Rising Overnutrition in Urban India

India is grappling with a paradoxical nutritional landscape. While undernutrition remains a concern in many regions, overnutrition is now rapidly escalating in urban centres. In 2021, India ranked second globally in overweight and obesity prevalence. The trend is particularly evident in metropolitan IT corridors, where professionals are unwittingly becoming the face of a silent metabolic crisis.
India’s double burden of malnutrition — rampant undernutrition coexisting with overnutrition — is reflected in its low ranking on the Global Hunger Index.

What are the CAUSES for overnutrition in urban India?

1. The “Nutrition Transition” and Changing Dietary Patterns:

• Shift from Traditional to Westernized Diets: Urbanization has led to a move away from traditional, home-cooked meals rich in whole grains, pulses, fruits, and vegetables. Instead, there’s a growing reliance on:
  • Ultra-processed foods (UPFs): These are typically high in refined sugars, unhealthy fats (trans fats, saturated fats), and sodium, while being low in essential nutrients and fiber.
  • Increased out-of-home eating: Busy urban lifestyles, especially among working professionals, lead to more frequent consumption of restaurant food, street food, and takeaway options, which are often calorie-dense and prepared with excessive oil and sugar.
  • Reduced intake of healthy foods: The consumption of traditional staples like coarse grains (millets) and pulses has decreased, and despite greater availability, the actual intake of fruits and vegetables often remains insufficient.
• Aggressive Marketing: The food industry aggressively markets unhealthy processed foods, particularly to children and youth, through various media channels, influencing food preferences and consumption habits.

2. Sedentary Lifestyles:

• Reduced Physical Activity:
  • Desk-bound jobs: Many urban occupations – particularly related to IT sector – involve prolonged sitting and minimal physical exertion.
  • Mechanized transportation: Increased reliance on private vehicles and public transport reduces walking and cycling.
  • Lack of green spaces and recreational facilities: Urban planning often prioritizes infrastructure over accessible parks, playgrounds, and safe walking/cycling paths, limiting opportunities for physical activity.
  • Increased screen time: Children and adults alike spend significant hours on digital devices (TV, smartphones, computers), contributing to a sedentary lifestyle.
• Convenience and Automation: Modern conveniences like elevators, escalators, and household appliances reduce daily physical activity.

3. Socioeconomic and Cultural Factors:

• Rising Incomes and Aspirations: As incomes rise, particularly among the urban middle class, there’s a tendency to spend more on convenient, often less healthy, processed foods and eating out, which are sometimes seen as symbols of modernization and higher living standards. According to NFHS-5, the prevalence of overweight or obesity rises from 10% in the lowest wealth quintile to 37% in the highest wealth quintile.
• Poverty and Food Insecurity (The Paradox): While overnutrition is often linked to affluence, it’s increasingly prevalent among the urban poor. This is because:
  • Cheaper calorie sources: Ultra-processed foods are often cheaper per calorie than fresh, nutritious foods, making them an economically viable option for those with limited budgets.
  • “Hidden hunger”: Even if calorie intake is sufficient, a diet dominated by refined grains and processed foods can lead to micronutrient deficiencies while simultaneously causing weight gain.
• Changing Family Structures: Nuclear families and working parents may have less time for home cooking, leading to a greater reliance on convenience foods.
• Maternal Health: Maternal obesity is a significant risk factor for childhood obesity, creating an intergenerational cycle.

4. Urban Environment (Obesogenic Environment):

• Food Environment: Urban areas are often characterized by an abundance of fast-food outlets, small shops selling processed snacks, and readily available sugary drinks, making unhealthy choices convenient and ubiquitous.
• Limited Access to Nutritious Food: While supermarkets exist, fresh produce may still be expensive or less accessible in certain urban pockets, especially informal settlements or lower-income neighborhoods, creating “food deserts” where healthy options are scarce.
• Air Pollution: Studies in Indian cities have linked high levels of air pollution (e.g., PM2.5) to reduced outdoor physical activity, contributing indirectly to weight gain.

5. Biological and Genetic Predispositions:

• Genetic Susceptibility: Indians, particularly South Asians, have a higher predisposition to abdominal obesity and related metabolic diseases (like Type 2 Diabetes) at lower BMIs compared to Caucasian populations. This means they are at higher risk even without being “clinically obese” by international standards.
• Fetal Origins of Adult Disease (FOAD): Poor maternal nutrition (both under- and overnutrition) during pregnancy can predispose the offspring to obesity and NCDs later in life.

What are the CONSEQUENCES of overnutrition in urban India?

1. Rise in Non-Communicable Diseases (NCDs): Overnutrition significantly increases the risk of chronic NCDs such as type 2 diabetes, hypertension, cardiovascular diseases, and certain cancers.

• India has witnessed a sharp rise in diabetes prevalence—from 5.9% in 2000 to 10.4% in 2017—amounting to about 72 million people affected.
• Hypertension rates have also climbed, with 29.2% of the population affected as of 2014.
• A recent article published in Nature magazine studied the prevalence of Metabolic Dysfunction Associated Fatty Liver Disease (MAFLD) among IT employees in Hyderabad found that 84% of the participants had fatty liver, indicating MAFLD, and 71% were obese.
• STEPS Survey (2023-24) in Tamil Nadu found out that 65% of deaths in Chennai are attributable to NCDs.

2. Dual Burden of Malnutrition: Urban India faces a dual burden: while undernutrition persists in some groups, overweight and obesity rates have surged, especially among women (about half of urban women affected). This coexistence complicates public health responses and stretches healthcare resources.

3. Childhood Obesity and Related Health Issues: Overnutrition among children is rising, leading to early onset of obesity, metabolic syndrome, and increased risk of adult NCDs. The cumulative prevalence of overweight/obesity among children has increased to 19.3%. According to an article published in Lancet, Childhood obesity has surged by 244% over the past three decades and is expected to climb another 121% in the next three. The National Family Health Survey-5 shows that obesity steadily rises with age, from 7% among men (15-19 years) to 32% among those aged 40 to 49 years.

4. Lower Immunity and Increased Infection Risk: Being overweight or obese is linked to a weakened immune system, making individuals more susceptible to infections, as seen during the COVID-19 pandemic.

5. Economic and Social Impact: The growing burden of NCDs leads to higher healthcare costs (Out of Pocket Expenditure), loss of productivity, and increased economic strain on families and the healthcare system.

6. Psychosocial Consequences: Overnutrition can lead to stigma due to obesity, low self-esteem, and mental health issues, particularly among children and adolescents.

7. Micronutrient Deficiencies: Despite excess calorie intake, urban diets often lack essential micronutrients, leading to hidden hunger and associated health problems.

What have been the government initiatives?

1. Eat Right India Movement (FSSAI):

• Objective: Led by the Food Safety and Standards Authority of India (FSSAI) under the Ministry of Health and Family Welfare, this movement aims to transform the country’s food system into one that promotes safer and healthier eating habits. It addresses the “triple burden of malnutrition” (under-nutrition, micronutrient deficiencies, and overnutrition).
• Key Pillars:
  • Eat Safe: Emphasizes personal and surrounding hygiene in food preparation and consumption.
  • Eat Healthy: Promotes diet diversity and balanced diets, focusing on reducing consumption of salt, sugar, and saturated fats, and eliminating trans fats. It also encourages fortification of staples to address micronutrient deficiencies, which can indirectly help in shifting dietary patterns away from ultra-processed foods.
  • Eat Sustainably: Promotes local and seasonal foods, and aims to prevent food loss and waste.
• Initiatives within Eat Right India:
  • Reformulation of Packaged Foods: Nudging food businesses to reduce salt, sugar, and fat content in their products and reformulate them to be healthier.
  • Consumer Awareness Campaigns: Engaging, exciting, and enabling people to make the right food choices through various activities like “Eat Right Melas,” quizzes, street plays, and educational materials.
  • Food Labeling: Educating consumers about ingredients, nutritional properties, and energy content to enable informed choices.
  • “Aaj Se Thoda Kam” Campaign: Encourages consumers to gradually reduce their intake of fat, sugar, and salt.
  • “The PURPLE Book”: A handbook providing general guidelines for hospitals on suitable diets for common medical conditions like diabetes and hypertension.

2. National Nutrition Strategy (NITI Aayog):

• Vision: “Kuposhan Mukt Bharat” (malnutrition-free India) by 2022, with a broader goal to progressively reduce all forms of undernutrition by 2030. While primarily focused on undernutrition, it acknowledges the co-existence of overnutrition.
• Key Strategic Areas of Action: While the strategy primarily emphasizes reducing undernutrition, it also implicitly contributes to tackling overnutrition through:
  • Promotion of balanced diets: Encouraging a diverse and healthy diet.
  • Community-based interventions: Awareness campaigns at the local level about healthy eating habits.
  • Integration with Health & Wellness Centres (HWCs): Strengthening HWCs to provide personalized diet counseling, regular screenings for malnutrition and NCDs, and locally tailored meal plans. This can extend nutrition services beyond maternal health to include adolescents, the elderly, and NCD patients.

3. POSHAN Abhiyaan (National Nutrition Mission): Launched in 2018, this mission aims to improve the nutritional status of children, adolescents, pregnant women, and lactating mothers. While its primary focus is on addressing undernutrition and stunting, its broader approach to improving nutritional outcomes and promoting healthy behaviors can have a positive spillover effect on preventing overnutrition.

4. Makkalai Thedi Maruthuvam (MTM) programme of Tamil Nadu government: It is a multisectoral approach to control the prevalence of NCD. It includes regular screening of employees through workplace interventions, 8km health walk & ‘Eat Right Challnege’ to encourage behavioral change & nutrition awareness.

4. Policy and Regulatory Interventions:

• Taxation on Unhealthy Foods: There have been discussions and recommendations for a graded taxation system on ultra-processed, high-sugar, and trans-fat-laden foods to curb unhealthy eating habits and promote affordable healthy alternatives. (While not fully implemented on a wide scale specifically for overnutrition, it’s a policy intervention under consideration).
• Amending National Food Security Act (NFSA): Suggestions to include millets in the Public Distribution System (PDS) to incentivize farmers to diversify crops and promote nutritionally superior grains, which can help in dietary diversification away from calorie-dense, nutrient-poor staples.

5. Awareness and Education:

• Public Awareness Campaigns: Various government bodies and health organizations conduct campaigns to raise awareness about the risks of overnutrition, the importance of physical activity, and healthy lifestyle choices.
• School and Workplace Initiatives: Promoting healthy eating habits in schools and workplaces through nutrition programs and meal plans.

What can be the way forward?

1. Policy and Regulatory Interventions:

• Taxation and Subsidies:
  • Graded taxation: Implement higher taxes on ultra-processed foods, sugary drinks, and foods high in unhealthy fats and sodium. This can discourage consumption and generate revenue for public health initiatives.
  • Subsidies for healthy foods: Subsidize fruits, vegetables, whole grains, and other nutrient-dense foods to make them more affordable and accessible, especially for lower-income households.
• Food Labeling and Advertising:
  • Mandatory front-of-pack labeling (FOPL): Enforce clear, easy-to-understand FOPL that highlights high levels of sugar, salt, and fat in packaged foods. This empowers consumers to make informed choices.
  • Restrictions on advertising: Regulate and restrict the aggressive marketing of unhealthy foods, especially to children, across all media platforms (TV, social media, celebrity endorsements).
  • Defining “junk food”: Establish clear thresholds for sugars, salt, and fats in ultra-processed foods to provide a standard for warning labels and advertising bans.
  • Health Star Rating: Proposed by FSSAI in 2022. It aimed to provide clear nutritional information on packaged food.
• Urban Planning and Infrastructure:
  • Promote active living: Develop pedestrian-friendly roads, cycling tracks, and safe public parks and recreational facilities to encourage physical activity and active commuting.
  • Increase green spaces: More parks and open areas can facilitate outdoor exercise and community activities.
• Procurement Policies:
  • Healthy food in public institutions: Implement policies that mandate healthier food options in government canteens, hospitals, and educational institutions.
  • Incentivize local and fresh produce: Encourage the procurement of locally sourced, fresh produce for public feeding programs.

2. Public Awareness and Education:

• Nationwide campaigns: Expand and intensify existing campaigns like “Eat Right India” and “Fit India Movement” with targeted, culturally relevant messages. These campaigns should:
  • Promote balanced diets, portion control, and the benefits of traditional Indian foods.
  • Educate about the risks of ultra-processed foods and sugary drinks.
  • Encourage regular physical activity.
  • Address common misconceptions, such as associating “chubbiness” with good health.
• School-based nutrition programs:
  • Integrate comprehensive nutrition education into school curricula from an early age.
  • Implement mandatory physical education and provide access to healthy meals and snacks in schools.
  • Discourage the sale of unhealthy foods on school premises.
• Community-led initiatives:
  • Empower local communities, self-help groups (SHGs), and faith-based organizations to lead awareness programs.
  • Leverage platforms like Ayushman Bharat Health & Wellness Centres (HWCs) as Nutrition Resource Centres offering personalized diet counseling and regular screenings.
  • Promote “Poshan Vatikas” (Nutri-Gardens) for homegrown nutrition.
• Digital and social media outreach: Utilize short educational videos, jingles, and engaging content in multiple languages to reach diverse audiences, as seen with the UNICEF India #MeriThaliSehatwali campaign.

3. Healthcare System and Services:

• Strengthening primary care: Extend and strengthen primary healthcare delivery mechanisms, especially in urban poor areas, to provide preventive, promotive, and curative services for overnutrition and related non-communicable diseases (NCDs).
• Early screening and intervention: Implement regular screenings for overweight, obesity, and NCDs across all age groups, particularly in health camps and clinics.
• Personalized counseling: Offer personalized diet counseling and lifestyle modification advice through trained health professionals.
• Accessibility of treatment: While expensive weight-loss drugs are emerging, focus on making sustainable behavioral change interventions and affordable management protocols universally available. Bariatric surgery should be considered only in extreme cases and be more accessible.

4. Food System Transformation:

• Promoting dietary diversity: Encourage the consumption of a wide variety of nutrient-rich foods, including millets, pulses, and leafy greens, reducing over-reliance on staple grains like rice and wheat.
• Support for local food systems: Strengthen local food production and distribution networks to increase access to fresh and seasonal produce.
• Responsible food industry: Encourage food businesses to reformulate products to reduce sugar, salt, and unhealthy fats. Incentivize the development and marketing of healthier food options.
• Food fortification: While crucial for micronutrient deficiencies, ensure it is complemented by dietary diversification to provide a holistic nutritional approach.

Conclusion:
Reversing the tide of NCDs demands not just awareness but action. Regulatory reforms, especially those addressing the food industry, are imperative. However, the success lies in the coherent strategy – integrating health, regulatory oversight, industry compliance, and civic engagement.