It is essential to have robust, longitudinal data to indicate direction and when and how to act. We seek India’s updated guidelines to validate and incorporate context-specific and validated risk thresholds.
Published Mar 05, 2025 | 8:18 AM ⚊ Updated Mar 05, 2025 | 1:48 PM
Close up overweight woman measuring her hip with tape measure. (iStock)
Synopsis: Almost a quarter of Indian adult population suffer from obesity. It is well known that abdominal obesity, independent of BMI, is a significant risk factor for unhealthy status. The current overemphasis on BMI underestimates the risk faced by Indians who have more central obesity when compared to the other races.
Close to a quarter of the adult population in India suffers from obesity. According to National Family Health Survey (NFHS-5), the prevalence of obesity among Indian adult males is 22.9 percent and 24 percent in Indian adult females.
The current sedentary lifestyle rates (50 percent of adults in India lead sedentary lifestyles) predict a substantial increase in obesity in the coming decades.
Most clinical societies and organisations have defined obesity as a complex, adiposity (abnormal or excess body fat) based chronic disease which impairs quality of life and reduces longevity.
The American Diabetes Association defines obesity as a progressive disorder with numerous medical, physical, and psychosocial complications, including a substantially increased risk for type 2 diabetes.
Metabolic syndrome, Circadian syndrome, diabetes, cardiovascular diseases, cancers, depression, and stroke are directly related to obesity, a significant public health concern directly related to lifestyle habits.
Recently, the Lancet Commission’s new obesity guidelines were published, which hinge on overt organ or tissue dysfunction before diagnosing “clinical obesity” and introduced the nebulous notion of “preclinical obesity” with ambiguous parameters.
These recommendations are criticised for sowing confusion and may even inadvertently delay vital interventions for high-risk individuals. Their approach is more focused on clinical care than preventive screening, leaving populations with atypical body composition, including South Asian “thin-fat” phenotypes, particularly vulnerable.
Furthermore, the Commission’s reliance on multifaceted anthropometric and biochemical testing is infeasible in primary care in many resource-strapped regions, which worsens health inequities. The Lancet Commission’s guidelines could divert limited healthcare resources toward overt cases, leaving a vast proportion of early stages of obesity at risk and potentially deepening the very crisis they aim to address.
Hitherto, Body Mass Index (BMI), an uncomplicated index calculated by dividing weight by height square, was a widely accepted screening tool for obesity. The Lancet Commission recommended that only above 40 kg/m2 of BMI can be considered a measure of excess adiposity without further confirmation.
However, large-scale evidence for cardiometabolic morbidity arises from an increase in BMI. Among the Asian population, the World Health Organisation (WHO) defines overweight as >23 kg/m2 and obese as >25 kg/m2.
A study from India in 2020 showed that each unit increase in BMI increases the probability of Diabetes by about 1.5% compared to non-overweight individuals.
India Obesity Commission has recently (Jan 2025) revised the obesity guidelines for Asian Indians. Along with the traditional anthropomorphic parameters such as BMI, the updated guidelines consider organ dysfunction and symptoms directly associated with obesity as crucial and integral components in defining obesity.
Shortness of breath, increased heart rate, owing to respiratory or cardiac conditions; poor exercise tolerance; limitation of movements primarily due to osteoarthritis of knees and hip or prolapse intervertebral disc; depression and anxiety arising due to physical conditions are key symptoms related to organ dysfunction which are to be evaluated in obese patients.
In Indians and other South Asians, visceral obesity, defined as fat around the organs, and ‘android obesity’ (central obesity), is well-established in increasing the risks of cardiometabolic diseases and reducing the quality of life.
Evidence from prospective studies unequivocally proven that indicators of abdominal obesity such as waist circumference (WC), waist-hip ratio (W-HR), and waist-to-height ratio (W-HtR) were stronger predictors for cardiovascular mortality than body mass index (BMI) alone.
WC is measured in cm just above the iliac crest at the end of normal expiration using a non-stretchable tape. At the same time, waist-hip ratio (WHR) is calculated by dividing WC by hip circumference (HC), measured at the widest point over the greater trochanters near the top of the thigh bone.
The cut-offs for defining central obesity among the Indian population are WC of >80 cm in females and >90 cm in males and WHR of >0.9 in males and >0.85 in females.
Under the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD), screening for Hypertension and diabetes is done for all adults >30 years by our frontline healthcare workers.
Obesity screening is typically done by calculating Body Mass Index (BMI) and measuring WC. Although WHR is an easy method to assess abdominal obesity and shows a strong correlation with body fat and is linked to an increased risk of developing cardiovascular diseases, particularly among South Asians, it is not practically feasible in field settings (especially among females), as it involves body shaming and privacy issues.
Moreover, measuring WHR is culturally inappropriate (exposure of body skin) and has not been standardised optimally.
Dividing the WC in cm by height yields a measure called waist circumference to height (W-HtR), which has emerged recently as a feasible alternative to the cumbersome WHR.
Evidence suggests that among Asian Indians who have a higher predilection for cardiometabolic risk factors, a combination of WC and W-HtR are better markers for obesity with more clinical utility than BMI and WHR for identifying at-risk populations.
In addition to BMI, the W-HtR is an ideal measure for screening for obesity in the population in community and field settings.
It is well known that abdominal obesity, independent of BMI, is a significant risk factor for unhealthy status.
The current overemphasis on BMI underestimates the risk faced by Indians who have more central obesity when compared to the other races. With the burgeoning rates of obesity in India, it is time to issue a clarion call for including evidence-based, feasible, and practical measurements such as W-HtR in our screening armamentarium for obesity in the Indian population.
For early identification and management of obesity, the absence of standardised, validated cut-offs and ambiguous definitions (such as preclinical obesity followed by the Lancet commission) inevitably produce inertia.
It is essential to have robust, longitudinal data to indicate direction and when and how to act. We seek India’s updated guidelines to validate and incorporate context-specific and validated risk thresholds.
At the same time, piloting and scaling up culturally sensitive measurements prioritising community-based screening and early intervention with cross-sector collaboration led by civil society is necessary to ensure equitable and timely obesity prevention and management.
(Dr. Raghupathy Anchala is the Dean of Academics and Professor of Epidemiology at the Indian Institute of Public Health, Hyderabad, Public Health Foundation of India. Dr Giridhara R Babu is a Professor of Population Medicine at the College of Medicine, QU Health, Qatar University.)
