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Obesity, the Metabolic Syndrome, and Type 2

Diabetes in Developing Countries: Role of Dietary
Fats and Oils
abc de b
Anoop Misra MD , Neha Singhal MSc & Lokesh Khurana MBBS
a
Department of Diabetes and Metabolic Diseases, Fortis Hospital, Vasant Kunj New Delhi
INDIA
b
Center for Diabetes, Obesity, and Cholesterol (C-DOC) New Delhi INDIA
c
Diabetes Foundation (India) New Delhi INDIA
d
Department of Food and Nutrition, Lady Irwin College New Delhi INDIA
e
University of Delhi New Delhi INDIA
Published online: 14 Jun 2013.

To cite this article: Anoop Misra MD, Neha Singhal MSc & Lokesh Khurana MBBS (2010) Obesity, the Metabolic Syndrome,
and Type 2 Diabetes in Developing Countries: Role of Dietary Fats and Oils, Journal of the American College of Nutrition,
29:sup3, 289S-301S, DOI: 10.1080/07315724.2010.10719844

To link to this article: http://dx.doi.org/10.1080/07315724.2010.10719844

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 Review

Obesity, the Metabolic Syndrome, and Type 2 Diabetes in

Developing Countries: Role of Dietary Fats and Oils

Anoop Misra, MD, Neha Singhal, MSc, Lokesh Khurana, MBBS

Department of Diabetes and Metabolic Diseases, Fortis Hospital, Vasant Kunj (A.M.), Center for Diabetes, Obesity, and Cholesterol
(C-DOC) (A.M., L.K.), Diabetes Foundation (India) (A.M.), Department of Food and Nutrition, Lady Irwin College (N.S.),
University of Delhi (N.S.), New Delhi, INDIA
Key words: fats, oils, diabetes, the metabolic syndrome, developing countries, obesity

Developing countries are undergoing rapid nutrition transition concurrent with increases in obesity, the
metabolic syndrome, and type 2 diabetes mellitus (T2DM). From a healthy traditional high-fiber, low-fat, low-
Downloaded by [University of Rochester] at 06:20 22 July 2013

calorie diet, a shift is occurring toward increasing consumption of calorie-dense foods containing refined
carbohydrates, fats, red meats, and low fiber. Data show an increase in the supply of animal fats and increased
intake of saturated fatty acid (SFAs) (obtained from coconut oil, palm oil, and ghee [clarified butter]) in many
developing countries, particularly in South Asia and South-East Asia. In some South Asian populations,
particularly among vegetarians, intake of n-3 polyunsaturated fatty acids (PUFAs) (obtained from flaxseed,
mustard, and canola oils) and long-chain (LC) n-3 PUFAs (obtained from fish and fish oils) is low. Further, the
effect of supplementation of n-3 PUFAs on metabolic risk factors and insulin resistance, except for
demonstrated benefit in terms of decreased triglycerides, needs further investigation among South Asians. Data
also show that intake of monounsaturated fatty acids (MUFAs) ranged from 4.7% to 16.4%en in developing
countries, and supplementing it from olive, canola, mustard, groundnut, and rice bran oils may reduce metabolic
risk. In addition, in some developing countries, intake of n-6 PUFAs (obtained from sunflower, safflower, corn,
soybean, and sesame oils) and trans-fatty acids (TFAs) is increasing. These data show imbalanced consumption
of fats and oils in developing countries, which may have potentially deleterious metabolic and glycemic
consequences, although more research is needed. In view of the rapid rise of T2DM in developing countries,
more aggressive public health awareness programs coupled with governmental action and clear country-specific
guidelines are required, so as to promote widespread use of healthy oils, thus curbing intake of SFAs and TFAs,
and increasing intake of n-3 PUFAs and MUFAs. Such actions would contribute to decelerating further
escalation of ‘‘epidemics’’ of obesity, the metabolic syndrome, and T2DM in developing countries.

Key teaching points:

N Prevalence of obesity, the metabolic syndrome, and type 2 diabetes mellitus in developing countries.
N Trends in consumption of fats and oils in developing countries.
N Association of total fat intake with obesity and other noncommunicable diseases, primarily the metabolic syndrome and type 2
diabetes mellitus, in developing countries.
N Association of various types of fatty acids (saturated fatty acids, polyunsaturated fatty acids, monounsaturated fatty acids, trans-
fatty acids) with the metabolic syndrome and type 2 diabetes mellitus in developing countries.
N Finally, the paper ends with guidelines and general direction regarding fats and various fatty acids with a focus on developing countries.

Address correspondence to: Anoop Misra, MD, Director and Head, Department of Diabetes and Metabolic Diseases, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj,
New Delhi 110070, INDIA. E-mail: anoopmisra@metabolicresearchindia.com
Abbreviations: AA 5 arachidonic acid, ALA 5 alpha-linolenic acid, AMDR 5 acceptable macronutrient distribution range, CHD 5 coronary heart disease, DALY 5
disability-adjusted life-years, DHA 5 docosahexaenoic acid, EPA 5 eicosapentaenoic acid, FAO 5 Food and Agricultural Organization, FBS 5 Food Balance Sheet,
HDL-c 5 high-density lipoprotein cholesterol, ICMR 5 Indian Council of Medical Research, IGT 5 impaired glucose tolerance, LA 5 linoleic acid, LDL-c 5 low-
density lipoprotein cholesterol, MAL 5 maximum limit, MIL 5 minimum level, MUFA 5 monounsaturated fatty acid, NCD 5 noncommunicable disease, PHVO 5
partially hydrogenated vegetable oil, PUFA 5 polyunsaturated fatty acid, P/S 5 PUFA-to-SFA ratio, T2DM 5 type 2 diabetes mellitus, TC 5 total cholesterol, TFA 5
trans-fatty acid, TG 5 triglyceride, TPFA 5 trans polyunsaturated fatty acid, SFA 5 saturated fatty acid, WHO 5 World Health Organization
Dr. Misra has received travel and lodging support from MPOB for conferences organized by them.

Journal of the American College of Nutrition, Vol. 29, No. 3, 289S–301S (2010)
Published by the American College of Nutrition

289S
 Role of Fats in Type 2 Diabetes in Developing Countries
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Fig. 1. Relationship between nutrition transition, urbanization, and the rise in obesity and the metabolic syndrome in developing countries. (Adapted
from [6].)

INTRODUCTION Recent evidence shows that specific fatty acids affect cell
metabolism, modifying the balance between fatty acid
Developing countries are undergoing rapid nutrition oxidation and lipogenesis. Changes in the quantity and quality
transition [1]. From a healthy, traditional, high-fiber, low-fat, of dietary fats may modify insulin sensitivity [5]. Table 1
low-calorie diet, a shift is being made toward consumption of summarizes the metabolic abnormalities (constituting the
refined carbohydrates, high total fat, and red meats, along with metabolic syndrome) in patients with impaired insulin
low intakes of fiber [2]. It is important to note that widespread sensitivity [6,7]. High intake of total fat is associated with
availability and commercial use of low-cost unhealthy fasting hyperinsulinemia [8,9] and a lower insulin sensitivity
vegetable oils have increased dietary intake of fats and index [10]. Data from epidemiologic studies in developed
trans-fatty acids (TFAs) [3]. These faulty dietary habits have nations show that total fat intake was higher in patients with
contributed to increases in obesity, the metabolic syndrome, T2DM than in normoglycemic controls [11]. Furthermore, a
and type 2 diabetes mellitus (T2DM) [4]. Fig. 1 shows the high fat intake has been shown to predict the development of
relationship between nutrition transition, urbanization, and the impaired glucose tolerance (IGT) in a group of healthy
rise in obesity, the metabolic syndrome, and T2DM in subjects [12] and progression from IGT to T2DM in patients
developing countries. The following discussion focuses on with IGT [13]. Impaired glucose-insulin-lipid metabolism may
rapid escalation of noncommunicable diseases (NCDs), occur consequent to a decrease in insulin sensitivity, starting a
specifically, obesity, the metabolic syndrome, and T2DM, in cascade of metabolic events causing T2DM and a clustering of
the context of trends in consumption and dietary preferences of other cardiovascular risk factors. The overall bulk of data,
fats and oils and their relationships with NCDs in developing except for a few studies [14–22], shows an association of
countries. excess fat intake with obesity and glucose-insulin metabolic

290S VOL. 29, NO. 3

 Role of Fats in Type 2 Diabetes in Developing Countries

Table 1. Abnormalities Associated with Insulin Resistance Asian diets, particularly in relation to insulin resistance and
NCDs, readers are referred to a recent comprehensive review
Glucose metabolism [24].
1. Fasting hyperinsulinemia
2. Elevated fasting glucose levelsa
3. Impaired glucose tolerance (elevated 2 hours post oral
glucose load levels) RISE OF NCDs IN DEVELOPING
Lipids and uric acid COUNTRIES
1. Raised triglyceridesa
2. Low levels of HDL-ca The prevalence of NCDs is rapidly increasing worldwide,
3. Increased small, dense LDL particles leading to increased morbidity and mortality. It is important to
4. Increased postprandial lipemia
5. Increased plasma uric acid concentrations note that about 60% of global burden of increase in NCDs is
expected to occur in developing countries, and most of the
Blood pressure regulationa
associated mortality is obesity-related and attributable to T2DM
1. Elevated sympathetic nervous system activity
2. Augmented renal sodium retention and coronary heart disease (CHD) [25]. Continuing undernutri-
3. Hypertension tion and infectious diseases, along with escalating overnutrition
Others (overweight/obesity), have created a ‘‘double burden’’ of
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1. Impaired fibrinolysis communicable diseases and NCDs in the developing world

2. Endothelial dysfunction [26–28]. This poses overwhelming health and economic
3. Augmented mononuclear cell adhesion challenges to the resource-constrained countries [29].
4. Polycystic ovary syndrome
5. Non-alcoholic fatty liver disease Obesity has become a challenging health problem through-
a
out Asia, Latin America, and parts of Africa. The prevalence of
These factors along with increased waist circumference make up the clinical
spectrum of the metabolic syndrome.
obesity over the past decade in some developing countries has
doubled or tripled [6,25]. Further, childhood obesity/over-
disruption, which may contribute to the development of weight is showing an increasing trend in many developing
T2DM. countries [30–32]. Similar to the increasing prevalence of
In this article, the term ‘‘developing country’’ is defined obesity, the prevalence of the metabolic syndrome has shown
according to the International Monetary Fund’s ‘‘World an increase, ranging from 16% to 34%, in sub-Saharan Africa,
Economic Outlook Report’’ (October 2009) [23]. The South America, South Africa, Morocco, Oman, Turkey, Iran,
literature search has been carried out using the terms ‘‘type Venezuela, and Brazil [33,34]. South Asian developing
2 diabetes,’’ ‘‘obesity,’’ ‘‘insulin resistance,’’ ‘‘hyperten- countries, including India, have shown a similar trend, with
sion,’’ ‘‘dyslipidemia,’’ ‘‘the metabolic syndrome,’’ ‘‘dietary about one fourth to one third of the urban population reported
fats,’’ ‘‘unsaturated and polyunsaturated fats,’’ ‘‘n-3 and n-6 to have the metabolic syndrome [35]. Such a high prevalence
polyunsaturated fatty acids,’’ and ‘‘trans-fatty acids,’’ in of obesity and the metabolic syndrome in many developing
‘‘South Asians, Asian Indians, and developing countries’’ countries is important because both are forerunners of T2DM.
from the medical search engine PubMed (National Library of Increasing prevalence of T2DM has been reported from
Medicine, Bethesda, MD) from 1966 to April 2010. A manual India, China, and other developing countries [29,36,37]. In
search for other important references and medical databases addition, an increasing trend of T2DM in children has been
was also done. Data have been assimilated from several recorded in several developing countries in Asia, Asia- Pacific,
nutritional surveys in various developing countries and from and the middle-eastern countries (MEC) region, including
websites and published documents of many national and Bangladesh, India, Taiwan, Thailand, United Arab Emirates
international bodies, including the World Health Organization (UAE), and so forth [38–40]. It is important to note that unlike
(WHO) and the Food and Agricultural Organization (FAO). developed countries, where a majority of people with diabetes
An attempt has been made to correlate intake of fats and oils in are older than 64 years of age, most people with diabetes in
developing countries with hyperglycemia and diabetes; developing countries are in productive age groups (between 45
however, because of the paucity of data in this context, we and 64 years of age) [41], which accounts for the heavier
have included associations with obesity, insulin resistance, the burden in terms of disability-adjusted life-years (DALYs).
metabolic syndrome, and rarely, lipids. Further, although, we According to projected estimates, by 2030, the number of
have attempted to provide data from developing countries, people with diabetes older than 64 years of age will be 82
some portions of this review are more focused on South Asians million in developing countries, as opposed to 48 million in
and Asian Indians because of our research interest, and developed countries. Further, it is projected that by 2020,
because a wealth of data on South Asian populations is around 70% of deaths due to diabetes will occur in developing
available. For more detailed reviews of Asian Indian and South countries [25].

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 291S

 Role of Fats in Type 2 Diabetes in Developing Countries
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Fig. 2. Per capita supply per day of fat from vegetable oils and animal fats in developed and developing countries. (Source: [42].)

INCREASING SUPPLY AND African children (1–9 years) in 1999, higher mean total fat
CONSUMPTION OF FATS AND OILS IN intake was reported in urban areas (26.5%en) compared with
DEVELOPING COUNTRIES rural areas (21%en) [44]. A study from 4 regions of Kenya
(716 urban and 292 rural women) showed high total fat intake
The following section provides data on supply and trends in (34.5%en) in urban areas and relatively high intake (27.7%en)
intake of dietary fats in some developing countries. It should even in rural areas. The Food Balance Sheet (FBS) data show
be noted that data from many of the developing countries are that in China, the per capita supply per day of energy intake
limited; however, most reported data show an increase in increased from 22.2%en in 1995–1997 to 27.2%en in 2001–
consumption of total fat in both rural and urban areas. 2003 [42]. In 2006, 57.9% of urban and 38.7% of rural Chinese
Fig. 2 shows the trends (1961–2003) in per capita supply consumed more than 30%en from fats compared with 19.8%
per day of fat from vegetable oils and animal fats in developed and 12.1%, respectively, in 1989 [45]. It is important to note
and developing countries [42]. Over the past 4 decades, the that the increase in total fat intake in China can be ascribed to
supply of animal fat in developing countries has increased, an increase in the intake of fat from animal foods [46]. In
while the supply in developed countries has decreased [42]. India, fat intake increased in rural (24 to 34 g/d) and urban (36
Global production for the domestic supply of vegetable oils to 41g/d) populations during 1973–2004 [47,48]. A study on
increased significantly between 1961 and 1963 and between urban slum dwellers in North India showed a median total fat
2001 and 2003, especially in developing countries, accounting intake of 24.7%en in men and 28.7%en in women [49]. In
for 68.8% of the total quantity of vegetable oils from 2001 to European regions, %en from dietary fat in Hungary, Lithuania,
2003, while developed countries produced 31.2% [43]. Latvia, and Estonia was estimated as 37.9%, 44%, 42%, and
Increased availability and consumption of vegetable oils have 36%, respectively [50,51]. It is interesting to note that fat
been significantly contributed by globalization and open intake (%en) decreased from 39.6 to 31.6 in the nationally
market economies adapted during the past decade by many representative sample of the Russian Federation between 1992
developing countries. and 2000 [52]. Finally, in metropolitan areas in Brazil, %en
Table 2 gives an overview of the mean intake of total fat from dietary fats increased from 25.8% in 1974–1975 to 30.5%
(%energy, [%en]) from some developing countries. In South in 2002–2003 [53].

292S VOL. 29, NO. 3

 Role of Fats in Type 2 Diabetes in Developing Countries

FAT INTAKE AND ITS RELATIONSHIP

PUFAs

11.3
5.9

4.0
5.5
4.4
5.8

3.3
5.1

4.0
WITH OBESITY, THE METABOLIC

NA
NA
SYNDROME, AND T2DM IN
DEVELOPING COUNTRIES
MUFAs

16.4

12.0

12.6
15.0
4.7

7.2
8.1

6.0
7.7
NA
NA
As was previously stated, high-fat diets promote weight
gain and insulin resistance and may play a role in the
development of T2DM [10–13,54]. However, secular data are
SFAs

14.1

25.4

11.2

10.6

14.0
5.7

4.1

7.4
5.0

6.0
8.8
limited regarding relationships between total fat intake and
obesity and the metabolic syndrome, and no data are available
Total Fat

regarding T2DM in developing countries.

42.8
37.9
50.7
13.1
32.1
25.7

26.7
21.1
35.6
37.9
20
Table 3 gives a summary of the relationship of total fat intake
to weight gain in some developing countries. The high intake of
traditional diets (rich in whole milk, fats, and oils) was associated
Age (y)

57
24–74
20–75

35–44

19–69

30–85
40–59
18–54 with greater risk of abdominal obesity in adult Mongolian
NA
49

females [55]. In Chile, during 1987–1995, an increase in the

prevalence of obesity in children younger than 5 years was noted,
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Sample Size (n)

Table 2. Overview of Mean Intake (%en) of Total Fat, SFAs, MUFAs, and PUFAs from Some Developing Countries

concomitantly with increased fat consumption during the same

15,951
1785

2349
135
115
105
503

839

200
224
423

time period [56]. In a population-based study in China (n 5

1460, age .25 y), participants with greater than 44.4%en intake
from fat had twice the odds of having the metabolic syndrome
compared with those having less than 28.9%en from fat [57].
Contribution of specific foods to fats and fatty acids, urban

Finally, in a study on adult Japanese Brazilians (age .30 y), a

MUFAs 5 monounsaturated fatty acids, NA 5 not available, PUFAs 5 polyunsaturated fatty acids, SFAs5saturated fatty acids.

positive association was found between the metabolic syndrome

International Study of Macro- and Micro-nutrients and

and total fat intake after adjusting for sex, age, and other multiple
confounders [58]. Clearly, more research is needed in developing
Mexican Health and Nutrition Survey (MHNS)

countries, especially regarding the effects of individual dietary

fatty acids on obesity and diabetes.
Data Source

Urban and semiurban (only women)

Blood Pressure (INTERMAP)

Government employees, urban

FATS AND OILS USED IN

Rural, suburban, and urban

DEVELOPING COUNTRIES
Survey from 1992–94

Table 4 gives the composition of most commonly con-

Rural and urban

Rural and urban

sumed fats and oils in developing countries. Importantly, the

cost and availability of fats and oils determine their usage in
Urban

developing countries. For instance, because of the high cost of

Rural

olive oil, it is used sparingly, while mustard, sunflower, and

soybean oils are used widely because of their low cost. The
following section describes fats and fatty acids in different oils
Reference

used in developing countries and clinical correlations of

[89]
[90]

[91]
[63]
[92]
[93]

[94]
[64]
[95]
[50]

consumption of these oils with metabolic disorders.

Saturated Fatty Acids

Publication
Year of

Significant quantities of saturated fatty acids (SFAs) are

2000
2004

1997
2002
2006
2007

2005
2004
1994
2005

present in oils such as coconut (90%), palm kernel (82%), palm

(45%), and palmolein (42%), as well as in Ghee or clarified
butter (65%) and partially hydrogenated vegetable oils
Adapted from [96].
South Korea
Costa Rica

(PHVOs) (24%). The SFA that predominates in margarine is

Cameroon
Country

Tanzania

Hungary
Mexico

Taiwan
Nigeria

palmitic acid, but its proportion may vary; contents of SFA in

China

India

margarine produced in Turkey range from 7.3% to 34.3%; in

Pakistan, the range is 1.9% to 33.8% [59,60].

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 293S

 Role of Fats in Type 2 Diabetes in Developing Countries

Table 2 shows varying intake of %en from intake of SFAs

Energy intake from fat was positively associated with BMI in males and

and lower percentage of carbohydrates. Second-generation immigrants

protein, increased overweight and obesity, TC, LDL-c, and fibrinogen.
Obese and those with central adiposity consumed higher percentage of fat

Energy density associated with energy intake and overweight; fat was not

explain the low total cholesterol, HDL-c, and HDL-c/cholesterol ratio.

High energy and fat intakes were consistent with high level of obesity.

High carbohydrate (80%en) and low fat intake (8%en). The latter may
women) intakes. No dietary variables were associated with obesity
in selected developing countries (4.1% in Tanzania [rural and

Migration from rural to urban increased percent energy from fat and

Increased risks of overweight (BMI $25 kg/m2) were influenced by

No significant association between BMI and total dietary fat intake.

higher energy (urban Cameroonian men) and protein (Jamaican

urban areas] to 25.4% in rural Nigeria), and highlights high
intake in some regions, sometimes even in rural areas. In
females of all ages, except in females from 10–18 years.

consumed more energy as fat than the first generation.

Brazil, the SFA intake increased from 7.5% to 9.6% from 1975
to 2003 [53]. In South Africa, SFA intake was higher in urban
children (age 1–9 y) (7.3%en) than in rural children (5.5%en);

(BMI $30 kg/m2) in Cameroon or Jamaica.

however, the PUFA/SFA ratio (P/S ratio) was higher in the
children in rural (1.3) than in urban (1.0) areas [44]. Ghee
Findings

(clarified butter containing 65% SFAs and conjugated linolenic

en 5 energy, NA 5 data not available, TC 5 total cholesterol, HDL-c 5 high-density lipoprotein-cholesterol, LDL-c 5 low-density lipoprotein-cholesterol, BMI 5 body mass index.
acid) is popularly used in home cooking in India. Annually,
about 800,000 tones are produced, and much of it is made by
a predictor of overweight.

traditional methods at home or at local dairies [61]. In general,

Ghee is considered unfavorable to health because of its high
SFA content (65%); however, this issue needs further
investigations [62]. Overall, data are limited regarding
the association between SFAs and T2DM in developing
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countries.
Table 3. Relationship of Total Dietary Fat Intake to Weight Gain (Data from Selected Developing Countries)

Polyunsaturated Fatty Acids

Reference

The polyunsaturated fatty acids (PUFAs), primarily linoleic

[100]

[101]
[102]
[103]

[104]
[97]

[98]

[99]

acid (LA) (n-6) and alpha-linolenic acid (ALA) (n-3), have

structural and functional roles in all cells and are essential
dietary components. Table 2 shows that the intake of PUFAs
Cameroon (n 5 1661),

ranged from 3.3% (India) to 11.3% (Taiwan), and varied

Jamaica (n 5 924)

13 villages and
3 subdistricts

between 4% and 6% in other developing countries. The intake

1290

1854

5783
530

337
120

of PUFAs in metropolitan areas of Brazil has increased from

N

7.7% in 1974–1975 to 8.9% in 2002–2003 [53].

n-6 Polyunsaturated Fatty Acids

The n-6 PUFAs are found in oils such as safflower (70%),
Age (y)

40–79

20–59

25–74
3–12
.10

.15

NA

NA

sunflower (60%), corn (55%), soybean (53%), sesame (42%),

and rice bran (41%). Data on n-6 PUFA intake from developing
countries are limited. In Costa Rica, the intake was 11.6 g,
Sub-Saharan African migrants’ children residing in Australia

12.5 g, and 13 g/d in rural, semiurban, and urban areas in 2002

[63]. In Korea, the intake was 9.5 g/d and 7.6 g/d in males and
Populations of African origin (Cameroon and Jamaica)

females, respectively in 2004 [64]. In Asian Indian adolescents,

Chinese adults (China Health and Nutrition Survey)

dietary n-6 PUFA contributed to 4.3%en [65]. In Brazil, higher

intake of n-6 PUFAs was shown to be inversely associated with
the metabolic syndrome [58]. However, in a study on Asian
Population/Country
Iran (Tehran Lipid and Glucose Study)

Indian adolescents and young adults, dietary n-6 PUFA was

shown to be an independent predictor of fasting hyperinsulin-
South Africa, urban (THUSA)

Japanese immigrants to Brazil

emia, a surrogate marker of insulin resistance [65].

Dietary intervention studies with n-6 PUFA in developing
countries or South Asians are few and mostly anecdotal.
Sankar et al. [66] showed that consumption of sesame oil (42%
Korean teachers

Thailand, rural

LA and 42% MUFAs) over 45 days decreased blood pressure,

plasma glucose, glycosylated hemoglobin, total cholesterol
(TC), low-density lipoprotein-cholesterol levels (LDL-c), and
triglyceride (TG) levels in Asian Indians. In a dietary
intervention study on Indo-Asians in the United Kingdom, a

294S VOL. 29, NO. 3

 Role of Fats in Type 2 Diabetes in Developing Countries

Table 4. Fatty Acid Composition of Various Fats and Oils (g/100 g) Used in Developing Countries

Fatty Acid Composition

Country Where Predominantly Used (only selected LA (n-6 ALA (n-3
Fat/Oil countries listed here) SFAs MUFAs PUFAs) PUFAs)

Coconuta Sri Lanka, South India, other tropical countries 90 7 2 ,0.5

Palmab Malaysia, Indonesia, Columbia 45 44 10 ,0.5
Oliveb Europe (mainly developed countries like Italy) 13 76 10 ,0.5
Rice branbc Japan, Korea, China, Taiwan, India, Pakistan 22 41 35 1.5
Mustardbd India 8 70 12 10.0
Groundnutb India 24 50 25 ,0.5
Soybeanc South America (Argentina, Brazil) 15 27 53 5
Cornc China, Brazil, Mexico 12 32 55 1.0
Sunflowerc Bulgaria 13 27 60 ,0.5
Safflowerc India, Mexico, Ethiopia, Kazakhstan, China, Argentina 13 17 70 ,0.5
Ghee (Clarified butter)ae India 65 32 2 ,1.0
PHVO (e.g., Vanaspati)f Most developing countries, including India, Pakistan, Costa Rica, 24 19 3 ,0.5
Argentina, Poland
Almondb Chile, Afghanistan, Pakistan 9 69 17 ,0.5
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Canolabd Canada 6 62 22 10
Flax seedd China, India, Ethiopia 10 21 16 53
Sesamebc Bulgaria, South India 15 42 42 1.0
Palmoleina Malaysia, Indonesia, Columbia 42 46 11 ,0.5
Palm kernela Malaysia, Indonesia, Columbia 82 15 2 ,0.5
PHVO 5 partially hydrogenated vegetable oil, SFAs 5 saturated fatty acids, MUFAs 5 monounsaturated fatty acids, LA 5 linoleic acids, ALA 5 alpha-linolenic acid,
PUFAs 5 polyunsaturated fatty acids.
Percentages may not add to 100% because of rounding and other constituents not listed. Where percentages vary, average values are used.
a
High in saturated fatty acid.
b
High in monounsaturated fatty acids.
c
High in linoleic acid.
d
High in alpha-linolenic acid.
e
Contains 2% trans-fatty acids.
f
Contains 53% trans-fatty acids.
Source: [62].

high n-6:n-3 PUFAs diet showed a trend toward loss of insulin LCn-3 PUFA supplementation in British Caucasians and Indo-
sensitivity, significant lowering of total membrane n-3 PUFAs, Asian Sikhs in the United Kingdom. After supplementation,
and a trend toward lower eicosapentaenoic acid (EPA) and concentrations of plasma TG, apo B-48, platelet phospholipids,
docosahexaenoic acid (DHA) levels [67]. In another study on and arachidonic acid (AA) decreased, while high-density
Indo-Asians by the same group, Brady et al. [68] reported that lipoprotein-cholesterol (HDL-c), EPA, and DHA levels
high dietary intake of n-6 PUFAs did not attenuate the beneficial significantly increased in Indo-Asians compared with British
effects of fish oil supplementation on plasma TG levels. Caucasians, but insulin sensitivity was not improved [70]. A
30-day dietary intervention study with salmon oil (rich in LCn-
3 PUFAs) in Mexican subjects showed a significant decrease
n-3 Polyunsaturated Fatty Acids
in TG levels and an increase in HDL-c levels in the
Fish, fish oils, and some vegetable oils (flaxseed, mustard, hypertriglyceridemic group, along with a significant decrease
canola) are good sources of n-3 PUFAs [69]. In Costa Rica, the in TC and TG and an increase in HDL-c in the hypercholes-
intake of n-3 PUFAs was 0.35 g, 0.41 g, and 0.44 g/d in rural, terolemic group [71]. In an important study in India, it was
semiurban, and urban areas, respectively [63]. In Korea, intake shown that 0.75% energy (2.2 g) ALA from vegetable oils (like
of n-3 PUFAs was 2.1 g/d and 1.5 g/d in men and women, flaxseed, mustard, and canola) may be required to increase the
respectively [64]. In diets of Asian Indian adolescents, n-3 LCn-3 PUFAs to about the same extent as 0.1% energy (0.3 g)
PUFAs contributed to 0.7%en [65]. from LCn-3 PUFAs derived from fish oils [72]. A study on
Only a few intervention studies have been conducted on T2DM and hypertensive patients (n 5 50) in Iran showed a
South Asians and other ethnic groups in developing countries decrease in TG and apo B-100 levels and no detrimental
using n-3 rich oils or diets. Short-term intervention studies effects on apo A-1, glucose, insulin, and glycosylated
with n-3 PUFAs in migrant South Asians have not yielded hemoglobin levels after 10 weeks of supplementation with
definitive results. Lovegrove et al. [70] compared the impact of 2 g/d n-3 PUFA capsules (520 mg EPA and 480 mg DHA) as

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 Role of Fats in Type 2 Diabetes in Developing Countries

compared with controls (1 g/d of 300 mg SFA, 100 mg MUFA, fats (margarines, shortenings, gel) account for 60%, 20%, and
and 600 mg LA) [73]. Overall, although the effects of n-3 10% of total usage, respectively. Limited data obtained in
PUFAs on triglyceride and HDL-c levels are convincing, their India on various types of biscuits and Indian sweets purchased
effects on insulin sensitivity and hyperglycemia are not clear at from local bakeries show that TFA content ranges between
present; long-term follow-up studies with higher doses and 30% and 40% and between 6% and 26% of total fatty acids,
large sample sizes may be required. respectively. Use of margarine spreads (made with PHVO)
increases the TFA content of the product [83].
Monounsaturated Fatty Acids In an urban slum population of North India, particularly in
men, the consumption of TFAs was greater than 1% of the
The MUFAs are present in the following oils: olive (76%),
energy [49]. Further, TFA intake (%en) was 1.1 among
mustard (70%), almond (69%), canola (62%), and groundnut
adolescents and young adults in North India [24]. TFAs
(50%). Other oils such as palm (44%) sesame (42%), and rice
accounted for 33% of fatty acids in products used in Iranian
bran (41%) also have fair quantities of MUFA. In developing
homes, with an average per-person intake of 14 g/1000 kcal
countries, MUFA intake ranged from 4.7% (Tanzania) to
[84]. In Costa Rica, 63% of subjects (n 5 1167) consumed at
16.4% (Cameroon) (Table 2). Asian Indians belonging to low
least 1% energy from TFAs [85]. TFA consumption increased
socio-economic status (SES) in India consumed less MUFA
from rural (3.5 g/d) to semiurban (3.86 g/d) to urban areas
(%en): males, 4.7; females, 5.7 [49]. Low MUFA intake has
(4.17 g/d) in Costa Rica [63]. Analysis of trans polyunsatu-
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also been reported in a study of adult urban males from 3

rated fatty acids (TPFA) in soybean oil in Brazil showed that its
different states (UP, Goa, and Kolkata) in India [74]. In Costa
contribution to the average TPFA intake per person is 0.4 g/d
Rica, MUFA intake varied from 28.9 g/d in rural areas to
[86].
32.1 g/d in urban areas in 2002 [63]. In Brazil, MUFA
contributed to 8.1%en in the diet in 2003 [53]. In Korea,
MUFA intake was 17.6 g/d in males and 13.8 g/d in females in Guidelines and General Directions regarding Fat
2004 [64]. In Mexican women (n 5 12), consumption of oleic
Intake: Focus on Developing Countries
acid (from avocado and olive oil, rich in MUFAs) in T2DM Following are general guidelines for fat intake in
patients in a cross-over study (for 4 weeks) showed greater developing countries, particularly in view of the rise of
decreases (20%) in plasma TG concentrations as compared T2DM and CHD in many of them. We first provide dietary
with diets high in complex carbohydrates (7%) although guidelines from the international organizations (WHO/FAO);
glycemic control was similar with both diets [75]. these are followed by country-specific guidelines, if any, most
of which focus on the Indian subcontinent. In general, many of
Trans-Fatty Acids the international guidelines should be individualized to
specific countries, while keeping in mind local dietary and
The TFAs, derived from partially hydrogenated vegetable
cooking practices and use of cooking oils.
oils (PHVOs), are unsaturated fatty acids with at least 1
carbon-carbon double bond in the trans-configuration. TFAs
are generated during partial hydrogenation of vegetable oils
Total Fat Intake
and offer advantages over unhydrogenated oils, such as longer According to the Joint Report of the WHO/FAO (2003) [25],
shelf life, solidity at room temperature, and greater stability the percentage of energy from dietary fats in the diet should be
during commercial deep-frying. TFAs are known to increase between 15% and 30% for the prevention of diet-related chronic
LDL-c levels, worsen insulin resistance, and contribute to the diseases (Table 5). A later WHO/FAO Expert Consultation
development of T2DM and CHD [76–78]. This issue assumes (2008), however, recommended that the acceptable macronutri-
special importance because of the widespread use of oils ent distribution range (AMDR) for dietary fat can vary between
containing TFAs in developing countries. 20% and 35%en (maximum: 35%en; minimum: 15%en). For
In developing countries, the major contribution (.4%en) to individuals with moderate physical activity, total fat intake of
dietary TFAs is due to consumption of industrially produced 30%en is recommended; for those with high physical activity
deep-fried and baked foods [79,80]. In North India, Vanaspati levels, the limit is extended to 35%en. The minimum level of fat
(oil containing 53% TFAs) is popularly used as a cooking intake should not be less than 15%en to meet the adequate intake
medium at homes and in the preparation of commercially fried, of essential fatty acids and energy needs [87].
processed, bakery, ready-to-eat, and street foods. The maxi- A recent Indian Council of Medical Research (ICMR)
mum consumption of Vanaspati in India has been analyzed to Expert Consultation (2009) came to similar conclusions: the
be ,20 g/person/d [81]. In some of the major cities in India minimum level of total fat energy for Asian Indians should be
(e.g., New Delhi), Vanaspati has a 37% share of oil sales [82]. 20%, with 10% coming from invisible sources and 10% from
In the Indian bakery industry, Vanaspati, butter, and specialty visible fats [88].

296S VOL. 29, NO. 3

 Role of Fats in Type 2 Diabetes in Developing Countries

Table 5. Recommendations of Dietary Fats for Prevention of Noncommunicable Diseases

Fats and Fatty World Health World Health Organization/Food and Indian Dietary Guidelines (Indian Council
Acids (%en) Organization, 2003 [25] Agricultural Organization, 2008 [87] of Medical Research 1989, 2009) [62,88]
Total fat 15–30 AMDR: 20–35 15–30
MAL: 35
MIL: 15
SFAs ,10 MAL: 10 ,10
PUFAs 6–10 AMDR: 6–11 ,8
MAL: 11
MIL(to prevent deficiency): 3
MIL(to prevent chronic disease): 6
n-6 PUFAs (LA) 5–8 AMDR: 2.5–9 3–7
Average LA requirement: 2
Individual LA level: 2.5
n-3 PUFAs 1–2 AMDR (n-3a): 0.5–2 .1
Minimum requirement (ALA): $0.5
AMDR (EPA + DHA) g/d: 0.250–2b
MALc , g/d: 3
MUFAs By differenced By differenced,e NA
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TFAs ,1 UL (from ruminants and industrially produced NA

sources): 1
ALA 5 alpha-linolenic acid, AMDR 5 acceptable macronutrient distribution range, DHA 5 docosahexaenoic acid, en 5 energy, EPA 5 eicosapentaenoic acid, LA 5
linoleic acid; MAL 5 maximum level, MIL 5 minimum level, MUFAs 5 monounsaturated fatty acids, NA 5 not available, PUFAs 5 polyunsaturated fatty acids, SFAs
5 saturated fatty acids, TFAs 5 trans fatty acids, UL 5 upper level.
a
ALA and n-3 long-chain PUFAs.
b
For secondary prevention.
c
Including supplements.
d
Calculated as follows: Total fat – (Saturated fatty acids + Polyunsaturated fatty acids + Trans-fatty acids).
e
Can amount to as much as 15% to 20% energy.

Saturated Fatty Acids recommends a 2%en average LA requirement for adults, with
an acceptable macronutrient distribution range (AMDR) of
Both International (WHO/FAO, 2003; WHO/FAO, 2008)
2.5% to 9%en [87]. According to the ICMR (India, 1989)
and ICMR (India, 1989) guidelines suggest that the intake of
guidelines, %en from n-6 PUFAs should be between 3% and
SFA should not exceed a maximum limit (MAL) of 10%en to
7% [62]; this has not been mentioned in the recent ICMR
keep cholesterol levels in a normal range and to reduce the risk
report [88] (Table 5).
of CHD [25,62,87].

n-3 Polyunsaturated Fatty Acids

Polyunsaturated Fatty Acids
WHO/FAO (2003) has recommended 1% to 2%en from n-3
The 1994 FAO/WHO report did not suggest nutrient intake PUFAs [25]. The WHO/FAO Consultation in 2008 recom-
values for total, n-6, or n-3 PUFA, but focused on the ratio of mended an AMDR for n-3 PUFAs as 0.5% to 2%en. The
LA to ALA in the diet. A decade later, WHO/FAO (2003) combined intake of EPA and DHA (LCn-3 PUFAs) should be
recommended 6% to 10%en from PUFAs [25]. According to between 0.250 and 2 g/d, and the maximum intake should
the latest WHO/FAO Expert Consultation (2008) [87], the total be 3 g/d [87]. According to the ICMR (India, 1989) guide-
intake of PUFAs (LA, ALA, EPA, and DHA) must be between lines, %en from n-3 PUFA should be greater than 1% [62]
6% and 11%en. The minimum level (MIL) to prevent (Table 5). However, no mention is made regarding n-3 PUFA
deficiency must be 3%en, and for prevention of chronic intake in the recent ICMR report [88].
diseases, 6%en is required (Table 5). Although ICMR
guidelines (India, 1989) recommended that intake of PUFAs
Monounsaturated Fatty Acids
should be kept below 8% in the diet [62], no mention is made
regarding it in the recent ICMR report [88]. The WHO/FAO Consultation (2003) recommended that
MUFA intake be calculated as total fat – (SFAs + PUFAs +
TFAs) [25]. Along similar lines, the later WHO/FAO Consul-
n-6 Polyunsaturated Fatty Acids
tation (2008) recommended that required MUFA intake should
WHO/FAO (2003) [25] recommended 5% to 8%en of n-6 be calculated as follows: Total fat intake (MIL 15%en, MAL
PUFAs, and the latest WHO/FAO Expert Consultation (2008) 35%en) minus SFAs (MAL 10%en) minus PUFAs (MIL 3%en,

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 297S

 Role of Fats in Type 2 Diabetes in Developing Countries

MAL 11%en) minus TFAs (UL 1%en). For this reason, MUFA 5. Galgani JE, Uauy RD, Aguirre CA, Diaz EO: Effect of the dietary
intake can show a wide range, depending on the total fat intake fat quality on insulin sensitivity. Br J Nutr 100:471–479, 2008.
and dietary fatty acid pattern; however, it can provide up to 15% 6. Misra A, Khurana L: Obesity and the metabolic syndrome in
developing countries. J Clin Endocrinol Metab 93:S9–S30, 2008.
to 20%en [87]. ICMR (India) guidelines [62, 68] have not given
7. Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha
any recommendations for MUFA intake.
D, Joshi SR, Sadikot S, Gupta R, Gulati S, Munjal YP: Consensus
statement for diagnosis of obesity, abdominal obesity and the
Trans-Fatty Acids metabolic syndrome for Asian Indians and recommendations for
According to the recommendations of the WHO/FAO (2003 physical activity, medical and surgical management. J Assoc
Physicians India 57:163–170, 2009.
and 2009), TFAs should be limited to less than 1% of total daily
8. Marshall JA, Bessesen DH, Hamman RF: High saturated fat and
energy in human diets [25,87]. However, adverse effects of
low starch and fibre are associated with hyperinsulinaemia in a
dietary TFAs at intakes as low as 1% to 3%en (2–7 g/person/d)
non-diabetic population: the San Luis Valley Diabetes Study.
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large free-living sample of Chinese adults: exploring the Received May 6, 2010.

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