India’s double burden of malnutrition

Among large cities, Kolkata and Hyderabad have the greatest proportion of obese people in India

Malnutrition in India has always been synonymous with under-nutrition. Not anymore. Data from the latest round of the National Family Health Survey (NFHS) shows that obesity among adults is nearly as big a problem in the country as under-nutrition. Even as under-nutrition continues to remain extraordinarily high in the poorer parts of the country, obesity has reached endemic levels in some of the richer parts of the country, the survey of over 6 lakh households conducted in 2015-16 shows.

When the previous round of NFHS was conducted in 2005-06, the proportion of underweight men and women in the country was found to be nearly three times the proportion of overweight men and women, respectively. The latest survey shows that the proportion of overweight women in India at 20.7% is only 2 percentage points lower than the proportion of underweight women. The trend among men is similar, with nearly one in five men overweight today.

While the proportion of underweight adults has fallen over the past decade, the proportion of overweight adults has shot up sharply. Individuals who have a body mass index, or BMI, of 25 or more are considered overweight while those with a BMI less than 18.5 are considered underweight. Women seem to be affected more by both forms of malnutrition compared to men. More women than men are obese, and more women than men are underweight, the data shows.

According to some scholars, the twin problem of high malnutrition and growing obesity may have a common cause: a high proportion of low birth weight babies in India. According to one hypothesis (the so-called thrifty genotype hypothesis), under-nutrition in the pre-natal stage programmes the foetal tissues to utilize food efficiently, making it difficult for low birth weight babies to deal with an abundance of food in later life. The double malnutrition trap can be particularly dangerous for Asian economies such as India, where urban populations are rising, and where people increasingly face a sedentary lifestyle.

A look at district-level data, however, shows a clear divide between districts which have high concentration of underweight men and women and those which have high concentration of obese or overweight men and women. At one end of the spectrum are districts such as Purulia in West Bengal and Malkangiri in Odisha, where nearly one in two women are underweight. These districts are among the poorest in the country, and have been hotbeds of leftwing extremism for many years. At the other end of the spectrum are cities such as Kolkata and Hyderabad, where four out of every 10 women are overweight. Delhi and Mumbai also figure in the top quartile of districts with high levels of obesity but the proportion of obese people in these cities are lower compared to Kolkata and Hyderabad.

Kolkata is somewhat of an outlier in West Bengal, which has a relatively low proportion of overweight women. Hyderabad though reflects a state-level trend. Along with other southern states such as Kerala and Tamil Nadu, Andhra Pradesh has among the highest levels of obesity in the country.

A look at the district map suggests that most of the high-obesity districts are clustered largely around the two ends of the country: the extreme north and the extreme south. The undernourished districts are largely located in central India. There seems to be a strong correlation between affluence, obesity and lifestyle diseases. Districts with a higher proportion of rich households (those with TV, computer, phone, and motorised two-wheeler/four-wheeler as per census 2011 data) tend to have a higher proportion of obese people and lower proportion of underweight people.

The link between malnutrition and sanitation is even stronger. Districts with low levels of toilet access have high levels of undernutrition and low levels of obesity. The converse is true for districts with high levels of access to toilets.

The stark nutritional divide across the country in many ways mirrors the divide in growth and development across the country.