At 34, Tarun Rajaputhran did not think he was a typical candidate for serious heart disease. But an episode of breathlessness and fainting at work changed that perception. On the way home, he and his wife decided to stop at a hospital for what they assumed would be a routine evaluation. Instead, a chest X-ray revealed around 60 per cent fluid accumulation in his lungs. His heart function had fallen to an ejection fraction of just 18 per cent, meaning his heart was pumping blood at severely reduced capacity. An angiogram revealed 60-70 per cent blockage in his coronary arteries. A balloon angioplasty was done to clear the blocked arteries, but within a year he had two blockages that had progressed to 99 per cent. He underwent coronary artery bypass grafting under cardiovascular and aortic surgeon Dr Niranjan Hiremath of Apollo hospitals in Bengaluru.
Rajaputhran was the youngest patient in the ward. For years, he had ignored warning signs—poor sleep, a sedentary, high-stress job, no exercise and an unhealthy diet with two to three litres of carbonated soft drinks a day. He was at his heaviest—136kg—in 2019. “For a very long time, I did not consider my diet unhealthy. In the humdrum of life, it just never occurred to me to be mindful,” he says.
In 2019, Sudeep Pathak, diagnosed with non-alcoholic fatty liver disease, underwent a liver transplant in Hyderabad. He was 43. A banker in Kolkata, he did not smoke or drink. But as early as 2012, his blood reports had shown abnormalities in liver enzymes. The advice remained generic—exercise more and make changes to the diet. By 2019, he weighed 92kg-94kg for a 170cm tall man, with spells of extreme fatigue, lethargy, loss of appetite, swelling in the feet and irregular sleep. His fatty liver had advanced to cirrhosis requiring an urgent transplant. He was told this the same day he was offered a role to helm his company’s operations in Dubai. This time, he chose health over career.
In Navi Mumbai, 13-year-old Aditi Kaudare’s parents were worried. She had been gaining weight steadily, weighing about 8kg over her ideal weight. They were also concerned about her menarche being delayed. It was only when she was taken to hospital in September 2025 that she was diagnosed with type 2 diabetes and obesity. Her blood sugar had climbed to around 390mg/dL postprandial and her HbA1c was approximately 10 per cent. “Her delayed menarche was a result of obesity/diabetes,” says Dr Prashant Gaikwad, endocrinologist and diabetologist at Medicover Hospitals, Navi Mumbai. Her mother Seema blamed their lifestyle for her daughter’s ailments. With both parents working, Aditi spent long periods alone, watching television, eating junk food and getting little physical activity. Over time, there was a change in her behaviour and energy levels along with weight gain. “She was so fatigued. She just wanted to eat, drink and sleep,” recalls Seema. It eventually started affecting Aditi’s studies, and she had to repeat a class.
These varied cases highlight a phenomenon experts call ‘Metabolic health clustering’, where risk factors such as central obesity, high blood pressure, high blood sugar and abnormal cholesterol occur together. These compound an individual’s risk for chronic diseases of the heart, liver, brain and kidneys. In a paper published in The Lancet, three metabolic factors—high blood pressure, high body mass index and high fasting plasma glucose—were identified among the leading global risk factors for years of life lost by 2040.
“There is absolutely no doubt that metabolic clustering has sharply risen. And these can be quietly building up beneath the surface,” says Dr Govind Makharia, professor of gastroenterology and human nutrition, AIIMS, New Delhi. “Hypertension, diabetes, hyperlipidaemia and fatty liver can all develop without symptoms in the early stages. People may discover several abnormalities only when they go for a health check.” He clarifies that the rise is partly because people are getting tested more, but there is also a genuine increase associated with changing lifestyles including long work hours, eating quickly, increased consumption of processed, high-fat, high-sugar, high-salt food and declining physical activity.
As per the International Diabetes Federation’s ethnicity-specific criteria for South Asian populations, metabolic syndrome is diagnosed when a person has central obesity—waist circumference over 90cm for men and over 80cm for women—along with two or more of the following: triglyceride concentration of 150mg/dL or above, HDL-C (good cholesterol) concentration below 40mg/dL for men or below 50mg/dL for women, blood pressure of 130/85mmHg or above, and fasting plasma glucose concentration of 100mg/dL or above. Doctors in India are now finding at least three of these markers in a single individual in a high number of cases.
The numbers are stark. As per the ICMR-INDIAB study, published in The Lancet in 2023, India has 254 million adults with generalised obesity and 351 million adults with abdominal obesity. Last year, another study in The Lancet mentioned that by 2050, India could have more than 440 million overweight and obese individuals. The ICMR-INDIAB study also put the diabetes population in India at 101 million. It also found that 136 million people could be living with pre-diabetes. As per figures from the WHO, quoted from papers published in JAMA and PLoS Medicine, it is estimated that at least one in four adults in India has hypertension, but only about 12 per cent of them have their blood pressure under control. As per a paper published in February 2026 by authors from CSIR Institute of Genomics and Integrative Biology, New Delhi, 38.9 per cent of Indian adults are estimated to be living with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), formerly known as non-alcoholic fatty liver disease. The most recent ICMR-INDIAB study (2026), which looked at lipids specifically, said nearly 87.3 per cent of Indian adults live with dyslipidaemia or at least one abnormal blood lipid level. And according to a meta-analysis published in PLoS, roughly one in three Indians lives with metabolic syndrome.
“India is facing an epidemiological shift,” says Dr Pramod Garg, professor of gastroenterology and associate dean (research) at AIIMS, New Delhi, and president, Indian Society of Gastroenterology. “Fatty liver is the clearest example. The disease is easy to find if we look for it, but we become aware of it only after the patient falls ill. We must move away from only treating diseases; we must now actively promote good health.” According to Makharia, every third person in India has a fatty liver, which he or she remains unaware of. Pathak from Kolkata would agree. “Everything was just so normal. I could never have imagined that this (MASLD) was brewing inside me,” he says.
That is true for all metabolic diseases, which doctors say silently accumulate damage for years before symptoms appear. “For instance, in the liver, fat accumulation over years or even decades can progress to inflammation, liver cell injury and eventually fibrosis/cirrhosis. The liver has considerable reserve, which is why patients can remain relatively symptom-free until disease is advanced,” explains Makharia. He adds that 80 per cent of people with diabetes have fatty liver disease, which is essentially metabolic clustering and so these conditions should not be treated in isolation. Also, metabolic risk can exist in people who do not particularly look obese.
The kidney, too, is keeping score. Chronic kidney disease (CKD) frequently travels alongside diabetes, hypertension, abnormal cholesterol and excess weight, and much of it develops silently. Rashmi Raj, 22, was pursuing her master’s in education when hypertension turned her life upside down. The Punekar had noticed swelling on her face and legs, but she says nothing alarming showed up in her medical reports. Three months later, she was diagnosed with CKD stage 5—complete failure in both kidneys. Doctors blamed severe hypertension that had been simmering for a while. She was put on immediate dialysis and, four years later, got a kidney transplant. “Just as they say, hypertension really was a silent killer that almost killed me,” says Raj, now pursuing her PhD.
Rather than occurring in isolation, these metabolic conditions, say doctors, interact. Obesity triggers stress hormones, which derail sugar control and insulin production. That, in turn, affects cholesterol metabolism and plaque formation—cholesterol deposition in artery walls—which can rapidly progress to narrowing of arteries in the heart and brain, causing heart attacks or strokes. According to Dr Sunil Shroff, urologist and founder trustee of MOHAN Foundation, 60 per cent of patients with kidney failure have diabetes and hypertension as comorbid factors and diabetes is the cause for 50 per cent of kidney failures in our country.
This correlation is often not known to many. Take, for instance, Amit Kumar Sharma, 39, who visited a doctor following sharp pain in the middle of his head. The doctor told him that his BP was so high that he could even have a brain haemorrhage. While that came as a shock, what shook him was that no one had told him about the link between hypertension and kidney disease. “No one had told me that this (high BP) could be a sign of serious kidney disease,” he recalls. “When the medicines gave me some relief, I stopped the treatment, while both my kidneys were slowly deteriorating. About a year later, when I started noticing foamy urine, I got myself checked by a nephrologist. After seeing the reports, the doctor told me that both my kidneys had completely failed and that dialysis was the only option.”
And, doctors are finding these metabolic markers in younger patients. Dr Arun Menon, endocrinologist at Amrita hospital in Kochi, has noticed a “definite increase” in metabolic health related cases striking younger patients. “I see about a 10 to 20 per cent increase,” he says. “Fatty liver and pre-diabetes are emerging as particularly common concerns, alongside a significant rise in hypertension, and they are all presenting a decade earlier than they did previously. If I was seeing these cases in people in their 40s before, now we are seeing it in those in their 30s.” Hiremath concurs, saying that about a decade ago, less than five per cent of the patients who came to him with heart disease were below 35 years. “But now close to 30 per cent of them are below the age of 35, which is quite alarming,” he says. The youngest patient he did a coronary artery bypass graft on was just 28.
Doctors emphasise how obesity, particularly visceral fat (fat accumulated around internal organs), plays a huge role in driving multiple metabolic diseases. As per the National Family Health Survey-5 data, approximately 40 per cent of Indian women and 12 per cent of Indian men live with abdominal obesity based on waist circumference thresholds, while broader waist-to-hip ratio metrics suggest up to 57 per cent of women and 48 per cent of men exceed safe thresholds for visceral fat.
Children, too, are increasingly affected. Paediatric obesity, says Gaikwad, has compressed the timeline of diseases traditionally associated with middle age. Dr Kochurani Abraham, consultant paediatric endocrinologist at Ankura Hospital for Women and Children, Pune, recalls a 12-year-old with rapid weight gain, declining focus, low energy, pre-diabetic HbA1c of 5.8, Vitamin D deficiency and borderline lipids. “The results painted a picture that is disturbingly familiar in paediatric clinics in recent times,” she says. “Left unaddressed, this trajectory often continues into insulin resistance, dyslipidaemia and fatty liver disease by adolescence or early adulthood.” This is representative of a much larger and quietly growing epidemic among schoolchildren, she explains. “All this is mostly in the adolescent age group when [academic pressure] is higher and workouts are less. And sadly, their medical history always points towards lifestyle reasons,” she says.
As per the World Obesity Atlas 2026, after China, India has the highest number of obese or overweight children, with an estimated 41 million children with high BMI and 14 million living with obesity. Dr Sudha Rao Chandrashekhar, medical director, Bai Jerbai Wadia Hospital for Children, Mumbai, says, “We have seen nearly 300 children and adolescents with obesity over the past three years, averaging around 100 children each year.” Gaikwad says there has been an increase of around 30 per cent in the number of such cases in children over the past year.
In both children and adults, experts point to ultra-processed food, sedentary lifestyle and long working hours as likely drivers, though the evidence is not yet conclusive. “I personally feel it might be the kind of food we are eating,” says Menon. But there is little proof, he adds. He stresses that India needs large, long-term epidemiological studies to understand what is driving the changing metabolic health profile. These diseases develop over years and decades, he points out, making short-term studies inadequate to establish underlying causes.
Air pollution is also increasingly linked to metabolic health, says Dr Satyanarayana Mysore, chairman and head of pulmonology, Manipal Hospitals. A study in Ecotoxicology and Environmental Safety concluded: “There is an observed association between long-term exposure to air pollution and a heightened risk of metabolic syndrome, particularly in men, younger individuals, those who are physically inactive and smokers…. Exposure to pollutants such as fine particulate matter (PM2.5) and PM10 can trigger oxidative stress and systemic inflammation, while also contributing to endothelial dysfunction or impairment of the normal functioning of the blood-vessel lining.”
Indoor air pollution, from sources like solid-fuel burning and radon exposure in older buildings, is an overlooked additional risk. “The relationship between air pollution and metabolic health may also be indirect,” says Mysore. “Pollution can impair lung function and exercise capacity, making physical activity more difficult. Reduced aerobic capacity and an increasingly sedentary lifestyle can, in turn, contribute to weight gain, insulin resistance and other components of metabolic syndrome.”
Dr Phulrenu Chauhan, endocrinologist at P.D. Hinduja hospital, Mumbai, says that genetics can set the stage for metabolic health, but they do not necessarily determine the outcome. “Certain people may inherit a greater susceptibility to obesity, insulin resistance, type 2 diabetes, dyslipidaemia or hypertension, but whether that genetic predisposition actually manifests depends significantly on the environment and lifestyle.” Diet, physical activity, sleep, stress and even exposure to factors such as air pollution can interact with these genetic pathways, she explains. “In other words, our genes may load the gun, but our environment and lifestyle can influence whether it gets fired,” she says.
State-wise, the ICMR-INDIAB study found sharp variation across every metabolic marker. Diabetes prevalence ranged from 4.8 per cent in Uttar Pradesh to 26.4 per cent in Goa; prediabetes from 6.8 per cent to 31.3 per cent, concentrated in central and northern India; hypertension from 24.3 per cent to 51.8 per cent, highest in southern and northeastern states; generalised obesity from 11.6 per cent to 53.3 per cent, highest in both northern and southern states; abdominal obesity from 18.4 per cent to 61.2 per cent, highest across north, central and south India; hypercholesterolaemia from 4.6 per cent to 50.3 per cent, concentrated in the northern region, Kerala and Goa; hypertriglyceridaemia from 21.2 per cent to 47.9 per cent, highest in Maharashtra, Assam, Telangana, Karnataka, Kerala and Tamil Nadu; and low HDL cholesterol—the most widespread abnormality—from 51.8 per cent to 83.1 per cent nationally.
This burden carries a heavy economic cost. As per an academic research by Rajesh Sharma and Mehak Nanda of Delhi Technological University, out-of-pocket expenditure accounts for 50.6 per cent of health expenditure in India, pushing about 39 million people below the poverty line each year.
As Shroff says, “Our policymakers are waking up to this now. This problem has been around for a long time. Now that things are getting worse, we are trying to firefight.” Menon is also critical of the gap between discussing prevention and actually implementing it at scale. He argues that while individuals are often told to take responsibility for their health, prevention needs to extend beyond the individual to policy, experts and government.
But until policy catches up, doctors say self-management remains the mainstay of recovery. Through dietary changes, exercise, weight management and treatment, Aditi lost 6kg, her HbA1c fell to 5.7 per cent, and she came off insulin and diabetic medication entirely, attaining menarche this June, says her mother. Rajaputhran found a “huge difference” after cutting soft drinks and red meat from his diet and becoming more active—he now sleeps eight hours, tracks recovery with a wearable, walks or cycles to work and has gone from 110kg to about 100kg. Pathak, now 50, weighs around 70-74kg and “tries to walk at least 10,000 steps a day”.
Their individual experiences are a call for all Indians to rethink health, not as an absence of symptoms but as something that needs to be actively maintained.
