Diabetes: Pakistan’s Silent Epidemic—Can the Order You Eat Make a Difference?

Clinical Professor of Medicine, George Washington University

Interventional Cardiologist practicing in the United States and Dubai at Zulekha Hospital

Email: [email protected]

Founder, The Fayaz Shawl Philanthropic Foundation

Pakistan now has the highest rate of diabetes in the world. The International Diabetes Federation (IDF) estimates that 34.5 million Pakistani adults were living with diabetes in 2024, an age-adjusted prevalence of 31.4 per cent, or close to one adult in three. Only three countries have more adults with diabetes. About 9.3 million of those affected, more than one in four, have not been diagnosed, and more than 10 million other adults have impaired fasting glucose, a stage that often comes before diabetes. Without stronger prevention, the IDF projects that the number of adults with diabetes in Pakistan will double to about 70 million by 2050. Each of these people is at risk of heart attack, stroke, kidney failure, vision loss, nerve damage and amputation. Food is one place where every family can begin to act.

For many Pakistani families, a meal brings together roti or rice, daal, sabzi, salan, dahi and dishes shared across generations. Advice about diabetes should make room for these familiar foods. The aim is to help people enjoy them in portions and combinations that support better health.

What we eat and how much we eat remain central to diabetes care. The order in which we eat may also help. A practical meal sequence is to begin with vegetables, either alone or with a modest serving of plain dahi or raita, then eat protein foods such as chicken, fish, eggs, lean meat, daal or chana, and finish with a modest portion of roti or rice at the end of the meal. Do not eat the roti or rice first.

Why the order may help

During digestion, starch in roti, naan and rice is broken down into glucose. In diabetes, the body has difficulty keeping this glucose within a healthy range. A large portion of carbohydrate can therefore produce a substantial rise in blood sugar.

Small clinical studies have found that eating vegetables and protein before carbohydrate can reduce the immediate rise in blood glucose in people with type 2 diabetes. This is a useful additional strategy, but the evidence is stronger for short-term meal responses than for lasting improvements in diabetes or prevention of its complications.

Foods interact during digestion. Fiber, protein and fat can influence how quickly a meal leaves the stomach and how rapidly glucose reaches the bloodstream. Eating vegetables first does not create a barrier that makes a large serving of rice harmless. Portion size still matters.

A small serving of nuts before the meal

One option is a small serving of unsalted walnuts and almonds, taken 20–30 minutes before a meal with a glass of water. About 10 almonds and 4 walnut halves, roughly 20 grams in total, is a practical portion rather than a prescribed dose. Count these nuts within your daily food intake, replacing other calories rather than adding them before every meal. Avoid nuts if you have a nut allergy.

In my clinical experience with continuous glucose monitors (CGMs), I have noticed smaller glucose spikes when nuts are taken before meals. This is an observation, not a controlled study; meal size, food choices and activity also influence the result.

A small randomized study in Asian Indians with prediabetes found benefits from 20 grams of almonds taken 30 minutes before meals. The walnut-and-almond combination and a 20-minute interval were not tested in that study. Nuts provide fiber, protein and unsaturated fats, which may influence digestion and fullness. Water supports hydration and may help you feel full sooner, but it has not been shown to lower glucose further. Anyone prescribed a fluid restriction should stay within it.

Start with vegetables

Begin with sabzi such as palak, methi, bhindi, lauki (ghiya), tinday, karela, gobhi or band gobhi, or a kachumber or cucumber salad. Cooked vegetables are suitable; there is no need to insist on raw food. Prepare them with moderate amounts of oil, ghee and salt. Give vegetables a generous place on the plate. Because roti is usually used to scoop up sabzi and daal, eat the first part of the meal with a spoon or fork and keep the roti for the end.

When it suits the meal, eat a modest serving of plain dahi or raita with the vegetables, or take a spoonful of dahi with the sabzi. In my CGM observations, combining plain dahi with non-starchy vegetables at the start of the meal was associated with a smaller post-meal glucose rise. Plain dahi generally causes only a small rise in blood sugar and adds protein, and strained (hung) dahi contains more protein than regular dahi. Unsweetened lassi made with salt, or chaach, is also a good choice. The vegetable-and-dahi combination has not been tested in a controlled trial. Treat it as an observation, not a proven treatment, and avoid sweet lassi, sweetened dahi, sugar, honey and gur.

Follow with protein: chicken, fish, eggs, meat or daal

Next, eat protein, such as fish, skinless chicken, eggs, or lean mutton or beef in moderate portions. Daal, chana, lobia and rajma are good choices, especially for anyone who eats little or no meat. If plain dahi or raita was not taken with the vegetables, it can accompany this part of the meal. Dahi does not have to be eaten before meat, and it is not compulsory at every meal. People with lactose intolerance or dairy allergy need an alternative.

Daal, chana and lobia are valuable sources of protein and fiber, but they also contain carbohydrate. Plain dahi contains natural milk sugar. Neither should be treated as a food that has no effect on blood glucose. Keep oily salan, karahi and qorma gravies, and fried foods, occasional.

Then add a small portion of roti or rice

After vegetables and protein, add one whole-wheat roti or chapati, or a smaller serving of rice, at the end of the meal, rather than with every bite from the start. These can be eaten with the vegetables, daal or protein remaining on your plate. There is no need to turn the meal into a rigid ritual or wait a set number of minutes between foods.

Whole-wheat roti still contains carbohydrate, as does cooled rice. Neither allows unlimited portions. Your appropriate serving depends on your activity, medicines, nutritional needs and blood glucose response.

Cook, cool and reheat the rice when you can

A practical option is to cook rice in advance, cool it promptly, refrigerate it for about 24 hours, and then reheat only the portion needed. During cooling, some of the cooked starch changes into resistant starch, which the body digests less readily. A small clinical study found that white rice refrigerated for 24 hours at 4°C and then reheated produced a lower post-meal glucose response than freshly cooked rice.

The evidence is limited and not completely uniform, so the effect cannot be guaranteed for every person or every variety of rice. Cooling and reheating do not remove the carbohydrate and do not make a large serving harmless. The most important steps remain a smaller portion, eating rice after vegetables and protein, and checking your own response when glucose monitoring is available.

Food safety matters. Put cooked rice into shallow containers and refrigerate it within two hours, or within one hour on a hot day or in a warm kitchen; keep the refrigerator at 4°C or below. Use it within about 24 hours, reheating only the portion you need until it is steaming hot throughout (74°C), and eat it promptly. Discard cooked rice that has been left at room temperature for longer than two hours (one hour in hot conditions).

Putting the advice into an everyday Pakistani meal

For an everyday meal of daal, sabzi, dahi and roti, start with the sabzi and a modest serving of plain dahi or raita. Have the daal next, then add one roti alongside the remaining daal and vegetables.

For a family meal of chicken karahi or aloo gosht with naan, begin with a salad and a vegetable dish, follow with a moderate serving of chicken or meat with little oil or gravy, and then add a small piece of naan or one roti. Count the potatoes in aloo gosht as starch, and avoid making bread or rice the largest part of the meal.

Breakfast, nashta and chai

Pakistani breakfasts often Centre on bread: paratha, puri, naan with nihari or channay, bun kabab, rusk and bakery items with chai. These are not nutritionally identical: some are simple refined-flour breads, while others are fried or made with generous ghee, butter or sugar. Recipes and sizes vary between homes and dhabas, so judge a dish by its ingredients, its portion size and your own glucose response rather than by its name alone.

Why these foods deserve special attention. Most naan, puri, paratha, bread and bakery items are made mainly from maida, or highly refined wheat flour. Milling removes much of the grain’s fiber and structure, so the starch is digested rapidly. Eating them by themselves, especially after an overnight fast, can produce a substantial glucose rise. Sesame or other seeds on top may add flavor, but they do not cancel the carbohydrate load of the flour.

Plainer starchy breakfasts: limit closely

Plain roti or chapati. Whole-wheat roti is the better everyday bread, but two or three pieces add up quickly. Keep to one, eaten after an egg or other protein.

Naan and kulcha. Made from refined flour and often large, one naan can contain as much starch as two or three rotis. When eaten with nihari, paye or channay, take a small piece and eat more of the protein and less of the bread.

White bread, bun and rusk. Made from refined flour and often eaten several pieces at a time with chai. Count every slice or piece, and choose whole-wheat bread when possible.

Rich, fried and sweet breakfasts: avoid while diabetes is uncontrolled

Paratha and aloo paratha. Layered or stuffed breads cooked with generous ghee or oil; the potato filling adds a second starch. The fat may delay the glucose peak without removing it. Avoid them while diabetes is uncontrolled and choose a plain roti with an omelette instead; after control improves, keep them occasional.

Halwa puri. Deep-fried puri with sweet suji halwa and channay combines fried refined flour, sugar and ghee. The glucose rise may be large and prolonged. Avoid it while diabetes is uncontrolled; after control improves, treat it as an occasional weekend or festival treat, not an everyday breakfast.

Jalebi, mithai and sweet breakfasts. These combine refined starch with added sugar or syrup and little fibre, making them among the least suitable choices. After control improves, keep them to a very small taste at an occasional celebration.

Bakery items: puffs, patties and cake rusk. Made from refined flour with butter or fat, and often eaten with sweet chai. They are dense in calories, and a later glucose rise is possible. Keep portions small and infrequent even after control improves.

Guidance while diabetes remains uncontrolled

When HbA1c is 7% or higher, or daily readings remain above your agreed target, the safest practical approach is to avoid the rich, fried and sweet breakfasts (paratha, halwa puri, jalebi, mithai and bakery items) and to pause or tightly limit naan, kulcha, white bread and bun. HbA1c below 7% is a commonly recommended goal for many nonpregnant adults, but it is not a universal definition of control. Age, risk of low blood sugar, pregnancy, kidney disease, other illnesses and treatment burden may require a different target set by your doctor.

Chai is usually not the main glucose problem when no sugar is added. The larger carbohydrate load usually comes from sugar in the cup and the rusk, biscuits or bakery items taken with it, especially over several cups a day. Doodh patti with sugar, sweet lassi, fruit juices, sugarcane juice (ganne ka ras) and soft drinks can contain as much sugar as a dessert. Replacing sugar with gur or honey does not solve the problem, because both raise blood sugar in much the same way.

How to reintroduce a small portion after control improves

1. Do not eat the bread first on an empty stomach. Begin with protein, such as a boiled egg, an omelette with onion, tomato and green chilli made with little oil, or anday ki bhurji.
2. Add plain dahi if desired. Plain dahi, raita or salty lassi without sugar can accompany the meal. It may make the meal more filling, but it does not make an unlimited bread portion safe.
3. Choose one bread and keep the portion visibly small. Because parathas and naans vary greatly in size, half of one or one small roti is more sensible than automatically eating the whole thing. Do not combine two starches, such as paratha with aloo bhujia, at the same meal.
4. Avoid sweet and fatty accompaniments. Do not add sugar, gur, jam, honey, or extra ghee, butter or makhan.
5. Measure your own response. Use a CGM when available, or check before the meal and about two hours after starting it, according to your doctor’s monitoring plan. A high-fat bread may cause a delayed rise, so the CGM trace over several hours can tell you more than a single early reading.
6. Walk after the meal when medically appropriate. See the walking advice below. Walking supports the plan; it does not make up for a large portion.

A practical breakfast example. Start with an omelette or anday ki bhurji and, if desired, plain dahi. If your glucose has reached its target, follow with one small whole-wheat roti, with chai without sugar. Avoid a second roti simply because breakfast continues. Review your CGM response to decide whether the portion was right for you.

Shaadi, Eid and dawat meals

At shaadis, Eid gatherings and dawats, the table often fills with biryani, pulao, naan, qorma, karahi and sweets. It is natural to begin with rice or naan and keep returning to them. For someone with diabetes, both the first bites and the total amount of rice and bread deserve attention. The serving order can remain traditional while you choose a different eating order: salad and vegetables first, protein and plain dahi or raita next, and rice or naan last.

Roti, naan and rice are central to Pakistani meals and often take up the largest part of the plate. Repeated large portions of white rice and refined breads can therefore be an important, changeable contributor to high post-meal glucose and poor diabetes control. They are not the only cause of diabetes (weight, activity, heredity, medicines and the rest of the diet also matter), but their quantity and timing deserve special attention in Pakistani meals.

This suggested sequence applies general diabetes nutrition principles to shaadi and dawat meals; it has not been tested as a specific plan. Menus and recipes vary between families, regions and caterers.

What to eat and in what order

1. Vegetables first. Begin with salad, kachumber, raita with cucumber or a vegetable dish if available. Take these before the rice and naan when possible. Aloo dishes and fried pakoras should count as starch, not as the vegetable starter.
2. Plain dahi and a modest protein portion next. Have some plain dahi or raita, followed by a small portion of chicken tikka, seekh kabab, grilled fish, or chicken or mutton with little gravy. Grilled BBQ items are usually better choices than fried ones or dishes in rich, oily gravy. These foods can be eaten together; there is no required pause between them.
3. Eat rice or naan last, in a small planned portion. After the vegetables, dahi and protein, take a small serving of biryani or pulao, or a small piece of naan, with the remaining food. Choose one rather than both, and set your portion aside so you can judge the quantity. Do not assume that food held at room temperature, especially in hot weather, is safe to eat or reheat.
4. Finish without another carbohydrate course. Choose water, salty lassi or green tea without sugar. If having dessert, take a small taste of zarda, kheer, gajar ka halwa or shahi tukray within your carbohydrate allowance rather than a full serving after the meal.

If vegetables are unavailable, start with a little plain dahi and a modest portion of the least fatty protein available, then add the small rice or bread portion. If you take insulin at mealtime, do not delay eating while waiting for a preferred dish.

Shaadi and dawat dos and don’ts

Do choose a few dishes to enjoy in small portions. You do not need a serving of every dish. Limit rich gravies such as qorma, and remember that dahi baray and sweetened raita are not the same as plain dahi.

Do limit fried foods such as samosas, pakoras and chapli kabab, and dishes cooked in large amounts of ghee or oil, such as nihari, paye and haleem with its tarka. These may be rich in saturated fat and calories. A low early glucose reading does not make a rich meal heart-healthy, and a fatty meal can also cause a later glucose rise.

Don’t treat a dish as a vegetable serving just because of its name. Aloo gobhi, sabzi pulao and vegetable pakoras can be rich in starch or fat. Choose plainer vegetables when available.

Don’t keep returning for naan and rice as dishes arrive, add soft drinks, Rooh Afza or sweet lassi, or treat an after-meal walk as permission to overeat. Continue your prescribed treatment, and if you use insulin, follow your agreed meal-timing and glucose-monitoring plan during a long shaadi meal.

Hosts can help by serving salad, vegetables and plain dahi early, offering smaller portions of rice and naan, and providing water or unsweetened drinks. Guests can then enjoy the celebration with choices that fit their health needs.

Eating out: let AI or a quick search help

Restaurant meals are often larger and richer than home cooking. Before you go out, or before you order, whether at a restaurant or through a food delivery app, give an AI assistant on your phone the name of the restaurant and ask, for example: “I have type 2 diabetes. What should I order at [restaurant name] to avoid a large blood sugar spike?” You can also search a dish online with the question “Is [dish] good for diabetes?” Many chain restaurants post nutrition information, including carbohydrate content, on their websites.

Treat these answers as a helpful starting point rather than medical advice: AI tools can make mistakes, and menus and portion sizes change. If you use a CGM, check afterwards which choices caused the smallest glucose rise, and keep a note of the dishes that work best for you at your Favorite restaurants. At the table, apply the same order: start with a salad or vegetables, choose a protein-based main dish, skip or limit the bread basket, ask for sauces and dressings on the side, and take part of a large portion home.

Make the whole meal count

A useful starting point is to fill about half the plate with non-starchy vegetables, one quarter with protein, and one quarter with carbohydrate foods. When daal or chana supplies the protein, remember its carbohydrate content when deciding how much roti or rice to add. Choose water or unsweetened drinks.

If you are physically able, begin a gentle 10- to 15-minute walk within 10–15 minutes of finishing your meal. Walking soon after eating helps reduce the post-meal glucose rise because active muscles take up glucose. A short walk after dinner is especially useful, and in the summer heat or monsoon rains, walking indoors or on a terrace works too. Treat this as a practical target, not a strict deadline, and adapt the pace and timing to your mobility, comfort and health.

Keep treatment individual

Meal order supports treatment; it does not replace it. Do not stop diabetes medicines because you have changed your diet. Eating less rice and bread can lower glucose quickly in people taking insulin or sulfonylureas such as glimepiride or gliclazide. Anyone taking these medicines should discuss substantial changes in carbohydrate intake or meal timing with their doctor before making them. If you plan to fast during Ramazan, see your doctor six to eight weeks beforehand to review your medicines. For some people, such as those who have recently had severe hypoglycemia or diabetic ketoacidosis, guidelines advise against fasting altogether. At iftar, break the fast with water and one or two dates, in keeping with tradition, rather than a handful, then eat vegetables, dahi and protein before other foods. Pakoras, samosas, fruit chaat with sugar and Rooh Afza add a large carbohydrate load, and a heavy paratha at sehri can cause a high morning reading; keep these small.

Families can make these habits easier by serving vegetables generously and offering smaller first portions of roti and rice. Familiar dishes can remain at the table. Begin with vegetables, include nourishing protein foods, keep starch portions sensible, and build habits that you can maintain every day.

Sources

Diabetes in Pakistan: International Diabetes Federation, IDF Diabetes Atlas, 11th edition, 2025

Food order and post-meal glucose: Shukla et al., Diabetes Care, 2015

Pre-meal almonds in prediabetes: Gulati et al., European Journal of Clinical Nutrition, 2023

Cooled and reheated rice: Sonia et al., Asia Pacific Journal of Clinical Nutrition, 2015

Walking after meals: Reynolds et al., Diabetology, 2016

Yoghurt and glycemic index: Wolever, Journal of Nutrition, 2017

Carbohydrates and individualized A1C targets: American Diabetes Association

Diabetes meal planning: CDC and NIDDK; refined grains: Harvard T.H. Chan School of Public Health

Leftovers and food safety: USDA Food Safety and Inspection Service

Disclaimer: My observations come from continuous glucose monitors, sensor patches worn on the arm that send readings to a mobile phone. Glucose may fall substantially after this dietary sequence; individual responses vary, and this is not a controlled trial. Patients taking insulin or medicines that can cause low blood sugar must coordinate with their treating physician about dose adjustment. During the early dietary change, monitor glucose frequently and do additional finger-stick tests, especially at bedtime, when the sensor shows a low or rapidly falling value, or when symptoms do not match the sensor reading. Do not change medication without guidance from your treating doctor.