Saturday, 7 May 2016

Diabetes: The rice you eat is worse than sugary drinks

By Salma Khalik, Senior Health Correspondent, The Straits Times, 6 May 2016

The health authorities have identified one of their top concerns as they wage war on diabetes: white rice. It is even more potent than sweet soda drinks in causing the disease.

Sharing his battle plan to reduce the risk of diabetes, Health Promotion Board chief executive Zee Yoong Kang said that obesity and sugary drinks are the major causes of the condition in the West.

But Asians are more predisposed to diabetes than Caucasians, so people do not have to be obese to be at risk. Starchy white rice can overload their bodies with blood sugar and heighten their risk of diabetes.

Mr Zee is armed with data. A meta- analysis of four major studies, involving more than 350,000 people followed for four to 20 years, by the Harvard School of Public Health - published in the British Medical Journal - threw up some sobering findings.

One, it showed each plate of white rice eaten in a day - on a regular basis - raises the risk of diabetes by 11 per cent in the overall population.

Two, it showed that while Asians, like the Chinese, had four servings a day of cooked rice, Americans and Australians ate just five a week.

But Mr Zee does not plan to ask Singaporeans to stop eating rice, a popular feature of meals here. What he would like is to see more people turn to healthier varieties.

Long grain white rice is also better than short grain when it comes to how it spikes blood sugar - a rise in sugar levels causes the pancreas to produce more insulin, and frequent spikes can lead to diabetes.

He would also like people to try adding 20 per cent of brown rice to their white rice. This amount is enough to reduce their risk of diabetes by 16 per cent."There is no need to fully replace what they now eat. Just increase the quantity of whole grain and brown rice."

Health Minister Gan Kim Yong said last month that this disease is already costing the country more than $1 billion a year. Diabetes is a major cause of blindness, kidney failure and amputations in Singapore.

Dr Stanley Liew, a diabetes expert at Raffles Hospital, advised people to eat less rice. He added that most junk food and sodas are just as bad and should be discouraged.

Hooked on white rice, but some ready to change diet
Around 4 in 5 polled consume the grain daily despite many being aware of diabetes risk
By Malavika Menon and Delphine Kao, The Straits Times, 6 May 2016

Singapore remains a nation of white rice eaters - and even the shadow of diabetes may not be enough to wean Singaporeans from their favourite staple.

Mr Zee Yoong Kang, chief executive of the Health Promotion Board, flagged white rice as one of the main agents behind the high rate of diabetes here.

But when The Straits Times spoke to 50 residents about their food habits, 42 - or 84 per cent - said they consumed white rice daily.

They did this even though the majority - 56 per cent - were aware that white rice could be harmful and raises the risk of diabetes.

For more than two in five people, the link between white rice and diabetes came as an eye-opener. Marketing executive Yao Xi Qing, 33, said: "I will really consider changing my intake, now that I know it contributes to diabetes."

Nine of the 50 respondents said they were prepared to completely replace white rice with brown rice in their diet, while some have already done so. Mrs Joanne Seow, 53, a manager, said: "Upon discovering how harmful white rice is, I've been cooking only brown rice for my family."

Sales executive Meeran Maricar, 29, agreed that brown rice, being a complex carbohydrate, was a healthier choice.

While reluctant to make a complete switch, many others were willing to compromise for the sake of their health.

Half the respondents were inclined to partially seek out healthier substitutes. While some of them said they would consider mixing brown and white rice, others were open to choosing long grain rice, which has a lower glycaemic index.

Among those unwilling to make a switch, convenience and the force of habit were major factors. Mr Ralph Marcos, 30, said: "Despite being a nurse, I prefer white rice as it is easily available. I am used to eating it daily."

Ms Amanda Stromberg, 39, also a nurse, cited resistance from her family. "Although I'm trying to gradually switch to brown rice, my children don't really like its appearance," she said.

Ms Natalie Goh, chief dietitian for Parkway Pantai hospitals in Singapore, offered several tips for those seeking healthier options.

She said wholegrain foods could be added gradually to the diet. Mixing a bit of brown rice with white was one option.

She suggested using brown rice bee hoon or brown rice mee sua when cooking noodle dishes.

"For those who enjoy baking, try experimenting with your existing recipes by replacing one-quarter portion of regular flour with wholegrain flour. I have experimented with baking a healthier version of pineapple tart with wholegrain flour. There is no difference in taste except for the texture."

Medical student Gui Chuan Hao, 20, plans to switch to brown rice. "Once my family sees how easy the transition can be, they will be motivated to make the switch," he said.

Asians 'more at risk of diabetes than Caucasians'
By Salma Khalik, Senior Health Correspondent, The Straits Times, 6 May 2016

Asians are genetically more predisposed to diabetes than Caucasians, said Dr Annie Ling, director of policy, research and surveillance at the Health Promotion Board (HPB).

For the same BMI, or body mass index, an Asian has 3 per cent to 4 per cent more fat than a Caucasian.

This is why although only 10.6 per cent of people here are obese, 11.3 per cent are diabetic. In Britain, which has an obesity rate of 25 per cent, only 6.2 per cent of its population are diabetic, said Dr Ling.

In fact, Singapore has the second- highest proportion of diabetics in its population among developed countries, trailing only the United States.

Indians are particularly susceptible, said Dr Ling. An Indian woman with a BMI of 20 - which is in the healthy range - has the same risk of getting diabetes as a European woman with a BMI of 30, which is classed as obese. A Chinese woman has the same risk with a BMI of 25.

Dr Ling said that for the same amount of carbohydrates consumed, the glucose response in the blood of Asians could be as high as double that of Caucasians.

This is why it is even more important for Asians to reduce consumption of food with a high glycaemic index as it can result in sugar spikes.

With more glucose in the blood, the pancreas has to produce more insulin. When this happens frequently, it could lead to either a shortage of insulin or insulin resistance. This could leave sugar in the blood, a condition that could damage organs such as the kidneys or the eyes.

Dr Ling said people here are consuming about the correct proportion of carbohydrates, which make up 52 per cent of the food they eat. The problem is that instead of taking rice and wheat in their natural form, most consume refined carbohydrates. These are digested quickly and result in a sugar spike.

Wholegrain rice made up only 5 per cent of rice sold here last year.

Aside from food, Dr Ling said exercise is important in reducing the risk of getting diabetes. Just a 15- minute walk every day can cut the risk of dying of the condition by 4 per cent. She added that the benefit of exercise for diabetics is even higher than for the general population.

Brown rice not to everyone's taste
Brown rice may be healthier, but it is also more expensive and its taste takes getting used to
By Melissa Lin, The Straits Times, 10 May 2016

More people are consuming wholegrain rice in Singapore.

Wholegrain rice made up about 5 per cent of total rice sales last year, up from about 2 per cent in 2008, said the Health Promotion Board (HPB). Supermarket chains have also noted an increase in demand for such rice.

But it is still an uphill battle getting people to swop their favourite staple for the wholegrain variety. Consumers say white rice is tastier, cheaper and easier to get hold of.

The Asian habit of eating rice regularly was thrown into the spotlight last week when the HPB said white rice is even more potent than sweet soda drinks in causing diabetes, as reported in The Straits Times last Friday.

HPB chief executive Zee Yoong Kang had cited studies which showed that each plate of white rice eaten in a day - on a regular basis - raises the risk of diabetes by 11 per cent in the overall population. Adding 20 per cent of brown rice to white rice is enough to cut the risk of diabetes by 16 per cent, he added.

Property agent Joanie Tan, 37, said despite the report, she would still choose white rice over brown "because it smells and tastes better".

Sales manager Victor Phuah, 32, said he was open to switching to brown rice even though he has been eating white rice since he was young.

"However, not every place will serve brown rice and it can also be more costly," he added.

A check with hawker centres and food courts in Ang Mo Kio, Bishan and Toa Payoh found that only one or two stalls at each food centre offer brown rice as an alternative to white rice. Consumers usually have to pay between 20 cents and $1 more to make the switch.

Madam Ding Lian, 61, a stall assistant at the Fo Lai Ping (Popular) Vegetarian eatery in Toa Payoh, estimates that five in 20 customers order brown rice instead of white. "Not a lot of them like to eat it because it is harder than white rice," she said.

At supermarkets, some healthier rice varieties such as unpolished brown or red cost 5 per cent to nearly 100 per cent more than white rice, depending on the type and brand.

HPB has worked with rice suppliers to incorporate at least 20 per cent of wholegrain in rice. Brands selling this mixed blend include FairPrice, Golden Eagle, Paddyking, Naturel and Songhe.

At FairPrice Online, a 5kg pack of house brand Thai fragrant white rice costs $6.50. A 2.5kg pack of house brand brown rice costs $5.50, while 2.5kg of house brand Thai rice blend costs $6.30.

Over the past three years, sales of more nutritious varieties of rice have grown by over 30 per cent at FairPrice, while Cold Storage saw double-digit growth.

Mr Andrew Tan, chairman of the Singapore General Rice Importers Association, is optimistic that demand for healthier varieties of rice will grow.

"Singaporeans are getting more health-conscious and have higher purchasing power," he said.

Additional reporting by Malavika Menon, Rachel Oh and Clarice Teo

War on sugar: Can taxman extract Asia's sweet tooth?
More countries proposing a tax on sugary drinks, but F&B industry puts up resistance
By Tan Hui Yee, Thailand Correspondent In Bangkok, The Sunday Times, 8 May 2016

On a sweltering evening in downtown Bangkok, thirsty joggers crowd around a drinks kiosk in Sukhumvit Road. Most reach for chilled water, or sweet ready-mixed green tea, each bottle containing almost 90 per cent the daily recommended allowance of sugar.

Thai health advocates are trying to bring this under control. Last month, a junta-appointed reform assembly submitted a proposal to tax packaged drinks according to their sugar content. This could result in beverages like soda, coffee, green tea and energy drinks becoming at least 20 per cent more expensive, and hopefully keep a lid on the incidence of obesity, diabetes and hypertension in the fast ageing country.

Thailand's attempt to wean its people off sugary drinks is part of a growing trend in Asia, where increasingly calorie-rich diets and sedentary lifestyles are producing health complications that threaten national budgets.

Philippine lawmakers last November introduced a Bill to charge a 10 per cent tax on sweetened drinks. India policymakers have proposed a 40 per cent rate. Vietnam mulled over but eventually scrapped a proposed 10 per cent tax in 2014 after commercial pressure, while Indonesia is facing similar opposition over its soda tax plans.

Singapore has no such tax, but the idea was brought up during last month's parliamentary debate.

The Singapore health authorities say that Asians are genetically more predisposed to diabetes than Caucasians.

Dr Annie Ling, director of policy, research and surveillance at Singapore's Health Promotion Board, has said that for the same amount of carbohydrates consumed, the glucose response in the blood of Asians could be as high as double that of Caucasians.

The World Health Organisation (WHO) recommends sugar consumption be limited to 12 teaspoons or about 50g a day, a limit easily reached by drinking one can of soda. Worryingly large numbers of children in Asia are doing this daily.

According to WHO data, 57.7 per cent of Thai children aged between 13 and 15 years consume carbonated soft drinks one or more times per day. In Brunei, the figure is 46.3 per cent; in Cambodia, 45.6 per cent; and in the Philippines, 42.2 per cent.

The overconsumption of sugar is "serious in most - if not all - Asian countries", Dr Katrin Engelhardt, the technical lead for nutrition in the WHO's regional office for the Western Pacific, tells The Sunday Times. "Sugar-sweetened beverages are a key source of sugar consumption in Asia", where its growing economies represent an important market for the food and beverage industry.

Indeed, it is the companies in this industry that put up the stiffest resistance to higher taxes. For instance, the Indian subsidiary of Coca-cola Co, which employs 25,000 staff, warned last year that it would be forced to consider shutting down some of its factories if there was a sharp decline in sales. And Indonesia's bottled tea maker PT Sinar Sosro told the Wall Street Journal last year that the tax may prompt the company to reconsider investment plans.

The consumption of sugar across Asia is steadily rising. According to data by market research firm Euromonitor, Japan topped the list of Asian countries in terms of sugar consumed from packaged food and drink in 2014. That year, each person in Japan consumed 75.2g of sugar every day, compared to 53.59g in Hong Kong, 31.75g in Singapore and 29.81g in Thailand.

But these figures likely understate the actual amount of sugar consumed, as they do not take into account sugar added to freshly prepared food and drink.

Thais, for example, spoon sugar onto their noodles. According to Dr Piyada Prasertsom, the manager of Thailand's Sweet Enough Network, which combats childhood obesity, each Thai person consumed an average of 100g of sugar every day last year.

The WHO says governments should complement fiscal measures by requiring sugar content to be properly displayed on food labels, as well as restricting the marketing of foods and drink high in salt, sugar and fat to children.

Thailand's health ministry has been urging government agencies to downsize snacks served during meetings, as well as offer water instead of soda.

But it is the tax proposals that have ruffled the most feathers. According to media reports, the Thai Beverage Industry Association has questioned the link between obesity and drinking soda.

Shopkeeper Chaiwat Pawanthapong, who sells soda and other drinks in Bangkok, warns that gloomy economic conditions may not be conducive to such a tax. "You don't want to impose a bigger burden on people," he said.

However, Dr Pornpan Bunyaratpan, a key member of the Thai National Reform Steering Assembly who is advocating the tax, points out that it need not be this way.

"If the companies reduce the amount of sugar in their drinks, they make people healthy and they won't be subject to the tax," she said.


Countries are fighting back against over-consumption of sugar. Among them are:

South Korea: Makers of snacks, processed food and beverages must label the amount of sugar in their products.

UK: To introduce a sugar tax on the soft drinks industry.

Thailand: Coffee shops and hotels urged to reduce size of sugar sachets served.

Malaysia: Ended sugar subsidy in 2013.

Mexico: Introduced a 10 per cent tax on sugared beverages in 2014.


Daily sugar consumption via packaged food and drink (2014, grams per person):

• USA: 126.89

• Mexico: 92.45

• Japan: 75.2

• Hong Kong: 53.59

• Malaysia: 32.84

• Singapore: 31.75

• South Korea: 30.87

• Thailand: 29.81

• Vietnam: 27.47

• Philippines: 22.53

• Taiwan: 22.43

• China: 18.84

• Indonesia: 14.44

• India: 5.13



Percentage of teenagers (13-15 years) who usually drink carbonated soft drinks one or more times a day during the past 30 days:

• Thailand (2015): 57.7

• Brunei (2014): 46.3

• Malaysia (2012): 31.3

• Philippines (2011): 42.2

• Vietnam (2013): 34.6

• Cambodia (2013): 45.6

• Laos (2015): 58.1


Fighting diabetes: Why the target is white rice
As a staple, more of it is eaten; but more brown rice will boost health
By Salma Khalik, Senior Health Correspondent, The Straits Times, 12 May 2016

News that the Health Promotion Board (HPB) is targeting white rice in its fight against diabetes has created a storm of protest from rice lovers. Could the staple food of Asians for centuries truly be bad for health, they asked.

Many of those outraged by the report on the targeting ("Diabetes: the rice you eat is worse than sugary drinks", May 6) were more than happy to make sweet drinks and junk food the real villains that cause diabetes, which, while enjoyable, are not part of Singapore's heritage. But they were vehement that it could not be the traditional, steaming bowls of white rice that they consider essential.

Yes, sweet drinks and junk food are bad, and no one, least of all the HPB, is denying this. What it is saying, though, is that white rice is also a major culprit - largely because it is a staple, so more of it is eaten.

Starchy white rice, it has been found, can overload Asian bodies with blood sugar and heighten their risk of diabetes. Then add to that, this in terms of consumption: The 2010 National Nutrition Survey found a typical serving of rice here was 250g, and that a third of Singaporeans' daily intake of calories comes from rice - compared to 3.5 per cent from sugary drinks.

Then there is this: A Harvard School of Public Health study found that each serving of white rice a day raises the risk of diabetes by 11 per cent. A study of rice and noodle consumption by 2,728 Chinese here by the National University Health System found it resulted in greater insulin resistance.

For those who argue that rice has been eaten for centuries with no ill effects, the counter-arguments are:
- In the pre-industrialisation era, there was a lot more physical exertion. Even in everyday life, people walked a lot more than today. Exercise is known to offset some of the ill-effects of unhealthy food.
- People did not live as long in the past. In Singapore, for example, life expectancy at Independence in 1965 was only 65 years. Today, Singaporeans are living 20 years longer. This alone provides chronic diseases with a greater opportunity to surface. Among people 65 years and older, one in three is diabetic.

For decades, nutritionists have condemned processed food as unhealthy. Traditionalists raising their eyebrows at brown rice might consider this: What is white rice but processed brown or red rice?

And consider this: White rice, which is a simple carbohydrate and tastes more starchy, is likely to turn into sugar more quickly than unpolished rice.

White rice has a glycaemic index (GI) of 78-98, while the GI for brown rice is 65-76. The higher the index, the more blood sugar is produced.

So while having a lot of white rice in the diet is certainly not the only contributory factor, it is difficult to deny that it does contribute significantly to the high level of diabetes here.

Having said that, changing people's taste is not an easy task.

This is why HPB's chief executive officer, Mr Zee Yoong Kang, has been quick to say that he is not asking people to stop eating white rice. What he would like to see is more people adding some brown rice to their diet - a modest 20 per cent of it mixed with 80 per cent white rice.

This is because another Harvard study, which followed 197,000 people over 20 years, found that replacing a fifth of white rice with brown cut the risk of diabetes by 16 per cent.

Soaking brown rice in water before adding it to the pot to be cooked with white rice makes it softer. With only one in five grains of rice being brown, the taste is pretty much like normal white rice.

Aside from having a lower glycaemic index - indicating a lower surge in blood sugar - brown rice also has vital nutrients, such as zinc and iron, that white rice lacks. These nutrients are taken off when the husk of bran and germ are removed. But getting people to adopt this 20 per cent brown-mixed-into-white-rice is going to be a big challenge.

The Government can take the lead by insisting that caterers serve such rice for all functions. Or at the very least, to offer this as a choice.

Foodcourts and restaurants should also be encouraged to sell this mixture. Many readers have complained that it is difficult to get brown rice when they eat out - which most workers do for weekday lunch.

Schools should also tell their canteen operators to offer this version instead of plain white rice, since habits picked up when young tend to remain as people age.


And, of course, a brown-white rice mix should be the default option served to full-time national servicemen. While they do a lot of physical activity - so white rice should do them less harm than the population at large - the combination is better for them.

Hopefully, after two years of eating this mix, they will continue with it after leaving NS. It would be even better if they were to urge their parents to serve this at home.

Today, brown rice costs more than white rice - which, when you think about it, doesn't make sense as there is less processing needed.

So the higher cost is probably due to low demand - only 5 per cent of rice sold here is unpolished. It then follows that if demand rises, the price should come down, so price would no longer be a major reason for choosing white rice.

While it is difficult to change people's tastes, it is not impossible.

The HPB has shown this with its campaign for wholemeal bread in 2009/10. At that time, only 18 per cent of bread sold here was wholemeal or wholegrain. This has gone up to 30 per cent today.

Part of this is due to the superfine wholemeal flour that is available today, that makes bread taste like soft white bread. With this flour, there are now also wholemeal noodles that are more nutritious and have a lower GI than noodles made from white flour.

People are generally reluctant to give up what they enjoy eating - which is why the focus is on adding some brown rice, rather than replacing white with brown.

So this battle will be a long one. In the meantime, the HPB should not let up on discouraging the consumption of junk food, including sweetened soda drinks.

One complaint that was a constant in comments from supporters of brown rice is the difficulty in getting this when eating out.

Several also said that at foodcourts and restaurants, water can be as expensive, and sometimes even more expensive, than buying drinks. Ensuring that all food outlets offer free water to diners would be a good way to reduce the unnecessary calories many are now consuming - sometimes unwillingly.

There is no one single formula for beating the rising rates of diabetes here. But action needs to be taken, and fast.

According to a study by the Saw Swee Hock School of Public Health, diabetes already costs Singapore $1 billion a year, and is expected to soar to $2.5 billion by 2050.

If we can reduce the rate of diabetes by just 10 per cent, it would cut $250 million off the bill in 2050. That's a lot of money.

More importantly, it would also cut down on much suffering, since diabetes is a leading cause of kidney failure, blindness and amputations.

Switch to whole-grain varieties, not just eat less white rice

The Singapore Nutrition and Dietetics Association (SNDA) has been following, with interest, the different views on white rice consumption triggered by recent articles in The Straits Times. Our association members have also received queries to clarify the content of the articles.

The SNDA's position is that the articles may have been misinterpreted as advocating that Singaporeans cut back on rice intake and that it is acceptable to consume sugared drinks without restrictions.

This is not the right thinking.

The SNDA is aligned with the Health Promotion Board (HPB) in terms of our assessment of the current evidence and the dietary advisory on refined carbohydrates such as white rice.

Management of carbohydrate quantity and quality in clinical settings reliably reduces elevated blood glucose. The effects of carbohydrate portioning and substitution from refined to whole-grain sources are immediate and well documented.

Given that Singaporeans consume a lot more refined carbohydrates from starchy staples, and given the effectiveness of carbohydrate management as part of diabetes care, we support HPB's approach of taking such intervention to the population level as a first approach to diabetes prevention. There is a need to cultivate carbohydrate literacy and encourage an adoption of whole-grain varieties.

Singapore's 2010 National Nutrition Survey showed that dietary energy from carbohydrate is well within the recommended allowance.

However, much of the refined carbohydrate in the local diet comes from starchy staples such as white rice, noodles and refined breads.

A highly refined carbohydrate diet, coupled with Asians' predisposition to higher blood glucose and insulin responses to carbohydrate intake, is a contributing factor to rising diabetes prevalence in Asia.

Singaporeans in modern living should focus on switching to whole-grain varieties instead of just cutting down on white rice intake.

Cutting down carbohydrate intake may have the effect of increasing fat intake as a proportion of dietary energy. This would lead to calorific excesses and obesity, which is another risk factor for Type 2 diabetes.

As part of clinical management of people with diabetes, dietitians are already advising patients to avoid sugar-sweetened beverages and gradually replace refined staples with whole-grain varieties.

This same advice should be given at the population level, as part of diabetes preventive intervention.

At the same time, we urge the Government to keep a focus on obesity and the consumption of sugar-sweetened beverages, especially among school-age children, and explore practical ways to curb this empty-calorie food source.

Chow Pek Yee (Ms)
Singapore Nutrition and Dietetics Association
ST Forum, 15 Jun 2016

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