Preface

Indian Foods: AAPI’s Guide to Nutrition, Health & Diabetes is a labor of love by a group of dedicated dietitians. This booklet has information which will guide Asian Indians and particularly Indian Americans of Indian origin better manage and prevent diabetes, hypertension, obesity and hyperlipidemia. In addition, this book can be used by physicians and other health care professionals who see patients in their clinic using the Asian Indian cuisine. I believe this book is a must have for all Indian Americans. It is available on the American Association of Physicians of Indian Origin (AAPI) website at www.aapiusa.org/resources. This revision is presented to the Indian American community and physicians as a community service on behalf of AAPI. The reader will find that this edition has a few added chapters and appendices. The two new chapters include “Do Indian Spices and Condiments Have a Role to Play in Preventive Health and Therapeutics” & “Renal Diet.” It is our small effort to help our community take charge to prevent diabetes, hyperlipidemia, and obesity and manage them if present.

With best wishes,

T.G.Patel, MD, MACP

Advisor, Public Health Committee, AAPI

Acknowledgement

The revised edition of the book was done in a timely manner due to Dr. Ranjita Misra’s leadership and coordinating efforts. We would also like to thank Padmini Balagopal as the coordinating editor for the first edition and Rita (Shah) Batheja as co-chair for her invaluable help in bringing together an expert group of contributors.

I want to personally thank the authors Nirmala Abraham, Padmini Balagopal, Chatterjee, Keya Deshpande, Madhu Gadia, Wahida Karmally, Karmeen Kulkar Rita Batheja, Sharmila i, Theja Mahalingaiah, Suraj Mathema, Ranjita Misra, Chhaya Patel, Sudha Raj, Nirmala Ramasubramanian, Janaki Sengupta and Geeta Sikand. These authors took time out of their busy family life, academics and work to revise this edition of the book. To date, this book is still one of the best resources on preventive health and disease management on the Asian Indian cuisine presented in a simple and user friendly format. This book can be downloaded in its entirety from the website www.aapiusa.org/resources/nutrition.aspx for use.

The reviewers Padmini Balagopal, Rita Batheja, Wahida Karmally, Karmeen Kulkarni, Ranjita Misra, T.G.Patel, Sudha Raj and Nirmala Ramasubramanian have done a tremendous job in getting the reviews back in time and in ensuring the accuracy of the material.

The Pocket Reference Card for diabetes was created by the Diabetes Committee of the Indo-US Health Summit, a new additions to this book. I want to thank Drs. Ritesh Gupta, Shashank Joshi, Anoop Misra, T.G.Patel and Banshi Saboo, along with the advisors who helped revise this Pocket Reference Card. This committee consists of Drs. Anuj Bhargava, Arvind Gupta, Neha Gupta, Shilpa Joshi, Sailesh Lodha, Mohan Mallam, Sundar Mudaliar, Rakesh Parikh, V. Ranga, Jayesh B. Shah, Ronak Shah, Priya Sivaprakasan, and Vijay Viswanathan. The Gestational Diabetes meal plan was created by Sharmila Chatterjee, another new addition to this book. I want to thank Padmini Balagopal for creating “What Can I Eat to Manage my Diabetes” and Wahida Karmally and Karmeen Karmally to review the document & the translators of the regional languages (Bengali, Gujarati, Hindi, Kannada, Malayalam, Marathi, Odia, Punjabi, Sindhi, Tamil and Telugu) Rajasri Chatterjee, Kaushik Chatterjee, Sharmila Chatterjee, Alokeraj Banerjee, Balwant Suthar, Rita Batheja, Bharat Shah, Varun Japee, Vanita Manchanda, Uday Meghani, Varsha, Roshan Khaki, Kavitha Simha, Sheela Krishnaswamy, Shaji Tewani, Alex Johnson, Vaishali Mohile Deepa Inamdar, Anita shra, GB Patnaik, Indu Jaiswal, Murali Sadani, Purshotam Sharangdhar, Sushila Sarangdhar, Suguna Lakshmi Narayanan, Anuradha Sivasundar, A Narasimha Reddy, Latha Sashi, N Lakshmi, and P Janaki Srinath.

Finally, I want to thank all the Indian Americans in the U.S. and Indians in India for helping us to assess data on our community by participating in different research projects. This book is a tribute to all Indian Americans and Indians all over.

T.G.Patel, MD, MACP

FORWARD BY AJEET R. SINGHVI, PRESIDENT AAPI

I am pleased to see the publication of the second edition of Indian foods: AAPI’s Guide to Nutrition, Health and Diabetes. The first edition was hugely successful and this edition was overdue and is being published at the right time.

Although there are over two thousand books on diabetes listed in the catalog of the Library of Congress (2,218 at the last count), however, there is a paucity of literature that deals with the largest population at risk: The Indian Population. The ancient Ayurvedic treatises by Sushruta and Charaka recommended diet as treatment for diabetes more than two thousand years ago in India. This is as relevant today, if not more so, as it was then. Further, it is not only of great value to Indians here in States but also to the general population India – especially given the expansion of quick service restaurants and the concomitant adoption of a diet of highly processed, high calorie, high sugar, high fat, but low nutrient value foods.

It will be of special benefit to all to realize that the concept of diet as treatment is centuries old. Through this concept, people will discover new and tasty foods that help manage or even reverse their diabetes and other related conditions.

This publication is truly unique. The contributors include M.D.s, Ph.Ds, and Registered Dietitians. There is a diet plan to suit every palate and for different ethnic groups and regions. The authors have taken into account the changing environment, customs, and preferences and have made modifications to suit all the segments of the population and all taste buds in the contemporary society.

This book makes us all proud. Health is wealth, and this book takes us a step forward in that direction. I am sure it will be very useful to the reader. I personally congratulate Dr TG Patel, Dr. Ranjita Misra and their entire team for this superb effort.

Sincerely,

Ajeet R. Singhvi, MD, FACG

President, AAPI president@aapiusa.org

Chapter 2

Epidemiology, Risks, and Complications of Type 2 Diabetes Mellitus

Ranjita Misra, PhD, CHES, FMALRC & TG Patel, MD, MACP

The prevalence (all cases) and incidence (new cases) of type 2 diabetes (T2DM) and pre-diabetes [as defined by impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)] are rapidly increasing both in developed and developing countries. The global burden of T2DM is more pronounced in India than any other country in the world. An estimated 57 million adult Indians will have diabetes by 2025, with the condition manifesting at an earlier age and lower body mass index. Although, the higher prevalence of T2DM in Asian Indians can be attributable to established causes such as growing levels of obesity and physical inactivity, various epidemiological studies have shown that these factors alone are not sufficient to explain this trend. One important factor contributing to increased prevalence of T2DM in Asian Indians is excessive insulin resistance. Insulin resistance is highly prevalent in Asian Indians despite low rates of obesity. While insulin resistance is very complex and not completely understood, this pathophysiologic abnorm-ality results in decreased glucose transport in muscle, elevated hepatic glucose production, and increased breakdown of fat resulting in hyperglycemia. Indians seem to have a genetic predisposition towards insulin resistance with a low BMI and high central adiposity, sometimes also known as the ‘Yudkin-Yajnik’ paradox. This increased genetic susceptibility is further enhanced by environmental triggers such as physical inactivity, excessive calorie intake, and obesity.

The main etiological (causal) risk factors for T2DM are older age, obesity, family history, physical inactivity and dietary factors such as a high proportion of energy consumed as saturated fat and low intake of fruit and vegetables. The rapid rise and epidemiological transition of T2DM in India, especially in urban areas, is associated with westernized lifestyle. Changes in the traditional lifestyles, dietary patterns and technological advancement have resulted in a pronounced physical inactivity and the affluence of society has lead to consumption of diets rich in fat, sugar and calories. The observation of an association between low birth weight and risk of diabetes in later life has also led to the development of an alternative to the thrifty genotype hypothesis. It is hypothesized that the risk of T2DM is programmed by fetal nutrition and the pattern of early growth. The causal nature of these associations is strengthened by studies that show the incidence of diabetes is reduced by interventions aimed at reducing weight, increasing activity and improving diet.

With more than a billion people India is also home to significantly diverse groups of people in terms of ethnicity, caste and religion, socioeconomic status, educational level, and lifestyle and food habits. Studies on prevalence of T2DM show the rates in rural areas is significantly lower (3-6%) as compared

Epidemiology, Risks, and Complications of Type 2 Diabetes Mellitus

to urban areas (8-14%) in India. Pre-diabetes rates are slightly higher than T2DM prevalence but follow a similar pattern with urban prevalence significantly greater than the rural populations. Although prevalence of T2DM is lower than urban areas, rural Indians have higher glycosylated hemoglobin level (A1c) or poor control of the disease resulting in higher complications and mortality. Community- based diabetes prevention program in a rural Indian community also found rural youths, 10-18 years of age, had higher level of pre-diabetes. Lack of knowledge of T2DM and its associated complications, access to care & medical services, low educational level and income are primary factors for elevated mortality of diabetic patients in rural India.

Studies on South Asians (includes Asian Indians, Pakistanis, Bangladeshis, Sri Lankans, Nepalese, Maldives, and Bhutan) immigrants in the United Kingdom, Canada, Australia, and Africa show a higher prevalence of T2DM and CVD as well. In the United States, the Diabetes among Indian Americans (DIA) national study showed prevalence rate of T2DM and pre-diabetes among immigrant Asian Indians as 17.4% and 33% respectively, higher than other racial/ethnic groups in the United States.

Table 1: Prevalence of diabetes among rural Indians, urban Indians and Indian Americans

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

In the same study, comparison of rural Indians, urban Indians and immigrant Asian Indians in the US showed rural Indians had the lowest rate followed by urban Indians and immigrants in the US (Table 1). Despite a perception that they have high socio-economic status and good access to health care, US Asian Indians have marked variations in educational attainment, income, and wealth, and a significant number lack education and job skills. Recent immigrant cohorts comprise both highly educated professionals as well as individuals who lack education and job skills. The latter are mostly family members of earlier immigrants.

T2DM Complications: A focus on Diabetes and Cardiovascular Disease

T2DM is one of the leading causes of morbidity and mortality because of its role in the development of optic, renal, neuropathic, and  cardiovascular disease. These complications, particularly cardiovascular disease (~50-75% of medical expenditures), are the major sources of expenses for patients with T2DM [for more information, please read the chapter on “Preventing Heart Disease in Asian Indians” and “Cardiovascular disease” in the introduction chapter]. In the United States, South Asian Indians have the highest ethnic-specific prevalence of CVD or coronary artery disease (CAD), with age-specific mortality two to three times higher than Caucasians. Results from the DIA study indicate traditional risk factors such as hypertension (21%), obesity (49.8%) and hypercholesterolemia (43.5%) may account for these high rates. Asian Indian immigrants have been found to have high rates of vascular disease in the United States and other countries. The CAD prevalence in US Asian Indians is 6 and 4 times higher than Chinese and other Asian Americans and associated with similarly higher prevalence of risk factors among this ethnic group. For example, the prevalence of central obesity, glucose intolerance, hypertension, high triglyceride levels, and low levels of high density lipoprotein cholesterol (HDL)-- the five ‘axes of evil’ of metabolic syndrome-- is the highest among the Asian Indians and continues to increase at a    rapid pace. Mortality from CAD is twice in Indian Americans than other racial/ethnic groups in the United States. The United Kingdom Prospective Diabetes Study, showed for each 1% increase in A1c, there was a 14% increase in incidence fatal or nonfatal myocardial infarction. Projections based on the Global Burden of Disease study have shown that by the year 2020, the overall burden of cardiovascular disease in India will surpass other regions of the world. There is no doubt that significant reduction in diabetes related morbidity and mortality is feasible through effective educational and lifestyle interventions to reduce smoking, promote regular exercise, monitor healthy dietary habits and reading food labels, and manage stress.

Epidemiology of Nutrition and Diabetes Mellitus: Etiology and Environmental Factors

There is considerable evidence to show as individuals migrate from resource poor rural settings to urban areas and westernized countries such as the United States and United Kingdom, the risk and prevalence for T2DM rises. This increase is due to rapid acculturation associated with the migration. Although the concept of acculturation originated within anthropology, in recent years it has assumed a prominent role within epidemiology as a risk factor for chronic disease. The association between acculturation to a Western lifestyle and prevalence of diabetes has been established in several Asian American subgroups due to changes in diet, obesity and other lifestyle factors modulating the prevalence of T2DM. Consumption of sugar-sweetened drinks increases the risk for obesity and predisposes to T2DM. Recent data suggests an increase in the consumption of high fructose corn syrup and association between obesity and T2DM in the US. Glycemic index, or GI, is a number between 0 and 100 that reflects the effects of carbohydrates from food on an individual’s glucose levels. Glycemic index is important for individuals with T2DM since higher GI will increase sugar levels. Foods rich in dietary fiber might be protective and vegetarian diets tend to have less saturated fat and high dietary fiber.

Epidemiology, Risks, and Complications of Type 2 Diabetes Mellitus

Saturated fatty acids are positively related to fasting and postprandial glucose levels in normoglycemic Dutch men, the effect being independent of energy intake and obesity. In the United States, studies show the relative risk of developing diabetes was significantly reduced amongst those with the highest intake of vegetable fats and fiber. While light to moderate intake of alcohol is associated with enhanced insulin sensitivity, smoking increases the risk for T2DM. Intervention trials indicate diet and exercise programs are associated with reduction (nearly 60%) in the risk of progression of pre- diabetes to T2DM. Diets restricted in saturated fatty acids and increased fiber content seems to be particularly successful in this context. Furthermore, weight loss is beneficial and reduces the risk for T2DM.

Conclusions

Asian Indians are disproportionately burdened by T2DM and related complications. Increased genetic susceptibility may be enhanced by environmental triggers such as physical inactivity, high calorie, fat, and sugar intake, and obesity as individuals migrate from rural areas to urban areas to Westernized countries. Acculturation, defined as the process of adopting the cultural traits and social patterns, and western lifestyle are associated with unhealthy habits such as increased intake of dietary fat and saturated fat, lower consumption of fiber-rich and low glycemic index foods, and physical inactivity. These unhealthy behaviors are associated with higher risk and prevalence of T2DM and diabetes-related complications.

Ranjita Misra, PhD, CHES, FMALRC is a Professor and Research Director, Center for the Study of Health Disparities, at Texas A&M University. She is also a member of the Intercollegiate Faculty of Nutrition at TAMU and a member of the Public Health Committee of AAPI. Contact information (979) 845-8726 or ranjitamisra@gmail.com.

TG Patel, MD, MACP is an Associate Professor of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD. Contact information (571)213-5393 or  thakorg@gmail.com.

References

1.         van Dieren S, Beulens JW, van der Schouw YT, Grobbee DE , Neal B. The global burden of diabetes and its complications: an emerging pandemic. Eur J Cardiovasc Prev Rehabil;17 Suppl 1:S3-8.

2.         Wild S, Roglic G, Green A, Sicree R , King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.

3.         King H, Aubert RE , Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414-31.

4.         Ramachandran A, Snehalatha C, Baskar AD, Mary S, Kumar CK, Selvam S et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India.  Diabetologia 2004;47:860-5.

5.         Gupta R, Sarna M, Thanvi J, Sharma V , Gupta VP. Fasting glucose and cardiovascular risk factors in an urban population. J Assoc Physicians India 2007;55:705-9.

6.         Mohan V , Deepa R. Risk factors for coronary artery disease in Indians. J Assoc Physicians India 2004;52:95-7.

7.         Misra R, Patel T, Kotha P, Raji A, Ganda O, Banerji M et al. Prevalence of diabetes, metabolic syndrome, and cardiovascular risk factors in US Asian Indians: results from a national study. J Diabetes Complications; 24:145-53.

8.         Gupta R. Predictors of health among Indians in United States. India Association of North Texas, Texas Indo American Physicians Society Meeting. Dallas, TX,2000.Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

9.         Rangaswamy P. Asian Indians in Chicago: Growth and Change in a Model Minority. In: I.M. G. H. P. Jones editor. Ethnic Chicago. Chicago: Wm. B.Eerdmans Publishing Co; 1995.

10.     Wild SH, Laws A, Fortmann SP, Varady AN , Byrne CD. Mortality from coronary heart disease and stroke for six ethnic groups in California, 1985 to 1990. Ann Epidemiol 1995;5:432-9.

11.     Enas EA, Garg A, Davidson MA, Nair VM, Huet BA , Yusuf S. Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J 1996;48:343-53.

12.     Enas A AS. Coronary Artery Disease In Asian Indians: An Update And Review. The Internet Journal of Cardiology 2001;1.

13.     Deedwania P, Singh V. Coronary artery disease in South Asians: evolving strategies for treatment and prevention. Indian Heart J 2005;57:617-31.

14.     Fernandez ML. Acculturation and biomarkers for type 2 diabetes in Latinos. J Nutr 2007;137:871-2.

15.     Colditz GA, Manson JE, Stampfer MJ, Rosner B, Willett WC , Speizer FE. Diet and risk of clinical diabetes in women. Am J Clin Nutr 1992;55:1018-23.

16.     Fung TT, Hu FB, Pereira MA, Liu S, Stampfer MJ, Colditz GA et al. Whole-grain intake and the risk of type 2 diabetes: a prospective study in men. Am J Clin Nutr 2002;76:535-40.

17.     Facchini F, Chen YD, Hollenbeck CB , Reaven GM. Relationship between resistance to insulin- mediated glucose uptake, urinary uric acid clearance, and plasma uric acid concentration. Jama 1991;266:3008-11.

18.     Balagopal, P., Kamalamma, N., Patel, T. G., & Misra, R. (2008). A community-based diabetes prevention and management education  program in a rural village in India. Diabetes Care, 31(6), 1097-1104.

Chapter 3

Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations

Geeta Sikand,MA,RD,FADA,CDE,CLS

Prevention of heart disease among Asian Indians or South Asians (including Bangladesh, Nepal, Pakistan and Sri Lanka) is a major concern. The occurrence of heart disease among Asian Indians is significantly higher worldwide. According to a recent World Bank Report, heart disease is the leading cause of death in Asian Indian adults (ages 15 to 69 years). All South Asian countries and India in particular are facing a "health crisis" with rising rates of heart disease, diabete. obesity, unhealthy diet and low level of physical activity. The report has also predicted that if the treatable risk factors e.g. excess body Weight, blood pressure and LDL cholesterol remain untreated; it could lead to a global epidemic of heart disease in low and middle income countries.

By 2030 heart disease will emerge as the primary cause of death (36%) in India. A recent study of 52 countries showed that Asian Indians or South Asians suffer their first heart attack six years earlier (53 years versus 59 years) than other countries worldwide.

Heart disease is also the leading cause of death in women in every major developed country e.g. US and also in most emerging economies. The myth that heart disease is only a "man's disease" has been debunked.

What is Heart Disease?

Heart disease refers to diseases of the heart and the blood vessels due to atherosclerosis.Atherosclerosis begins with the deposition of cholesterol filled cells in the inner wall of blood vessels. Due to inflammation, a plaque is formed in the blood vessels. A plaque is a thickened wall of the artery. A damaged plaque can cause a blood clot with very rapid narrowing or blockage of the artery. A heart attack occurs when the blood flow to a part of the heart is blocked (often by a blood clot). Your diet and other lifestyle choices ccm affect your blood cholesterol and triglyceride levels. The good news is that heart disease can be prevented and treated with current knowledge. At the conclusion of this chapter a nutshell or six strategies geared towards how Asian Indian can adopt a heart-healthy diet, will be provided. The same strategies will be helpful for the treatment or high LDL, high triglycerides and the metabolic syndrome.

Risk Factors for Heart Disease

Risk factors increase the chances of a person developing atherosclerosis is and heart disease. According to the National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines, the major risk factors for heart disease are:

• Cigarette smoking
• Diabetes mellitus (fasting plasma glucose equal to or greater than 126 mg/do
• Hypertension (Blood Pressure equal To or greater than 140/90 mmHg)
• High LDL cholesterol (equal to or greater than 100)
• Low HDL cholesterol (men less than 40mg/do, women less than 50)
• Obesity (Body Mass Index greater than 25)
• Lack of physical activity
• Family history of premature heart disease(presence of heart diseases in male first-degree relative less than 55 years & in female first degree relative less than 65 years)­
• Age (men greater than 1.5 years; women greater than 55 years)

Indian Foods: AAPI'S Guide to Nutrition,Health and Diabetes

Additional risk factors

Your physician will determine whether you need these additional tests.

1. Lipoprotein (a),
2. Remnant lipoproteins
3. Small LDL particles
4. Fibrinogen
5. High-sensitivity C-reactive protein (CRP)
6. Impaired fasting plasma glucose(110- 125mg/di)
7. Presence of subclinical atherosclerosis (measured by exercise testing, carotid intimal-medial thickness [CT scan],and/or coronary calcium [EBCT].

Presence of diabetes doubles the risk of heart disease in men and quadruples the risk in women. Lack of healthy dietary habits and a lack of physical activity along with being overweight increase the risk of heart disease,diabetes,high blood pressure and stroke.Asian Indians have a higher prevalence of high triglycerides, low high density lipoprotein (good cholesterol) levels, glucose intolerance, and central obesity. Metabolic syndrome or pre-diabetes is also common in Asian Indians. Some adults as well as children are also at a higher risk for developing heart disease associated with high LDL cholesterol(bad cholesterol)and high triglycerides due to overweight and diets high in fat and refined sugars. Genetic factors also play a role in heart disease.

Target Numbers for Asian Indians to Prevent Heart Disease

• Non HDL-Cholesterol less (Total Cholesterol-HDL= Non HDl- Cholesterol)
• LDL-Cholesterol less than 100 mg/dl
• Blood pressure. less than 40/80 mm
• Waist Circumference. less than 35" for men and less than 31" for women

Target Numbers for Asian Indians with Heart Disease or Diabetes

• Non-HDL-Cholesterol less than 100 mg/dl
• LDL-Cholesterol less than70 mg/dl
• HDL-Cholesterol greater than 40mg/dl for males and greater than 50 mg/dl for females
• HbA1c less than 6.5
• Blood pressure 120/80 mm if you are a diabetic
• Waist circumference less than 35" for men and less than 31" for women

It is important to achieve the target numbers as noted above. If any of your numbers are abnormal, the information provided in this chapter will help you understand the role or a heart healthy diet and lifestyle in preventing heart disease. This chapter also provides six practical strategies geared towards the Asian Indian cuisine. It is also important to seek your physician's advice, lake medications tmder medical suspension so as to reach your target numbers. A registered dietitian (RD) could also partner with you to help you achieve your target numbers. To find a registered dietitian (RD) in your area: www.eatright.org Click on the "Find a Nutrition Professional" link toward top of the page.

Preventing Heart Disease in Asian indians: Diet &Lifestyle Recommendations

What is HDL cholesterol

High-density lipoprotein is a part of the total cholesterol measurement. It is often referred to as "good" cholesterol. The recommended level for men with diabetes is greater than 40mg/dl and for women with diabetes is greater than 50 mg/dl.

What is LDL cholesterol

Low-density lipoprotein is a part of the total cholesterol in the blood. It is often referred to as "bad" cholesterol. LDL should be less than 70mg/dl for those with diabetes and/or heart disease.

Dietary Recommendations to reduce LDL (bad) cholesterol level

The National Cholesterol Education Program Adult Treatment Panel III recommends:

1. Adjust caloric intake to achieve and maintain a healthy weight. Weight gain raises LDL (bad) cholesterol and triglyceride levels in the blood.
2. Choose a diet low in saturated fat (less than 7% of caloric intake), trans-fat (less than 1 % of caloric intake) and dietary cholesterol (less than 200 mg/day) by consuming a diet high in fish (especially fatty fish), non-fat dairy products,small amounts of lean meat and/or lean meat­alternatives e.g. dry beans e.g. rajma,channa,soybeans (like edamame), lentils (daal) and tofu.
3. Include food sources of plant sterols & stanols. At the recommended dosage of 2 gm per day, plant sterols reduce cholesterol absorption in the intestine by up to 30% cu1d reduce LDL ``bad" cholesterol by 10%. Plant sterols have the same chemical structure as animal cholesterol which blocks the absorption of cholesterol eaten in the diet as well as cholesterol manufactured by the liver.
4. Increase intake of viscous (soluble) fiber to 7-l3g daily e.g. oats, fruits such as strawberries, apples, vegetables such as okra, eggplant, brussel sprouts and legumes such as lentils. Soluble fiber can lower LDL cholesterol 3-5%.

It is recommended that adults eat 21 to 38 grams of total fiber daily.

Diet & Lifestyle Recommendations for Heart­ Health

A heart healthy diet includes fish (if religion pennits), fruits, vegetables, fiber, low-fat dairy products and low in salt and saturated fat. This dietary pattern is recommended for lowering LDL (bad) cholesterol and blood pressure when accompanied by regular physical activity and weight loss (if overweight). Regular physical activity at a moderate-intensity level for at least 30 minutes on most days of the week helps make your heart stronger and can help manage your weight.

• Enjoy your food, but eat less. Avoid oversized portions.
• Maintain a healthy weight or a BMI, (body mass index) of less than 23. Waist circumference should not exceed 35" in Asian Indian men and 31" in Asian-lndian women.

Make half your plate fruits & vegetables.

Switch to fat free or low fat milk (1%). Reduce calories from solid fats and added sugars (So FAS) and choose foods high in potassium, dietary fiber, calcium, and vitamin D.

Reduce salt by comparing sodium in foods e.g. soup, bread & frozen meals & choose foods with lower numbers.

• Drink water instead of sweetened beverages.
• Regular physical activity can also help you manage your cholesterol by raising your "good" HDL levels and lowering your triglyceride levels.

Source: 2010 US Dietary Guidelines (www.dietaryguidelince.gov)

Summary of a Heart Healthy Diet Pattern based on 2000 Calories per Day

• Fruits and vegetables. 4.5 cups daily (one serving= 1 cup raw leafy vegetable, V2 cup raw or cooked vegetable,½ cup vegetable juice;1 medium fruit, ½ cup fresh fruit).

Indian Foods AAPI's Guide to Nutrition, Health and ½ Diabetes

• Fish: 2 servings per week if religion permits ( 1 serving= 4 oz cooked fish preferably fatty fish e.g. salmon, mackerel, catfish).
• Legumes or lentils. Vegetarians: 5-7 times per week e.g. lentils, daal, rajma, channa and for non-Vegetarian;ms: at least 2 times per week (one serving=½ cup cooked legumes or lentils)
• Whole grains 3 serving per day choose from 1 slice whole grain bread, 1 OL dry whole grain cereal, ½ cup cooked whole grain brown rice,½ cup whole grain pasta, 1-6" chapati.
• Fiber 30 g daily (choose legumes, vegetables, fruits, whole grain, oats, rye, bran cereal, berrie , brown rice etc); 7 to 13 t,rrn soluble fiber e.g. whole oats, rye, barley.
• Nonfat Dairy Products. 2 to 3 servings per day (choose from 1 cup non fat or 1% milk, non-fat yogurt, 1% buttermilk),
• Fats & oils. 4. to 6 tsp daily (choc monounsaturated or polyunsaturated oils e.g. canola, corn, olive, soybean, safflower oil)
• Nuts and seeds. 2 to 4 times per week (½ cup or 1 1/2 oL nuts, avoid macadamia nuts and salted nuts, 2 tablespoon or ½ oz eecb).
• Sugar: limit to 5 servings week ( 1 servmg=1 tablespoon sugar, jelly or jam)
• Saturated fat 7%/total energy intake ( fat on meat or chicken skin, packaged desserts, whole milk, ice cream, huller, cheee, sour cream etc.
• Tran-fatty acid 0 gram (found in processed food., e.g. cookie , chip, Indian savory snack and fried foods).
• Cholesterol. limit to 200 mg daily (found in animal meats, organ meats, egg, etc).
• Alcohol. if you drink it is recommended you limit lo 1 serving per day (women) and 2 serving per clay (men). (1 serving= 5 oz "1ne, 12 oz beer, 1.5 oz of 80-proof spirits, or 1 oz of 100-proof pirils))
• Sodium: 1500 mg per day (read food labels, prepare food with as little salt as possible).

What is the metabolic syndrome?

Metabolic syndrome is the primary cause of an increase in heart disease in Asian Indians.. The American Heart Association and the National Heart, Lung, and Blood Institute recommend that the metabolic syndrome be identified as the presence of three or more of these components:

1. Central obesity measured by' elevated waist circumference 1n Asian Indians Waist circumference in Asian Indians greater than 35" Asian Indian Women: greater than 31"
2. High triglyceride.Equal to or greater than 1.50mg/el

3. Reduced HDL (''good'') cholesterol.
   Men -Less than ,to mg/dl
   Women - Less than 50 mg/dl

4. High blood pressure. equal to or greater than 130/85 mm Hg
5. High fasting glucose 100 lo 125 mg/dl(pre­ diabetes)

Other components of the metabolic syndrome (insulin resistance and prothrombotic state) cannot be identified by routine clinical evaluation . However, in the presence of central obesity, they can be assumed to be presento some degree.

Metabolic Syndrome Treatment Recommendations by American Heart Association

The primary goal of treating the metabolic syndrome is to reduce the risk for heart disease and type 2 diabetes. Combining a heart healthy diet pattern and regular physical activity with even a small amount of weight loss (7-10%) in overweight people can reverse the metabolic syndrome. The primary approach is to reduce the major risk factors for cardiovascular disease: stop smoking and reduce LDL cholesterol, blood pressure and glucose levels to the recommended levels by:

Preventing Heart Disease in Asian indians: Diet & Lifestyle Recommendations

1. Weight loss to achieve a desirable body weight (BMI less than 25 kg/m²)
2. Increased physical activity with a goal of at least 30 minutes of moderate-intensity activity on most days of the week. Seek your physician's approval before starting your exercise program.
3. Healthful eating habits that include reduced intake of salt, saturated fat e.g. butter, ghee,conut, coconut oil and coconut milk, palm oil, fatty meats, Trans fat e.g. vanaspati (Dalda), partially hydrogenated oils used in Indian savory snacks and dietary cholesterol e.g. egg yolks, meat, dairy.

What are triglycerides?

Triglycerides are a type of fat found in the blood. If triglycerides levels are high, they can increase the risk of heart disease. Triglycerides are stored in the fat cells. When caloric intake is excessive, the additional calories are converted into triglycerides (fat) and stored in fat cells. This is how the body stores its body fat. Take your triglyceride number seriously. Extremely high triglyceride (1000 or higher) can cause pancreatitis (inflammation of the pancreas). Several risk factors can increase the risk for very high triglycerides:

• Overweight / obesity
• Lack of exercise
• High LDL(bad)cholesterol and low HDL(good)cholesterol
• Type 2 diabetes
• Certain medications
• Family history

Table 1: National Cholesterol Education Program
(NCEP) cut points for normal to very high
triglyceride levels

Blood levels of triglycerides are measured in the fasting state after a 12-hour fast and no alcohol for 48hours before the blood test

To lower triglycerides

The National Cholesterol Education Program's Adult Treatment Panel III recommends:

1. Weight loss of 7 to 10% of body weight should be encouraged if indicated.
2. Avoid excessive intake of carbohydrate (not more than 50% of calories) especially refined carbohydrates e.g. sugar and sweets
3. Choose fats Wisely and lower the intake of fat to not more than 35% of calories in the diet.
4. Eat plenty of vegetables, fruits and whole grain, non-fat milk and non -fat dairy products, choose fatty fish, lean meat and lean meat alternatives e.g. tofu, soybcam lentils and legumes
5. Abstain or limit alcohol intake according to your doctor's instructions
6. Include regular physical activity such as walking for a minimum of 30 minutes on most days of the week.

Are fats & oils bad for a heart healthy diet?

All fats and oils are high in calories and can cause weight gain when excessive calories are consumed. However, some fats are good for heart health provided their calorie contribution does not cause weight gain. Fats are divided into 3 types based on the main type of fat they contain.

1. Unsaturated fats

Unsaturated fats are liquid at room temperature and are generally considered "good fats" such as omega- 3 (marine and plant derived), monounsaturated and polyunsaturated fats (omega-6).

Marine Derived Omega-3 fatty acids

Marine derived Omega-3 fatty acids found in fatty fish e.g. salmon are considered as "good fats" for

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

two reasons. Firstly, they can lower the risk of heart disease and secondly lower triglycerides. Two servings (3.5 oz each) of fatty fish per week are associated with a 30-40% reduced risk of death from a heart attack or stroke in persons without heart disease. Fatty fish are a good source of omega-3 fatty acids e.g. eicosapentanoic acid (EPA) and dexahexanoic acid (DHA). If religion permits it is important to consume fatty fish. Good sources of marine omega -3 fatty acids:

• Salmon, farmed or wild
• Mackerel
• Herring
• Sardines

Methyl Mercury concerns from eating· fish

Limit eating large fish due to greater mercury content such as:

• - Swordfish
• - King mackerel
• - Albacore tuna
• - Shark
• - Tile fish

It is advisable for pregnant women and young children to avoid eating these fish according to the United States Food and Drug Administration /Environmental Protection Agency.

Plant derived Omega-3 fatty acids

Plants can also be a source of omega-3 fatty acids primarily alpha-linolenic acid (ALA). However, very small amounts of ALA convert to EPA and DHA.

Two to three grams/day of ALA may reduce risk of heart disease. Good sources of ALA (plant omega-3) are:

• Canola oil 1TBS = 0.94 g/senring
• Ground flax seeds 1TBS-1.6 g/serving
• Flaxseed oil 1TBS=7.3 g/serving
• English walnuts 1 TBS (7 halves) - 2.6 g/serving
• Soybean oil 1 TBS 0.94 g/serving
• Chia seeds (sabza) 1 tsp = 1.7 gm/serving

Chia seeds are a good source of plant omega 3 ALA. One ounce of chia seeds "sabza" provide 5 gm of ALA. Chia seeds are also a good source of antioxidants, fiber and calcium. This petite whole grain has a mild flavor and can be eaten whole or ground, raw or cooked. Chia seeds can be soaked in water and added to salads, dhal or chapatti flour. Try them sprinkled on yogurt, salad and soup or tossed with rice. Traditionally chia seeds are used in Indian desserts that are high in saturated fat and calories e.g. kulfi faluda. To increase intake of ALA, flax seed powder can also be used in preparing curries like sambar or dhal (lentil soup), vegetables, chappatis and salad dressing.

Monounsaturated fat(omega-9)

Monounsaturated fat (omega-9) are considered "good" fats because they may lower LDL (bad) cholesterol and may help raise HDL (good) cholesterol. Good sources of monounsaturated fats are:

• Olive oil, canola oil, peanut oil
• Avocados, olives (high in sodium)

Table 2: American Heart Association Recommendations for Omega-3 Fatty Acids (2002)

Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations

• Nuts: almonds,peanuts,pecans,pistachios, hazelnuts

Polyunsaturated fat (omega- 6)

Polyunsaturated fat (omega- 6) are considered "good" fats because they help lower LDL (bad) cholesterol when used in place of saturated fat. Good sources of polyunsaturated fat (omega 6) are:

• Com oil, safflower oil, sunflower oil
• Sunflower seeds

2. Saturated fats

Saturated fats are considered "bad" fats because they can raise LDL (bad) cholesterol. Saturated fats should be avoided or eaten in small amounts. Saturated fats are solid at room temperature. Sources of saturated fat are:

• Fatty cut of lamb, pork, beef, poultry with skin, beef fat, lard, bacon, sausage, hotdogs
• Whole milk & whole milk dairy products: butter, cheese, cream, ice-cream, yogurt made from whole milk
• Palm oil, palm kernel oil and coconut oils

3. Trans-fats

Trans-fats are also considered "bad" fats because they can raise "bad" LDL cholesterol and should be eaten in small amounts. Trans-fats are primarily man-made from vegetable oils as a result of food

processing which changes vegetable oils into semi­ solid fats e.g. partially hydrogenated fats. Trans-fats are also produced when oil is re-used. Trans-fats are also found naturally in meat, cheese, butter and dairy products. Sources of trans- fat are:

• Baked goods: pastries, cakes, donuts, cookies
• Fried foods: French fries, fried chicken, onion-rings, Indian savory snacks cooked in re-used oil e.g. chevda, bhel
• Stick margarine, shortening, dalda (vanaspati)

Diel lo lower blood pressure

Although some salt is essential to maintain life excessive intake of salt (sodium chloride) can raise blood pressure. The American Heart Association recommends no more than 1500 mg of sodium per day. A high salt intake also has effects causing damage to the heart, kidneys, and arteries independent of blood pressure. Be aware of how much salt is added to food during preparation and also read labels of ready-prepared foods. In addition to a low salt diet a blood pressure lowering diet should also be low in saturated fat and high in vegetables, fruits and non-fat dairy products. Weight loss and increased physical activity are also important components of a blood pressure lowering diet,

Six strategies for a heart healthy diet for Asian Indians

The following six strategies are practical tips geared towards the Asian Indian cuisine. For regional cuisines, refer to the variety of regional cuisines in this book e.g. Bengal, Gujarat, Mal1arashtra, North India, South India and Nepal.

Strategy # 1 Protein Foods: 2 to 3 Servings Daily

• One serving includes ½ cup cooked lentils (dhal or dal or daals) or ½ cup cooked dry beans (rajma, channa, soy beans), or 2-3 oz each of protein foods e.g. lean meat, fish or poultry (chicken & turkey) or 4 oz tofu or one egg plus two egg whites combined.

Choose a variety of protein foods if your religion allows. Good food sources of protein include beans, lentils, seafood, poultry, lean meat and egg whites. Fatty fish e.g. salmon is an excellent source of omega 3 fatty acids (good fat).

• Eat fish twice at least per week if religion permits. Increase the amount and variety of fish and seafood consumed by choosing seafood in place of some meat and poultry if your religion pennits. Fish with lowest mercury are preferred. These fish are smaller in size e.g. salmon, pollock, catfish, cod, clams, flounder, sole, canned light tuna, shrimp, crabs and scallops.

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

• One egg three times per week is quite acceptable in an otherwise low saturated fat/low cholesterol _ diet. Substitute frequently with egg whites e.g. egg white omelets. Egg whites have no fat or cholesterol while they are an excellent source of protein.
• Tofu is a good source of protein especially for vegetarians. To reduce saturated fat, consume tofu in place of paneer in "palak paneer" or "matar paneer".
• Lentils (daals) or legumes (rajma, channa, black­ eyed beans) prepared with only a small amount of oil are an excellent source of protein and soluble fiber.
• Soybeans (edamame) are an excellent source of protein & fiber. Legume (dried beans and lentils) including "daal" are naturally low in fat, high in protein and carbohydrate, plant sterols and fiber.
• Vegetarian burger patties can be a convenient and nutritious alternative to tl1e meat patties. Check tl1e total fat, saturated fat and cholesterol content on tl1e label.

Strategy # 2 Dairy Products 2 to 3 Servings Daily

• One sen1ng includes 1 cup=8oz non-fat milk or 1% milk or low fat buttermilk or non-fat yogurt.
• Increase intake of fat-free or lmv-fat milk cu1d milk products, such as milk, yogurt, cheese, or fortified soy beverages.
• Select evaporated skim milk or non-fat powder milk or non-fat yogurt when making fruit smoothies, fruit shakes and desserts.Use 1% milk or evaporated skim milk (along with sugar·substitutes) when preparing Indian desserts e.g.kheer, payasscun, paneer or chenna.

Strategy # 3: Vegetables & Fruits 8 Servings (4.5 Cups) Daily

• Increase vegetable and fruit intake. Eat a variety of vegetables, especially dark-green cu1d red cu1d orange vegetables and beans and peas.
• Consume a higher intake of vegetables than fruits. Fruits are higher in carbohydrates as well as calories than vegetables. For e.g. one sen1ng of a vegetable equals ½ cup cooked or 1 cup raw=25 calories cu1d one serving of a fruit = one small to medium fruit or ½cup fresh fruit=60 calories.
• Select green vegetables in place of starchy ones as starchy vegetables are higher in calories and carbohydrate. Consume leafy green vegetables (spinach, cabbage, kale, mustard greens) & cruciferous vegetables (cauliflower, brussel sprouts, broccoli) eitler raw or prepare them in a small amount of oil

Strategy # 4: Whole Grains: 6 Servings Daily

• Consume at least half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains. Reduce the amount of rice/chapatis when potatoes or other starchy vegetables are also included in the same meal.
• Select 100% whole wheat chapati flour. Add oatmeal (high in soluble fiber) &/or soy flour (high in protein) to chapatti flour. To control calories, avoid putting ghee/oil when making chapatis

Substitute other whole grains for rice & pulao e.g. quinoa (high in protein), barley and oats (high in soluble fiber), brown rice (high in fiber).

Choose foods with soluble fiber to help lower LDL cholesterol (bad cholesterol) e.g. whole oatc;, barley, dried beans, fruits and vegetables such as okra, brussel sprouts.

Limit the consumption of foods that contain refined grains cooked with solid fat., (butterghee, shortening) and added sugar e.g. cookies, cakes, pies and indian sweets such as laddoos, mathris, shakarparas.

Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations

Strategy # 5: Fats & Oils 4-6 tsp Daily

• 1 serving - 1 tsp oil or 6 almonds, or 2 walnuts or 2 TBS avocado
• Prepare foods using lower fat cooking methods such as grilling, broiling and baking instead of frying and sauteing. To reduce caloric intake, cook with a minimum amount of oil.
• Avoid ghee, butter, whole milk & cream in food preparation & processed foods to reduce saturated fat intake. Avoid coconut or coconut cream or use a lesser amount than call for in the recipe. Although coconut and coconut cream are high in saturated fat, coconut water (nariyal- paani) is not high in saturated fat. Limit use of whole milk in Indian tea "chai" because it adds saturated fat in the diet.
• Limit consumption of sweets e.g. pastries, kulli, rasmalai, kheer, barfi, halwa pcclas, pies, cake and cookies. These are generally prepared with saturated fat e.g. butter, ghee and whole milk and may raise LDL cholesterol, triglyceride and body weight.
• Avoid foods high in trans-fats. Like saturated fat, trans- fat raises LDL cholesterol levels & may lower "good" HDL cholesterol. Re-use of cooking oils increases the trans-fat content of the oil. Trans-fats are found in Indian savory/snack foods e.g. mathri, shakar paras chewda, bhel, sev etc. These are made with saturated fat and trans-fat e.g. ghee, shortening (vanaspati) and re-used cooking oils.
• Select a heart healthy spread (free of saturated and trans- fat) instead of butter or ghee, Read the label to make sure there is no "partially hydrogenated" oil in the ingredients list. Then look for as little saturated fat as possible. Look for spreads with less than a total or 2 grams from saturated and trans-fat per serving. Also look for "light" or "lite" spreads as they are half the calmies and also half the fat of regular spreads.
• Plant sterols and stanol-esters are found primarily in fortified foods e.g. Bennecol spread and Promise Active spread. Only 2 or 3 tablespoons of these spreads containing plant stanol esters provide 2 grams of plant stanols and may lower LDL cholesterol by 7-15 %. Beverage supplements containing plant stanols such as Cholest-off cmd Minute Maid Heart Wise orange juice may also help lower LDL cholesterol. Plant sterols in food or supplements should be consumed with meals because they help to lower the absorption of dietary cholesterol. The largest LDL cholesterol lowering response is noted when the dose is spread Over two or 3 meals per clay. Higher doses above 2 g/day offer little additional benefit. Since plant sterol/stanol fortified spreads and supplements also provide calories, other sources of fats should be reduced to maintain caloric intake to avoid weight gain.
• Avoid excessive intake of nuts and avocados as they are high in calories and may lead to weight gain. However, inclusion or few unsalted nuts e.g. walnuts, almonds, peanuts, pistachios in a heart healthy diet may decrease LDL cholesterol when weight is not gained. When weight is not gained, consumption of 5 oz of unsalted nuts per week is associated with a reduced risk of heart disease.
• In Indian restaurants select appetizers and entrees cooked in a tandoor. Good choices for appetizers are tandoori fish, tandoori vegetables, vegetable salads, fruits salads (fruits chaat) & roasted papadam with mint chutney. Avoid entrees prepared with added cream or butter or fried foods.

Strategy # 6 Decrease your Salt Intake to 1500 mg Sodium Daily to Lower Blood Pressure

• The American Heart Association and the recent US dietary guidelines recommend less than 1500 mg of sodium per clay. This sodium goal is lower than in previous guidelines because new data support this limit.

Indian Foods: APJ's Guide to Nutrition, Health and Diabetes

• Reduce salt intake by cooking with as little salt as possible.
• Compare sodium in foods by reading labels e.g. soup, bread & frozen meals. Choose foods with lower numbers.
• Substitute salt with herbs & spices e.g. cilantro, mint, cumin, black pepper, lemon.
• Avoid highly salted foods e.g. salted nuts, pickles, chutneys and salted savory/snack foods e.g. chevda, bhel etc.
• Prepare savory snack foods e.g. chewda, bhel etc at home with minimum salt and oil. To reduce salt in the recipe, enhance flavor by using more spices e.g. amchur, cumin, asafetida.

Alcohol Guidelines

If you drink and if your physician approves because you have no medical reasons not to drink alcohol, you should limit to one drink or less per day for women and two drinks or less per day for men. In general, one drink is 1 jigger or 1.5 oz hard liquor (80 proof spirits) e.g. whiskey, bourbon, vodka etc or 5 oz dry red or white wine or 12 oz beer.

What is the role of vitamin supplements and antioxidants in preventing heart disease?

Vitamin C supplements in combination with vitamin E and/or beta carotene have not shown any benefit in the prevention of heart disease. Some studies have shown they could be harmful. Vitamin D is also under study. It is expected that ongoing research will shed further light on the role of vitamin D supplementation in the prevention of heart disease.

Do you need a Registered Dietitian (RD) ?

A registered dietitian has expertise in nutrition. With the help of a RD, a heart healthy meal plan will be developed while taking your personal food preferences and medical history and lab reports into account. Follow up visits with your RD are also recommended to reach your heart health goals. This is referred to as medical nutrition therapy (MNT) by a registered dietitian (RD).

Geeta Sikand, MA, RD, CDE, Cl.S is a consultant dietitian in private practice in Irvine, California and an Associate Clinical Professor of Medicine: Cardiology at the University of California Irvine. Contact information (949) 726-1840 or gsikand@gmail.com

References

1. South Asia at Health Crossroads with High Rates of Heart Disease, Diabetes, Obesity and Other Non communicable Diseases- New World Bank Report. Press Release No: 2011/325/SAR Washington, February 9, 2011. www.worldbank.org/ sarncdreport
2. An epidemic of risk factors for cardiovascular disease The Lancet, Volume 377, Issue 9765, Page 527 , February 12, 2011.
3. Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women-2011 Update: A Guideline from the American Heart Association. Executive Writing Committee, Mosca L, Benjamin EJ et al Circulation. 2011; 123:00-00. Februcu 16, 2011.
4. The Importance of Population-Wide Sodium Reduction as a Means to Prevent Cardiovascular· Disease and Stroke: A Call to Action from the American Heart Association". Appel et al http://circ.ahajounals.org Published on line Circulation Jan 13, 2011
5. 2010 Dietary Guidelines for Americans released January)"31,2011\\IWw.dietaryguidelines.gov.
6. The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults: Bethesda, Md: National Institute of Health National Heart Lung & Blood Institute; 2000.NIH Publication No 00-4084. http://www.nhlbi.nih.gov/guidelines/obesity/prct gd c.pdf
7. ATP III Treatment Panel Report. May 2001. Detection, Evaluation and Treatment of High Blood Cholesterol in adults. NIH Publication No. 01-3670 May 2001.
8. Van Hom L, McCoin M, Kris Etherton P M, Burke F, Carson J, Champagne C, Karmally W, Sikand G. "The Evidence for Dietary Prevention and Treatment of Cardiovascular Disease." J Am Dietet Assoc 2008; 2: 287-331
9. Grundy SM et al. Circulation 2005; 112: 2735- 2752.
10. Enas EA. Dyslipidemia among indo-Asians: Strategies for identification and management. Brit J of Diabetes and Vascular Dis 2005; 5: 81- 90 (Review).
11. Superko HR, Enas EA, Kot.ha P, Bhat NK, Garrett B. High-density lipoprotein subclass distribution m individuals of Asian Indian descent: the National Asian Indian Heart Disease Project. Prev Cardiol 2005; 8:81-6.
12. Bhalodker N, Blum S, Rana T, Bhalodker A, Kitchappa R, Kim K-S, Enas EA. Comp;u-ison of large ;md small High density lipoprotein cholesterol in Asian Indian men compared to men in the Framingham Offspring Study. Am J Cardiol 2004; 94: 1561-1563.
13. Eckel RH et al Preventing cardiovascular disease and diabetes; a call to action from the Amer Diabetes assoc and the Amer Heart Assoc. Diabetes C
14. Lichtenstein AH et al Diet & Lifestyle Recommendations revision 2006: A Scientific Statement from the American He;ut Association Nutrition Committee. Circulation, 2006; 114:82-96
15. Look AHEAD Research Group. Reduction in Weight and Cardiovascular Disease Risk Factors in Individuals with Type 2 Diabetes. Diabetes Care 2007;30:1374-1383.
16. Abumweis SS, Barake R, Jones PJ. Plant Sterols/stanols as cholesterol lowering agents: a meta-analysis of randomized controlled trials. Food Nutr Res. 2008;52. Doi: 10.3402/ fnr.v52i0.1811.
17. Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C, for the Conference Participants. Definition of the Metabolic Syndrome, Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004; 109: 433-438.
18. Screening for Obesity in Adults: Recommendations and Rationale, Rockville, Md: Agency for Healthcare Research and Quality, US Preventive Services Task Force: Nov 2003. http://www.ahrq.gov/clinic/3rduspstf/obesity/obesrr.htm
19. Sikand G, Kris Etherton PM & Frank GF. Cardiovascular· Nutrition: In Wong ND, Garden J & Black H, eds. Preventive Cardiology, McGraw Hill 1999; 13: 319-72.
20. Mccoin M, Sikand G, Johnson E & Vanhorn L. The Effectiveness of Medical Nutrition Therapy Delivered by Registered Dietitians for Disorders of Lipid Metabolism: A Call for Further Research. J Am Dietet Assoc 2008; 2:233-239
21. Sikand, G; Kashyap, ML; Wong ND; Hsu .J C. Dietitian intervention improves lipid values and saves medication costs in men with combined hyperlipidemia and a history of niacin non­ compliance. J Am Diet Assoc. 2,000; 100:218- 224.
22. Dhawan J. Coronary heart disease in Asian Indians. Curr Opin Lipidol. 1996;7: 196-198.
23. Yagalla MV, Hoerr SL, Song WO, Enas E, Garg A. Relationship of diet, abdominal obesity, and physical activity to plasma lipoprotein levels in Asian Indian physicians residing in the United States. J Am Dietet Assoc. 1996, 96(3): 257-61.
24. Grundy SM. Small LDL, atherogenic dyslipidemia, and metabolic syndrome. Circulation. 1997; 95:1-4.
25. Reaven G. Insulin resistance and compensatory hyperlinsulinemia: role in hypertension, dyslipidemia and coronary heart disease. Am HeartJ. 1991;121:1283-1288
26. Sikand G, Kashyap ML, Yang I. Medical Nutrition Therapy lowers serum cholesterol and saves medication costs in men with hypercholesterolemia. J Am Diet Assoc. 1998;98: 889-894.
27. Barnett and Garg, Preventing cardiovascular complications in diabetes and Szapary and Conway, Functional foods in the prevention of cardiovascular disease In: Carson, Burke, Hark. Cardiovascular Nutrition: Disease Management and Prevention. Chicago, IL: American Dietetic Association, 2004
28. What you need to know about mercury in fish and shellfish. FDN/CFSAN Consumer Advisory EPA-823-R-04-005. March 2004. http://www.cfsan.fda.gov/ ~dms/admehg3.html.

Chapter 4

Renal Diet for Asian Indians

Chhaya Patel, MA, RD, CSR

1 meat serving =

• 1 oz. of poultry, seafood, or fish
• 1 medium egg or ¼ cup egg substitute
• ¼ cup tuna
• 1 oz. natural cheese(Limit to________ ounces per week.)
• ¼ cup cottage cheese (Limit to______per week.)

1 bread or starch =

• 1 slice of bread/Chapati/puri/½ nan
• ½ cup cooked rice or noodles
• ¼ pita (6 in. wide)
• ½ cup cooked cereal
• ¾ cup dry cereal
• ½ bagel or sandwich bun

1 vegetable serving =

• ½ cup vegetables
• 1 fruit serving =
• ½ cup canned fruit
• 1 medium-sized fresh fruit (about the size of a tennis ball)
• ¼ - ½ cup fruit juice



Foods to Enjoy

• Fresh fish, eggs and poultry
• Enriched bread or pasta and rice
• Allowed vegetables and fruits
• Olive oil, butter or margarine

The following food and diet information will help you to eat as healthy as possible while receiving hemodialysis treatments.

Protein

Protein is the backbone of the hemodialysis diet. It is necessary for growth and repair of body tissues. It helps your body fight infection and prevents loss of muscle. The highest quality protein comes from animals. Although plant foods have protein, the quality is low. Those on hemodialysis need high quality protein.

Foods to Enjoy

Fish

Poultzy

Seafood

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Acceptable Starches

White Rice

Vermicelli

Chapati

Parathas

Masala Dosai

Pongal

Puris

Jowar Roti

Naan

Renal Diet for Asian Indians

Miscellaneous

Reminder!

Always remember to take your phosphorus binders with a meal or snack.Protein foods are high in phosphorus.

Portion Guide for Protein Foods

• Half chicken breast is about 3 to 4 ozs.
• Chicken thigh is about 2 to 2 ½ ozs.
• Chicken leg is about 1 to 1 ½ ozs.
• Deli roast meats, 2-3 slices are about 3 ozs.
• 12 large shrimp are about 3 ozs.
• ¼ cup of unsalted tuna is 1 Oz
• 1 egg is equal to 1 oz.
• ¼ cup egg substitute is 1 oz.

Dialysis and Protein Foods

Each time you have a hemodialysis treatment, protein is removed from your blood along with the waste products. The amount of protein you eat must be enough to replace that loss in hemodialysis and provide your daily requirements.

To determine whether you are getting enough protein , the amount of Albumin in your blood will be measured monthly. If your albumin is 4.0 or higher you are eating enough protein. Studies have shown that people on dialysis who have an albumin of 4.0 or higher live longer and healthier.

These protein-rich foods are high in sodium and should be limited or used sparingly

Processed Meats

• Lunch meats
• Pickled fish
• Sardines/canned fish

Other Foods

• Cheese
• Buttermilk
• Canned or frozen dinners
• Canned or packaged soup
• Fast foods
• Pot pies

These protein foods are high in Potassium and Phosphorus. Check with your Dietitian before using

• Pinto beans
• Brown beans
• Navy beans
• Red beans
• Black beans
• Lima beans
• Refried beans
• Purple hull peas

Peanuts/peanut butter

Can I be a vegetarian if I have chronic kidney disease?

If you are diagnosed with chronic kidney disease (CKD) and are a vegetarian you can remain as one. You do not have to start eating meat because you have CKD or have started dialysis. In order to continue with your vegetarian lifestyle as well as incorporate a renal diet, you will need to devise a meal plan to fit your nutritional needs. You should talk with a renal dietitian about foods that are kidney-friendly and vegetarian-specific. Here are some things your dietitian may implement for your new diet:

• Monitor your calorie intake to make sure you are getting enough calories.
• Include vegetarian sources of protein and calorie supplements when needed.
• Increase your phosphate binders that may be needed for meals and snacks.
• Lower potassium dialysate for those on dialysis to control potassium levels.
• Make sure your dialysis prescription is adjusted as needed for acceptable urea clearances.
• Provide resources and renal education material specific to your needs.

indian Foods: AAPI's Guide to Nutrition, Heald1 and Diabetes

Kidney-friendly foods for a vegetarian

Vegetarian diets can meet protein needs. Protein is made up of chains of amino acids, which are sometimes referred to as "the building blocks of life." Plant foods contain many essential amino acids and some can be considered as complete protein foods. Some plant protein may lack one or more essential amino acids, but a variety of vegetarian foods can be combined throughout the day to provide adequate amounts of essential amino acids without consuming meat, eggs or milk. Plant protein can be enough to get adequate protein into your renal diet.

Protein enriched foods for vegetarians on a kidney diet can include:

• Meat analogs (meat substitutes such as soy burgers, tofu hot dogs and deli slices)
• Soy products (tofu, tempeh)
• Beans and lentils
• Nuts and nut butters
• Eggs and egg substitutes
• Dairy products
• Grains

The protein and nutrient content can vary for tofu products, soy milk and meat analogs. It is important to check product labels for the specific nutrient content per serving (such as protein, sodium, potassium, phosphorus, etc.). Powder and liquid protein supplements may be an option for patients with unusually high protein needs or who are unable to meet their protein needs by food alone. Eggs or egg substitutes are a source of HBV (high biological value) protein, also known as high quality protein. HBV protein can be consumed by lacto-ovo vegetarians.

Calories

It is important that you eat a variety of foods-not just protein. If you do not get enough calories from foods other than those high in protein, your body will break.down your muscle tissue to use for energy. You may need to add some high calorie foods to keep from losing weight or to regain weight you have lost.

High calorie foods to enjoy (If you have diabetes, please consult your dietitian before using these foods)

Candy

• Mints
• Gum drops
• Hard candies
• Jelly beans
• Marshmallows

Cake

• Angel food cake
• White/yellow cake with icing
• Coffee cakes without nuts
• Pound cake

Pie

• Fruit pies with allowed fruits
• Lemon meringue pie
• Fruit tarts

Miscellaneous

• Danish rolls
• Donuts (raised)
• Honey
• Jam or jelly
• Lemonade

Renal Diet for Asian Indians

• Vanilla sandwich cookies
• Sugar cookies
• Syrup
• Table sugar
• Toaster pastry
• Vanilla wafers
• Non-dairy whipped topping

Indian Desserts

• Burfi
• Halwa

These foods are high in Phosphorus and/or Potassium. Please limit or avoid!

• Candy with chocolate, nuts or peanut butter
• Chocolate cake
• Bro-wnie
• Fudge
• Chocolate cookies
• Cream pies
• Sweet potato pie
• Pumpkin pie
• Milkshakes
• Nuts
• Potato chips
• Ice cream
• Burfi and Halwa
• Dessert made with milk

Helpful Hints for Adding Calories

• Add sugar to beverages and cereal
• Add jam, jelly, honey or syrup to bread, muffins, cmd rolls
• Drink beverages that have calories
• Eat an allowed dessert daily
• Add whipped topping to dessert or fruits
• Eat allowed candies between meals
• Spread frosting on cakes and cookies
• Spread margarine or butter on hot bread or rolls
• Use margarine or butter on cooked vegetables, rice, noodles and cooked cereals
• Fry meats, fish or eggs in margarine or oil
• Add low salt gravies to your meat.
• Use mayonnaise or salad dressing on sand" ches and salads

More high calorie foods to enjoy

Fats can add a lot of the calories you may need if you want to gain or maintain weight.

• Butter
• Ghee
• Margarine
• Crecun cheese
• Cooking oil
• Mayonnaise

Your portions of these foods will be reduced if you are on a low fat, low cholesterol d1et Please consult your dietitian.

Phosphorus

Phosphorus is a mineral that is necessary to build strong, healthy bones and teeth. It is also important in storing and efficiently using energy in body cells. When the kidneys are not working the phosphorus level can get too high. A high phosphorus level can make your bones weak and brittle and also lead to calcium deposits that can form in the blood vessels and soft tissues of your body. A good phosphorus level for people on dialysis is 3.5 to 5.5.

There are 3 ways to keep your phosphorus in good range

• Come to and complete all of your dialysis treatments.
• Follow your diet.
• – Eat low phosphorus foods. Ask your dietitian to suggest some.
• – See "Foods That May Cause Phosphorus Trouble" below.
• Take your phosphorus binders
• – Phosphorus is in almost all foods so it is important to take your phosphorus binders every time you eat.

Phosphorus Binders

Binders keep phosphorus out of your blood. Phosphorus binders are taken with meals and snacks. Remember...the only way binders work is to take them with food. Phosphorus binders come in many names: Renvela, Fosrenol, PhosLo, Calcium Carbonate (Tums), Alternagel are some of the names. Take the amount of binders that are prescribed for you! Your Dietitian or Doctor will tell you how much binder you need to take with each meal and snack to keep your phosphorus normal.

Foods that May Cause High Phosphorus (Please limit or avoid!)

Dairy Products

• Milk, eggnog
• Cheese
• Yogurt
• Pudding
• Custard
• Ice cream
• Cream soups
• Milkshakes
• Casseroles made with cheese

Dried Beans

• Red or black beans
• Mung beans
• Lentils and Dals
• Navy beans
• Lima beans
• Pinto beans
• Kidney beans
• Blackeyed peas
• Pork and beans
• Soybeans

Nuts and Seeds

• Pecans
• Almonds
• Cashews
• Walnuts
• Peanuts
• Peanut butter
• Sunflower seeds
• All other nuts and seeds

Protein Foods

• Enhanced meats
• Liver
• Oysters
• Canned salmon
• Organ meats
• Sardines

Whole Grains and Cereals

• Bran
• Granola, trail mix
• Brown rice
• Bran muffin
• Whole grain breads
• Whole grain cereals
• Biscuit, canned, froz, or fast food

Other Foods

• Beer
• Colas & all phosphoric acid-containing drinks
• Pizza
• Cocoa

Renal Diet for Asian Indians

• Molasses
• Macaroni and cheese
• Wheat germ
• Carmel
• Chocolate
• Dried fruits
• Coffee drinks made with milk
• Cake donuts
• Commercial pancakes and waffles
• Desserts made with milk Helpful

Hints to Lower Phosphorus

• Use non-dairy milk substitutes, such as Mocha Mix®, Coffee Rich®, Coffee-Mate, Rice Dream® or Dairy Delicious® in place of milk on cereals and in recipes.
• Try cream cheese on crackers or sandwiches instead of cheese or peanut butter.
• when using cheese in cooking, choose the sharpest flavor and use less than the amount listed in the recipe.
• Enjoy sorbet, fruit ice, Italian ices, popsicles or sherbet instead of ice cream for a cool and tasty treat.
• Drink non-cola sodas. All cola drinks (diet and regular) contain phosphoric acid. Try some of the flavored seltzer waters or make your own. Check labels on canned or bottled beverages to make sure they do not contain phosphates.
• Eat popcorn (unsalted) instead of nuts for a snack.
• Choose hard candy as it has less phosphorus than chocolate.
• Try mixed vegetables instead of lima beans or corn with meals.
• If biscuits, pancakes, and waffles are a favorite, make them from scratch as mixes and commercial products are high in phosphorus.

Phosphate restriction for vegetarians with kidney disease

About 50 to 70 percent of phosphorus is absorbed in the body from a typical diet of both plant and animal-based foods. In general, phosphorus is greater in animal products than from plant-based food. Much of the phosphorus in grains and legumes can be in the form of phytic acid, known as the main storage area of phosphorus in many plant tissues, which reduces the absorption of phosphorus to around 50 percent.

Legumes, nuts and seeds will need to be limited for patients with chronic kidney disease, if potassium and phosphorus levels become an issue. Consumption of a vegetarian diet may require an increase in the number of phosphate binders for patients in end stage renal disease. (ESRD) or on dialysis.

Potassium

Potassium (K) is a mineral that is necessary to keep your muscle., functioning properly. The heart is your biggest muscle. That is why your heart is affected when potassium levels are too high or too low.

Healthy kidneys regulate the amount of potassium the body needs. In kidney failure, the amount of potassium in the body can get too high and cause dangerous problems .

High Potassium in the blood may cause:

Nausea

Difficulty breathing

Irregular heartbeat

↑K  Cardiac arrest/heart attack

Tingling In tJ1e

extremities Loss of

consciousness Slow or

weak pulse

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Low Potassium in the blood may cause:

• Muscle weakness
• Nausea, vomiting, diarrhea
• Irregular heartbeat
• Dizziness

Normal Potassium Level 3.5 to 5.5.

• Your dialysis treatment helps control your • blood potassium level. Make every scheduled • treatment and stay the full length of the treatment.
• If your Potassium is lower than this you should talk to your Dietitian about getting more potassium in your diet.
• If your Potassium is higher than this you should limit the amount of potassium that you eat.
• Most of the Potassium in your diet comes from Fruits and Vegetables. Use the following tables to determine which fruits and vegetables are the best choices.

Foods to Enjoy(Serving Size 1/2 cup unless otherwise stated)

Fruit



• Apple, applesauce
• Apricots(1)
• Blackberries
• Blueberries
• Boysenberries
• Cherries
• Coconut
• Cranberries
• Cranberry sauce
• Figs(2)
• Fruit cocktail
• Grapefruit(½)
• Grapes
• Kumquats
• Lemon
• Lime
• Manclcuin oranges, canned
• Peaches, end, fresh 1 small or ½ lge

• Pears, canned,1 small or ½ lge
• Pineapple, fresh or canned
• Plums (2)
• Prunes (2)
• Raspberries

Rhubarb

• Strawberries (5 medium)
• Tangerine (1)
• Watennelon (1 cup)

Grapefruit juice: Discuss medication reactions with your dietitian or doctor:

Vegetables

• Asparagus
• Bamboo shoots, canned
• Bean sprouts
• Beets, canned
• Broccoli
• Brussels sprouts
• Cabbage
• Carrot
• Cauliflower
• Celery
• Collards
• Corn^*
• Cucumber
• Eggplant
• Endive
• Green beans, wax beans
• Kale
• Leeks

• Lettuce
• Mushrooms
• Mustard greens
• Okra
• Onion
• Parsley
• Peas, green*
• Peppers, green or red, mild or hot
• Radishes
• Summer squash
• Spaghetti squash
• Snow peas
• Toria
• Turnips & turnip greens
• Watercress
• Waterchestnuts, cnd
• Zucchini

Potatoes-0nly if soaked 2 to 4 hrs to reduce potassium (Ask your dietitian about "Dialyzing" potatoes)
(*allowed but high in phosphorus)

(poisonous for dialysis pts,not based on K+ content). Do Not Eat!

Juices

• Orange juice
• Prune juice

Avoid any juices with added calcium

Miscellaneous Foods

• Bran cereal
• Chocolate
• Salt substitute
• Lite salt
• Nuts and seeds
• Soy milk



Vegetables



• Artichokes
• Avocado
• Bamboo shoots, fresh
• Beans, dried, ckd (kidney, lentils, lima, navy, pinto, soy)
• Beets, fresh and beet greens
• Cactus
• Chard
• Chinese cabbage
• Fenugreek leaves
• Kohlrabi
• Papadi
• Peas (dried)
• Pickles
• Potatoes, unless "dialyzed"
• Pumpkin
• Rutabagas
• Sauerkraut* *
• Spinach (cooked)
• Succotash
• Sweet potatoes
• Tomato
• Tomato paste, puree or sauce
• Tuver
• Waterchest:nuts, fresh



Juices



• Carrot juice
• Tomato juice* *
• Prune juiceM
• Vegetable juices* *
• V-8 juice cocktail * *

* * also High Sodium

Helpful Hint

Reduce the amount of potassium in vegetables by dialyzing them.

• Clean, peel and thinly slice or chop the vegetable.
• Cover vegetable with water and soak for one hour. Potatoes should be soaked two to four hours or longer.
• Drain the water and cook the vegetable your favorite way.

Potassium restriction for vegetarians with kidney disease

Fruits and vegetables are the biggest source of potassium and may need to be limited for vegetarians with chronic kidney disease. Other foods high in potassium that vegetarians may use are soybeans, textured vegetable protein (TVP), soy nuts, soy flour, natto (soybean paste) and wasabi. Careful planning of these foods can be worked into a vegetarian diet. However, potassium amounts will need to be modified and levels monitored carefully.

Sodium

Too much sodium can cause:

• High blood pressure
• Increased thirst
• Damage to the heart
• Difficulty breathing
• Puffiness and swelling

Therefore, you should limit the amount of sodium in the foods you eat.

Sodium in Foods

• The main source of sodium in the diet is salt.
• Sodium generally comes from convenience foods, fast foods, processed and canned foods, and snacks that have sodium or salt added during their processing.
• To reduce the salt, and therefore sodium, in your diet, decrease your intake of processed foods. This means any food that has been processed. If a food is not fresh, it is usually high in sodium.

Helpful Hints

• Many restaurants are providing nutrition information including sodium.
• Learn what foods contain large amounts of sodium and which foods have a small amount of sodium.
• Read labels. Compare different brands of similar items (like salad dressings) and choose the one with the least sodium.

Sodium restriction for vegetarians with kidney disease

Sodium content of some vegetarian foods can be high. The foods with high sodium content are usually processed, commercially-produced plant proteins. To reduce sodium intake, the use of high sodium foods such as meat analogs, salted nuts, miso, frozen entrees, marinated tofu products,savory snacks and meals in a cup should be limited. In comparison to meat, meat analogs have much higher sodium content and need to be limited.

Add a little spice…

Mix these spices together and use instead of salt.

• Garlic powder
• Marjoram
• Thyme
• Parsley
• Savory
• Mace
• Onion powder
• Black pepper
• Sage
• Cumin
• Curry powder
• Garam masala

Other low sodium seasonings to use

Almond extract, allspice, anise, basil, bay leaf, carraway seed, cardamom, celery seed, chili powder, chives, cilantro, cinnamon, clove, cumin, curry, dill, dry mustard, garlic, garlic powder, ginger, horseradish, lemon juice, mace, maple extract,onion powder, oregano, paprika, parsley, pepper, peppermint, poppy seeds, poultry seasoning, rosemary, saffron, sage, Tabasco® brand hot sauce only (other have added sodium), tarragon, thyme, vanilla extract, vinegar, Wright’s Liquid Smoke®, Mrs. Dash^®.

High sodium seasonings to avoid

Accent ^®, BBQ sauce, seasoned salt such as Lawry’s^® ,celery salt, garlic salt, onion salt, Old Bay^®, pickles, soy sauce, steak sauce, Worchestershire sauce.

Salt substitues contain potassium chloride (KCl) and should not be used by hemodialysis patients. Check labels on seasoning blends to make sure KCl is not an ingredient. Morton’s Salt Substitute®, Nu-Salt® and Morton’s Lite Salt® all contain potassium.

Foods That May Cause High Sodium
(Please limit or avoid!)

• Processed cheese like American
• Canned or dried soups
• Canned vegetables or tomato juice
• Pizza, frozen dinners, pot pies
• Potato chips, corn chips, pretzels
• Salted microwave popcorn
• Salt pork
• Soy sauce
• Dill pickles and olives
• Barbecue sauce
• Saurkraut

Fluids

Your fluid intake must be balanced with the amount of fluid you excrete in your urine. If you drink or eat more fluid than you excrete daily you will retain fluid and gain “fluid weight”.

When measuring your fluids, use an 8 oz. cup or measuring cup.

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Here's a simple way to keep track of your daily fluid allowance

1. Each morning, measure your daily fluid allowance in water and store it in a container.
2. Every time you drink some type of fluid or use any other fluid like ice, jello, or Popsicle; pour out an equal amount of water out of your container.
3. When all the water is gone, it will tell you that you have used up your fluid allowance and it is time to Stop!

Learn to stretch your fluid allowance to last you the whole day. Follow some of the hints provided below.

Helpful Fluid Hints

• Drink only when thirsty. Don’t drink from habit or to be sociable.
• Satisfy thirst by eating cold or frozen fruit such as grapes.
• Avoid high sodium/salty foods like canned soup, Chinese foods, fast foods, chips, etc.
• Rinse your mouth frequently with water, but don’t swallow. Keep your mouth moist all the time.
• Chew gum. Sport gums are especially helpful.
• Have a piece of hard sour candy or bite down on a piece of frozen lemon wedge.

Remember: 2 cups of fluid will equal 1 pound of weight gain!




Fluid Foods:Visible Fluids



• Water
• Milk, cream
• Soup
• Coffee
• Tea
• Lemonade
• Kool-aid
• Soft drinks
• Alcoholic drinks



"Hidden" Fluids



• Ice
• Popsicles
• Gelatin
• Ice cream



Here are some ideas to help you make good choices when dining out

Appetizers



• Choose fresh, simple items to avoid salt
• Allowed fresh vegetables and fruits are a good choice



Salad



• Fresh salad of allowed fruits and/or allowed vegetables
• Ask for oil and vinegar dressing or dressing on the side so that you can control the amount you use
• Try squeezing lemon or lime over salad greens for a dressing



Entrees



• fish, seafood, chicken and other poultry
• Ask for gravies, sauces and marinades “on the side” so you can control the amount eaten

Renal Diet for Asian Indians

• Vegetarians can substitute beans, lentils or tofu for meats
• Portions served in restaurants may be very large; watch your serving size and take excess home
• Grilled items are good choices
• Mixed dishes such as casseroles are generally high in phosphorus and sodium



Vegetables

• Fresh, steamed, or fried; unsalted



Breads/Starches

• Nan, Chapati, Paratha, Puris, White or Italian breads and rolls (without garlic salt)
• Idli, Dosa and rice products
• Pasta, macaroni, noodles and rice



Dessert

• Allowed fruits, sorbet, angel food cake, plain cookies, gelatin
• Desserts with out milk products, Pies or cobblers made with apple, blueberry, cherry or lemon



Beverages

• Tea (made from tea bag), coffee, iced tea(made from tea bag), lemonade, water (within allowed amount of fluids)

Dialysis Vitamins

Hemodialysis removes water soluble vitamins. To stay your healthiest, you should replace these vitamins by taking a renal vitamin supplement. Your doctor will prescribe a vitamin for you. Please take only vitamin and mineral supplements that have been approved by your doctor, nurse or dietitian.

Take your vitamin after hemodialysis on dialysis days and anytime on other days.

A balanced vegetarian diet that includes a variety of plant foods is able to meet the needs for vitamins and minerals, as well. The position of the American Dietetic Association on vegetarian diets states, “appropriately planned vegetarian diets are healthful, nutritionally adequate and provide health benefits in the prevention and treatment of certain diseases.”

Iron, calcium, zinc, vitamin D and B12 should not be a concern for vegetarians on dialysis. The renal vitamin that hemodialysis patients are usually prescribed should contain vitamin B12 and zinc.

Nutritional Supplements

A variety of nutritional supplements are available to provide nutrition when you are unable to eat enough or do not feel like eating. If you are having problems eating, your dietitian can provide information on supplements and recommend the best one for you.

Chhaya Patel, MA, RD, CSR is DaVita Renal / Divisional Dietitian in the San Francisco Bay Area. She is a Certified Specialist in Renal Nutrition, the Area 1 Representative for Renal Practice Group of ADA, and she was Associate Chair and Region V representative for the Council on Renal Nutrition / NKF. Contact information 925-937-0203 or chhaya88@hotmail.com.

Reference

1. Chhaya Patel and Mary Denny, Cultural Foods and Renal Diets: Multilingual Guide for Kidney Disease Patients and Clinical Guide for Dietitians, CRN Northern CA. 1997.

Chapter 5

Eastern Indian Diet: Odia & Bengali Cuisine

Ranjita Misra, PhD, CHES, FMALRC

The dietary habits of people in the Eastern coastal states of Odisha (language spoken is Odia) and West Bengal (language spoken is Bengali) include the consumption of both vegetarian and non- vegetarian food. It is rare to find strict vegetarians in this region since Brahmins of Odisha (previously called Orissa) and Bengal eat fish and meat (mostly chicken and mutton). Cooked with very little or, at times without oil, these two eastern states offer a variety of low-calorie delicacies. There are many similarities yet vast cultural and linguistic diversity exists, which along with the geographic heterogeneity makes the Odia and Bengali cuisine unique. Both regions have their distinctive food habits and cooking styles: Bhaja, Bhapa, Bhuna, Chachchari, Chhenchara, Dalma, Dalna, Dum, Ghanto, Jhol, Pora, and Tarakari. To the casual palate, the Eastern Indian food means rice and fish. Both states share the love for fish and rice due to the long coastline shared by them on the Bay of Bengal. Fish and other sea food such as crab and shrimp are in plenty in this region and so are the recipes. Rice is the staple food in Eastern India. The other characteristic features of coastal cuisines include the use of coconut in many recipes. Unlike other coastal kitchens, however, coconut oil is not commonly used. Instead, the preferred cooking medium is mustard oil or refined vegetable oil (mostly groundnut). Traditionally food was cooked on cowpat (made of dried cowdung), wood or charcoal fires but recent years have seen an emergence of gas, electric, and microwave ovens.

In terms of day-to-day cooking, Eastern Indians don't use many spices. The flavors are usually subtle, foods are delicately spiced unlike the fiery curries typically associated with Indian cuisine. The main seasoning is ‘Panch phutana’ (in Odia) or ‘Panch Phoran’ (in Bengali), which is a mixture of mustard seeds, coriander seeds, methi seeds, black coriander seeds etc. This mix is widely used for tempering vegetables and dhal/lentils, while garam masala, curry power, and turmeric are commonly used for non-vegetarian curries. The other major ingredient is garlic and mustard seeds finely ground together, called as Besara in Odia and Sorsho Bata in Bengali. Odias and Bengalis are rice eaters and along with rice, a typical Odia or Bengali meal has to have a combination of a stir fried or deep-fried vegetable; lentils; a mixed vegetable curry typically cooked with garlic and mustard paste or saag made from various green vegetables such as spinach or fenugreek and seasoned with paanch puoran; and of course, the ubiqitous Maccher Jhol or fish curry.

Odia and Bengali cuisine recognizes and gives a place for the five basic tastes of astringent, bitter, sweet, sour and hot. While the Odia meal does not have a specific course of serving the food items, an authentic Bengali meal does. It begins with bitters, either in the form of shukto (a kind of stew with vegetables, drumsticks or bitter gourd) and moves on in stages through the dhals with fries and fritters, a vegetable dish like a ghonto or chhokka, to the non-vegetarian items of fish or meat. Before ending on a sweet note, there is the occasional treat of astringent or sweet chutney.

Eastern Indian Diet: Odia & Bengali Cuisine

In general, Odia and Bengali meals include one or more of the following.

• Rice, white and parboiled (most commonly used). Rice is the staple food in Odisha and Bengal and is incorporated in many ways. For example puffed rice is used frequently for breakfast and snacks. Pakhala, a popular Odia dish consumed during the summer months, is made of cooked rice, water, and yoghurt.
• Rotis are consumed mostly at dinnertime or during breakfast.
• Dhals and legumes of various kinds. Most common dhals are toor, urad (especially to make cakes and snacks), gram and mung (most frequently used). Dhal is sometimes cooked with vegetables called “dalma.”
• Fish is an integral part of the diet. In fact it is considered auspicious, and no Odia and Bengali function can do without fish. The fish is prepared in innumerable ways – steamed or braised, stewed with greens or other vegetables and with sauces that are mustard based. Fish curry cooked with mustard and garlic paste is very popular. There is a preference for Hilsa fish followed by Bass, Mullet, Rohu and Katla (all are fresh water fishes). The delicious Dahi Macch is prepared with fried fish dipped in gravy made of curd.
• Mutton, chicken, and eggs, along with seafood are also used. The coastline offers an abundant variety of shrimps, lobsters, and crabs that are relished in a variety of cooking styles and often spiced up.
• Consumption of lamb and pork are not very common in Eastern India.
• Vegetables are consumed in different forms: stir-fried, sautéed, bhartha (pureed or minced vegetables), or curried with a paste of garlic, ginger, and onion. Fresh vegetables are often seasoned with light spices (Panch phoran or Panch Phutana). Often vegetables are cooked with fish, mutton, and chicken, especially in the curry form.
• Fruits are consumed fresh, mostly as after dinner desserts. These include watermelon, mango, lichees, apples, oranges, guavas, papayas, and a variety of plantains, and bananas.
• Tea is the most popular drink and is usually served with milk and sugar. Use of coffee is rare in the average households. Other popular drinks include coconut milk (from the young coconut, mostly a popular street-side drink), Lassi, a delicious iced curd drink, and Nimbu paani (lemon squash).
• Ghee is served on top of cooked rice to enhance flavor.
• Water is served with meals. For most traditional meals, people sit down on the floor on a mat and eat with their fingers.
• Coconut – is abundantly available and mostly used in the cooking (curries, dalma, sweets, chutneys) etc.

Sweets

People of Odisha and West Bengal are sweet lovers, and have always been known for their particular weakness for sweets. It is rare to see meals completed without sweets. The choice of sweets for Odia and Bengali meals are unlimited. From the ubiquitous mishti doi and rossogolla, to the rarer pithey and pulli, the choice is boundless. Certain sweets are made on special events. Use of chhana (reduced milk) for making sweets is honed to perfection. Rasgolla and innumerable varieties of sandesh are available today. Besides these the tradition of homemade pitha, and sweets made of rice powder, sweet potato, kheer, coconut and gur is still common.

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Meal Pattern for the Traditional Odia/Bengali Client with Type 2 Diabete

Eastern Indian Diet: Odia & Bengali Cuisine

Some Examples of Healthy and Not so Healthy Foods:

Weekend and Party Planning

Food plays an important role in social gatherings of Oriyas and Bengalis. Festivals and weekends are the time when people indulge in rich and high calorie food, alcoholic beverages, and soft drinks. Plan ahead and adjust your food intake for the whole day to avoid a heavy overload of carbohydrates and fats and protein. Request your host or the Restaurant to prepare 1-2 special or modified dishes for you!

Ranjita Misra, PhD, CHES, FMALRC is a Professor and Research Director, Center for the Study of Health Disparities, at Texas A&M University. She is also a member of the Intercollegiate Faculty of Nutrition at TAMU and a member of the Public Health Committee of AAPI. Contact information (979) 845-8726 or ranjitamisra@gmail.com

References

1. Introductory Nutrition and Nutrition Therapy by Marian Maltese Eschleman. Lippincott Publishers, Philadelphia, 1996.
2. "Bengali Cooking: Seasons and Festivals" by Chitrita Banerji. Published by Inbook.
3. "The Calcutta Cook Book: A Treasury of Recipes from Pavement to Palace" by Minakshie Dasgupta. Penguin Publishers.
4. "A Taste of India" by Madhur Jaffrey. Macmillan Publishing Company, Incorporated.
5. "The Healthy Cuisine of India: Recipes from the Bengal Region" by Bharti Kirchner. Published by Lowell House, Los Angeles.
6. http://hicalcutta.com/sutapa/recipes

Chapter 6

South Indian Cuisine

Nirmala Ramasubramanian, MS, RD, CDE

South Indian cuisine refers to foods from 4 states, namely Tamil Nadu, Karnataka, Andhra Pradhesh and Kerala; also included is Pondichery, which is a union territory. Variations in food practices along with language, culture, heritage and customs are very apparent among the 4 states. There are innumerable area- based specialty foods. For example, Pondichery cuisine is a blend of different cultures, including Tamil Nadu, Kerala and Andhra Pradesh while it also reflects the French influence. However, one may be able to find some common features.

In general, South Indian meals include one or more of the following in varied forms:

• Rice, white or parboiled. Since rice is the staple food of South India it is incorporated in various ways.
• Dhals or legumes of various kinds. Most common dhals are toor, urad, Bengal-gram and mung. The 2 staples, namely rice and different dhals are used in a variety of ways- pounded, ground, fermented, boiled, sautéed and so on. e.g. Idli, Dosa etc.
• Most commonly used animal protein foods are fish, chicken, lamb, mutton and eggs for non- vegetarians
• Vegetables, both green and starchy, are generally stir-fried or roasted to crispness (curry or porial) and/or served wet including dhals and coconut (koottu)
• Fruits are usually consumed fresh or as juices
• Desserts are generally made from reduced milk and white sugar (payasam or kheer), jaggery or brown sugar-based cooked rice and lentils (sweet pongal, appam,adirasam, jilebi), and other sweetmeats, using clarified butter, nuts and spices like cardamom (Kesari, Halwa etc).
• Ghee or clarified butter is served with rice as a flavor enhancer. Sesame, peanut and vegetable oils are generally used in cooking
• Salt served separately on the plate for optional use
• Pickles and pappads (crispy wafers) are often used as side dishes
• Water served with meals
• Hot beverages such as "milky" coffee or tea with sugar
• The most commonly used spices are coriander, asafetida, cumin seeds, fenugreek, ginger, pepper (red, green, and black), turmeric, saffron, cardamom and various combinations of these used as curry powders and dessert enhancers.

Shredded coconut, coconut oil, coconut milk, fried plantain chips and fish are more common in Kerala and Pondicherry, whereas spicier foods are popular in Andhra, including pickles and chutneys. Cereal- lentil preparations using oil or clarified butter are more common in Karnataka and Tamil Nadu.

Acculturation of Indians in America includes the selection of American or other ethnic foods as main meals or snacks especially by younger generation. e.g. Sandwiches, pizza, pasta etc. Additionally foods from other regions of India are commonly used by South Indians, e.g. puris, samosas, chapathis, etc.

South Indian Cuisine

Meal Pattern for the Traditional South Indian Client with Diabetes Type 2

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

South Indian Cuisine

Tips for changes

1. Use brown rice instead of white rice. The increase in fiber content will improve glycemic control. There is a general misconception that diabetics must avoid all rice, which is not necessary. Avoiding excess portions is the key.
2. Instead of using rice as the main staple grain, include a variety of grains such as cracked wheat, oats, barley, quinoa, ragi and other millets.
3. Avoid washing rice several times before cooking or cooking in excess water and draining.
4. Keep in mind that the recommended portions are for cooked products wherever applicable. e.g.1 Serving of dhal= 2 Tbsp of uncooked dhal 1 Serving of rice = 3 Tbsp. of uncooked rice. This is important because the finished product may vary greatly in quantity and consistency!
5. Try to cook with minimum amount of oil. Preferred oils are olive, canola or peanut oils as they are high in monounsaturated oils.
6. While using potato, green plantain or other starchy vegetables, remember to count them as carbohydrates and cut down on rice eaten at the same meal. Smarter thing would be to select green vegetables more often than starchy ones.
7. Use green vegetables more freely and learn to cook them in small amounts of oil. Salads are good with every meal. Simple lemon and vinegar dressings may be freely used.
8. Switch over to fat free, skim or 1% milk instead of whole milk. This will reduce the saturated fat and calorie content of the diet.
9. Avoid fried snack foods as much as possible; learn to cook with recipes requiring dry roasting, baking etc. Remember people with diabetes are more susceptible to high cholesterol in their blood, as well as heart disease.
10. Use lean cuts of animal proteins (meats/poultry) and use appropriate portion sizes. Avoid using more than 3 eggs per week. Egg whites are okay.
11. Vegetarians may increase and improve the quantity and quality of protein by incorporating soy curd (tofu), soy flour, skim milk powder, nut butters and if allowed, egg whites.
12. Pickles, chutneys, pappadums, etc. are very high in sodium. People with hypertension must take note that table salt, baking powder, and baking soda are sources of sodium and therefore must be used carefully.
13. Desserts must be restricted to allowed quantities of fresh fruits. Artificially sweetened low fat desserts or desserts using allowed foods with minimal amount of real sugar may be used with prudence.
14. Drink plenty of water throughout the day, at least 6 to 8 cups a day.
15. Learn to read the nutrition labels on food packages.

Weekend and Party Planning

South Indians are very similar to other immigrants in trying to entertain and relax on the weekends. Food becomes an important part of the social gatherings. Quite often, festivals and holidays are celebrated on the weekends with friends. Pot-luck dinners are very popular. Men may indulge in alcoholic beverages while women generally limit themselves to sodas and juices.

Party meals consist of several varieties of rice, vadas, and bondas as well as fried and creamy vegetables prepared with liberal quantities of oil and coconut, nuts and dry fruits. Fried home made rice/lentil snacks, roasted nuts, potato chips, rice and lentil wafers, and chutneys make the feasts mouth watering and of course calorie-laden! Special desserts of various kinds appropriate to the festival/celebration are also brought in, in addition to cakes and doughnuts to satisfy the palate of the younger generation.

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Party Tips

1. Try to eat a sensible, small snack, like a bowl of soup, before leaving the house, to curb overindulgence.
2. With appetizers, use a small plate, fill it with healthy snacks, and limit the number of fried snacks.
3. Drink seltzer with lime/lemon for a splash of flavor, without the calories of juice, soda or alcohol.
4. When dinner items are served, survey all the offerings first, and envision your plate accordingly: ½ salads and green vegetables, ¼ rice/breads, ¼ chicken, fish or other protein.
5. Take the time to enjoy your food and refrain from going back for seconds.
6. When choosing desserts, be very sensible. Choose fruit.

Hosting the party or festival

1. When hosting, offer fresh, colorful veggies (baby carrots, cucumber strips, bell pepper strips, cauliflower florets) in lieu of,or in addition to fried snacks. Serve the veggies with coriander chutney or a low-fat yogurt-based dip.
2. Try to offer 1 or 2 vegetable dishes, lightly stir- fried or steamed, and a healthy salad. Ensure that your guests have good, healthy options.

Nirmala Ramasubramanian, MS, RD, CDN, CDE has extensive experience in acute care dietetics and clinical research of diabetes. She is presently employed at North Shore University Hospital/Healthcare System in Manhasset, New York. Contact information 718-969-1827 or nirmala1@gmail.com

References

1. India & Pakistani Food Practices, Customs, and Holidays. American Dietetic Association. American Diabetes Association Inc.
2. Chandra Padmanabhan. DAKSHIN: Vegetarian Cuisine from South India, Angus & Robertson Publishers.

Chapter 7

Maharashtrian Cuisine

Keya Deshpande Karwankar, MS

Maharashtrian cuisine boasts of being wholesome, nutritious and intricate. You would find one ingredient like dal could be made in three or four elaborately different ways. The cuisine encompasses a variety of food preparations, from the coconut based coastal cuisine to an interior distinctive cuisine known as Varadi cuisine. Although, all the them share a lot of commonalities:

Grain Group

Examples of one serving size would be: 1 chapati, ½ cup of cooked rice, ½ cup of pohe.

• As in most of the other states of India, rice is the staple food grain in Maharashtra too. A maharashtrian meal cannot be complete without chapati or bhakri (jawar or bajra roti) with toop (clarified butter-ghee).
• Breakfast comprises of preparation like pohe(seasoned beaten rice).
• Desserts or sweets like sheera (sweet semolina), kheer, shankarpaali (made out of refined flour and sugar) are common. And special occasions call for puris (deep fried) or one of the most liked maharashtrian dish called puranpoli (chapati with a lentil and jaggery filling).

Vegetable Group

Example of a serving size would be ½ cup of cooked vegetables and 1 cup of raw vegetables, like spinach.

• There is an enormous variety of vegetables in the regular diet made in both gravy and dry style. Curries like bharlivangi, bharlibhendi are made on special occasions.
• The vegetables are more or less steamed and lightly seasoned so as to retain their nutritional value. Deep frying and roasting is not a common practice. And few of the common dishes are bharit (lightly cooked or raw vegetables in yogurt), paale bhaji (leafy vegetables), paatal bhaji (spinach or fenugreek with lentil and peanuts), zunka (made with gram flour and vegetable).
• Salad or koshimbir is a very important part of every meal. It is made out of a variety of raw vegetables like cucumber, tomatoes, onions, spinach. And this is garnished with coriander and peanut powder, and is lightly seasoned with phodni (hot oil with spices).

Fruits Group

Example of a serving size would be a tennis ball size of apple, a medium banana, ½ cup of aam ras.

• Fruits are consumed both whole and pureed. Aam ras (mango puree) and shikran (banana in milk) are commonly consumed. And in summer pana (raw mango juice) is relished.
• (Pureed ,sweetened fruits carry concentrated calories and adjustments have to be made accordingly to avoid a high sugar load at any one meal).

Milk/Yogurt Group

• Example of a serving size would be 1 cup of milk, ½ cup of yogurt, 1 cup of butter milk.
• Milk is used in the preparation of tea and many of the sweet preparations like kheer.

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

• Yogurt is a very vital ingredient in preparing koshimbir, bhajis (vegetables), chutney (spicy accompaniment made out of a variety of foods) and it is also used to make a famous maharashtrian dessert, shrikhand (Curd whey with sugar).
• Taak (buttermilk) and yogurt is also eaten with rice. Buttermilk is also used to make taaka chi kadi (buttermilk with gram flour).

Meat, Poultry, Fish, Dry beans/Lentils, Eggs and Nuts Group

• An example would be ½ a cup of dal, ½ cup of chicken or mutton curry.
• Dal (Toor dal) or umpti (sweet and sour toor dal) are a must with rice for a maharashtrian. A variety of lentils like masoor, chana, toor, mung are used in the preparation of varan (dal).
• Mooga chi dal (mung dal) , mooga chi usal , vatana chi usal (dried peas) are also the delicacies. Sprouted mung dal is used widely and is prepared in many different ways.
• Peanuts are used in a lot of preparations like chutney, chikki (peanut and jaggery), and it is used as garnish for many of the koshimbiri and bhaji.
• The people in the coastal parts of maharashtra enjoy a variety of fish like bombil (bombay duck), which is batter fried, bangda (mackerel) is curried with red chilles, ginger and tirphal (a spice). Paaplet (pomphret) is usually barbecued or shallow fried.
• Lamb and chicken is mainly consumed in the interior part of maharashtra.
• Foods in this group are excellent sources of proteins, B vitamins, iron and zinc. Lentils/ dals are also a good source of fiber.

Food preparations during upaas (fast)

Fasting time actually turns out like a feast, as maharashtrians prepare numerous dishes garnished with peanuts. Sabudana chi khichadi, sabudana wada (a deep fried snack) bagaar (a type of rice), batata cha khees (grated potato-seasoned) are the hot favorites during fasting.

Jaggery, tamarind and kala masala (is a special blend of spices) is added in most of the vegetables and lentils which makes the foods piquant .

Although maharashtrians usually tend to stick to the traditional cooking style, maharashtrians in America have incorporated a tad of western cooking, making it a nice blend of both.

One Day Menu Plan for a Traditional Maharashtrian Client with Type II Diabetes

Maharashtrian Cuisine

Weekend and Party Planning

Weekends are usually spent with friends and relatives and food becomes a major part of the good times. Presentation of food has a lot of importance for Maharashtrians. Party favorites include a different type of rice preparation like vaangi bhaat (brinjal rice), tondli bhaat (tindora rice). Fried snacks like chewda (made out of beaten rice), chakli (deep fried, made out of gram flour) are often served. Shrikhand (curd whey and sugar), aamrakhand, or kheer are served as desserts.

Keya Deshpande Karwankar, MS is Senior Manager of Operations and Quality at Apollo Health and Lifestyle Limited in Hydrabad India. Contact information keyakarwankar@gmail.com.

Macronutrient calculations were done by Anwar Al- Mansoor, MPH Nutrition candidate, Hunter College, New York. Contact information anwar.almansoor@gmail.com.

Chapter 8

Gujarati Cuisine

Rita Batheja, MS, RD, CDN

Gujarati Cuisine is primarily vegetarian with Jain and Buddhist influences. Gujarat can be divided into 4 regions and due to the different climatic conditions; there are slight variations in eating habits and preparation of food. The four regions are South and North Gujarat, Kathiavad and Kutch. Gujaratis have a sweet tooth and therefore add jiggery and/or sugar to every dish from vegetables to chutneys including dal and pickles. Jains do not eat onion and garlic. Rotli is prepared soft like a petal, Phulkas to a crunchy bone dry texture called Khakhras. Khakhras are used for breakfast or as a snack or while travelling.

South Gujarat

In Surat, vegetable dishes like Undhiyu and Paunkh are very popular. Suratis add green chilies to add life to the food. They love sweets like Nankhatais and Gharis which they buy from local bakeries and shops. No expensive ingredients are used or elaborate preparations are made yet food in its simplicity tastes exotically different.

North Gujarat

Food is non-spicy and oil is used sparingly. It is popular for its traditional Gujarati Thali, which has its origins in this city. It consists of Farsan (appetizer) like Khaman Dhokla and Khandvi (chickpea flour), one variety of Dal or Kadhi (prepared from yogurt), hot fluffy Puri or Rotli, couple of vegetables, sprouted beans, Raita (yogurt), Doodhpak (sweetened milk with saffron and nuts), Papad, Chutney and Pickle.

Kathiawad

Kathiawadis love Dhebras (made from wheat flour, yogurt, spinach, green chilies, sugar and salt) that they eat with Chhunda (sweet, sour and hot mango pickle). They also use Methia Masala (dry powder made from fenugreek seeds, chili powder and salt) to sprinkle on vegetables. They also use red chili powder to make spicy cuisine and eat lot of peanuts and til (sesame seeds) – Peanut Chiki (made with gud) tastes delicious.

Kutch

Kutchi cuisine is very simple. They mainly use rice and pulses. Main dish is Khichdi (mixture of rice and mung dal) and Kadhi (curry made of yogurt) or Bajra no rotlo (made from Millet) with homemade pure ghee (butter) and gud (jaggery), guvarnu shak (vegetable) and Chhash (buttermilk). Kutchhis also eat Dudhi Muthia (made from Snake Squash and flour) and some common dishes like Dhokla (a salty steamed cake), Doodhpak or Shrikhand (sweet made of Whoe Milk Yogurt, Cardamom, Slivered Pistachio/ Almonds, Saffron and Charodi) with hot fluffy puris.

In short, Gujarati Cuisine’s concentration is on fried snacks and the use of plenty of ghee, oil, sugar and jaggery. Many Gujaratis do not eat green vegetables frequently and hardly eat fruits.

Gujarati Cuisine

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Weekend and Party Plannig

Gujaratis love weekend gatherings and partying, which starts from Friday evening till Sunday evening. Mostly men drink few pegs of scotch with snacks such as kachoris, samosas, vegetable cutlets, cashew rolls and varieties of Bhajias. Problems in this area that call for your attention before you go to that party or the restaurant: Remember PORTION CONTROL and move more eat less that makes perfect sense. Plan your day’s meal ahead of time so that importance is given to healthful preparations, the kind and amount of fat used and the importance of avoiding carbohydrate or fat loading.

Party meal consists of

Fried Papad, Puries, Shrikhand (rich sweet made from whole milk yogurt, sugar, Cardamom, Slivered Pistachio/Almond, Saffron and Charodi ) Valor nu shak (pulses or legumes),Undhiyu (mixed vegetables, potato, flour ball – muthias swimming in oil), Vegetable Pulao, Kadhi (made with buttermilk), Raita, Kataki ( cubed mango pickle).

It is recommended that to go easy on appetizers,offer variety of sliced vegetables with Humus (Mediterranean dish) as an example. Humus is made from ground chick peas, sesame paste (Til- high in calcium), green chillies, ginger and lemon (easy recipe – can keep in the refrigerator).

Consider serving Handva, Dhokla and Idli instead of fried items. Example 1” square Dhokla = 1 Rotli,½ cup Pauva = 1 Rotli, got the idea! That is called carbohydrate counting. Dairy, vegetables, fruit and food from the grains group all contain carbohydrate. Consumers with Diabetes need to learn about serving sizes.

Modified Party Meal

• ½ cup lettuce and tomato salad
• 1 teaspoon fat free salad dressing (Walden farm brand tastes good)
• 1 3” Puri
• ⅓ cup Undhiyu
• ¼ cup Kadhi
• ¼ cup Vegetable Pulao
• 1 small oven baked Samosa
• 1 oz. Shrikhand
• ¼ cup fresh fruit salad

Gujarati Cuisine

Rita (Shah) Batheja, MS RD CDN is an Internationally Renowned Registered Dietitian and Integrative Nutritionist in Private Practice in Long Island, New York and the Founder of the Indian American Dietetic Association. Contact information 516-868-0605 or krbat1@juno.com.

Macronutrient calculations were done by Anwar Al- Mansoor, MPH Nutrition candidate, Hunter College,New York. Contact information anwar.almansoor@gmail.com.

References

1. Ethnic and Regional Food practices, a series Indian and Pakistani food practices, customs and Holidays, 2^nd edition – American Dietetic Association. American Diabetes Association,Inc.
2. Little India, December 1996 Vol. No. 12 “Affairs of the Heart – Health Watch.
3. Practical Management of Diabetes – 2^nd edition.Sharad Pendsey, MD – Diabetes Clinic and Research Center, Nagpur, India.

Chapter 9

North Indian Cuisine

Madhu Gadia, MS, RD, CDE

North Indian cuisine typically represents foods of Punjab, Haryana, Delhi, Jammu and Kashmir, Himachal Pradesh, Uttar Pradesh, Uttarakhand, Rajasthan, Bihar, Jharkhand, Chhattisgarh, and Madhya Pradesh. Basically, all the states north and west of Maharashtra are often clumped together in this generalization. Each state has its own specialties but it is the similarities that classify the food of this region. North Indian food is often called “Punjabi food”. North Indian food is the most popular food in restaurants and therefore it is synonymous with Indian food throughout the world.

Wheat is the staple food of this region. “Basmati” rice is grown in the northern plains and is often the rice of choice for pulaos and biryanis. Variety of dals or beans such as garbanzo, kidney, urad as well as moong and toor dal are used. Milk, butter and ghee are used extensively. Chicken and mutton are the most popular meats eaten in this region. Most of the cooking is done on the stovetop using the roasting and frying method.

Punjabis and refugees from West Punjab (which is now in Pakistan), came and settled in Punjab and Delhi. They were very enterprising people and had a style and food of their own. They popularized tandoori food (that gets its name from the tandoor clay oven in which the food is cooked) in this region. Punjabis opened restaurants at every corner and thus tandoori food was born. They developed a ‘formula’ that worked and Punjabi food became very popular. Today most Indian restaurants around the world serve tandoori dishes and typically Punjabi food.

North Indian food is a combination of simple to very elegant vegetarian and non-vegetarian fare. A simple vegetarian meal may consist of moong dal, subji and phulka (thin whole wheat roti). The food is seasoned with asafoetida, cumin, turmeric, coriander powder and garam masala. The garam masala is often referred to as a north Indian spice blend. Onion and garlic may or may not be used. Then there are the non-vegetarian favorites like chicken and lamb dishes heavily seasoned with spices, onion, ginger and garlic. Foods like stuffed paratha, saag and makki-ki-roti (corn roti), chole and bhature, kofta, rogan josh, tandoori chicken, biryanies and pulao are very popular in this cuisine. Variety of desserts such as barfi, laddu, and gulab jamun are extremely popular in this region.

North Indian food is often described as “rich”. The food is often fried, and a fair amount of ghee, butter and nuts may be is used. The food is seasoned heavily with onion, ginger, garlic and spices like cardamom, cinnamon and cloves that give the food a “rich” color and flavor.

Nutritionally speaking, north Indian meals with plenty of whole grains, green leafy vegetables, and beans are high in complex carbohydrates, fiber, vitamins and minerals. The overall fat and saturated fat content of traditional meals may be high due to extensive use of milk, butter, ghee and oil. The meal can be easily modified in overall fat content by using small amount of unsaturated oil to season the food. In order to reduce saturated fat, substitute low fat or fat free milk wherever possible and use butter and ghee sparingly.

North Indian Cuisine

North Indian food can be easily incorporated into a healthy lifestyle. If you have diabetes, it is important to watch the carbohydrate content of each meal. Plan balanced meals of roti, dal, meat (if non- vegetarian) non-starchy vegetables and salad. A typical ‘thaali’ meal (pre-portioned out foods in small cups served on a large plate or ‘thaali’) with balance of nutrients, flavors and textures may work well with diabetes and a healthy diet. The amount of carbohydrate in each meal should be individualized. Portion size of foods is important to determine the actual carbohydrate intake. Remember within reason most foods can fit into a diet for a person managing his/her diabetes. See sample menu below.

Sample Menu

A sample menu of a typical vegetarian (and non- vegetarian meal) and a modified meal plan is given below. A typical meal as mentioned earlier is high in carbohydrate and fat. By some modification in the amount of oil and ghee used, substituting low fat and low

carbohydrate vegetables as well as cutting down on portions will help in cutting down in carbohydrate and fat content and therefore the total calorie intake. The recommendations for a well-balanced meal plan are carbohydrate 50 to 70 percent, protein 10 to 20 percent, and fat 30 to 35 percent. Consult a dietitian for an individualized meal plan.

Table below identifies foods to eat often and foods to eat less frequently

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Menu Plan for a Traditional North Indian with Type II Diabetes

Weekends and Parties

There is often a distinct difference in our eating between weekdays and weekends. Weekdays we are bound by time and schedules and it is easier to control the types and amounts of foods we eat. People will often say they do so well Monday to Friday implying that they make good choices in their meal selection. But come weekends (starting Friday night) we lose all restraints in our food selection. Indians love to party, as it is our way of socializing and connecting with our culture. Socializing is associated with special occasion foods of puri, chole, pakore, and not to mention kheer and halwa (generally high-fat foods). Portion control is a good tool to use here. If you are the host, plan your parties to balance meals and incorporate some lower fat foods like vegetable trays as appetizers and use less fat in your dishes. If you are the guest at a party and everything you see is high in fat and calories watch your portion sizes, enjoy the company and thank the hosts for a wonderful evening. You will be much happier on Monday morning!

North Indian Cuisine

Madhu Gadia, MS, RD, CDE (Registered Dietitian and a Certified Diabetes Educator) is an author of New Indian Home Cooking (Penguin Group 2000) and The Indian Vegan Kitchen (Penguin Group 2009). She is a Wellness Director for Compass Group and teaches the art of Indian cooking around the country. Contact information www.cuisineofindia.com.

References

1. Exchange Lists for Meal Planning, American Dietetic Association, 1995.
2. The Indian Vegan Kitchen: More Than 150 Quick and Healthy Homestyle Recipes; Madhu Gadia, M.S., R.D., 2009.
3. New Indian Home Cooking: More than 100 delicious, nutritional and easy low fat recipes!; Madhu Gadia, M.S, R.D., 2000.

Chapter 10

Nepali Cuisine

Suraj Mathema, MS, RD, CDE

Many people of Nepalese origin following Nepali dietary practices live in India. Nepali cuisine, in part, has been influenced by cooking practices in North India and Tibet. But, there are many typical indegenous dishes such as gundruk, lapsi achar, qua gasa (Newari dish), sukti etc. Also, the sub-ethnic groups have their own variations of dishes.

In general, Nepali meals include one or more of the following in varied forms:

• Rice is most popular in grains, then wheat. Maize is not as popular as rice and wheat. Even less popular are millet, barley and buckwheat
• Dals or legumes of various kinds. Most common dals are toor, urad, gram and mung. The two staples, namely rice and different dals are used in a variety of ways such as pounded, ground, boiled, sautéed and so on.
• Most commonly used animal protein foods are, chicken, goat, water buffalo and eggs for non- vegetarians
• Green vegetables are stir-fried, while most other vegetables are seasoned with light spices and prepared in curry form.
• Fruits are usually consumed fresh or as juices.Lapsi is typically eaten as achar.
• Commonly consumed sweets are: Kheer, Gulaab Jaamun, Halwa, Mahi (by product of milk after the butter had been churned out, often sweetened before consumption), Rasogolla, Rasmalai, Laddoos etc.
• Hot tea is most popular drink for all seasons. It is served with milk and sugar.
• Ghee or clarified butter is often served with rice as flavor enhancer. Mustard oil is mostly used for cooking.
• Water served with meals
• The most commonly used spices are coriander, cumin, ginger, turmeric. And others used in typical dishes are timur (szechwan pepper – used in aloo achar, qwa gasa etc.), jimbu ( used in urad dal)

Heart Healthy Meal Pattern for the Traditional Nepali Client

Nepali Cuisine

Many Nepalese following traditional meal time eat Lunch at about 9:00 AM and snack at 1:00 PM ₂ Rice refers to cooked rice wherever mentioned in this article

Tips for changes

1. Encourage brown rice instead of white rice.
2. Instead of using only rice, select from a variety of grains, such as cracked wheat, oats, and barley.
3. Avoid washing rice several times before cooking or cooking in excess water and draining. Doing this may lose valuable vitamins and enriched iron.
4. Keep in mind that the recommended portions are for the cooked product where applicable
5. Try to cook with minimum amount of oil, preferably olive oil or canola oil which are high in monounsaturated fats.
6. While using potato, or other starchy vegetables, remember to propotionately cut down on the amount of rice eaten. Smarter thing to do is selecting a green vegetable more often than starchy ones.

Indian Foods: AAPI's Guide to Nutrition, Health and Diabetes

Some examples of Heart-healthy and Not So Heart-healthy foods:

7. Use green vegetables more freely and learn to cook them in a small amount of oil. Salads are good with any meal. Simple lemon or vinegar dressings may be freely used.

8. Switch over to skim or 1% low fat milk instead of whole milk. This will reduce the saturated fat content in the diet.

9. Avoid frying of snack foods; learn to look for recipes, requiring dry roasting, baking etc. Remember people with diabetes are more susceptible to high cholesterol in their blood and heart disease. Practice low fat cooking methods, using non-stick pans.

10.Use only lean cuts of animal proteins and practice correct portion sizes. Avoid using more than 3 whole eggs/week. Egg whites are okay.

11.Pickles, chutneys etc are very high in sodium. People with hypertension must take note that table salt, baking powder, and baking soda are sources of sodium and therefore must be used carefully.

12.Desserts should be restricted to fresh fruits; artificially sweetened low fat desserts made from allowed foods may be used occasionally.

13.Drink plenty of water, at least 6 to 8 cups a day.

Weekend and Party Planning

Food plays a major role during the weekends and the social gatherings. Nepalese tend to live in an extended family environment. As a result, members of the family constantly get in and out of the house at different times. Thus, food is constantly being prepared to ensure that nobody remains hungry including the guest that come unannounced, which is a common event. Most Nepalese prefer to eat home cooked meals. It is quite common for family members and guests to consume high caloric foods. High caloric fried snacks and desserts are commonly offered to guests. Refer to the Summary section on how to eat healthy.

Suraj Mathema, MS, RD, CDN, MBA is a Registered and Certified Dietitian who has worked as Dietitian with geriatric and developmentally disabled population for more than sixteen years. He is currently working in New York City as a Consultant Dietitian for Nutrition Consulting Services. Contact information smathema1@yahoo.com

References

1. The Nepal Cook Book, Association of Nepalis in The Americas 1996
2. Cooking in Nepal, Ratna Pustak Bhandar (1982)
3. Creative Nepali Cooking with Tulsi Regmi, Tulsi Regmi.

Chapter 11

Low Fat Cooking & How to Modify a Recipe

Nimesh Bhargava, MS, RD, CNSD, MBA

Diet related diseases like heart disease, obesity, cancer and diabetes greatly affect the quality of life. The need to manage these diseases with proper diet and a growing health-consciousness has brought awareness in people to explore new ways of cooking and eating. There are many sources to draw from including low-fat cookbooks and the latest sources are the numerous websites that offer low-fat recipes.

It is important to remember that while fats, ‘ghee’ or oils bring richness and taste to the food, they also contain twice the amount of calories as compared to carbohydrate or protein. Besides being a concentrated source of calories they are readily converted and stored as body fat. The type of fats and oils as well as amounts used will determine if a recipe is heart-healthy or not. Most of your favorite recipes can be easily changed to lower the fat, salt, and sugar content and increase fiber. This section of the book is devoted to tips on making your favorite recipes healthier.

Making your favorite recipes healthier

With a little practice, you can turn any favorite recipe into a healthy dish.

Always ask yourself – “Can I reduce the amount of salt and ghee / oil?”

Always use a measuring cup or a measuring spoon. Never pour from a container or guess the amount of salt and oil. You may know the amount of oil or salt to be added in the recipe. With time the serving size increases if you do not measure the ingredients.

• Fats like ghee, butter, oil or even margarine can be cut by half to two thirds the amount in the recipes. Try cutting the amount by small amounts first then gradually increasing to half to two thirds the amount. To replace the loss of taste when ghee or oil is reduced, consider adding alternatives such as vegetable broth, vegetables, fruit juices, herbs, spices, skim milk or skim milk powder.
• Change the cooking recipe: Instead of frying, bake, boil, broil or steam the food item. This will significantly reduce the amount of fat you consume.
• Use nonstick cooking pots and pans. Coating baking pans with vegetable cooking spray rather than using ghee or oil.
• Sauté foods in water, wine, or fruit juice rather than oil or ghee.
• Removing or cutting down oils from curry, dal, sambar or rasam. If the recipe was cooked with too much oil, cool it after cooking. Then skim the excess fat with a tea spoon to remove e the oil from the surface.

Use a plastic degreaser constructed like a pitcher with a spout that allows the liquid to be poured from the bottom instead of the top.

• Trimming fat from poultry, beef or pork: Remove the skin of the chicken or turkey. Trim visible fat from beef or pork before cooking.



LowFat Cooking & How to Modify a Recipe

• Reduce the amount of salt by adding spices and herbs. Below is the list of spices that goes well with Meat, Vegetables and Fruits:

Vegetables:              Add lemon, ginger, vinegar, dry mango powder, anardana, black pepper, corriander dry or green leaves, sesame seeds, fennel seeds, basil, oregano, onion, garlic, turmeric, tamarind and tarragon

Fruits:                       Cinnamon, cloves, cardamom, vanilla, or mint

Fish, Poultry, Meat: Bay leaf, chives, dry mustard, lemon, garlic, onion sage, or basil

• Increase fiber by cooking brown rice instead of white rice, use whole wheat bread instead of white bread, do not sieve the flour before making the flat bread or “rotti” and leave skins on fruits or vegetables.

The following table shows how you can substitute ingredients to make your recipe healthier:

Guide to Ingredients

Anise  seed              :    Ajwain or Carum

Asfoetida                  :    Hing

Aborigine                 :    Begun or baingan (eggplant)

Chapatti  flour         :    Atta

Bay  leaf                  :    Tej patta

Bitter  gourd            :    Karela

Black   pepper          :    Kali mirch

Cardamom                :    Elaichi

Red  chilies              :    Lal Mirch

Cinnamon                 :    Dalchini

Cloves                      :    Lavang

Coconut                    :    Nariyal 

Coriander   seeds      :    Dhaniya 

Cumin                       :    Jeera

Curry  leaves            :    Kari patta

Fennel                      :    Saunf

Fenugreek                :    Methi

Garlic                       :    Lahsun

Ginger                      :    Adrak

Gram   flour             :    Besan or chickpea flour

Jaggery                     :    Gur

Mace                        :    Javitri

Mango  powder       :    Amchoor 

Mint                         :   Hara pudeena

Mustard                    :   Sarson or Rai

Nutmeg                     :    Jaiphal

Onion   Seeds           :    Kalonji 

Oregano   seeds       :     Ajwain

Parsley                     :    Ajmood ka patta

Paneer                      :    Indian cheese 

Pomegranate seeds  :    Anardana

Poppy   seeds           :    Khus khus or posta dana

Raisin                       :    Kismish

Red  lentils               :    Masoor dal

Saffron                     :    Kesar

Sesame  seeds          :    Til

Tamarind                  :    Imli

Toor   Dhal              :    Yellow split lentils

Turmeric                   :    Haldi

Vinegar                     :    Sirka 

Yellow split peas       :   Channa dal 

Yogurt                       :    Dahi

Sambar (Serves 4) (Original recipe)

• ½ c red lentils
• 1 tablespoon vegetable oil
• 1 tsp mustard seeds
• ½ tsp asafetida
• ½ tsp fenugreek seeds
• ½ tsp cumin seeds
• 1 dried red chili halved
• 2-3 curry leaves
• 2 green chili
• 1 cup mixed vegetables cut small pieces (onion, potato, radish, eggplant, zucchini, green bell pepper)
• 2 tbsp tamarind juice
• 1 cup water
• 1 tbsp sambar powder
• 1 tbsp chopped fresh coriander

Cook the lentils in boiling water for about 1 hour until tender then drain and set aside. Heat the oil and fry the mustard seeds, asafetida, fenugreek, and cumin seeds, red and green chili and curry leaves until the mustard seeds start crackling. Add the green chilies and vegetables and fry for 2 minutes. Add the tamarind juice, water, sambar powder, turmeric and salt, cover and simmer over a low heat until the vegetables are tender. Stir in the cooked lentils and simmer for 5 minutes. If the sambar needs to be thickened, blend the rice flour with the water, stir it into the pan and simmer for a few minutes. Garnish with coriander and serve hot with rice.

LowFat Cooking & How to Modify a Recipe

Sambar (Modified recipe)

• ½ c red lentils
• 1tsp mustard seeds
• ½ tsp asafetida
• ½ tsp fenugreek seeds
• ½ tsp cumin seeds
• 1 dried red chili halved
• 2-3 curry leaves
• 2 green chili
• 1 cup mixed vegetables cut small pieces (onion, potato, radish, Aborigine, zucchini, green bell pepper)
• 2tbsp tamarind juice
• 1 ½ cup water
• 1tbsp sambar powder
• 1 tbsp chopped fresh coriander