An Indian perspective of Mediterranean diet

To have an indian perspective of Mediterranean diet we’ve to read the research of Shweta Khandelwal is currently working as a Research Scientist and Adjunct Assistant Professor at the PHFI, New Delhi. (a trained public health nutritionist) and Dorairaj Prabhakaran (ardiologist and epidemiologist by training).

Several publications report the cardio-protective benefits conferred by this dietary pattern, however, the applicability and suitability of the Mediterranean diet in the Indian context have not been studied previously.

India is in the midst of a ‘nutrition transition’, where changes in diet parallel an expanding industrial economy and a rapidly progressing epidemic of obesity and non-communicable diseases, particularly in urban locations. Furthermore, it is well known that Indians have a higher risk of developing diabetes and cardiovascular disease (CVD) than other populations. Although the reasons for this are unclear, diet could play a major role.  By and large, a typical Indian diet is rich in carbohydrates (largely refined cereals), low quality proteins (largely from legumes), rich gravies (high in saturated fats and salt) and has low levels of fresh fruits and vegetables. The overall meat consumption is not very high, even among those who report non-vegetarian food consumption.

Summary of the Mediterranean and Indian diet

In India, cooking oils vary considerably depending upon the region. However, some mono unsaturated fatty acid-rich oils in India similar to olive oil include ground nut oil, rice bran oil and mustard oil. There is not much evidence on the cardio-protective effects of oils used in Indian cooking. However, some studies suggest that mustard oil conferred about 50% lower risk reduction for ischemic heart disease among the Indian population. Even rice bran oil has been shown to have hypolipidemic effects, Further evidence on long term usage of these oils on cardiovascular health from good quality longitudinal studies is warranted. Olive oil has not gained huge popularity in India until now as a result of its cost, as well as its unsuitability for Indian frying conditions. However, recent subsidies provided by the Agricultural Ministry for olive cultivation confirm the increasing interest and the rising demand among Indians for olive oil.

An Indian perspective of Mediterranean diet: components


Although India is the second largest producer of fruits and vegetables in the world (annual production of 94 million tons), the consumption per capita is quite low and has steadily declined in the last 50 years (120 to 140 g/day) . A number of studies have reported a declining fruit and vegetable consumption pattern in different Indian populations. The most documented reasons for sub-optimal consumption involve affordability, awareness and access issues . India can learn from some of the successful strategies to increase consumption in other countries. Most of the evidence supports starting early and using multi-component interventions for increasing fruit and vegetable intake. Inexpensive, culturally-acceptable and feasible interventions for boosting the fruit and vegetable consumption must be piloted and scaled up if successful. Policy interventions, such as subsidies on growing and storing fruits and vegetables, can offer sustainable solutions for enhancing consumption among developing countries such as India.

Key to the Mediterranean diet, consumption of legumes may be associated with a reduced risk of coronary heart disease (CHD). Legumes are high in bean protein and water-soluble fiber, and are a good source of proteins, vitamins, minerals, omega-3 fatty acids and non-starch polysaccharides. Per capita availability of legumes in India has decreased from 60 g in 1950 to 38 g in 1990, a reduction of nearly 40 per cent. On the other hand, the per capita availability of cereal and millets has increased from 330 g to 470 g in spite of a four-fold increase in population. The cereal-to-pulse ratio, which should be ideally 8:1, has risen from 6:1 to 12:1. Even though pulses production increased by 3.35% per year during the last decade, the cost of production and consequent prices are too high to be affordable to many people; to increase production at lower cost is a bigger challenge. Experts suggest that technological efforts need to be supported by the right policy environment to leverage research and development in agriculture.

Another important item in the Mediterranean diet is fish, which owes its heart-healthy attribute largely to the long chain omega 3 fatty acids (n-3) . While fish is widely consumed in the Mediterranean diet, consumption in India varies considerably depending on the region. Studies indicate that irrespective of the fish eating behavior, the plasma and erythrocyte levels of n-3 are usually very low across the Indian population. This may be because the consumption of n-3 rich foods is not frequent and when subjected to intense cooking methods, even the small available amounts get nearly eliminated. Several studies from other parts of the world have also looked at supplementation with n-3 as an isolated nutrient versus whole fish consumption. The latter seemed to offer better cardiovascular health benefits. This may be because of additional protective constituents (such as fiber, protein, minerals and so on) or their synergistic effect in fatty fish as a whole.

An Indian perspective of Mediterranean diet: risks


Indian diets also have some alternative sources of n-3, such as mustard oil, some nuts and flaxseeds. However, these sources usually contain the shorter chain n-3, which need to get converted in vivo to their longer chain counterparts to offer a similar cardio-protective role. This conversion (dependent on the elongase and desaturase enzymes) is usually limited due to an excess of omega-6 fats (which compete for the same enzymes) in Indian diets]. However, a few studies in India have shown a modest beneficial impact especially on lipid profiles of adults when their diets were supplemented with flaxseeds and mustard oil.

In terms of whole grains, Indian diets are rapidly transitioning. The traditional home cooked meals consisting largely of coarse grains and whole cereals are now replaced by cheaper refined versions. The latter are devoid of the fiber and other healthier components of complex carbohydrates. Recent studies in India have established strong positive associations between refined grain intake and type 2 diabetes, and confirm the protective effect of fiber, which is contained in whole grains . Carbohydrates are integral to Asian Indian dietary traditions and re-introduction of culturally acceptable, traditional, carbohydrate-rich grains with high nutrient density may be a prudent step in reducing disease burden in this population.

Indians are usually characterized as binge drinkers, largely consuming whisky or beer, in contrast to everyday wine consumers from western and European countries. The pattern of consumption also varies; in India people usually consume alcohol before meals while in other countries, it is consumed along with meals.  The differential preference in the type of alcohol and pattern of drinking seem to reverse the cardio-protective effect conferred by small-moderate quantities of everyday wine consumption in other populations. Longitudinal data evaluating the role of alcohol in CVD risk among Indians are currently unavailable but urgently warranted.

Processed red meat is associated with a higher CVD risk profile. While red meat consumption is generally low in those adopting a Mediterranean dietary pattern, the UN Food and Agriculture Organization (FAO, 2007) reported Indians’ per capita annual consumption of meat is rising. Although the consumption statistics are still lower than the global average (Indian per capita annual consumption is about 5 to 5.5 kilograms or 11 to 12 pounds; and for the rest of the world, it is about 38 kilograms or 83.7 pounds), the steady rise in meat consumption among Indians reflects changing dietary preferences. Religion, and to some extent income, dominates the meat consumption pattern in India. While Hindus avoid beef, Muslims shun pork among the non-vegetarian populations in India. Longitudinal data from studies assessing the association between red meat consumption in India and CVD outcomes are needed.

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