Lifestyle changes, including diet modification (reduction of total calories, refined carbohydrates, and added sugars, and promotion of fiber-rich foods) have been shown to significantly decrease the progression of type 2 diabetes in Asian Indians, even in the absence of weight loss.29
The typical Asian Indian diet is high in carbohydrates (70–80% of total daily caloric intake)12
and low in protein (9–10% of total daily caloric intake) 12
. The current Asian Indian diet is higher in carbohydrate and lower in protein than recommendations from both the Indian Council of Medical Research (60% carbohydrate, 10–12 % protein) 12
and the U.S. Institute of Medicine (45–65% carbohydrate, 10–35% protein). 30
Many studies have shown the benefits of lower carbohydrate (35–40%) and higher protein diets (20–30%) including greater satiety, 31–33
weight loss, 32, 34–35
and improvements in cholesterol 32
and insulin parameters.32
These studies focused on varying the macronutrient composition (i.e. lower carbohydrate) rather than the macronutrient quality (i.e. better carbohydrate). There are other studies that have specifically studied macronutrient quality (i.e. substitution of whole grains) without varying macronutrient composition and found benefit through the reduction in risk factors for CVD, including BMI, insulin sensitivity, and type 2 diabetes. 36
Asian Indians may doubly benefit from ancient whole grain substitution by both decreasing overall amount of carbohydrate and increasing carbohydrate quality. For example, in , if one serving of white rice is replaced with quinoa, the amount of carbohydrate decreases by 17.5 grams and protein increases by 7.3 grams. This carbohydrate substitution would serve to subtly shift the daily macronutrient balance to the recommended levels without conscious avoidance of carbohydrate or supplementation of protein in the diet. Additionally, quinoa contains 4.2 extra grams of fiber along with a host of other micronutrients, indicative of better carbohydrate quality. Gram for gram, ancient whole grains offer fewer carbohydrates and more protein, and additionally contain beneficial fibers, proteins, and micronutrients.
Nutritional Content of White Rice and Healthier White Rice Substitutes *†
Overall Benefits of Whole Grains
It is well documented that consumption of whole grains, even without reduction in overall carbohydrate intake, 37
reduces risk factors for CVD, including BMI, insulin sensitivity, and type 2 diabetes.36
Various epidemiologic cohort studies have demonstrated that a 2- or 3-serving-per-day increase in whole grain consumption is associated with a 20–30% decrease in type 2 diabetes, even after adjustment for confounders such as age, gender, and BMI.16–18
Several lines of evidence, including observational epidemiologic studies with humans, human studies of glycemic response, animal studies, and studies of adiponectin and lipids, have demonstrated the beneficial effects of a whole grain diet. Brown rice (whole grain) intake has been associated with a lower risk of type 2 diabetes, while white rice (refined grain) intake is associated with higher risk.15
Thus, risk of chronic disease could intensify as refined grains displace traditional whole grains: the risk of type 2 diabetes increases as the ratio of refined grain to whole grain food intake increases.38
An Indian study comparing pearl millet (bajra
), barley, and corn found that glycemic response to pearl millet (bajra
) and barley, but not corn, was significantly lower than glycemic response to white bread, particularly in individuals who did not already have type 2 diabetes.39
For diabetic patients in India, it has been shown that wheat-based and millet-based formulations yield lower glycemic indices than rice-based formulations.40
Postprandial glucose and insulin levels have been shown to be suppressed in a Japanese population, after replacing a serving of white rice with 30%, 50%, and 100% rolled barley.41
When Japanese millet protein was fed to diabetic mice, they experienced several beneficial trends: their plasma levels of adiponectin and high-density lipoprotein (HDL) cholesterol were increased, while glucose and triglyceride levels were decreased.42
As a group, whole grains have been associated with lower total plasma cholesterol and/or low-density lipoprotein (LDL) cholesterol.43–44
Further, there is speculation that whole grain foods, through their fiber, antioxidants, and other components, causally reduce the risk of coronary heart disease (CHD), because the inverse association between whole grain consumption and CHD exists in a dose-dependent manner.45
Benefits of Fiber in Whole Grains
Some have also postulated that the combination of compounds in whole grains—fiber, proteins, vitamins, phytochemicals, and minerals—may explain their protective effects.46
Because they are digested more slowly than refined grains, which have been stripped of the germ and bran that cover the starchy endosperm, whole grains maintain a lower glucose and insulin response in the body than refined grains.17, 46
Soluble fibers in whole grains may contribute to the reduction of CVD, and their effects could be enhanced by the relatively slow digestion of carbohydrates in whole grains; additionally, insoluble fibers in whole grains promote bowel health by speeding intestinal transit time with less reabsorption of water.17
Both adults and children with high intakes of dietary fiber also have lower blood pressure and serum cholesterol levels, reduced glycemia and insulin sensitivity, and lower risks of developing stroke, hypertension, type 2 diabetes, obesity, certain gastrointestinal diseases.47
Some have also hypothesized that outside of the whole grain fiber content, the structure of whole grains may affect carbohydrate metabolism: the necessary breakdown of the germ and bran before reaching the starchy, inner endosperm could delay or render some starch unavailable for absorption, thereby reducing glycemic index in those who consume whole grains.17
This is aligned with the idea that “the food matrix,” or the combination of naturally occurring components of foods, promotes health, rather than the individual constituents of food.48
Therefore, promotion of whole grain carbohydrate provides a less reductionist approach to clinical care than focusing on specific macro or micronutrients.
Benefits of Protein and Micronutrients in Whole Grains
Some have also postulated that increasing protein in the diet increases satiety34
; thus, while whole grains should not be considered the main source of protein in the diet, an individual who eats whole grains with relatively high protein content may both benefit from this supplementary source of protein and consume fewer calories in a day. Some whole grains provide double the protein content of refined grains: for example, 100-grams of uncooked of white rice contains seven grams of protein, while the same amounts of amaranth and quinoa contain fourteen grams (see ). 12, 49
Whole grains also provide valuable micronutrients to the diet that refined grains may not, unless they are fortified or enriched with specific micronutrients after they have been stripped of their germ and bran layers. Whole grains such as wheat, brown rice, barley, sorghum, and millet provide large amounts of potassium, phosphorus, magnesium, iron, zinc, copper, and manganese, and the B vitamins, excluding vitamin B12
Iron is a particularly important mineral for Asian Indian vegetarians, because vegetarian diets may not provide the amounts of iron needed to avoid iron-deficiency anemia. When whole grains are eaten in appropriate quantities so as not to displace other healthy foods such as fruits and vegetables, they provide certain essential micronutrients and their effects may be bolstered by the micronutrients available in other foods that are eaten at the same time.50
For example, green, leafy vegetables may provide calcium and thus supplement the relatively low amounts of calcium available in whole grains.50
Thus, the use of whole grains as replacement for refined grains in Asian Indian diets will provide not only healthier carbohydrate alternatives for patients, but also a host of other micronutrient advantages.
Ancient Grains in the Historic Asian Indian Diet
Indian cuisine is often described as indescribable, because of its complexity and variety across the different regions of the country. A history of invasions, migration, and imperialism has not only shaped India’s social and political position in the world today, but also its food culture across the subcontinent. Since prehistory, through the Indus Valley civilization and the Aryan tribes who migrated into the subcontinent in the one or two millennia B.C.E., dietary staples consisted of rice, millet, barley, wheat, and lentils.19
As Hinduism developed around 1000 B.C.E., followed by Jainism and Buddhism, many Indians incorporated vegetarianism into their diets to align with the idea of ahimsa
, or nonviolence.19
Through the early to recent centuries C.E., various ruling dynasties and migrations influenced Indian cuisine with Persian, Portuguese, Asian and British influences until Partition and Indian independence from the British in 1947.19
Despite regional distinctiveness in cuisine, recent studies of diet in India generally reveal high intake of refined carbohydrates (>60% of total daily caloric intake), in the form of white rice or refined wheat flour.51
Some historical analyses of Indian cuisine have mentioned the use of ancient, whole grains, such as barley and millet.19, 52
However, after Indian independence in 1947, India relied on foreign food aid, and thus one of the priorities for the Indian government was to develop high-yield strains of grains that could feed the country’s inhabitants. As a result of this “Green Revolution” in 1951, per capita consumption of refined rice and wheat in India has nearly tripled. Today, India is one of the world’s foremost exporters of rice and wheat, and these grains have eclipsed other, more healthful grains, such as barley and millet.19
A negative perception now accompanies the use of certain grains: white, basmati rice is considered “richer”52
or more often consumed by the “upper class” than brown rice (or red rice, which is consumed in some parts of South India), and its consistency and shorter cooking time makes white, refined rice more desirable in Indian dishes. Thus, the use of ancient grains that do not have an associated negative perception may provide an easier way to incorporate more healthful grains into the modern Asian Indian diet. Use of these grains may also promote cultural approval of serving and eating grains with high nutritional value, thereby reducing the negative perception associated with commonly-known whole grains such as brown rice.
The five most common ancient grains that have the potential to be used more in Asian Indian cooking, along with brown rice as a replacement for white rice, are amaranth (rajgira in Hindi), barley (jau), pearl millet (bajra), finger millet (ragi), and sorghum (jowar) (see and ). These grains have higher fiber and protein content and can be used to make the commonly eaten rotis and chapatis. Many Indian recipes that describe traditional preparations of these grains are available through oral tradition as well as commercial Indian cookbooks. It is likely that the elderly generation alive today may remember recipes using grains such as bajra and jowar, while younger recent Asian Indian immigrants may not know how to cook these grains. However, the idea of using traditional recipes incorporating whole grains might appeal even to those Asian Indian immigrants who may not have habitually eaten these grains in India. Using traditional Asian Indian recipes with familiar mixtures of spices or vegetables may be a more attractive option for Asian Indians than new recipes that come from a Western cultural background. In addition to incorporating ancient grains that were grown in India into their diets, Asian Indians—especially those who live in Western countries and have access to more varied ingredients—may benefit from experimenting with ancient grains grown in other parts of the world. Couscous and quinoa are high protein and fiber substitutes for rice, as are amaranth and spelt for wheat. These grains, though not native to India, could be incorporated into traditional Indian cuisine and diets to allow for culturally acceptable and healthy dietary modification.
Table 2 Nutritional Content of Wheat and Healthier Wheat Substitutes12*†
The Modern Asian Indian Immigrant Diet
Today, while some Asian Indians are vegetarian, a majority are not.19
The prevailing stereotype that Asian Indians—or specifically, Hindus—are all vegetarian is not necessarily correct, although there are some parts of India (e.g. the state of Gujarat) that have more vegetarian inhabitants than others.52
However, it is clear that for the past few millennia, the dietary staple in India has been grain. The modern Asian Indian diet is predominantly filled with refined carbohydrate consumption, to the point of displacing vegetables and protein.13
These food practices are carried over by immigrants from India to the U.S., where they may be melded with Western eating habits as well.
It is well documented that exposure to Western lifestyles increases risk for chronic diseases in immigrants to the U.S., resulting from the changes in access to healthcare, physical activity, and diet that accompany such a transition.53
However, studies have indicated that the Asian Indian immigrant population is one that is particularly apt to maintain cultural eating habits rather than adopting a completely new, Western diet.20
Bicultural eating patterns can emerge, during which individuals maintain traditional eating patterns at certain meals or occasions and incorporate host country eating patterns at other times.53
Changes in types of “traditional” foods that immigrants choose to prepare may also be a result of changes in food supply and availability, the prestige associated with certain foods, and the time or technological constraints of the food preparer.54
Food can be understood as a cultural construct in terms of the meanings and emotions it evokes in individuals. The preparation of traditional food is a marker for immigrant families and communities, and it serves as a fulcrum for historically constructed ethnic or nationalist identity.55
Frequent preparation and consumption of culture-specific foods in immigrant communities may be reflective of a unique phenomenon: a shift in eating patterns which include more frequent preparation of ethnic foods that are associated with periods of festivals or special occasions and not typically eaten as part of the daily diet in the immigrants’ country of origin. “Festival foods” are culturally specific foods that are traditionally prepared and are related to specific festivals or special cultural occasions, usually in amounts limited by cultural significance and food availability. Festivals and rituals have often been viewed as fertile soil for planting food-centered memories, and they evoke the positive emotional connection between food and comfort that immigrants may draw upon while coping with the stress of acculturation in a new country. 55
In the case of Asian Indian immigrants to the U.S., and perhaps even Asian Indians in higher socioeconomic situations living in India, it is possible that “festival foods” play a role in the disproportionately high prevalence of chronic disease. Fried foods, sweets (mithai), and other less-commonly prepared foods are becoming ubiquitous in the Asian Indian American diet, as ingredients and pre-prepared foods are cheaply and readily available at Indian and even other ethnic and gourmet grocery stores. However, foods that are perceived to be “traditional” and foods that are “healthy” need not be mutually exclusive. In the same sense, foods that are “traditional” should not be equated with foods that always promote poor cardiovascular health; the negative association often attached to prominent foods in the immigrant diet should not result in a perceived need on the part of the individual to discard these traditional practices. Instead, alternative preparations and modifications can make traditional foods and healthy foods one and the same. For example, everyday traditional recipes could be prepared with ancient, whole grains that provide more nutritional value, saving the refined grains for infrequent festival times, as had been done in the early 1900s.
White rice is one of the main grains eaten in southern regions of India—and thus by many Asian Indian immigrants—and it is usually boiled and served with dal
, a generic term that describes a variety of lentils or pulses. Rice can also be ground, mixed with lentils, fermented, and then steamed to make dishes such as idlis
, or spread on a griddle to make crispy dosas
includes nutrition information on white rice, as well as the ancient grains that could be substituted for white rice in many Indian recipes. Brown rice, barley, couscous, and quinoa could be substituted for white rice in many of these recipes. The amounts of fiber and protein in these particular grains are much higher, and the ratios of carbohydrates to fiber and protein are remarkably lower, as compared to those in white rice. While there are many different varieties of white rice, fiber and protein are available in greater quantities in whole grains; thus, we do not recommend substituting one variety of white rice for another. Additionally, while glycemic index is a measure that is often used by nutritionists and clinicians working with diabetic patients, relying on glycemic index alone for these whole grain substitutions is not recommended. Glycemic indices for various whole grains are roughly comparable and other ingredients or components of the meal, such as fat and protein, may substantially affect the glycemic index.
Wheat is the staple grain of the northern regions of India, used often to make dough that is then rolled out and cooked with butter or ghee
(clarified butter) on the griddle to make a roti
. This bread, along with many other varieties such as parathas
(deep fried), and naan
(baked in a tandoor
oven) is eaten with dal
and other vegetables. While rotis
are made with whole wheat flour, others such as naan
are made with refined flour52
; additionally, the unlabeled whole wheat flour available in Indian grocery stores in the U.S. may also be mixed with other flour to dilute the whole grain content. A further downside of consuming whole or refined wheat flour is that the process of milling whole wheat into flour may essentially achieve some of the digestion that would otherwise have promoted a longer period of satiety had it occurred in the digestive tract. includes nutrition information on whole and refined wheat, as well as the ancient grains that can be substituted for wheat in many Asian Indian recipes. Whole-grain wheat flour, millet, sorghum, finger millet, amaranth, and spelt can be substituted for refined wheat in many of these recipes. The amounts of fiber and protein in whole-grain wheat flour, millet, sorghum, finger millet, amaranth, and spelt are much higher, and the ratios of carbohydrates to fiber and protein are remarkably lower, as compared to refined wheat flour.
The basic combination of either rice or wheat with lentils—an equivalent to the Anglo “meat and potatoes”—provides certain amino acid and fiber combinations that are beneficial in some respects.19
However, the central incorporation of white rice and/or refined wheat as the primary carbohydrate in this combination is believed to increase risk of chronic disease in a population that is prone to type 2 diabetes and other cardiovascular diseases.
While there has been much work in the efficacy of substitution of whole grains for refined grains in several other countries including Mexico,37
there are few studies on the effectiveness of these substitutions, particularly in Asian Indian populations. One recent study in India56
showed that a higher fiber and protein roti was acceptable in taste and texture when compared to a refined wheat flour roti. Future research should strive to translate these efficacy studies of whole ancient grains into effectiveness studies for Asian Indian populations.