November 14, 2023

In India, almost 23% of men and 24% of women have a BMI in the overweight or obesity range- many more in urban areas than in rural areas (33.2% of women and 29.8% of men compared to 19.7% of women and 19.3% of men, respectively).

Source: World Obesity Federation: World Obesity Atlas 2023.

The number of adults with a BMI in the overweight or obesity range has increased approximately 3-4% since 2015-2016.¹ A recent study projects that the prevalence of overweight may double, and obesity may triple, by 2040.²

While the prevalence of obesity and overweight is higher in urban areas, rural areas are rapidly catching up, particularly those that are in closer proximity to large cities. In these areas, there is greater consumption of convenience foods and a higher likelihood of nonfarm occupations. Obesity and overweight have also started to shift from the wealthy to lower and middle socioeconomic groups in these areas, especially among those who eat less diverse diets.¹¹ In fact, lack of dietary diversity plays a role in both under- and overnutrition in both high and low socioeconomic households throughout India.¹² 

Cost and Impact of Overweight and Obesity

In 2019, the total cost of obesity in India, including direct (i.e. health care) and indirect (i.e. lost productivity) costs was, in U.S. dollars, $23.24 billion, approximately 0.8% of the gross domestic product (GDP).³ By 2060, the total costs are projected to be $839 billion in U.S. dollars, or 2.49% of the GDP, the third highest of 161 countries studied.⁴   

Table 3.1: Projected Trends in the Prevalence of Obesity

	Health care impact of BMI ≥ 25kb/m2, US$ million	Total economic impact of BMI ≥ 25kb/m2, US$ million	Estimated GDP US$ billion	Impact of BMI ≥ 25kb/m2 on GDP
2020	2,456	31,603	2,645	1.2%
2025	3,785	50,696	3,815	1.3%
2030	5,730	81,527	5,206	1.6%
2035	8,430	129,326	7,117	1.8%

Source: World Obesity Federation: World Obesity Atlas 2023.

The projected global economic impact of overweight, including productivity loss at work, from 2020 to 2035 is shown in Figure 3.2. The rise in obesity and overweight in India has occurred alongside significant economic growth over the last couple of decades. This has led to a more sedentary lifestyle, with a greater number of people in white-collar office jobs than in blue-collar or agricultural jobs where they expend more energy.⁵ Fast food has become more readily available as globalization has increased in the country,⁶ and the sales of packaged and processed food almost doubled from 2012 to 2018.^7,8 Other contributing factors, depending on gender, area of the country and level of development, include rising age, access to motorized transport, increased TV watching and reductions in smoking.⁹ A recent study showed that 4 out of 10 people living in India do not get the recommended amount of physical activity. This is particularly true among women and those living in urban areas.¹⁰

Source: World Obesity Federation: World Obesity Atlas 2023.

The prevalence of non-communicable diseases (NCDs) such as heart disease and diabetes has risen in India due to urbanization and globalization, causing an increase in traditional cardiovascular disease risk factors such as obesity. ^{13 36} Unfortunately, there has been a lack of appropriate response to NCDs in the public sector due to a number of factors: “a lack of risk-factor and disease surveillance systems, poor access to drugs and diagnostic services, limited public financing or insurance, and human resource limitations.”¹⁴ Therefore, most treatment takes place in tertiary hospitals in the private system.¹⁴ In one study, 50-70% of those seeking treatment for NCDs did so through private health care services.¹³ In 2017, NCDs made up approximately 47% of deaths, with 55% of those in urban areas.¹⁵ Almost two-thirds of these deaths were among people under the age of 70. Furthermore, hospitalization rates due to NCDs rose from 29% in 2004 to 38% ten years later.¹³ Economic costs related to NCDs are high; a 2018 review showed that most studies estimated that the cost burden related to NCDs accounted for 5-10% of GDP.¹⁶    

Because of these issues, more attention needs to be paid to obesity, a key risk factor for non-communicable diseases. Education and access to opportunities for physical activity are two strategies that could help.   

Lack of knowledge about their own health status is another issue. For example, more than half of people with diabetes are unaware of their diagnosis.18 Employers can provide screening programs for diabetes and risk factors for other NCDs through on-site clinics, health checks and preventive care benefits to ensure that employees get the care they need to be healthy and productive at work.

Obesity Stigma and Mental Health Concerns

There are few studies on weight stigma in India. One out of three women studied with a BMI over 35 kg/m² reported stigma and discrimination, as did 18% with a BMI over 30 kg/m² and 5% with a BMI over 25 kg/m². Fifty-nine percent to 95% of these women reported dissatisfaction with their weight, again with dissatisfaction increasing as weight increased.²⁵ Another study looked at the correlation between stigma, mental health and disordered eating patterns among individuals receiving services at a bariatric clinic. Those who reported high levels of stigma were more likely to be women; to report bingeing, overeating, or grazing; and to have mental health diagnoses.²⁶

Research on weight stigma in the U.S., Western Europe and Australasia (which includes Australia, New Zealand and some neighboring islands) may be applicable to India. Studies show that stigma changes health behaviors for the worse and can lead to depression, anxiety and suicidality. Furthermore, emerging research in low- and middle-income countries suggests that it is highly distressing and may lead to similar outcomes.²⁷ In 2023, only 7% of employers responding to a survey said that they had programs to address weight stigma in the workplace, even though 40% said it was moderately severe.¹⁷  

More work has to be done on the relationship between people with obesity and mental health in general among the Indian population. A study of patients at a bariatric clinic with a BMI over 40 kg/m2 without any co-morbidities, or a BMI over 35 kg/m² with significant medical problems, found that 33.33% of respondents had a mental health condition, most commonly depression and dysthymia. Close to a fifth of respondents had a substance use disorder. However, the population studied was fairly small (n=60).²⁹ Another study of adolescents in Kolkata showed that obesity was correlated with depression, anxiety and stress.³⁰ On the other hand, research conducted among patients at two hospitals in South India showed no correlation between overweight or obesity and risk for depression, except among individuals under the age of 40.³⁰

As of 2022, the Insurance Regulatory and Development Authority of India (IRDAI) has mandated that insurance companies cover mental health under their policies. However, only hospitalization of at least 24 hours is required, not out-patient services such as counseling.^31,32 Employers can support their employees’ mental health by providing comprehensive benefits that cover outpatient counseling and medication provisions, as well as employee assistance programs (EAPs) and other solutions, such as mindfulness, stress management and resilience programs.

Addressing Rising Rates of Obesity and Overweight in India: Trends in Employer Coverage, Policy Developments and Interventional Approaches

Bariatric surgery was first performed in India in 1999, and now is offered in both private and public hospitals. Since then, surgeries have increased annually, but a stigma remains. Starting in 2019, “bariatric and metabolic surgery has been included in health insurance by the Insurance and Regulatory Development Authority of India (IRDAI) for the treatment of obesity.” This is likely to increase the number of surgeries taking place  in the country as well as awareness of the procedure.³³ The Obesity and Metabolic Surgery Society of India recommends that adults ages 18-65, who have tried repeatedly to lose weight and have a BMI greater than 37.5 kg/m² without any co-morbidities, and a BMI of 32.5 kg/m² with any related co-morbidities, be considered for bariatric surgery. Those older than 65 or younger than 18 may be considered in certain circumstances, such as severe co-morbidities in older adults or after attainment of puberty and pediatric certification in those younger than 18.³⁴

Orlistat is currently approved for pharmacological use for weight management in India. It may also lead to improvements in cardiovascular risk factors, blood pressure and serum lipid levels, although risk factors related to oily stools and increased defecation are possible, among others. Medication is only recommended once lifestyle interventions have not been successful in reducing weight.²⁴

The Executive Committee of the Endocrine Society of India has proposed medical nutrition therapy (MNT) -- “a process and provision of nutritional assessment, counselling, advice (dietary, nutritional and culinary) and follow-up for prevention and/or management of obesity by a qualified or trained health care provider” -- to support dietary changes in people living with obesity or overweight. However, MNT is not covered by insurance in the country and individuals must pay out of pocket. Furthermore, doctors generally aren’t aware of its importance, and there aren’t an adequate number of trained nutritionists. MNT also isn’t generally individualized to the needs of the patient. Overall, the society recommends that a multidisciplinary team that incorporates diet, exercise, and pharmacotherapy as needed be involved in supporting patients living with obesity and overweight.²⁴  

Data from Business Group on Health’s Global Weight Management Survey show that weight management programs offered through health plans  include outpatient services/nutrition counseling and bariatric surgery.¹⁷ Employers who don’t offer weight management programs most often cite lack of demand, cost or coverage through the public health care system as the reasons for not including those programs. 

Obesity and Overweight in India

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