Abstract

Dietary advice forms the cornerstone in the management of cardiometabolic disease. Though various national and international guidelines suggest different macronutrient proportions, locally framed person-centric diet prescriptions are likely to have a better compliance. In this article, we propose an indigenous traditional Indian Ocean (TRIO) diet, which constitutes a similar pattern of the dietary practices followed by inhabitants of the Indian Ocean littoral region. The TRIO diet highlights on concepts of procurement, preparation, presentation, prioritization, preservation and partaking and may be a good alternative to the Mediterranean diet followed in western countries.

Keywords: Cardiometabolic disease, person-centric diet prescription, TRIO diet, littoral, Mediterranean diet 

BACKGROUND

Metabolic and nutritional diseases are emerging as a major global health care challenge. Diabetes, obesity, hypertension and cardiovascular disease have attained pandemic status, and show no signs of abating.¹ As we try to address these diseases, the role of healthy nutrition is of paramount importance.² Though there are myriad definitions of healthy eating, the term ‘Mediterranean diet’ is often associated with health protection and promotion.

Current guidelines underscore the need for culturally relevant medical nutrition therapy prescriptions for the prevention and management of metabolic disease, including diabetes.³ While multiple diet patterns are shown to have short-term benefits, the Mediterranean diet is suggested to be one of the most useful diets for long-term health. At the same time, it should be clarified that there is no single dietary plan, which is suited for all people.

THE MEDITERRANEAN DIET

In 2010, UNESCO, defined the Mediterranean diet as a set of skills, knowledges, rituals, symbols and traditions concerning crops, harvesting, fishing, animal husbandry, conservation, processing, cooking and particularly the sharing and consumption of food. Thus, it includes the production, processing and partaking of food.⁴

Modern medicine discovered the benefits of the Mediterranean diet when Ancel Keys conducted the Seven Countries Study in 1958, providing evidence of its cardiovascular advantages.^5,6 Balanced use of fiber-rich, antioxidant-rich, unsaturated fatty acid-rich foods, with a lower proportion of animal fats, characterize the Mediterranean diet. The rough proportion of nutrients is 55% to 60% carbohydrates (of which 80% are complex), 10% to 15% proteins (of which 60% are of animal origin) and 25% to 30% fat (mostly olive oil). Nutritionists and policy makers represent the diet as a Food Pyramid, which includes a variety of foods, in the right proportion, taken in moderation.⁷

From an Afro Asian perspective, one limitation of the Mediterranean diet, is its nomenclature. The name might imply that a foreign diet is better, and must supplant locally grown foodstuffs. An unwarranted emphasis on olive oil, which is not easily available and affordable, nor is it appropriate for the Afro Asian style of cooking, might lead to excessive and unnecessary expenditure on food.

THE TRADITIONAL INDIAN OCEAN (TRIO) DIET

In this communication, we attempt to conceptualize and define an Indian Ocean diet, as an authentic and appropriate, alternative to the Mediterranean diet.

The Indian Ocean diet is a diet that is inspired by, and incorporates, the dietary preferences and habits of the peoples who inhabit the littoral countries of the Indian Ocean. We propose the traditional Indian Ocean (TRIO) diet as a healthy option for the prevention and management of metabolic diseases.

We define the TRIO diet as the style and method of meal procurement, preparation, preservation, presentation and partaking, followed by the inhabitants of the Indian Ocean littoral region, which contributes to metabolic and overall health.

The Indian Ocean Littoral Region

The Indian Ocean, the third largest ocean in the world, touches the shores of Africa, the Middle East, South and South East Asia, as well as Australia. Though the inhabitants of this vast region represent a seemingly complex and diverse collection of people they are also united in many ways. Age-old trading and travel links have created a “fusion” of cultures, which has influenced cuisines as well.

In this communication, we define the Indian Ocean littoral region as including all the countries and islands which touch the Indian Ocean or are included in it. The authors represent the following countries: Australia, Bangladesh, Indonesia, India, Iran, Kenya, Malaysia, Maldives, Mauritius, Mozambique, Myanmar, Oman, Pakistan, Singapore, South Africa, Sri Lanka, Tanzania, Ghana, Thailand and the United Arab Emirates.

Cooking and dining are a family affair, and sometimes, even a community affair. The sense of sharing (Ubuntu in South Africa) extends to presenting food and preparing food in joint family kitchens.

Most traditional Indian Ocean littoral cuisines are based upon locally available whole grains (rice, wheat, maize), eaten in various forms. In recent years, the proportion of whole grain consumption, as opposed to refined grain intake, has reduced. This is especially true in island states, which import their cereal requirements.⁸

The cereal is usually consumed with dishes that are made of vegetables, legumes and lentils. Coastal cuisines have a strong presence of fish, seafood and fish products. Meat is an integral part of Indian Ocean littoral states, but is not a major contributor to caloric intake in most cuisines.

Beverages such as water, lemonade, hibiscus juice, kokum juice, coconut water, soup, tea and coffee are a prominent part of the Indian Ocean diet. This is a necessity, due to hot weather that prevails throughout much of the year in the region.

Various means of cooking are used across the region, including boiling, steaming, sautéing, baking and frying. In most settings, economy of fuel and economy are in the interest of parsimony. A wide range of cooking oils is used, as per availability. Coconut oil and palm oil, which are clubbed as ‘tropical oils’ are used in the eastern Indian Ocean littoral region, while mustard oil, peanut (groundnut) oil and clarified butter (ghee) are used elsewhere.⁷

Mustard oil is a liquid oil that is low in saturated fat and is popular in South Asia. Australia, New Zealand and the European Union (27 countries) have established upper limits for tolerable intake of mustard oil. In contrast mustard oil is one of the most popular cooking oils in Asia, particularly in India where it is recommended as a heart-healthy oil by the Lipid Association of India (LAI). However, the US Food and Drug Administration (FDA) has banned the use of mustard oil for cooking.⁹ Fruits are ubiquitous in Indian Ocean diet. Locally available, seasonal fruits are preferred. Some parts of the region, such as the Middle East and South Asia, exhibit a preference for rich (and tasty) desserts.

THE TRADITIONAL INDIAN OCEAN AND MEDITERRANEAN DIET

In most ways, the Indian Ocean diet that we describe is similar to the Mediterranean diet. Reliance on whole grains, vegetables, legumes and fruits is common to both systems. Use of fish is noted in coastal Indian Ocean communities as well as the Mediterranean. Nuts and olive oil, important features of Mediterranean diet, are represented by groundnuts and other cooking oils in the Indian Ocean. Less focus on use of red meat, processed meat and refined cereals is common in both traditional cuisines. Similarly, the concept of an Indian Ocean diet, can be used to create an overarching model that can be customized as per local needs and requirements.

THE HEALTHY TRAY

We suggest the healthy thali (tray) rubric, rather than the pyramid or plate, to represent the Indian Ocean diet.

The healthy tray provides a conceptually practical person-friendly means of representing the food and drink that should be consumed, to the regional population, in order to ensure healthy nutrition and accomplish healthy outcomes. It represents a wholesome and comprehensive method of representing an optimal diet in a person-friendly manner. The healthy tray goes beyond mere nutrition by including culinary science and art in education. The concepts of plating and presentation, along with portion size meal sequencing, can be demonstrated through the tray model.

THE WAY FORWARD

The concept that we share has the potential to become a useful tool for sharing and teaching healthy nutrition. The advantage is its relevance to a vast swathe of the world’s population, and the sense of empowerment as well as responsibility that it brings to them. This will hopefully invite more interest, discussion and debate, as well as research in order to achieve this potential. In many countries, the local food is a blend of different cultures. For instance, people from Mauritius enjoy eating locally adapted Chinese cuisine as much as they enjoy Indian cuisine. Blending brings cultural enrichment of existing traditions. However, as much as we are keen to respect our traditions or any associated influences from other cultures, it is our duty to educate our patients on what could be deleterious to their health. For e.g., we may still respect the plating of a particular dish, whilst decreasing the proportion of carbohydrates. Quantity is often overlooked and this issue should be addressed as well. Also, we may still address our food eating behaviors while enjoying the same food without it being harmful to our health. For instance, some studies are advocating for meal sequencing for better metabolic benefits.^10,11

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