Rising concern: Rural India faces the double burden of undernutrition and obesity

Rising obesity among rural inhabitants is playing out alongside the alarming story of under-nutrition in the country. The National Family Health Survey-5 figures released in December 2020 show a big spike in obesity in the villages of India.

Patralekha Chatterjee
| Updated: March 2nd, 2021

Photo: Unicef India

Manguraha in Bihar’s East Champaran district is one of those villages that rarely makes ‘news.’ But a Patna-based family physician who runs a weekend rural clinic at Manguraha that has a population of about 3,500 people has noticed a worrying health trend —  rising obesity. 

The stunted, wasted and underweight still hugely outnumber the overweight in India. But obesity is rising, and it is no longer just an urban problem. Even poor men, women and children in impoverished parts of the countryside are affected.

Pratyush Kumar has converted part of his ancestral home in Manguraha into a health clinic. Every weekend, he hops onto a bus and heads to his village. While he has not quite kept count, he says there has been a noticeable rise in the number of obese patients in recent years. “The problem is more acute among the elderly but a good many of even those in their forties are overweight,” he observed. 

Pic for representation purpose only. Photo: Adam Cohn/flickr

What is driving this trend?

There has been no systematic study of the underlying factors contributing to obesity in this patch of India but Kumar lists a few possible reasons.

“The patients I see have a carbohydrate-rich diet —  lots of rice and potatoes. Both can lead to weight gain. The lifestyle, especially of women, has become more sedentary. Add to that increasing penetration of junk food and fast food into villages,” Kumar pointed out to Gaon Connection

Nutrition researchers say that the determinants of obesity in India deserve to be studied in much greater detail. Photo: Jayanti Baruda

“There is another important factor. Many people living in villages now suffer from chronic obstructive pulmonary disease (COPD) and arthritis. They are in deep pain because of this; sometimes, they start taking steroids like Dexamethasone and Betamethasone. These are prescription drugs, but the villagers manage to get them over-the-counter without a doctor’s prescription,” Kumar said. When they come to his clinic, they already show signs of long-term abuse of these drugs, which includes weight gain, he added.

What is showing up in Manguraha is a tiny part of a much-larger problem cropping up in India’s villages. 

Also read:  Karnataka makes headway in improving nutrition levels but 50% women and 66% under-5 kids still anaemic

Rising rural obesity

According to the latest National Family Health Survey (NFHS-5, 2019-2020), 14.2 per cent of women in rural Bihar are overweight or obese, up from 9.7 per cent in NFHS-4 ( 2015-2016); the percentage of obese and overweight men has also shot up in Bihar’s villages from 10.9 per cent during NFHS-4 to 13.6 per cent of those surveyed for NFHS-5. 

NFHS-5 also reveals that 2.4 per cent of children under five in rural Bihar are overweight. In 2015-2016, that number was statistically insignificant and did not feature among the nutrition indicators. 

A large number of children do not get an adequate diet in India. Photo: Neetu Singh

In Assam, 33.6 per cent of children under five years are underweight. But significantly, 4.5 per cent of children surveyed in the same age group were found to be overweight, according to the latest NFHS data.

Going by The Comprehensive National Nutrition Survey (CNNS 2016- 2018) data, states with the highest prevalence of overweight in children between five and nine years were Goa and Nagaland (15 per cent) while states with the lowest prevalence of overweight in children between five and nine years were Jharkhand and Bihar.

Rising rural obesity and urbanisation of rural spaces

In a recent article titled India’s rural transformation and rising obesity burden in World Development (World Development, Volume 138, February 2021), three US-based scholars — Anaka Aiyar, Andaleeb Rahman and Prabhu Pingali —  make four key observations.

The rise in rural obesity in India is closely associated with urbanisation of its rural spaces; these risks have increased disproportionately among lower socio-economic classes; those living near towns with a population of 50,000 and those living in more economically developed states are at greater risk; and greater diet diversity alleviates the urban effect of the rural obesity pandemic.

Aiyar, Rahman and Pingali note that  “One kilometre (km) reduction in rural-urban distance leads to 0.06 per cent increase in obesity incidence for women in rural areas. More plainly, an additional kilometre of urban influence on surrounding villages leads to an increase in obesity incidence among approximately 3,000 rural women.”

A pregnant woman, stands on weigth machine as Anganwadi worker looks at machine inside Anganwadi centre in Dhumodi village. Photo: Unicef India

The researchers point out that the perverse outcome of the increasing threat of obesity among the rural poor is that this could increase their risks of facing catastrophic health shocks induced by the burden of non-communicable diseases.

Obesity and undernutrition, both rising

Rising obesity among rural men, women and children is not confined to any specific part of the country and is playing out alongside the alarming story of under-nutrition.

Today, rural distress and rural obesity exist cheek-by-jowl. The prevalence of obesity among men and women in the country as a whole has doubled from 1998-99 to 2015-16. The latest data from India’s National Family Health Survey-5, released last December, shows that the obesity gap between rural and urban women is narrowing. The reason: a big spike in obesity among rural populations. Experts say that obesity is now growing faster in rural parts of the country, bringing with it a host of related diseases. 

The Comprehensive National Nutrition Survey 2016- 2018 that flags the problem of overweight and obesity in the country as a whole highlights a key concern —  adult diseases are starting in childhood.

Unicef team measuring weight of a child. Photo: Unicef India

“Undernutrition in-utero and early childhood can predispose individuals to become overweight and develop noncommunicable diseases such as diabetes and heart disease in adulthood (WHO, 2017). Excessive weight in mothers is also associated with overweight and obesity in their offspring. Rapid weight gain following acute malnutrition early in life may predispose children to excess weight and the associated risks in adulthood.”

Nutrition researchers say that the determinants of obesity in India deserve to be studied in much greater detail. Turning the tide against obesity and related morbidities like high blood sugar in both urban and rural areas requires a restructuring of India’s food systems. Healthy foods must not only be available but affordable for all.

“The double burden of undernutrition and overnutrition is recognised worldwide. However, the determinants of the rise of overweight or obesity have not been systematically investigated in India. The study found that the risk of overnutrition at the individual level tended to be particularly high in states with a higher level of socio-economic development however the recent significant rise in the prevalence of overweight and obesity was observed in states of lower socioeconomic development also,” noted Mohammed Shannawaz and Perianayagam Arokiasamy in a November 2018 report titled Overweight/Obesity: An Emerging Epidemic in India in the Journal of Clinical and Diagnostic Research.

Obesity is a serious public health challenge in India, now a hot spot for non-communicable or lifestyle diseases because it increases the risk of other diseases and health problems, such as heart disease, diabetes, high blood pressure and certain cancers. Obesity is also a risk factor for severe COVID-19. Public policies to tackle malnutrition must pay heed to obesity as well as undernutrition.