J Epidemiol Community Health 61:802-809 doi:10.1136/jech.2006.053801
  • Research report

Income inequality and the double burden of under- and overnutrition in India

  1. S V Subramanian1,
  2. Ichiro Kawachi1,
  3. George Davey Smith2
  1. 1School of Public Health, Harvard University
  2. 2Department of Social Medicine, University of Bristol
  1. Correspondence to:
 S V Subramanian
 Department of Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Avenue, KRESGE 7th Floor, Boston, MA 02115-6096, USA; svsubram{at}
  • Accepted 13 November 2006


Objectives: Developing countries are increasingly characterised by the simultaneous occurrence of under- and overnutrition. This study examined the association between contextual income inequality and the double burden of under- and overnutrition in India.

Design: A population-based multilevel study of 77 220 ever married women, aged 15–49 years, from 26 Indian states, derived from the 1998–99 Indian National Family Health Survey data. The World Health Organization recommended categories of body mass index constituted the outcome, and the exposure was contextual measure of state income inequality based on the Gini coefficient of per capita consumption expenditure. Covariates included a range of individual demographic, socioeconomic, behavioural and morbidity measures and state-level economic development.

Results: In adjusted models, for each standard deviation increase in income inequality, the odds ratio for being underweight increased by 19% (p = 0.02) and the odds ratio for being obese increased by 21% (p<0.0001). Income inequality had a similar effect on the risk of being overweight as it did on the risk of obesity (p = 0.01), and state income inequality increased the risk of being pre-overweight by 9% (p = 0.01). While average levels of state economic development were strongly associated with degrees of overnutrition, no association was found with the risk of being underweight.

Conclusions: Rapidly developing economies, besides experiencing paradoxical health patterns, are typically characterised by increased levels of income inequality. This study suggests that the twin burden of undernutrition and overnutrition in India is more likely to occur in high-inequality states. Focusing on economic equity via redistribution policies may have a substantial impact in reducing the prevalence of both undernutrition and overnutrition.