Dietary guidelines across different countries & comparisons to dietary guidelines for Indians, 2024

Food groups of different countries’ DGs

The graphic illustration of DG also differs across the countries. The plate, according to the Australian DG, is partitioned into five food groups and surrounded by water, a small amount of fats and sometimes a minimum amount of alcoholic beverages, fast food and sugars. The Spanish food plate is partitioned into four food groups and suggests the consumption of olive oils instead of other fats/oils. South Africa shows places square and cereals in the centre surrounded by the six other food groups, including water. Argentina’s food plate is partitioned into six food groups and in the centre, emphasis is given to water. The United States of America divides the plate into four food groups surrounded by dairy products. The Chinese represent food as a pyramidal pagoda separated into five layers of food groups surrounded by intake of water and physical activity (PA). The Indian plate is divided into five food groups surrounded by 300 mL of milk.

The Indian, American and Australian guidelines give detailed food group division, considering different age groups (infant to elderly), dietary patterns (e.g., vegetarian/non-vegetarian) and sex-specific. The DGs for Americans (DGA) provide daily or weekly amounts from different food groups and components, based on individual calorie levels. South Africa’s DGs are for age >5 yr and above, with energy requirements based on age and sex. China, Spain and Argentina provide general guidelines for the adults. The details of all food groups have been mentioned in table II. Countries use different measurements to describe the amount of food groups. DGA mentions cup equivalent and ounces (1 ounce =28.3 g), whereas Australia and Argentina mention in terms of different units. WHO, India and China mention raw/uncooked gram weights and South African guidelines mention units.

Food groups comparison across DGs

Physical activity (PA)

All countries follow WHO guidelines for PA across age groups. Age group between 5-17 yr of all guidelines mentions 60 min/day of moderate to vigorous activity. DGI mentions additional strength training PA at least 3 days/wk. For ages between 18-64 yr, on average, 150-300 min/wk of moderate intensity aerobic activity is suggested in all guidelines. Age 65 and above, all guidelines recommend 150-300 min/wk of moderate intensity aerobic activity PA. Comparison of PA is mentioned in table VI.

Comparison of DGs of different countries and WHO (Adults)

Revised DGI were released in May 2024 by ICMR and ICMR-NIN, after a gap of 13 years from the last second edition published in 2011⁴. In the last decade, dietary habits and the epidemiological transition from communicable diseases to NCDs have drastically emerged in India. The prevalence of obesity, CVD and diabetes has increased, with persistent problems of undernutrition and anaemia continuing to affect half of the women of reproductive age and children. A recent study reports that 56.7 per cent of the disease burden in India is due to an unhealthy diet²⁷. Compared to previous guidelines, the current guidelines highlight restrictions on ultra-processed foods, focus more on protein quality and suggested avoiding regular consumption of protein supplements to build muscle mass. The latest guidelines emphasise reading information on food labels to make informed and healthy food choices. The current edition introduces the concept of ‘My plate for the day’ and microgreens⁴. The latest guidelines mention 10 food groups compared to the previous (four food groups), focusing more on micronutrients and macronutrient content⁴. Vegetables are divided into three different food groups. Also, special mention of herbs and spices as a food group, signifying their importance in our meals. Current guidelines use the updated ICMR-NIN Nutrient requirements 2020 report, with a reference to a sedentary man weighing 65 kg with a 2000 kcal/day.

The compassion between Chinese residents’ dietary pattern and the Chinese DGs shows inadequate consumption of dairy products, fruits and tubers, alongside the excessive intake of grains derived from livestock and poultry²⁸. A systematic review²⁹ indicates that 40 per cent of both high-income countries (HIC) and low-middle income countries (LMIC) do not adhere to their national FBDGs. Fruit and vegetables were mostly adhered to between 7 per cent and 67.3 per cent as per FBDGs. HICs consume more discretionary foods (salt, sugar and alcohol), while mixed results were observed in LMICs. In both HICS and LMICs, grains and dairy were consumed below recommended levels, however, consumption of animal proteins exceeded the recommended levels (>30%), particularly red meat³⁰. Risk for all-cause mortality was found to reduced (56%) with increasing intake (for each daily serving) of whole grains, vegetables, fruits, nuts and fish. However, higher intake of red meat and processed meat was found associated with a 2-fold increased risk of all-cause mortality in a linear dose-response meta-analysis³⁰.

For a balanced diet, carbohydrates are recommended to be 50-60 per cent of calories. A prospective cohort study has shown a U-shaped relationship between life expectancy and total carbohydrate intake. Individuals consuming 50-55 per cent carbohydrates showed increased lifespan. However, both low (<40%) and high (>70%) carbohydrate diets were associated with an increased risk of all-cause mortality³¹. All guidelines recommend 45-60 per cent of total carbohydrate intake from cereals. Rice, wheat and jowar are the major cereals consumed in India³². The National Sample Survey Office’s latest Household Consumption Expenditure Survey (HCES) report reveals a steady decline in cereal consumption from 350-425 g/day in 1999-2000 to 270-320 g/day in 2022-2023 in India³³. Yet, the current consumption is higher than the recommended amount by the DGI, 2024 (250 g/day). The higher consumption of cereals, particularly white rice (>450 g/day), has been associated with increased prevalence of type 2 diabetes (T2D) among the Indian population³⁴.

DGI highlights the important concept of microgreens, which are rich in amino acids, fatty acids, micronutrients, antioxidants, bioactive compounds and phytochemicals. All countries’ guidelines recommended a similar quantity and quality of fruits and vegetables (500-600 g/day). National Non-Communicable Monitoring Survey (NNMS) in India reported that 98.4 per cent of adults do not consume fruits and/or vegetables according to DGI and WHO recommendations. The mean serving of fruits and/or vegetables was 1.7 servings/day (170 g)³⁵. Similarly, food consumption data of Chinese residents reveal the gap between actual consumption and recommended values of vegetables and fruits²⁸. Canned foods contain excessive added sugar and the canning process can lead to the loss of heat-labile nutrients. They are a major source of bisphenol A, an endocrine-disrupting chemical positively associated with coronary artery disease³⁶. All the guidelines recommend avoiding canned products.

There is poor agreement among countries regarding guidelines for pulses. DGI includes animal protein along with pulses. A multilevel model analysis found that per capita consumption of pulses was about 50 per cent lower than the recommended intake across India and was influenced by availability, preferences, accessibility, affordability and cultural traditions³⁷. Though animal products are highly nutritious, scientific evidence suggests reducing meat and increasing the consumption of other protein sources, such as legumes. Meta-analysis found consumption of processed meat, particularly red meat, as a risk factor for the development of T2D³⁸. A systematic review³⁹ of RCTs suggested a protective effect on total cholesterol and low-density lipoprotein cholesterol by replacing animal protein with plant protein, which may decrease the risk of CVD mortality and T2D incidence.

Nuts and oilseeds have anti-inflammatory, anti-fibrotic, and antioxidant effects⁴⁰. Systematic reviews and meta-analyses have shown that nuts have cardiovascular benefits beyond lowering LDL cholesterol and Apo B; they improve blood glucose and endothelial function^41,42. A meta-analysis showed a reduction in relative risks for CVD and all-cause mortality on a daily intake of 28 g of nuts⁴³.

Dairy products are disproportionately recommended across all countries, and all guidelines emphasise low-fat milk and milk products. A review concluded that dairy products may protect against NCDs, and very few reported adverse effects due to lactose intolerance in some populations⁴⁴. Miller et al⁴⁵ reported from the global dietary database that the mean milk consumption in India was lower (100 mL/day) than the recommended intake (300 mL/day). Another study showed that per capita milk consumption per day was 83.3 mL in the milk-consuming families. An average monthly milk consumption was higher in milk-producing households than in families relying on market purchases⁴⁶. Another study showed that increased dairy consumption was associated with a lower risk of obesity and high fasting plasma glucose compared to a low dairy intake. A total dairy intake of ≥5 cups per day was also protective against hypertension and metabolic syndrome compared to an intake of ≤1.4 cups per day⁴⁷.

WHO urges a 30 per cent reduction in salt intake by 2025⁴⁸. Studies concluded that salt consumption in India exceeds recommended levels in the guidelines^49-51. A systematic review reported the mean salt intake of 11 g/day across India⁵². NNMS reported that more than 96 per cent of adults exceed the recommended daily intake (<5 g salt/day). Women consume less salt across all age groups than men and the mean dietary salt intake was 8 g/day³⁶. Hidden forms of sodium increase overall salt intake. In India, 43.8 per cent of adults consumed home-based salt-added snacks weekly and 36.1 per cent consumed namkeen, papad and packaged chips monthly. The urban population consumed salt-containing foods more frequently than the rural population³⁵.

As per Indian regulation, fortification of specific food items is allowed to combat nutrient deficiencies at the community level (e.g., salt fortified with Iodine). FSSAI implemented food fortification regulations for fortifying staple foods, namely wheat and rice flour, with vitamin B-12, iron and folic acid and oil and milk with vitamin D^26,53. Fortification of ultra-processed foods or foods high in salt/sugar/fat does not make them healthy. Guidelines encourage wholesome and minimally processed food intake to ensure safety and sustainability.

Guidelines on physical activity (PA)

WHO recommended levels of PA are not met by 41.3 per cent of adults in India. Women reported being more active than men, with the lowest of 39.8 per cent in urban women. Only 10.5 per cent of all adults are voluntarily involved in any form of PA (like fitness, sports). On a typical day, the average time spent being sedentary was 308.9 min. Urban adults spent a mean of 324.4 min and rural adults spent 301.1 min a day being sedentary³⁵. Several barriers exist to PA, prompting researchers to develop a culturally acceptable dance/fitness intervention called Taking High-Intensity Interval Training (HIIT) and Dance to Adolescents for Victory over NCDs (THANDAV). There was a significant increase in the heart rate and VO₂ post-intervention. THANDAV is improves cardiorespiratory fitness and prevents NCDs⁵⁴. The Diabetes Community Lifestyle Improvement Program (D-CLIP) was designed to increase Moderate to Vigorous PA (MVPA) to ≥150 min per wk. Results indicated a significant (P< 0.05) increase in the participants reporting ≥150 weekly min of MVPA by 28.5 per cent, 13.6 per cent and 14 per cent at 6, 12 and 18 months, respectively⁵⁵.

A systematic review⁵⁶ indicates that women in the preconception period and throughout pregnancy often fail to meet the DGs, associated with increased BMI and diabetes risk⁵⁶. They consume fewer fruits, vegetables, whole grains, and nutrients like fibre, folate, iron and calcium, while consuming more carbohydrates, saturated fats, and less protein. Demographic factors impact adherence, with potential implications for future policy and practice⁵⁷. Nutrition education and counselling can enhance maternal nutrition in pregnancy, which will aid in reducing maternal and foetal complications⁵⁸. All these studies indicate the importance of these guidelines and mandate the implementation and monitoring process.

Strategies to implement DGs

A multi-sectoral approach is essential for effective implementation of DGs⁶¹, involving the public-private sector, NGOs, the health sector, the education sector, government bodies and industrial and company stakeholders (Figure). Technology can help trace meals, calories and PA, standardised and tailored to individual needs and social media for dissemination of information. Policies and standards should be established for the food industry to improve the nutritional quality, following the guidelines (e.g., reduce sodium, fat and sugar content) and by regulating the marketing and sale of unhealthy, ultra-processed foods.

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Figure.

Multi-sectorial approaches and strategies for the implementation of dietary guidelines.

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The limitations of the current review are that the comparison of FBDG with selected countries is not across the global landscape. This is a narrative review and does not include systematic or meta-analysis approaches to actually quantify the food groups among the countries.