Dietary Patterns, Habits, and the Rising Burden of Noncommunicable Diseases in India

The burden of noncommunicable diseases (NCD) is increasing in India. The prevalence of diabetes, hypertension, obesity, and cardiovascular diseases are on the rise and this is seen both in the urban and the rural population. The change in dietary patterns, the tendency for increased consumption of processed foods, reduced physical activity, and lifestyle changes are among the factors which have led to this growing crisis. Recognizing the urgency of this issue, Prime Minister of India, Sri Narendra Modi, emphasized the need for enhancing awareness in the recent nationwide address and urged for a collective action to reduce obesity. The need for dietary modifications to combat the epidemic of obesity, diabetes, and other NCDs was also highlighted. This underscores the urgency of addressing India’s shifting nutritional landscape.[1] Historically, health policies in India focused on undernutrition, but the nation is now experiencing an epidemiological transition marked by an alarming rise in obesity and metabolic disorders. NCDs now account for 60% of all deaths in India.[2] The trend is largely driven by a transition in dietary patterns due to urbanization, economic growth, and cultural changes.[3] THE CURRENT STATUS OF NONCOMMUNICABLE DISEASES IN INDIA India is witnessing a surge in obesity, diabetes, hypertension, and cardiovascular diseases, affecting both urban and rural populations. The prevalence of diabetes has risen dramatically, with estimates suggesting over 100 million Indians are affected.[4] Hypertension affects nearly one in four adults, while chronic kidney disease has emerged as a silent epidemic, with an estimated prevalence of 17%.[5] Analysis of data from the National Family Health Survey over the years 2005–2020 revealed an increasing prevalence of obesity from 12.6% to 24% among women and from 9.3% to 22.9%.[6] The India State-level disease burden study of the GBD study group reported that there has been a 2–3-fold increase in the number of prevalent cases of ischemic heart disease and stroke in India between 1990 and 2016. Since 1990, the burden of NCDs in India has increased, with a significant rise in cardiovascular diseases, diabetes, chronic respiratory diseases, mental health disorders, cancers, musculoskeletal issues, and chronic kidney disease. Diabetes saw the largest increase in disease burden (80%), followed by ischemic heart disease (34%). The report noted a 2–3-fold increase in the number of prevalent cases of ischemic heart disease and stroke in India between 1990 and 2016.[7] In addition, the emerging concept of Cardiovascular-Kidney-Metabolic Syndrome underscores the interconnected nature of metabolic disorders, emphasizing the need for a holistic approach to managing NCDs.[8] These trends align with dietary shifts, increased consumption of fast foods, high-sugar beverages, and decreased physical activity. THE EVOLUTION OF THE INDIAN DIET Conventionally, Indian diets were home-cooked, predominantly plant-based, and rich in legumes, whole grains, vegetables, fruits, and nuts. Fermented foods, which promote gut health, were also common. However, a downside was the high intake of salt from pickles, papads, and chutneys. Recent decades have seen a shift toward diets high in refined carbohydrates, fats, sugar, and salt, along with increased consumption of Ultra-processed foods (UPFs). This transition, coupled with sedentary lifestyles, has led to the “Asian Indian phenotype”– characterized by central obesity and visceral adiposity even at lower BMI levels, predisposing individuals to metabolic disorders.[9] DIETARY COMPONENTS CONTRIBUTING TO NONCOMMUNICABLE DISEASES Overconsumption of refined carbohydrates Refined grains, particularly highly polished white rice, dominate Indian diets. While fiber-rich brown rice improves glycemic control, white rice consumption is linked to insulin resistance and metabolic syndrome. A study in Chennai[10] reported that the mean refined grain intake in a cohort of 2042 participants was 333 g/day (46.9% of total calories). Finely milled, refined wheat flour, commonly referred to as “Maida,” exacerbates metabolic dysfunction due to its low fiber content.[11] Furthermore, frequent consumption (2–3 times per week or more) of fried potatoes is associated with a higher mortality risk.[12] Added sugars As per the last available data by ICMR NIN, 2016 (Survey Population - 20,000 households+), the average daily consumption of added sugars (note the fact, that refined carbohydrates, sugars from milk and fruits are excluded from the calculation) in urban cities was 16 g/person/day and rural population was 13 g/person/day.[13] 24-h diet recall suggests majority of sugar comes from sweets consumption, packaged fruit juices, carbonated beverages, and cakes.[14] Sugar is ever-present in the modern world and is estimated to be found in 75% of packaged foods.[15] Change in the amount and type of cooking oils Urbanization has led to increased consumption of oils such as palm and sunflower, replacing traditional fats. The decline in n-3 polyunsaturated fatty acids and the rise in trans fats contribute to higher cardiovascular risk. In North India, the use of vanaspati (53% trans fats) in fried and baked foods is a major concern. Studies show that higher trans fat intake correlates with increased coronary artery disease prevalence.[16] Between 2007 and 2020, India’s per capita ghee and butter consumption nearly doubled. 4.48 kg/year (12.3 g/person/day) in the year 2020 from 2.7 kg/year (7.4 g/person/day) in 2007. Fast food and processed foods India consumed 8.68 billion servings of instant noodles in 2023, with the true figure likely higher due to offline sales. According to The Ministry of Statistics and Program Implementation and ICICI Securities research, urban elite households allocated nearly half of their food budget to packaged food, dining out, and delivery, up from 41.2% a decade ago.[17] Spending on processed food rose 2.2 times for elite urban consumers and 3.3 times for the middle class. Quick commerce and delivery platforms have transformed eating habits, increasing reliance on convenience foods and reducing home-cooked meals, especially in urban areas. Misleading food labeling Food manufacturers often obscure sugar content using over 400 different names, such as maltose, inverted sugar, and high-fructose corn syrup. Many “sugar-free” products still contain multiple forms of sugar. In addition, UPFs contain different types of preservatives, stabilizers, and synthetic flavor enhancers, all of which contribute to adverse health effects. ULTRA-PROCESSED FOODS AND THEIR IMPACT ON NONCOMMUNICABLE DISEASES UPFs, classified under the NOVA system, are industrially manufactured products that undergo extensive processing. They are reconstituted with additives to enhance flavor, texture, and shelf life but lack essential nutrients while being high in sugar, salt, unhealthy fats, and artificial ingredients.[18,19] They often contain emulsifiers, artificial sweeteners, synthetic colors, and preservatives, contributing to mitochondrial dysfunction, oxidative stress, chronic inflammation, and metabolic derangements.[20] UPFs can be identified by their ingredient lists, which often include artificial flavors, emulsifiers, sweeteners, and preservatives that enhance taste and shelf life but reduce nutritional value. A key indicator is the presence of substances not commonly found in home kitchens. Notably, a critical factor in assessing a product’s composition is the order of its ingredients, as the first three listed typically constitute most of the product by weight. If these include sugar, refined flour, or additives, the product is likely to be nutritionally poor. SCIENTIFIC EVIDENCE LINKING ULTRA-PROCESSED FOODS TO NONCOMMUNICABLE DISEASES Numerous studies link UPF consumption to increased NCD risk. A study in an adult Mediterranean population found that a 10% increase in UPF consumption correlated with a 14% higher risk of all-cause mortality.[21] UPFs are strongly associated with obesity, cardiovascular diseases, intestinal cancers, and type 2 diabetes, largely due to their high glycemic load, chemical additives, and gut microbiota disruption. THE ROLE OF COMMERCIAL DETERMINANTS IN SHAPING INDIA’S DIETARY PATTERNS With changing times and increasing urbanization, the dietary patterns have changed in India. They are also influenced by aggressive marketing, expansion of fast-food chains, and the affordability of UPFs. These commercial determinants of health have driven a shift from traditional diets to high-calorie, low-nutrient options.[22] About 74% of Indians cannot afford a healthy diet due to low-income levels.[23] The pricing of UPF is often lower than that of healthy food, leading to increased dependence on UPFs. PUBLIC HEALTH IMPLICATIONS AND RECOMMENDATIONS Addressing the dietary determinants of NCDs in India requires a multi-pronged approach: Nutrition education: Emphasizing the benefits of traditional diets and raising awareness about the health risks of UPFs Policy measures: Implementing taxation on sugary beverages, enforcing stricter food labeling regulations, and promoting healthy eating campaigns Research and surveillance: Continuous monitoring of dietary trends and evaluating policy interventions to curb NCD risk. ROLE OF PHYSICIANS IN PREVENTING NONCOMMUNICABLE DISEASES THROUGH LIFESTYLE CHANGES Physicians are crucial in preventing NCDs by advocating diet and lifestyle changes as the primary intervention beyond prescribing medications. They can suggest a diet rich in whole foods, regular exercise, and weight management all of which significantly lower disease risk. Even modest weight loss improves metabolic health, while stress reduction aids in hypertension control. Physician-led counseling has been effective in increasing smoking cessation rates. However, many doctors seldom find time to counsel patients on these habits. Enhancing physician training in lifestyle medicine can significantly improve NCD prevention efforts and by leveraging their authority and trust; and quoting guidelines, doctors can guide patients toward evidence-based treatment for NCDs. Interestingly, the physician’s personal health behavior instills a lot of confidence in him and influences his decision to use lifestyle counseling as an important and primary tool in controlling NCDs.[24] As they say “Charity Begins at Home,” let us all inculcate these habits in us, and translate it in our practice. CONCLUSION The dietary transition in India – marked by an increasing intake of UPFs, refined carbohydrates, added sugars, and unhealthy fats – has fueled the rising burden of NCDs. Addressing these dietary determinants requires a comprehensive strategy involving policy reforms, clinical interventions, and public education. By promoting traditional diets, regulating UPFs, and integrating dietary counseling into medical practice, India can mitigate the impact of NCDs and improve population health. Author contributions UK conceptualized the manuscript and prepared it. HS collected data and contributed to manuscript preparation. Both authors contributed equally to the manuscript revision.