Similarly, grains and meat products are of interest, in regards to whether whole grains and refined grains, or unprocessed red meats, processed meats, and poultry should be distinguished.
Existing studies of the Mediterranean diet have used varying definitions of the diet and found associations of adherence to the diet with different health outcomes. However, none of them has fully examined the traditional Mediterranean diet, reflecting the difficulty of attempting to use a simple definition to describe dietary behavior which is inherently complex.
Future research should, therefore, aim to amalgamate existing definitions of the Mediterranean diet with up-to-date scientific evidence of health outcomes associated with individual components. Furthermore, the Mediterranean diet is essentially part of a lifestyle, requiring the simultaneous consideration of other non-dietary behavioral factors when assessing its effects.
What the Mediterranean diet, therefore, means in the context of some countries with distinct cultural diets and lifestyles, such as for instance in China, India, and parts of Africa, needs further research and thought, despite the fair amount of evidence among the Western and, particularly, Mediterranean countries. Shweta Khandelwal, Dorairaj Prabhakaran Figures 6 and 7. She is a trained public health nutritionist and her current research is focused on exploring the role of omega-3 fatty acids on cardiovascular disease risk factors among the Indian population.
Dorairaj Prabhakaran is a cardiologist and epidemiologist by training. His research work spans from mechanistic research to understand the causes of the increased propensity of cardiovascular diseases among Indians to developing potential solutions for CVDs through translational research and human resource development. Several publications report the cardio-protective benefits conferred by this dietary pattern [ 15 , 59 — 63 ].
However, the applicability and suitability of the Mediterranean diet in the Indian context have not been studied previously. Furthermore, it is well known that Indians have a higher risk of developing diabetes and cardiovascular disease CVD than other populations [ 66 , 67 ]. Although the reasons for this are unclear, diet could play a major role. In this regard it is attractive to speculate that the Mediterranean diet may exert a protective role. Here, we discuss the constituents of the Indian diet that are similar to the Mediterranean diet, and evaluate the potential of adapting the Mediterranean diet to an Indian context.
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 [ 68 — 70 ]. 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. Even rice bran oil has been shown to have hypolipidemic effects [ 71 , 78 , 89 ]. 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 [ 90 , 91 ].
The Mediterranean Diet: Constituents and Health Promotion: Medicine & Health Science Books @ compcommanalporth.gq The Mediterranean Diet: Constituents and Health Promotion explores in detail the relationship among the Mediterranean Diet, nutritional status, and disease.
High consumption of fresh fruit and vegetables is a principal characteristic of the Mediterranean diet. A number of studies have reported a declining fruit and vegetable consumption pattern in different Indian populations [ 68 , 84 , 87 , 88 ]. The most documented reasons for sub-optimal consumption involve affordability, awareness and access issues [ 93 ]. India can learn from some of the successful strategies to increase consumption in other countries [ 92 , 94 ]. Most of the evidence supports starting early and using multi-component interventions for increasing fruit and vegetable intake [ 95 , 96 ].
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 [ 97 ]. Key to the Mediterranean diet, consumption of legumes may be associated with a reduced risk of coronary heart disease CHD [ 98 , 99 ]. 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 [ 77 ].
Per capita availability of legumes in India has decreased from 60 g in to 38 g in , a reduction of nearly 40 per cent [ ].
On the other hand, the per capita availability of cereal and millets has increased from g to g in spite of a four-fold increase in population. The cereal-to-pulse ratio, which should be ideally , has risen from to [ 99 ]. Even though pulses production increased by 3.
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. 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 [ 80 — 82 ]. 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.
While moderate wine consumption is typical in those consuming a Mediterranean diet, 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.
References Alsaffar AA. Mediterranean diet and age-related cognitive decline: a randomized clinical trial. Observational-longitudinal [ 1 , 32 , 36 ], randomized controlled trial [ 30 ]. Mediterranean diet for primary prevention of cardiovascular disease. More recently, Yang et al.
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, 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. 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. The emphasized need for a higher quantity and quality of nutrition studies becomes even more relevant because nutrition research in India is still very nascent. Further, the commonly employed dietary data collection methods in Indian studies are not well standardized and contain self-reported information.
These limitations further prevent high quality evidence building in the field of nutrition research. Indians are already known to have higher cardiovascular disease risk than other populations [ 66 , , ]. Since unhealthy diet exacerbates the already high cardiovascular risk profile, well-designed nutritional epidemiological studies are warranted in the Indian population.
Successful dietary interventions need to be adapted, particularly for dietary patterns rather than isolated nutrients, and tested in Indian settings for comparison with available global evidence.