The double burden of malnutrition—the coexistence of underweight and micronutrient deficiencies with overweight and obesity—has become a major global public health concern. It is particularly acute in rapidly expanding urban areas, where the ready availability of cheap, processed foods and sugary drinks along with increasingly sedentary lifestyles have contributed to overnutrition, particularly among poorer populations. At the same time, socioeconomic disparities persist within and across urban and rural areas, affecting all forms of malnutrition. Understanding these inequalities related to wealth status and residence is vital to identifying solutions for the double burden.
Our new study focuses on these issues in India. We investigated the malnutrition trends and disparities between socioeconomic groups and urban-rural residence in India from 2006-2016, providing insights needed to effectively address the impacts of inequality on nutrition. Among the findings: While overnutrition among Indian adults doubled in the studied period, with the fastest rate of increase in rural areas, stunting among children remains high and disproportionately affects the poor.
To identify nutritional disparities, we used data from the 2005-2006 and 2015-2016 National Family Health Surveys, which gather demographic, health, and nutrition data across India. We examined changes in height and weight outcomes for rural, urban slum, and urban non-slum households, as well as evolving in economic inequalities.
Stunting and obesity trends
Between 2006 and 2016, wealth and living conditions improved for all three residence groups, as well as undernutrition indicators. For children, stunting dropped from 48% to 38%. Child rates of overweight/obesity, however, remained the same. The prevalence of underweight for adults decreased significantly as well; from 36% to 23% among women, and from 34% to 20% for men. These declines were largest among rural populations, followed by urban slum and non-slum dwellers.
While these results may look promising, we also observed a concerning jump in overweight/obesity rates among adults, from 10% to 21%. Relative increases were highest in adults from rural communities, more than doubling (103% for women, 136% for men), but also high in in slums (83% for women, 88% for men) and urban non-slum settings (24% for women, 49% for men).
Effects of inequality
Wealth inequality is strongly associated with nutritional deficiencies. One way to assess these differences is the slope index of inequality (SII), a weighted measure representing the absolute difference in health indicator estimates between the most-advantaged and most-disadvantaged. A greater positive number indicates the health problem is concentrated among wealthier households; a greater negative, among poorer households.
Across all residential areas, in both 2006 and 2016, child stunting and adult underweight rates were higher among poorer compared to wealthier households, but the wealth gap shrank over time, with the SII ranging from -22 to -33 percentage points in 2006, and -12 to -23 pp in 2016.
But inequalities related to overweight/obesity rose, with the problem more concentrated among wealthier households within each group (the one exception being urban non-slum populations). In other populations, the SII for overweight/obesity grew between 2006 and 2016, going from +21 to +28 pp in rural areas and +22 to +29 pp in urban slum areas.
The highest prevalence of adult overweight/obesity in India is currently found in urban non-slum households (at 33% for women and 29% for men) but, if past trends continue, rural and urban slum dwellers will quickly catch up to their urban counterparts.
Oddly, one typical area of inequality in malnutrition outcomes was not observed in this data: Men and women had both a similar prevalence of underweight and overweight/obesity. Typically, gender differences in physical activity, sedentary lifestyles, food consumption choices, and sociocultural beliefs cause the prevalence of overweight/obesity to be higher in women than in men. Unfortunately, not enough information is available to explain this phenomenon.
What do our findings imply for India’s future efforts to fight malnutrition?
Although India has made progress in reducing undernutrition, the rapid increase in overweight/obesity rates and large wealth inequalities indicate that the country has many nutritional challenges left to tackle. The rapid growth of India’s urban population has resulted in increasingly crowded slums, and our findings highlight the precarious nutritional challenges of these populations. Vast socioeconomic differences remain, indicating that more needs to be done to implement improved services for both urban slum and rural populations. Such service upgrades should be tailored to the needs of these specific populations in order to ensure effectiveness.
India has a robust policy framework to address malnutrition; however, these policies are largely focused on reducing rates of stunting and underweight. It is time for India to expand these programs to address all forms of malnutrition—including the nutritional deficiencies resulting in stunting, and overnutrition problems such as obesity and diet-related non-communicable diseases such as diabetes. “Double-duty” interventions should be utilized that address malnutrition while also mitigating the negative consequences such as obesity that can be an unintended outcome of programs seeking to address food insecurity and undernutrition.
Phuong Hong Nguyen is a Senior Research Fellow with IFPRI’s Poverty, Health and Nutrition Division (PHND) based in Viet Nam; Samuel Scott is a PHND Research Fellow in New Delhi; Honor Dearlove is a former IFPRI Communications Intern.
This research was funded by the Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
