The Big Fat Indian Story

Dr Ambrish Mithal is chairman and head, Endocrinology and Diabetes Division at Medanta, The Medicity, Gurgaon
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Sugar is not all you should watch out for in a hearty meal

THE LINK between diabetes and sugar is deeply embedded in our minds. Diabetes is referred to as ‘sugar’ in common parlance. To most people, a diet for diabetes means a ‘diet without sugar’. It is true that the link between diabetes and sugar is strong. But is diabetes only about sugar? Many of us don’t realise that fat intake also plays a major role in influencing diabetes.

There are three broad ways by which fat intake could impact diabetes. One, fats are high calorie food (one gram of fat provides nine calories, as compared to a gram of sugar, which provides only four). Diets high in fat provide extra calories, which leads to weight gain and greater risk of diabetes and heart disease. Two, if one already has diabetes, extra calories obtained through fat will worsen diabetes control. Three, the risk of heart attack is two to four-fold higher for diabetics—and unhealthy fat intake could aggravate this increased risk.

Why are patients with diabetes more prone to heart attacks? In addition to high blood sugar, such patients commonly have blood pressure and lipid (cholesterol) abnormalities, all of which promote heart diseases. Cholesterol is a ‘waxy’ substance— important for many processes in the human body like building cell membranes and nerve sheaths, and for making vitamin D and steroid hormones. However, if there is too much cholesterol in the blood, it gets deposited in our arterial walls, leading to blockage and strokes. Only 20 per cent of the cholesterol in blood comes from the diet—the rest of it is made in our liver and intestine.

The recently released ‘American Dietary Guidelines’ (2015- 2020) have recognised the limited role of dietary cholesterol in most humans, and have removed restrictions on intake of cholesterol (commonly found in eggs and full fat dairy products). This is good news for egg lovers, since eggs are high in cholesterol but relatively low in saturated fat. This recommendation has generated controversy and discussion in the media and nutrition circles, with many rushing to conclude that cholesterol has been exonerated of all untoward effects. What has changed, however, is merely the recommendation for dietary cholesterol and not for blood cholesterol, which (particularly LDL cholesterol) continues to be regarded as a risk factor for heart disease. Thus the recommendation to limit the intake of ‘bad’ dietary fats— like trans and saturated fats—remains unchanged, as they can impact blood LDL cholesterol level. Trans fats, produced when liquid fats are solidified by hydrogenation and also when oils are subjected to repeated heating, are the worst offenders. Processed food items and fried snacks are loaded with trans fats and their consumption should be reduced in our diet. Saturated fats, present in full fat dairy products, red meats, butter and ghee should be used in moderation. More than 50 per cent of the fat in butter and ghee is in saturated form. Indians were among the earliest users of both. Indian mythology is replete with descriptions of Lord Krishna’s fondness for butter. The use of ghee in religious practices (offering to Agni, the God of fire) has been prevalent for more than 3,000 years. Ghrat (Sanskrit for ghee) appears numerous times in the Rig Veda. Some experts feel that adverse impact of saturated fats has been over-emphasised all these years. In 2014, The New York Times announced the return of butter (‘Butter is Back’). Unfortunately, for butter lovers, this is probably not true. One spoon of butter, 5 gm, provides 45 Kcal; nutrition societies continue to recommend that saturated fat intake should provide less than 10 per cent of our daily calories.

Replacing bad fats with carbohydrates is not a good idea. Unlike carbs, fats provide satiety and reduce hunger pangs. It is much better to replace them with healthy fats. Unsaturated— poly and mono fats—are found in almonds, walnuts, and pistachios, which are a good source of proteins. Other sources of healthy fats include flaxseeds, pumpkin seeds, chia seeds, and oils like olive, canola, and soyabean. Even with good fats, however, one has to be careful of the calorie count. Are these measures enough or should we resort to drugs like statins to lower blood cholesterol levels? There is considerable evidence that statins reduce the risk of heart attacks in high risk patients or those who have heart disease. All expert groups recommend that patients with diabetes should not discontinue their statins if they have been advised to take them (unless, of course, they are having side effects). Statins protect our heart in many ways—not just by lowering cholesterol. For many individuals with diabetes, statins are as—if not more—important than glucose lowering medications.