The Double Burden of Malnutrition among Adults in India: Evidence from

746672 adults aged 15-49

List of authors

Mili Dutta

Research fellow

International Institute for Population Sciences (IIPS),

Govandi Station Road,

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Mumbai. 400088.

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Mail id: duttamili90@gmail.com

Y Selvamani
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Research Fellow
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Department of Development Studies,

International Institute for Population Sciences (IIPS),
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Govandi Station Road,

Mumbai. 400088.
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India
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Pushpendra Singh
Research Fellow
Department of Humanities & Social Sciences,
Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India-247667
Mail id: push.dhs2015@iitr.ac.in

Lokender Prashad
Research Fellow
Tata Institute of Social Sciences
Mumbai. 400088.
India
Mail id: lokenderlokender@gmail.com

*Corresponding author

Y Selvamani
Email: selvinsw@gmail.com or selvamani@iips.net

Funding

The authors received no specific funding for this work.

ACKNOWLEDGEMENTS

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We acknowledge the ORC Macro (USA) and International Institute for Population Sciences
(IIPS), Mumbai for providing data access.
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AVAILABILITY OF DATA AND MATERIALS
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The datasets generated and/or analysed during the current study is available in the DHS
Program repository, http://dhsprogram.com/data/ available-datasets.com. For data access,
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registration with the website is the first step. All the steps of data access are elaborated in the
following link https://dhsprogram.com/data/Access-Instructions.cfm.
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 The Double Burden of Malnutrition among Adults in India: Evidence from National
Family Health Survey 4 (2015-16)

Abstract

OBJECTIVES: India is still facing the burden of undernutrition and communicable diseases;
and there is steady growth of overweight or obesity. The discourse of dual burden due to
underweight and overweight is not widely explored for both the male and female. The present
study assessed the determinants of underweight and overweight/obesity in India amongst
adult men and women aged 15-49.

METHODS: The population-based cross-sectional and nationally representative data from

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the National Family Health Survey-4 (2015-16) with a sample of men and women were

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analyzed. The stratified two-stage sampling was used as a sampling design in NFHS-4. The

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bivariate and adjusted multinomial logistic regression analysis were carried out to understand
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the correlates of underweight and overweight/obesity.
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RESULTS: The result suggested the persistent high prevalence of underweight and the
increased prevalence of overweight/obesity in India. The likelihood of underweight was
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higher in the central and western regions, and also among those who consumed either smoke
or smokeless tobacco. The overweight/obesity was higher in the urban areas, Southern region
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and adults belonging to the age group 35-49. Furthermore, years of education and wealth
index showed positive association with overweight/obesity. On the contrary, educated and
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wealthier were less likely to be underweight.

CONCLUSIONS: The underweight was already prevalent, and the overweight/obesity is

increasing rapidly in India; more among men. The dual burden of underweight and
overweight is alarming and needs to be taken into consideration; hence, public health
measures must be adopted through public policy.

Keywords: Underweight; Overweight; Obesity; Socioeconomic status; Nutrition of India;

Dual burden of malnutrition; National Family Health Survey

1
INTRODUCTION

The rising prevalence of overweight and obesity along with undernutrition is a significant

health challenge in the low and middle-income countries. On one side, the improvement in

economic conditions, urbanization, sedentary lifestyle and dietary changes caused the steady

increase of overweight or obesity [1-3]. However, many South Asian and Sub-Saharan

African countries are facing the challenges of undernutrition and associated consequences [4].

In India, the share of adult underweight is the highest in the global share of the underweight

population with the ongoing rise of overweight and obesity [4, 5]. Similarly, countries in

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South Asian region such as Bangladesh and Nepal have higher share of adult underweight

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along with growing prevalence of overweight/obesity [6, 7]. The presence of underweight

and the rising prevalence of overweight or obesity is defined as the dual burden of
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malnutrition, and it is posing major health challenges among the adult population in the
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developing countries including India.

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Both undernutrition and overnutrition are associated with adverse health outcomes. It is well
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documented that overweight or obesity is a significant predictor of all-cause of mortality [8],

chronic diseases such as diabetes [9], cardiovascular disease [10], multimorbidity conditions
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[11, 12] , and disabilities [13]. Similarly, underweight is strongly associated with premature

mortality, disabilities, poor self-rated health, and wellbeing, particularly the association is

stronger in the developing countries [14, 15].

The determinants of the dual burden of malnutrition differ considerably in relation to gender,

socioeconomic, and behavioral factors. Economic status has emerged as an important

determinant of overweight or obesity, particularly in the developing countries [15-18]. On the

contrary, the less educated and socially disadvantages adults tend to be underweight [19, 20] .

2
Studies also suggest the risk factors associated with low and high body mass index such as

physical inactivity, poor diet, and tobacco use [21-23].

In India, only a few studies have examined the relationship between socioeconomic status,

tobacco use, dietary pattern, and body mass index. Further, most of the studies focussed on

women respondents in understanding the body mass index. It is also necessary to address the

changing pattern of body weight of men for understanding the modifiable health factors of

men. Furthermore, considerable variations in body mass index have been noted across

different states in India [24, 25] with the diverse and unequal pattern of economic

development, demographic and epidemiological transition across different regions [26, 27].

Therefore, it is necessary to understand the co-existence of dual burden of under and over

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nutrition among the male and female population in India. In this background, the present

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study assesses the determinants of underweight and overweight in India for men and women.
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MATERIALS AND METHODS
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Data source
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The present study used the National Family Health Survey (NFHS-4), fourth in the series of
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NFHS data. The survey was conducted in 2015-16 and provided information about
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population, nutrition, and health for the different states of India and for the country as a

whole. NFHS-4 interviewed randomly selected women belonging to the age group 15-49 and
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men belonging to the age group 15-54. The stratified two-stage sampling was used as a

sampling design in NFHS-4. In the first stage, the primary sampling units (PSU) were

selected, and in the second stage, the households for the study were selected. PSUs with at

least 300 households were divided into segments of around 100-150 households. Two of the

segments were selected using the systematic sampling with probability proportional to size.

Further, from every selected rural and urban cluster, 22 households were selected using

systematic sampling (Figure 1a).

<Figure A>

3
Measures

Dependent variable

Body Mass Index (BMI): BMI is defined as the weight in kilogram divided by the square of

the height in meters (kg/m2). In this study, objectively measured height and weight were used

to calculate BMI. We followed WHO standard for the categorisation of body mass index. The

level of BMI was categorized into three categories, viz., Underweight: Less than 18.5,

Normal: Between 18.5 and 24.9, Overweight/obesity: Equal to and greater than 25.0 [28].

Predictor Variables

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Education level: The education level of the study population was categorized into four types:

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no education, primary education, secondary education, and more than secondary education.

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Wealth index (poorest, poorer, middle, richer and richest): The wealth index was generated

by using the number and type of consumer goods a household own and the housing
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characteristics. Each household asset was allocated a weight or factor score measure through
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the principal component analysis and was standardized in relation to normal distribution.

Further, the sample was divided into quintiles.

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Tobacco use: Tobacco use was categorized into four types; no tobacco, only smoke tobacco

(cigarettes, bidis, cigars, and pipe hookah), only smokeless tobacco (paan masala or gutkha,

khaini, paan with tobacco, another type of chewing tobacco, snuffs), and both smoke and

smokeless tobacco.

Food consumption: To identify the impact of food consumption on underweight and obesity,

the frequency of various food items intake was taken in the study. The food intake was

categorized into three categories viz., never, occasionally, and daily.

4
Region: The regions of India were categorized into six categories viz., North, Central, East,

West, North East, and South. The North region comprises of Chandigarh, Delhi, Haryana,

Himachal Pradesh, Jammu and Kashmir, Punjab, Rajasthan, Uttarakhand. The Central region

includes Chhattisgarh, Madhya Pradesh, Uttar Pradesh; and the East region includes

Jharkhand, Odisha, West Bengal, and Bihar. The Northeast region includes Nagaland, Sikkim,

Arunachal Pradesh, Manipur, Mizoram, Tripura, Meghalaya, and Assam; the West region

includes Dadra and Nagar Haveli, Daman and Diu, Gujarat, Maharashtra, and Goa. Last, the

South region consists of Andaman and Nicobar Islands, Andhra Pradesh, Karnataka, Kerala,

Tamil Nadu, Telangana, Puducherry, and Lakshadweep.

Covariates

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The selected covariates included age group (15-19, 20-34 and 35-49), place of residence

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(rural and urban), caste (SC, ST, OBC, and Others), religion (Hindu, Muslim and Others),
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currently working (no, yes), marital status (unmarried, currently married, widowed,

divorced/separated).
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STATISTICAL ANALYSIS
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In this study, bivariate analysis was carried out to understand the weighted prevalence of
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underweight and overweight/obesity in relation to background characteristics. Further, the

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state-level differences in underweight and overweight/obesity were shown. In addition, the

multinomial logistic regression analysis was used to assess the determinants of underweight

and overweight/obesity. The relative risk ratio with confidence intervals was presented.

Moreover, separate analysis was conducted for men and women. The analysis was restricted

to the women of the age group 15-49, and they were not pregnant as well as have not given

birth within two months before the survey (n=646262) and men considered for the study were

of the age group 15-49 (n=100410). All the analysis was carried out in STATA 14.0.

<Figure 1>

5
RESULTS

The prevalence of underweight has decreased although the prevalence of overweight or

obesity has increased during the study period amongst male and female (Fig 1). The

prevalence of both underweight and overweight were higher among female. The result also

indicated that the prevalence of obesity among male has almost doubled from 2005-06 to

2015-16 period.

Figure 2a and 2b show the distribution of underweight and overweight or obesity among men

across different states of India. The higher prevalence of underweight among men was found

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to be clustered in Uttar Pradesh, Bihar, and Madhya Pradesh. However, the prevalence was

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low in the Southern, Northern, and some of the North Eastern region. A high prevalence of
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overweight or obesity was found in Goa, Andhra Pradesh, and Sikkim among more than 30
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percent men, which is followed by Kerala, Tamil Nadu, and Punjab where 25 to 30 percent of

men have obesity problem. It can be observed from the map that Telangana was the state
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with similar prevalence (20 to 25%) of underweight and overweight or obesity.

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<Table 1>
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Figure 3a and 3b show the prevalence of underweight and overweight or obesity among

females in the Indian states. Bihar and Jharkhand showed higher prevalence of underweight.

Further, underweight was found to cluster more in the middle part of India including

Rajasthan, Gujarat, Madhya Pradesh, Chhattisgarh, Odisha, Uttar Pradesh, and Assam. Figure

3b shows the lower prevalence of overweight or obesity in the above-mentioned states.

Overweight or obesity was found to be highly clustered in the Southern states of India. In

addition, Punjab, Goa, and Delhi showed high prevalence of overweight. Maharashtra and

Karnataka showed similar prevalence for both underweight and overweight or obesity.

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 <Figure 2>

Table 1 illustrates the percentage distribution and association of underweight and overweight

or obesity depending on the background characteristics. The prevalence of underweight was

higher among men and women of the age group 15-19 age group, while the

overweight/obesity was higher among men and women of the age group 35-49. The

prevalence of overweight or obesity was higher in the Southern region for men and women.

Underweight was more prevalent in the rural areas, whereas overweight was higher in the

urban areas. The prevalence of underweight was higher among Scheduled Tribe, Hindus,

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never married, less educated, poorest male and female. However, the prevalence of

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overweight or obesity was higher among male and female belonging to other caste and

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religion, have more than secondary education, high wealth index, and non-tobacco consumers.
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It is also evident from the Table that more non-working men were underweight, but the
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working status of women did not make much difference in the prevalence of underweight.
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Moreover, the prevalence of overweight or obesity was higher among working men, but it
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was reverse in the case of women. The percentage distribution and association of
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underweight and overweight or obesity according to food consumption is shown in Table 2. It

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is apparent from the Table that overweight was higher if foods were consumed daily, whereas

underweight was higher if foods were never consumed. However, the predicting power of

food consumption on underweight and obesity were estimated in Table 4.

<Figure 3>

Estimates of multinomial logistic regression to identify the factor affecting body mass

index in India, NFHS 2015/16

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 The factors affecting underweight and overweight or obesity in male and female by

background characteristics are shown in Table 3. The result showed that the likelihood of

underweight was decreasing with increase in age. However, the likelihood of obesity tended

to increase with age amongst male and female. Male in the age group 35-49 years was 3.14

times more likely to be overweight/obese compared to male in the age group 15-19 years.

Similarly, female in the age group 35-49 was 4.59 times more likely to be overweight/obese

than female in the age group 15-19 years. Males in all the regions were more likely to be

overweight/obese except for the Central region in which the likelihood of overweight/obesity

decreased in comparison to the Northern region. In the case of the females, the likelihood of

obesity was higher among women in the East, West, North East and South regions than the

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North region. It is evident that urban men were 1.18 times more likely to be overweight/obese

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than rural men. Urban females were 10.5 percentage less likely to be underweight and 1.28

times more likely to be overweight/obese than the rural females. It was also apparent from the
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Table that Scheduled Tribes were less likely to be overweight/obese, whereas people of
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Others caste were more likely to be overweight/obese for both male and female.
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Currently working men were less likely to be underweight, and females were less likely to be
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overweight. Further, married male and female were less likely to be underweight, and the

likelihood of overweight was much higher in this group compared to other groups. With
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increase in the level of education, the likelihood of underweight tended to decrease, while the

likelihood of overweight tended to increase. The higher wealth index increased the likelihood

of overweight and decreased the likelihood of underweight. The highest wealth quintile male

and female tended to be 5.1 and 5.6 times more likely to be overweight/obese. The use of

tobacco increased the likelihood of underweight among both male and female but it

decreased the likelihood of overweight.

The likelihood of underweight decreased with occasional and daily consumption of milk

among male, while among female, it decreased with daily consumption (Table 4). Further,

8
the occasional and daily consumption of pulses decreased the likelihood of overweight

among female. In addition, the occasional and daily intake of vegetables and fruits decreased

the risk of underweight among female. However, the daily intake of fruit was found to

increase obesity among male. The occasional consumption of fish increases the risk of

overweight. Moreover, the daily and occasional intake of aerated drinks significantly

increased the risk of overweight amongst male and female.

<Table 2>

DISCUSSION

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Using the recent data from National Family Health Survey-4, this study examined the

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determinants of undernutrition and overnutrition among the adult men and women belonging
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to the age group 15-49 in India. In particular, the focus was to understand the role of

socioeconomic status, diet, tobacco use on underweight and overweight or obesity. We

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further studied the variations in body mass index across the states of India.
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We noticed a sharp rise in the prevalence of overweight from 2005-06 to 2015-16.

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Nevertheless, a larger proportion of men (19.6 %) and women (22.4 %) in the age group of
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15-49 in India were underweight, thus suggesting the presence of dual burden of malnutrition

among the adult population in India. It was also found that underweight was prevalent in

most of the Empowered Action Group (EAG) states, which are the socially backward states

that lag behind in various demographic and social indicators. However, the Southern states

were experiencing high prevalence of overweight. Further, the prevalence of underweight and

overweight was found to be dependent on the socioeconomic status. Particularly, the

association between wealth quintile and overweight was highly significant and positive for

men and women. The percentage of underweight was observed among adults in the poor

socioeconomic status.

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 <Table 3>

The results of this study are consistent with previous literature, thus showing higher

prevalence of underweight among adults in the low socioeconomic status [20]. Similarly,

overweight is more prevalent among educated and wealthier people [16-18]. Previous studies

conducted in India illustrate the socioeconomic status as an important player in the greater

access to food, which can influence body weight. It also appears that the higher

socioeconomic status is strongly correlated with physical inactivity, which subsequently

plays an important role in determining the body weight [16]. Gender differences in the body

mass index are notable. Though the prevalence of obesity is higher among women

respondents, the gender gap in obesity is gradually declining. The gender differences

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prevalent in obesity in India can be attributed to health risk factors such as less physical

activity among women respondents [21].

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In this study, tobacco use is significantly associated with body mass index. This association is
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found to be positive with underweight and negative with overweight/obesity, and the results
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are in line with the existing studies conducted in India [22, 23]. The strength of association
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between tobacco use and underweight is found to be strong for women respondents in
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comparison to men. The existing literature has identified tobacco use as the main cause of
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suppressing the appetite, which is reflected in reduced food intake and body mass index [29-

31]. Tobacco is smoked especially by adults of low socioeconomic status, which raises

concern about tobacco use, as it has shown a strong association with various adverse health

outcomes including mortality.

Behavioural risk factors such as intake of milk/curd, vegetables, fruits, fish, eggs, and aerated

drinks are associated with the body mass index. Previous literature has shown that frequent

consumption of vegetables and dairy products are positively associated with the body mass

index [1]. It is observed that the consumption of pulses, milk, and vegetables reduces the risk

10
of underweight and high consumption of fish and aerated drinks increases the risk of

overweight/obesity [32].

<Table 4>

The coexistence of underweight and overweight in the developing countries like India calls

for attention. The proactive measures to prevent underweight and overweight are important.

The results from this study strongly suggest that overweight is prevalent among adults having

higher socioeconomic status, thus suggesting possible measures to change in the dietary

pattern and physical activity. In this study, tobacco use has emerged as a significant factor in

determining body mass index, and the prevalence of tobacco use is high in India. In this

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context, creating awareness about the implications of tobacco use on nutritional status is

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important. Furthermore, measures to promote physical activity are important. In India, more

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than half of adults age 20 or above are physically inactive [21]. Particularly, women are at
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higher risk of being inactivate. In this context, measure to promote physical activity will have
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significant implications on reducing the burden of overweight/obesity and chronic conditions.

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In future research, the reasons why women's physical activity is low, the reasons why high-
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income people are obese and the public health strategies to solve the problems should be
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investigated Limitations
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The limitations of this study include, the data used in this study is cross-sectional. Therefore,

any causal relationship cannot be established. Furthermore, we have used only underweight

and overweight/obesity as the measures of nutritional status. Furthermore, NFHS provide no

information on risk factors of underweight and overweight/obesity such as physical activity,

sleep pattern and amount of stress.

However, the strength of the study is that the data used in this study is a large-scale nationally

representative data. Therefore, the results of this study can be generalized at the national level.

Furthermore, most of the previous literature have focussed mainly on correlates of body mass

11
index of women in reproductive age group. This study provided information on prevalence of

underweight and overweight/obesity across states of India for men and women and their

major correlates.

CONCLUSION

The findings suggest the persistence of dual burden of malnourishment in India. The

underweight is already prevalent, and overweight is increasing rapidly in India more among

men. The study further shows the high clustering of underweight in most of the EAG states,

while obesity is mostly clustered in the Southern states. The result of this study suggests the

presence of a significant association between the socioeconomic variables and underweight.

The major risk factor of underweight is tobacco use, especially, the consumption of smoke

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tobacco was found to be a threat to the nutrition level. However, adults belonging to the age

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group 35-49, residing in the North East region, currently working, more educated, belonged
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to high wealth index are less at the risk of suffering from underweight. On the contrary, with
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increasing age, adults residing in West and South region, urban adult, and more educated and
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wealthy were prone to suffer from overweight or obesity. Not much difference is found
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between the risk factors of underweight and obesity with respect to gender in India. The dual
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burden of underweight and overweight is alarming and needs to be taken into consideration,

so that public health measures can be adopted through public policy. From this perspective,
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the measures to prevent tobacco and obesity-related interventions may enhance the nutritional

status of the adult population in India.

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activation of POMC neurons. Science. 2011;332(6035):1330-2.

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32. Basu S, McKee M, Galea G, Stuckler D. Relationship of soft drink consumption to

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global overweight, obesity, and diabetes: a cross-national analysis of 75 countries.

American journal of public health. 2013;103(11):2071-7.

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16
 Table 1: Percentage distribution of underweight and overweight/obesity by
socioeconomic characteristics, NFHS-4, 2015/16, India.
Male Female
Background Underweight Overweight/ Underweight Overweight/
(N) (N)
Characteristics (%) Obesity (%) (%) Obesity (%)
Age Group***
15-19 44.9 4.8 18493 42.0 4.3 1,17,924
20-34 16.6 17.7 45927 22.8 17.9 2,94,396
35-49 12.3 27.6 35990 14.0 32.2 2,33,942
Region***
North 16.5 19.5 22161 19.4 22.2 1,29,946
Central 26.4 11.9 25446 26.4 15.4 1,70,828
East 22.2 13.8 15433 26.7 15.4 1,16,030
West 21.3 22.3 10901 24.7 23.7 52,276
North East 18.2 14 12922 22.0 14.7 91,146
South 14.2 27.5 13547 17.0 29.7 86,036
Place of residence***
Rural 23 14.3 69022 26.8 15.1 4,56,728
Urban 15.5 26.6 31388 15.5 31.4 1,89,534
Caste***

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SC 22.9 15 17963 25.3 17.3 1,14,935

in
ST 25.1 9.8 17887 31.8 10.1 1,16,898
OBC 20.3 19.6 39059 23.0 20.9 2,53,061
Other
Religion***
Hindu
16.6

20.7
24.7

18.4
19919

74920
pr 17.8

23.6
27.4

19.9
1,31,157

4,80,743
of
Muslim 19.3 19.9 13886 21.6 23.7 86,135
Others 13.9 24.5 11604 16.4 26.5 79,384
ad

Currently working***
No 32.8 11.1 25772 22.7 22.2 85,597
Yes 16.1 21.5 74638 22.7 20.6 27,239
e

Marital status***
ah

Never Married 30.7 10.2 38688 37.4 6.6 1,67,696

Married 13.6 24.5 60458 18.4 25.2 4,50,995
Widowed 24.2 13.5 577 18.1 26.5 20,000
Divorced/separated 22.3 15.4 687 20.2 22.7 7,571
ub

Education level***
Not educated 22.6 12 12251 24.7 16.9 1,83,128
Ep

Up to primary 21.7 16.4 12335 22.0 21.8 81,509

Up to secondary 22.3 18 59890 24.0 21.4 3,08,908
More than secondary 10.4 28.5 15934 16.0 25.9 72,717
Wealth index***
Poorest 31.9 4.8 16639 36.0 5.9 1,21,389
Poorer 26.6 9.8 21039 29.6 11.4 1,37,673
Middle 20.5 16.6 21970 23.1 18.8 1,36,665
Richer 16.2 24.4 20798 17.1 28.2 1,29,062
Richest 10.6 32.7 19964 11.6 36.2 1,21,473
Tobacco use***
No tobacco 20.9 21 51663 22.5 21.2 5,77,413
Only smoke tobacco 16.6 19.2 15473 31.9 12.2 5,462
Only smokeless tobacco 20.8 15.7 22335 28.4 15.0 60,988
Both smoke and
20.1 13.2 10939
smokeless tobacco 26.1 13.0 2,399
Note: Chi square level of significance *** (p<0.01).

17
 Table 2: Percentage distribution of underweight and overweight/obesity by food
consumption, NFHS-4, 2015/16, India.
Male Female
Food
Underweight Overweight/ Underweight Overweight/
Consumption N N
(%) Obesity (%) (%) Obesity (%)
Milk/curd***
Never 26.3 12.8 6045 27.7 17.8 55,707
Occasionally 22.6 16 51468 25.9 17.2 3,32,412
Daily 17 22.7 42897 19.0 25.0 2,58,143
Pulses***
Never 21.7 14.6 456 28.9 19.9 3,586
Occasionally 21.2 17.9 55127 23.7 19.9 3,67,030
Daily 19 20.1 44827 21.9 21.8 2,75,646
Vegetables***
Never 25.6 12.9 418 30.6 16.8 2,117
Occasionally 21.5 18 52730 23.9 20.0 3,26,903
Daily 18.6 20.1 47262 21.8 21.7 3,17,242

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Fruits***

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Never 26.9 9.9 2015 30.1 14.0 15,451
Occasionally 20.8 18 88024 23.9 19.4 5,63,351
Daily
Eggs***
14.2 28.4 10371
pr 14.5 31.8 67,460
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Never 21.4 18.7 20378 23.2 20.8 1,95,825
Occasionally 20.1 18.6 75671 23.1 20.3 4,29,937
ad

Daily 16.5 24.3 4361 17.7 27.7 20,500

Fish***
e

Never 21.2 18.3 28481 23.3 20.5 2,33,755

Occasionally 20.2 18.9 67796 23.5 20.3 3,85,262
ah

Daily 13.6 23.4 4133 14.6 27.6 27,245

Chicken***
ub

Never 21.2 18.3 23521 23.1 20.6 2,11,694

Occasionally 19.9 19.1 75153 23.0 20.7 4,26,757
Daily 18.8 21 1736 17.7 28.0 7,811
Ep

Fried food***
Never 19.5 20.2 7659 22.1 24.1 29,181
Occasionally 20.3 18.9 81140 23.1 20.5 5,40,818
Daily 19.8 18.1 11611 21.7 21.0 76,263
Aerated drinks***
Never 21 16.2 12549 25.9 17.8 1,06,120
Occasionally 20.3 19 81401 22.5 21.3 5,09,147
Daily 17.2 22.8 6460 20.3 22.3 30,995
Note: Chi square level of significance *** (p<0.01).

18
 Table 3: Adjusted relative risk ratio covariates of underweight and overweight/obesity
from multinomial logistic by socioeconomic characteristics, NFHS-4, 2015/16, India.
Male Female
Background Underweight Overweight/ Obesity Underweight Overweight/Obesity
Normal Normal
Characteristics weight® RRR [CI-95 %] RRR [CI-95 %] weight® RRR [CI-95 %] RRR[CI-95 %]
Age Group
15-19®
20-34 0.401*** (0.38 - 0.42) 2.138*** (1.95 - 2.34) 0.68*** (0.65-0.72) 2.305*** (2.1-2.53)
35-49 0.341*** (0.32 - 0.37) 3.149*** (2.85 - 3.48) 0.443*** (0.41-0.47) 4.524*** (4.11-4.98)
Region
North®
Central 1.324***(1.25 - 1.4) 0.886*** (0.83 - 0.94) 1.076*** (1.02-1.13) 0.987 (0.93-1.04)
East 1.044 (0.98 - 1.11) 1.171*** (1.09 - 1.26) 1.153*** (1.09-1.22) 1.056 (0.98-1.13)
West 1.585*** (1.48 - 1.7) 1.221*** (1.14 - 1.31) 1.616*** (1.52-1.72) 1.143*** (1.07-1.22)
North East 0.652*** (0.6 - 0.71) 1.294*** (1.19 - 1.4) 0.599*** (0.55-0.65) 1.061 (0.98-1.15)
South 0.981 (0.91 - 1.05) 1.572*** (1.47 - 1.68) 1.071** (1-1.14) 1.444*** (1.36-1.54)
Place of residence
Rural®
Urban 1.007 (0.96 - 1.05) 1.178*** (1.13 - 1.23) 0.889*** (0.85-0.93) 1.282*** (1.23-1.33)
Caste
SC®
ST 0.795*** (0.75 - 0.84) 0.83*** (0.77 - 0.9) 0.974 (0.92-1.03) 0.76*** (0.71-0.81)
OBC 0.966 (0.92 - 1.01) 1.07** (1.01 - 1.13) 0.967 (0.93-1.01) 1.02 (0.97-1.07)
Other 0.867*** (0.82 - 0.92) 1.22*** (1.15 - 1.3) 0.878*** (0.83-0.93) 1.133*** (1.07-1.2)

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Religion

in
Hindu®
Muslim 0.931** (0.88 - 0.99) 0.995 (0.93 - 1.06) 0.911*** (0.86-0.96) 1.295*** (1.22-1.37)

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Others 0.686*** (0.63 - 0.74) 1.147*** (1.07 - 1.23) 0.596*** (0.56-0.64) 1.087*** (1.02-1.16)
Currently working
No®
Yes 0.721*** (0.69 - 0.75) 1 (0.94 - 1.06) 0.963**(0.93-1) 0.927*** (0.89-0.97)
of
Marital status
Never Married®
Married 0.757*** (0.72 - 0.8) 1.906*** (1.8 - 2.02) 0.638*** (0.61-0.67) 2.191*** (2.05-2.34)
Widowed 1.141 (0.92 - 1.41) 1.345** (1.02 - 1.78) 0.694*** (0.62-0.77) 2.001*** (1.79-2.23)
ad

Divorced/separated 1.062 (0.86 - 1.31) 1.31** (1.03 - 1.66) 0.829** (0.72-0.96) 1.902*** (1.62-2.23)
Education level
Not educated®
e

Up to primary 1.035 (0.97 - 1.11) 1.198*** (1.1 - 1.3) 0.886*** (0.84-0.94) 1.154*** (1.09-1.22)
ah

Up to secondary 0.875*** (0.83 - 0.93) 1.231*** (1.15 - 1.32) 0.858*** (0.82-0.9) 1.19*** (1.13-1.25)
More than
0.589*** (0.54 - 0.64) 1.379*** (1.27 - 1.5) 0.711*** (0.66-0.76) 1.045 (0.97-1.12)
secondary
Wealth index
Poorest®
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Poorer 0.847*** (0.8 - 0.89) 1.609*** (1.47 - 1.76) 0.845*** (0.81-0.89) 1.754*** (1.62-1.9)
Middle 0.684*** (0.65 - 0.72) 2.486*** (2.27 - 2.72) 0.727*** (0.69-0.76) 2.76*** (2.55-2.99)
Richer 0.595*** (0.56 - 0.64) 3.688*** (3.37 - 4.04) 0.603*** (0.57-0.64) 4.334*** (3.99-4.71)
Ep

Richest 0.432*** (0.4 - 0.47) 5.1*** (4.63 - 5.62) 0.472*** (0.44-0.51) 5.626*** (5.15-6.15)
Tobacco
No tobacco®
Only smoke
1.09*** (1.03 - 1.15) 0.783*** (0.74 - 0.83) 1.491*** (1.25-1.77) 1.022 (0.83-1.25)
tobacco
Only smokeless
1.048** (1 - 1.1) 0.848*** (0.81 - 0.89) 1.371*** (1.3-1.45) 0.885*** (0.83-0.95)
tobacco
Both smoke and 1.04 (0.98 - 1.11) 0.732*** (0.68 - 0.78) 1.056 (0.77-1.45) 0.797 (0.61-1.05)
Smokeless tobacco
Note: RRR-Relative Risk Ratio, CI-Confidence Interval, ®-Reference Category, Significance level: * (p<0.10),
** (p<0.05), *** (p<0.01).

19
 Table 4: Adjusted relative risk ratio of underweight and overweight/obesity by food
consumption pattern from multinomial logistic regression model, NFHS-4, 2015-16,
India.
Male Female
Food
Consumption Normal Underweight Overweight/Obesity Normal Underweight Overweight/Obesity
weight® RRR [95% CI] RRR [95% CI] weight® RRR [95% CI] RRR [95% CI]
Milk/curd
Never®
Occasionally 0.816*** (0.76-0.88) 0.944 (0.86-1.03) 1.02 (0.96-1.08) 0.972 (0.91-1.04)
Daily 0.746*** (0.69-0.81) 0.986 (0.9-1.08) 0.918*** (0.86-0.98) 0.94* (0.88-1.01)
Pulses
Never®
Occasionally 1.033 (0.8-1.34) 1.17 (0.85-1.61) 1.038 (0.83-1.29) 0.723*** (0.57-0.92)
Daily 1.049 (0.81-1.36) 1.239 (0.9-1.71) 1.022 (0.82-1.27) 0.732** (0.57-0.94)
Vegetables
Never®
Occasionally 0.899 (0.71-1.14) 1.081 (0.78-1.51) 0.762** (0.59-0.98) 0.94 (0.68-1.3)
Daily 0.847 (0.67-1.08) 1.138 (0.82-1.59) 0.729** (0.57-0.94) 1.047 (0.76-1.45)

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Fruits

in
Never®
Occasionally 1.016 (0.91-1.14) 1.097 (0.93-1.29) 0.909* (0.82-1) 1.014 (0.88-1.16)
Daily 1.011 (0.89-1.15) 1.253** (1.05-1.49) 0.822*** (0.73-0.92) 1.128 (0.98-1.31)

pr
Eggs
Never®
Occasionally 0.918** (0.86-0.98) 0.931* (0.86-1.01) 0.981 (0.92-1.04) 0.892*** (0.83-0.96)
of
Daily 1.025 (0.91-1.15) 1.02 (0.91-1.15) 1.156** (1.03-1.3) 1.003 (0.9-1.12)
Fish
Never®
Occasionally 1.023 (0.96-1.09) 1.1** (1.02-1.19) 0.977 (0.92-1.04) 1.067* (0.99-1.15)
ad

Daily 0.844*** (0.74-0.96) 1.038 (0.92-1.17) 0.781*** (0.7-0.87) 1.085 (0.98-1.2)

Chicken
Never®
e

Occasionally 0.953 (0.88-1.03) 1.071 (0.98-1.17) 0.992 (0.92-1.07) 1.065 (0.98-1.16)

Daily 1.09 (0.91-1.3) 1.093 (0.92-1.29) 0.995 (0.83-1.2) 1.07 (0.9-1.27)
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Fried food
Never®
Occasionally 1.001 (0.93-1.07) 0.956 (0.89-1.03) 1.063 (0.98-1.15) 0.862*** (0.79-0.94)
Daily 1.008 (0.92-1.1) 0.93 (0.85-1.02) 1.031 (0.94-1.14) 0.89** (0.81-0.98)
ub

Aerated drinks
Never®
Occasionally 0.984 (0.93-1.04) 1.147*** (1.08-1.22) 0.896*** (0.86-0.94) 1.114***(1.06-1.17)
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Daily 0.892** (0.81-0.98) 1.183*** (1.08-1.3) 0.912** (0.83-1) 1.073 (0.98-1.18)

Note: RRR-Relative Risk Ratio, CI-Confidence Interval, ®-Reference Category, Significance level: * (p<0.10),
** (p<0.05), *** (p<0.01). Results are adjusted for age, marital status, caste, religion, place of residence,
schooling, wealth quintile, work status and tobacco use.

20
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