The study's findings carry direct implications for disease patterns already emerging in South India. The region already reports India's highest diabetes prevalence, with urban areas in some cities exceeding 20%.
Published Oct 04, 2025 | 7:00 AM ⚊ Updated Oct 04, 2025 | 7:00 AM
Eggs, meat, fish and poultry are part of the diverse and traditional diet of the majority in the state.
Synopsis: A multisectoral approach involving healthcare, agriculture, and socioeconomic policy is crucial for fostering healthier diets and lowering NCD risk in India. Because healthcare is a state government responsibility in India, the study’s findings are vital for helping states to enhance their PDS plans and to promote subsidies that prevent NCDs.
A national nutrition survey revealed a pattern that public health officials had not anticipated: South Indian states consume dangerously low levels of protein while simultaneously experiencing surges in added sugar intake that rival the nation’s most urbanised metros.
The Indian Council of Medical Research (ICMR)-INDIAB study analysed dietary patterns of over 18,000 adults across all 28 Indian states and Union Territories, documenting nutritional imbalances in a region that has invested heavily in healthcare infrastructure.
Kerala recorded the nation’s lowest protein intake at just 10.5% of total energy consumption—a figure that fell below the recommended 15-20%.
Kerala presented a complex nutritional picture, revealing that the state’s protein intake comprises merely 5.7% plant protein—also the lowest nationally—1.7% dairy protein, and 1.3% animal protein.
Protein builds and repairs body tissues, muscles, and organs, and intake below 15-20% of total energy leads to muscle loss, impaired growth in children, and increased risk of malnutrition.
The data from Kerala becomes more striking when examined against its geography. Despite having a 590-kilometer coastline, the state’s omega-3 fatty acid intake was just 0.1%—the lowest in South India. Fish protein contributed a mere 0.7% to the state’s diet, while eggs accounted for just 0.1%, poultry 0.1%, and red meat 0.2%.
Fish protein delivers high-quality amino acids along with omega-3 fatty acids that reduce inflammation and support heart and brain health, making it superior to most other protein sources.
Whereas, Omega-3 fatty acids reduce inflammation, support brain function, and protect against heart disease, with deficiency linked to increased cardiovascular risk and inflammatory conditions.
Omega-6 fatty acids support growth and brain function, but excessive intake relative to omega-3 ratios above 4:1 promotes inflammation and increases the risk of chronic diseases.
The study found Kerala’s omega-6 intake at 7.4%, creating an omega-6 to omega-3 ratio of approximately 74:1, far exceeding the recommended 4:1 ratio.
Karnataka maintained its position as the country’s millet champion, with 10.4% of energy derived from whole millets—the highest in India. It reflected a successful retention of traditional dietary practices.
However, the state also recorded 10.4% of total energy intake from added sugars, tying it with Delhi for the third-highest in the nation, behind Haryana’s 11.0%, and Odisha’s 10.7%
Karnataka presented a complex nutritional picture. While the state successfully retained traditional millet consumption—consuming 10.0% of energy from milled whole wheat and 10.4% from milled whole millets—it simultaneously showed added sugar penetration matching Delhi’s urbanisation levels, likely driven by Bangalore’s rapid IT sector growth and cafe culture.
The state’s added sugar consumption was 2.5 times the national average of 4.2%, placing it ahead of other South Indian states: Puducherry at 9.5%, Kerala at 7.5%, Andhra Pradesh at 7.4%, and Tamil Nadu at 4.8%.
Karnataka’s overall protein intake was just 11.5%—comprising 8.1% plant protein, 2.1% dairy protein, and 0.8% animal protein. Approximately 76% of the state’s energy intake is derived from carbohydrates, despite having India’s best whole grain diversity.
The state’s total fat intake of 23.0% marked the lowest in South India, with saturated fat at 9.5%, monounsaturated fat at 5.0%, and polyunsaturated fat at 6.9%. Karnataka’s fish protein intake was a mere 0.2% despite portions of the state having coastal access, while egg protein registered 0.1%, poultry 0.4%, and red meat 0.1%.
Fat provides energy, helps absorb vitamins, and supports cell function, with optimal intake between 20-35% of energy—too low impairs vitamin absorption while too high increases obesity risk.
The survey’s findings on fish consumption revealed a pattern that contradicted assumptions about coastal access: South Indian coastal states performed far below landlocked Northeastern states in omega-3 intake.
Andhra Pradesh, with its 974-kilometer coastline, recorded 0.0% fish protein in the diet. Tamil Nadu managed only 0.3% fish protein, while Puducherry recorded 0.5%.
Compare this to landlocked Manipur’s 1.5% fish protein and 0.9% omega-3 intake—4.5 times the national average. Meghalaya, another landlocked state, recorded 1.1% fish protein and 0.4% omega-3, exceeding its coastal southern counterparts.
The omega-3 paradox—where landlocked Manipur and Meghalaya vastly outperformed coastal Andhra Pradesh, Kerala, and Tamil Nadu—represented a policy and cultural failure of monumental proportions.
Northeastern states dominated omega-3 consumption: Manipur and Nagaland both recorded 0.9%, Mizoram 0.5%, Meghalaya 0.4%, and Arunachal Pradesh 0.3%. These figures stemmed from traditional freshwater fish consumption and fermented fish preservation practices.
In contrast, coastal South Indian states, Kerala recorded 0.1%, Andhra Pradesh 0.2%, Tamil Nadu 0.2%, Karnataka 0.2%, and Puducherry 0.2%.
Andhra Pradesh recorded the highest saturated fat intake in India at 15.3% of total energy, 53% above the WHO-recommended maximum of 10%.
Andhra Pradesh’s complete fat profile: total fat 26.6%, saturated fat 15.3%, monounsaturated fat 5.9%, total polyunsaturated fat 7.9%, omega-6 at 7.4%, and omega-3 at 0.2%. This profile exceeded other South Indian states’ saturated fat levels: Tamil Nadu (7.4%—lowest in South), Kerala (9.0%), Karnataka (9.5%), and Puducherry (9.0%).
Nationally, only Rajasthan approached Andhra Pradesh’s saturated fat levels at 13.9%, followed by Punjab (11.5%), Delhi (11.5%), and Haryana (11.3%). These northern states’ high saturated fat intake stemmed from dairy-heavy diets, whereas Andhra Pradesh’s derived from cooking practices involving heavy ghee and coconut oil use, plus deep-frying traditions.
The combination in Andhra Pradesh of 15.3% saturated fat, 38.4% refined cereals, and 11.5% protein created what nutritionists described as a ‘triple threat’ for cardiovascular disease, diabetes, and malnutrition.
Andhra Pradesh’s total protein intake stood at 11.5%, comprising 7.2% plant protein—second lowest in South India—2.4% dairy protein, and 0.7% animal protein. The state recorded fish protein at 0.0% despite its extensive coastline, poultry at 0.4%, eggs at 0.2%, and red meat at 0.1%.
Tamil Nadu presented a different pattern among South Indian states. While its protein intake of 11.9% remained below optimal levels, it recorded the lowest added sugar consumption in the region at just 4.8%—below Karnataka’s 10.4% and even below the national average of 4.2%.
The state’s protein profile showed 8.1% plant protein, 2.0% dairy protein, and 0.9% animal protein. Tamil Nadu recorded the highest egg protein consumption in South India at 0.3%, along with 0.3% fish protein, 0.3% poultry, and 0.1% red meat.
However, Tamil Nadu’s reliance on refined cereals created problems, with 51.5% of energy coming from refined sources, primarily white rice at 47.3%—the highest white rice consumption in South India.
Tamil Nadu’s low added-sugar consumption relative to its urbanization suggested either continued adherence to traditional dietary patterns or possible use of jaggery not captured as “added sugar” in the study’s methodology.
Puducherry recorded 11.8% total protein, comprising 8.0% plant protein, 1.5% dairy protein—lowest in South India—and 1.2% animal protein—highest in South India. The Union Territory showed fish at 0.5%, poultry at 0.3%, red meat at 0.2%, but eggs at 0.0%.
Puducherry’s added-sugar intake stood at 9.5%, making it the second highest in South India after Karnataka.
The Union Territory demonstrated the region’s most balanced fat profile: 25.4% total fat (highest in South), 9.0% saturated, 7.0% monounsaturated (highest in South), 9.0% polyunsaturated (highest in South), 8.5% omega-6, and 0.2% omega-3.
The protein crisis extended uniformly across all South Indian states, with every state in the region falling below 12% protein intake. The rankings within South India: Tamil Nadu led with 11.9%, followed by Puducherry at 11.8%, Karnataka and Andhra Pradesh tied at 11.5%, and Kerala at 10.5%.
By comparison, India’s northeastern region averaged 13.6%, with Nagaland leading nationally at 17.6%—comprising 7.7% plant protein, 1.5% dairy protein, and 7.4% animal protein, including 4.2% red meat and 1.0% fish. Mizoram followed at 16.0% (6.8% plant, 6.9% animal), Meghalaya at 14.3% (7.9% plant, 4.9% animal), and Manipur at 14.2% (9.3% plant, 3.1% animal).
The gap between South India’s lowest performer (Kerala at 10.5%) and the national leader (Nagaland at 17.6%) represented a 67% difference—Nagaland consumed 7.1 percentage points more protein than Kerala.
Notably, northeastern states maintained low added sugar despite high protein: Mizoram 1.5%, Manipur 1.3%, Tripura 1.8%, Sikkim 1.9%—reflecting minimal processed food penetration.
South India’s refined cereal consumption added another dimension to the crisis: Tamil Nadu 51.5% (white rice 47.3%), Kerala 42.5% (white rice 39.5%), Andhra Pradesh 38.4% (white rice 35.8%), Puducherry 36.0% (white rice 33.6%), Karnataka 25.8% (white rice 23.8%).
The national average stood at 28.5% refined cereals, 16.2% white rice.
Karnataka’s 25.8% refined cereals, while the lowest in South India, still contributed to metabolic risk when considered alongside its 10.4% sugar.
The study’s findings carry direct implications for disease patterns already emerging in South India. The region already reports India’s highest diabetes prevalence, with urban areas in some cities exceeding 20%.
“Using nationally representative data, we report high intakes (62.3%) of low-quality carbohydrates (refined cereals like white rice, milled whole grains, and added sugar) and saturated fat, and low protein intake,” the authors stated.
“Carbohydrate intake, regardless of grain type, was associated with a 14–30% higher metabolic risk.”
The study found that replacing refined cereals with whole wheat or millet flour did not associate with a lower risk. “However, replacing 5%E from carbohydrates with 5%E from plant, dairy, egg, or fish protein was associated with lower risk of newly diagnosed T2D and prediabetes, while replacement with fat of any subtype did not change risk,” the researchers report.
Carbohydrates supply the body’s primary energy source, but high intake above 55-60% of energy—especially from refined sources like white rice—increases risk of diabetes and metabolic disorders.
The findings challenged assumptions about whole grain benefits in the Indian context.
“In India, most whole grains are consumed as milled flour for flatbreads such as chapati and roti. Milling lowers the particle size of whole wheat and increases its glycemic index to the extent that the glycemic response becomes similar to that of refined wheat products and white rice,” the study explained.
“Given minimal intake of intact whole grains (brown rice, whole wheat and whole millets), public health recommendations should focus on lowering total carbohydrate intake from both refined and milled whole grains, which are the country’s primary cereal staples,” the authors recommended.
The research demonstrated that protein substitution produced measurable benefits. “Replacing carbohydrates with protein from plant sources, dairy, eggs, or fish was associated with lower T2D risk, unlike western studies where animal protein was associated with a higher T2D risk,” the study found. “This likely reflects the predominance of plant protein in Indian diets.”
The study specified that protein quality matters. “In our study, protein from pulses and legumes, but not cereals, was associated with a lower risk of T2D. Replacing rapidly digested carbohydrates (refined grains) with legume protein may improve glycemic control and lower the overall glycemic index of the diet, while also addressing protein deficiencies,” the researchers stated.
“Although literature surrounding dairy and egg consumption and metabolic risk has been inconsistent, replacing low-quality carbohydrates with dairy, egg, or fish can mitigate metabolic risk in the Asian Indian population due to high-carbohydrate intakes and low protein intakes. In fact, low yogurt intake alone accounts for 13% of South Asia’s T2D burden,” the study noted.
The researchers called for fundamental restructuring of India’s food subsidy and agricultural support systems.
“Based on our findings, national guidelines and policy changes should emphasize reduced consumption of refined carbohydrates and saturated fat, and recommend increased consumption of protein, primarily from plant and dairy sources,” the authors urged. “Public health messaging should highlight practical strategies such as gradually increasing the ratio of pulses, legumes, and dairy in the diet to achieve a desirable macronutrient composition for NCD prevention.”
The study targeted the Public Distribution System directly. “Widespread reliance on subsidized rice and wheat likely drives high cereal intake, highlighting the need to prioritize pulses and legumes in subsidy programs over refined cereals. Subsidies through the PDS should emphasize healthier protein sources (pulses and legumes) and healthier edible oils (low in saturated fat) over refined grains like white rice,” the researchers argued.
“Minimum support prices for cereals, if extended to pulses, legumes, and dairy, can improve both the quality and the quantity of protein consumed,” they added.
For saturated fat reduction, particularly critical in Andhra Pradesh, the study recommended policy shifts. “Saturated fat intake also exceeds recommendations in many states, likely due to high intakes of ghee (clarified butter) in the North and the use of subsidized palm oil and coconut oil in the South. In addition, palmolein, due to its lower cost compared to other vegetable oils, is widely used in the food industry and in processed foods. Policies should shift toward the provision of healthier oils through the public distribution system (PDS) and raising consumer awareness to support healthier choices,” they stated.
The study addressed Karnataka’s added sugar crisis: “Excess added sugar further endangers public health, and current tax rates on carbonated drinks have not reduced consumption, suggesting the need for alternative strategies.”
The authors concluded: “A multisectoral approach involving healthcare, agriculture, and socioeconomic policy is crucial for fostering healthier diets and lowering NCD risk in India. Because healthcare is a state government responsibility in India, the study’s findings are vital for helping states to enhance their PDS plans and to promote subsidies that prevent NCDs.”
(Edited by Majnu Babu).
