Diabetes: Pakistan's Silent Epidemic

Pakistan now has the highest rate of diabetes in the world. The International Diabetes Federation (IDF) estimates that 34.5 million Pakistani adults were living with diabetes in 2024, an age-adjusted prevalence of 31.4 per cent, or close to one adult in three. Only three countries have more adults with diabetes. About 9.3 million of those affected, more than one in four, have not been diagnosed, and more than 10 million other adults have impaired fasting glucose, a stage that often comes before diabetes. Without stronger prevention, the IDF projects that the number of adults with diabetes in Pakistan will double to about 70 million by 2050. Each of these people is at risk of heart attack, stroke, kidney failure, vision loss, nerve damage and amputation. Food is one place where every family can begin to act. For many Pakistani families, a meal brings together roti or rice, daal, sabzi, salan, dahi and dishes shared across generations. Advice about diabetes should make room for these familiar foods. The aim is to help people enjoy them in portions and combinations that support better health. What we eat and how much we eat remain central to diabetes care. The order in which we eat may also help. What we eat and how much we eat remain central to diabetes care. The order in which we eat may also help. A practical meal sequence is to begin with vegetables, either alone or with a modest serving of plain dahi or raita, then eat protein foods such as chicken, fish, eggs, lean meat, daal or chana, and finish with a modest portion of roti or rice at the end of the meal. Do not eat the roti or rice first. During digestion, starch in roti, naan and rice is broken down into glucose. In diabetes, the body has difficulty keeping this glucose within a healthy range. A large portion of carbohydrate can therefore produce a substantial rise in blood sugar. Small clinical studies have found that eating vegetables and protein before carbohydrate can reduce the immediate rise in blood glucose in people with type 2 diabetes. This is a useful additional strategy, but the evidence is stronger for short-term meal responses than for lasting improvements in diabetes or prevention of its complications. Foods interact during digestion. Fibre, protein and fat can influence how quickly a meal leaves the stomach and how rapidly glucose reaches the bloodstream. Eating vegetables first does not create a barrier that makes a large serving of rice harmless. Portion size still matters. A small serving of nuts before the meal. One option is a small serving of unsalted walnuts and almonds, taken 20-30 minutes before a meal with a glass of water. About 10 almonds and 4 walnut halves, roughly 20 grams in total, is a practical portion rather than a prescribed dose. Count these nuts within your daily food intake, replacing other calories rather than adding them before every meal. Avoid nuts if you have a nut allergy. In my clinical experience with continuous glucose monitors (CGMs), I have noticed smaller glucose spikes when nuts are taken before meals. This is an observation, not a controlled study; meal size, food choices and activity also influence the result. A small randomised study in Asian Indians with prediabetes found benefits from 20 grams of almonds taken 30 minutes before meals. The walnut-and-almond combination and a 20-minute interval were not tested in that study. Nuts provide fibre, protein and unsaturated fats, which may influence digestion and fullness. Water supports hydration and may help you feel full sooner, but it has not been shown to lower glucose further. Anyone prescribed a fluid restriction should stay within it. Start with vegetables. Begin with sabzi such as palak, methi, bhindi, lauki (ghiya), tinday, karela, gobhi or band gobhi, or a kachumber or cucumber salad. Cooked vegetables are suitable; there is no need to insist on raw food. Prepare them with moderate amounts of oil, ghee and salt. Give vegetables a generous place on the plate. Because roti is usually used to scoop up sabzi and daal, eat the first part of the meal with a spoon or fork and keep the roti for the end. When it suits the meal, eat a modest serving of plain dahi or raita with the vegetables, or take a spoonful of dahi with the sabzi. In my CGM observations, combining plain dahi with non-starchy vegetables at the start of the meal was associated with a smaller post-meal glucose rise. Plain dahi generally causes only a small rise in blood sugar and adds protein, and strained (hung) dahi contains more protein than regular dahi. Unsweetened lassi made with salt, or chaach, is also a good choice. The vegetable-and-dahi combination has not been tested in a controlled trial. Treat it as an observation, not a proven treatment, and avoid sweet lassi, sweetened dahi, sugar, honey and gur. Follow with protein: chicken, fish, eggs, meat or daal. Next, eat protein, such as fish, skinless chicken, eggs, or lean mutton or beef in moderate portions. Daal, chana, lobia and rajma are good choices, especially for anyone who eats little or no meat. If plain dahi or raita is not taken with the vegetables, it can accompany this part of the meal. Dahi does not have to be eaten before meat, and it is not compulsory at every meal. People with lactose intolerance or dairy allergy need an alternative. Daal, chana and lobia are valuable sources of protein and fibre, but they also contain carbohydrates. Plain dahi contains natural milk sugar. Neither should be treated as a food that has no effect on blood glucose. Keep oily salan, karahi and qorma gravies, and fried foods occasional. Then add a small portion of roti or rice. After vegetables and protein, add one whole-wheat roti or chapati, or a smaller serving of rice, at the end of the meal, rather than with every bite from the start. These can be eaten with the vegetables, daal or protein remaining on your plate. There is no need to turn the meal into a rigid ritual or wait a set number of minutes between foods. Whole-wheat roti still contains carbohydrate, as does cooled rice. Neither allows unlimited portions. Your appropriate serving depends on your activity, medicines, nutritional needs and blood glucose response. Cook, cool and reheat the rice when you can. A practical option is to cook rice in advance, cool it promptly, refrigerate it for about 24 hours, and then reheat only the portion needed. During cooling, some of the cooked starch changes into resistant starch, which the body digests less readily. A small clinical study found that white rice refrigerated for 24 hours at 4°C and then reheated produced a lower post-meal glucose response than freshly cooked rice. The evidence is limited and not completely uniform, so the effect cannot be guaranteed for every person or every variety of rice. Cooling and reheating do not remove the carbohydrate and do not make a large serving harmless. The most important steps remain a smaller portion, eating rice after vegetables and protein, and checking your own response when glucose monitoring is available. Food safety matters. Put cooked rice into shallow containers and refrigerate it within two hours, or within one hour on a hot day or in a warm kitchen; keep the refrigerator at 4°C or below. Use it within about 24 hours, reheating only the portion you need until it is steaming hot throughout (74°C), and eat it promptly. Discard cooked rice that has been left at room temperature for longer than two hours (one hour in hot conditions). For an everyday meal of daal, sabzi, dahi and roti, start with the sabzi and a modest serving of plain dahi or raita. Have the daal next, then add one roti alongside the remaining daal and vegetables. For a family meal of chicken karahi or aloo gosht with naan, begin with a salad and a vegetable dish, follow with a moderate serving of chicken or meat with little oil or gravy, and then add a small piece of naan or one roti. Count the potatoes in aloo gosht as starch, and avoid making bread or rice the largest part of the meal. Pakistani breakfasts often Centre on bread: paratha, puri, naan with nihari or channay, bun kabab, rusk and bakery items with chai. These are not nutritionally identical: some are simple refined-flour breads, while others are fried or made with generous ghee, butter or sugar. Recipes and sizes vary between homes and dhabas, so judge a dish by its ingredients, its portion size and your own glucose response rather than by its name alone. Why these foods deserve special attention. Most naan, puri, paratha, bread and bakery items are made mainly from maida, or highly refined wheat flour. Milling removes much of the grain's fibre and structure, so the starch is digested rapidly. Eating them by themselves, especially after an overnight fast, can produce a substantial glucose rise. Sesame or other seeds on top may add flavour, but they do not cancel the carbohydrate load of the flour. (To Be Concluded) The writer is a Clinical Professor of Medicine (George Washington University) and an interventional cardiologist practising in the United States and Dubai at Zulekha Hospital, and can be reached at fshawlmd @aol.com