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India is still grappling with the novel coronavirus pandemic, but the country’s next health crisis may be closer than we think. The prevalence of obesity among adults is expected to triple between 2010 and 2040, and by 2040, an estimated 30% of the population is likely to be overweight.
For Indians, obesity is defined as a body mass index (BMI) of 25 or more. Obesity is associated with greater risk of non-communicable diseases like diabetes, cardiovascular disease and hypertension.
The COVID-19 crisis has made the gaps in India’s healthcare system painfully visible. The spread of obesity could increase the burden on our already stressed health infrastructure.
Though obesity is present mainly in urban areas, where there is easy access to fast food and physical activity is lower than in rural settings, the numbers are rising in the countryside too. Obesity among rural women, for instance, is projected to increase six times between 2010 and 2040.
Excess weight is also bridging the gap across socio-economic statuses (SES). Overweight is more prevalent among higher SES but the condition is on the rise among lower SES as well. The number of obese children and adolescents is also growing. Dr Manish Baijal, a bariatric surgeon at Max Hospital, Gurgaon, said all groups are at risk: “It’s a multifactorial disease.”
These numbers are worrying, but they are also likely to be underestimated. Obesity is determined by BMI, which measures mass, not adiposity, or fat tissue. Different ethnic groups have different adiposity at the same weight. Indians have more body fat than Caucasians at the same BMI. So international BMI cut-offs formulated for Caucasian bodies underestimate obesity in Indians.
A group of doctors recently created BMI classifications specifically for Indians, but the discrepancy means obesity is rising even more sharply than previous studies predict. The same doctors concluded that an additional 10-15% of the country would be overweight by their new scale.
Though the wealthy exhibit obesity in a country’s initial stages of development, the burden shifts to lower SES as economic development progresses. India is currently undergoing this transition. Since the economy opened up in 1991, the country has witnessed a ‘diet liberalisation’: a shift from traditional low-fat, high-fibre diets to globalised, energy-dense diets. Multinational corporations are marketing their low-nutritional-value offerings across the country.
India’s globalising diet puts the urban poor especially at risk. One study discovered that 13.9% of residents of a Delhi slum were obese, and another found accelerating obesity among urban poor women. In addition to the reduction in physical activity and change in diet the urban well-off experience, the urban poor also face the stressors of living in an expensive city on a low income, which can contribute to obesity.
The increase in obesity may seem like an indicator of greater food consumption and rising incomes, but that is only true to an extent. Malnutrition has worsened in the last few years even as obesity has risen. The recent National Family Health Survey (NFHS) 5 showed that India has lost its past gains in malnutrition reduction. A possible explanation for this parallel rise in obesity and malnutrition is India’s sharpening economic inequality. As the growing middle class’s access to fast food expands, food security declines for the poorest in our society.
This does not necessarily mean malnutrition and obesity are disparate problems. Malnutrition in a pregnant mother can lead to obesity in the child. (The NFHS 5 finding that many pregnant women are anaemic is especially troubling in this light.)
The pandemic has exacerbated the situation on all counts. The gap between haves and have-nots has widened. India’s poorest were forced to choose between earning enough to eat and following lockdown orders, and may be once again. Some researchers fear the pandemic will fuel obesity due to closure of gyms, increased food intake to fend off stress and other factors.
Developed countries, which are further along the obesity curve, have started taking policy action to reduce obesity. For example, fast-food outlets in America are federally required to list calorie counts on menus. As food companies face greater scrutiny abroad, they may try to buffer sales by focusing on developing countries like India, where government programmes are still tackling malnutrition. PepsiCo and the Coca Cola Company are already offsetting declining sales in America with bigger pushes in Brazil and China. Just as obesity within nations shifts from the rich to the poor, global obesity may move from developed countries to developing ones.
Obesity is a challenging issue to address because it affects something as personal as the appearance of one’s body. The fact that obesity is linked to food consumption, which is enmeshed in emotions, cultural traditions and social interactions, makes it difficult to regulate. Some believe shaming people about their weight will motivate them to change, but this is misguided: weight stigma is ineffective in reducing obesity and actually worsens the situation. It is more important to promote positive behaviours like exercising and eating well.
The two levels of obesity prevention are individual and institutional. The individual method involves expanding awareness and relying on people to make healthier choices. This has worked in Sweden, where researchers attributed the stabilisation of obesity to greater awareness and local initiatives in the absence of a national obesity-reduction programme.
However, some argue that individual measures will be ineffective without institutional change because food choices are often made subconsciously, through environmental influence. For example, seeing images of food releases dopamine and makes the viewer crave food, the desired outcome of food advertising. One widely discussed policy intervention is taxing sugar-sweetened beverages. A modelling study suggested such a heavy tax would reduce obesity and overweight in India. Policy interventions are difficult to implement, however, for reasons such as resistance from food corporations and potential paternalism. No government has reversed its country’s obesity trend through policy action yet.
Given that malnutrition is still a pressing problem, it’s unlikely India will see policies to counter obesity anytime soon. Dr Baijal says that makes awareness paramount. “Obesity starts very early. We have to make families aware.” He stresses that prevention is crucial because once a person’s BMI crosses 40, weight loss becomes exceedingly difficult.
In a country where two out of five children are undernourished, it may seem myopic to flag obesity as an issue requiring national attention. Obesity has long been viewed as a “rich person’s disease” in low-income countries. However, the numbers are clear: obesity is fast becoming a nationwide problem. If we don’t take preventive steps, the current nutritional transition will eventually make inexpensive, nutritionally void food the mainstay of our poor, piling the burden of NCDs onto those least able to afford their treatment.
Ashira Shirali is an editorial intern at The Wire.