Keywords:
Gujarat diet - Gujarati cuisine - Gujarat diabetes
Introduction
Gujarat is a state in western part of India, rich in culture and tradition. However,
Gujarati cuisine is not limited to the state of Gujarat. Gujaratis constitute a considerable
portion of Indian Diaspora, hence, Gujarati cuisine is consumed, in some form or the
other throughout the world.
In this article, we have explored the current state of diabetes in Gujarat and the
contribution of Gujarati diet and lifestyle to the diabetes epidemic.
Characteristics of Gujarati Diet and Lifestyle
Characteristics of Gujarati Diet and Lifestyle
The Gujarati cuisine is predominantly lactovegetarian. Lactovegetarianism is consumption
of diet that includes vegetables and dairy products but devoid of meat, fish, and
eggs. The Gujarati food items are well known to have a ‘sweet tinge'. It is believed
that there is liberal use of oil and ‘ghee' for preparation of most food items. Desserts
and sweets are essential parts of most meals including breakfast. Dairy and diary-products
are favored in Gujarat and most major meals end with buttermilk.
‘Farsans' are traditional snacks or appetizers which accompany most meals and also
consumed during the midmorning and afternoon period. Food items such as ‘Dhokla',
‘Khaman', ‘Kachoris', and ‘Samosas' are examples of ‘farsans'. These food items are
often consumed without portion control and Gujaratis are often obsessed with ‘farsans'
and ‘sweets'. Needless to say, these food items are often rich in fat and have high
salt content. Pickles and papads having high salt content accompany most meals and
hence salt intake is generally very high in Gujarati diet.
However, traditionally and predominantly in rural households, the consumption of sugar,
sweets, and ‘farsans' is limited. Carbohydrate is mainly consumed in forms of ‘mixed
grains' and ‘Bajra' in rural households. The rural household consumes more of fresh
fruits and vegetables and a good portion of fresh dairy products.
There is a small difference in dietary habits from various parts of Gujarat. South
Gujarat includes areas such as Surat, Valsad, and Vapi. They prefer adding ‘green
chillies' to a large number of food items. There is also an influence of Parsi culture
in these parts. ‘Nankhatai' are shortbread biscuits, seem to have originated in Surat
and have an influence of Dutch cuisine.
Farsans such as ‘Khaman Dholka' are popular in Central and North Gujarat while the
region of Kathiawad is popular for ‘Dhebras' (a form of spicy bread), ‘Chunddas' (which
is a popular form of sweet pickle) and ‘Rotlas' (a form of thick bread made from Bajra).
The food consumed in Kutch region (the North-West part of Gujarat) is relatively simple
compared to other parts of Gujarat and tend to have similarities to Rajasthani cuisine.
‘Dabeli' is something like a burger which is a popular snack originating from Kutch.
The diet in Gujarat, as with other parts of India, is also influenced by religion.
‘Jainism' is an important religion practiced in Gujarat and Jain cuisine is devoid
of onion, garlic, and vegetables grown underground such as potato. Additionally, they
refrain from eating after sunset. Those who follow the ‘Swaminarayan sect' also refrain
from having onion and garlic in their diet. The ‘Vaishnav' diet involves foods that
are offered to Lord Krishna. As mentioned in Bhagawad Gita, Lord Krishna consumes
only the food which is considered ‘sattvik'. Again, they are devoid of onion and garlic.
The Bohra Muslims of Gujarat have unique traditions. Their meals start with a pinch
of salt and a dessert which is followed by bread and then the main course. Family
members often dine together and often in a single large plate called ‘Thal'. No grain
of rice is wasted, as per the tradition.
The Parsi comminity has a strong influence on the diet and lifestyle of Gujaratis
living in South-Gujarat and the Gujarati community in Mumbai. Unlike the Gujarati
Hindu diet, the Parsi diet is not restricted to vegetarianism and meat is consumed
during dinner time. ‘Dhanshak' is a popular Parsi dish which is a mixture of lentil
and meat consumed with rice or roti.
Apart from the diet, there are certain other lifestyle practices in Gujarat which
may have positive or negative influences on health. For example, Alcohol consumption
is legally prohibited in the state of Gujarat. Gujarat ranks third lowest in alcohol
consumption with a prevelance of alcohol intake of 11%.[1]
Tobacco consumption in Gujarat, however, is very high with more than 50% of men and
around 7% of women admitting to using tobacco in some form or the other.[2] Gujaratis all over the world are mainly involved in sedentary occupation. They are
mainly traders, businessmen, and brokers. Sports are not an important part of the
Gujarati culture and apart from Cricket, Gujarat' s representation in other sports
has been fairly limited. Another unique lifestyle practice in some parts of Gujarat
is having a regular afternoon nap. In fact, in some part of Gujarat, shops and offices
are closed in the afternoon from 2 pm to 4 pm to account for the cultural practice
of an afternoon nap!
Prevalence of Diabetes and Obesity in Gujarat
Prevalence of Diabetes and Obesity in Gujarat
The second phase of Indian Council of Medical Research–INdia DIABetes (ICMR-INDIAB)
study evaluated the prevalence of diabetes in 8 states from the mainland and 6 from
the northeastern part of the country. Gujarat was one of the states included in Phase
II. The total prevalence of diabetes in Gujarat was 7.1% based on this study. The
prevalence of diabetes was lower in Gujarat compared to Andhra Pradesh, Punjab, Karnataka,
and Tripura but was higher than that of Bihar and all the other North-Eastern states.[3] The prevalence was also lower than that of states of Chandigarh, Tamil Nadu, and
Maharashtra which were part of the Phase I of this study.[4] Overall, Gujarat stands in 8th position in the prevalence of diabetes amongst 18
states studied in the two phases of the ICMR trial. The prevalence of diabetes in
Gujarat is lower than the national average which is close to 8%.[5]
The ICMR studies also compared the prevalence of diabetes with the GDP and concluded
that in most states the prevalence of diabetes was directly proportional to the GDP
of the state. Gujarat ranks high in per capita GDP, however, the prevalence of diabetes
is lower compared to its enviable stand in the GDP ranks.[3]
The prevalence of diabetes in the city of Ahmedabad, which is the largest city in
Gujarat is 7.3%.[6] This is lower than the most urban cities of India including Delhi (10.3%), Mumbai
(9.3%), Bengaluru (12.4%), Chennai (13.5%), and Jaipur (8.6%).[7] Interestingly, Mumbai that has a sizeable Gujarati population also has a lower prevalence
of diabetes compared to Delhi, Bengaluru, and Chennai. Prevalence of diabetes has
almost doubled in Ahmedabad over a period of 3 decades, whereas it has increased by
10 times over the same period in Delhi.[8]
The National family health survey (NFHS4) gives us insights into the prevalence of
obesity in the state of Gujarat. The survey shows that around 20% of men and 23% of
women between the ages of 15 to 45 years are overweight (BMI >25kg/m2). There is a
significant increase in the prevalence of obesity in Gujarat compared to NFHS3 survey
a decade ago. However, the prevalence of obesity is significantly less as compared
to the neighboring state of Maharashtra which is comparable to Gujarat in a number
of parameters. According to NFHS-4 survey, 3.5% of men and 2.5% of women have ‘very
high' blood glucose (defined by the survey as blood glucose >160mg/dl). The survey
also reveals that 9.9% of adult men and 7.4% of adult women in Gujarat are hypertensive.
A district-wise breakdown of the NFHS-4 survey data gives more insights into the prevalence
of overweight, ‘high' blood glucose, and hypertension in the state of Gujarat. Data
from a representative district from each area of Gujarat is represented in [table 1]. It is not surprising to see a higher prevalence of high blood glucose, obesity,
and hypertension in the more urban districts of the state such as Central and South
Gujarat.
Table 1
Prevalence of overweight, very high blood glucose and hypertension in men and women
of various representative districts in various regions of Gujarat (based on National
family health survey-4 DATA)
|
REGION
|
NORTH GUJARAT
|
CENTRAL GUJARAT
|
SAURAHTRA
|
KUTCH
|
SOUTH GUJARAT
|
|
REPRESENTATIVE DISTRICT
|
PATAN
|
AHMEDABAD
|
RAJKOT
|
KUTCH
|
SURAT
|
|
OVERWEIGHT MEN
|
15.30%
|
26.40%
|
22.30%
|
20.40%
|
23.20%
|
|
OVERWEIGHT WOMEN
|
17%
|
30.70%
|
36.10%
|
19.90%
|
34.50%
|
|
MEN WITH VERY HIGH BLOOD GLUCOSE
|
1.90%
|
3.70%
|
3.50%
|
3.20%
|
4.70%
|
|
WOMEN WITH VERY HIGH BLOOD GLUCOSE
|
2.00%
|
2.90%
|
3.50%
|
1.80%
|
2.80%
|
|
MEN WITH HYPERTENSION
|
7.40%
|
11.90%
|
8.30%
|
6.90%
|
9.50%
|
|
WOMEN WITH HYPERTENSION
|
7.50%
|
7.50%
|
5.90%
|
3.40%
|
8.40%
|
Macronutrient and Micronutrient Composition of Gujarati Diet
Macronutrient and Micronutrient Composition of Gujarati Diet
Jonnalagadda et al.
[9] conducted a study of dietary intake of Gujaratis who have immigrated to the US.
They found that the Gujaratis in the US had a macronutrient distribution as follows:
carbohydrate 57%, protein 12%, and total fat 33%. Amongst the micronutrients, the
consumption of vitamin D, copper, zinc, and potassium was less than the recommended
intake.
Since Gujaratis are predominantly vegetarian, it is not surprising to see that the
protein intake was below the recommended intake. The fat intake was above the recommendations
while the carbohydrate intake was appropriate.
The conclusion which we can draw from this is that Gujaratis consume more dietary
fat and have lower protein consumption compared to recommended guidelines, however,
their carbohydrate consumption is appropriate.
Is Gujarati Diet and Lifestyle Diabetogenic?
Is Gujarati Diet and Lifestyle Diabetogenic?
Type 2 diabetes, as it is well known, has multifactorial etiology based on both genetics
and environmental influences. Though Gujarati diet may appear ‘diabetogenic' and the
Gujarati lifestyle seemingly sedentary, still the prevalence of diabetes in Gujarat
is lower than other states of India which have comparable GDP. Additionally, the prevalence
of diabetes in Ahmedabad is lower than that in other large cities in India.
There are many plausible explanations for this observed difference. One of the possible
reasons is a genetic susceptibility to diabetes may be lower in Gujarati population.
Additionally, as discussed above, the dietary intake in rural, traditional, and poor
households of Gujarat is predominantly composed to low glycemic index carbohydrate
meals compared to the urban, rich, and more modern Gujarati households.
Other unique features of the state of Gujarat which may contribute to lesser prevalence
diabetes compared to other states are lactovegetarianism and presumably lower alcohol
consumption.
Jenkins et al. wrote a review on ‘Diabetes and Vegetarian diet'. The authors of the review concluded
that though vegetarian diet has several advantages in several aspects of metabolic
parameters, the lower risk of diabetes with vegetarian diet is probably secondary
to the weight loss. The benefit of a vegetarian diet on diabetes in absence of weight
loss needs to be seen.[10]
A study performed in Sweden established that “high alcohol consumption increases the
risk of abnormal glucose regulation in men”.[11] However, it would be naïve to conclude that despite the legal prohibition on alcohol,
alcohol consumption in Gujarat is low. According to a study by Patel et al., 60% of men living in a village in Gujarat reported alcohol consumption which was
equivalent to the alcohol consumption amongst the Gujarati men living in Britain.[12]
The aforementioned study by Patel et al. reveals some interesting insights. They compared the Gujarati living in Britain to
their counterparts living in a village in Gujarat. They found that diabetes prevalence
was high in both the groups despite the fact that the Gujarati in Britain had greater
BMI and greater fat intake. The 2-hour post-glucose challenge plasma glucose was higher
in the Gujarati living in their native village and the difference was significant.[12]
Finally, it was noted in the recent National family health survey (NFHS4) that 25%
men and 27% women in Gujarat are underweight. Thus, approximately a quarter of the
population is thin. This may have an influence on diabetogenesis and diabetes prevalence
in the state.[13]
Suggestions for a ‘Healthier' Gujarat
Suggestions for a ‘Healthier' Gujarat
The prevalence of diabetes in Gujarat is lower compared to other states of India with
comparable GDP, however, the alarming increase in the prevalence of diabetes and metabolic
syndrome in Gujarat needs to be curbed.
One of the major dietary issue is inadequate protein intake in the diet owing to the
predominant vegetarian dietary practices. Some of the Gujaratis, especially those
living in urban areas have no objections to consumption of ‘eggs'. However, this is
often discouraged by the more traditionalists in the family. The increase of consumption
of eggs, especially those who are open to the idea, should be encouraged to increase
the protein content of the diet. Additionally, use of soy products can act as substitute
for the lack of animal protein in the diet. Apart from this, the consumption of ‘farsans'
and ‘sweets' which have become second nature to the Gujarati cuisine should be controlled.
The culture of ‘sports' (especially sports other than cricket) need to be inculcated
especially in Gujarati Youth. Schools and colleges can help in building a sports culture
in the state by encouraging sports activities and participation in competitive sports
and athletic events.
The rapid urbanization and rise of the neo-middle class do carry the burden of increased
prevalence of lifestyle disorders, however, increasing awareness of the lifestyle
measures to curb the menace of metabolic syndrome can help reduce the burden of these
modern age epidemics.
Conclusion
The question we started with while writing this review was “Is Gujarati diet diabetogenic?”
Consequently, the evidence for diabetogenic nature of the Gujarat diet and lifestyle
is weak. Consumption of high fat, low glycemic carbohydrate diet by the majority of
the traditional and rural households may contribute to the lower prevalence of diabetes
despite having a sedentary lifestyle. The protein intake, however, needs to be increased
in the Gujarati diet. There is nothing in the published literature to suggest that
the Gujarati diet and lifestyle have any significant negative impact on the risk of
diabetes in the state. However, the evidence for the same is only circumstantial and
only a well-designed epidemiological study can help answer the question with certainty.
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