March 2021 Issue
Dynamics of Diabetes: Diabetes Meal Planning
By Constance Brown-Riggs, MSEd, RDN, CDCES, CDN
Today’s Dietitian
Vol. 23, No. 3, P. 12
Helping Clients Rediscover the High-Carbohydrate Foods They Love
Having diabetes shouldn’t prevent clients and patients from living healthy lives and enjoying the ethnic foods they grew up with. Unfortunately, that’s not the message many people of color with diabetes receive during encounters with nutrition professionals. All too often, starchy vegetables such as pumpkin, plantain, and cassava, which are the foundation of many global cuisines, are classified as “bad” because of their high carbohydrate content and value on the glycemic index (GI). This article provides insights on how Black, Indigenous, and people of color (BIPOC) and Asians with diabetes can safely include traditional starchy vegetables in their meal plans.
Of the more than 34 million people in the United States with diabetes, BIPOC and Asians are disproportionately represented. According to the Centers for Disease Control and Prevention (CDC), more than 13% of non-Hispanic Blacks, 11.2% of Asian Americans, and 10.3% of Hispanics, compared with 9.4% of non-Hispanic whites, are living with diabetes and face the devastating consequences of the disease without proper treatment.1 The cooking and eating traditions of these ethnic groups often include nutrient-rich vegetables such as cassava (yuca), yam, taro (cocoyam), plantains, sweet potato, and white potato. Studies show traditional diets that include these vegetables are more healthful than the standard American diet and they can be safely included in a diabetes meal plan.
For example, a study in The American Journal of Clinical Nutrition found that Black and Hispanic adults with diagnosed diabetes who maintained a traditional Caribbean starch pattern, which included yuca/cassava, starchy green banana, plantains, and yautia had a more healthful dietary pattern than those who didn’t. Moreover, Hispanics who lived in the United States the longest were less likely to follow a more healthful dietary pattern. The study authors suggest that nutrition interventions for these populations should provide strategies for maintaining healthful aspects of traditional diets.2
Many starchy vegetables contain resistant starch—a type of carbohydrate that resists digestion and doesn’t increase glucose levels. Plantains, cassava, green bananas, taro, and white potatoes all contain resistant starch. In clinical studies, vegetables with resistant starch have improved insulin sensitivity and stabilized blood glucose.3
Another study in Clinical Nutrition found that adults with type 2 diabetes who ate a mixed evening meal with skinless potatoes had a lower overnight blood glucose response compared with a dinner including low-GI basmati rice. Of note, in this study, potatoes that were cooked and cooled (which increases resistant starch) produced a low glycemic response.4
Understanding how traditional starchy vegetables show up on the plate is the first step in helping clients and patients maintain cultural traditions and rediscover the food they love.
African Cuisine
“Starchy vegetables are a mainstay of African cuisine, with most countries on the continent including at least one starchy vegetable in local meal patterns,” says Los Angeles–based Cordialis Msora-Kasago, MA, RDN, regional nutrition manager for Sodexo. Cassava, taro, and yam—not to be confused with the southern yam or sweet potato—are the most commonly consumed starchy vegetables. But sweet potatoes and plantains also are enjoyed. Msora-Kasago, who’s from Zimbabwe, says, “It’s not uncommon for Zimbabweans to enjoy cassava, sweet potato, or pumpkin with a piping hot cup of tea for breakfast or midday snack.”
Starchy vegetables also are dried and milled into flour and used to create staples. “Throughout southern and eastern Africa, maize meal is used to make a thick porridge that’s accompanied by a stew and leafy greens. This porridge is known by names such as sadza in Zimbabwe, pap in South Africa, nshima/nsima in Zambia and Malawi, and ugali in East African countries, including Tanzania, Uganda, and Kenya,” Msora-Kasago says. Since many nutrition professionals are unaware of these food traditions, Msora-Kasago offers the following counseling tips:
• Balance the plate. Sometimes individuals don’t feel as though they’ve eaten a meal unless it includes their favorite starchy staple. Instead of eliminating it, focus on what they can add to their plate to create balance.
• Be flexible. Understand that the plate method, while valuable in promoting an overall healthful eating pattern, may not always work for some meals. For instance, a patient may enjoy sadza with fermented milk for a meal and can’t include vegetables. Give the patient the skills needed to include these favorites while ensuring balance at other meals.
Caribbean Cuisine
Starchy vegetables, known as provisions, are ubiquitous in the Caribbean. “Plantains are a popular starchy vegetable that can be found on many Caribbean islands of African, Latino, and Indian influence,” says Kimberley Rose-Francis, RDN, CDCES, CNSC, LD, clinical nutrition manager with HCA Healthcare in central Florida. You’ll find plantains on the menu for breakfast, lunch, dinner, and even for a snack. “At breakfast, plantains may come in the form of a sweetened porridge. It can also be boiled, mashed, or sautéed in oil to accompany scrambled eggs. For lunch and dinner, plantain may be a side dish that’s fried until golden brown to accompany a meat entrée that may or may not have a nonstarchy side,” says Rose-Francis, a native of Jamaica.
“Cassava [also known as yuca] is another popular starchy provision found in the Caribbean diet. One of the many cassava uses is flour that can be made into bread and sweet dessert items. Cassava can also be prepared as a savory dish eaten for breakfast, lunch, or dinner by simply boiling it in a pot of salted water. It can also be eaten plain, added to soup, or fried in a skillet,” she says.
Rose-Francis offers the following counseling tips for RDs:
• Suggest the perfect pairings. Clients should be encouraged to pair plantains with a nonstarchy vegetable and a lean meat source.
• Suggest smaller portion sizes and teach clients and patients about mindful eating. Both strategies will help them avoid overindulgence, especially with cassava-rich sweets.
Chinese Cuisine
“Lotus root, pumpkin, sweet potato, taro, and white potato are common starchy vegetables found in Chinese cuisine,” says Ka Hei Karen Lau, MS, RDN, LDN, CDCES, a nutrition educator for the Asian American Diabetes Initiative at Joslin Diabetes Center in Boston.
These vegetables, high in carbohydrate, often are eaten as one of the ingredients in an entrée or as a side dish, such as a hot and sour potato stir-fry made with julienne potatoes, dried chili, Sichuan pepper, and black rice vinegar. In Chinese cuisine, white potatoes generally are cooked as a savory dish. But, Lau says, “starchy vegetables also can be used to make sweet soup and eaten as a dessert. For example, sweet potato sweet soup is a pretty easy recipe; just boil the water, dice the sweet potato into large pieces, toss in a few slices of ginger, and sweeten it to your taste.”
Lau offers the following counseling tips for dietitians:
• Reduce other high-carb foods. Ask your client to reduce the amount of rice, noodles, or other carbs they’re eating to allow them room for starchy vegetables. If they’re using a small bowl to eat, use the bowl as a measuring tool to help them gauge how much of these carbs they can have in the meal. If they don’t use a bowl to eat, use their fist as a gauge instead.
• Ask the right questions. Be mindful that many people, particularly Chinese, mistakenly believe pumpkin and sweet potatoes can treat their diabetes. So when doing a food recall, ask whether they consume starchy vegetables as part of their meals and how often. Then make sure they understand that pumpkin and sweet potato are high in carbohydrate and will increase blood glucose.
Dominican Cuisine
In the Dominican Republic, many people eat root vegetables, such as yuca, daily for lunch or dinner. “Yuca is one of my favorite root vegetables,” says Brooklyn, New York–based Wendy Lopez, MS, RD, CDCES, cofounder of Food Heaven, LLC, an online source for healthful recipes and nutritious living, as she recalls spending summers in the Dominican Republic on her family’s farm where they grow yuca.
Lopez says individuals can mash, boil, fry, and roast yuca, or prepare it in other ways. “I typically enjoy it with fried cheese and eggs, sautéed onions, and a side of vegetables,” she says.
Yuca shows up on the plates of Dominicans for breakfast, lunch, and dinner. Yuca mash, made with yuca, salt, and butter, is enjoyed with eggs for breakfast. Yuca fritters (arepitas de yuca), made with yuca, eggs, anise, herbs, salt, and butter, usually are eaten as an appetizer for lunch. And yuca pie (pastelon de yuca) is a savory dish that can be enjoyed both as an appetizer or main dish. “Yuca pie is made with yuca and whatever you want to stuff it with. It can be cheese, chicken, [or other] meat, or you can get creative and make a vegetarian version with lentils,” Lopez says.
Lopez offers the following counseling tips for RDs:
• Celebrate yuca as a nutritious carbohydrate that clients can enjoy with other foods that contain protein, fiber, and fat.
• Suggest healthful combinations. Instead of just having yuca fries or a yuca fritter, suggest pairing yuca with eggs, avocado, meats and seafood, and nonstarchy vegetables for a healthful meal. This way, clients feel more satisfied and are less likely to have blood sugar spikes.
Reclaiming Cultural Foods
These strategies provided by the dietitians interviewed fall in line with the Diabetes Nutrition Guidelines from the American Diabetes Association. The guidelines emphasize the need to address individual nutrition needs based on personal and cultural preferences and maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence.5
“When all is said and done, the most important thing is to allow cultural foods to remain in the diet as much as possible—no matter the disease condition,” Rose-Francis says. “Food is an expression of culture and an important link in one’s ancestral heritage.” Furthermore, evidence indicates that the quantity and type of carbohydrate consumed influence blood glucose levels and that the total amount of carbohydrate consumed is the primary predictor of glycemic response.5 “Therefore, creating nutrition prescriptions that accommodate cultural foods likely will promote adherence, reduce hyperglycemia, and improve overall health outcomes of diabetes care and management, which is the primary goal,” Rose-Francis says.
— Constance Brown-Riggs, MSEd, RDN, CDCES, CDN, is a national speaker and author of the award-winning Diabetes Guide to Enjoying Foods of the World, a convenient guide to help people with diabetes enjoy all the flavors of the world while still following a healthful meal plan.
References
1. US Department of Health and Human Services; Centers for Disease Control and Prevention. National Diabetes Statistic Report 2020: estimates of diabetes and its burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Published 2020.
2. Davis NJ, Schechter CB, Ortega F, Rosen R, Wylie-Rosett J, Walker EA. Dietary patterns in Blacks and Hispanics with diagnosed diabetes in New York City's South Bronx. Am J Clin Nutr. 2013;97(4):878-885.
3. Keenan MJ, Zhou J, Hegsted M, et al. Role of resistant starch in improving gut health, adiposity, and insulin resistance. Adv Nutr. 2015;6(2):198-205.
4. Devlin BL, Parr EB, Radford BE, Hawley JA. Lower nocturnal blood glucose response to a potato-based mixed evening meal compared to rice in individuals with type 2 diabetes [published online October 8, 2020]. Clin Nutr. doi: 10.1016/j.clnu.2020.09.049.
5. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care. 2019;42(5):731-754.