Local community environments drive India's obesity epidemic: multilevel evidence using Asian-specific BMI criteria

Background/Objectives The obesity epidemic in low- and middle-income countries requires accurate population-specific assessment criteria. Using Asian-specific BMI thresholds (overweight: ≥23.0 kg/m²; obesity: ≥25.0 kg/m²), we examined the relative contribution of geographic factors at state, district, and Primary Sampling Unit (PSU) levels to variation in obesity prevalence among Indian adults, providing critical insights for intervention targeting. Subjects/Methods We analyzed National Family Health Survey-5 (2019-21) data from 750,000 adults aged 15–49 years across 707 districts in 36 states/Union Territories. Multilevel logistic regression models partitioned geographic variation in obesity outcomes across three hierarchical levels, controlling for individual socioeconomic characteristics. State-specific analyses examined within-state variation patterns. Results Asian-specific criteria revealed overweight/obesity prevalence of 38.0% among women and 40.1% among men—substantially higher than conventional BMI estimates. PSU-level factors dominated geographic variation, accounting for 51.1% among women and 62.4% among men after adjustment, while state-level factors contributed 34.7% and 27.2%, and district-level factors only 14.2% and 10.4%, respectively. State-specific analyses confirmed PSU-level dominance across most states, with individual socioeconomic factors explaining substantial district-level but minimal PSU-level variance. Notable state variations emerged, with some states showing > 90% PSU-level attribution. Conclusions Local community environments, not broader administrative districts, primarily drive geographic disparities in India's obesity epidemic. Asian-specific BMI criteria reveal a substantially higher burden requiring urgent attention. These findings challenge conventional district-focused interventions, suggesting that obesity prevention in resource-limited settings should prioritize local environmental modifications—a critical insight for LMICs experiencing similar nutrition transitions.