Published Jul 03, 2026 | 7:00 AM ⚊ Updated Jul 03, 2026 | 7:00 AM
India's public health infrastructure for non-communicable diseases is largely built around middle age, when these conditions are typically diagnosed.
Synopsis: A long-term study tracking people born in rural Telangana found that many men crossed key risk thresholds for diabetes and heart disease by their late twenties or early thirties, well before these conditions are usually diagnosed. Researchers followed more than 2,000 participants and nearly 1,700 of their mothers over two decades, finding that men showed a faster rise in body weight, abdominal fat and blood sugar levels than women.
By their late twenties, many men in rural Telangana will already have crossed key biological thresholds associated with future diabetes and heart disease, years before either condition would typically be diagnosed, according to one of India’s longest-running birth cohort studies.
The findings suggest the path to chronic disease begins far earlier than India’s health system is designed to detect.
India has almost no studies like this one. Most research into the country’s rising burden of diabetes and heart disease relies on snapshots—surveys that measure a population once and infer change by comparing different age groups at a single point in time.
The study followed the same individuals from childhood through adolescence and into their mid-thirties across two full decades.
Researchers from the ICMR-National Institute of Nutrition began with more than 2,000 children born between 1987 and 1990 in 29 villages in what is now Telangana.
They returned to measure those children in 2003, then again in 2009, 2011 and finally 2021, alongside nearly 1,700 of their mothers.
The result, published in the International Journal of Epidemiology, is not a single data point but a trajectory: a rare, direct view of how cardiovascular risk accumulates across a single generation’s life.
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Consider a composite figure built from the study’s reported averages, not a real participant, but the kind of path the data describes for a typical rural man in this cohort.
At 15, his BMI sits at 16.6 kg/m², unremarkable by any measure. The study found that BMI “increased non-linearly with age, with a higher increase observed in males than in females,” and by 27.7 years, his BMI crosses 23 kg/m², the point at which the World Health Organization considers an Asian adult to carry elevated health risk.
South Asians tend to develop metabolic complications at lower BMI thresholds than other populations, carrying more fat relative to muscle even at similar weights, which is why this cut-off sits well below the global overweight threshold of 25.
He feels nothing on the day that line is crossed. What changes is harder to see: where his body has begun storing fat. By 33.7 years, his waist circumference passes 85 cm, the South Asian risk threshold for abdominal obesity, while the study reported that in females, “the mean WC, WHR, and WHtR stayed below the adult risk cut-off points” throughout.
Waist size matters here in a way overall weight does not, because fat stored around the abdomen behaves differently from fat stored elsewhere, interfering more directly with how the body manages insulin and raising cardiovascular risk independent of total weight.
By 36, his fasting blood glucose reaches 100 mg/dL on average, the threshold for prediabetes. The study found fasting glucose increased linearly in both sexes, “with a higher rate of change observed in males” than in females.
The same body that looked ordinary at 15 has, within roughly two decades, accumulated three separate, measurable markers of disease risk, each crossed quietly, each invisible without a clinical test.
This is the shape the study traces for men across the cohort as a whole.
The authors describe the broader pattern this way: “an adverse shift was seen in the BMI trajectory of all age groups that was not restricted to recent birth cohorts or attributable solely to ageing.”
Once the overall pattern was established, a second finding emerged: the climb was markedly steeper in men than in women.
The study found that at 15, females actually had “a similar mean WC, lower mean WHR, and higher mean WHtR compared with males,” a gap that would later reverse. By adulthood, the average woman in the cohort crossed the WHO’s BMI risk threshold at 30.6, almost three years after men.
Her waist measurements rose more gently too, and the study reported that “the difference between sexes widened with age” as the years went on.
The authors trace this divergence to where fat settles on the body, saying “results indicate differential fat deposition by sex with increase in weight.”
Women in the cohort tended to carry fat just beneath the skin, around the arms, hips and waist, a pattern generally linked to lower metabolic risk. Men increasingly stored fat around the abdomen and upper body instead, the kind of distribution that tracks more closely with insulin resistance and heart disease.
Describing the rising waist-to-hip ratio in men against a stable ratio in women, the authors called this evidence of “higher abdominal fat deposition (harmful) over the pelvic region (protective).”
They added that this same pattern was “additionally confirmed by higher rates of increase in the WC and WHtR” in men.
The study also found that the decrease in supra-iliac skinfold, a measure of superficial fat near the waist, ran “at a higher rate in females than in males,” which the authors said “indicates that this abdominal fat deposition may be visceral or deep-subcutaneous in both sexes.”
Skinfold measurements taken in earlier rounds, available only up to the mid-twenties, reinforce the same divide.
The study found that by 25, women had “a higher average sum of skinfolds and skinfold thickness at biceps, triceps, and supra-iliac sites, while males had a higher average at the subscapular site,” the spot just below the shoulder blade tied to central fat storage.
The authors said this faster rise in subscapular fat among men “might additionally explain the early progression of males to prediabetes by the third decade.”
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The study did not stop with the children. By tracking nearly 1,700 of their mothers across the same two decades, the researchers added something a single-generation study cannot offer: a view of how this same metabolic drift continues across an entire adult lifespan, not just the journey from adolescence to early adulthood, but the decades that follow.
The study found that BMI in mothers “increased linearly, with a higher rate of increase observed in young mothers” under 35 at baseline, who gained 0.25 kg/m² a year and reached the WHO’s risk threshold by 42.9.
Mothers aged 35 to 44 at baseline crossed the same line at 50.3, and the oldest mothers, 45 and above at the start, did not cross it until 64.8, some two decades later than the youngest group.
Read alongside the children’s data, the mothers’ trajectories suggest that rising cardiovascular risk is not a phase rural India’s young adults are passing through. It is closer to a sustained climb, one that continues, at varying speeds, across the rest of life.
Cardiovascular disease in India has long carried an urban signature, framed as a consequence of desk jobs, processed food and traffic-bound days.
This study complicates that picture. The authors said the shift in BMI trajectories seen in rural Telangana is “strikingly similar to those found in upper-middle and high-income countries,” where successive birth cohorts crossed into overweight categories at progressively younger ages, only decades earlier.
They added that it is useful to draw on “the quicker cardiovascular disease risk progression in migrant populations to urban areas” as a framework for understanding development itself as a driver of risk.
The forces at work, changing diets, declining physical activity, mechanisation of farm work and the wider pace of rural development, appear to be compressed into a single generation here.
The authors’ central recommendation is to rethink when screening for diabetes and heart disease begins. India’s public health infrastructure for non-communicable diseases is largely built around middle age, the decades when these conditions are typically diagnosed.
This study suggests that approach may already be too late for a significant share of the rural population, since the underlying risk factors, elevated BMI, abdominal fat and rising blood sugar, are measurably established by the late twenties and early thirties.
That has direct implications for how rural screening programmes are designed. A system that waits for symptoms, or for diagnosis in a patient’s forties or fifties, will miss the window in which intervention is most likely to change a person’s trajectory.
The authors said “targeting structural determinants that drive adverse changes in rural lifestyle and environments is needed,” framing this as a problem that extends well beyond individual clinics, into the broader systems shaping how rural India eats, moves and works.
The study’s design lends weight to these conclusions. The study reported that researchers retained 80 percent of the original child cohort and 88 percent of the mother cohort across the full follow-up period.
Even in the most recent round, conducted two decades after the study began, follow-up rates of 39 percent for children and 72 percent for mothers were, the authors noted, “higher than those of other cohort studies in India with participants in their third decade of life.”
