dietary advice for asian diabetics

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Dietary advice for Asian diabetics Judith Baylis MSC SRD Research Dietitian Research Nutritionist Nutrition & Diabetes Research Group, Willesden Hospital, London, NWIO 3RY Correspondence Ms J Baylis, Consultant Dietitian, 79 Moreland Court, Church Walk, London, NW2 2TP Jayshree Dattani BSC Dip Hum Nut It is well recognised that appropriate dietary advice is important in promoting and maintaining good diabetic control. There is an urgent need for health profes- sionals who work in areas of Britain with an ever-increasingcultural diversity to give dietary advice that is relevant to their par- ticular patients. This means acquiring considerable knowledge and understan- ding about the diet, lifestyle and attitudes of the ethnic groups concerned. In this paper, we refer to the findings of the Brent Asian Diabetic Diet Study and suggest practical ways in which the BDA dietary recommendations can be applied to the Asian diet. Brent The London Borough of Brent is an ex- ample of a culturally diverse area, where approximately 20% of the population are of Asian origin, 17% Afro-Caribbean and a significant proportion of the remainder from other European countries. Thirty per cent of patients attending the diabetic clinics in the Borough come from the In- dian sub-continent, ie India and Pakistan, either direct or via East Africa. Most of these patients are middle-aged (they came to Britain in the early 1970s) and most have been diagnosed as diabetic for less than 10 years. The majority do not require insulin and are treated with diet and/or tablets. About 70% of the Asian diabetics in Brent are Gujerati Hindus. Although Hindus are commonly vegetarian, we found that this was more so for the women than the men. Patients from Pakistan are usually Muslim. Although this is generally the case, it is important for health workers to ascertain the rele- vant details about their particular client group, as attempts to stereotype can be very misleading. Dietary patterns In our survey (Ref I), we found that most patients followed a fairly traditional diet, with wheat and rice as the principal staple foods. In areas where people originated from Southern and Eastern In- dia, rice is likely to be the main staple. Wheat is usually eaten in the form of an unleavened bread (chapati), made with or without the addition of fat, usually oil, to the dough. Chapatis may be eaten dry or spread with fat, usually butter or ghee. The thickness of the chapati is often dependent upon the region of origin, peo- ple from Northern India eating a thicker chapati than Gujeratis. Three to six may be eaten in a day, depending on size and thickness. Other types of bread commonly 194 eaten are puris and parathas, where the dough is fried in ghee (clarified butter) or oil. Rice is usually boiled, although fried rice is eaten by most communities on special occasions. These staples are generally eaten with vegetables such as okra, aubergine, spinach and potatoes, in the form of a curry. Diabetics often make a point of eating karela, a bitter gourd, for its believed hypoglycaemic effect. Traditionally, pulses and beans, main- ly pigeon pea, mung, urad, chick pea and black-eye bean, are also included in the main meal. However, due to changing lifestyles, there may be reluctance to spend time in preparing these dishes and for this reason they may be omitted. A variety of pulses and beans may be used; these may be processed in various ways and cooked with varying quantities of water. For ex- ample, chick peas can be eaten whole or ground into a flour, or the split form (dahl) may be used to make a watery soup or a thick puree. A side-salad of vegetables such as cucumber, tomato, carrot, lettuce and onion may accompany the meal. Fresh fruit generally follows the main course and, although all varieties are wide- ly eaten, mangoes and bananas are especially favoured. Non vegetarians Chicken, fish, eggs and mutton, in that order of preference, are the animal pro- ducts frequently eaten by non-vegetarians. Muslims eat meat killed by the ‘halal’ method and most do not eat pork. Beef may be eaten by some non-vegetarian Hin- dus, although the cow is traditionally con- sidered to be sacred. It is important that patients are asked about their personal choices and are not assumed to adhere to traditional values. Meat is generally cur- ried but may be baked in an oven (tan- doori). Both fish and eggs may be curried, although fried fish and fried eggs are the most popular methods of cooking. Dairy products and fats Both vegetarians and non-vegetarians use fresh milk, mainly in tea, as yogurt or as lassi (a sweet or sour yogurt drink). Homogenised milk is preferred, for its ex- cellent yogurt-making qualities. Cheese does not form a major part of the tradi- tional diet of most communities, although paneer (a curd-type cheese) is commonly eaten by North Indians. Butter is widely eaten. This is mainly clarified to make ghee, which is then used as a spreading fat, incorporated into sweet dishes and used in making chapatis and curried dishes. Vegetable oils, for example corn and groundnut, are also commonly used in making curries; the quantity is very variable and depends on individual taste. Oil is also necessary for the deep frying of snacks, such as samosas, ganthias and chevda. Margarine is not commonly us- ed and is not acceptable for making ghee. Sweets Sweet dishes such as burfi, gulab jamun and halva are generally eaten only on special occasions like weddings, parties and family gatherings. Understandably, it is difficult to resist them when they form such an integral part of socially acceptable behaviour. As well as sugar, jaggery (un- processed rock sugar) is also used when making certain sweets. Both these sources of refined carbohydrate are commonly added to curries and pickles by some Gu- jerati communities. Other frequent sources of refined carbohydrate in the diet are sweet biscuits, cakes, confectionery and fizzy drinks, eg cola and Lucozade. Alcohol Although it is commonly believed that Muslims do not drink alcohol, nowadays this may not apply to everyone and it is recommended that relevant questions be asked of individual patients when obtain- ing the history. Fasting Not all Asians fast. However, women generally practice this more than men. When Muslims fast it is usually over the month of Ramadhan. They will then on- ly eat and drink before sunrise and after sunset. Hindus may fast on certain days throughout the year. The frequency can vary from once or twice a week to once a year. However, they may eat certain foods, eg chips, nuts, cassava, plantain, fruits and most dairy products, during the fast since these are considered to be ‘pure‘. In 1982 the British Diabetic Association published a policy statement of dietary recommendations for the 1980s (Ref 2), in which they advocated an increased pro- portion of energy (50% or more) to be derived from carbohydrate, the majority of this to come from foods rich in dietary fibre. They also recommended that the total fat be reduced, especially that from animal and dairy foods, thereby decreas- ing particularly the amount of saturated fat. In line with current guidelines for a healthy diet for the general population (NACNE 1983) (Ref 3), a decrease in the Current recommendations Practical DIABETES July/August 1986 Vol 3 No 4

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Page 1: Dietary advice for Asian diabetics

Dietary advice for Asian diabetics Judith Baylis MSC SRD

Research Dietitian Research Nutritionist Nutrition & Diabetes Research Group, Willesden Hospital, London, NWIO 3RY

Correspondence Ms J Baylis, Consultant Dietitian, 79 Moreland Court, Church Walk, London, NW2 2TP

Jayshree Dattani BSC Dip Hum Nut

It is well recognised that appropriate dietary advice is important in promoting and maintaining good diabetic control. There is an urgent need for health profes- sionals who work in areas of Britain with an ever-increasing cultural diversity to give dietary advice that is relevant to their par- ticular patients. This means acquiring considerable knowledge and understan- ding about the diet, lifestyle and attitudes of the ethnic groups concerned. In this paper, we refer to the findings of the Brent Asian Diabetic Diet Study and suggest practical ways in which the BDA dietary recommendations can be applied to the Asian diet.

Brent The London Borough of Brent is an ex-

ample of a culturally diverse area, where approximately 20% of the population are of Asian origin, 17% Afro-Caribbean and a significant proportion of the remainder from other European countries. Thirty per cent of patients attending the diabetic clinics in the Borough come from the In- dian sub-continent, ie India and Pakistan, either direct or via East Africa. Most of these patients are middle-aged (they came to Britain in the early 1970s) and most have been diagnosed as diabetic for less than 10 years. The majority do not require insulin and are treated with diet and/or tablets. About 70% of the Asian diabetics in Brent are Gujerati Hindus. Although Hindus are commonly vegetarian, we found that this was more so for the women than the men. Patients from Pakistan are usually Muslim. Although this is generally the case, it is important for health workers to ascertain the rele- vant details about their particular client group, as attempts to stereotype can be very misleading.

Dietary patterns In our survey (Ref I ) , we found that

most patients followed a fairly traditional diet, with wheat and rice as the principal staple foods. In areas where people originated from Southern and Eastern In- dia, rice is likely to be the main staple. Wheat is usually eaten in the form of an unleavened bread (chapati), made with or without the addition of fat, usually oil, to the dough. Chapatis may be eaten dry or spread with fat, usually butter or ghee. The thickness of the chapati is often dependent upon the region of origin, peo- ple from Northern India eating a thicker chapati than Gujeratis. Three to six may be eaten in a day, depending on size and thickness. Other types of bread commonly

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eaten are puris and parathas, where the dough is fried in ghee (clarified butter) or oil. Rice is usually boiled, although fried rice is eaten by most communities on special occasions. These staples are generally eaten with vegetables such as okra, aubergine, spinach and potatoes, in the form of a curry. Diabetics often make a point of eating karela, a bitter gourd, for its believed hypoglycaemic effect.

Traditionally, pulses and beans, main- ly pigeon pea, mung, urad, chick pea and black-eye bean, are also included in the main meal. However, due to changing lifestyles, there may be reluctance to spend time in preparing these dishes and for this reason they may be omitted. A variety of pulses and beans may be used; these may be processed in various ways and cooked with varying quantities of water. For ex- ample, chick peas can be eaten whole or ground into a flour, or the split form (dahl) may be used to make a watery soup or a thick puree. A side-salad of vegetables such as cucumber, tomato, carrot, lettuce and onion may accompany the meal. Fresh fruit generally follows the main course and, although all varieties are wide- ly eaten, mangoes and bananas are especially favoured.

Non vegetarians Chicken, fish, eggs and mutton, in that

order of preference, are the animal pro- ducts frequently eaten by non-vegetarians. Muslims eat meat killed by the ‘halal’ method and most do not eat pork. Beef may be eaten by some non-vegetarian Hin- dus, although the cow is traditionally con- sidered to be sacred. It is important that patients are asked about their personal choices and are not assumed to adhere to traditional values. Meat is generally cur- ried but may be baked in an oven (tan- doori). Both fish and eggs may be curried, although fried fish and fried eggs are the most popular methods of cooking.

Dairy products and fats Both vegetarians and non-vegetarians

use fresh milk, mainly in tea, as yogurt or as lassi (a sweet or sour yogurt drink). Homogenised milk is preferred, for its ex- cellent yogurt-making qualities. Cheese does not form a major part of the tradi- tional diet of most communities, although paneer (a curd-type cheese) is commonly eaten by North Indians. Butter is widely eaten. This is mainly clarified to make ghee, which is then used as a spreading fat, incorporated into sweet dishes and used in making chapatis and curried dishes.

Vegetable oils, for example corn and groundnut, are also commonly used in making curries; the quantity is very variable and depends on individual taste. Oil is also necessary for the deep frying of snacks, such as samosas, ganthias and chevda. Margarine is not commonly us- ed and is not acceptable for making ghee.

Sweets Sweet dishes such as burfi, gulab jamun

and halva are generally eaten only on special occasions like weddings, parties and family gatherings. Understandably, it is difficult to resist them when they form such an integral part of socially acceptable behaviour. As well as sugar, jaggery (un- processed rock sugar) is also used when making certain sweets. Both these sources of refined carbohydrate are commonly added to curries and pickles by some Gu- jerati communities. Other frequent sources of refined carbohydrate in the diet are sweet biscuits, cakes, confectionery and fizzy drinks, eg cola and Lucozade.

Alcohol Although it is commonly believed that

Muslims do not drink alcohol, nowadays this may not apply to everyone and it is recommended that relevant questions be asked of individual patients when obtain- ing the history.

Fasting Not all Asians fast. However, women

generally practice this more than men. When Muslims fast it is usually over the month of Ramadhan. They will then on- ly eat and drink before sunrise and after sunset. Hindus may fast on certain days throughout the year. The frequency can vary from once or twice a week to once a year. However, they may eat certain foods, eg chips, nuts, cassava, plantain, fruits and most dairy products, during the fast since these are considered to be ‘pure‘.

In 1982 the British Diabetic Association published a policy statement of dietary recommendations for the 1980s (Ref 2), in which they advocated an increased pro- portion of energy (50% or more) to be derived from carbohydrate, the majority of this to come from foods rich in dietary fibre. They also recommended that the total fat be reduced, especially that from animal and dairy foods, thereby decreas- ing particularly the amount of saturated fat. In line with current guidelines for a healthy diet for the general population (NACNE 1983) (Ref 3), a decrease in the

Current recommendations

Practical DIABETES July/August 1986 Vol 3 No 4

Page 2: Dietary advice for Asian diabetics

salt intake is also recommended. In the overweight diabetic, it is important to reduce the overall energy intake. This should include any contribution from alcohol and especially diabetic foods con- taining sorbitol and fructose. The timing and spacing of meals remains an impor- tant consideration, especially for diabetics requiring insulin or hypoglycaemic agents. The necessity for adapting the recommen- dations to meet individual requirements is stressed, as is the need to have ap- propriate printed matter in place of stan- dardised diet sheets.

Practical application In this section we explain some practical

ways of applying the BDA recommenda- tions, based on our knowledge of what is acceptable to Asian patients in Brent.

(1) Reducing refined carbohydrates We recommend that patients be advis-

ed not to add sugar or jaggery when mak- ing curries and pickles. However, in view of the social pressures surrounding the consumption of foods such as sweets, biscuits, cakes and fizzy drinks, we believe it is more realistic to advise a reduction of these foods than total avoidance.

Patients may be unaware of the ar- tificial sweeteners, eg saccharine, Sweetex, Hermesetas or Canderel, that can be us- ed as a substitute for sugar. They will therefore need to be shown ways of using them to their advantage. Patients are IikeIy to find them useful in drinks. However, replacing sugar in some sweet dishes is unlikely to be successful, due to the dif- ficulty of simulating the textural quality that sugar gives to the recipe. Shrikand is one example in which an artificial sweetener can be successfully used.

(2) Reducing fats Using less ghee in cooking and

spreading, less oil or ghee in cooking and changing to skimmed or semi-skimmed varieties of milk are the most practical ways of decreasing the total fat in the diet. It is important to explain to the patient why this reduction is necessary. Increase in weight and damage to the heart as a result of eating too much of these foods is generally an adequate explanation. In our study we found that most people had between 3 - 1 pint of fresh milk daily, although a considerable number had more than a pint. Milk is an important source of protein, calcium, vitamin A and riboflavin, particularly for vegetarians. As fresh homogenised milk contains approx- imately 4% fat, compared with 82% in butter and 99% in ghee and oil, we feel it is more nutritionally sound to emphasise the need to decrease the oil, ghee and but- ter intake than to risk a reduction in the intake of the essential nutrients provided by milk.

With fried foods, such as chevda, crisps and ganthia, it is more realistic to expect patients to restrict their intake to special occasions than to avoid them completely.

Practical DIABETES July/August 1986 Vol 3 No 4

Again, the association between their con- sumption and rapid weight-gain should be pointed out. Acceptable ways in which non-vegetarians can reduce their saturated fat intake include: changing their method of cooking, eg curried or boiled eggs rather than fried, curried or grilled fish rather than fried; buying the leanest meat they can afford, removing any visible fat before cooking.

(3) lncreasing fibre It is very difficult to assess fibre intake

in the Asian diet, as few reliable figures are available in food analysis tables. However, in our experience the intake is unlikely to be much more than the pre- sent UK national average of 20g per day. The recommended b e 1 is 30g per day and patients are encouraged to have at least one pulse or bean dish a day as an accep- table way of increasing their fibre intake. It is important to note that, if the pulses are eaten in the form of a watery dahl, the effectiveness of the fibre will be reduced.

All patients have chappati flour daily and, at 85% extraction, this makes a significant contribution to the total daily fibre intake. We found that less than half our patients regularly ate bread and breakfast cereals and white bread was preferred by most people. Rather than try- ing to persuade all patients to eat wholemeal bread and breakfast cereals, it is more effective to identify those patients who do eat these products regularly. White Basmati rice was preferred by everyone and we found patients unwilling to accept brown rice.

Most of our patients had fresh fruit and vegetables at least once a day. Aubergine, fenugreek, karela and guar are among the popular varieties. In view of recent research into the possible beneficial effects of guar on diabetic control (Ref 4) it is in- teresting to note that this vegetable has been part of the traditional Asian diet for many centuries.

(4) Diabetic foods We found that diabetic and low-calorie

drinks are the only diabetic products wide- ly used by Asian patients. These seem to play a useful part in the calorie-controlled diets of the many Asian diabetes who are overweight. In line with the current BDA recommendations, we feel it is inap- propriate to promote speciality diabetic foods, as these can make a significant con- tribution to the total energy intake.

(5) Salt We did not undertake the estimation of

the sodium content of the diet, although it is our impression that this could be con- siderable, due to the large amounts of salt generally added during cooking.

(6) Timing of meals Confusion may arise over the term

'meal'. This may mean only the main meal of the day to some patients, resulting in under-reporting of meal frequency. Rather

Dietary advice for Asian diabetics

than asking how many meals are consum- ed, it is more accurate to ask patients at what times of the day they eat and what they have on each occasion. It is general- ly recommended that patients have three meals evenly spaced throught the day, although it must be remembered that those requiring insulin will need to cover the effect of this by including between- meal snacks.

General guidelines In addition to dietary advice, general

guidelines on taking prescribed medica- tion, testing urine frequently and keeping active need to be included in any educa- tion material prepared for diabetics. The advice needs to be carefully promoted in ways which are sensitive to the needs of the client group concerned. In addition, Asians and also some other ethnic groups may need material prepared in their own languages. Any material that is produced can only cover the needs of groups of peo- ple and individual patients may need ad- vice to be tailor-made. This can only be achieved if the health professionals con- cerned have the necessary knowledge and understanding to do this. In this paper, we have made suggestions for implementing current BDA recommendations in the Asian diet. Although these suggestions are appropriate for most of the Asian com- munities in Britain, we strongly recom- mend first finding out about individual practices and then adapting the necessary advice, thereby making it acceptable to the patient and increasing the likelihood of compliance.

Acknowled ements We grateful 7 y acknowledge support

from Dr D B Peterson and Dr E M Jep- son and research grants from the North West Thames Regional Health Authority (locally organised research scheme) and the Joint Finance Scheme of the Brent Health Authority and Brent Social Ser- vices which enabled us to undertake the Asian Diabetic Diet Study.

References Peterson D B, Dattani J T, Baylis J M, Jep- son E M. Dietary practices of Asian diabetics, Br Med J , 1986; 292 170-1.

British Diabetic Association. Dietary recommendationsfor diabetics for the 198k - a p o k y stateme8t by the British Diabetic Association. Human Nutrition: Applied Nutrition,

James W P T. Proposals for nutritional guidelines for health education in Britain. Health Education Council, 1983.

An, A, Uusitupa M, Voutllainen E, Her- sion K, Korhonen T, Siitonen 0. Improved diabetic control and hypocholesterolaemic effect induced by long-term dietary supplementation with guar gum in Dpe 2 (insulin-independent) diabetes Diabetoiogia, 1981; 21: 29-33,

1982; 36A 378-94.

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