How traditional diets can improve diabetes care
Toups reports she is an employee of Oldways. Weiner reports she is a clinical adviser to Livongo Health.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with Kelly Toups, MLA, RD, LDN, director of nutrition at Oldways, about benefits of whole grains and other cultural foods for people with diabetes.
Oldways is a nutrition education nonprofit organization best known for creating the Mediterranean diet pyramid and the whole grain stamp.
Weiner: Cultural competence and cultural humility are essential aspects of dietetic care. What other considerations should dietitians be aware of when screening people of diverse racial and ethnic backgrounds for diabetes?
Toups: Historically, most people with a BMI below 25 kg/m2 have not been considered at risk for diabetes. However, emerging research indicates that we can’t make assumptions about people’s health or diabetes risk based solely on their BMI, body size or appearance.
One example of how ancestry might influence diabetes screening is in the Asian American community. Studies suggest that Asian American people may have increased diabetes and health risks at a lower BMI. Because of this, the World Health Organization recommends screening Asian American adults for diabetes at a BMI of 23 kg/m2 or greater, rather than 25 kg/m2.
Research also suggests that the link between BMI and diabetes is strongest among white and lowest among Black people, indicating that other factors outside of overweight or obesity may increase diabetes risk among those of certain racial and ethnic backgrounds. For example, in a study published in 2019 in Diabetes Care, Hispanic, Asian and Hawaiian/Pacific Islander adults with overweight had the same diabetes risk as whites, Blacks and Native American adults who were in the highest obesity tier.
Likewise, although waist circumference is an easy-to-measure predictor of diabetes and heart disease risk, one measurement may not indicate the same level of risk across all races or body types. In a study published in BMJ Global Health in 2018, researchers found that among 375 African-born Black adults living in the U.S., a waist circumference of 38 inches or greater for Black women and 36 inches or greater for Black men was predictive of insulin resistance, which indicates increased diabetes risk. This differs from the existing waist circumference thresholds for a general adult population — 35 inches for women and 40 inches for men.
Weiner: As people move away from eating traditional diets and fall into the standard American diet, nutrition typically worsens. Are there evidence-based solutions for managing diabetes through traditional diets?
Toups: Although BIPOC — Black, Indigenous, people of color — food traditions have historically not been as well represented in nutrition research, more and more studies are highlighting a cultural approach. The U.S. Department of Agriculture’s 2020-2025 Dietary Guidelines for Americans include a large focus on cultural diets, explicitly stating that “relying on the expertise of professionals in nutrition and in specic cultural foodways can help people prepare foods healthfully while retaining heritage.”
Nutrition professionals can and should incorporate culturally relevant foods into meal plans. Take time to build a rapport with your clients and learn more about the cultures of your patient population. From leafy green vegetables in African heritage cuisine, to the soy foods and legumes of Asian cuisine, to the peppers and fruits of Latin American heritage cuisine, there are many healthy food traditions to celebrate.
One of the most well-studied cultural diets for diabetes is the Mediterranean diet. It is no coincidence that U.S. News & World Report named the Mediterranean diet as tied for the No. 1 Best Diet for Diabetes in its 2021 rankings, in addition to being named the No. 1 Best Diet Overall. The Mediterranean diet is linked with a lower risk for comorbidities like hypertension and dyslipidemia for people with diabetes, and it is also linked with a reduced risk for developing diabetes in the first place.
Weiner: What lessons can we learn from traditional diets to help us enjoy food and better manage blood sugar?
Toups: The more we learn about traditional diets like the Mediterranean diet, the more we discover about the inherent wisdom in the typical food pairings and dishes of this region. For example, by preparing a carbohydrate food like bread, pasta or potatoes with olive oil or vinegar, the fat and the acid can help reduce the glycemic impact. Traditional diets also emphasize whole grains, such as bulgur in the Mediterranean diet or teff and sorghum in African heritage diets.
Weiner: Some people with diabetes might be nervous to eat grain-based foods for fear that the carbohydrates will spike their blood sugar. What are your recommendations for prioritizing whole grains without elevating blood sugar?
Toups: For people with diabetes, it is especially important to make every carb count. Because whole grains contain more fiber from the bran and healthy fats from the germ, they have a gentler impact on blood sugar than their refined counterparts, which generally contain only the starchy endosperm of the grain.
Furthermore, eating more whole grains can help prevent conditions like heart disease. Since people with diabetes are at an increased risk for heart disease and other complications, strategies to maximize nutrition and further prevent chronic diseases are of the utmost importance. In a 2020 meta-analysis of randomized controlled trials, published in the Journal of the Academy of Nutrition and Dietetics, researchers found that for adults both with and without risk factors for heart disease, substituting whole grains for refined can improve total and LDL cholesterol, HbA1c and inflammation.
Weiner: Aside from considering the ingredients, such as whole grains, refined grains or added sugars, how much does the processing method affect blood glucose?
Toups: Generally speaking, foods with a larger particle size that are closer to nature are going to have a lower glycemic index than foods that are milled into smaller pieces and are more highly processed. Many intact whole grains have a very low glycemic index score. For example, whole-grain barley has a glycemic index of about 28. Similarly, steel-cut oatmeal, large-flake oatmeal, muesli and granola produce a significantly lower glycemic response (53-56, in the low/medium range) than quick cooking and instant oatmeal (71-75, in the medium/high range).
However, not all processing is bad. Many people are surprised to learn that both whole grain and refined pasta have glycemic index scores below 50. That’s because extruding pasta through the dies during production compacts the starch structure, causing it to be digested much more slowly than the same amount of flour made into bread. Not only does this lower postprandial glucose after the pasta meal, but it lowers postprandial glucose after your next meal as well, in a phenomenon known as the second-meal effect.
For more information:
Kelly Toups, MLA, RD, LDN, is director of nutrition at Oldways. She can be reached at firstname.lastname@example.org.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at email@example.com; Twitter: @susangweiner.