Background Cardiovascular diseases (CVDs) are the leading cause of death in most low- and middle-income countries (LMICs). CVDs and their metabolic risk factors have historically been concentrated among urban residents with higher socioeconomic status (SES) in LMICs such as India. However, as India develops, it is unclear whether these socioeconomic and geographic gradients will persist or change. Understanding these social dynamics in CVD risk is essential for mitigating the rising burden of CVDs and to reach those with the greatest needs. Methods Using nationally representative data with biomarker measurements from the fourth (2015-16) and fifth (2019-21) Indian National Family and Health Surveys, we investigated trends in the prevalence of four CVD risk factors: tobacco consumption (self-reported, any type), unhealthy weight (BMI ≥ 25kg/m2 ), diabetes (random plasma glucose concentration ≥200mg/dL or self-reported diabetes), and hypertension (one of: average systolic blood pressure ≥ 140mmHg, average diastolic blood pressure ≥ 90mmHg, self-reported past diagnosis, or self-reported current antihypertensive medication use) among adults aged 15-49 years. We first described changes at the national level and then trends stratified by place of residence (urban versus rural), geographic region (northern, northeastern, central, eastern, western, southern), regional level of development (Empowered Action Group member state or not), and two measures of socioeconomic status: level of education (no education, primary incomplete, primary complete, secondary incomplete, secondary complete, higher) and wealth (quintiles). Findings Unhealthy weight increased among all social and geographic groups but both the absolute and the relative changes were substantially higher among people with low SES (as measured by education or wealth) and in rural areas. For diabetes and hypertension, the prevalence increased for those from disadvantaged groups while staying constant or even decreasing among the wealthier and more educated. In contrast, tobacco consumption declined for all social and geographic groups. Interpretation In 2015-16, CVD risk factors were higher among more advantaged subpopulations in India. However, between 2015-16 and 2019-21, the prevalence of these risk factors grew more rapidly for less wealthy and less educated subpopulations and those living in rural areas. These trends have resulted in CVD risk becoming far more widespread throughout the population; CVD can no longer be characterized as a wealthy urban phenomenon.

The authors have declared no competing interest.

This work was supported by the Alexander von Humboldt Foundation [NS]; the Stanford Diabetes Research Center [PG] and the Chan Zuckerberg Biohub [PG]. The funders of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit for publication.

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