Addressing Diabetes and Regulating the Food and Beverage Industry: Misplaced Stigmatization of Rice

Culture is integral to how we live our everyday lives, how we experience health and illness, and how we negotiate our health seeking behaviors. Cultural context is a salient aspect of our everyday experiences of health, giving meaning to our negotiations of health.

Yet, culture is often either neglected in health promotion efforts emanating from the West or deeply ingrained in Western values. Even more problematically, these Western-based ideologies of health promotion often work to precisely turn culture as a barrier to healthy behavior, instead working to change cultures elsewhere based on Western scripts, values, and concepts.

Culture thus emerges in health promotion efforts as backward and as the object of Western-style health promotion campaigns, using the narrative of health thus to disseminate Western-style values of health. What we have as a result often in the name of health promotion is a Western hegemony of health, pushing behaviors that are deeply Western, dressing these behaviors up in the name of science, and thus strategically obfuscating the Western cultural values underlying the proposed behavior.

Paradoxically, as I have noted in my work over the last fifteen years, the Western behaviors being promoted as healthy are often fundamentally unhealthy, and in other instances, are deeply embedded in value-driven notions of what is health. Nations such as the US and the UK are deeply problematic in terms of their unhealthy lifestyles and behaviors, thus witnessing the epidemics of diabetes and heart disease.

The role of culture in health is salient when considering diabetes, its prevention and treatment. Diabetes as a lifestyle disease, is a disease of globalization, the global movement of the unhealthy lifestyles of the West that have been projected as symbols of prosperity and upward mobility. Consider for instance, the global diffusion of the Pepsi and Coca Cola lifestyle that is attached to youth and symbols of upward mobility and modernity (unfortunately equated with Westernization).

It is another example of a paradox then when Western-imported knowledge claims are offered as solutions to a health problem that is in many ways a product of the "ways of the West."

Given the recent emphasis on addressing the diabetes epidemic in Singapore, it’s worthwhile to consider the cultural context of diabetes and the way in which culture may be taken into account in addressing the risks of diabetes as well as in developing potential solutions.

A nuanced understanding of culture and cultural context is however missing from most top-down health communication efforts that fail to take into account the lived experiences of people. In these interventions, culture is often treated as a barrier that needs to be transformed in order to diffuse the health solution.

Culture gets in the way and should be changed so that the health behavior can be disseminated among the target audience.

Consider for instance the recent coverage of diabetes prevention that has appeared in the mainstream media in Singapore. The "War on Diabetes" takes on rice, an unfortunate example of turning local cultural  practices into pathology and uncritically circulating Western knowledge claims. The targeting of rice by the Health Promotion Board's recent diabetes campaign apparently is based on meta-analyses published by the Harvard School of Public Health. An introduction to the campaign makes the following reference to the studies:

"A meta- analysis of four major studies, involving more than 350,000 people followed for four to 20 years, by the Harvard School of Public Health - published in the British Medical Journal - threw up some sobering findings. One, it showed each plate of white rice eaten in a day - on a regular basis - raises the risk of diabetes by 11 per cent in the overall population."

The reference to the study is not available in the references to it, and the study therefore is not accessible for analysis to the lay public. When I started looking for the study through targeted literature searches based on the description, I came across the following study published by Hu et al. (2012) in the British Medical Journal (BMJ) (this is probably the study the HPB is referring to but it is difficult to be certain given the lack of citation).

When the Hu et al. study was published, it came under criticism for its methodological drawbacks and a debate ensued in the May 2012 issue of the BMJ. These articles, published by Naqvi et al. (2012), Hu et al. (2012), and Kadoch (2012). Unfortunately, this debate is inaccessible to the public because it is located behind a firewall.

The Naqvi et al. article questioned the methodology adopted by the Hu et al. (2012) study, noting the limitations of self-reported measures of diabetes used in the study. In their response, Hu et al. (2012) acknowledged the unrepresentativeness of the study participants in comparison to the general population in those countries, thus limiting the generalisability of the findings.

In his response to the BMJ article, noted Dr. Michael Kadoch (2012, p. 28) of the Mount Sinai Medical Center: 

"White rice has been the staple of the Asian diet for thousands of years. For most ofthat time it produced some of the most slender people in history. Western diseases such as diabetes and coronary artery disease were almost unheard of in this region. Only after the comparatively recent adoption of high fat Western dietary habits, focused primarily on animal products and highly processed junk foods, have these illnesses become more prevalent in Asia."

Acknowledging the presence of White rice in the Asian diet for thousands of years, Dr. Kadoch draws attention to the rise in diabetes in Asia corresponding with the globalization of Western lifestyles to Asia more recently, accompanied by the rise of high fat Western dietary practices focused on junk food and animal products. Certainly as an anchor to the debate on lifestyles and diabetes, he draws attention to the unhealthy effects of the global diffusion of Western-style lifestyles.

He then goes on to note:

"Diets centred on white rice have, in fact, produced some of the most dramatic health benefits reported in the medical literature. The rice diet, as pioneered by Walter Kempner, has repeatedly been shown to drastically reduce hypertension, insulin resistance, and obesity. Low fat diets emphasising starch have reversed diabetes and coronary artery disease. These remarkable studies were all inspired by the traditional Asian cuisine. Encouraging patients to choose intact whole grains such as brown rice is certainly warranted. However, to rescue the Asian population from a mounting epidemic of chronic lifestyle diseases, most effort should be focused on removing the cause- the toxic Western diet. This may even justify promoting a return to white rice, instead of condemning it outright."

Note in the article the acknowledgment of traditional Asian cultural practices such as the practice of eating white rice as a potential solution to Western-induced lifestyle diseases. This debate in the pages of the BMJ draw attention to the questions that remain about the viability of the simplistic claim "White rice causes diabetes." Moreover, the debate attends to the important role of culture and cultural practices within the broader context of health outcomes. 

Let's then situate this debate in the backdrop of the Health Promotion Board's "War on Diabetes."

The lead Straits Times story on Diabetes prevention that appeared online on May 6, 2016 sought to hit home the point that Singaporeans needed to reduce their intake of rice. The story compared rice with sugary drinks, noting that eating a bowl of rice is equivalent to eating two cans of sugary sweet drinks.

The brief story description on FB summarized: “ICYMI: Starchy white rice can overload Asian bodies with blood sugar and heighten their risk of diabetes. It is even more potent than sweet soda drinks in causing the disease.”

The juxtaposition, while may be accurate when comparing carbohydrate content, does not take into account the everyday lived experiences of Southeast Asians with rice and the history of eating rice across various parts of Asia. Rice has long been a part of Southeast Asian cultures, a staple to most meals. 

Southeast Asian countries such as Thailand have comparatively lower diabetes prevalence rate and yet are mostly rice-consuming.

In Singapore, rice is a part of everyday culture, integrated into the ways of life of Indian, Malay, Chinese communities. In each of these cultural contexts however, rice is never eaten by itself. It goes along with some combination of vegetables, fish, meat etc.to make up what would be considered a balanced Asian meal.

It’s not just about eating the rice but also about how it is eaten and what is the portion of the meal. It is also about understanding the local cultural context, its nuances, and the lived experiences of everyday food habits.

In response to the ST Facebook post, one commenter noted “How to shiam rice in our Asian diet? We are fed rice the day we started to eat solids as a baby. If you go to angmo countries, you still yearn for rice for your meals. There is really no substitute for rice.”

One solution proposed in the story is adding brown rice to the mix. This suggestion, while worthwhile, also needs to take into account the cultural meaning of brown rice, the taste and texture of brown rice in the context of the entire meal, and the cost of brown rice compared to white rice. In the comments section of the Straits Times Facebook story, each of these aspects have been raised by community members. 

To consider culture is to make room for voices of community members in developing solutions that would be meaningful to them and their lived experiences. A culture-centered approach to addressing diabetes in Singapore would begin with understanding local cultural practices of eating and living, cultural understandings of diabetes, and developing culturally situated solutions through partnerships with everyday Singaporeans. Such an approach would celebrate local cultural practices as positive entry points toward developing solutions to health and well being.

Moreover the message foregrounding sugary sweet drinks as the benchmark for rice underplays the health effects of sugary sweet drinks as well as the prevalence of sugary sweet drinks such as “Coca Cola” and “Pepsi” in increasingly Westernized Asian lifestyles. Contrary to how the message might be interpreted as underplaying the role of sugary sweet drinks in diabetes, sugary sweet drinks and other processed foods are indeed key risk factors in the context of diabetes.

The health effects of sugary sweet drinks and processed foods on children and adolescents needs serious consideration. This is especially the case given the large proportion of advertising of sugary sweet and processed foods that is carried on online and offline media targeting children and youth. Policies need to carefully look at ways to regulate the food and beverage industry, particularly its targeting of children and youth through advertising and promotion. Policies might similarly look at raising the taxes on unhealthy foods such as sugary sweet drinks and snacks. Certainly, these are some of the approaches being adopted closer home in Asia.

Unfortunately, the comparison of white rice to diabetes framed in a message "The health authorities have identified one of their top concerns as they wage war on diabetes: white rice. It is even more potent than sweet soda drinks in causing the disease" can be misleading for parents. It might lead them to underestimate the poor health effects of sugary sweet drinks, especially when parents might not even be aware of the negative health effects of sugary sweet drinks to  begin with.

Similarly, the role of processed foods in the context of diabetes need to be carefully examined, simultaneously developing appropriate regulatory tools for processed food advertising and marketing.

Addressing diabetes, just as addressing any other health risk, calls for a deeper understanding of cultural complexities. Bringing community members to dialogues in developing participatory solutions, and understanding their everyday lived experiences are integral to the solutions that are developed. 

Finally, addressing the structural contexts of poor health and developing appropriate regulatory measures targeting the Food and Beverage industry is an important policy component.

In sum, a starting point in addressing diabetes in  Singapore ought to engage the local cultural practices, look at culture as a positive resource, understand the local cultural context, and make available the evidence on the basis of which claims are made for public engagement. Through these open dialogues on evidence that engage local communities and develop culturally meaningful solutions, Singapore's addressing of diabetes can emerge as a global exemplar.

Prof. Mohan J Dutta is Provost’s Chair Professor of Communication at the National University of Singapore, where he specializes on health communication and culture. He sits on the Advisory Board of WHO Europe’s “Cultural Contexts of Health Expert Advisory Group.”