities aimed to decrease the burden of overweight and obesity. Some policy interventions, such as increasing taxation on unhealthy food (like the SSB tax), making healthy food more affordable, and addressing environmental and socioeconomic factors like tackling air pollution, can encourage outdoor activities. These interventions can also include incorporating parks, walking tracks, and bicycle tracks into urban planning. With the availability of new drugs for obesity such as Semaglutide, Liraglutide, and Tirzepatide healthcare professionals need to follow clear evidence-based guidelines for the use of these “antiobesity drugs” prudently. Obesity is an urgent and growing challenge and needs a multipronged strategy with individualised dietary and pharmacological prescription by the physician, which is affordable, culturally feasible, and sustainable. A community-level strategy aimed at creating awareness about unhealthy food, encouraging physical activity, and a positive approach without stigmatizing the affected individuals, and focusing on preventing childhood and adolescent obesity with lifestyle improvements. The government and regulatory approaches toward the food industry, planning and actions aimed at tackling the epidemic of obesity in India before it blows out of proportion, would go a long way in the prevention of various NCDs in India and thus contribute to the nation’s health and economy.