Introduction

The recent Global Burden of Disease study showed that the prevalence rate of diabetes in India among adults increased from 5.5% to 7.7% between 1990 and 2016. This translates to an increase in the number of people with diabetes from 26 million in the year 1990 to 65 million in 2016. India is one of the top 5 countries in the South East Asian (SEA) region with an age-standardized diabetes prevalence of 9.6% in 2021 whereas Mauritius in the SEA region had the highest prevalence rate (22.6%), followed by Bangladesh (14.2%), Sri Lanka (11.3%), and Bhutan (10.4%). However, given India’s population of nearly 1.4 billion people, this translates to 74 million people with type 2 diabetes (T2D), which represents one in 7 adults with the disorder in the world. In contrast, European countries and the United States of America report a lower prevalence of T2D despite higher obesity rates. Moreover, among white Europeans, the peak occurrence of T2D is observed around 55 y of age, whereas in India, the onset occurs at least a decade earlier. In the 1970s, the prevalence of diabetes in urban areas of India was around 2% in and that in rural areas was 1%. However, the prevalence of diabetes started rising gradually at first, and after 1991, it increased at an accelerated pace as the country went through rapid economic growth following the opening up of the economy in terms of direct foreign investments. This led not only to a rapid rise in obesity and diabetes rates but also to noncommunicable diseases overtaking communicable diseases as the commonest cause of death. Diabetes prevalence rates rose to double figures and soon were in excess of 20% in the larger metropolitan cities. The Indian Council of Medical Research India Diabetes (ICMR-INDIAB) study showed that there were large differences in the prevalence of diabetes even within India and that states with higher GDP has a higher prevalence of diabetes. In addition, in the more affluent states, at least in urban areas, those belonging to the lower socioeconomic strata were observed with higher rates of diabetes for the first time, resembling the prevailing situation in developed countries.

The question that is often argued is whether the diabetes epidemic is driven by genetic factors or by environmental factors. Although genetic factors are obviously important, it is clear that the genetics did not change during the 50-y period when diabetes rates increased by almost 10-fold in India. This clearly points to the role of environmental factors having a greater role in the causation of the diabetes epidemic. Indeed, the rapid socioeconomic changes in the region has led to changes in both the quantity and quality of diets consumed along with markedly reduced physical activity leading to obesity, one of the main contributors to T2D.

Nutrition transition

At the time of her independence in 1947, India had a “ship to mouth” existence wherein major food grains such as wheat were imported from the United States to meet the country’s requirement. The advent of the “Green Revolution” (1960s) driven by modern technology and supportive economic and public policies saw a major boost in the production of rice and wheat, which helped the country attain food self-sufficiency in 25 y. The availability and access to staple foods led to a gradual decline in severe forms of undernutrition. However, undernutrition slowly paved way to obesity while micronutrient deficiencies still exist in the country, resulting in the triple burden of nutritional disorders.

Today, the transitioned Asian Indian diets are predominantly carbohydrate-based with excess intake of calories but are insufficient in protein, fiber, and micronutrients. There has been a steep rise in the consumption of refined cereals such as white rice (WR) in the recent years. Between 1983 and 2011, the contribution of calories by millets declined from 23% to 6% in rural and from 10% to 3% in urban households. This was a big change from the traditional fiber-rich Asian Indian diets, which were composed of coarse cereals, fruits, and vegetables. Although the consumption of milk, eggs, and poultry meat increased to some extent, this did not translate to the adequacy of nutrient intake, especially protein and micronutrients.

Using data of national surveys by the Government of India such as the National Nutrition Monitoring Bureau, the National Sample Survey Organization (NSSO), and the National Family Health Survey (NFHS) and of other published scientific literature, the present review discusses the quality of Asian Indian diets with specific reference to macronutrients such as carbohydrates, proteins, and fats in the context of T2D. It also suggests some possible strategies to slow down the epidemic of T2D.

Quality of Indian diets

India has a wide variety of cuisines and it is a near impossible task to bring them all under the banner of “a typical Asian Indian diet.” The staple food is WR in the Southern, Eastern, and Northeastern regions, whereas wheat (as whole wheat flour) is consumed in the Northern, Western, and Central regions of India. The main course of a meal involves predominantly refined carbohydrates with WR or wheat forming the bulk of the calories. The methods of preparation, the oils used, and the combination of different food groups vary considerably from one region to another. The vast majority of the population is considered “nonvegetarian” identified by any intake of meat, poultry, fish or eggs, although the consumption of these foods is low, probably due to the lack of affordability. Notably, 29% of women and 17% of men are vegetarians. The frequency of consumption of various foods in India is summarized, which shows that there is a lack of dietary diversity in the diets. Less than 50% of the adults regularly consume ≥3 other food groups, including milk, pulses, or green leafy vegetables, and <10% of them consume good quality protein. Furthermore, the statistics reported that 25% of men and 15% of women consume carbonated beverages them at least once a week. There were also some differences in the consumption pattern for urban and rural areas, with the former showing a lower intake for cereals but higher intake of fat, and vice versa for the latter; however, the majority of the calories comes from refined cereals (carbohydrates) . The “What India Eats” study estimated the total carbohydrate intake to be 289 and 368 g for urban and rural adults in India, respectively. Indeed, refined cereals formed the major source of carbohydrates and contributed to 73% and 80% of the total carbohydrate intake in the respective urban and rural diets. In urban areas, >50% of the energy intake came from cereals, whereas for rural areas, the corresponding figure stood at 65%. Overall, 97% of adults in the rural areas and 67% in urban areas consumed more than the recommended intake of cereals. In contrast, the share of energy from pulses, legumes, and animal foods was only 11%. Only 9% of the adults in rural areas and 17% of adults in urban areas consumed vegetables as per the recommended intake (350 g/d). High salt, high fat, and energy-dense foods such as chips, chocolates, biscuits, and juices contributed to 11% and 4% of the total energy in urban and rural areas of India, respectively.

Besides the lack of diversity, the average daily consumption of all other food groups except for cereals and fats is much lower than the recommendations for a 2000-kcal/d diet. The recent “My plate” recommendations from the Indian Council of Medical Research, National Institute of Nutrition, suggest that cereals (preferably “coarse”) intake should be <45%E, that of pulses, egg, and flesh foods should be 17%E, that of total fat should be 30%E, that of milk and milk products should be 300 mL/d, that of all vegetables including green leafy and tubers (except potato) to be 350 g/d, that of fruit intake should be 250 g/d, and that of nuts should be 20 g/d.

In the past, when the hand pounded rice was consumed, traditional Asian Indian diets were rich in dietary fiber and micro- and phytonutrients, but with the advent of modern rice mills, the rice underwent refining and milling to such an extent that the final product has only the starchy endosperm. Nationwide, the intake of coarse cereals declined from 35% to 5% and from 17% to 3% in rural and urban areas, respectively, between 1961 and 2011. This was replaced by refined cereal staples that are high in GI, thereby increasing the GL of the meal.

Studying the dietary profile of 2042 adults in urban Chennai in India, we reported that 64% of calories came from carbohydrates, followed by fat (24%) and proteins (12%). Besides, the intake of micronutrient-rich foods such as fruits and vegetables was 265 g/d, which was well below the recommended concentrations of 500 g (5 servings) or the Asian Indian recommendation (350 g of vegetables and 150 g of fruits) per day. Unsurprisingly, the diet was also largely inadequate in fiber–an important nutrient in prevention and management of T2D.

Carbohydrates and T2D risk in South Asians

We examined the relationship between dietary carbohydrates and GL with risk of T2D in 1843 adult men and women in Chennai, India. We noted that the highest intake of carbohydrates (587 g/d) was associated with a 5-fold increased risk of T2D compared with the lowest intake (294 g/d).

Commonly consumed Indian WR varieties belong to the high GI category, but even the minimally polished rice varieties have a high GI. White rice-based diets elicit higher glycemic responses as compared to brown rice-based diets. With progressive polishing, brown rice, which is a whole grain, gets depleted in protein, fat, fiber, y-oryzanol, polyphenols, vitamin E, total antioxidant activity, and free radical scavenging abilities and its GI increases. A randomized control trial that compared the effect of brown rice compared with WR on the risk factors for T2D showed significant reduction in glycosylated hemoglobin (HbA1c) in the brown rice consuming group, which was more marked in those with metabolic syndrome (MS). Improvement in total and LDL cholesterol was also seen in participants with obesity (BMI ≥ 25 kg/m2) with brown rice consumption. Thus, brown rice can be a healthier option for WR, at least in those with higher cardiometabolic risk.

Next, we looked at the effect of excess consumption of WR with an increased risk of incident T2D. The multiethnic, multinational, Prospective Urban Rural Epidemiology Study that was performed in 132,373 participants from 21 countries with a mean follow-up period of ∼9.5 y documented that higher intake of WR was associated with an increased risk of T2D, and this risk was more marked among South Asians who had the highest consumption of WR. Furthermore, it was of interest that in those who had adequate physical activity, risk of T2DM was partly mitigated even among those who consumed WR. Thus, there is increasing evidence to suggest that WR-based diets may be one of the important contributors of T2D risk in India and South Asia.

Carbohydrates, dyslipidemia, and CVD risk

In a study of 2042 adult men and women from Chennai, the association between total carbohydrate intake, dietary GL, and high-density lipoprotein cholesterol (HDL-C) was studied using a validated semiquantitative food frequency questionnaire. It was found that both total carbohydrate and dietary GL were inversely associated with lower plasma HDL-C concentration. A prominent feature of the “South Asian” or “Asian Indian phenotype” is the unique dyslipidemia with very low HDL (good) cholesterol and high serum triglycerides leading to increased CVD risk. The term MS refers to a constellation of cardiometabolic risk factors, including higher waist circumference, blood pressure, fasting blood glucose, serum triglyceride concentrations, low high-density lipoprotein cholesterol, and increased insulin resistance, which confer a higher risk of cardiovascular diseases. A significant association has been documented between high concentrations of refined grain intake and MS [odds ratio: 7.8; 95% CI: (4.7–13).

Thus, the overall picture that emerges is that high intake of dietary carbohydrate in the form of refined grains such as WR and refined wheat flour is a major contributor to risk of MS and T2D in South Asia in general, especially in India.

Proteins

As mentioned earlier, the overall intake of protein is low in India. This is further compounded by the fact that among vegetarians, the protein options are limited. Pulses and legumes are a good and probably the main source of protein for vegetarians. Consumption of pulses in India has, however, shown fluctuations over time. According to the NSSO, the monthly per capita consumption of pulses rose by 78 g (from 705 to 783 g) in rural and by 77 g (from 824 to 901 g) in urban areas between 2004 and 2005 and between 2011 and 2012. However, from then, the consumption of pulses declined to ∼38 g in 2016 due to a steady increase in prices of pulses between 2013 and the first half of 2016. The “What India Eats” study thus estimates that the energy share from pulses stood at 119 kcal/d for an urban adult and 144 kcal/d for a rural adult. By studying the data from large-scale surveys across the country, it has been estimated that, on average, disadvantaged populations and those in urban slums, tribal areas, and the sedentary rural population consumed ∼1 g of pulses/kg of body weight/day. However, 60% of the proteins come from cereals, which are relatively low in quality and digestibility. Swaminathan et al. postulated that if the dietary adequacy is assessed with regard to protein quality, about one-third of the rural population is likely to be at risk of not meeting the requirement for proteins. Using the Digestible Indispensable Amino Acid Score (DIAAS) based on true ileal digestibility, a ratio of 3:1:2.5 cereal-legume-milk composition of the diet is recommended. Increasing intake of pulses is important because a higher intake of pulses and legumes was found to be protective against risk of T2D in a prospective study. In addition, pulses and legumes do provide a good amount of dietary fiber and also contain higher amylose, both of which could further explain the lower glycemic properties of this food group, thus mitigating T2D risk.

Dairy and animal foods offer proteins of higher quality when compared to plant sources. About 78% of rural and 85% of urban households reported drinking milk in 2011–2012. In 2019, the household per capita consumption of milk was 280 mL for rural India whereas it was 402 mL for urban areas. India is currently the highest producer of milk in the world and had a per capita availability of 411 g/d in 2018 against 302 g for the rest of the world. Milk not only offers good quality protein but also increases the total dairy intake. At least 2 servings/d of milk compared with zero intake has been shown to be associated with a lower risk of MS (OR: 0.76, 95% CI: 0.71–0.80, P trend < 0.0001), hypertension (HR: 0.89; 95% CI: 0.82–0.97, P trend = 0.02), and diabetes (HR: 0.88; 95% CI: 0.76–1.02; P trend = 0.01). While studying the association of dairy products with T2D risk, we observed that there was a negative association between the consumption of milk, yogurt, buttermilk, and cheese with T2D.

In India, the annual per capita meat consumption was below 5 kg. Although 29% of rural and 38% of urban households consume eggs, only about a quarter of the households eat fish or chicken. Less than 10% of the households eat goat, meat, or beef. Cost and religious beliefs likely influence their intake. The Indian Market Research Bureau’s report (2017) on the Indian food market states that protein deficiency among Indians stands at >80%, measured against the recommended 60 g/d.

A meta-analysis of several cross-sectional studies concluded that the intake of plant-based sources of proteins (legumes, nuts, and seeds) was inversely associated with T2D (OR: 0.60; 95% CI: 0.37, 0.99), whereas animal sources of protein, especially red meat, increased the susceptibility to T2D (RR:1.19; 95% CI: 1.11, 1.28).

Fats

Fats are a high source of energy and offer great satiety value besides playing an important role in cell metabolism. However, the quantity and quality of fat in the diet are also related to risk of T2D and CVD. Over the last 30 y, even though there has been a 6% increase in the energy derived from fats, the Asian Indian diet continues to remain unbalanced in their fatty acid intake. The 2014 NSSO survey reports the monthly per capita edible oil intake to be 674 g for rural India and 853 g for urban India for the period 2010–11. Although 36% of rural households consumed refined oils, the figure was over 50% for urban areas. About 6% and 5% of rural and urban households, respectively, used margarine for cooking, whereas the rest used traditional oils such as groundnut, mustard, and gingerly oil and ghee and vegetable shortening. Fat intake and its share in energy for the Indian adult population. Fat intake of urban adults is much higher than that of rural adults, with 57% of the total intake coming from visible fat compared with ∼45% of the intake from visible fat in rural adults.

The dietary fatty acid profile and its association with T2D were assessed on a sample of 1688 adults in Chennai. The fatty acid profile of the common foods consumed was assessed through pooled food samples, and these values were substituted in the nutrient database for calculation of fatty acid and nutrient intake. Overall, a quarter of the daily calorie intake of the participants came from fats. Fried potato chips and traditional Indian sweets had the highest amounts of fat (47 g and 42 g per 100 g, respectively). Higher intake of calories from SFA and, to a lesser extent, calories from n6 PUFA, were associated with an increased risk of T2D, whereas MUFA and linolenic acid elicited a lower risk of T2D. Another study on 1875 adults reported the prevalence of MS to be higher among users of sunflower oil as compared with palmolein or groundnut oil. This risk was further compounded with a concomitant increase in the consumption of refined cereals such as WR. Although, sunflower oil is a good source of PUFA, the MUFA content of palmolein is higher as compared to sunflower oil and thereby could confer beneficial effect(s), despite containing high SFA. An earlier study by Ghosh concluded that the fatty acid composition of foods and more importantly, its degree of saturation were important influencers of risk of obesity in women from Kolkata (Eastern region of India). Gupta et al. Showed an imbalanced fatty acid profile with high total fat and SF, and inadequate intake of MUFAs and n-3 PUFAs as possible factors for risk of obesity and insulin resistance among urban Indian adolescents and young adults. However, there is no single oil with perfect fatty acid combination in the need to balance the Indian diet. Therefore, a judicious combination of cooking oils is suggested to be used to balance the dietary fatty acids in the Indian diet.

What dietary strategies can be used to mitigate risk of T2D and CVD?

Addressing, the T2D and CVD risk requires a multi-pronged approach by modifications in diet and lifestyle, health intervention, and breaking the intergenerational cycle of micronutrient deficiency during pregnancy. Deshmukh, et al. Investigated over 800 pregnancies in rural Pune (India) and reported that mothers with low maternal vitamin B12 and high folate status had offspring who became insulin resistant at 6 y of age, which contributed to the epidemic of adiposity and T2D in India. In another study, the author presents findings of how maternal obesity and diabetes were also drivers of non communicable diseases (NCDs) and that the genetic predisposition to diabetes was exacerbated by a sedentary lifestyle.

Role of the government

In response to the UN action plan on the global strategy for the prevention and control of NCDs, India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in 2010. India was among the first countries to adopt the National Action Plan with specific targets and indicators aimed at reducing the number of global premature deaths from NCDs by 25% by 2025. The strategies formulated to achieve these targets included integrated and multisectoral coordination mechanisms, health promotion, strengthening of the health system and surveillance, monitoring, evaluation, and research.

Regulatory measures to curtail the intake of highly processed foods through levying higher taxes on foods with higher fat, salt, and sugar content has been suggested as a method of preventing and controlling NCDs. Other measures include mandatory labeling on the packaged foods indicating amounts of simple sugar, total fat, SFA, transfat, dietary fiber, and sodium content. The enhanced diversity of foods in the public distribution system is another important step. However, most of the claims on the labels of food were misleading with no scientific proof. Regulations to control such misleading/false nutritional/health claims can help in improving the food environment.

The National Food Security Act was enacted in 2013, wherein 75% of the rural population and 50% of the urban population are legally entitled to receive subsidized food grains through the public distribution system. Besides this, pregnant, lactating mothers, and children aged 6 mo to 14 y, are entitled to a free meal through the Anganwadis (early childhood centers) and provision of free midday meals in schools. Despite the enhanced production, it is estimated that there is a 35%, 33%, and 43% loss of calories, digestible protein, and fat respectively across the food supply chain from the stage of cropping to residual food availability. Thus, future strategies should also address postharvest losses and improve the distribution and storage facilities of food.

The affordability of nutritious food is another major issue. Using 2011 NSSO data on price index and wage rates, it has been estimated that 63% of the rural population comprising of nearly 527 million people, cannot afford a nutritious diet even if they spent their entire earnings on food. The most expensive foods were meat, dairy items, and fruits. Measures to reduce inflation and provide subsidies so that healthier foods (for example, whole grain and pulses) are brought, under the public distribution system are desirable ways to ensure nutrition security. The introduction of agricultural remedies to correct nutritional maladies and encouraging the components of a farming system involving crops, farm animals, and wherever feasible, fish, could be made priorities. Increasing plant-based protein foods such as pulses and legumes should be a priority to be adopted by the government. One should also keep in mind that pulses are rain-fed crops and are pest prone, needing better agriculture practices. Appropriate subsidies for the cultivation of pulses and legumes could be considered. Agricultural biotechnology has aided in the development and popularization of biofortified crops (iron and zinc fortified), newer seed lines that are higher in amylose (lower in GI) that not only enhance the nutritional value especially of micronutrients, but also to combat chronic diseases such as T2D and CVD.

In 2006, the Food Safety and Standards Authority of India (FSSAI) set up an expert committee to recommend guidelines for the labeling of processed market foods as either high or low in fat, salt, and sugar. However, India has to still go a long way in generating awareness among the public on interpreting labels and in recognizing the dangers of a high salt, fat, and sugar foods, especially in the face of market forces actively promoting these unhealthy foods.

Focus on modifiable risk factors

We tried to evaluate what are the modifiable risk factors to prevent T2D. A cohort of 3589 individuals were followed up for a period of 10 y, and data were analyzed for 1376 individuals who were free of T2D at baseline. It was observed that 80.7% of incident or new -onset T2D was attributable to a combination of 5 modifiable risk factors namely obesity, physical inactivity, unhealthy diet score, hypertriglyceridaemia, and low HDL cholesterol. Modifying these risk factors could prevent a substantial number of cases of T2D in India with just diet and improved physical inactivity alone reducing the future risk of T2D by 50%. Misra et al. Have laid down guidelines for prevention of NCDs such as T2D and CVD.

Dietary guidelines for prevention of NCDs

• Reduction in the intake of total carbohydrates (reduce total calories from carbohydrates)
  
  

• Intake of complex carbohydrates [(for example, cereals (whole wheat, brown rice, etc.), millets (for example, pearl millet, finger millet etc.), pulses (red gram, green gram)]
  
  

• Higher intake of fiber
  
  

• Lower intake of saturated fats
  
  

• Reduction in trans fat
  
  

• Ensuring the optimal ratio of essential fatty acids (n3:n6)
  
  

• Reduction in added salt, sugar and fat

These guidelines were from the study of Misra et al.

Type of cereals

Understanding the effect of different types of cereals on blood glucose concentrations has been useful in identifying foods with a lower GI for effective meal planning and in preparation of exchange lists. The effect of WR, brown rice, and brown rice with legumes on the blood glucose and insulin response of individuals with overweight / obesity were studied. The mean glucose concentrations were 20% lower during a 24 h. period in the group that consumed the brown rice than the same group consumed WR. When brown rice combined with legumes, it further decreased the glycemic response to 23%. Fasting insulin concentrations were also significantly lower in the brown rice and brown rice with legumes group.

Role of millets

Although whole grain millets are undoubtedly a healthier alternate to WR, a market study of 48 brands of millets in South India, which included little, foxtail, proso, barnyard, and kodo millets revealed that they were highly polished, and had a high GI. A consumer awareness survey revealed that the respondents had no knowledge of the fact that millets could be polished like rice. Polished millets are nutritionally inferior and starchy and could contribute to an increase in the GL of diets. Conventional unpolished millets or whole grains are more nutritious in terms of higher dietary fiber, micronutrients, and phytochemicals in contrast to the WR. Thus, the inclusion of unpolished millets in daily diets should be encouraged along with the production and market supply of unpolished millets.

Role of nuts

Contrary to the common belief that nuts could lead to obesity and worsen the blood lipid profile, studies with almonds, cashew nuts, and pistachios in participants with MS, prediabetes, and T2D have shown no impact on body weight. Indeed, they show significant improvement with respect to glycemic markers (HbA1c and fasting blood glucose), lipid profile (lowers total, LDL-C, and triglyceride, increases HDL-C), and blood pressure. If the calorie substitution is done, then there is no weight gain as well. Thus, nuts could be included as part of a healthy diet for prevention and control of NCDs such as T2D and CVD.

Role of other dietary modifications

Other approaches to improve diets and reduce risk of NCDs include minimal processing of the grains, utilization of bigger particle size grits instead of finely milled flours, increasing the proportion of pulses in the meal or food products, the inclusion of soluble fiber isolates with different functional and physiological properties and inclusion of slow digesting/resistant starches in formulations. These strategies can help to prepare foods or products with lower glycemic properties. Food technologists and scientists should come together to develop products with lower GI, lower fat (by utilizing fat replacers etc.) and lower sugar and salt products, which can expand the healthier food choices and thus reduce the future risk of T2D and other NCDs.

The explosion in obesity has generated a search for a quick weight loss program resulting in the emergence of several fad diets such as the ketogenic diet with a very low carbohydrate diet (∼<50 g/d), and high fat. On the positive side, in the DiRECT Trial from the United Kingdom, individuals lost weight during the during the first 3 mo accompanied by a dramatic reduction in serum triglyceride concentrations, fatty liver, and some even “reverse” their T2D. On the negative side, such diets are not sustainable, particularly in countries where carbohydrate intake is very high. People tend to gradually increase the intake of carbohydrates and thereby regain the lost weight and their diabetes also comes back. Moreover, prolonged high intake of fat could lead to an increase in LDL cholesterol and oxidative stress, and biological aging and increased risk of CVD.

What would be an ideal macronutrient composition of diets in South East Asia?

The recent ICMR-INDIAB study has used mathematical modeling to derive the optimal macronutrient distribution for the prevention of T2D to be 49–57%E of carbohydrates, 16–20%E of protein, 20–26%E of fats, and 4–6%E from dietary fiber at -risk population-like adults with prediabetes. Admittedly, we need randomized clinical trials to prove this hypothesis, as pointed out in a commentary in the same journal.

Role of communication specialists

Understanding the barriers and facilitators to dietary and lifestyle changes faced by the target group would assist in planning more effective nutrition education/communication interventions. However, behavior change is not just an individual centric issue but is dependent on a host of social, cultural, contextual, economic factors, and policies that shape and create an enabling environment. Therefore, it is equally important to develop and communicate specific, action messages for creating stronger advocacy tools to garner family public and political support for behavior change to occur and be sustained.

Role of the family

The family plays a key role in determining the intrahousehold allocation of resources including, money, and use of household goods as well as in sharing of household responsibilities. Women play multiple roles and are engaged in unpaid family labor, childcare, and housework. On an average day, women spend ∼3 times as much time on domestic chores as men (that is, 4.7 h as against 1.7 h). Using a large international sample of individual data, it has been shown that even in developed countries of the European Union, women are more likely than men to experience food insecurity. In over two-thirds of the households, women are the last members of the family to eat. In many countries such as India, men are the breadwinners of the family, and hence, there is a perception that they deserve a larger share of food. This is particularly true among poor and vulnerable households, where men are given preference in terms of food quantity, eating order, and consumption of special foods–at the cost of the women’s consumption of these foods. Fortunately, this trend is changing and women are nowadays eating along with other family members. However, the mindset that women must sacrifice their food intake for the sake of other family members continues to be rampant in some communities. These food taboos and unequal access to food within a household can have a negative effect on the health and wellbeing of women. Therefore, sensitizing family members to the need for providing support to women is an important strategy at the community level. Women can also play an essential role in maintaining the health of the family and community because of their innate role as care-takers of the family.

In conclusion, there is an exponential increase in the number of people affected by T2D in south Asia in general, especially in India. Poor quality of diet with excess carbohydrate from refined grains, deficiency of good quality protein, excess of unhealthy fat, and low dietary fiber along with a decrease in physical activity are some of the drivers of the T2D epidemic. It is time for multiple stake holders to come together to tackle the epidemic of T2D, and in this effort, providing healthier diets with lower carbohydrates and higher protein and fiber content along with healthy fats would be one of the most important steps. The time to act is now!