India is facing an obesity crisis among its newly wealthy middle class as millions of its rural poor still struggle for enough to eat.
As the country becomes richer, many people are becoming fatter and, like Westerners, they are seeking medical help. Patients at Sanjay Borude's clinic choose between keyhole surgery for gastric banding to cut the size of the stomach and a rarer, more serious gastric bypass that restricts the amount of food absorbed.
These operations were hardly ever needed in India a decade ago. Now Borude has an ever-increasing workload at his practice in Mumbai, and he is training doctors from other towns and cities to meet a growing demand for slimming surgery.
Although obesity in the West is associated with poverty, in the developing world it is a problem for the newly rich. Borude's clients are from an urban, professional elite who pay substantial fees to shed their weight.
Seventy-six percent of women in the capital, New Delhi, are suffering from abdominal obesity, according to a survey by the All-India Institute of Medical Sciences.
`Serious problem'
"It is a serious problem for India," said Anoop Misra, the co-author of the study.
"In major metropolitan areas it is almost epidemic," Borude said. "People are living much more sedentary lives. If you are rich, you can pick up a phone and order a pizza. You have a car, so you don't need to walk anywhere."
The problem underlines the vast divide between India's thriving urban areas and the impoverished rural regions, where millions are struggling to feed themselves.
Around 45 percent of Indian children under five suffer from malnutrition, the World Bank says.
Indian society increasingly stigmatizes overweight people. Surgeon Mohan Thomas said half of the patients at his Cosmetic Surgery Institute in Mumbai wanted help to lose weight.
"Having a beer belly was a sign of prosperity, but that's changing. Men are concerned about the male breast area and love handles," he said.
After 30 years in the US, Thomas returned to India to open his clinic three years ago, and found the increase in obesity startling.
"Before I left it was rare, but it's so unremarkable now that no one turns their heads," he said.
Fast-food industry
Explosive growth by India's fast-food industry has fueled a dramatic change in eating habits. A McDonald's branch in Delhi is crowded with customers buying Chicken Maharajah Macs. The chain is expanding to other towns and cities.
Although Indian food was always high in calories, families now spend more than ever on eating out and buying processed food, according to a survey published last week.
"Over the last few years there has been an extremely rapid change in diet -- not just in Delhi and Mumbai, but in smaller towns, too," Misra said. "People are snacking in a new way. Many children no longer take lunchboxes to school. They drink cola and eat burgers. There is no awareness among parents that this is a problem."
With obesity come related problems, from diabetes to heart failure. An estimated 25 million Indians have diabetes, and this is forecast to grow to 57 million by 2025. Doctors say the government has failed to register the scale of the impending crisis.
"Politicians still ask `How can people here have obesity when they are dying of malnutrition?' They think malaria and TB are much more serious," Misra said.
"You can treat TB with six months of treatment. But diabetes needs to treated until the patient dies, and heart disease is expensive to treat. This is going to be disastrous," he said.
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