Preventing the global burden of type 2 diabetes by …...maize ugali Puerto Rico Brown rice, beans,...
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Introduction The prevalence of type 2 diabetes (T2D) has increased rapidly in many countries around the world, as economic growth and urbanization fuel nutrition transitions that promote positive energy balance. A major characteristic of these transitions has been an overall reduction in diet quality due to increasing intake of processed foods, added sugar and refined carbohydrates such as white rice and white wheat flour. Consumption of high-quality carbohydrates, such as whole grains, can reduce the risk of developing T2D by improving blood glucose and insulin levels. In contrast, consumption of refined grains has been associated with an increased risk of T2D. Adopting a diet that is rich in high-quality carbohydrates in place of refined grains could therefore be a cost-effective, feasible, and sustainable approach to T2D prevention, particularly in low- and middle-income countries (LMIC) that have limited resources to manage escalating rates of T2D and other chronic diseases. • Using culturally appropriate interventions, reduce T2D risk factors by improving diet quality with an emphasis on carbohydrates in Puerto Rico and 12 LMIC’s in Asia, Africa, the Middle East and Latin America. • Provide evidence to motivate policies and dietary recommendations to reduce the burden of chronic diseases in the study countries and globally. Conclusion • T2D has become a major public health challenge due to global nutrition transitions promoting unhealthy diets high in refined carbohydrates, processed foods and added sugars. • Through focus groups and taste tests, GNET researchers have identified culturally acceptable substitution foods to replace low-quality carbohydrates and have documented barriers and motivators to increasing intake of these high-quality traditional foods. • GNET countries are at varying stages in developing interventions to improve diet quality targeting staple carbohydrate foods as a way of reducing markers of diabetes risk. • Improving diet quality in LMIC’s could play a key role in diabetes prevention. Global research efforts to identify and promote intake of culturally- acceptable, high quality staple foods are crucial to combat the growing global diabetes epidemic. Vasanti Malik, Josiemer Mattei, Hannia Campos, Walter Willett, Donna Spiegelman, Frank Hu and partners from international collaborating institutions • Main barriers to brown rice acceptance: lack of awareness of health benefits, texture, palatability, cost and scarcity. Longer cooking time not a major barrier. • Suggestions to improve acceptance: large-scale promotion of health benefits, subsidies to reduce cost, celebrity endorsement, special recipe advertisements, free samples, mixing with usual food. Country Substitution Foods China Brown rice India Brown rice (different degrees of refining) Tanzania Brown rice, sorghum ugali, coarse maize ugali Puerto Rico Brown rice, beans, high-fiber breakfast cereal, coconut water Costa Rica Brown rice, beans Kuwait Brown rice, beans, wheat berries, whole wheat pita bread Nigeria Brown rice • India Worksite intervention study to prevent diabetes • Brown rice vs White rice intervention study on biomarkers of diabetes risk India •Effect of peanut snack vs white rice snack bars on markers of diabetes •Formative study on cafeteria intervention China •Alternate healthy beverages among high schoolers - FGD Kuwait •Glycemic index value of common staple foods •Perceptions, barriers/ facilitators for substituting brown rice for white rice - FGD Iran •Brown rice as a replacement for white rice in the 3 main ethnic groups in Malaysia (Indian, Malay and Chinese) - FGD Malaysia •Glycemic index testing of brown rice and white rice •Brown rice replacement for white rice - FGD Nigeria •Bean intake and perceptions about beans in Mexico Mexico •Formative study on worksite intervention to improve diet quality Tanzania •Diet of rural adolescents and associated psychosocial factors Costa Rica •Focus groups and taste test for rice, cereal and beverages •Food frequency data on diet quality Puerto Rico •Nepal Pioneer Worksite Intervention Study to prevent cardio-metabolic risk Nepal Figure 1. 2015 age-adjusted comparative prevalence of diabetes in the fourteen GNET countries/territories for the age group 20-79 Tanzania 4.1% Kenya 2.4% Nigeria 2.3% Costa Rica 8.5% China 9.8% India 9.3% United States 10.8% Brazil 10.4% Malaysia 17.9% Mexico 15.8% Iran 10.1% Nepal 3.7% Puerto Rico 12.1% Kuwait 20.0% Preventing the global burden of type 2 diabetes by improving diet quality: the Global Nutrition and Epidemiologic Transition (GNET) Initiative Figure 2. The four phases of GNET projects • 202 adults with diabetes or metabolic syndrome randomly assigned to white rice (WR) or brown rice (BR) group and consumed ad libitum for 16 weeks • Substituting BR for WR did not lead to substantial improvements in metabolic risk factors GNET’s website: www.hsph.harvard.edu/gnet Contact: Elena Hemler ([email protected]) Table 1. Findings from focus group studies Dietary Intervention: Shanghai, China Data obtained from International Diabetes Federation: Diabetes Atlas, 2015. • Suggestion of improvement in HDL in BR compared to WR group (p=0.07) • Diabetic participants had greater reduction in diastolic blood pressure in BR compared to WR group (p=0.02) and greater reduction in LDL cholesterol in WR compared to BR group (p=0.02) • Limitations: • Decreased power to detect between group differences due to improvements in risk factors in both BR and WR groups; Duration of study may be insufficient to detect meaningful changes; Higher proportion of diabetic individuals in WR group; BR group significantly reduced dairy and fruit consumption as well as physical activity, which could have offset benefits of BR Figure 4. Active GNET projects • More studies with larger sample sizes, longer follow-up duration and different varieties of rice are needed Figure 3. Poster from a randomized crossover trial substituting brown rice for white rice in India Phase 1 • Identification of staple & alternative foods • Focus groups • Taste tests Phase 2 • Selection of intervention foods • GI testing and Continuous Glucose Monitoring Phase 3 • Intervention studies using biochemical markers Phase 4 • Multicenter clinical trial with diabetes as the endpoint GNET Initiative Objectives
Transcript of Preventing the global burden of type 2 diabetes by …...maize ugali Puerto Rico Brown rice, beans,...
IntroductionThe prevalence of type 2 diabetes (T2D) has increased rapidly in many countries around the world, as economic growth and urbanization fuel nutrition transitions that promote positive energy balance. A major characteristic of these transitions has been an overall reduction in diet quality due to increasing intake of processed foods, added sugar and refined carbohydrates such as white rice and white wheat flour. Consumption of high-quality carbohydrates, such as whole grains, can reduce the risk of developing T2D by improving blood glucose and insulin levels. In contrast, consumption of refined grains has been associated with an increased risk of T2D. Adopting a diet that is rich in high-quality carbohydrates in place of refined grains could therefore be a cost-effective, feasible, and sustainable approach to T2D prevention, particularly in low- and middle-income countries (LMIC) that have limited resources to manage escalating rates of T2D and other chronic diseases.
• Using culturally appropriate interventions, reduce T2D risk factors by improving diet quality with an emphasis on carbohydrates in Puerto Rico and 12 LMIC’s in Asia, Africa, the Middle East and Latin America.
• Provide evidence to motivate policies and dietary recommendations to reduce the burden of chronic diseases in the study countries and globally.
Conclusion• T2D has become a major public health challenge due to global nutrition transitions promoting unhealthy diets high in refined
carbohydrates, processed foods and added sugars.• Through focus groups and taste tests, GNET researchers have identified culturally acceptable substitution foods to replace
low-quality carbohydrates and have documented barriers and motivators to increasing intake of these high-quality traditional foods.• GNET countries are at varying stages in developing interventions to improve diet quality targeting staple carbohydrate foods as a way
of reducing markers of diabetes risk. • Improving diet quality in LMIC’s could play a key role in diabetes prevention. Global research efforts to identify and promote intake of
culturally- acceptable, high quality staple foods are crucial to combat the growing global diabetes epidemic.
Vasanti Malik,Josiemer Mattei,Hannia Campos,WalterWillett,DonnaSpiegelman,FrankHuandpartnersfrominternationalcollaboratinginstitutions
• Main barriers to brown rice acceptance: lack of awareness of health benefits, texture, palatability, cost and scarcity. Longer cooking time not a major barrier.
• Suggestions to improve acceptance: large-scale promotion of health benefits, subsidies to reduce cost, celebrity endorsement, special recipe advertisements, free samples, mixing with usual food.
Country Substitution FoodsChina Brown rice
India Brown rice (different degrees of refining)Tanzania Brown rice, sorghum ugali, coarse
maize ugaliPuerto Rico Brown rice, beans, high-fiber breakfast
cereal, coconut waterCosta Rica Brown rice, beansKuwait Brown rice, beans, wheat berries, whole
wheat pita breadNigeria Brown rice
• IndiaWorksiteinterventionstudytopreventdiabetes
• BrownricevsWhitericeinterventionstudyonbiomarkersofdiabetesrisk
India
•Effectofpeanutsnackvswhitericesnackbarsonmarkersofdiabetes
•Formativestudyoncafeteriaintervention
China
•Alternatehealthybeveragesamonghighschoolers- FGD
Kuwait
•Glycemicindexvalueofcommonstaplefoods
•Perceptions,barriers/facilitatorsforsubstitutingbrownriceforwhiterice- FGD
Iran
•Brownriceasareplacementforwhitericeinthe3mainethnicgroupsinMalaysia(Indian,MalayandChinese)- FGD
Malaysia
•Glycemicindextestingofbrownriceandwhiterice
•Brownricereplacementforwhiterice- FGD
Nigeria
•BeanintakeandperceptionsaboutbeansinMexico
Mexico
•Formativestudyonworksiteinterventiontoimprovedietquality
Tanzania
•Dietofruraladolescentsandassociatedpsychosocialfactors
CostaRica
•Focusgroupsandtastetestforrice,cerealandbeverages
•Foodfrequencydataondietquality
PuertoRico
•NepalPioneerWorksiteInterventionStudytopreventcardio-metabolicrisk
Nepal
Figure1.2015age-adjustedcomparativeprevalenceofdiabetesinthefourteenGNETcountries/territoriesfortheagegroup20-79
Tanzania4.1%
Kenya2.4%
Nigeria2.3%CostaRica
8.5%
China9.8%
India9.3%
UnitedStates10.8%
Brazil10.4%
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Malaysia17.9%
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Mexico15.8%
Iran10.1%
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Nepal3.7%
PuertoRico12.1%
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Kuwait20.0%
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Preventingtheglobalburdenoftype2diabetesbyimprovingdietquality:theGlobalNutritionandEpidemiologicTransition(GNET)Initiative
Figure2.ThefourphasesofGNETprojects
• 202 adults with diabetes or metabolic syndrome randomly assigned to white rice (WR) or brown rice (BR) group and consumed ad libitum for 16 weeks
• Substituting BR for WR did not lead to substantial improvements in metabolic risk factors
GNET’swebsite: www.hsph.harvard.edu/gnet Contact:ElenaHemler([email protected])
Table1.Findingsfromfocusgroupstudies
DietaryIntervention:Shanghai,China
DataobtainedfromInternationalDiabetesFederation:DiabetesAtlas,2015.
• Suggestion of improvement in HDL in BR compared to WR group (p=0.07)
• Diabetic participants had greater reduction in diastolic blood pressure in BR compared to WR group (p=0.02) and greater reduction in LDL cholesterol in WR compared to BR group (p=0.02)
• Limitations:• Decreased power to detect between group differences
due to improvements in risk factors in both BR and WR groups; Duration of study may be insufficient to detect meaningful changes; Higher proportion of diabetic individuals in WR group; BR group significantly reduced dairy and fruit consumption as well as physical activity, which could have offset benefits of BR
Figure4.ActiveGNETprojects
• More studies with larger sample sizes, longer follow-up duration and different varieties of rice are needed
Figure3.PosterfromarandomizedcrossovertrialsubstitutingbrownriceforwhitericeinIndia
Phase1• Identificationofstaple&alternativefoods
• Focusgroups• Tastetests
Phase2• Selectionofinterventionfoods
• GItestingandContinuousGlucoseMonitoring
Phase3• Interventionstudiesusingbiochemicalmarkers
Phase4• Multicenterclinicaltrialwithdiabetesastheendpoint
GNETInitiativeObjectives
