Abdominal obesity in India: sex stratified multilevel estimates across 707 districts from a nationally representative cross-sectional survey

Abdominal obesity, measured using the waist-to-hip ratio, is an emerging public health concern in India, yet national averages mask important subnational variation relevant for local policy and prevention planning. We sought to quantify district-level variation in abdominal obesity and to examine its individual- and contextual-level determinants across India. Using nationally representative data from the National Family Health Survey 2019–2021, we analysed 664,646 women aged 15–49 years and 96,010 men aged 15–54 years across 707 districts and 30,112 communities using multilevel logistic regression. Abdominal obesity was defined using WHO-anthropometric cut-offs for WHR (women: >0.85; men: >0.90). National prevalence was high, affecting 56.6% (95% confidence interval [CI]: 56.41–56.74) of women and 48.9% (95% CI: 48.31–49.46) of men, with higher levels among older adults, wealthier groups, and urban residents. Marked inter-district heterogeneity was observed, with clusters of high prevalence in northern and eastern India and distinct sex-specific spatial patterns. Variance partitioning indicated that individual-level factors accounted for about 67% of total variation among women and 70% among men, while community-, district-, and state-level factors together explained the remaining variation. These findings demonstrate the value of small-area estimates for identifying high-burden populations and informing geographically targeted public health planning.