India's Metabolic Crisis: Why Affluence Fuels Diabetes, Expert Warns

In Kerala, Goa, and Puducherry, one in four adults now carries a diagnosis of diabetes. That figure—25 to 26 percent—marks a metabolic transformation that has unfolded across India over the past quarter century, and according to Dr. V Mohan, one of the country's leading diabetologists, it tells a story that begins not with disease but with prosperity.

A new 25-year review has identified abdominal obesity as the fastest-growing metabolic risk in urban India, outpacing even diabetes itself. But the numbers alone obscure something more fundamental: the way Indians store fat is different from Europeans, and that difference, combined with decades of economic change, has created what Mohan calls the price of affluence. India moved from a nation importing food in the 1960s to one where junk food is ubiquitous and sedentary life is the norm. The Green Revolution brought food security. Economic liberalization in 1991 brought rising incomes. The IT boom brought desk jobs and disrupted sleep schedules. Each shift rewired how Indian bodies metabolize calories.

The mechanism is biological. South Asians, including Indians, have fewer small fat cells on the abdominal wall compared to white Europeans. When excess calories arrive—especially from carbohydrate-heavy and processed foods—those cells saturate quickly. The fat then migrates inward, becoming visceral fat, the kind that wraps around organs and enters the liver. This is not the soft padding under the skin. This is metabolically active, inflammatory fat that triggers insulin resistance, which leads to diabetes. It accumulates around blood vessels and the heart. Mohan describes it as living in a state of continuous inflammation, almost like having COVID constantly. The consequences are severe: diabetes, hypertension, heart attacks, strokes, and certain cancers. Indians now suffer heart attacks in their 20s and 30s, decades earlier than Europeans typically do.

The regional patterns reveal how prosperity reshapes metabolism. Punjab and Haryana have abdominal obesity rates nearly as high as Kerala, yet Kerala's diabetes prevalence is almost twice as high. The difference lies partly in physical activity. Punjab and Haryana produce many of India's athletes; people there remain more active. Kerala, by contrast, experienced economic growth earlier through remittances from the Middle East and the rise of IT hubs in nearby cities. As incomes rose, people bought vehicles, walked less, and ate more. The southern states became prosperous first, and they are now paying the metabolic price first. In contrast, states like Uttar Pradesh, Bihar, and the northeastern regions show much lower diabetes rates, partly because economic development has been slower and undernutrition persists. In rural Jharkhand, Mohan found communities with virtually no diabetes because people remained undernourished.

Women bear a disproportionate burden. Biological and social factors converge at three critical life stages. At puberty, hormonal changes coincide with reduced physical activity—girls are often discouraged from outdoor play while boys continue sports and gym routines. During pregnancy, families encourage excessive eating; many women gain far more than the recommended eight to twelve kilograms, and that weight rarely comes off afterward. Motherhood brings sleep deprivation and little time for exercise. At menopause, declining estrogen naturally increases abdominal weight gain. Beyond biology, social expectations compound the problem. Household work is often deemed sufficient exercise. Women eat what remains after the earning member is fed. They wake first and sleep last. The result is that abdominal obesity is significantly more common among Indian women than men.

Measuring waist circumference—90 centimeters or more in men, 80 centimeters or more in women—is a far better indicator of metabolic risk than BMI, which conflates muscle and fat. Yet most health camps and clinics still rely on BMI alone. A simple measuring tape reveals what matters: visceral fat. Mohan has seen six- and eight-year-olds arriving with pronounced abdominal fat, the result of constant junk food and no outdoor play. The problem is no longer confined to adults.

New drugs offer hope but not salvation. Semaglutide and tirzepatide, originally developed for diabetes, reduce abdominal obesity and liver fat while lowering cardiovascular risk. Nearly 80 to 100 obesity medicines are in development. Yet these are not magic. They are expensive, even in generic form. They must be taken indefinitely—stopping them reverses the benefits. Side effects include nausea, vomiting, constipation, and diarrhea in early weeks; rare cases of pancreatitis and vision problems have been reported. They require proper medical supervision, not gym trainers or wellness centers. They are tools, not cures.

Mohan argues that individual behavior cannot solve a systemic problem. Cities must be redesigned to make physical activity easy: proper footpaths, safe pedestrian zones, free and well-maintained public gyms. Fruits and vegetables must become affordable—if an apple costs 80 rupees, ordinary families cannot eat one daily. Schools must make physical activity compulsory, not optional. Children must bring healthy food, not processed snacks. The White Revolution made milk affordable across India; a similar effort could make nutritious food accessible to every family. This is not a problem medicine alone can solve. It requires urban planners, schools, governments, food systems, and families working in concert. The metabolic crisis is a crisis of affluence, but only a whole-of-society response can reverse it.