|Year : 2021 | Volume
| Issue : 1 | Page : 24-30
Beneficial effects of Indo-Mediterranean type of diets, for double burden of diseases
Ram Bir Singh1, Shaw Watanabe2, Adrian Isaza3, Saibal Chakravorty4, Ghizal Fatima5, Vikas Patel6
1 Department of Medicine, Halberg Hospital and Research Institute, Moradabad, Uttar Pradesh, India
2 Department of Medicine, Life Science Association, Tokyo, Japan
3 Department of Cardiology, Everglades University, Tampa, FL, USA
4 Department of Medicine, Metro Group of Hospitals, Noida, Uttar Pradesh, India
5 Department of Biochemistry, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
6 Department of Research, Metro Group of Hospitals, Noida, Uttar Pradesh, India
|Date of Submission||31-Jan-2022|
|Date of Decision||01-Feb-2022|
|Date of Acceptance||01-Feb-2022|
|Date of Web Publication||13-Apr-2022|
Prof. Ram Bir Singh
Halberg Hospital and Research Institute, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The concept of Indo-Mediterranean type of diets was developed by Singh et al. based on Indian Experiment of Infarct Survival published in 1992, which was confirmed by a landmark study from France by De Lorgeril et al., who demonstrated that eating alpha-linolenic acid rich Mediterranean style diet can cause significant decline in mortality and cardiovascular diseases (CVDs). Recently, PREDIMED study from Spain also reported that a modified Mediterranean style diet can cause significant decline in CVDs, type 2 diabetes mellitus (T2DM), and cancer. It seems that Indo-Mediterranean diet is superior to Mediterranean diet as well as dietary advice to stop hypertension (DASH) diet because it contains millets, porridge and spices; turmeric, cumin, cinnamon and coriander, etc., These foods are rich sources of polyphenolics and flavonoids, calcium and iron as well as proteins which are useful in the prevention of double burden of diseases. It is possible that Mediterranean style diet and DASH diets have similar influence on coronary risk factors and CVDs and all-cause mortality. However, Indo-Mediterranean style diet may have additional protective effects due to improved food diversity and lower glycemic index as well as palatability.
Keywords: Diabetes, dietary advice to stop hypertension diet, fruits, hypertension, Mediterranean diet, vegetables
|How to cite this article:|
Singh RB, Watanabe S, Isaza A, Chakravorty S, Fatima G, Patel V. Beneficial effects of Indo-Mediterranean type of diets, for double burden of diseases. J Intern Med India 2021;15:24-30
|How to cite this URL:|
Singh RB, Watanabe S, Isaza A, Chakravorty S, Fatima G, Patel V. Beneficial effects of Indo-Mediterranean type of diets, for double burden of diseases. J Intern Med India [serial online] 2021 [cited 2023 Mar 24];15:24-30. Available from: http://www.upjimi.com/text.asp?2021/15/1/24/343034
| Introduction|| |
The concept of Indo-Mediterranean type of diets was developed by Singh et al. based on Indian Experiment of Infarct Survival published for the first time in 1992.,, This concept was confirmed by a landmark study from France by De Lorgeril et al., who demonstrated that eating alpha-linolenic acid rich Mediterranean style diet can cause significant decline in mortality and cardiovascular diseases (CVDs). Most of the high-quality diets are characterized with unrefined, unprocessed or minimally processed foods, such as whole grains, vegetables, nuts and fruits, healthy vegetable oils; mustard or canola oil, rape seed oil or olive oil and healthy sources of proteins; pulses, beans, cottage cheese, white meats; chicken, fish and other sea foods.,,, These foods are also recommended in the Mediterranean style diets. Indo-Mediterranean style diets differs because it has more of whole grains; in particular, millets, porridge, green beans and a variety of healthy spices such as cumin, turmeric, coriander, cinnamon, black peppers, clove, etc., It is possible that this diet can prevent the double burden of diseases due to undernutrition as well as over-nutrition.
There are marked alterations in the dietary guidelines over the recent few years as research became more accurate in determining what we should eat to attain optimal health and body weight in particular waist circumference.,,,, The potential evidence to date indicate that calories have tremendous role, however, focusing on quality of foods is equally important for prevention of weight gain and for promoting weight loss, due to various qualities of foods.,,,, (Diets for a better future. https://eatforum.org/knowledge/diets-for-a-better-future/file:///D:/Users/A/Downloads/200717-Diets-for-a-Better-Future_G20_National-Dietary-Guidelines.pdf accessed Feb 1, 2022.). This review aims to high light the role of the Indo-Mediterranean style diets which may be determinant of beneficial effects of this high quality diet, compared to Mediterranean diets or dietary advice to stop hypertension (DASH) diet.
| National Dietary Guidelines and Health|| |
The National Dietary Guidelines of most countries follow either WHO guidelines or American Heart Association Guidelines on dietary intakes for prevention of diseases and for health promotion. Most health agencies including WHO advise that in a healthy diet, should contain, approximately 30 percent of total daily calories from healthy fat such as rape seed or mustard or canola or olive oil.,,,,,, This means that consuming about 50–80 g of fat each day which provides the body, energy as well as fatty acids for metabolic demand of the body tissues. The body utilizes only about 10% of fat into glucose and rest is used as fatty acids in the tissues for physiological and metabolic and functions. If the fat content specially saturated fat is more than 10% of calories, it may deposit in the adipocytes, liver, brain, heart, and all other organs resulting in to metabolic syndrome.,,, Some guidelines have advised lower intake of fat among Asians, because it varies between 15% and 25% in the traditional diets and Japanese, has the longest life expectancy., The consumption of fat is also lower among Chinese, Koreans, and South Asians, without any evidence of undernutrition.,, The guidelines for limits of body mass index and waist girth for obesity and central obesity, respectively, are also lower for Asians. Therefore, it is logical that guideline for fatty acid intake is lower for Asians., In view of these observations, food-based guidelines have been proposed by most of the agencies.,,
The U.S. Dietary Guidelines recommend the limit the consumption of saturated fatty acids (SFA) to <10% of calories to prevent diseases and for health promotion. The quality of SFA has different biologic effects, which is further modified by the food matrix and the carbohydrate content of the diet. There is evidence that certain foods relatively rich in SFAs, such as dark chocolate and whole-fat dairy, dark chocolate, and unprocessed meat, may not be associated with increased risk of CVD or type 2 diabetes mellitus (T2DM), possibly due to food diversity in such diets.,,, It seems that there is no landmark evidence that current population-wide arbitrary upper limits on saturated fat intake in the diets will prevent CVD or reduce mortality. However, a large body of evidence from cohort studies and clinical trials has demonstrated that the quality of diets may be responsible for half of the deaths in world.,, All the clinical trials published in the last three decades, using Mediterranean style diets have reported a significant decline in cardiovascular events and all causes of mortality.,,
| Why Indo-Mediterranean Style Diet is Superior than Other Diets|| |
After publication of the Indian experiment on role of Indo-Mediterranean type of diets (1992) and Lyon Heart study in 1994, several experts became advocate of these types of diets which are rich in vegetables, fruits, nuts, and whole grains with vegetable oils and low in red meats and eggs.,,,,, All the guidelines advise against use of preserve meats, because majority of the studies reported increased risk of CVDs, T2DM, and cancer.,, An Indo-Mediterranean diet rich in high quality functional foods; millets, spices, guava fruits, mustard oil is also high in nutrient density with high food diversity and low glycemic index (GI). It has lower saturated fat and total fat, salt, and sugar but high omega-3 and flavonoids and other nitric oxide activating foods which may be protective against CVDs as well as other NCDs.,,,,,,,,,, A meta-analysis of studies relating to three randomized, controlled single blind trials on the role Indo-Mediterranean style foods and nutrients in the prevention of CVDs including heart failure has also been published. These studies compared the intervention and control groups; for behavioral risk factors, food intakes, fatty acid intake and ratio of polyunsaturated fatty acid (PUFA)/flavonoid intake, respectively, in the two groups (n = 1446 vs. 1320). The findings showed marked beneficial effects of Indo-Mediterranean style foods and nutrients, on heart failure and arrhythmias, almost similar to the Mediterranean diets. Indo-Mediterranean diet also included fish intake (100–150 g twice weekly) for nonvegetarians which has been found to reduce all-cause mortality. Fruits and vegetable are rich sources of potassium, magnesium and fiber whereas whole grains such as beans and millets are rich in fiber, protein, polyphenolics and flavonoids, magnesium, calcium, iron and folic acid. These nutrients can take care of the double burden of diseases. A large body of evidence has shown that a diet rich in healthy plant based foods and with fewer animal source foods; fish other sea foods and poultry; up to five servings of animal source foods per week, can confer both improved health and environmental benefits. Some experts believe that diet used in the DASH study may be superior to conventional Mediterranean diet.,, The differences in the three styles of diet are given in [Table 1].
|Table 1: Comparison of Indo-Mediterranean diet with other scientific diets|
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The DASH diet is rich in vegetables, fruits, and low-fat dairy products; contains whole grains, fish, poultry, and nuts; and limits saturated fat, red meat, sweets, and sugar-containing beverages. The DASH diet is comprised of lower amounts of total and saturated fat, and cholesterol while providing higher amounts of potassium, magnesium, calcium, fiber, and protein. Despite minor differences between DASH diet and Mediterranean diets, some studies have investigated other beneficial effects of this dietary pattern such as reducing insulin resistance and controlling fasting blood glucose and lipid profiles suggesting this dietary pattern, may also be useful for the prevention of CVDs and lipid profile., The traditional Mediterranean style diets focuses on a high intake of olive oil, fruits, nuts, vegetables, and grains; moderate intake of fish and poultry; low intake of dairy products, red meat, processed meat, and sweets; and moderate consumption of wine.,,, Randomized, controlled trials have found that increased adherence to the Mediterranean style diets resulted in a positive effect on CVD's risk and mortality.,
In a cross-sectional survey, including 1363 nonhypertensive adults, adherence to the DASH and Mediterranean style diets was calculated using a semi-quantitative food frequency questionnaire. Compared to the lowest, participants with the highest adherence to the DASH dietary pattern revealed significantly lower systolic blood pressure (SBP) (111.3 ± 11.8 vs. 112.8 ± 12.5; P = 0.010) and diastolic blood pressure (DBP) (70.7 ± 9.2 vs. 71.8 ± 9.8; 0.042). There was no significant difference in the mean SBP and DBP among the participants across tertiles of Mediterranean diet or diet adherence. Higher scores of the DASH and Mediterranean diets were inversely associated with lower SBP after adjustment for all potential confounders (odds ratio [OR] = −0.04, P = 0.039) and (OR = −0.04, P = 0.044), respectively. In addition, DASH and Mediterranean dietary patterns were associated with decreased OR of prehypertension occurrence by 13% (OR: 0.87; P for trend = 0.042) and 16% (OR: 0.84; P trend = 0.035), respectively. Adherence to the DASH and MED diets was inversely associated with the odds for prehypertension and SBP. There is a paucity of research examining how the DASH and Mediterranean diets relate to lipids in less-developed ethnic minority regions (LEMR). A total of 83 081 participants from seven ethnic groups were retrieved from the baseline data of the China Multi-Ethnic Cohort study. The DASH scores were negatively associated with total cholesterol (TC), high density lipoprotein (HDL)-cholesterol, and TG. Comparing the highest quintiles with the lowest DASH scores, TC decreased 0·0708 (95% CI − 0·0923, −0·0493) mmol/l, HDL-cholesterol decreased 0·0380 (95% CI − 0·0462, −0·0299) mmol/l, and TG decreased 0·0668 (95% CI − 0·0994, −0·0341) mmol/l. The Mediterranean diet scores were negatively associated with TC, low-density lipoprotein (LDL)-cholesterol, and HDL-cholesterol. Comparing the highest quintiles with the lowest Mediterranean diet scores, TC decreased 0·0816 (95% CI − 0·1035, −0·0597) mmol/l, LDL-cholesterol decreased 0·0297 (95% CI − 0·0477, −0·0118) mmol/l, and HDL-cholesterol decreased 0·0275 (95% CI − 0·0358, −0·0192) mmol/l. Although both the DASH diet and the Mediterranean diet were negatively associated with blood lipids, those associations showed different patterns in LEMR, particularly for TG and HDL-cholesterol. Since Indo-Mediterranean diet is mainly plant based, it can better serve the sustainable development goals (SDGs) of the food system and health.
The ten characteristics of a high quality diet
It seems that all the dietary guidelines that are a necessary component of food policy and an essential first step to promote healthy eating habits should possess all the 10 qualities of a high quality diet. Increased intake of high quality foods through health educational programs or public awareness campaigns can be quite useful in reducing double burden of diseases.,,,, There has been an increased trend, in the last two decades, toward increased intake of unhealthy foods, characterized by overconsumption of red meat, butter, sugar, salt and highly processed refined foods and under consumption of high quality of foods, leading to a marked increase in the risk of CVDs and T2DM. It is possible that at the global level, unhealthy diet quality now poses a greater risk to morbidity and mortality compared to sedentary behavior, alcoholism, unsafe sex, drug addiction, and tobacco use combined.,, The world's population still faces burdens of undernutrition, with more than 820 million people having insufficient food and many more consuming low-quality foods., Therefore, all of the health agencies need an extraordinary effort to shift dietary patterns toward high quality functional foods with sustainable food system and a global commitment to reverse trends of poor quality diets in the rest of the world. Thus, educating people and governments about high quality functional foods and traditional diets, with all the ten qualities, and their effects on health and risk of NCDs., A review of Indo-Mediterranean diet (more of whole grains such as millets, porridge, beans, but no animal foods like except fish) and other diets indicate that, it has all the ten common qualities, which are less common in the Mediterranean diet and DASH diet (red meat, preserve meat, refined foods and egg) [Table 1] and [Table 2].
Low glycemic index
Foods that are slowly absorbed have low GI. The GI may be defined as a numerical figure to represent the ability of a high carbohydrate food to increase the levels of blood glucose. GI can be expressed as a percentage of the incremental area under the glycemic response curve (AUC) produced by a food portion with 50 g carbohydrate in comparison with the AUC elicited by a standard reference food of 50 g glucose or white bread in the same participant. It seems that the slower the rate of carbohydrate absorption into the blood, the lower is the rise in blood glucose level and the lower the value of GI. The concept of GI may provide a useful marker to select the most appropriate carbohydrate-containing foods or for the maintenance of health and the treatment of several diseases. Eating a high carbohydrate, rapidly absorbed foods may be associated with rapid increase in triglycerides, free fatty acids, as well as higher amount and activity of nuclear factor kB which is transcription factor that regulates the activity of at least 125 genes, most of which are pro-inflammatory. High GI foods also increase pro-inflammatory transcription factors; activating protein-1 (AP-1); and early growth response protein-1 as well as are markers of endothelial dysfunction. These transcription factors can also have adverse effects on adipocyte, beta cells of pancreas, leading to increased risk of obesity and insulin resistance.
The value of GI of ≥70 is considered high, a GI value ≤55 is low, and a GI value 56–69 inclusive is medium, where glucose = 100. The GI food-based intervention could be an important tool in the management and prevention of diabetes and CVDs. The GI data of non-Western foods are scarce in Middle East, South Asia, in contrast to the current international GI tables. Low GI foods are known to decrease insulin demand and lipid concentrations, improve blood glucose control and reduce body weight, thus may prevent glycemia-induced complications of CVDs and T2DM. It is known that non-Western traditional foods have lower GI, whereas fast foods, including tater tots, and French fries, some spreads, such as margarine spreads or peanut butter, some snack foods, such as chips, crackers, and cookies, most fried foods, including fried chicken, onion rings, and nuggets, nondairy creamer and preprepared cake frostings, have higher GI. Observational studies have shown that the consumption of low GI foods is associated with a lower risk of CVDs and T2DM, significantly less insulin resistance and a lower prevalence of the metabolic syndrome.,, In many Asian countries, grain-based carbohydrates provide ~ 60% of total energy consumption compared with 42% for Caucasians.,,, The consumption of such high-carbohydrate diets yield high glucose and insulin response, thus contributing to insulin resistance. Nonetheless, the quality of carbohydrate consumed is as important as the quantity. Poor quality carbohydrates are quickly digested and absorbed, thereby giving rise to high blood glucose and insulin leading to insulin resistance.
Food diversity is the most important quality of a high quality diet which is highest in the Indo-Mediterranean diet compared to Mediterranean and DASH diets. The association between food quality, dietary diversity, and nutrient adequacy with health and risk of diseases are continuous and graded.,,,,,,, The growth of infant and children with emphasis on peri-conception and perinatal factors and socioeconomic status of the family and community are known to influence food quality and food consumption as well as food production. Food diversity can be measured using a simple count of foods or food groups over a given reference period with due consideration on traditional diets. There is a consistent positive association between food diversity and growth of infants and children and evidence from a multicountry analysis suggests that food diversity at household-level is strongly associated with social class and availability of total energy from food quantity indicating, that food diversity may be a useful indicator of food security and important quality of the ten qualities of the high quality diet., Although the nutrient contribution of animal foods to nutrient adequacy is indisputable, there is definite scope for Indo-Mediterranean high quality plant foods which may provide all the Ten Qualities of High Quality Foods which may be adequate for infant and child growth as well as for the prevention of NCDs in later adult life.,,,, There is clearly an unmet need for a promising measurement tool, for assessment of food diversity to improve and harmonize measurement approaches and indicators. Cohort studies indicate that high quality foods with food diversity can decrease morbidity and mortality as well as increase healthy and possibly happy life expectancy.,,,,,,,,,, The Healthy Eating Plate is a prudent approach for providing high quality diets with food diversity to individuals and communities, which may include traditional foods of the concerned community and country [Figure 1].
Dietary fatty acids
It seems that the Indo-Mediterranean diet may be superior to Healthy eating plate because of its food diversity and low GI. In Western countries, the limits for fat intake is 30% of total calories intake including 10% energy from saturated fat and rest from monounsaturated and poly unsaturated fatty acids including omega-3 fatty acids., The intake of trans fat in foods is limited, up to 3% in most guidelines in most countries., The policy options are made available for eliminating or reducing trans fats in the food-supply chain. It explores how such policies could contribute to decreasing the double burden of diseases caused by intake of industrially produced trans fats in the WHO European Region (http://www.sciencedirect.com/science/article/pii/S0735109720356874). The recommendation to limit dietary saturated fat intake would persist despite mounting controversy., Saturated fat increases LDL cholesterol, which is not on account of increasing levels of small, dense LDL particles, but rather larger LDL particles, that have adverse effects on occurrence of CVD risk. It seems that the health effects of foods cannot be predicted by their content in any nutrient group without considering the overall macronutrient distribution, in particular food diversity and GI. Whole-fat dairy products, unprocessed meat, and dark chocolate are SFA-rich foods with a complex matrix that is not associated with increased risk of CVDs which may be due to protective nutrients available in the whole diets. The totality of available evidence does not support further limiting the intake of these foods.,,,,
Flexitarian diet and microbiota
There is evidence that plant foods rich in vegetables, whole grains, nuts, and fruits as well as fish intake have a beneficial effects on gut microbiota, whereas meat consumption has adverse effects. Some experts advise that eating a flexitarian diet, more of plant foods with meat in moderation may be an healthy approach for health promotion and prevention of CVDs with improved SDGs.,,,, Diet and lifestyle factors plays an important role in shaping gut microbiota.,,, In a recent study, dietary intake and gut microbiota were analyzed in a community-dwelling cohort of 441 Colombians. Microbial diversity was higher in individuals with increased intake of nutrients obtained from plant-food sources, whereas the intake of food groups and nutrients correlated with microbiota structure. Interestingly, communities composed of short-chain fatty acid producers were more prevalent in the microbiota of individuals consuming diets rich in fiber and plant-food sources, such as fruits, vegetables, and beans. However, an inflammatory microbiota composed of bile-tolerant and putrefactive microorganisms along with opportunistic pathogens thrived in individuals consuming diets enriched in animal-food sources and of low quality, i.e., enriched in ultra-processed foods and depleted in dietary fiber. It is clear that diet is strongly associated with the gut microbial community and highlights generalizable connections between healthy and adverse effects.
| Diet and Sustainable Development Goals and Food Systems|| |
The SDGs of the UNO may depend on the quality of food consumption and food production as well as on the safety of farming with reference to how much food is lost or wasted. It seems that food systems should have transition from being a net source of greenhouse gas emissions to a net sink, while conserving the food quality (FAO, UNO. The State of Food and Agriculture: Sustainable Food Systems for Food Security and Nutrition. “http://www.fao.org/”http://www.fao.org/docrep/meeting/028/mg413e01.pdf accessed Jan 2022). Most experts agree that a shift toward healthy plant based diet in conjunction with sea food may be central to this goal. Any gas that has the property of absorbing infrared radiation (net heat energy) emitted from Earth's surface and reradiating it back to Earth's surface, thus contributing to the greenhouse effect. Carbon dioxide, methane, and water vapor are the most important greenhouse gases. Thus, greenhouse gases are those gases that absorb and emit radiant energy within the thermal infrared range, resulting into greenhouse effect. The primary greenhouse gases in Earth's atmosphere, related to food production and consumption are, water vapor, carbon dioxide, methane, nitrous oxide, and ozone, that have may have adverse effects on environment and health. Unfortunately, food consumption is rarely considered as a solution for sustainability in meeting climate targets.
It has been proposed that diets for better future and healthy life expectancy may depend on health effects and sustainability of diets and foods available for consumption.,,,,,,,,, It seems that dietary transitions to healthy foods would decrease total global food-related greenhouse gas emissions and enable more equitable distribution of these emissions within planetary boundaries. This may ensure to address worldwide all forms of malnutrition while leaving our children a thriving and healthy planet. It is possible that that the world cannot achieve this goal without leadership by the G20, as this is a critically important goal. In G-20 countries, most food consumption patterns are not aligned with those of a healthy flexitarian diet and most national dietary guidelines are not ambitious enough to bring food systems within planetary boundaries, including limiting global warming to 1.5°C.,,, The countries such as China, India, and Indonesia have current consumption patterns aligned with the model necessary to protect health and the planet, which appears due to lower modernization and continuation of traditional food consumption pattern., However, shifting in all other G20 countries is critical due to attack by advertising food industry, in protecting planet and people. The report by EAT Lancet investigators also indicates that current food consumption patterns and the efficacy of national dietary guidelines in G20 countries is far away from the Planetary Health Diet. It seems that G20 countries are presented with clear opportunities to lead reduction of greenhouse gas emissions and realize the health and related economic benefits of shifting toward more healthy and sustainable diets, which are likely to serve the SDGs of the UNO. It is interesting to look at The Harvard TH Chan School of public Health guidelines to Use the Healthy Eating Plate as a guide for creating healthy, balanced meals; whether served on a plate or packed in a lunch box (The best diet, quality counts. Harvard TH Chan School of Public Health. https://www.hsph.harvard.edu/nutritionsource/healthy-weight/best-diet-quality-counts/accessed Jan 2022). The International College of Nutrition as well as International College of Cardiology have proposed to modify the guidelines of National Cholesterol Education Program of the American Heart Association and American College of Cardiology., This seems to be an important message from the seven Country study.
In summary, the Indo-Mediterranean style diet appears to be superior to Mediterranean diet as well as DASH diet. The food diversity and GI appear to be basic requirements of a high quality diet. The given ten characteristics of a high quality diet appear to be fundamental, for a better future; healthiness and healthy life expectancy and longevity. It is possible to demonstrate the leading role, G20 countries can and must take to realize the exponential changes required for a healthy and sustainable world. A support of International College of Nutrition in this attempt may be crucial.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]