Introduction

Health and nutrition are the most important contributory factors for human development. Countries, undergoing an economic transition, such as nations emerging in the international marketing competition, have to face new challenges in the treatment of nutrition related problems.

Nowadays India is passing through an impressive economic growth, accompanied by a very slow decline, almost stagnation, in malnutrition levels [1]. Malnutrition in India is not a child specific problem but it is prevalent in every age group and its adverse effects consist of greater susceptibility to infections, increased morbidity and mortality, enhancing decreased productivity and lower quality standards along all stages of life-evolution [2]. Adequate intake of food and regular nutrition habits are the major contributing factors for the maintenance of general health status.

India’s poli-geographic terrain [3, 4] and pluralistic cultural background [5], offers a high variety of alimentary differences, like cereals, pulses, vegetables, fruits, milk and milk products, including also categories of minor national consumption, like meat and poultry, roots and tubers, fats, nuts and oils.

Cereals are the most economic source of energy, representing, therefore, the principal aliment for low income social classes [6]. Fruits and vegetables, though occupying about 65 % of cultivatable terrain, are consumed less frequently in India’s general population [7], even if a regular intake of these aliments is recognized as an important health promoter, reducing prevalence of cardiovascular disease and obesity significantly [8, 9]. Milk and dairy products from animal sources (cow's milk or buffalo’s milk) are an important part of Indian diet, and India has indisputably one of world’s greatest milk and milk product producers. Furthermore diets rich in milk, cheese, yogurt and similar products provide important vitamins and minerals essential for human growth and development [10]. The beneficial health effects obtained from milk are mandatory for human body and help in prevention of chronic ailments [11].

Constant monitoring of nutrition habits and dietary intake, involving also families and communities in informative campaigns, ensures healthy balanced diets and therefore improvement of life-quality. Such initiatives offer efficient preventive strategies against the rise of non-communicable diseases, such as diabetes, coronary diseases and overweight [12].

India, with regard to massive changes on a socio-economic level, has to face new epidemics, despite problems related to under-nutrition, such as a progressively increasing rate of over-nutrition. As a consequence, the rise of disorders, traditionally perceived as western culture-driven, is emerging as a significant issue [13–15], especially in urban areas [16], where also cases of diabetes mellitus and coronary heart disease are becoming more frequent than in rural contexts [17, 18]. Overall, prevalence of overweight/obesity results to be higher among women (10.9 %) compared to men (7.8 %) [19, 20]. Such gender related differences, however, are due to a social family structure where women are commonly relegated within intra-domestic activities, featuring a prevalent sedentary life. Such a condition of inactivity contributes as an increasing risk factor to the accumulating of fat deposals. This data has been confirmed by researches conducted in different Indian regions [14, 21] and moreover in other South-Asian realities [22].

In developing countries, however, studies about dietary patterns and their relationship with nutritional status are scarce [23].

Aim of this paper, therefore, consists in reviewing existing literature, focused on most common trends in food consumption and energy intake, across the different regions of India.

Material and Methods

PubMed was searched for publications from 2002 and 2012 using the keywords: [food* OR (“meal pattern*”) OR (“eating pattern*”)] AND (“nutrient intake”) AND India*.

Moreover nutritional manuals and nutritional documents have been consulted, such as: i) Dietary Guidelines for Indians: A manual. National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India; ii) Department of Women and Child Development. 1995–96. India Nutrition Profile. Government of India, New Delhi (http://wcd.nic.in/); iii) National Nutrition Monitoring Bureau (NNMB). 1979–2002. NNMB Reports: National Institute Of Nutrition, Hyderabad, India (http://www.nnmbindia.org/); iv) Indian Council of Medical Research. 2009, constituted important sources to retrieve existing literature. Furthermore “Nutrient requirements and recommended dietary allowances for Indians” as well as the “National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India” have been taken into consideration.

Inclusion criteria were survey study design, food consumption reported by food-groups which constitute a scientific and clinical reference for nutritionists and studies enrolling Indian population.

Results

The search gave back 84 results, 6 of them were reviews. Among the items evaluated, 21 were considered relevant to the subject, and eventually 7 papers were included in this study, because of their focus on food intake and consumption in India. Table 1 lists the included papers, featuring a brief description of the sample and the methods used to retrieve information on food consumption, and Table 2 reports the respective outcomes.

Table 1 Results of literature search
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Table 2 Summary of findings: mean daily food intake (grams) or percentage of daily food intake according to RDA standards
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The retrieved studies reported the mean (g/day) or percentage of daily intake of food-groups among different Indian populations, both in rural and urban contexts. With regard to researches, using 24-h Recall Method and questionnaires, cereals and millets formed the bulk of dietaries in all states and selected samples, followed by vegetables, dairy products and others [23–29]. Within the review, therefore, articles have been chosen according to geographical areas taken into analysis, from north to south India, involving pre-school children, school aged kids and adolescents.

Pre-school age is considered as a dynamic period of growth and development, where children undergo physical, mental and emotional development. Adequate food intake results being the most important requisite granting for healthful development [24]. But only 20.3 % of pre-school children are found nutritionally normal, while the others suffer from mild, moderate, or severe malnutrition [25]. This data revealed, that mean food and nutrient intake was lower than the Recommended Daily Allowance (RDA). None of the food-groups analyzed across the papers satisfy the recommended values [26, 29].

Parvinder et al. [26], whose study is focused on feeding practices and dietary patterns of 9–36 mo old children in an urban slum of Delhi, assessed energy intake levels through a ten-item questionnaire on frequency and amount of alimentary consumption. The results indicate that the mean intake of cereals, vegetables, fruits, fat and sugar was mostly inadequate, meeting only 43 %, 39 %, 28 %, 40 % and 56 % respectively of the recommendations for children aged 6–36 mo.

A cross-sectional study, carried out in New Delhi investigated diet quality and nutritional status of rural adolescent girls [28]. Mean daily intake of the subjects was compared with the suggested amounts of various food groups indicated for girls aged 13 to 15 y. According to this dietary study, adolescent girls consumed primarily cereals and milk as well as its related products. The mean daily intake of green leafy-vegetables and other vegetables, instead, ranges between 26 g and 34 g, compared to 100 g of the recommended values for each vegetable. The mean daily intake of fats/oils and fruits was lower than other food-products, reaching only 16 g and 3 g respectively, while the sugar consumption agrees with the suggested value (20 g/d). Data revealed that the mean daily intake of dairy products, green leafy-vegetables, other vegetables, fats/oils and fruits was highly unsatisfactory. Only that of fats/oils was approximately adequate, meeting 65 % of the recommended standards. Also, intake of cereals was almost adequate revealing a deficit of just 7 %.

The consumption of food has been evaluated according to regional differences, co-responsible in influencing and modifying dietary status. Accordantly, a survey conducted in five rural eastern states [24] – Assam, Bihar, Orissa, West Bengal and Tripura – evaluated, that although these contexts show different alimentary habits, all intake values were deficient for all food groups, except cereals. Consumption of cereals, indeed, was satisfactory except in Assam, where it fell short according to RDA parameters. Only 10.2 % satisfied the 460 g portion per day. Even if consumption of green leafy vegetables was generally adequate, in Orissa a deficient intake of 28.9 % with regard to RDA standards (50 g/d) has been recorded. The consumption rates of dairy products was lower than the respective RDA (50 –90 % of the RDA, 150 g/d) within households of all districts [18]. The mean intake of fats and oils, sugar and jaggery, fruits and nuts was deficient in most of the regions. The overall picture of this nutritional survey is that rural families consumed adequate or marginally satisfactory amounts of cereals and roots and tubers, but other food groups, namely pulses and legumes, fruits and nuts, animal food, and milk and milk products, fell far short according to RDA.

A recent survey always conducted in eastern India, (Orissa state) [23] analyzed the mean intake of rural populations, divided by gender. According to this study, the mean intake of cereals and millet of males and females is even higher than RDA values (460 g/d). Intake, instead, of green leafy-vegetables, dairy products, fruits, fats and oils, sugar and jaggery is reported to be lower than RDAs [30]. As expected, the mean of food intake for males is higher than that of the female populations [23].

A nutritional investigation was undertaken with the aim of assessing the dietary intake of rural pre-school children [29]. For this target, children between age of 1 and 5 y were selected from five rural regions near Mysore (southern India). Food intake was assessed in three different seasons (Summer, Monsoon and Winter) to observe seasonal variations. Findings revealed that diets were predominantly cereal based, while consumption of protective foods, such as milk and milk products, green leafy vegetables and fruits, were found to be negligible. Seasonality was observed only in the consumption of cereals and pulses (showing higher values during monsoon and winter seasons) but not in the consumption of vegetables or fruits. The mean intake of all food stuffs was below the national average. In all the seasons for both age groups, similar nutrition values have been reported if compared to those of southern India [17].

In southern India (Tamil Nadu) a dietary study has been performed, selecting specific adult samples. Nazni et al. [25] analyzed the nutrition attitudes and eating habits of sportsmen. All athletes belonging to different disciplines (volleyball, run and weight lift) present with lower cereals intake (about 340 g/d) than the 550 g/d consumption, recommended for sportsmen. The intake of vegetables and milk was low among all the participants (except milk intake of runners). Such data is confirmed also in consumption of fruits and vegetables, particularly indicated for those practicing high levels of physical activity [25]. Fat intake of athletes, instead, showed even higher than RDA, while the mean consumption of sugar depends on the specific type of sport being practiced [25].

Discussion

In India, food habits are strictly associated to symbolic signifiers, cultural peculiarities and different expressions of social identities. This complex system of interdependent climatic, geographical as well as traditional variables made India an enormous apparatus of food production, especially grains, cereals and greens. Moreover, Indian cuisine varies from region to region [24] and from season to season [29], reflecting the widespread cultural pluralism in this subcontinent, which became a unique blend of various cuisines across Asia and around the world [31].

Food plays a vital role in the growth of a nation, still in economic transition from underdeveloped country to post-industrialized reality [29]. Food requirements and suggested dietary intakes, currently recommended by national and international organizations, are primarily intended for healthy normal growth during the rapid stages of development such as infancy and childhood, and to meet additional demands during pregnancy and lactation [32].

The publications taken into consideration by this review are heterogeneous in terms of study population since urban and rural contexts, low and middle-high income classes and different age groups are involved.

Nevertheless, this review provides evidence of poor state of nutrition among children and adults in India, following a monotonous and vegetarian diet [27]. Food intake described by dietary assessment methods, suggested that their diets were predominantly cereal based, rich in carbohydrates and poor in other nutritional elements [33]. Carbohydrates, indeed, constitutes among 60 and 70 % of Indian population’s total energy intake [6]. Such a finding represents a countertrend according to general changes in eating habits on a global scale during the last 30 y, where consumption of carbohydrate based products decreased to about 7 % [34]. Such a condition, in contrast to general tendencies, reflects however a common situation among Indians of Asian origin, whose intake rates of carbohydrates and especially cereals results to be higher than in other ethnic groups living in this macro-cultural context [35]. The consumption, instead, of aliments rich in proteins, such as milk products as well as flesh foods and fibers contained in green leafy vegetables and fruits, were found to be negligible [28]. Their absence in Indian diet leads to micronutrient deficiencies, such as vitamins and iron, which are extremely needful in order to grant adequate alimentary intakes, promoting general wellbeing and health status. Such a nutrition lack may lead to increase in several diseases in children and early adulthood like greater risk of insulin resistance [36]. According to the survey conducted by Nazni et al. [25] on sportsmen revealed that consumption of fat based aliments is in line with increasing intake levels (6 %) worldwide [34].

In India and other developing countries, 80% of the population has dietary intakes below the RDA [37]. When observing dietary patterns of people living in rural areas it was observed that, except for green leafy vegetables, other dietary sources rich in vitamin A, iron, vitamin C, folic acid, and calcium did not satisfy the recommended standards [18]. In these contexts intake of pulses and legumes, containing proteins besides fibers and vitamins, remained almost unsatisfying, while the intake increased significantly in urban areas, mostly in the middle income classes [34]. Because of little or no intake of protein-rich food, above all in rural areas and amongst economically disadvantaged populations, the value of dietary intake results being less than average. Hence, protein deficiency occurs due to both, the quality and quantity of proteins consumed by this population [18].

Micronutrient deficiency is a serious public health problem in most developing countries. In India, iron deficiency, vitamin A deficiency, and iodine deficiency related disorders constitute topics of urgent interest for public health. According to Venkaiah et al. [23] the mean intake of iron, calcium, and riboflavin was lower in both, men and women selected for the survey, if compared to RDA [30]. Another study conducted within an Indian rural adolescent sample, observed that the average intakes of all nutrients were below the RDA parameters [38].

From the studies included within the review it also emerged how consumption of food varies, in relation to different regional and urban areas. The evaluation criteria are mainly focused on the frequency of consumption of certain alimentary categories which result to be associated to geographical peculiarities and climatic changes.

Analysis of dietary patterns may offer, therefore, benefits by educating general population towards more healthful and diversified eating habits. Such informative campaigns should be implemented by public health, in order to promote efficient and prescient resources for the prevention of dietary related diseases.

Study Limitations

This review has been carried out principally through the online data resource “PubMed”, in order to line up the most recent developments in research about eating disorders in a strictly quantitative perspective. Further reviews should consider also contributions published in other scientific sectors, such as economies, anthropology and social sciences, adopting qualitative or combined methodologies, too. Different ontological approaches may enrich research on nutrition disorders in India by analyzing the symbolic, cultural and commercial structure of such an enormous context. Investigations should be focused, therefore, on the rapid changes this pluralistic macro-context is undergoing since the recent economic growth and the fast diffusion of technological mediated communication systems, promoting globalization and urbanization processes on a micro- and macro-social level.

Conclusions

All nutritional studies reported in this review, carried out with different methods, indicate that: i) most of the subjects (from children to adults) followed a monotonous and vegetarian diet, based on cereals; ii) dietary consumption and food expenditure vary across geographic areas (rural or urban) and cultural contexts; iii) food intake is almost lower than RDA, and this may lead to nutrient deficit, which singly or in combination have an important role in making the person (especially child) vulnerable to morbidity and mortality. Strategies and interventions must be therefore proposed to prevent and control micronutrient deficiencies.