India's burden of malnutrition and obesity: where diet makes or breaks

The Hindu

27-05-2025

For the past eight years or so Sobha, who is in her 50s and works as a domestic help, has been diabetic. Apart from religiously taking her metformin tablets, she did not think too much about her condition. Recently, however, constant fatigue, swollen ankles, and vision problems made her go back to her doctor. She was shocked when she was told that her blood sugar levels were too high, her haemoglobin and vitamin D levels were dangerously low, and that she was borderline obese.
'But I eat a normal diet and I do not indulge in sweets often. I do not know why my sugar is high or why I seem to be putting on weight, despite not eating much. The doctor wants me to eat more vegetables and fruits and switch from rice to ragi. But I work as a domestic help and mostly eat the food provided by my employers. Also, I cannot afford to buy fruits and vegetables on my income. Even fish has become so expensive. We also do not get pulses or legumes at subsidised rates from ration shops anymore,' she says.
Sobha's story is being played out across the country. People like her are among the millions of malnourished, obese, persons with diabetes in the country, who will, over time, develop serious complications of diabetes such as renal failure because basic lifestyle changes-- especially dietary changes -- that are required to keep non-communicable diseases (NCDs) under control are beyond their means.
Eating healthy is expensive
'In a bid to ensure that people do not go hungry, the nation opted for food security, and for this calorie-dense grains and cereals are supplied at subsidised rates to people through the public distribution system. But it is the poor in the country who are now paying the price for the lack of nutritional content and dietary diversity in their food with their health. Healthy foods are expensive, and in the absence of any policy-level effort to make these accessible to the poor, the cycle of malnutrition, obesity, and NCDs will continue,' says T.S. Anish, Associate Professor of Community Medicine, Government Medical College, Manjeri.
The Global Food Policy Report 2024, 'Food systems for healthy diets and nutrition', released by the International Food Policy Research Institute (IFPRI) last year, reported that 16.6 % of Indians suffered from malnutrition because of poor dietary habits. It said that at least 38 % of the Indian population ate unhealthy foods, while only 28 % ate all five recommended food groups, which included at least one starchy staple food, one vegetable, one fruit, one pulse, nut or seed, and one animal-source food.
Yet another report, the United Nations' State of Food Security and Nutrition in the World report published in July last year said that 55.6% of Indians cannot afford a healthy, balanced, and diverse diet because eating healthy is a costly affair. This is however lower than the 2017 data, when the figure was 69.5 %. The report, published by five UN agencies, described a 'healthy diet' as comprising four key aspects: diversity (within and across food groups), adequacy (sufficiency of all essential nutrients compared to requirements), moderation (foods and nutrients that are related to poor health outcomes) and balance (energy and macronutrient intake).
Economic and gender disparities
Socio-economic and gender disparities have been fuelling India's double burden of malnutrition -- a paradox wherein malnutrition co-exists with obesity. According to the WHO, 'the double burden of malnutrition is characterised by the coexistence of undernutrition along with overweight and obesity, or diet-related noncommunicable diseases, within individuals, households, and populations, and across the life course.'
Urbanisation seems to be one of the driving factors of this double burden, as the urban lifestyle encourages the easy availability of high-fat and ultra-processed food and beverages. The situation is exacerbated by additional factors such as low levels of physical activity and sedentary lifestyles.
Maternal undernutrition compromises foetal growth and increases the risk of children who may be underweight, stunted, and micronutrient deficient. On the other hand, maternal obesity or overnutrition could lead to gestational weight gain (possibly complicated by gestational diabetes) and babies who run the risk of insulin resistance in later life.
As per National Family Health Survey - 5 data, under-nutrition in children is rampant -- 36% stunted, 19% wasted, 32% underweight -- while among adults, 31.7% of women and 28.6% of men in urban areas and 19% of women and 18.8% men in rural areas were obese.
Too many carbs, too little protein
The Dietary Guidelines for Indians (DGIs) developed by the Indian Council of Medical Research (ICMR)-National Institute of Nutrition (ICMR-NIN), Hyderabad, and released last year, said that 56.4% of total disease burden in India could be attributed to unhealthy diets.
The report recommended that no more than 45% of calories in the daily diet should come from cereals and millets; 15% from pulses, and beans (protein sources), and the rest should come from nuts, vegetables, fruits, and milk. But the reality of the Indian diet is that it is highly deficient in protein, with nearly 70% of the caloric requirement met through carbohydrates and the intake of micronutrient-rich vegetables, and fruits much below recommended levels.
In 2019, the EAT-Lancet Commission published recommendations about healthy diet patterns that can sustain 10 billion people in an environmentally friendly manner by 2050. In 2020, the International Food Policy Research Institute published a paper on how well the Indian dietary pattern fitted in with the EAT-Lancet reference diet.
The study found that Indian households who spend the least on food show the greatest reliance on whole grains, starches, and processed foods, with little else. This pattern is maintained across the rural-urban divide. Protein makes up only 6-8% of the caloric intake, against the 30% in the reference diet. Fruits and vegetables make up about 8% of daily calories in the reference diet.
The wealthiest city dwellers get almost a third of their calories from processed foods. Even among the poorest, 8% of calories come from these foods for urban and rural residents. In South India, processed foods make up 13% of diets, vs. 8% in North-east and North India.
The study pointed towards 'a lack of availability, accessibility, awareness, and acceptability' as other major causes for the poor quality of Indian diets and recommended that subsidies on healthy foods should be the norm. Large-scale awareness campaigns were needed to help people understand why their dietary diversity needed to improve.
The need for affordable, diverse diets
Sreejith N. Kumar, a Thiruvananthapuram-based physician who has been at the forefront of Eat Right campaigns in Kerala, says that dietary diversity or the quality of one's diet need not be a complicated affair.
'One just needs to follow the 'MyPlate' dietary guideline (from the U.S. Department of Agriculture) which says that half of your plate be filled with fruits and vegetables, a quarter each is filled with grains and protein. This roughly falls in line with the ICMR-NIN guidelines that no more than 45% of calories come from cereals,' he says.
The heavy reliance on carbs in every meal and sedentary work has led to spiralling levels of abdominal obesity in both rural and urban India. This excessive carb and fructose (from sugary, processed foods) intake is the starting point of fatty liver disease, a phenomenon that has engulfed Kerala, Dr. Sreejith says.
Ensuring dietary diversity or the consumption from a wide range of food groups is key to achieving optimal nutrition and staving off micronutrient deficiencies and thus malnutrition.
NFHS-5 data shows that only 28% of adults consume all five recommended food groups.
Dr. Sreejith says that the first imperative to healthy eating should be awareness of the importance of dietary diversity and a change in mindset on what needs to be on one's plate.
'For healthy eating to be affordable, the accent should be on encouraging people to eat vegetables and fruits which are locally and seasonally available. You do not need broccoli, spinach, and Greek yoghurt, but can opt for the innumerable varieties of leafy vegetables (amaranthus), moringa leaves, and other local vegetables (eg: banana stem and flower). Eggs are an affordable source of protein,' he says.
The idea is to prioritise vegetables, include moderate amounts of protein and fat, and lower the amount of carbs.
The need for healthy food policies
In Kerala, local self-governments and Kudumbasree units have taken up several initiatives at the ward level to encourage household vegetable farming in grow bags so that fresh produce is available at least in a small way in every household. However, larger policy initiatives are needed to support the nutritional requirements of a huge section of the nation's population, including the subsidised supply of healthy and diverse food options as well as the imposition of a fat tax or health tax on the sale of ultra-processed and high fatty foods to limit the consumption of these items.
In this context, Arun Gupta, paediatrician, public health expert, and convenor of the Nutrition Advocacy in Public Interest, points out that weak and subjective labelling and advertising laws are letting junk food giants enjoy the freedom to make profits at the expense of public health.
In an article in The Hindu, 'Flawed food regulations fuel the obesity crisis', Dr. Gupta says that the Economic Survey 2025 recommendation that a health tax be imposed on ultra-processed foods to curb their consumption is being derailed by the same 'industry-friendly, subjective food marketing regulations'.
'India should adopt a stringent front-of-pack marketing labelling system (to curb unrestricted advertisements of unhealthy processed foods); fix clear salt/sugar/fat limits for foods high in fat/salt and sugar and frame stringent advertising laws. Lastly, the government should consider launching a campaign on the risks of consuming ultra-processed food in all languages,' Dr. Gupta adds.
At the State-level too, farming policies should be able to leverage local food systems which include a diverse variety of local vegetables, pulses, and millets, so that the nutritional content of diets can be improved.