A decade into the twenty-first century, it is the environment of our very own 'development' and 'progress' that is breeding the largest public health crises of modern times. Obesity, high blood pressure, type 2 diabetes (herein referred to as diabetes), cardiovascular (heart) disease, cancer and gastrointestinal disorders are non-communicable diseases (NCDs) and illnesses that are quickly overtaking today's urbanizing world. In India, the incidence of NCDs is believed to have surpassed that of communicable and infectious diseases (CDs)—previously the main public health threat in the developing world. In 2003, South Asia had the largest diabetic population with 46.3 million people affected by the disease, with India alone, the "king of diabetes", accounted for over 31.7 million people. With a projected doubling in these numbers by the year 2030, the World Health Organization has called type 2 diabetes an epidemic of potentially devastating proportions.
The behavior and environmental risk factors of these diseases are well known: lack of physical activity, stress, alcohol and tobacco consumption combined with an improper diet. Excess refined carbohydrates like white flour and white rice and sugar (simple carbohydrates) is a main dietary cause along with too many refined and saturated fats, and salt. Such a diet tends to also be deficient in fresh fruits and vegetables, unrefined whole grains, and dietary fiber (complex carbohydrates). Dietary and lifestyle changes are widely recognized as being more effective than allopathic medicine for both treatment and prevention of metabolic syndrome and diabetes.
As a Fulbright fellow in Kathmandu, Nepal for the last year I studied food habits and the health impacts of dietary change in Nepal's capital city. To conclude my research I distributed brown rice, although unpopular in Kathmandu an important and extremely healthy, whole grain praised by doctors and chefs alike for its rich flavor and ability to help prevent and manage NCDs. Giving the brown rice along with surveys, it was my aim to understand whether switching from eating refined white rice to unrefined brown rice was a possible habit change for average people to make. As summarized near the end of this article, my results were largely favorable.
Here in Kathmandu, studies show that 18% of the adult population over the age of 40 has diabetes and an additional 10-40% of people suffer from a pre-diabetic state called Impaired Fasting Glycaemia and/or metabolic syndrome. This is compared to diabetes rates of only 3-4% in the Nepali rural adult population. While rural Nepalis are generally physically active and eating relatively wholesome fresh foods, Kathmandu's urban population is increasingly sedentary and eating more and more processed foods.
Globally, non-communicable diseases cause 60% of deaths, 80% of these being among middle and low-income families. In South Asia, the annual direct medical costs of diabetes alone total an estimated $1.2 billion. In 2000, for a low-income household in India, 34% of family income would be drained if one of the household members needed diabetes care. But diabetes is only a fragment of the big picture, cardiovascular disease causes 50-80% of deaths in diabetic patients and is now the leading cause of death in the world accounting for over 6.4 billion deaths per year—30% of total deaths. By the year 2010 India is predicted to host 60% of the world's total heart disease burden which, combined with other chronic diseases, could cost the country up to $237 billion in the next ten years.
Considering the enormous shift of the health care burden taking place in developing countries, one would expect international development agencies and governments to react to such trends accordingly. However this is not the case. In 2006, of $26 billion Official Development Assistance provided by the international community (OECD/DAC/EC), only 100 million supported basic nutrition and no funding was allocated specifically for prevention and control of NCDs. Instead most attention remains directed towards CDs.
One reason no significant shift of focus has taken place is because NCDs are commonly labeled "lifestyle diseases" of the rich and elderly. Obesity, diabetes and heart disease were once called "diseases of affluence" because in the recent past only wealthier people were eating refined foods and privileged enough to not do physical labor and hence were contracting these NCDs. Today younger and younger groups are being affected and upper, middle and low class people share an environment extremely conducive to being sedentary and eating mostly processed foods. In fact, NCDs pose a greater threat and burden in poor and disadvantaged communities for whom fresh fruits and vegetables are relatively more expensive and good education is a rare commodity.
Labeling metabolic syndrome, diabetes, and cardiovascular disease "western diseases" is a more appropriate term than "diseases of affluence." It is in fact the environment molded by "progress" and "development" originally brought from the western world that is kindling the fire of the current NCD pandemic. The extraordinarily harmful nutritional transition taking place throughout the world and underpinning the NCD pandemic is largely the product of the widespread industrialization of food production. The growth of sophisticated supply chain management on a global scale coupled with the expansion of market economies and the growing concentration of global food manufacturers explain why the cheapest and most widely available foods bought by a rapidly urbanizing population are energy (calorie) dense, nutrient-poor foods rich in simple carbohydrates and unhealthy fats. Quite ironically however, it is this so called "sophisticated" global food system that is greatly responsible for much unnecessary illness and loss of human life on the planet.
Throughout our history, humans have lived by eating primarily vegetables, fruits, whole grains, and legumes that provide plenty of complex carbohydrates, micronutrients, protein, and dietary fiber. Our bodies are therefore biologically best suited for such unrefined, whole and natural foods. Only during the last century—most dramatically in the past 50 years—have people started to eat refined carbohydrates and fats as the basis of their diet. This short period is also the first time in which metabolic illness and NCDs have emerged in pandemic proportions, providing a good indication that such processed foods are not nutritionally suitable for good human health.
The nutritional science behind diabetes and Metabolic Syndrome is simple enough. Carbohydrates in the food we eat are converted into glucose, a type of sugar that is used to provide energy to the body. The complex carbohydrates found in vegetables, fruits, legumes, and whole grains like brown rice, corn, millet, buckwheat, and barley are converted into glucose relatively slowly because the composition of these foods is naturally rich in micronutrients and dietary fiber—essential elements for proper metabolism and good health. (Moderate amounts of whole grains, fruits, vegetables, legumes and healthy fats in the diet are associated with low risk of developing NCDs like diabetes and heart disease.) Processed simple carbohydrates like white sugar, white rice, and white flour on the other hand are converted to glucose very quickly because they lack any significant amount of micronutrients or dietary fiber, which are stripped away during the refining processes.
Insulin, a hormone produced by the pancreas, acts as a 'key' to open the 'doors' of our body's cells, allowing glucose in the blood to enter cells and be utilized as energy. When we eat simple carbohydrates in large quantities over long periods of time, the body becomes overwhelmed and loses its ability to deal with so much glucose. The pancreas eventually becomes tired, no longer producing good keys (insulin), the cells' doors' become worn out, becoming jammed. Glucose that thus does not enter cells stays in the bloodstream where it is a harmful substance that attacks the body and creates disease. This circumstance, called "insulin resistance", is the underlying cause of "metabolic syndrome"—a term that refers to a host of interrelated symptoms including obesity, high blood pressure, high cholesterol and high blood fat (triglyceride) levels. Left unmanaged, the conditions of metabolic syndrome pave the road to NCDs like diabetes, cardiovascular disease, kidney failure, eye damage, blindness and limb amputation.
In Kathmandu most people consume a towering portion of white rice two to three times every day. Compared to the rice, curried vegetables and dal (watery lentil soup) are taken in much smaller quantities. This great proportion of grain on the plate is suitable for the traditional agrarian lifestyle of rural Nepal, but transplanted into modern Kathmandu all of this white rice is a recipe for disaster. Today's most popular snack foods are also almost entirely simple carbohydrates, all being made from refined white flour combined with unhealthy amounts of refined oils: chowmein, chow chow packaged noodles, samosas, naan, puri, sweets, sodas, fried chips, donuts, white bread, and of course the quintessential sugar sweetened Nepali chiya (tea) served with white flour biscuits that some people will take up to 15 times per day in the winter season.
It was not long ago that white sugar, white flour and white rice were rare and expensive commodities in Kathmandu's capital city. At that time people were consuming unpolished brown rice with vegetables fresh from their garden. Besides rice people enjoyed (and still do in rural areas) bread and other dishes prepared from a diverse array of whole grains like corn, millet, buckwheat and barley.
Unfortunately, for most of Kathmandu's residents today, the only thing synonymous with real food is white rice. Even while recognizing the great healthfulness of food items made from different whole grains, people tend to associate dhido, roti, and even brown rice with the "poverty" and "backwardness" of village life. Many people come to Kathmandu from their village trying to abandon hardship and seeking the facilities and comforts of modern life. White rice and white flour are items that "look good", are "easy to eat" and "soft to chew". Brown rice "looks dirty" people say, "we eat rice that has been cleaned". Really, only by calling micronutrients and fiber dirty can we call white rice cleaner. It is a lack of these micronutrients and fiber that is not only partially responsible for the current NCD pandemic sweeping the world, but also for the increasing number of people suffering from constipation, gastritis, mouth sores, and pain and tingling in the limbs.
Besides the conceptual reasons I have mentioned, market availability, cost, and advertising from processed food producers are major factors accounting for the attractiveness and overwhelming consumption of refined foods. With such a vast subject of food and health at hand, I eventually focused my research on one topic alone. Assuming that some change in diet is necessary for improved health in Kathmandu, seeing rice as the most common food in the diet, and recognizing brown rice—naturally rich with important dietary fiber and micronutrients—as the healthiest form of the grain, I decided to research whether switching from eating white rice to brown rice was a habitual transition people are capable of making.
Initially, while talking to people about their conceptions of brown rice, I found people with a previous habit of eating it said that they really like it. On the other hand, people who had neither eaten nor heard of it before tended to respond negatively when ask about the rice, usually assuming that brown rice would be hard to eat and unpalatable on top of looking bad. For my final research, I distributed brown rice to over 200 random research subjects to be eaten over two weeks. After analyzing peoples' responses to eating the rice written in a simple survey that was given with the rice, I found that only about 23% of people indeed did have a negative experience the first time eating the brown rice opposed to 41% of people who had a positive first experience. Of those people with initial negative experiences however, and similarly for the subject group as a whole, about 55% of people said that their experience improved as they continued eating the brown rice—it become tastier and more enjoyable to eat with time. Overall 56% of people said that they found the brown rice "good", "tastier" or "better" in comparison to white rice.
Most of the research subjects had been eating white rice for their entire lives. My research concludes that however deeply rooted that habit of eating white rice may be, most people can switch to eating brown rice: by the end of only two weeks 51% of the research subjects said that they had gained the habit of eating brown rice, an additional 11% saying that they were trying to gain the habit. 57% of people said that they wanted to buy the brown rice again. By the end of the two-week period only 7% of people said that they disliked the rice. Over one quarter of the research subjects (27%) said that they found it to be "extremely delicious" ("dherai mitho"). About half of the people said that they would serve the brown rice to guests.
An even larger portion of people, 67%, subjectively found some positive effect on their health. Of those who commented, 26% said that their body or stomach felt lighter, 20% said that their constipation was lost, 13% said that they felt their diabetes managed (two people reported fasting glucose levels dropping from over 150 mg/dl to under 100 while eating the brown rice germinated), and 36% reported a great amount of strength and energy. Other people had sores in the mouth lost, improved digestion and appetite, and limb pain reduced, along with other benefits. Another good thing about brown rice, as 63% of people commented, is that it is filling; thus it can be eaten in smaller quantities and prevents one from feeling hungry very quickly.
My research indicates that changing eating habit is not necessarily an easy thing to do—it takes some effort. As one subject wrote on their survey, "at first I did not like the taste and found this rice hard to eat. Learning how to cook it well, and with a little bit of time, now I really like it and I only want to eat this kind of rice." I found a positive correlation between the amount of times people ate the rice and the how much they enjoyed it or created a habit of eating it. While among people who ate the brown rice four or more times per week (101 people), 71% enjoyed the taste, 80% had a positive health experience, 62% created a habit of eating it, and 70% wanted to buy it again; those who ate the brown rice 2 or less time per week (52 people), only 32% enjoyed the flavor, 36% had a positive health impact, 8% created a habit of eating it, and 37% of people wanted to buy it again.
"I feel great, you should give information about brown rice to everyone" writes one subject. Indeed, from the grassroots to the international community level, it is essential that coordinated efforts exist to provide education and awareness about the dangers of modern refined foods while making wholesome foods more widely available. "I am worried that this kind of rice wont be available in the future and that I will have to eat white rice again" writes another person.
Brown rice is not a sole solution to the NCD crisis in the Indian subcontinent, there is a diverse variety of wholesome foods being lost from the urban diet that need to be recovered in proper balance. My research indicates that no matter how dark the horizon may seem, humans are very adaptable creatures capable of changing their habits for the better. Undoubtedly, such change is necessary and must be supported from all levels of society.
