The great Indian obesity epidemic

By Anindita Mukhopadhyay

India, still a developing nation that is struggling with poverty, malnutrition, and disease, now has the second highest number of obese children in the world, at 14.4 million. A recent study spanning 195 countries and territories from 1980 through 2015, published in The New England Journal of Medicine ascertained that 2.2 billion children and adults worldwide, were struggling with obesity. Of the 600 million adults grappling with obesity, the US topped the list with 79.4 million obesity-afflicted people, followed by China with 57.3 million people. However, in the case of the nearly 108 million children, China leads with 15.3 million obese children, shadowed closely by India at 14.4 million.

The silent epidemic

Obesity is identified as a medical condition marked by the accumulation of excessive body fat with negative health impacts. It is generally reported in terms of body mass index (BMI), a value obtained by dividing an individual’s weight by the square of their height. A BMI beyond 30kg/m2 is considered obese, while a value between 25-30kg/m2 is defined as overweight. A combination of excessive calorie intake, predominantly sedentary lifestyles, and a genetic susceptibility are cited as the causal factors of the condition. It increases the likelihood various diseases, particularly cardiovascular disorders, type 2 diabetes, osteoarthritis, certain cancers, and depression.  

The study indicates an increase in the prevalence of obesity in most nations, with its incidence almost doubling in more than 70 countries. Although obesity in children is not quite as pervasive, the rate of increase in childhood obesity in several countries was found to be higher than that of adults. The findings represent “a growing and disturbing global public health crisis”. Among the 20 most populous countries, the highest proportion of obese children and young adults were found in the US at nearly 13%. Egypt topped the list for adult obesity at about 35%. Lowest rates were in Bangladesh and Vietnam, respectively, at 1%.

Obesity in India

Obesity in India differs from the rest of the world. Indian obesity is marked by the ‘Thin-Fat Indian Phenotype’. This essentially refers to a markedly higher proportion of body fat, abdominal obesity, and visceral fat in the Indian population, as compared to our Caucasian and European counterparts. Hence, world obesity generally reported in terms of waist circumference, and a BMI beyond 30, significantly underestimates the prevalence of obesity in India. Therefore, Indian obesity must be estimated according to a lower threshold of BMI 25. Additionally, even a normal BMI of up to 23, might show higher instances of isolated abdominal obesity.

Data released by the World Obesity Federation, a community of organizations dedicated to solving the problem of obesity, shows that the percentage of Indian adults living with obesity is set to jump to around 5% by 2025, from 3.7% in 2014. Our genetic predisposition for high lipoprotein(a) levels predisposes us to a higher risk of developing diabetes mellitus, cardiovascular diseases, and death, particularly at a younger age than the rest of the world. With India still struggling against rural malnutrition, the rising threat of urban obesity serves as a double-edged sword.

What are the causal factors?

An inactive lifestyle and unhealthy diet are the main culprits of the obesity epidemic. However, genetic factors also play a significant role. This is supported by the ‘Thrifty Gene Hypothesis’ put forth by James Neel, which suggests that periods of famines in human evolutionary history resulted in a favoured selection of a thrifty genotype which led to highly efficient fat storage during periods of abundance.

Additionally, the traditional diet of India is rich in carbohydrates, with large quantities of rice in the coastal regions, chappatis in the interiors, and heavy consumption of bread all over. The widespread availability of fried and unhealthy fast food, adds empty calories to the diet. With Indians caught between these two carbohydrate-rich diets, it is no wonder that obesity is on the rise in the country.

Moreover, it has been observed that the higher people belong on the social ladder, the lesser physical work they perform. However, this is best perceived amongst the middle class who still view a ‘healthy’ body structure as a reflection of prosperity. The upper class, with an increased disposable income, are far more conscious of their health and maintain an active lifestyle. It has become imperative for people to bring their weight under control before they hit age 30. As the years pass, a person’s metabolism slows down, leading to accumulation of fat, making it increasingly difficult to achieve any sustained weight loss.  

The consequences of obesity

Ashkan Afshin, from University of Washington’s Institute for Health Metrics and Evaluation (IHME), asserts, “Excess body weight is one of the most challenging public health problems of our time, affecting nearly one in every three people.” The prevalence of the global issue has shown an alarming increase, steadily affecting more and more low and middle-income countries. Globally, in 2016, the number of overweight children under the age of five, was estimated to be over 41 million. Almost half of these children under 5 lived in Asia and one quarter lived in Africa.

Childhood obesity is associated with a higher chance of premature death and disability in adulthood. Overweight and obese children are more likely to remain obese into adulthood as well, going on to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age. Obesity increases cardiovascular mortality fourfold, and cancer-associated mortality twofold. Beyond a BMI of 25, mortality rises by approximately 30% for every 5kg/m2 increase; it lowers the life expectancy of the individual. Additionally, of the four million deaths worldwide, attributed to excess body fat in 2015, nearly 40% occurred among people whose BMI fell below 30, the obesity threshold.  

The increase in mortality and morbidity comes with an added economic burden on the patient’s kin and the country. Studies have depicted a concurrent increase in medical expenditures, including a rise in outpatient visits, with the growth of the overweight and obese population. This leads to additional stress on the over-burdened healthcare system. Moreover, a less-than-healthy population results in productivity loss, corresponding to economic losses on a broader scale.

Steps to take: Prevention and management

Obesity and its related diseases are largely preventable through a strict lifestyle and dietary regimes. At least 150 minutes of moderate-intensity physical activity per week is the recommended mandatory exercise for every individual. Also, more than 300 minutes of the same, per week, is necessary for sustained weight loss. This physical activity should be incorporated into the daily routine through leisure activities and domestic work, including walking, climbing stairs, household chores, gardening or sports. Greater emphasis on physical education in schools and colleges is a must.

Providing exercise facilities and allotting definite time for exercise at workplaces, construction and use of footpaths and bike-paths in urban areas or promoting dance forms or martial arts from a young age are just a few alternatives to physical activity. In particularly extreme cases, pharmacotherapy and surgical treatment can also be considered. The significantly increased mortality of afflicted individuals reiterates the importance of preventing and treating this epidemic.

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