Vellore cohort reveals India's growing double burden of malnutrition in school-age children
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Children growing up in a low-income urban community in Vellore are now facing two seemingly opposite forms of malnutrition simultaneously: persistent thinness and rising obesity by the time they reach primary school age. A longitudinal birth cohort study of 251 children found that while thinness remained common, the prevalence of overweight and obesity nearly tripled between ages 7 and 9, underscoring the country's growing "double burden of malnutrition."
The double burden of malnutrition, as defined by the World Health Organization, refers to the coexistence of undernutrition along with overweight, obesity or diet-related noncommunicable diseases within individuals, households and populations.
The study, a collaboration between the Advanced Research Unit on Metabolism, Development and Aging (ARUMDA) at the Tata Institute of Fundamental Research (TIFR) and Christian Medical College (CMC), Vellore, was led by Dr. Beena Koshy (CMC Vellore) and Dr. Birsen Yilmaz (ARUMDA, TIFR). The analyses were carried out on a longitudinal birth cohort established by CMC Vellore and now maintained by Koshy. The paper is published in The Lancet Regional Health - Southeast Asia journal.
Of the 251 children enrolled at birth, 205 (82%) were followed up to 9 years of age, with height and weight measured at multiple time points. The study showed that most children maintained a normal body mass index (BMI) in the first five years of life. However, by mid-childhood, a more complex picture emerged. At age 7, 26.3% of children were classified as thin and 5.2% as overweight or obese.
By age 9, thinness remained high at 21.6%, while overweight and obesity had risen to 14.6%, nearly a threefold increase in just two years, indicating the double burden of malnutrition in this population.
Koshy, who presently maintains the cohort at CMC Vellore, said, "Our findings show that children in low-income urban communities are now facing both thinness and emerging obesity before they even enter their teens, which means malnutrition in India is no longer just about underweight toddlers, but about the entire childhood years."
The researchers also found that low maternal BMI and the child's low birth weight were strongly linked to children remaining thin later in childhood, highlighting how malnutrition can be passed from one generation to the next.
At the same time, children born with normal birth weight were more likely to go on to develop obesity by age 9, pointing to the influence of changing diets and physical activity patterns in rapidly urbanizing environments. Together, these findings show that Indian children may move from early growth deficits to later excess weight within a single decade of life.
Dr. Nihal Thomas of CMC Vellore commented, "Undernutrition in early life can lead to two potential trajectories. Persistence of undernutrition, besides leading to stunting, can potentially lead to defects in insulin secretion and even situations where lean individuals develop diabetes in relation to malnutrition.
"On the contrary, in those with overnutrition, the potential of higher body fat accumulation, coupled with a sedentary lifestyle and other environmental factors, could lead to an exponential increase in overweight and subsequently increase the risk of diabetes, hypertension and cardiovascular disease."
The work adds an important time dimension to India's nutrition story by identifying the primary school years, especially between ages 7 and 9, as a period when overweight and obesity begin to rise rapidly, even as undernutrition remains common. This has direct relevance for public nutrition programs in India, which have traditionally focused on the first 1,000 days and preschool years.
The study posits that policies must now simultaneously strengthen maternal nutrition before and during pregnancy, continue growth monitoring into the school years, and improve nutrition support and physical activity environments in and around schools if India is to curb the rising double burden of malnutrition and future risks of metabolic diseases.
Prof. Ullas Kolthur (ARUMDA, TIFR) and Prof. Mahendra Sonawane (TIFR, Mumbai) emphasized the importance of extending attention beyond early childhood: "Our findings suggest the importance of focusing on child growth beyond the first 1,000 days. Extending nutrition, growth monitoring, and healthy food and physical activity initiatives into the primary school years is essential because this is when children's metabolic profiles are being shaped.
"Acting in this window could have a major impact on preventing the progression from early growth faltering to later obesity and related metabolic disorders in adulthood."
Thomas noted that addressing India's double burden of malnutrition would require balanced public health strategies. "The public health policies that need to evolve in this regard would need a judicious blend of lifestyle interventions and the balance of dietary co-interventions that may appear to contravene, but essentially involve promoting higher-protein diets through potentially cost-effective formulations."
More information
Birsen Yilmaz et al, Double burden of malnutrition by mid-childhood in an Indian birth cohort: a longitudinal study (2010–2021), The Lancet Regional Health - Southeast Asia (2026). DOI: 10.1016/j.lansea.2026.100784
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