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Consensus Dietary Guidelines for Healthy Living and Prevention of Obesity, the Metabolic Syndrome, Diabetes, and Related Disorders in Asian Indians

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India is undergoing rapid nutritional transition, resulting in excess consumption of calories, saturated fats, trans fatty acids, simple sugars, salt and low intake of fiber. Such dietary transition and a sedentary lifestyle have led to an increase in obesity and diet-related non-communicable diseases (type 2 diabetes mellitus [T2DM], cardiovascular disease [CVD], etc.) predominantly in urban, but also in rural areas. In comparison with the previous guidelines, these consensus dietary guidelines include reduction in the intake of carbohydrates, preferential intake of complex carbohydrates and low glycemic index foods, higher intake of fiber, lower intake of saturated fats, optimal ratio of essential fatty acids, reduction in trans fatty acids, slightly higher protein intake, lower intake of salt, and restricted intake of sugar. While these guidelines are applicable to Asian Indians in any geographical setting, they are particularly applicable to those residing in urban and in semi-urban areas. Proper application of these guidelines will help curb the rising "epidemics" of obesity, the metabolic syndrome, hypertension, T2DM, and CVD in Asian Indians.
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Review
Consensus Dietary Guidelines for Healthy
Living and Prevention of Obesity, the Metabolic Syndrome,
Diabetes, and Related Disorders in Asian Indians
Anoop Misra, M.D., Rekha Sharma, M.Sc., Seema Gulati, Ph.D., Shashank R. Joshi, M.D., D.M.,
Vinita Sharma, Ph.D., Ghafoorunissa, Ph.D., Ahamed Ibrahim, Ph.D., Shilpa Joshi, M.Sc.,
Avula Laxmaiah, MBBS, M.P.H., Anura Kurpad, M.D., Ph.D., Rebecca K. Raj, Ph.D.,
Viswanathan Mohan, M.D., Ph.D., Hemraj Chandalia, M.D., Kamala Krishnaswamy, M.D.,
Sesikeran Boindala, M.D., Sarath Gopalan, M.D., Siva Kumar Bhattiprolu, Ph.D., Sonal Modi, M.Sc.,
Naval K. Vikram, M.D., Brij Mohan Makkar, M.D., Manju Mathur, M.Sc., Sanjit Dey, Ph.D.,
Sudha Vasudevan, M.Sc., Shashi Prabha Gupta, M.Sc., Seema Puri, Ph.D., Prashant Joshi, M.D.,
Kumud Khanna, Ph.D., Prashant Mathur, M.D., Sheela Krishnaswamy, M.Sc., Jagmeet Madan, Ph.D.,
Madhukar Karmarkar, M.D., Veenu Seth, Ph.D., Santosh Jain Passi, Ph.D., Davinder Chadha, M.D., D.M.,
and Swati Bhardwaj, M.Sc. for the National Dietary Guidelines Consensus Group
1
Abstract
India is undergoing rapid nutritional transition, resulting in excess consumption of calories, saturated fats, trans
fatty acids, simple sugars, salt and low intake of fiber. Such dietary transition and a sedentary lifestyle have led
to an increase in obesity and diet-related non-communicable diseases (type 2 diabetes mellitus [T2DM], car-
diovascular disease [CVD], etc.) predominantly in urban, but also in rural areas. In comparison with the pre-
vious guidelines, these consensus dietary guidelines include reduction in the intake of carbohydrates,
preferential intake of complex carbohydrates and low glycemic index foods, higher intake of fiber, lower intake
of saturated fats, optimal ratio of essential fatty acids, reduction in trans fatty acids, slightly higher protein
intake, lower intake of salt, and restricted intake of sugar. While these guidelines are applicable to Asian Indians
in any geographical setting, they are particularly applicable to those residing in urban and in semi-urban areas.
Proper application of these guidelines will help curb the rising ‘‘epidemics’’ of obesity, the metabolic syndrome,
hypertension, T2DM, and CVD in Asian Indians.
Introduction
Asian Indians (people of Indian origin living in India or
living in other countries) have become more affluent,
urbanized, and mechanized during the previous decade. A
hectic lifestyle and the easy availability of convenience foods
have led to irregular meals and frequent snacking on energy-
dense fast foods (‘‘fast foods’’ refer to energy-dense foods
prepared and sold commercially by roadside vendors and
food outlets, prepared either by deep frying or with preheated
or precooked ingredients; these foods typically have low nu-
tritional value and preparation time), including ready-to-use
gravies and soups, packaged salty snacks, ready-made
cookies, and commercial fast-foods rather than traditional
home-cooked food.
1
Furthermore, consumption of animal
foods, sweetened carbonated drinks, sugar, and sweeteners
(Table 1) has also increased.
3
In addition, traditional Indian
energy-dense foods continue to be consumed. Overall, this
nutritional transition, particularly noticeable in children,
has resulted in high consumption of calories, saturated fats
(Table 2), trans fatty acids (TFAs), simple sugars, and salt,
along with low intake of fiber, monounsaturated fatty acids
(MUFAs), and n-3 polyunsaturated fatty acids (PUFAs).
1
This
nutrition transition has the potential to cause obesity and
other diet-related non-communicable diseases (DR-NCDs)
such as type 2 diabetes mellitus (T2DM), hypertension, and
cardiovascular disease (CVD),
3
predominantly in urban areas
but also in semi-urban and rural areas.
6,7
Despite possible influences of genetic and perinatal factors,
imbalanced diets and physical inactivity (Table 3) are likely
to have greater and overriding influence on the increas-
ing prevalence of obesity in India.
3,12
Persistent obesity
1
Affiliations and group members are given in Appendix 1.
DIABETES TECHNOLOGY & THERAPEUTICS
Volume 13, Number 6, 2011
ªMary Ann Liebert, Inc.
DOI: 10.1089/dia.2010.0198
683
dysregulates metabolic processes, including action of insulin
on glucose–lipids–free fatty acid metabolism, causing clus-
tering of dysglycemia, dyslipidemia, hypertension, and the
procoagulant state, known as the metabolic syndrome. Obe-
sity and the metabolic syndrome are immediate precursors of
T2DM and CVD.
13
The prevalence of insulin resistance and
the metabolic syndrome is rapidly increasing in urban areas in
India. The severity of insulin resistance and related cardio-
vascular risk factors is higher in Asian Indians than white
Caucasians.
3
Furthermore, T2DM and CVD occur a decade
earlier in Asian Indians than in white Caucasians and lead to
more complications.
14
The magnitude of T2DM, CVD, and
other metabolic disorders, however, varies according to the
affected populations (rural or urban), socioeconomic strata,
and region of residence in India.
15
The increasing prevalence
of DR-NCDs in the Asian Indian population is of great con-
cern, necessitating preventive steps.
Why Revisions in Dietary Guidelines Are Needed
The following factors have necessitated revision of existing
dietary guidelines. Moreover, the present guidelines specifi-
cally focus on healthy living and on prevention of DR-NCDs
in Asian Indians:
1. Recent dietary transition in India as discussed above
3,16
2. Rapid increase in DR-NCDs in India
1
3. New research data on macronutrients and micro-
nutrients in Indian diets
4. Need to acquire user-friendly dietary guidelines that
could be understood and used not only by nutritionists
and general physicians but also by the general population
Table 1. Secular Trends of Nutrient
Consumption in India
Average values
a
Product 1979–1981 1989–1991 1999–2001
Total animal product 120 163 196
Animal fat 23 28 47
Eggs 3 5 6
Seafood 5 7 8
Meat 16 20 22
Milk-excluding butter 71 102 111
Total vegetable product 1,963 2,202 2,296
Alcoholic beverages 5 8 11
Cereals 1368 1508 1470
Fruits 31 34 51
Oil crops 25 37 43
Pulses 120 133 109
Rice (milled) 670 779 751
Starchy roots 41 40 49
Sugar and sweeteners 193 221 247
Sugar crops 8 9 11
Vegetable oils 127 158 239
Vegetables 32 35 45
Wheat 390 461 493
Grand total 2,083 2,365 2,492
Data are obtained from the Food and Agricultural Organization
Database (FAOSTAT).
2
a
All variables expressed in the unit calories/capita/day.
Table 2. Consumption of Fats and Fatty Acids in Urban Adolescents and Adults in India
Total fat
(% energy)
(RDA 15–30%)
SFA
(% energy)
(RDA <10%)
PUFA
(% energy)
(RDA <8%)
o-3 PUFA
(% energy)
(RDA not <1%)
o-6 PUFA
(% energy)
(RDA 3–7%)
MUFA
(% energy)
(RDA <10%)
TFA
(% energy)
(RDA <1%)
Male Female Male Female Male Female Male Female Male Female Male Female Male Female
Age group M SD M SD M SD M SD M SD M SD M SD M SD M SD M SD M SD M SD M SD M SD
Adolescents
13–18 years
(n¼797)
a
32.4 7 35.6 6.3 11.6 4.0 10.7 3.8 7.9 3.2 10.2 3.7 0.9 0.6 1.2 0.8 7.2 3.3 9.2 3.7 9.3 2.5 10.1 2.8 1.1 (0–10.7) 1.1 (0–10.2)
Adults
19–49 years
(n¼325)
a
30.8 8.4 34.1 6.7 8.9 3.7 9.3 3.1 9.5 3.6 10.1 3.6 1.4 0.9 1.9 1.0 8.2 3.8 8.3 3.8 9.6 3.1 11.6 3.4 0.4 (0–4.1) 0.6 (0–9)
>50 years
(n¼124)
a
31.2 6.8 33.5 6.2 9.2 3.2 9.7 3.7 9.7 3.4 9.9 3.8 1.0 0.7 1.5 1.2 8.7 3.7 8.4 4.0 9.2 2.8 10.5 3.4 0.3 (0–6.2) 0.4 (0–6.8)
18–69 years
(n¼227)
b
24.7 (12–78.9) 28.7 6.6 (0.9–21.5) 6.5 (1.1–22.1) 1.3 0.6 1.7 0.8 3.1 1.1 3.8 3.1 4.7 (1.4–16.1) 5.7 (1.2–17) 1.0 5.2 0.8 1.7
Table adapted from Misra et al.
1.
Mean (M) and SD values are given, and numbers in parentheses denote the range.
a
Representative sample from general population in New Delhi, India (authors’ unpublished results).
b
People belonging to low socioeconomic stratum living in urban slums, New Delhi.
4
PUFA, polyunsaturated fatty acids; RDA, recommended dietary allowance for Asian Indians;
5
SFA, saturated fatty acids; TFA, trans fatty acids.
684 MISRA ET AL.
5. Need to evolve food-based dietary guidelines to trans-
late nutrient recommendations into foods for easy in-
terpretation.
The Consensus Development Process
and Preparation of This Article
The objectives of this consensus process are to critically
analyze current nutrition transition and based on this analy-
sis, revise the previous dietary guidelines for India (prepared
in 1998 by the National Institute of Nutrition), specifically for
healthy living for Asian Indians and prevention of DR-NCDs,
and to make dietary guidelines user-friendly.
Experts (see Appendix 2) from across the country and be-
longing to the various related fields, including nutrition,
internal medicine, diabetes, metabolism, endocrinology,
cardiology, exercise physiology, and sports medicine
and representing reputed medical institutions, hospitals,
government-funded research institutions, and policy-making
bodies participated in a ‘‘Consensus Summit’’ to develop
Asian Indian–specific dietary guidelines. All the research
groups in India doing original research on nutrition were
contacted and invited. The Steering Committee (see Appendix
2) prepared a draft document well in advance of the summit,
which was communicated to all prospective participants for
feedback and comments. After the valid suggestions were
incorporated, the revised consensus document was circulated
among all the experts for a second review before the consen-
sus meeting (April 5, 2009, in New Delhi). The experts
appraised the rationale, background, and proposed changes
in the form of five lectures, followed by two panel discussions
steered by four or five reputed experts, during the summit.
Discussions were held based on the following questions/
issues, taking into account the research data in Asian Indians
published from India and elsewhere:
1. What should be the recommendation(s) for the follow-
ing?
a. Carbohydrates and fiber
b. Proteins
c. Fats and TFAs
d. Quality and quantity of cooking oils
e. Water intake
f. Alcohol intake
g. Salt and sugar intake
2. Choice of foods while eating out
3. Meal timings and gaps between meals, and other die-
tary habits
4. Cooking methods
The summary points were presented to the whole group
and unanimously adopted as consensus guidelines. A writing
group led by experts who have done research on specific
nutrients worked on the article (see Appendix 2). The draft of
the manuscript was again circulated by e-mail to all (even
those who did not participate [see Appendix 2]) for any
editing before the publication.
The literature search was done using the key words ‘‘Diet
and Asian Indians or dietary recommendations for Asian
Indians, or trends in dietary intake in Asian Indians’’ from
the medical search engine PubMed (National Library of
Medicine, Bethesda, MD) from 1966 to October 2009.
Manual searches for other important references and nutri-
tional databases were also conducted. Many of the food
articles have been named both in English and in Hindi
(given in italics).
The Secular Trends in Intake of Macronutrients in India
Data regarding time trends in food and nutrient intakes are
available from the National Nutrition Monitoring Bureau,
which was established in each of 10 major states in India in
1972. Repeat National Nutrition Monitoring Bureau surveys
have shown a decrease in the average intake of all the mac-
ronutrients between 1975–1979 and 1996–1997 among rural
adults. The intake of protein was 62 g/consumption unit/day
in 1975–1979 and declined to 54 g in 1996–1997 among rural
adults 18 years age; energy also declined from 2,350 Kcal in
1975–1979 to 2,110 Kcal in 1996–1997.
17
A similar trend was
observed among tribal population in various parts of India:
protein, 55 g/day in 1985–87 and 54 g/day in 1998–1999; en-
ergy, 2,213 Kcal/day in 1985–1987 and 2,239 Kcal/day in
1998–1999.
18
While carbohydrates remain the major source of
energy in Indian diets, the percentage of total energy intake
derived from carbohydrates has declined (1975–1979, 80.3%;
2001, 75.5%), with an increase in the percentage of energy
coming from dietary fats (1975–1979, 8.9%; 2001, 13.9%).
However, the proportion of dietary energy from fat still re-
mains less than 15%, which is lower than the recommended
dietary allowance (RDA) of 15–30%.
19
Consumption of oils,
fats, and animal products has increased in almost all the
states.
17
Energy intake is lower in urban areas, in spite of
higher intake of fats and oils, because of lower cereal con-
sumption compared with rural areas.
20
Several reasons at-
tributable for these dichotomous observations of decreased
energy intake with rising prevalence of obesity, could be:
under-reporting of dietary consumption data,
20
higher energy
intake in comparison with energy expenditure,
21
and in-
creasingly sedentary lifestyle.
17
Table 3. Differences in Physical Activity Among Asian Indians Versus Whites/Europeans
Study Ethnic group
Physical activity
criteria/parameter
Asian
Indians Whites/Europeans
Mohanty et al.
8
Asian Indians (n¼555),
non-Hispanic whites (n¼87,846)
Reporting vigorous activity 33% 40.7%
Shaukat et al.
9
Asian Indians (n¼89), Caucasians (n¼82) Physical activity index 8.5
a
13.7
Dhawan et al.
10
Asian Indians (n¼80), Caucasians (n¼82) Exercise for at least 20 min
once a week
17% 34%
Petersen et al.
11
Asian Indians (n¼49),
Caucasian children (n¼292)
Physical activity index 2.1
a
2.3
a
Unit not given as this is a ratio.
DIETARY GUIDELINES FOR ASIAN INDIANS 685
Energy Recommendation
The recommended energy should be adequate to maintain
ideal weight and health in adults. If body weight and physical
activity (Tables 4 and 5) of an individual are known, it is easy
to calculate the extra needs of energy for a particular situation.
In the case of energy, the RDA represents only the average
daily requirement corresponding to daily average expendi-
ture of an individual. The energy requirements are suggested
based on type of activity profile (sedentary, moderate, and
heavy), age, gender, and physiological status of an individu-
al.
24
Energy requirement for any individual is calculated by
multiplying the activity factor by ideal body weight of that
individual (Tables 4 and 5). For example, an Asian Indian man
with medium body frame, 165 cm tall, should ideally weigh
62 kg and would require 1,850 Kcal to maintain a healthy
weight if that person is sedentary. Ideal body weight should
be aimed to maintain a body mass index between 18 and
22.9 kg/m
2
.
25
Carbohydrates and Fiber
Carbohydrates are divided into simple and complex car-
bohydrates. Simple carbohydrates (like sugar, refined flour,
candies, toffees, etc.) should be avoided as they break down
much faster and cause insulin levels to spike quickly. Com-
plex carbohydrates (whole cereals, unpolished rice, barley
[jaun], buckwheat [kuttu], oats [jai], millets, etc.) are sub-
divided as starches and fiber, are best consumed in the un-
processed form, and should be the principal source of energy.
Diet high in natural fiber ameliorates the slow release of
glucose in the blood from the intestine and helps in regulating
blood glucose levels. The RDA for carbohydrates should be
50–60% of total energy, which would ensure an appropriate
macronutrient balance. While deciding for carbohydrates, the
glycemic index (GI) of foods should also be considered. GI is a
measure of the effects of carbohydrates on blood sugar levels.
Carbohydrates that break down quickly during digestion and
release glucose rapidly into the bloodstream have a high GI,
whereas carbohydrates that break down more slowly, re-
leasing glucose more gradually into the bloodstream, have a
low GI. Emerging research, globally and from India, has
shown the relevance of GI in the Indian context.
26–29
The
amount of carbohydrate consumed also affects blood glucose
levels and insulin responses. The glycemic load of a food is
calculated by multiplying the GI by the amount of carbohy-
drate (in g) provided by a food and dividing the total by 100.
Although fructose has a low GI, recent research indicates that
eating too much fructose may increase the rate of liponeo-
genesis and lipid storage in the liver. Hence intake of pro-
cessed fructose or high fructose corn syrup–containing foods
and drinks should be minimized.
The Dietary Approaches to Stop Hypertension (DASH)
trial demonstrated that a carbohydrate-rich diet consisting of
whole grains, fruits, vegetables, and low-fat dairy products,
low in saturated fat, total fat, and cholesterol, substantially
lowered blood pressure and low-density lipoprotein choles-
terol level.
30
At least four or five servings of fruits and vege-
tables (rich sources of fiber) in the diet also ensure adequate
intake of micronutrients, including antioxidants, fiber, and
phytonutrients. The World Health Organization recommends
an intake of a minimum of 400 g of fruits and vegetables per
day for the prevention of chronic diseases.
31
Key principles
1. Eat complex carbohydrates with low GI instead of
simple sugars or high GI carbohydrates.
2. Eat high fiber foods.
3. Quantity and quality of carbohydrates are equally im-
portant in the daily diet.
Recommendations
1. The daily carbohydrate intake should be approximately
50–60% of the total calorie intake. For example, in 1,800
and 2,000 calorie diets, the carbohydrate intake for a
sedentary to moderately active individual should be
225–270 g/day and 250–300 g/day, respectively.
2. The primary source of complex carbohydrates in the
diet should be cereals (whole wheat, brown rice, etc.),
millets (pearl millet [bajra], finger millet [ragi], great
millet [Jowar]), pulses (red gram [tur dal], green gram
[sabut moong], etc.), and legumes (soya, horse gram
[kulthi]). Complex carbohydrates should be preferred
over refined carbohydrates and its products (e.g., whole
grain bread over white [maida] bread).
3. Low GI foods (e.g., oats [jai], unpolished rice, parboiled
rice, whole pulses, beans [fali], and legumes (sabut anaz)
and some whole fruits [like guava, apple, etc.]) should
be preferred. High GI foods (refined flour, root vege-
tables such as yam [sooran/shakarkand], potato, tapioca
[a type of shakarkand], colocasia [arbi], etc.) should be
consumed in moderation.
4. The total dietary fiber in daily diet should be 25–40 g/
day (e.g., 100 g of apple [1 small apple] gives 1.0 g of
fiber; 100 g of whole wheat flour gives 1.9 g of fiber).
Whole grains, cereals, pulses, vegetables, and fruits
contain high dietary fiber.
5. A minimum of four or five servings per day of fruits
and vegetables is recommended (i.e., approximately
400–500 g/day including three vegetable and two fruit
portions [e.g., 100 g of (one katori) raw vegetables (e.g.,
Table 4. Calculation of Ideal Body Weight
Build Women Men
Medium 100 lbs (45.5 kg) for the first 5 feet (152 cm) height,
plus 5 lb (2.3 kg) for each additional inch
106 lbs (48 kg) for the first 5 feet (152 cm) of height,
plus 6þlbs (2.7 kg) for each additional inch
Small Subtract 10% Subtract 10%
Large Add 10% Add 10%
Adapted from the 1977 publication by the American Diabetes Association and the American Dietetics Association.
22
686 MISRA ET AL.
cauliflower, brinjal, etc.) ¼20–30 Kcal; 100 g of fruit e.g.,
one apple ¼59 Kcal]). Fruits should be eaten whole,
preferably with the skin, whenever feasible instead of
fruit juices.
6. Simple sugars like crystalline sugar, sugarcane juice,
sweetened carbonated beverages, fruit juices, and sugar
syrups should be avoided.
Fats
A small amount of fat is present in almost every food item
(invisible fat). The fat in processed and ready-to-eat foods
(hidden fat) and visible fat (vegetable oil, ghee, and vanaspati),
used for cooking together contribute to the total fat intake of
an individual. Dietary fats (lipids) are important components
of human diet, providing energy and essential fatty acids
(linoleic acid [LA] and a-linolenic acid [ALA]) and serving as a
source of fat-soluble vitamins (e.g., vitamins A, D, E, and K).
Fats improve texture and palatability of foods and have an
important role in inducing satiety. The nutritional and health
effects of dietary fats are determined by the nature of their
constituent fatty acids (>95%) and the composition of minor
components (<5%), collectively designated as ‘‘nonglyceride
components.’’
Fatty acids are categorized as follows: saturated fatty acids
(SFAs), MUFAs, and PUFAs. All fatty acids generate energy
and when taken in excess are stored in adipose tissue. The
nutritionally significant and naturally occurring MUFAs and
PUFAs have a cis configuration. TFAs are mainly generated
by industrial partial hydrogenation of vegetable oils. In ad-
dition, small amount of TFAs are present in ruminant fats by
bacterial hydrogenation of PUFAs in the rumen of ruminants
(e.g., cattle, buffalo, camels, goats, etc.). The industrial hy-
drogenation process results in formation of predominantly
elaidic acid (20–50%) as the trans isomer.
The pathological processes involved in the causation and
complications of coronary heart disease comprise distur-
bances in lipoprotein metabolism (high levels of low-density
lipoprotein, low levels of high-density lipoprotein, and high
levels of serum triglycerides), endothelial dysfunction, in-
crease in pro-inflammatory cytokines, prothrombotic shift in
arterial homeostasis [high levels of lipoprotein (a) and
thromboxane/ prostacyclin ratio], and insulin resistance.
31,32
SFAs raise total and low-density lipoprotein cholesterol
levels, reduce insulin sensitivity, and enhance thrombo-
genicity, thus contributing to an increase in coronary heart
disease risk. TFAs increase low-density lipoprotein choles-
terol (an effect similar to SFA), decrease high-density lipo-
protein cholesterol (an effect different from SFA), and
increase the total cholesterol/high-density lipoprotein cho-
lesterol ratio, a powerful predictor of increased risk of cor-
onary heart disease. The consumption of excess TFAs
increases coronary heart disease risk to a greater extent than
diets with excess SFAs.
31
The intake of ruminant TFAs is low
compared with those obtained from partial hydrogenation of
vegetable oils, and hence the focus should be on reducing
TFAs from partial hydrogenation of vegetable oils.
33,34
PU-
FAs enhance peripheral glucose utilization, improve insulin
action, and reduce adiposity. Recent evidence suggests that
diets providing high intakes of both PUFAs (LA and ALA),
balanced LA/ALA ratio, and long-chain n-3 PUFAs from
fish/fish oils prevent DR-NCDs.
35–37
Hence, optimal intakes
of these fatty acids may be compromised with low fat diets.
Plant sterols and other unique components (oryzanols and
sesame lignans) in the nonglyceride component of fats in
foods and vegetable oils also contribute to lowering of low-
density lipoprotein cholesterol.
38
Key principles
1. The lower limit of fat should be adequate for the energy
needs (15% of total energy), should prevent essential
fatty acid deficiency (LA, 3% of total energy; ALA, 0.5%
of total energy), and should facilitate optimal absorp-
tion of fat-soluble vitamins.
39
2. High levels of SFAs and TFAs promote dyslipidemia
and atherosclerosis.
Recommendations
For optimal health across the life course the following
recommendations, along with food-based guidelines, are
suggested:
31,36
1. Fats should provide not more than 30% of total energy/
day and SFAs should provide no more than 10% of total
energy/day. For individuals having low-density lipo-
protein cholesterol of 100 mg/dL, SFAs should be
<7% of total energy/day.
2. Essential PUFAs (LA) should provide 5–8% of total
energy/day.
3. ALA should be 1–2% of total energy/day.
4. The optimal ratio of LA/ALA should be 5–10.
5. Long-chain n-3 PUFAs should be obtained from fish,
walnuts, flaxseeds, canola oil, etc.
6. Cis MUFAs should provide 10–15% of total energy/
day.
7. TFAs should be <1% of total energy/day.
8. Cholesterol intake should be limited to 200–300 mg/
day.
Food-based guidelines to ensure optimal fat quality
in Asian Indian diets
1. Complete dependence on just one vegetable oil
does not ensure optimal intake of various fatty acids
(Table 6), use of two or more vegetable oils is rec-
ommended.
2. The recommendation for oils are as follows:
41
a. Preferred vegetable oil(s) along with ALA-contain-
ing oil(s) or vegetable oil containing high LA levels
along with oil(s) containing moderate or low LA
levels are listed in Table 7. However, the latter
Table 5. Calculation of Energy Requirement
Energy requirement (Kcal/kg of IBW/day)
Activity level Obese Normal Underweight
Sedentary 20–25 30 35
Moderate 30 35 40
Heavy 35 40 45–50
According to Williams.
23
IBW, ideal body weight.
DIETARY GUIDELINES FOR ASIAN INDIANS 687
combination would ensure moderation in LA intake
only and is recommended when other dietary
components provide high ALA levels or fish is
consumed. Improvement of n-3 PUFA nutritional
status in Indian adults has been shown with two of
these oil combinations (groundnut oil/sunflower oil
and canola).
41
b. Consumption of butter and ghee (clarified butter)
should be kept to a minimum.
c. Use of partial hydrogenation of vegetable oils (va-
naspati) as the cooking medium should be strictly
avoided.
d. Coconut oil, palm kernel oil, palm oil, and palmo-
lein or their solid fractions should be substituted for
partial hydrogenation of vegetable oils in foods that
require solid fats (bakery fats, shortening, etc.).
These oils are high in SFAs but are TFA free.
3. To ensure correct balance of fatty acids from dietary
components other than visible fat, the following dietary
guidelines are recommended:
41–43
a. Regular consumption of foods with high ALA con-
tent (wheat, pearl millet, pulses, green leafy vege-
tables, fenugreek, flaxseed, and mustard seeds)
(Table 8).
b. Partial replacement of visible fat and invisible fats
from animal foods with whole nuts such as pista-
chios and almonds.
c. Moderation in the use of animal foods containing
high levels of fat, SFAs, and cholesterol.
d. For nonvegetarians, consumption of 100–200 g of
fish (four to six pieces)/week.
e. Minimizing consumption of premixed, ready-to-eat,
fast foods, bakery foods, and processed foods pre-
pared in partial hydrogenation of vegetable oils like
savory (namkeen).
f. Choose low fat dairy foods such as double-toned
milk (fats <1.5%) or curd prepared from such milk.
The preference for low fat dairy foods would also
reduce ruminant TFAs.
Proteins
The protein requirement as suggested by the 2007 World
Health Organization/Food and Agriculture Organization/
United Nations University Expert Consultation is 0.66 g/kg/
day for healthy adults.
45
The safe level of protein intake was
identified as the 97.5th percentile of the population distribu-
tion of the suggested requirement (i.e., 0.83 g/kg/day).
However, these estimates are for completely digested and
high-quality protein. Based on calculations of the protein
quality and digestibility of proteins in an Indian mixed veg-
etarian diet (with milk products), the protein digestibility
corrected amino acid score (PDCAAS) of these mixed proteins
comes to about 85%. Hence, the adequate protein intake
would be about 1 g/kg/day (requirement divided by the
Table 6. Approximate Fatty Acid Composition
of Commonly Available Fats and Oils
(% of total fatty acids)
Fats/oils SFAs MUFAs
a
LA ALA
High medium-chain SFAs
Coconut 92 6 2 —
Palm kernel 83 15 2
Butter/ghee* 68 29
b
21
High MUFAs
Olive 16 71 12 1
High SFAs and MUFAs
Palmolein 39 46 11 <0.5
High MUFAs and
moderate LA
Groundnut 19 41 32 <0.5
Rice bran 17 43 38 1
Sesame 16 41 42 <0.5
High LA
Cottonseed 24 29 48 1
Corn 12 35 50 1
Safflower 9 13 75 —
Sunflower 12 22 62 —
LA (n-6) and ALA
Soybean 14 24 53 7
Canola 6 60
c
22 10
Mustard/rapeseed 4 65
d
15 14
Flaxseed 10 21 16 53
High TFAs
Vanaspati** 46 49
e
4—
Data are from the 1996 Codex Alimentarius commission report.
40
a
Mainly oleic.
The following superscripts indicate the percentage of TFA:
b
5%,
e
7% (range, 5–38% for Indian data compiled between 2000 and 2009).
The following superscripts indicate the percentage of erucic acid:
c
*2%,
d
*50%.
*Clarified butter.
**Hydrogenated fat.
ALA, a-linolenic acid; LA, linoleic acid; MUFAs, monounsaturated
fatty acids; PUFAs, polyunsaturated fatty acids; SFAs, saturated
fatty acids; TFAs, trans fatty acids.
Table 7. Recommended Oil Combinations in Indian Diets (Oils in 1:1Proportion)
Oil containing LA þoil containing both LA and ALA Oil containing high LA þoil containing moderate or low LA
Groundnut/sesame/rice bran/cottonseed þmustard Sunflower/safflower þpalmolein/olive
Groundnut/sesame/rice bran/cottonseed þcanola Safflower/sunflower þgroundnut/sesame/rice bran
Groundnut/sesame/rice bran/cottonseed þsoybean
Palmolein þsoyabean
Safflower/sunflower þpalmolein þmustard
Data are from Ghafoorunissa.
42
Health-promoting non-glyceride components include all oils, vitamin E, and plant sterols; sesame oil
includes lignans; rice bran oil includes tocotrienols and oryzanols; and palmolein includes tocotrienols. Oils to be used for frying include
palmolein/palm oil, groundnut, rice bran, sesame, and cottonseed as single/blends (home/commercial).
ALA, a-linolenic acid; LA, linoleic acid.
688 MISRA ET AL.
PDCAAS score). It is also relevant to consider the relationship
of the protein energy with the total dietary energy (pro-
tein:energy ratio). Protein requirement usually does not
change (unless body weight changes); however, the energy
requirement can change, thus changing protein:energy ratio.
Simply adding protein into the daily diet will not improve
muscle mass. Physical exercise is required to improve muscle
mass; because additional exercise will increase the energy
requirement, the protein:energy ratio is not likely to change
significantly.
Key principles
1. Optimal protein intake is required for healthy growth
and prevention of protein malnutrition.
2. Utilization of protein only occurs with a diet adequate
in micronutrients.
3. Usually, there is no need to recommend diets with a
protein:energy ratio of >15% for growth, or even when
enhancement or preservation of skeletal muscle mass is
required.
Recommendations
1. Protein intake should be based on body weight. This
should be 1 g/kg/day, considering the quality of pro-
tein in a usual Indian vegetarian diet.
2. In conjunction with energy intake, the protein intake
should provide 10–15% of the total calories/day in
sedentary to moderately active individuals.
3. Recommended protein sources:
a. Non-vegetarian: egg white, fish, and lean chicken.
b. Vegetarian: soya, pulses, whole grams (channa,rajma,
green gram, etc.), milk, and low fat dairy products.
Salt
Dietary sodium content is an important determinant of
individual and population levels of blood pressure. Reducing
dietary sodium consumption reduces blood pressure and
vascular risk.
46
The prevalence of hypertension is increasing
in urban India.
15
Some studies suggest an increasing trend of
high salt intake (8.5–9 g/day), which is considerably higher
than that recommended by the World Health Organization
(5 g/day).
47
Excess salt intake in Asian Indians may be due to
intake of Indian pickles (fruits and vegetables pickled and
preserved in salt and oil), papad (indigenous savory salty
snack), namkeens (salty fried snacks), and chutneys (condi-
ments, usually involving a fresh, chopped primary vegetable
or fruit with added seasonings mixed with salt used to en-
hance taste). Furthermore, consumption of salted potato chips
by children may be an additional important contributor to
high salt consumption.
48
Key principle
Consumption of salt should be restricted in accordance to
currently prevailing international guidelines.
Recommendations
1. Salt intake should be less than 5 g of sodium chloride
(or about 2 g of sodium)/day.
31
2. Addition of extra salt at the dining table should be
avoided.
3. Dietary intake of sodium from all sources ( pickles,
chutneys,namkeens,papads, bakery items, potato chips,
popcorn, salty biscuits, preserved meat products, other
pre-prepared and preserved foods, soups, cheese, and
fast foods) should be limited. Avoid processed foods
that have high salt content.
4. Reading of food labels to determine sodium content of
the commercial foods should be encouraged. Sodium in
such foods may be added in such foods in the form of
sodium benzoate, monosodium glutamate, baking
powder, and baking soda.
Sugar and Artificial Sweeteners
Simple sugars promote a positive energy balance. Total
energy increases when the energy density of the diet is in-
creased by sugars or fat.
49,50
Although common traditional
beverages consumed in Asian Indian households include
lemon water (with sugar and salt), tea (with sugar), and lassi
(a beverage made by blending yogurt with water and salt/
sugar), recently an increasing consumption of sweetened
carbonated beverages has been seen especially by adolescents.
On an average, about 1.8 cans of cola per week (540 mL/
week) per person consumption has been reported in urban
adolescents (1 can [300 mL] ¼132 kcal and 33–40 g of sugar).
51
Key principle
Intake of simple sugars should be restricted.
Recommendations
1. Free sugars should be less than 10% of total calories/
day, which includes all added sugars and sugars pres-
ent in honey, syrups, and fruit juices.
31
Table 8. Quantities of Foods Required
for Furnishing 0.1gofa-Linolenic Acid
Foods Grams
Cereal/millet
Wheat and pearl millet (bajra)70
Pulses
Black gram (kala chana), kidney beans
(rajmah), and cowpea (lobia)
20
Vegetables
Green leafy 60
Purslane (lunia)25
Other vegetables 400
Fruits*
Raspberry 80
Avocado 90
Guava 100
Strawberry 155
Kiwi 240
Spices
Fenugreek seeds (methi)5
Mustard (sarson)1
Unconventional oil seeds
Flaxseed (alsi) 0.5
Perilla seeds (Bhanjira) 0.3
Data are from Ghafoorunissa
43
unless otherwise indicated.
*U.S. Department of Agriculture Nutrient Data Base.
44
DIETARY GUIDELINES FOR ASIAN INDIANS 689
2. Alternatives to sweetened beverages can be water, skim-
med buttermilk, tender coconut water, and low fat milk.
3. Indian sweets (halwa [a gelatinous sweet dish made
from grain flour, ghee, sugar, and nuts] and kheer [a
sweet dish made from boiling rice with milk, sugar,
cardamoms, saffron, and nuts], puddings, ice creams,
sweetened biscuits, cakes, pastries, and baked goods
are high in added sugars and should be restricted.
4. Encourage reading of food labels to determine sugar con-
tent. Some of the names in the ingredients list for the
presence of added sugars include brown sugar, corn syrup,
dextrose,honey,maltsyrup,sugar,molasses,andsucrose.
Artificial sweeteners could be used in moderation. How-
ever, these do not contain any beneficial nutrients, and the
long-term health benefit, if any, is not clear in individuals
without diabetes. The Food and Drug Administration has
approved five artificial sweeteners: saccharin (e.g., Sweetex
[Reckitt Benckiser, Slough, UK]), aspartame (e.g., Equal [Ca-
dila Healthcare Ltd., Ahmadabad, India]), acesulfame-K (e.g.,
Sweet One [Hugestone Enterprise Co., Ltd., Jiangsu, China]),
neotame (e.g., NutraSweet [NutraSweet Co., Chicago, IL])
(both acesulfame-K and neotame are used in beverages, dairy
products, pharmaceutical products, chewing gum, etc.), and
sucralose (Sugar Free Natura [Acme Remedies, Malvern, PA])
as safe.
52–54
Although doubts have been raised regarding
safety of saccharin, the Food and Drug Administration has
approved it to be used in limited quantity because of low
price, good shelf life, and heat stability. Stevia (e.g., Stevi0cal
[Rigil BIotech (P) Ltd., New Delhi, India]) and some sugar
alcohols (e.g., erythritol [Zsweet
, Zsweet, Dublin, UK], etc.)
have been approved by the Food and Drug Administration
under Generally Recognized as Safe status.
Other Dietary Habits
Water
Water is necessary for metabolism and for physiological
functions in the body and is also a source of essential minerals,
including calcium, magnesium, and fluoride. Fluid require-
ments vary depending on individuals and specific population.
55
Advocacybysomeindividualsondrinkingexcessquantitiesof
water is scientifically untenable. However, increased water in-
take is recommended under special circumstances, such as
vigorous work and outdoor activity in hot climates.
56
Recommendation. An individual should have 1.5–2 L (8–
10 glasses) of water every day; intake could be increased in
hot climates.
Alcohol
According to the guidelines of the 2001 National Cholesterol
Education Program, Adult Treatment Panel III
57
and in 2006
the American Heart Association,
58
alcohol intake should be
limited to one drink per day (equivalent to 30 mL of whisky/
gin/vodka, 120 mL of wine, or 300 mL of beer) for women and
two such drinks per day for men. However, alcohol should not
be taken if serum triglycerides are 500 mg/dL or above
59
and in
the presence of significant liver dysfunction. Most of these
studies have evaluated white Caucasian subjects, and whether
these results can be extrapolated in Asian Indians, who already
have a high prevalence of fatty liver, is not clear.
Recommendations. Regular excessive intake of alcohol is
harmful. Until more data are available for Asian Indians,
nonconsumers of alcohol should not have alcohol; however,
individuals taking a small quantity of alcohol should not be
discouraged.
Food choices while eating out
The report of the Joint World Health Organization/Food
and Agriculture Organization Expert Consultation on ‘‘Diet,
Nutrition, and the Prevention of Chronic Diseases’’ clearly
stated that eating behaviors linked to overweight/obesity and
consequent chronic diseases include snacking/eating fre-
quency, binge-eating patterns, and eating out.
31
Recommendations.
1. Choose healthy snacks.
2. Follow the healthy dietary guidelines while eating out
as described above.
3. Smaller-sized portion should be preferred.
4. Avoid sweetened carbonated drinks and commercially
available high calorie drinks and opt for beverages like
buttermilk, coconut water, fresh lime with water, etc.
Meal portion and times
Psychological parameters of eating patterns also seem to
influence risk of obesity, with the ‘‘flexible restraint’’ pattern
having lower risk of overweight than the ‘‘rigid restraint/
periodic disinhibition’’ pattern. In the same context, a high
frequency of eating shows a negative relationship with weight
gain.
31
Recommendations.
1. Small frequent meals at regular intervals should be taken.
2. The gap between two meals should be 3–4 hours.
Regular breakfast
Eating breakfast plays a significant role in effective weight
control. The National Health and Nutrition Examination
Survey III (1988–1994) data showed that people who skip
breakfast had higher mean body mass index than those who
did not.
60
Breakfast skipping leads to excessive/imbalanced
eating later in day, a dietary pattern associated with obesity.
Recommendation. A healthy regular breakfast should be
an essential part of the meal plan.
Cooking methods
Correct cooking methods can minimize intake of fats in
the diet.
Recommendations. To minimize dietary fat intake, deep-
frying of foods should be avoided.
61
If such a cooking method
is unavoidable, then methods (such as using a blotting paper)
should be used to drain out the excess oil from the fried
cooked food.
Instead, roasting or grilling not only eliminates added oil
but may also allow any fat already present in food to drip
away. Hence, the following methods are recommended:
690 MISRA ET AL.
boiling, steaming, roasting, grilling, stewing, broiling, or
making saute
´ed and poached preparations.
Conclusions
In comparison with the previous guidelines of the National
Institute of Nutrition, the Consensus Group recommends a
reduction in the intake of carbohydrate (50–60% of total en-
ergy/day), preferential intake of complex carbohydrates and
low GI foods, higher intake of fiber (25–40 g/day), lower in-
take of saturated fats (less than 10% of total energy/day),
optimal ratio of essential fatty acids/day (LA 5–8% and ALA
1–2 % of total energy, optimal ratio of LA/ALA 5–10, cis
MUFAs 10–15%, TFAs <1% of total energy), slightly higher
protein intake (10–15% of total energy/day), lower intake of
salt (5 g/day), and restricted intake of sugar (less than 10% of
total energy/day). Although these guidelines are applicable
to Asian Indians in any geographical setting, they are partic-
ularly applicable to those residing in urban and in semi-urban
areas. Proper application of these guidelines will help curb the
rising ‘‘epidemics’’ of the metabolic syndrome, T2DM, and
CVD in Asian Indians.
Appendix 1
Anoop Misra, M.D., Fortis CDOC Center of Excellence for
Diabetes, Metabolic Diseases and Endocrinology, Fortis Flt.
Lt. Rajan Dhall Hospital, Vasant Kunj; Diabetes Foundation
(India) & National Diabetes, Obesity and Cholesterol Foun-
dation, New Delhi, India; Rekha Sharma, M.Sc., Diabetes
Foundation (India) & Medanta, The Medicity, Gurgaon, In-
dia; Seema Gulati, Ph.D., Diabetes Foundation (India) & Na-
tional Diabetes, Obesity & Cholesterol Foundation; Shashank
R. Joshi, M.D., D.M., Lilavati & Bhatia Hospital, Mumbai,
India; Vinita Sharma, Ph.D., Department of Science and
Technology, Ministry of Science & Technology, New Delhi;
Ghafoorunissa, Ph.D., National Institute of Nutrition, Hy-
derabad, India; Ahamed Ibrahim, Ph.D., National Institute of
Nutrition; Shilpa Joshi, M.Sc., Mumbai Diet and Health
Centre, Mumbai; Avula Laxmaiah, MBBS, M.P.H., National
Institute of Nutrition; Anura Kurpad, M.D., Ph.D., St. John’s
Research Institute, Bangalore, India; Rebecca K. Raj, Ph.D., St.
John’s Research Institute; Viswanathan Mohan, M.D., Ph.D.,
Dr. Mohan’s Diabetes Specialties Centre, Chennai, India;
Hemraj Chandalia, M.D., Jaslok, Saifee, and Breach Candy
Hospitals, Mumbai; Kamala Krishnaswamy, M.D., National
Institute of Nutrition; Sesikeran Boindala, M.D., National In-
stitute of Nutrition; Sarath Gopalan, M.D., Nutrition Foun-
dation of India, New Delhi; Siva Kumar Bhattiprolu, Ph.D.,
National Institute of Nutrition; Sonal Modi, M.Sc.,
Dr. Chandalia’s Diabetes Endocrine Nutrition Management
and Research Centre, Mumbai; Naval K. Vikram, M.D., All
India Institute of Medical Sciences, New Delhi; Brij Mohan
Makkar, M.D., Sri Balaji Action Medical Institute, Delhi, India;
Manju Mathur, M.Sc., Government Medical College & Hos-
pital, Chandigarh, India; Sanjit Dey, Ph.D., University of
Calcutta, Kolkata, India; Sudha Vasudevan, M.Sc., Madras
Diabetes Research Foundation, Chennai; Shashi Prabha
Gupta, M.Sc., Ministry of Women and Child Development,
Government of India, New Dehli; Seema Puri, Ph.D., Institute
of Home Economics, New Delhi; Prashant Joshi, M.D., Indira
Gandhi Government Medical College, Nagpur, India; Kumud
Khanna, Ph.D., Institute of Home Economics, New Delhi;
Prashant Mathur, M.D., Indian Council of Medical Research,
New Delhi; Sheela Krishnaswamy, M.Sc., ChiHealth, Banga-
lore; Jagmeet Madan, Ph.D., SVT College of Home Science,
Mumbai; Madhukar Karmarkar, M.D., Diabetes Foundation
(India); Veenu Seth, Ph.D., Lady Irwin College, New Delhi;
Santosh Jain Passi, Ph.D., Institute of Home Economics; Da-
vinder Chadha, M.D., D.M., Command Hospital, Bangalore;
and Swati Bhardwaj, M.Sc., Diabetes Foundation (India) &
National Diabetes, Obesity & Cholesterol Foundation.
Appendix 2
Conceptualization, Execution, and Steering Committee
Anoop Misra, Rekha Sharma, Shashank R. Joshi, Vinita
Sharma, Brij Mohan Makkar, and Seema Gulati.
Core Faculty and Expert Panelists
Anoop Misra, Ahmad Ibrahim, Anura Kurpad, Sesikeran
Boindala, Siva Kumar Bhattiprolu, Brij Mohan Makkar, Da-
vinder Chadha, Dheeraj Bhatia, G.S. Toteja, Ghafoorunissa,
Hemraj Chandalia, Ishi Khosla, Jageet Madan, Kamla Krish-
naswamy, Kumud Khanna, Avula Laxmaiah, Madhukar Kar-
markar, Naval K. Vikram, Prashant Mathur, Prashant Joshi, P.K.
Chowbey, Prema Ramachandran, Priyali Shah, Puneet Mishra,
Radhika Govindh, Rajiv Gupta, Rekha Sharma, Rebecca K. Raj,
Ritesh Gupta, R.M. Pandey, Sarath Gopalan, Seema Gulati,
SeemaPuri,S.K.Wagnoo,ShashankR.Joshi,ShashiPrabha
Gupta, Shaukat Sadicot, Santosh Jain Passi, Shilpa Joshi, Sonal
Modi,U.V.Mani,UshaSrivastava, Vishwanathan Mohan, Va-
nisha Nambiar, Vinita Sharma, and Y.P. Munjal.
Lead Groups for Manuscript Preparation:
overall (concept, design, editing, flow,
and all the lead topics as below)
Anoop Misra, Rekha Sharma, Seema Gulati, Shashank R.
Joshi, and Vinita Sharma.
Trends in the Macronutrient Intake: Avula Laxmaiah.
Proteins, Salt, and Sugar: Anura Kurpad, Rebecca Kuriyan
Raj, and Shilpa Joshi.
Carbohydrates: Hemraj Chandalia, Sonal Modi, Vishwa-
nathan Mohan, Radhika Ganeshan, and Sudha Vasudevan.
Fats: Ghafoorunissa, Ibrahim Ahmad, and Shashank R.
Joshi.
Other Dietary Habits: Anoop Misra and Seema Gulati.
Other participating faculty
Aachu Agarwal, Ana A. Sinha, Ankita, Anshu Gupta,
Anuja Aggarwal, Ashutosh, Beena Mathur, Chhavi Kohli,
Dimple Kondel, Gyan Prakash, Himanshu, Jaya Mathai,*
Jasjeet S. Wasir, Kanika Dhawan, Kanika Varma, Kollung
Longmei, Lokesh Khurana, Mahak Sharma, Mallika Jankira-
man, Manish Bansal,* Manju Mathur, Meenakshi, Meeta Lall,
Nammita Bhatia, Namrata Singh, Neha Mithal, Neha Singhal,
Nimali Singh, Prashant Sakharkar, Pratima Shrama, Priyanka
Nigam, Puneet Kaur Chadha, Rahul Mehrotra, Rajiv Gupta,
Ravi R. Kasliwal,* Richa Ravindra, Ritu Jain, S.N. Bhat, Sanjit
Dey, Shabnam Chabbra, Sheela Krishnaswamy,* Shikha Rai,
Shilpa Wadhva, Shreya Pandey, Shukha Rai, Shweta Khen-
delwal, Surya Prakash, Swati Bhardwaj, Umesh Kapil, Va-
sundhara Singh, Vatsala, Veny Uppal, Veenu Seth,* and Vilas
DIETARY GUIDELINES FOR ASIAN INDIANS 691
Shirhatti. (*These individuals were physically not present but
have actively contributed to the guidelines.)
Institutions represented
Science for Equity, Empowerment and Development Di-
vision, Department of Science and Technology, Ministry of
Science and Technology, Government of India, New Delhi;
Department of Diabetes and Metabolic Diseases, Fortis Hos-
pital, New Delhi; Fortis CDOC Center of Excellence for Dia-
betes, Metabolic Diseases and Endocrinology, Fortis Flt. Lt.
Rajan Dhall Hospital, Vasant Kunj, New Delhi; Diabetes
Foundation (India), New Delhi; National Diabetes, Obesity
and Cholesterol Foundation, New Delhi; National Institute of
Nutrition, Hyderabad; St. John’s Research Institute, St. John’s
National Academy of Health Sciences, Bangalore; All India
Institute of Medical Sciences, New Delhi; Lilavati & Bhatia
Hospital, Mumbai; Dr. Mohan’s Diabetes Specialties Center,
Chennai; Jaslok, Saifee, and Breach Candy Hospitals, Mum-
bai; Nutrition Foundation of India, New Delhi; Sri Balaji Ac-
tion Medical Institute, New Delhi; Government Medical
College & Hospital, Chandigarh; Department of Physiology,
University of Calcutta, Calcutta; Food and Nutrition Board,
Ministry of Women & Child Development, Government of
India, New Delhi; Department of Nutrition, Institute of Home
Economics, New Delhi; Lady Irwin College, New Delhi; De-
partment of Medicine, Indira Gandhi Government Medical
College, Nagpur; Indian Council of Medical Research, De-
partment of Health Research, Ministry of Health and Family
Welfare, Government of India, New Delhi; Department of
Food and Nutrition, SVT College of Home Science, SNDT
Women’s University, Mumbai; and Command Hospital (Air
Force), Bangalore.
Acknowledgments
This study was partially funded by the Department of
Science and Technology, Ministry of Science and Technology,
Government of India; Nestle
´India; Marico Ltd.; GlaxoSmith-
Kline Pharmaceuticals Ltd.; and PepsiCo India. We ac-
knowledge the cooperation and support from all the
participants of the consensus process.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Anoop Misra, M.D.
Chairman
Fortis-CDOC Center of Excellence for Diabetes, Obesity
Metabolic Diseases and Endocrinology
Fortis Flt. Lt. Rajan Dhall Hospital
Vasant Kunj
New Delhi 110070, India
E-mail: anoopmisra@metabolicresearchindia.com
694 MISRA ET AL.
... However, some of the commonly consumed food, such as potato chips, contained high amounts of palmitic acid, which could be attributed to the type of cooking oil used in their preparation [55]. The WHO's dietary guidelines [56] state that SFA consumption should be less than 10% of total energy intake, and the National Dietary Guidelines Consensus Group [57] recommends that for Asian Indians who have higher LDL concentration (≥ 100 mg/dL), SFA intake should be < Figure 2. Interaction of GRS with SFA intake on log-transformed waist circumference. p values adjusted for age, sex, type 2 diabetes, duration of diabetes, anti-diabetic medication, smoking status, and alcohol intake. ...
... However, some of the commonly consumed food, such as potato chips, contained high amounts of palmitic acid, which could be attributed to the type of cooking oil used in their preparation [55]. The WHO's dietary guidelines [56] state that SFA consumption should be less than 10% of total energy intake, and the National Dietary Guidelines Consensus Group [57] recommends that for Asian Indians who have higher LDL concentration (≥100 mg/dL), SFA intake should be <7% of total energy intake per day. Moreover, intake of SFA at 8.6% of total energy was found to be associated with increased risk of T2D in Indians [55]. ...
... Moreover, intake of SFA at 8.6% of total energy was found to be associated with increased risk of T2D in Indians [55]. In the present study, the median intake of SFA was 8.5% of total energy intake, which is within the WHO's dietary guidelines [56], but as Indians are predisposed to dyslipidaemia, reducing SFA even further as recommended by the National Dietary Guidelines Consensus Group [57] might help to prevent central obesity in individuals with a high genetic risk. ...
Article
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Abnormalities in lipid metabolism have been linked to the development of obesity. We used a nutrigenetic approach to establish a link between lipids and obesity in Asian Indians, who are known to have a high prevalence of central obesity and dyslipidaemia. A sample of 497 Asian Indian individuals (260 with type 2 diabetes and 237 with normal glucose tolerance) (mean age: 44 ± 10 years) were randomly chosen from the Chennai Urban Rural Epidemiological Study (CURES). Dietary intake was assessed using a previously validated questionnaire. A genetic risk score (GRS) was constructed based on cholesteryl ester transfer protein (CETP) and lipoprotein lipase (LPL) genetic variants. There was a significant interaction between GRS and saturated fatty acid (SFA) intake on waist circumference (WC) (Pinteraction = 0.006). Individuals with a low SFA intake (≤23.2 g/day), despite carrying ≥ 2 risk alleles, had a smaller WC compared to individuals carrying < 2 risk alleles (Beta = −0.01 cm; p = 0.03). For those individuals carrying ≥ 2 risk alleles, a high SFA intake (>23.2 g/day) was significantly associated with a larger WC than a low SFA intake (≤23.2 g/day) (Beta = 0.02 cm, p = 0.02). There were no significant interactions between GRS and other dietary factors on any of the measured outcomes. We conclude that a diet low in SFA might help reduce the genetic risk of central obesity confirmed by CETP and LPL genetic variants. Conversely, a high SFA diet increases the genetic risk of central obesity in Asian Indians.
... These are 1200 Kcal for those with initial weight of 54-77 kg, 1500 Kcal for 80-98 kg, 1800 Kcal for 100-112 kg, and 2000 Kcal for an initial weight of more than 114kg (Cunningham et al., 2006). Similarly, the European or Canadian guidelines recommend 45-60% of total energy as carbohydrate, 10-20% as protein, and less than 35% as fat while Indian guidelines recommend 50-60% energy from carbohydrates, 10-15% from protein (Dworatzek et al., 2013;Mann et al., 2004), and less than 30% from fat (Misra et al., 2011). However, the American Diabetes Association concluded that there is no ideal mix of macronutrients for all people with diabetes and recommended individually tailored goals (Evert et al., 2013). ...
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Background: Management of diabetes demands reduction of carbohydrates and moderation of total calories, fats and protein to promote weight loss while controlling postprandial blood glucose. Hospitals prescribe menus to diabetic patients to achieve these reasons. Whether these menus provide meals that help improve diabetes outcome remains unknown. Aim: Therefore, this study assessed six menus from six different referral hospitals in Malawi. Method: We formulated three separate diets (n = 3) encompassing breakfast, 10 am snack, lunch, 3 pm snack and super that a diabetic person would consume in a day as prescribed by each menu. We developed nutritionally adequate meals based on foods listed on the menu. We calculated, using the Malawi Food Composition Table (MFCT), total available carbohydrates, energy, protein, total fats, SAFA, MUFA and PUFA that each diet provides. We averaged the nutrient content from the three diets. Results: Menus from QECH and ST Joseph Mission Hospital provide significantly higher total carbohydrates (p = 0.001), total energy (p = 0.000) and fats (p = 0.01) but contain similar proteins (p = 0.761). The proportion of energy from carbohydrates for all the menus is very high and ranges from 68–81% while protein and fat proportions are lower and range from 7–16% and 7–20%, respectively. Conclusion: These menus have high propensity to increase postprandial blood glucose and promote weight gain that could be harmful to a diabetic person. All the menus deviate from a somehow recommended energy contribution of approximately 50:25:25 from carbohydrates, fat and protein, respectively.
... /fmed. . healthy living and obesity prevention and related disorders in Asian Indians (50). ...
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Current evidence suggests obesity alters the expression of various genes related to oxidative stress, inflammation, and aging. The complementary therapy like yoga-based lifestyle intervention (YBLI) is used as an adjunct therapy to modern medicine. This study examines the efficacy of 12-weeks of YBLI with standard care (SC) on the expression of genes related to oxidative stress, inflammation, and aging in obese adults. This was a two-arm parallel randomized control trial implemented at Integral Health Clinic (IHC), an outpatient facility that regularly conducted YBLI programs for the prevention of lifestyle diseases like obesity and diabetes in the Department of Physiology, All India Institute of Medical Sciences (AIIMS), New Delhi. Blood samples at baseline and weeks 2,4 and 12 were collected from 72 adults (male n=21; female n=51) of age 20-45 years with a body–mass index (BMI) of 25–35 kg/m2 who were randomized to receive either a 12-week SC (n=36) or YBLI (n=36). SC included recommendations for the management of obesity as per Indian guidelines including a low-calorie individualized diet and physical activity. Asana (physical postures), pranayama (breathing exercises), and meditation were included in the YBLI. Primary outcomes were relative fold changes in the expression of genes associated with oxidative stress (Nuclear factor-kappa B [NF-Kappa B]), inflammation (Tumour necrosis factor-α [TNFα], interleukin-6 [IL-6]), and aging (human telomerase reverse transcriptase [TERT]) in peripheral blood mononuclear cells between the two groups at week-12. There were no significant changes in fold change of TERT, IL-6, and NF-kappa B between the groups at week 12. The relative fold change of TERT was significantly greater in the YBLI group (p=<0.0001) vs the SC group at 2 weeks. TERT expression was significantly increased at week 2 though the change was greater in the YBLI group (p<0.0001). TNF-α gene expression was significantly lower at weeks 2 and 4, compared to baseline level, in the SC group but it increased at week 12. The results while did not confirm our hypothesis, are important to share with the scientific society, to be able to improve prospective study designs and find optimal time/intervention/biological marker settings for this highly important scientific field.
... The Indian dietary guidelines for managing T2DM recommend 50-60% energy from carbohydrates, 10-15% from protein, and \30% from fat [48]. However, India has the lowest (\48 g/day) average protein consumption [49] and the highest carbohydrate consumption [50,51]. ...
Article
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Introduction: Partial meal replacement (PMR) offers potential glycemic and weight control benefits in type 2 diabetes mellitus (T2DM) patients. We evaluated the clinical impact of PMR (diabetes-specific nutritional supplement [DSNS]) in overweight/obese Indian patients with T2DM. Methods: PRIDE, a 12-week, phase IV, open-label, multicenter study randomized (1:1) newly diagnosed T2DM patients (≤ 1 year) to either DSNS plus standard of care (SOC; diabetes treatment with dietary counseling) group (PMR) or SOC alone group (SOC). The primary endpoint was mean change in glycated hemoglobin (HbA1c) from baseline to week 12. Secondary endpoints were changes in glucose profiles, body weight, waist circumference, lipid profile, and factors impacting quality-of-life (QoL) at week 6 and 12 from baseline. Safety was assessed throughout the study. Results: Of the 176 patients enrolled, 171 (n = 85 in PMR group; n = 86 in SOC group) were included in the modified intent-to-treat population. The mean reduction in HbA1c at week 12 from baseline in PMR group was significant compared to the SOC group (- 0.59 vs. - 0.21%, p = 0.002). At week 12, the PMR group showed significant reduction in mean body weight (- 2.19 vs. - 0.22 kg; p = 0.001) and waist circumference (- 2.34 vs. - 0.48 cm; p = 0.001) compared to SOC group. Mean fasting plasma glucose and post-prandial glucose significantly reduced from baseline at week 6 and 12 in each group (p < 0.05). No significant change was observed in lipid profile. QoL parameters (treatment adherence, general well-being, and energy fulfilment) in the PMR were significantly better than SOC group (p < 0.05). Patients were satisfied with the taste of DSNS. No serious adverse events were reported. Conclusions: DSNS is an encouraging option for PMR strategy, as it significantly improved HbA1c, body weight, waist circumference, and overall well-being among overweight/obese Indian T2DM patients. Trial identification no: CTRI/2019/10/021595.
... 43 The consensus group recommends a reduction in simple carbohydrates intake (50-60% of total energy), favourable intake of complex carbohydrates, and low GI foods for Asian Indians. 44 The excessive intake of sugar along with other refined carbohydrates is a major factor driving the epidemics of T2D and CVD among the Asian Indian population. 45 A randomized controlled trial on the rural population of West Bengal, India detailed that long-term consumption of carbohydrate-rich diet results in increased levels of fasting blood glucose, TG, very low-density lipoprotein and fasting serum insulin level which have a significant role in the development of insulin resistance syndrome, dyslipidemia, and subclinical inflammation. ...
... All patients were encouraged to have meals according to Asian Indian guidelines that took into consideration weight, activity level, etc (20). All patients were told to perform physical activity as per guidelines for Asian Indians (21). ...
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Background and Objective Excess hepatic and pancreatic fat may contribute to hyperglycemia. The objective of this study was to examine the effect of dapagliflozin (SGLT-2 inhibitor) on anthropometric profile, liver, and pancreatic fat in patients with type 2 diabetes mellitus (T2DM). Research Design and Methods This is an observational interventional paired study design without a control group. Patients (n, 30) were given dapagliflozin 10mg/day (on top of stable dose of metformin and/or sulphonylureas) for a period of 120 days. Changes in anthropometry (circumferences and skinfold thickness), surrogate markers of insulin resistance, body composition, liver, and pancreatic fat (as were measured by MRI-derived proton density fat fraction) were evaluated. Result After 120 days of treatment with dapagliflozin, a significant reduction in weight, body mass index (BMI), body fat, circumferences, and all skinfold thickness was seen. A significant reduction in blood glucose, hemoglobin A1c, hepatic transaminases, fasting insulin, homeostatic model assessment –insulin resistance (HOMA-IR), and postprandial C-peptide was noted while HOMA-beta, post parandial insulin sensitivity and fasting adiponectin were significantly increased. There was no change in lean body mass. Compared to baseline there was a significant decrease in mean liver fat fraction (from15.2 to 10.1%, p <0.0001) and mean pancreatic fat fraction (from 7.5 to 5.99%, p <0.0083). Reduction in liver fat was significant after adjustment for change in body weight. Conclusion Dapagliflozin, after 120 days of use, reduced pancreatic and liver fat and increased insulin sensitivity in Asian Indian patients with T2DM.
... Research evidence show that a diet containing an abundance of fruits and vegetables, fish, whole grains offers significant protection and lowers CVD risk. 52 The National Dietary Guidelines Consensus Group recommends reducing carbohydrates and high glycemic foods, preferential intake of complex carbohydrates, higher intake of fiber and unsaturated fats, reduction in transfatty acids, and salt intake, etc. 53 Traditional diets in LMIC, once rich in whole grains and dietary fibers, now include highly refined carbohydrates, such as polished white rice and refined flours. Global Nutrition and Epidemiologic Transition Initiative recommended increasing whole grain and cereal fiber consumption and reducing total and high-glycemic index carbohydrate strategies to prevent T2DM and CVD in the general population. ...
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The epidemic of obesity or adiposity-based chronic diseases presents a significant challenge with the rising prevalence of morbidities and mortality due to atherosclerotic cardiovascular diseases (ASCVD), especially in low- and middle-income countries (LMIC). The underlying pathophysiology of metabolic inflexibility is a common thread linking insulin resistance to cardiometabolic-based chronic disease (CMBCD), including dysglycemia, hypertension, and dyslipidemia progressing to downstream ASCVD events. The complex CMBCD paradigm in the LMIC population within the socio-economic and cultural context highlights considerable heterogeneity of disease predisposition, clinical patterns, and socio-medical needs. This review intends to summarize the current knowledge of CMBCD. We describe recently established or emerging trends for managing risk factors, assessment tools for evaluating ASCVD risk, and various pharmacological and non-pharmacological measures particularly relevant for LMICs. A CMBCD model positions insulin resistance and β-cell dysfunction at the summit of the disease spectrum may improve outcomes at a lower cost in LMICs. Despite identifying multiple pathophysiologic disturbances constituting CMBCD, a large percentage of the patient at risk for ASCVD remains undefined. Targeting dysglycemia, dyslipidemia, and hypertension using antihypertensive, statins, anti-glycemic, and antiplatelet agents has reduced the incidence of ASCVD. Thus, primordial prevention targeting pathophysiological changes that cause abnormalities in adiposity and primary prevention by detecting and managing risk factors remains the foundation for CMBCD management. Therefore, targeting pathways that address mitochondrial dysfunction would exert a beneficial effect on metabolic inflexibility that may potentially correct insulin resistance, β cell dysfunction and, consequently, would be therapeutically effective across the entire continuum of CMBCD.
... The plan included carbohydrates (50%-60%), fats (total fat <30%, saturated fat <10%, monosaturated fat 10%-15%, polyunsaturated fat 5%-8%, cholesterol <200-300 mg/day), protein 10%-15%, dietary fiber 25-40 g/day, and salt intake <5 g/day. 33 A moderate-intensity physical activity (30 min for 5 days/week), for example, jogging (4-7 m/sec), brisk walking, stair climbing, cycling, and swimming, was also prescribed. 34 Yoga-based lifestyle intervention. ...
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Background: Telomeres and telomerase are considered cardinal biomarkers of cellular aging. Shorter telomeres and low telomerase activity have been associated with obesity and accelerated aging. Objective: To compare the effects of a yoga-based lifestyle intervention (YBLI) with the standard of care (SOC) on cellular aging by estimating telomere length (TL) and telomerase activity in obesity. Design and setting: A parallel, two-arm, randomized-controlled trial was conducted at the Integral Health Clinic, Department of Physiology, All India Institute of Medical Sciences, New Delhi, from March 2017 to October 2019. Participants: Obese (n = 72), body mass index (BMI), 25–35 kg/m2, aged 20–45 years, male (21), and female (51). Intervention: Seventy-two obese participants were randomized to receive either a 12-week SOC (n = 36) or YBLI (n = 36). SOC included management of obesity as per Indian guidelines including a hypocaloric individualized diet and physical activity. The pretested YBLI included asana (physical postures), pranayama (breathing exercises), and meditation. Methods: Blood samples were collected from both the groups at baseline, 2, 4, and 12 weeks. DNA was extracted from peripheral blood mononuclear cells. TL was measured by quantitative PCR, and serum telomerase levels by immunoassay. Outcome measures: Primary outcome measures were the changes in the TL and telomerase levels between the two groups at week 12. Secondary outcome measures were the changes in TL and telomerase, and anthropometric parameters (body weight, BMI, waist-to-hip ratio) at 2, 4, and 12 weeks of intervention in both SOC and YBLI groups. Results: There were no significant changes in TL and telomerase levels between the groups at week 12. The TL was significantly greater in the YBLI group versus the SOC group (p < 0.0001) at 2 weeks. The anthropometric and physiological parameters were influenced positively by both SOC and YBLI. Conclusion: The study did not meet the primary objective, although the results are suggestive of a positive impact of YBLI on aging in obesity as noted within the YBLI group. However, the results should be interpreted carefully, and in the light of other published data. Larger studies to better understand the possible positive benefits of YBLI on cellular aging are recommended. Clinical Trial Registration No. CTRI/2016/08/007136.
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Achieving lasting impact on health outcomes requires a focus not just on patient care, but on community wide approaches (such as school) aimed at improving population health. Interventions that address the conditions in the places where we live, learn, work, and play have the greatest potential impact on our health and beginning early in school settings can go a long way. The study aimed to assess the biophysical and anthropometric indices of children enrolled in a customized sports club in a school setting along with assessing the feasibility and effectiveness of establishing a customized “Sports Club” in a school setting. Uncontrolled quasi experimental design was employed. Students of 5 – 8 standard who consented to participate were enrolledin a customized “Active Sports Club” for 90days. Pre-tested questionnaire, anthropometric and biophysical measurements were conducted before and after the intervention. The customized sports club schedule included 15 minutes of Pranayam daily; fixed set of aerobic exercise and sports conducted alternately. Overall the enrollment of boys (64%) was double than girls (36%) in the sports club and girls of 12-14 years had higher values of total body fat (TBF%) as per the cut-offs. Blood pressure values were in the “at risk” range. The sports club was well accepted by students, teachers and parents. Post intervention proportion of children having normal nutritional status increased; undernourished decreased while overweight remained stagnant. TBF percent values did not shift in “at risk” category and the blood pressure values reduced dramatically among the selected children. The customized sports clubcan be extrapolated the school facilities and could be managed with existing staff as well as time and a positive impact on the anthropometric and biophysical parameters of the participants was recorded.
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The purpose of the WHO scientific review on trans fatty acids (TFAs) was to examine the evidence generated since the 1993 Joint FAO/WHO Expert Consultation on Fats and Oils in Human Nutrition, and to inform member countries on the health consequences of TFAs consumption that have emerged since the last report was released. The new information was deemed sufficient to recommend the need to significantly reduce or to virtually eliminate industrially produced TFA from the food supply in agreement with the implementation of the 2004 WHO Global Strategy on Diet, Physical Activity and Health. This goal has been accomplished in some countries and cities, by the virtual elimination of partially hydrogenated vegetable oils in the human food supply, replacing them with healthy cis-unsaturated fatty acids. The document provides the evidence base to promote discussion between the international scientific community related to nutrition and health as well as between agriculturalists, food producers, relevant health professionals, national and international food regulatory agencies, civil society and the private sector to achieve the stated goal.Keywords: trans fatty acids, coronary heart disease, partially hydrogenated vegetable oils, feasibility, Scientific Update
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This important and timely book comprises the comprehensive and authoritative independent report of the British Nutrition Foundation Task Force on the link between emerging aspects of diet and cardiovascular disease, a major cause of early death and disability. Written by leading experts in the area, Cardiovascular Disease: Diet, Nutrition and Emerging Risk Factors looks further than the well recognised factors such as high blood cholesterol and smoking to identify and explore more subtle markers of risk. Chapters include coverage of novel lipid factors, vascular function, clotting factors, inflammatory factors, oxidative stress and homocysteine and early origins of adult disease. The impact of obesity, insulin resistance, genetic predisposition and factors related to adipose tissue are also addressed. Of vital use to a wide range of health professionals this cutting-edge book provides the reader with: Core information for health professionals as well as those involved in food formulation in the food industry. A dedicated question and answer chapter. Important conclusions and recommendations with 'take-home messages' Dietitians, nutritionists, general and family practitioners, cardiologists, cardiovascular specialists, community nurses, personnel in the food industry involved in product formulation, production, labelling of packaging and marketing will find this a valuable reference. Lecturers, undergraduates and postgraduates in nutrition, dietetics, food science and medicine; libraries in all research establishments, commercial organisations, medical schools and universities where these subjects are studied or taught will also find this an important addition to their shelves.
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Twenty animal and plant foods (1.5-cm cubes) were deep-fat fried for varying times and their fat contents were determined. Sixteen of the foods absorbed frying fat (6.1 to 86.3 g/ 100 g, dry weight basis), with the higher amounts being absorbed into the plant foods that initially had high water and low fat contents than into the animal foods (up to 21.8 g fat absorbed/ 100 g). One animal food underwent a net loss of fat, while three animal foods showed no significant change in fat. Fish sticks were coated with six types of coatings and deep-fat fried. Frying fat uptake into the coating, fish, and the total product was measured. Batters but not breadings markedly retarded fat movement into the fish.
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LR: 20061115; JID: 7501160; 0 (Antilipemic Agents); 0 (Cholesterol, HDL); 0 (Cholesterol, LDL); 57-88-5 (Cholesterol); CIN: JAMA. 2001 Nov 21;286(19):2401; author reply 2401-2. PMID: 11712930; CIN: JAMA. 2001 Nov 21;286(19):2400-1; author reply 2401-2. PMID: 11712929; CIN: JAMA. 2001 Nov 21;286(19):2400; author reply 2401-2. PMID: 11712928; CIN: JAMA. 2001 Nov 21;286(19):2400; author reply 2401-2. PMID: 11712927; CIN: JAMA. 2001 May 16;285(19):2508-9. PMID: 11368705; CIN: JAMA. 2003 Apr 16;289(15):1928; author reply 1929. PMID: 12697793; CIN: JAMA. 2001 Aug 1;286(5):533-5. PMID: 11476650; CIN: JAMA. 2001 Nov 21;286(19):2401-2. PMID: 11712931; ppublish