A few months ago, I had a curious insight into India’s scariest disease. I was at a medical conference, and the morning had been spent reviewing newer therapies for diabetes mellitus. The audience had drowsed through an hour of statistics, woken up briefly at the mention of a new molecule, and then relapsed into stupor until rescued by coffee.
The next session was on bariatric surgery for obesity. The poster boy for the procedure was that weighty politician, Nitin Gadkari. Stapling his stomach hadn’t improved his appearance, and the surgeon came in for some spirited heckling. When he returned to his seat, I overheard him say, “If only they’d scheduled my paper after lunch—”
I never learnt why because he was abruptly cut off from view. At some silent signal, every man and woman in the hall sprang up in a single-minded lunge towards the exit. The aisle thundered with physicians and surgeons in mad stampede, elbows out, glazed eyes fixated on the door, pushing and squeezing their way out as if their lives depended on it.
Was it a fire? A bomb threat? Or all that coffee reminding them there were just two restrooms for two hundred?
Nothing so casual. This was a more existentialist crisis. It was lunch.
It took me more than half an hour to get to the food. Even then I had to fight my way past the phalanx queued up for second helpings. Everybody was eating everything: desi, Continental, Chinese, Italian, Middle Eastern, even something that looked coyly Japanese.
“So much better than the usual greasy samosa,” a diabetologist mumbled into his shawarma.
His wife shuddered delicately. Her plate had a small floury bun, dingy beneath its peeling eczema of oats and cracked wheat. The midsection oozed olive oil. She mopped up some more from a glistening puddle of shrivelled fungi and fern, then swiftly speared a forkful of pasta before it could slither away.
“Extra virgin,” she confided, “wouldn’t touch it otherwise. I only eat Mediterranean.”
I wondered what kind of dessert they had served this polyphagic platoon.
“Ice cream, ras malai, Black Forest,” the chef hissed through clenched teeth. “All gone in ten minutes.”
Suddenly, bariatric surgery seemed a great idea.
Back in the lecture hall, I found myself next to the Mediterranean.
“The figures have just come in,” she said to me breathlessly. “Have you seen them? Shocking!”
She was referring to the International Diabetes Federation’s newly updated Diabetic Atlas. This 5th edition carries global data for 2011. The figures were indeed shocking.
In 2011, China led with 90 million diabetics. India ran a close second with 61.3 million. The projected figures for 2030 were 129.7 million for China and 101.2 million for India.
I don’t know about China, but judging from the past few hours, India was Usain Bolting towards that goal.
The tea break, with its assortment of cakes and cookies, was ahead. By the time the crowd dispersed then, each man and woman would have consumed two days’ worth of calories. Yes, dinner was yet to come. And they had talked all day about how to tackle India’s most frightening epidemic, diabetes.
How could they be so supremely unconscious of the irony? Their attitude revealed the schism we’re unable to bridge. We’re unable to translate what we know into what we do.
Here’s what we know. As many as 61.3 million Indians suffer from diabetes mellitus. The commonest form of diabetes in India is type-2 diabetes mellitus (T2DM). The estimated number of Indians afflicted with T2DM was 51 million in 2010. The figure projected for 2030 is 87 million. All regions of our country have diabetics, but Tamil Nadu leads, since 2008, with the most, 18.6 per cent.
The statistics are growing worse, and faster than expected. Let’s leave the numbers aside. Who is afflicted?
It used to be the fiftyish, now it is the mildly forty. Now it is the young, the productive, the middle-class. Think parents with school-going children. Think salaried wage earners, often singly supporting large families. Think hotshot innovators, salt-of-the-earth mothers, fathers working overtime at desk jobs to make school fees, tuitions for college. Think straphangers making two-hour commutes to eight-hour jobs that barely meet their month’s expenses. Think you, think me.
Diabetes is no longer a disease of affluence. Most deaths from this disease now occur among the lower middle-class. It is no longer an urban disease. Rural India has decided to emulate the urban epidemic.
Is diabetes different now from what it used to be? Its trajectory remains the same. It still maims and kills the way it did before. It is the victim of diabetes who has changed.
Ten years ago, the average diabetic looked different from most diabetics today. Overweight, yes, but with a more modest waistline. He also ate a lot less and walked a lot more. The particular factor in this surge of diabetes is ‘central obesity’—polite for paunch. Also, there is the additional element of ‘upper body obesity.’ Statistics are futile; just look around you.
There is excellent research, especially from Chennai, the Indian hotspot for diabetes, that tells us why we’re like sitting ducks for the disease.
An Indian does not have to be as fat as a Caucasoid to be at risk for diabetes. The Indian standard is a lower BMI, Body- Mass Index. We may be smaller, but our percentage of body fat is higher, and most of this is around the waist.
Indian babies have lower birth- weights but are more likely to grow up obese. Why? Is it because they have greater insulin resistance, or because they are raised on dangerous nutrition?
Diabetes occurs when the body cannot utilise sugars efficiently because the hormone insulin isn’t doing its job. Either the body does not make enough insulin, or else insulin fails to act. In T2DM, both take place.
Obesity is often part of Metabolic Syndrome, a condition where insulin does not act effectively. This pre-diabetic state increases the risk of cardiovascular complications.
Is diabetes genetically predetermined? There is a cozy fatalism in that thought, and yes, the number of genes implicated in diabetes is growing. In practical terms, it translates into nothing at all. Our ‘genetic predisposition’ is validation of what we’ve known for centuries: diabetes runs in families.
And that places us, quite guiltlessly, in The Great Indian Comfort Zone: We are like this only. But, the diabetes scenario says, We are not like this only, we are much worse.
We cannot, suddenly, acquire a national set of diabetogenic genes. We have inherited them. What is making them produce so many more diabetics now than ever before?
Let’s consider Chennai. It has more diabetics than elsewhere in India. Over the last decade, most insights on this Indian epidemic have emerged from Chennai. The numbers for obesity are staggering. You don’t need to visit the city to check this out. Switch to a Tamil channel on TV. Almost everybody is overweight. The reason, too, is evident if you tarry long enough and encounter any of the many cooking shows.
Naturally, all the cooking shows are about nouvelle cuisine. The chefs, excellent with traditional dishes, really go to town on the novelties: dairy, oils, nuts, and maida (called ‘all purpose flour’ in the West).
Even if these dishes do not translate directly into the family meal, the message subtly alters the cook’s perception of what’s hot and what’s not. It’s not as if these ingredients are alien to South Indian cooking—but they are traditionally kept to a minimum. Increasing their use also shifts cooking methods from the traditional ‘steam-and-sauté’ to the crisper, flakier, sexier ‘fry-or-bake.’ It also buys credence for the home meal by making it closer to what Indians all over the country call ‘outside food.’ (I’ll stick to this term because it’s so loaded with angst.)
What is ‘outside food’ like in Chennai? Oh, the usual:
The fancy quotient will vary, but what’s the common denominator?
Not the aromatic warmhearted atta that makes the hearty roti, but the odourless, tasteless, chalky-white maida that makes our daily bread.
So here’s a population with suspect genes and centuries of eating rice as a staple, with steaming as the basic cooking method, suddenly opting for a lot of maida. This decision is concurrent with an alarming increase in obesity and diabetes. And it’s not just Chennai, the rest of the nation is also consuming unimaginable amounts of maida.
I got a bird’s eye view of that just after Diwali. My friendly neighbourhood general store usually sells about 20 kg of maida a month. This jumps to 100 kg in the festive season.
“That’s nothing! People here don’t cook anymore,” the owner told me. “They buy all their mithai and farsan. But at my other store, in Kandivli, I sold more than 600 kg maida this Diwali, and with that you can calculate the amount of sugar and ghee.” It was a very intelligent comment on diabetes from a man who was neither a physician nor a cook.
When you consider maida, ghee and sugar are a given. Heated together, they achieve the irresistible Maillard reaction and the delicious caramelised crust that defines crispness. Sure, you can get that with atta too. But with atta it will be hard, not crisp; tough, not brittle; chewy, not tender. Chefs, take your choice.
Maida is a no brainer when it comes to delicacies, but why do we need it every day? Texture and appearance apart, what makes maida work is convenience. When you’re rushed, lazy, overworked, fatigued, or just can’t-be-bothered, can anything be more convenient than a sandwich? You can stuff it with whatever you want, pack it anyhow, eat it anywhere, and serve it to anyone with teeth. Take two slices of bread and there’s a meal before you can blink. Hate that soft white sliced loaf as much as you will, it is difficult to survive without it.
The other Indian staple is the biscuit. We eat more biscuits than any other nation, and calling them cookies isn’t fooling anyone. It’s just your local bakery maal in a fancy wrap.
Me, I’m all for convenience. I don’t agree with the widespread view that what’s wrong with maida is that it’s lacking in bran. As a heartily herbivorous nation, we’re downing fibre by the tonne every day. Besides, certain dishes do need very fine flour, and we’ve been eating them for centuries—so why should, all of a sudden, maida be so wrong?
That’s because maida isn’t just very finely milled and sieved wheat. Try sieving atta through a very fine mesh and what rains down will still not look like maida. Maida is white. It is wheat bleached out of recognition by the addition of a long list of avoidable chemicals— among them, alloxan.
Alloxan, as any medical undergraduate can tell you, is toxic to the beta cells of the pancreas that produce insulin. There’s a coda to this, a qualifying clause that researchers are very quick to add: alloxan destroys insulin-producing cells in mice, but the human pancreas seems curiously resistant to it.
I know they’re quoting two studies that have been lamely floating around for decades. There’s also another argument that’s common—there is no evidence of beta cell destruction in T2DM since there’s no lack of insulin, it simply doesn’t hit the target.
I find these arguments specious.
If we’re in the grip of a killer disease, and we’re eating huge amounts of a food contaminated with a chemical that has the toxic potential to encourage this disease, then we should not be eating that food at all.
Besides alloxan, maida contains benzoyl peroxide, bromates, chlorides and other objectionable ingredients. It might make you queasy to learn that it is also enriched with an amino acid sourced from human hair.
Bleached flour is banned in all European Union countries. China banned it in 2011. Countries where it’s still sold, like the US, also sell unbleached all purpose and pastry flours. Why are we still eating bleached flour?
For the last two years I’ve been worried enough to do two things. One, talk to flour manufacturers into putting unbleached maida on the market, and two, bake a decent loaf without maida.
Most flour companies aren’t listening. Some do, but point out that the market won’t accept maida that isn’t dead white.
“Whiteness is a mark of our purity,” one of them told me modestly. “Purity is important to Indians.”
And as for my bread, it is lighter and fluffier than store-bought, but you won’t like it if you like your bread dead white.
How many people would want their flour dead white if they knew it was making them sick? With the diabetic epidemic worsening, with obesity in every second household, isn’t it time we boycotted bleached flour?
Maida’s fall from grace has spawned a niche industry in baked goods that is a complete swindle—breads with a smidgen of whole grain flour marketed as ‘whole wheat’, ‘multigrain’ breads with a sprinkling of oats and millet on the crust, wholly inedible bricks that call for a saw at the breakfast table, and brown bread coloured with burnt bran and molasses. High-end bakeries know that customers who OD on gateaux will also buy a loaf that looks like poxy pumice because it’s good for the soul.
None of this is nutritionally superior to store-bought white, simply because, despite the fancy disguise, it still is mostly maida.
The solution lies in making the use of unbleached flour mandatory in the baking industry. That might compel flour manufacturers to start marketing it too. And the awareness will give people the opportunity to choose.
Will it contain India’s diabetes?
It may, and in an indirect manner. It will force people to realise what’s on their plate makes the difference between sickness and health. That is a very big step. It places responsibility back where it properly belongs—with each of us. It restores to us a power we have long abdicated—the power of conscious choice.
An epidemic is silly season for new therapies, new investigations, new fads. Instead of getting an abdominal CT scan to display visceral fat deposits, try taking a closer look at what is stacked on your plate. Low glycemic rice? A pool of olive oil? Flax, spelt, steel-cut oats? We weren’t a diabetic nation before we heard of these wonders. Do we really need them now?
Will that glass of wheatgrass or karela juice, that nostrum of jamun seed and methi sold at the park really add to the virtues of a thirty minute walk? Perhaps it will, if swallowed by the tonne, but it will never counter our menu for the rest of the day.
Think about it. The only way to evade diabetes is to stop evading responsibility for what we eat. There is no magic molecule on the horizon, no stem cell shot, no enchanted grain or seed growing secretly on an undiscovered mountaintop that will deliver us from blindness, paralysis, coronaries, gangrene and the many other morbidities of diabetes.
The last free lunch was so yesterday. Nowadays, we pay.