As the country develops economically, its double burden of malnutrition and its health implications will increasingly affect women and those who are socio-economically weak
India has one of the highest burdens of underweight women in the world, with rising obesity levels. Using the World Health Organisation classification based on body mass index, or BMI (the ratio of the weight of the body in kilograms to the square of its height in metres), there were about 31.5 per cent underweight women in the age group 20-49 years in 1998. The share came down to 26.6 per cent in 2005. In contrast, the share of the overweight (including the obese) rose from 13 per cent to 18.2 per cent.
The coexistence of the underweight and the overweight is often referred to as the “double burden of malnutrition.” Besides, the burden of overweight (and obesity) is expected to shift to households with lower socio-economic status (SES) as India develops economically. Before a nutritional transition, the overweight and the underweight tend to be concentrated in high and low SES groups, respectively. During the transition, however, the overweight burden shifts to low SES groups, while the underweight burden remains high, exposing them to the double burden.
Here we will focus mostly on the ratio of underweight to overweight (including obese) women. While both underweight and overweight are “bads,” serious concerns have been expressed about an emerging obesity epidemic and, consequently, a growing burden of non-communicable diseases (for example, a likely epidemic of diabetes in India in the near future). So whether this ratio is less than one (more overweight than underweight women) or greater than one (more underweight than overweight women) needs close scrutiny as the health policy implications differ vastly. This analysis is based on a nationally representative survey, the India Human Development Survey, 2005.
Women & regional ratios
Our estimates show that at the all-India level, the ratio of underweight to overweight women aged 22-49 was 1.21. So, there were 121 underweight women for 100 overweight women in 2005. In the rural areas, there were more than twice as many underweight women as overweight but a little over a third in the urban areas.
The lowest ratio is observed in the southern region and a moderately higher ratio in the northern region, with fewer underweight than overweight women in the former and more underweight than overweight in the latter. The central region had the highest number of underweight women relative to the overweight, followed by the eastern and then the western regions.
Out of the 22 States analysed, nine (for example, Punjab, Delhi, Kerala) had fewer underweight women than overweight ones. Punjab had the lowest number of underweight women relative to the overweight, while Kerala had a slightly higher number. In sharp contrast were six States, including Orissa, Bihar, Chhattisgarh, Uttarakhand, and Madhya Pradesh, where the number of underweight women exceeded substantially that of the overweight. In Madhya Pradesh, Uttarakhand, Chhattisgarh and Bihar, there were twice as many or more underweight women than the overweight. Orissa stood out as the worst with nearly four times as many underweight women as the overweight.
Economic status and caste
To throw light on the relationship between SES and the ratio of underweight to overweight women, we first examine the association between this ratio and per capita monthly expenditure. The higher the expenditure, the lower was the ratio of underweight to overweight women. In the lowest expenditure group, for example, underweight women were over four times as many as the overweight, while in the highest expenditure range they were barely one-third. So there is an inverse association between this ratio and affluence.
Another measure of economic status is in terms of assets (for example, motorcycle, car, refrigerator, sewing machine, television, cellphone). The association is similar to that obtained using expenditure. Underweight women were four times as many as the overweight in the lowest asset group, while they were a little over one-fifth of the overweight in the highest asset group. Thus the number of underweight women declines sharply as wealth rises.
These monetary measures of economic status are supplemented by caste affiliation. The caste hierarchy manifests itself not just in different levels of economic well-being but also in aspects of social deprivation. Some of the most socio-economically disadvantaged groups comprise the Scheduled Tribes (STs), followed by the Scheduled Castes (SCs), and Other Backward Classes, with the residual group, Others, as the least disadvantaged. The STs are also the socially most excluded group as they are confined largely to remote regions.
Underweight women were just under four times the number of the overweight among the STs, and more than twice as many among the SCs. In sharp contrast, underweight women were two-thirds of the overweight among Others. Thus, the socio-economic patterning of the underweight and the overweight was largely intact.
Age matters too. There is an inverse association between the ratio of underweight to overweight women and age-group of women. The ratio was highest in the youngest, aged 22-28, and lowest in the oldest, aged 43-49. In the former, underweight women were three times as many as overweight women but in the latter just two-thirds.
The effect of marital status — ever married women — on the ratio of underweight to overweight women was negative in the urban sample but not significant in others. This implies that ever married women were less likely to be underweight but not so generally. Social obligations play an important role, particularly in eating pattern changes upon marriage that help gain weight. Besides, married people smoke less and exercise less, and are thus likelier to be heavy.
Sanitation and hygiene (for example, an indoor toilet, a safe drinking water facility and a kitchen with ventilation) are associated with lower ratios of underweight to overweight women as the risks of infectious diseases are lower — especially those acquired by ingesting contaminated food or water, or other exposures in the environment.
The risk of overweight/obesity is considerably lower with higher ratios of female-to-male workers, implying that greater opportunities for female employment are associated with greater physical activity and a lowering of the prevalence of overweight among women.
Media exposure is linked to more leisure and more frequent eating, and thus a higher risk of being overweight. Other evidence confirms this result but fails to substantiate these links.
Contrary to assertions that SES is key to the prevalence of underweight and overweight among women, our analysis suggests that the effects of relative food prices through dietary changes are larger. Although we find significant effects of the ratio of cereal to milk and milk product prices, cereal to vegetable prices, and cereal to edible oil prices, the commodity classification is not sufficiently detailed (for example, the nutritional effects of potato and leafy vegetables differ, as also of how they are cooked — boiled or fried). More generally, weight gain seen for specific foods and beverages arises from varying portion sizes, patterns of eating, effects on satiety, or displacement of other foods or beverages. Consumption of starches and refined grains is less satiating, increases hunger signals and total calorie intake, as compared with equivalent calories obtained from less processed food, and higher fibre foods that also contain healthy fats and proteins. Other experimental evidence unravels a relationship between sleep, diet and obesity. Reduced sleep induces preferences for calorie-dense, refined-carbohydrate foods. Weight gain is lowest among persons who sleep six to eight hours a night and is higher among those who sleep less than six hours or more than eight hours.
The health implications of being underweight and overweight are grim: underweight women are highly prone to risks of disease, disability and mortality. Besides, children born to them are more likely to be overweight or obese. Overweight and obesity elevate risks of non-communicable diseases (NCDs) such as heart disease, hypertension and adult-onset diabetes. However, given the rising burden of NCDs while that of infectious diseases remains high, and as India increases its focus on the health needs of overweight and obese people, it must address simultaneously the needs of the large number of severely undernourished people in society.
For Indian women, the pervasiveness of the malnutrition burden is matched only by the grimness of their existence and survival prospects.
(Vani S. Kulkarni is research associate, Department of Sociology, Yale University and Veena S. Kulkarni is assistant professor in the Department of Sociology, Criminology and Geography, Arkansas State University. Raghav Gaiha was professor of Public Policy, Faculty of Management Studies, University of Delhi.)