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Unique-Kashmiri-Binge-Eating: 40-Kcal-Plate for Four-to-Relish

By relishing a plate of Wazwan (Kashmiri cuisine) and engulfing 10,000 calories in less than one hour, Kashmiri population has defeated English in Binge Drinking (ingest 6,300 calories in 24 hours-drinks: 1476 calories, food that night: 2829 calories & food next day: 2051 calories). We abuse ourselves, our family members, relatives, neighbors and friends (around 2,000 invitees in one marriage ceremony) by this Calorie Bomb on 4 instances (2 lunches and 2 dinners) each time we marry a loved one as against weekend Binge drinking in the West. This has caused exceptional metabolic stress to our community and is the focal point for extremely high occurrence of metabolic syndrome, Insulin resistance, truncal obesity, Diabetes mellitus, Non-Alcoholic Fatty Liver Disease, Dyslipidemia and possibly coronary artery disease/heart attacks.

40-Kcal-Plate for Four-to-Relish





40-Kcal-Plate for Four-to-Relish

By relishing a plate of Wazwan (Kashmiri cuisine) and engulfing 10,000 calories in less than one hour, Kashmiri population has defeated English in Binge Drinking (ingest 6,300 calories in 24 hours-drinks: 1476 calories, food that night: 2829 calories & food next day: 2051 calories).  We abuse ourselves, our family members, relatives, neighbors and friends (around 2,000 invitees in one marriage ceremony) by this Calorie Bomb on 4 instances (2 lunches and 2 dinners) each time we marry a loved one as against weekend Binge drinking in the West. This has caused exceptional metabolic stress to our community and is the focal point for extremely high occurrence of metabolic syndrome, Insulin resistance, truncal obesity, Diabetes mellitus, Non-Alcoholic Fatty Liver Disease, Dyslipidemia and possibly coronary artery disease/heart attacks.


                                                                                                                                      “Kashmir is in the middle of an epidemic of metabolic syndrome (also known as syndrome ‘X’) and non-alcoholic fatty liver disease (commonly synonymized as NAFLD), a potentially progressive liver disease, shall pose serious problems to our community in near future.”   This is the opinion of Prof. Mohammad Sultan Khuroo, who is the Director of the newly envisaged Digestive Diseases Centre at Khyber Medical Institute, Nowpora, Srinagar Kashmir. Prof. Khuroo is to establish a state-of-art tertiary care centre in Kashmir. This shall take another 3 to 6 months to operate and shall be opened in a phasic manner at Khyber Medical Institute at Nowpora Srinagar, Kashmir.  As of today, he has developed a modern “Day-care-centre” which does consultations for patients with gastrointestinal and hepatic diseases and is backed up by a highly-sophisticated biochemistry unit, ultrasonography with color Doppler facilities and a modern 2 suite endoscopy laboratory. As per north American practice for evaluating a patient, the Digestive Diseases Centre critically analyzed all patients registering for consultations for known risk factors to gastrointestinal and hepatic diseases and other common medical illnesses namely cardiac and renal diseases, diabetes mellitus etc. This involves a thorough assessment of anthropometric data, history and physical examination, laboratory tests including lipid profile and ultrasonography of the abdomen with color Doppler examination. Over the previous one and a half month since the centre has been operational, over 800 patients with gastrointestinal nd hepatic diseases have been assessed. The data have been recently analyzed for the pattern of disease profile seen in the medial practice as of today, in Kashmir. “We were surprised to find that one of the common problems seen during this period has been a new disease, named as the metabolic syndrome and its abdominal component, the non-alcoholic fatty liver disease (NAFLD)” remarked prof. Khuroo.   During this period over 45 patients had fulfilled ATP III (Adult Treatment Panel III, NIH, USA, 2001) criteria for diagnosis of metabolic syndrome. All these 45 patients had abdominal component of metabolic syndrome, the NAFLD. NAFLD has 2 disease forms, the benign fatty liver and the progressive disease, the NASH (nonalcoholic steatohepatitis). Fatty liver, wherein fat globules develop in the liver cells without inflammation and fibrosis is a reversible disease and if treatment is instituted the liver returns to normal functions. However, NASH in which fat globules are accompanied by hepatitis (inflammation of liver) and fibrosis is progressive disease leading over years to liver cirrhosis, end-stage liver disease and finally to liver cancer. Liver biopsy is the gold standard to diagnose and stage NAFLD.  “We were constrained by non-availability of liver biopsy in all our patients (for logistic and ethical reasons) and thus could not classify these patients in one of the 2 forms of NAFLD” agrees Prof. Khuroo. However, it was remarkable that 4 of these 45 patients had clinical, biochemical, radiological and endoscopic features of end stage liver disease. End stage liver disease develops in NALFD after years and years of aggressive NASH and in fact is the tip of an iceberg in this phenomenon.  Thus, NAFLD in its worst form must be existent in this community and this large pool of population is harboring a time bomb to be exploded anytime in future. Liver cancer, which was previously thought only to follow hepatitis B and hepatitis C, is another end result of NAFLD after decades of disease activity.  It is too early to see this in our community as of today, but shall threaten us in near future if we do not intervene now.  

                     Liver biopsy showing diffuse round fat globules in liver cells



Further analyzing the data on the patients of NAFLD seen at Khyber Medical Institute, majority of these patients were unaware of their liver disease. In fact, the commonest symptom of such patients was upper abdominal discomfort, indigestion and excessive fullness after meal, a common symptom in the community and diagnosed as functional dyspepsia. However, fat infiltration in liver distends it and causes discomfort and heaviness and such symptoms may last for many years without causing other symptoms, till symptoms and signs of liver failure ensue. So, for many years NAFLD behaves and masquers itself as functional dyspepsia. All these patients had had medical consultations in the past (many had multiple consults) and in none (except 2 patients) were symptoms attributed to NAFLD. Also, none of these patients had the diagnosis of metabolic syndrome made in these medical consults. The reasons for such phenomenon could be multiple; one lack of awareness of this new disease syndrome in the public and medical community and inability to assess patients for risk factors through thorough anthropometric data, history and physical and critical evaluation of laboratory tests especially lipid abnormalities and use of scoring system to classify patients in to metabolic syndrome. ATP III report (NIH, USA, 2001) has grossly simplified the diagnosis of metabolic syndrome by using simple scoring system of parameters which are available to clinicians in every consulting chamber and need to be used for every patient which comes for medical consult for diverse reasons.



Ultrasound liver. A. normal liver, B. Fatty liver


A                                                                B












What is the metabolic syndrome and what is its implication to healthcare in the West? The disease encompasses spectrum of NAFLD, central obesity, “type II diabetes” and dyslipidemia and the central focus of all these is the phenomenon of insulin resistance. In fact, both metabolic syndrome and NAFLD are the resultant of insulin resistance syndrome. NAFLD as of today, is the most common cause of chronic liver disease in the United States. It has superseded chronic hepatitis C as the liver disease epidemic of the new millennium. It is estimated that around 20 to 25 % populations in Western countries have NAFLD and underlying metabolic syndrome. NAFLD is the commonest cause of cryptogenic liver cirrhosis in such countries and in this form the disease is the third common indication for liver transplantation in such countries.


This epidemic of NAFLD and metabolic syndrome which has hit the Western countries and shall have major implication on the health of the community in the new millennium is related to the epidemic of obesity in such countries. At present, around two third of Americans are overweight and one third suffer from obesity. Morbid obesity, a disease with serious health risk occurs in around 4.7% Americans. The epidemic of obesity which is ongoing in the West is related to changed life style of such population and the changed dietetic habits over the last few decades. Fast food chains namely McDonald’s are synonymous with obesity in West. The foods in such facilities are extremely high caloric value and rich in fats. In Addition, the drinks from such facilities, though of carbohydrates are of high caloric values and as these are being increasingly consumed; the caloric intake of such population is extremely high. Of major disturbance, has been the occurrence of obesity early on in adolescents and young adults, leading to metabolic disturbances early on in life of this population.


Two aspects of obesity are worth mentioning here. One is the role of adipocytes, the fat cells. For long many years’ adipocytes were considered as fat storage houses, without any other role. Now it is proved beyond doubt that every adipocyte of the body is an endocrine power house producing a number of chemical substances, including hormones which have substantial part to play in body metabolism. Another aspect is the different role of fat cells (adipocytes) deposited in buttocks, arms and legs (peripheral obesity) versus adipocytes deposited in the abdomen and abdominal wall (central obesity). The fat deposited inside the abdomen and the abdominal wall is far more significant as far as metabolic disturbances of obesity are concerned (namely insulin resistance syndrome) and the fat in the buttocks and limbs may not be as harmful and some believe it may be protective!! This is due to difference in the endocrine functions of the fat cells at 2 sites and that, also, central fat cells release their stuff (free fatty acids) directly to liver while that from peripheral fat cells is released in to blood and reaches liver secondarily. To make the matter simple, it is now recognized that the obesity which is concentrated inside abdomen and abdominal wall (central obesity) is more serious than that which is around buttocks and limbs. Thus, insulin resistance is basically a phenomenon of central obesity and not so much of overall obesity.


Another point is worth mentioning here. As a result of central obesity and insulin resistance syndrome, type-II diabetes (diabetes in adults) has exploded in an epidemic form in such countries. The disease has major implications on its own end and predisposes population to endless combinations. To name a few include atherosclerosis with resultant heart attacks and stroke, eye problems, kidney diseases, infections, loss of feet (gangrene) etc. Another aspect of metabolic syndrome is a particular form of dyslipidemia (abnormality in lipids, high triglycerides). Although the major cause of heart disease (coronary artery disease) in the West is result of different form of dyslipidemia (high LDL-cholesterol), it is now increasingly recognized that dyslipidemia associated with metabolic syndrome can also lead to higher coronary artery disease. Thus ATP III report (NIH, USA, 2001) has recommended targeting dyslipidemia associated with metabolic syndrome as goal beyond controlling LDL-cholesterol alone.


You may ask me that “Is such a short experience in clinical practice enough to make such implications about the metabolic syndrome and NAFLD in our community”. I agree that to make a final opinion we need at least 2 years of continuous experience in practice to know exact load of NAFLD in this community here. Also, epidemiological studies in the general community are needed to give an exact incidence and impact of disease. But, a number of observations do make me to believe that NAFLD and metabolic syndrome is in the epidemic here only to explode in near future. First, over years of my previous practice (1970 to 1995) in this population I had never encountered NAFLD and its serious implications in Kashmir. In fact, I never had seen a patient of end stage liver disease caused by NAFLD in Kashmir during these years. In contrast, during my short trips to Kashmir in the last 10 years and assessing patients for short periods (from one month to 6 months) I had been impressed by increasing load of this disease over the years.  The purpose of this report should also have been taken to make public awareness of this increasingly recognized disease in the West. Also, medical fraternity needs to address their concern towards this illness and get geared to identify metabolic syndrome and NAFLD among patients and public by use of simple scoring system in their practices.


I have asked myself and my colleagues at Digestive Diseases Centre, at Khyber Medical Institute “What could be possible reasons for introduction of metabolic syndrome in our community”. We can take lessons for the West. The focus has to be our changing food habits and sedentary life style. First the food we take. I believe we could target three of our major habits namely Wazwan, excessive consumption of mutton and consuming large amounts of rice. Oh! All these habits have been with us for long and why should these lead to such an epidemic now. However, I believe that in the recent past some changes have occurred in our society which may be important to tip off the disease status. First effluence and recent massive indulgence in making our food habits of extraordinarily nature have made significant deviation of our food habits. Also, over the past few decades we have increasingly developed sedentary habits which make the caloric intake and consumption imbalance leading to obesity.


Wazwan! One of our staff member trained in nutrition did an intensive study of the caloric intake of what is being served at wazwan. During a routine effluent party at wazwan, the chef and the host displays and serves up to 40,000 kcal per plate (this includes 1580 g carbohydrates, 1150 g proteins and 3120 g fats) and as the plate is being shared by 4 persons, each one leaves the party after engulfing up to 10,000 kcal (which is sufficient for one week for a sedentary person). This includes 397 g carbohydrates, 288 g proteins and 780 g fats. This form of “binge eating” is unprecedented in history and must be loading the metabolism of the individual and it should take an unknown yet prolonged time to correct the metabolic abnormality. This amount of “binge eating” caloric dose can be compared to “binge drinking” prevalent in he West and which is one of the major causes of alcoholic hepatitis and alcoholic liver disease, cirrhosis and end stage liver disease in that community. A person in the West during “binge drinking” has to consume 2.5 litre of absolute alcohol or equivalent 5 litre (5 bottles) of Scotch whisky (50% alcohol) to engulf 10,000 caloric load. So, we can compare it to our society that after every wazwan feast one is leaving the party after engulfing food items with calories comparable to a person from West after engulfing 5 bottles of Scotch whisky in the pub. Against predominantly single food item in Alcohol which is consistently metabolized by the liver by dedicated enzyme system, the items in wazwan are diverse and predominantly of fats which are more difficult to metabolize. Rest is for all of us for conjecture!!


Over the years our society has made significant change in dietary habits. For centuries, we were known to take rice and sag (hak-batta) as our stable diet, how excellent!! Now, all of us can not think of eating a lunch or a dinner without taking mutton. In fact, when we are in good health or indisposed we need different forms of mutton preparation. Vegetables, we cannot tolerate and causes gas, distension and abdominal discomfort and we all shun it. In fact, it is insulting to serve a guest with vegetables. Fruits, Kashmir is known for its apple industry and this should have made our food habits very good. However, I believe Kashmir has the worst display of fruits in the market and we have no habit or liking for fruits. It should startle every body that Kashmir imports up to 1.5 million sheep from other states per year and this along with our local production should make Kashmiri as the highest mutton eater in the World. Also, the mutton we like and take is one with excessive fat content and what a dish it makes for all of us. This is comparable to phenomenon of fast food chain like McDonald in the West where in the major item in all foods served is beef, ham or mutton. So, the change we have made in our food is exactly what West has made but in different form.


Kashmir is rice growing region and understandably we are rice eaters. We also import large quantities of rice from other states and export nil. This is related to large plates of rice we take in our 2 main meals. I believe with effluence we have indulged in taking larger quantities of rice than before when availability was a constraint. I may mention that intake of carbohydrates as in rice also leads to obesity and dyslipidemia known to occur in metabolic syndrome.


Not one but all the 3 food habits together along with the sedentary life style we live or forced to live is enough reasons for our many health problems, the front runner of which is this newly known and highly publicized metabolic syndrome and non-alcoholic fatty liver disease. Where do we go from here? Society needs a massive education drive, intensive introspection of our habits and interventions at various levels for necessary corrections. I do not think we can afford to lose our identity by banning wazwan (I would hate to give such a slogan, as I like it on occasions), but we can set a standard that the chef and the host is asked to serve not more than 3000 kcal per plate and that also with least amount of animal fat. Social workers and Government indulgence have made enough efforts in this direction with mixed affects; let us watch what the health advisors can do in this regard. It would also be nice if we can start tolerating vegetables and go back to our well-established habit of hak-batta (fresh vegetables) rather than churby-Maz (mutton rich in fat) which all of us relish. Fruits, we need good display of such items in the market and adopt a slogan that “An apple a day keeps the doctor away”. Also, we did not need to import any rice as we always were rice growers and this should suffice our needs. Only we need to show moderation in using it. Importing such large quantities of livestock as above for human consumption is a huge drain for our economy, a huge health risk as it increases chances of heart disease, cancer as well as metabolic syndrome in our community. We need to come out of our shells and lead active life by dedicated exercises which are good for our hearts and society at large.

Table: Food items in wazwan with nutrient value served in one plate which is shared by 4 persons.










raw item

1500 g


7.5 g

100 g

990 g



2750 g


350 g

440 g



visible fat

250 g


250 g





750 g


15 g

500 g



One piece

60 g


15 g

10 g

4 g

Oils & oily substances


250 g


100 g





750 g


750 g




animal fat

1500 g


1500 g



Milk & milk products


250 ml


5 g

8 g

11 g



1000 g


40 g

31 g

30 g

Sweet dish


500 g


23 g

46 g

223 g


basmati rice cooked with dry fruits

300 g


67 g

15 g

130 g

Cold drinks

 Pepsi or coca cola

2000 ml



2 g

200 g

Grand total

11.8 kg


3123 g

1152 g

1588 g

The above figures were drawn from a random sample of 10 parties. The number of dishes served varied from 16 to 35 (median 23) and the mutton served per plate was from 2 to 5 kg (median 3 kg). The above data were calculated on mutton serving of 3 kg per plate.