How does the Indian diet fit in with the EAT-Lancet Reference Diet?

There is much interest in discovering and assessing diets to maintain or enhance health without imposing an undue cost on the ecosystem. In 2019, the EAT-Lancet Commission published recommendations about healthy diet patterns that can sustain 10 billion people in an environmentally friendly manner by 2050.

Based on this, in 2020, a group of researchers at India’s International Food Policy Research Institute analyzed how well the Indian food consumption pattern agrees with this reference diet. The paper, published in the journal BMC, reveals that most of India remain undernourished, with inadequate protein intake, fruits, and vegetables.

Study: A comparison of the Indian diet with the EAT-Lancet reference diet. Image Credit: Social Media Hub / Shutterstock

Introduction

An unhealthy pattern of food consumption is inevitably linked to poor nutrition and chronic diseases, being a major risk factor, along with lack of adequate physical activity, for non-communicable diseases (NCD). Poor diet quality is marked by attributes such as increased consumption of fats, especially of animal origin; inadequate intake of fruits and vegetables; high salt consumption; and increased intake of highly processed foods.

India suffers from both communicable and non-communicable diseases. Over the years from 1990 to 2016, heart disease was reported to be the number one killer among diseases. This is typically related to overnutrition or eating too much.

The primary risk factor for disability was, meanwhile, dietary iron deficiency. This is typically the result of malnutrition. Thus, these conditions form a syndemic reflecting the presence of both excessive and inadequate food consumption in India.

The EAT-Lancet diet

In producing food for human consumption, it is necessary to protect the planet against exploitation. The EAT-Lancet reference diet delineates a diet for various age groups beginning at two years. Overall, it comprises plant-based foods, for the most part, contributing carbohydrates, proteins, unsaturated oils, vitamins, and minerals.

Fish, other seafood, and poultry are included in moderate amounts, but meat (red or processed) is absent or present in small amounts only. Added sugar, white flour, and starchy vegetables are all excluded. This diet only lays out a pattern, acknowledging the different needs of the two sexes, various stages of growth and development, the presence of pregnancy, sickness, or increased physical activity.

The central point at which the EAT-Lancet reference diet diverges from other recommended daily allowances (RDAs) established by various professional bodies is that it also accounts for the ecological footprint of the foods included. In the current paper, however, this aspect of the Indian diet is not explored.

The Consumption Expenditure Survey (CES) provided data for the study. This is a national survey by the National Sample Survey Organization (NSSO) covering a representative sample of households, both rural and urban, carried out in 2011-12.

The survey covered almost 7,500 rural and over 5,000 urban households, providing the most recent representative data available in India. The scientists used the NSSO food consumption data to calculate the daily calories from each food group.

Indians include refined flour or white flour, semolina, rice and wheat flour, and other processed cereals, to make staple foods as well as snacks. Oils used in the NSSO’s CES survey vary somewhat from the classification used by the EAT-Lancet group in that Indians tend to use both saturated and unsaturated oils either as a mixture or alternatively.

They are also fond of sweet drinks, such as tea, coffee, and other drinks, along with chips and chocolates. Spices make up 1-2% of total calories in the Indian diet but are unaccounted for in the EAT-Lancet reference diet.

What did the study show?

Even as India claims its place as a global power, the NSSO data from a little over a decade ago reveals that mean daily food consumption still falls below the recommended level of ~2,500 kcal/day for 95% of the population. Only the top 5% in terms of income levels have daily intakes at or exceeding these levels.

People in the top deciles of monthly per capita consumption expenditure (MPCE) consumed about a fifth more than the reference diet, at about 3,000 kcal/day. This is two times the consumption of those in the lowest deciles, who consume about 1,600 kcal/day.

Interestingly, this coexists with rising rates of obesity, probably due to the fact that more than half of Indians are not physically active, especially females and urban residents.

Cereal-based calories

When compared to the EAT-Lancet reference diet, the average Indian consumes more calories from whole grains but less from fruits and vegetables, legumes, and foods of animal origin such as meat, fish, and eggs.

Whole grains provide the staple consumed food. In addition, the intake of dairy and dairy-based foods, starchy vegetables, and palm oil are all in excess of the levels recommended in the reference diet.

Indians follow the same dietary patterns, however, irrespective of rural or urban settings, at comparable MCPE. Indian households who spend the least on food, that is, those in the lowest tenth of spending on food consumption, show the greatest reliance on whole grains, starches, and processed foods, with little else. Again, this pattern is maintained across the rural-urban divide.

Low protein

Protein makes up only 6-8% of the caloric intake, vs. ~30% in the reference diet. All over India, regardless of income, this deficiency is observable but is more marked in rural areas, where only 6% of the calories come from protein. In the top 5%, consumed protein calories still come to less than 50% of the recommended protein intake in the reference diet.

Legume intake is lowest among the people of North-eastern India. The production of legumes has declined steadily over the last half-century.

Little fruit and vegetable calories

Fruits and vegetables make up about 8% of daily calories in the reference diet. Interestingly, only Indians with the highest incomes meet recommendations for the intake of fruits and vegetables. Still, the rich eat more of these foods and fats than the poor.

Fats, fruits, and other calories

Fat-based calories in the Indian diet also fall below the reference diet, even though fat consumption went up by 3-5% in the period between 1993-94 and 2011-12. Saturated fats comprise a higher proportion of consumed fat, particularly palm oil, the chief component of vanaspati, or partially hydrogenated vegetable oil.

Vanaspati is generally used in domestic, restaurant, street, and industrial food preparation, having risen by more than half between 1993-94 and 2011-12. Western Indian states use the most vanaspati.

The mean fruit consumption accounts for less than half of the reference diet, while vegetable consumption falls short but by a smaller margin.

Processed foods are also consumed at higher rates, particularly among wealthy urban residents. On average, more calories come from processed foods than from fruits, at 10% of mean total caloric intake, whether rural or urban.  

The wealthiest city dwellers get almost a third of their calories from processed foods, vs. 13% of the wealthiest rural Indians. Even among the poorest, 8% of calories come from these foods for urban and rural residents.

In South India, processed foods make up 13% vs. 8% in North-east and North India.

Animal protein makes up 6% of total caloric intake in the reference diet but is low in the typical Indian diet, except in South India and the North-east. Red meat intake is low overall.

What are the implications?

The average Indian diet is unhealthy when compared with the EAT-Lancet reference diet. Indians depend on cereals, often whole grains, for their caloric needs but fail to meet their requirements for protein, vegetables, and fruits.

Animal protein consumption is strikingly low in India. Thus, overconsumption of animal meat or products is not an issue in India. Even while up to 80% of Indians now report themselves to be non-vegetarian, “majority of the non-vegetarians report that they consume meat only occasionally.”

The main issue with the reference diet is its high cost, which would make it one-and-a-half times more expensive than the cheapest nutritionally sound diet. The most expensive food components the world over are fruits, vegetables, and animal products. The cost of healthy foods is rising faster than that of fats and vegetables in India.

The reference diet in South Asia would account for over 60% of mean household income per capita per day. With wheat and rice being available at subsidized prices via the Public Distribution Systems, coupled with low market prices for these grains due to market management, Indians naturally rely on cereals for their major caloric intake.

Yet, even the wealthiest fail to meet reference diet recommendations, splurging on processed foods and cereals in preference to protein and fruits or vegetables. “This points towards a lack of availability, accessibility, awareness, and acceptability as other major causes for the poor quality of diets.’

If anything, the CES survey underestimates food consumption by not accounting for meals taken outside the home or processed foods. However, the National Food Security Act (NFSA)-2013 allowed wheat and rice to be distributed at low prices to the poorest two-thirds of the Indian population.

This fuels dependence on cereals. To reverse this is a herculean task, including policies supporting the production of healthy foods rather than rice, wheat, and sugarcane and making the former available at cheaper rates. Subsidies on healthy foods should be the norm, and awareness campaigns need to be held to help people understand why they should raise their intake of such foods rather than rice and wheat.

“Indian policymakers need to accelerate food-system-wide efforts to make healthier and sustainable diets more affordable, accessible and acceptable.’

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.