Maltese eating more carbs, less fibre 30 years on from diabetes study

Diabetes patients are not changing their bad habits, doctors say in obesity study that shows little may have changed since WHO study in 1983

Malta was confirmed as the most obese nation in the European Union in 2016
Malta was confirmed as the most obese nation in the European Union in 2016

Diabetics in Malta appear not to be changing their lifestyle habits once they are given their diagnosis, according to a study carried out by doctors who compared the results to a 1983 study by the World Health Organisation.

35 years on, the results shows sufferers of Type 2 diabetes are eating more carbohydrates, less fat and fibre – a sign that the Maltese don’t heed medical advice very well.

With its location at the centre of the Mediterranean, much is said of what the traditional diet in Malta should be: a protein-rich diet of fish, nuts and olives, culled from the sun-drenched soil and the abundance of the sea.

And then there is the reality. Amongst Malta’s population of 420,000 the prevalence of diabetes is 9.9%. Of this population, one in four (26.6%) is obese, a problem which according to an estimate confirmed by health minister Chris Fearne in parliament, costs the nation some €44 million.

Malta was confirmed as the most obese nation in the European Union in 2016, outweighing second-placed Latvia by almost five points (21.3 per cent), and then Hungary (21.2 per cent), Estonia (20.4 per cent) and the UK (20.1 per cent), according to a European Health Interview survey (EHIS).

Behind the harrowing data, is a culture that seems to have withstood the better advice of doctors and nutritional scientists who prescribe more physical activity and higher intake of fruit and veg. According to the EHIS, 74% of the respondents consumed fruit at least once a day and 51% consumed vegetables at least once a day.

Little if anything, seems to have changed from a national 1983 study on diabetes commissioned by the World Health Organisation. A study by the universities of Malta and Roehampton, UK, conducted amongst 166 patients at Mater Dei – of whom 75 were diabetics – found a prevalence of obesity amongst sufferers (49%) compared to 22% of non-sufferers, and higher intakes of carbohydrates when compared with the 1983 study.

Carbohydrates are now replacing the extra fat that the Maltese used to ingest at the time. Paradoxically the amount of simple sugars has decreased
Carbohydrates are now replacing the extra fat that the Maltese used to ingest at the time. Paradoxically the amount of simple sugars has decreased

Better off when we had less

Much has changed over the centuries as standards of living in Malta picked up. Before the nineteenth century, the Maltese had a lower standard of living. By the account of historian Victor Mallia Milanes, the island’s diet consisted of ‘barley bread, cheese, olives, garlic, dried fruit, salt-fish, oil and similar foods’. The Maltese ate in abundance whatever was in season and ‘drank moderate amounts of wine’. 

The general improvement in standards of living brought a change in diet: more bread, pasta and meat, which previously were almost non-existent. Today that diet includes more red meat, fried foods, refined sugars, fats and carbohydrates. 

In the 1983 study, the WHO found that the Maltese tended to have just one main meal and minor snacks during the day.

But over the following 30 years, the use of the private car increased heavily and physical activity levels failed to pick up. 

In the new study, the doctors said one in two diabetics were obese, compared to one in five among non-diabetics. Behind these figures, is a dietary intake rich in bread and pasta, and not enough fish and vegetables.

Compared to the 1983 study, protein intake among the Maltese has remained similar (around 16% among men and women), while fat intake has decreased, down to 33% from some 45%, but carbohydrate intake has increased from some 40% to 44%. And there is a major decrease in dietary fibre intake: an average daily 18g today compared to 28g in 1983.

The 1983 study had commented on the extremely high fat intake in the population. Those levels have markedly decreased in males but more exponentially in females, today. Dietary cholesterol was also much higher, probably reflecting a change in lifestyle habits that shows the Maltese are ingesting less saturated animal fats than they used to.

But total carb intake has increased considerably compared to the 1980s. “Possibly this has happened because carbohydrates are replacing the extra fat the Maltese used to ingest at the time. Paradoxically the amount of simple sugars decreased when compared to the 1983 data. This means that carbohydrate intake today is mostly made up of complex carbohydrates as opposed to 20 years ago. Even though the types of food have not been looked into specifically, from simple observation we believe the most popular forms of carbohydrate now eaten in Malta are bread and pasta,” the authors of the study, Ruth Caruana and Michael Patterson, said.

There was also a major decrease in dietary fibre intake for both males and females in the current cohort as compared to the 1983 study. “As previously mentioned this may show that the Maltese are eating less fruit and vegetables. There is a concomitant increase in carbohydrate intake and this suggests that fibre rich foods are being replaced by carbohydrates.”

More worryingly, they say Maltese sufferers are not keen on changing their habits.

“Diabetics appear not to be changing their diets once they are given their diagnosis,” the doctors said. “Education is needed regarding all aspects of a healthy lifestyle including dietary advice. Lifestyle changes need to become a priority to achieve better outcomes and hence quality of life.”

“Patients are not changing their diets after being given the diagnosis of T2DM [type 2 diabetes]. There seems to be a general difficulty in changing lifestyle habits when it comes to increasing exercise and eating healthier foods. Since these lifestyle habits are dependent on complex factors like socioeconomic status and attitudes determined by culture they are very difficult to change,” Caruana and Patterson, say.

“It would be easier to instil healthier attitudes among children who will hopefully grow up to be healthier adults.”

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