Rural diets under pressure: food environments and their influence on diets in South Asia

Unhealthy food consumption is rising in rural South Asia, yet food environments in the region remain understudied. To address this gap, we characterised rural food environments and assessed how food affordability, accessibility, availability and desirability are associated with dietary patterns and quality in Bangladesh, India and Nepal. We used household (n 9711) and market (n 1646) data from the Transforming Agrifood Systems in South Asia (TAFSSA) survey conducted in five rural districts in 2023: Nalanda (India), Surkhet and Banke (Nepal) and Rangpur and Rajshahi (Bangladesh). Participants included adult women, men and adolescents. Primary outcomes included weekly consumption of twenty-five food items and Global Diet Quality Scores (GDQS): GDQS plus (0-32) and GDQS minus (0-17). Predictors included proximity to markets, food prices, vendor density, food availability and exposure to advertising or nutrition messaging. Multivariate regressions were used to assess associations and were adjusted for sociodemographic and household characteristics. Diets in these settings were characterised by low healthy food intake (GDQS plus scores ranged from 6·6 to 7·7) and high unhealthy food intake (GDQS minus scores from 9·3 to 11·7). Ultra-processed food vendors were present in > 80 % of villages. Snacking was the strongest predictor of both higher healthy (+1·11 GDQS plus) and unhealthy (-0·67 GDQS minus) food intake (P < 0·001), indicating that snacking increases overall dietary intake. Key predictors of suboptimal diets include low affordability of nutritious foods, alongside the widespread availability and desirability of inexpensive ultra-processed products. These findings highlight structural and behavioural drivers of rural dietary transitions and provide evidence to guide food system interventions aimed at improving nutrition in underserved populations.