Background
The epidemiologic transition
Global burden of diabetes
The case for improving carbohydrate quality for diabetes prevention
The nutrition transition: the concurrent downshift in carbohydrate quality
Discussion
Improving carbohydrate quality to prevent diabetes: examples from GNET countries
Stage of nutrition transition | Country | Traditional or potential high-quality staple foods | Current low-quality staple foods | Main findings and ongoing research activities |
---|---|---|---|---|
Early transition | Nigeria | • Fufu (pounded/mashed mixed meal of coarse cereals and roots) | • White rice | • White rice is current main staple food, and there are regional variations in staple food preferences |
• Fufu (mostly refined maize/cassava flour) | ||||
• Currently evaluating sensory attributes, barriers and motivators for replacing white rice with brown rice, and suggestions to promote intake | ||||
• Roots and tubers | ||||
Early transition | Tanzania | • Ugali (coarse maize flour mash) | • White rice | • Main reasons for increase in white rice included greater palatability; ease of storage; ease of preparation; variety of preparation methods; influence of Western dietary patterns |
• Ugali (refined maize flour) | ||||
• Millet | • Imported refined grains and cereals | |||
• Whole grain ugalis and brown rice were highly rated for sensory perceptions; whole grain ugali was highly acceptable while brown rice was unpopular | ||||
Early transition | Kenya | • Ugali (coarse maize, millet or sorghum flour porridge) | • Ugali (refined maize) | • Maize remains primary staple, as well as rice and wheat products |
• Refined cereals and breads | ||||
• Beans, cassava, sweet potato | • White rice and wheat products | • Currently evaluating the glycemic index of potential high-quality alternative staple foods | ||
Ongoing transition | India | • Hand-pounded rice (under milled) | • White rice | • White rice was preferred because of tradition, cooking quality, and appearance |
• Refined wheat products | ||||
• Health benefits of brown rice were unfamiliar | ||||
• Coarse/whole cereals | • Willingness to switch to brown or undermilled rice, if affordable and had education on health benefits | |||
• Legumes and lentils | ||||
• Roots and tubers | • Suggestions to promote brown rice included advertising special recipes, celebrity endorsement, dispensing free samples, government-initiated education campaigns | |||
• Compared to white rice, brown rice improved 24- h glycemic and insulinemic response over 5 days using continuous glucose monitoring in overweight subjects; addition of legumes had no significant effect | ||||
• Currently analyzing data from 3-month cross-over trial comparing brown to white rice meals on biomarkers in cafeteria setting | ||||
Ongoing transition | China | • Brown rice | • White rice | • Cultural barriers to accept brown rice were perception of rough texture, unpalatable taste, and higher price |
• Whole grains | • Refined wheat products | |||
• SSB | ||||
• Legumes | • Promoting health benefits of brown rice could improve attitudes towards increasing its consumption | |||
• Roots and tubers | ||||
• Participants are willing to participate in brown rice intervention study | ||||
• Intake of brown rice compared to white rice did not improve metabolic risk factors in a 16-week parallel-arm randomized intervention; some benefit on blood pressure in brown rice arm were observed among participants with diabetes | ||||
Ongoing transition | Malaysia | • Brown rice | • White rice | • Currently evaluating feasibility and acceptability of substituting brown rice for white rice, and barriers and motivators to consuming brown rice in 3 main ethnic groups |
• Legumes | • Refined wheat products | |||
• Roots and tubers | ||||
Ongoing transition | Brazil | • Brown rice | • White rice | • Currently identifying main contributors to carbohydrate and fiber intake |
• Legumes (beans) | • Refined flour breads | |||
• SSB | ||||
Ongoing transition | Mexico | • High-fiber nixtamalized commercial corn tortillas, or whole wheat tortillas. | • Commercial corn tortillas | • Currently analyzing data on consumption habits and attitudes towards beans |
• ‘Masas de maiz’ made with nixtamalized corn flour (bran removed) | ||||
• ‘Masas de maiz’ (corn dough) made from high-fiber nixtamalized corn flour | ||||
• Refined wheat flour bread | ||||
• White rice | ||||
• Legumes | • SSB | |||
• Whole wheat bread | ||||
• Brown rice | ||||
Transitioned | Costa Rica | • Brown rice | • White rice | • Brown rice was very unfamiliar |
• Legumes | • Tradition and family support were main drivers for intake of white rice | |||
• Consuming more white rice and fewer beans was engrained in the culture | ||||
• Beans-to-white rice ratio of 1:1 was rated as most pleasant among 8 white or brown rice and beans preparations | ||||
• Strategies to increase brown rice and bean intake included introducing them in childhood, promoting health benefits, lowering cost, increasing availability, masking unpleasant sensory qualities, and engaging women as agents of change | ||||
Transitioned | Kuwait | • Brown rice | • White rice | • Factors influencing consumption habits were taste, ease of preparation, and cost |
• Wheatberries (e.g. Jereesh, Harees) | • Refined grain (wheat) products | |||
• Barriers to substituting refined grains with whole grains included unfamiliar taste, long cooking times, lack of cooking knowledge, cost, lack of availability | ||||
• Legumes (lentils) | ||||
• Whole wheat bread | ||||
• Motivators to promote healthier consumption were awareness about health benefits, learning how to prepare whole grain meals, more availability, reasonable prices | ||||
Transitioned | Puerto Rico | • Legumes | • White rice | • Overall positive perceptions of legumes; main reasons for consumption of legumes were taste and nutrition |
• Brown rice | • White bread | |||
• Roots and tubers | • Cold breakfast cereals | |||
• Whole wheat bread | • SSB | • Higher consumption of legumes among those with more positive opinions or more bean variety | ||
• High-fiber cereals | ||||
• Currently identifying other foods contributing to carbohydrate and fiber intake | ||||
• Currently analyzing data from taste and focus group studies that assessed perceptions, motivators and barriers, and taste preferences for of four possible replacement foods | ||||
• Currently analyzing data from 3-week pilot to determine compliance and acceptability of possible replacement foods |
Countries in early transition
Nigeria
Tanzania
Kenya
Countries in ongoing transition
India
China
Malaysia
Brazil
Mexico
Transitioned countries
Costa Rica
Kuwait
Puerto Rico
Summary
Data and research needs: | |
---|---|
• | Systematic and recurring dietary assessment and surveillance at the global level |
• | Standardized data collection on level of processing and refinement and consumption by type of carbohydrate source |
• | Studies on the carbohydrate quality and the effect of roots, tubers, minor grains, and mixed meals on diabetes biomarkers |
• | Evidence of whole grain effects using sustainable and cultural approaches in larger studies in free-living, community settings |
Potential strategies for global studies and promoting high-quality foods: | |
• | Conduct formative research to identify main foods, cultural attitudes, and dietary preferences in the specific population |
• | Adapt the intervention using culturally-accepted foods and settings, as supported by evidence |
• | Preserve cultural preferences for sensory qualities of foods |
• | Harness people’s willingness to switch to healthy foods and interest in health benefits into high participation in dietary interventions and programs |
• | Promote health benefits of high-quality staple foods (knowledge and skills that could help increase intake; mass media health promotion) |
• | Consider cost-reducing strategies of the high-quality staple foods, such as subsidies or incentives |
• | Consider cost increases or limiting the availability of low-quality staple foods, such as taxes or bans |
• | Develop large-scale global changes in food marketing, trade, promotion, regulations and policies |
Challenges, opportunities, and recommendations for conducting global partnerships: | |
• | Challenges include limited advocacy, capacity and resources; coordinating multiple sites; navigating diverse social norms and policies; and securing international funding |
• | Trans-disciplinary partnerships can help share ideas, advice, education, training, capacity-building, resources, expertise, and funding |
• | Leverage existing global policy frameworks |
• | Partner with similar initiatives as well as with national government agencies and community partners |