X

A New Carbohydrate Food Quality Scoring System to Reflect Dietary Guidelines: An Expert Panel Report

by Adam Drewnowski, Matthieu Maillot, Yanni Papanikolaou, Julie Miller Jones, Judith Rodriguez, Joanne Slavin, Siddhartha S. Angadi and Kevin B. Comerford

Abstract

Existing metrics of carbohydrate food quality have been based, for the most part, on favorable fiber- and free sugar-to-carbohydrate ratios. In these metrics, higher nutritional quality carbohydrate foods are defined as those with >10% fiber and <10% free sugar per 100 g carbohydrate. Although fiber- and sugar-based metrics may help to differentiate the nutritional quality of various types of grain products, they may not aptly capture the nutritional quality of other healthy carbohydrate foods, including beans, legumes, vegetables, and fruits. Carbohydrate food quality metrics need to be applicable across these diverse food groups. This report introduces a new carbohydrate food scoring system known as a Carbohydrate Food Quality Score (CFQS), which supplements the fiber and free sugar components of previous metrics with additional dietary components of public health concern (e.g., sodium, potassium, and whole grains) as identified by the Dietary Guidelines for Americans. Two CFQS models are developed and tested in this study: one that includes four dietary components (CFQS-4: fiber, free sugars, sodium, potassium) and one that considers five dietary components (CFQS-5: fiber, free sugars, sodium, potassium, and whole grains). These models are applied to 2596 carbohydrate foods in the Food and Nutrient Database for Dietary Studies (FNDDS) 2017–2018. Consistent with past studies, the new carbohydrate food scoring system places large percentages of beans, vegetables, and fruits among the top scoring carbohydrate foods. The whole grain component, which only applies to grain foods (N = 1561), identifies ready-to-eat cereals, oatmeal, other cooked cereals, and selected whole grain breads and crackers as higher-quality carbohydrate foods. The new carbohydrate food scoring system shows a high correlation with the Nutrient Rich Food (NRF9.3) index and the Nutri-Score. Metrics of carbohydrate food quality that incorporate whole grains, potassium, and sodium, in addition to sugar and fiber, are strategically aligned with multiple 2020–2025 dietary recommendations and may therefore help with the implementation of present and future dietary guidelines.

Read full article

The Need for Nuance: Carbohydrate Quality Is Much More Than the Glycemic Index

There is no globally accepted definition of carbohydrate quality – no equation, algorithm, or succinct way of identifying the quality of a carbohydrate-containing food, meal, or diet. Unlike protein and fat – where deficiency can lead to serious and even life-threatening situations – the physiological impacts of carbohydrate food intake are much more complex and individualized. Effects can vary with one’s lifestyle, dietary habits, health status, and age – among many other factors. Despite this complexity, carbohydrate dietary guidance often heavily relies upon a single, simplistic marker – Glycemic Index (GI) – despite its notable flaws and application limitations.

The Alliance for Potato Research and Education interviewed a select group of carbohydrate experts to better understand how the carbohydrate quality debate got to where it is today. This is the second of two articles exploring this topic – read the first article here.

Glycemic Index is an oversimplified approach with unintended consequences

Since it was developed in the 1980’s, the GI has been used as a simple surrogate for glycemic response – which was then made a measure of carbohydrate quality. Yet, over the decades, numerous scientific studies and nutrition experts have indicated that although the GI has its utility in a clinical or laboratory setting, this metric has significant shortcomings that make it a less-than-optimal measure of carbohydrate quality for consumers.

For one, experts argue that GI is a narrow indicator. Jamie Baum, PhD from the University of Arkansas states that “GI alone is not the right tool to determine the quality of a carbohydrate food. Among other things, it fails to account for total nutrition – the vitamins, minerals, fiber, and protein – in a food.” According to Julie Miller Jones, PhD, professor emeritus from St. Catherine’s University, negative health consequences can arise from selecting foods solely based on GI. “Some low-GI foods are high in fat and fructose, and elevated intake of many of these foods is not advisable. Meanwhile, avoiding breads and cereals – especially whole-grain versions – based on their high GI value might lead to low intake of cereal fiber, a dietary component associated with lower risk of cardiovascular disease and obesity. While avoiding potatoes due to GI concerns means missing out on a food that has a high satiety value and is a low-cost source of fiber and potassium.”

Even as a research tool, GI has its limitations. Several studies suggest that the GI is difficult to replicate, even in the same person following the same protocol. While researchers have gotten better over the years with standardizing procedures to minimize variability, people in the real world don’t live in the regimented way of a laboratory setting. Human routines often differ from day-to-day or week-to-week. Consequently, the GI results gathered under rigid lab conditions rarely reflect the actual response in free-living situations. 

Dr. Brooke Devlin, PhD from Australian Catholic University pointed out several confounders that make reliance on GI a dubious endeavor. “In the laboratory, the GI of a food is assessed by testing that food in isolation, and not as part of a meal. This is not how people eat in the real world. In addition, GI is usually tested in healthy subjects in the morning, limiting its utility for people with type 2 diabetes or in assessing its effects when eaten at different times of the day, including before or after meals. Finally, GI in the lab is based on the body’s response to 50 grams of available carbohydrate in a food. In order to consume 50 grams of available carbohydrate, one would have to eat an entire mini watermelon or unreasonable quantities of many other foods. The volume of food required to obtain a GI value could certainly produce a false perspective of the food’s impact on the body in normal circumstances.” 

Nick Bellissimo, PhD from Ryerson University in Toronto further elaborates on the concern with applying the GI to real-life settings, where mixed meals are typically eaten, and different preparation techniques are used. He explains, “a small amount of butter or oil added to a high GI food can greatly reduce the glycemic response to that food and, consequently, its GI. Additionally, evidence shows that two forms of the same food can lead to highly different glycemic responses – such as choosing a store-bought frozen potato product versus a homecooked potato. This makes GI an inadequate tool for representing the highly varied food options chosen by consumers today.”

For all these reasons, Richard Bruno, PhD, RD – a nutrition scientist at The Ohio State University – says, “I don’t put too much stock in the GI as a marker of carbohydrate quality. In a research setting, including my own where we study acute hyperglycemia on vascular dysfunction, GI is a helpful tool to model responses to isolated foods or to induce a physiological effect. However, it is nearly impossible to predict the GI of a mixed food based on its macronutrient composition. There are too many variables in play including carbohydrate type, and interactions with other dietary constituents.”

Research and guidance must move beyond GI to consider other impacts on health – both glycemic and otherwise

While carbohydrate-containing foods have often been classified according to their GI value, this solitary and flawed focus needs to shift. According to Siddhartha Angadi, PhD, a cardiovascular exercise physiologist and assistant professor at the University of Virginia, carbohydrates may not even be the most concerning macronutrient for insulin resistance and impaired glucose tolerance. “Physiologists have known for close to a century that if you want to make someone insulin resistant or worsen glucose tolerance in a clinical laboratory setting, you feed them an excess amount of fat (especially saturated fat) – not carbohydrates,” explains Dr. Angadi. “The decades-long focus on defining carbohydrate foods based on GI therefore needs to shift to better health indicators, especially when considering outcomes related to chronic disease.”

Of course, it is important to note that the health impact of a carbohydrate-containing food is not just related to its nutritional components. Dr. Angadi explains that “factors such as genetics, physical activity, sex, age, and body mass index can have just as much of an impact on the body’s metabolic response as the food itself.” Meanwhile, individual choices such as food preparation techniques or specific meal combinations can also have a notable impact, as explained by Dr. Bellissimo.

Developing a new definition for quality carbohydrate-containing foods thus requires a shift away from the singular focus on GI towards a more holistic approach. While focusing on the nutritional value of a food is an important first step in defining quality, the approach must also recognize the need for individualistic adaptations based on personal lifestyle choice and genetic factors. Only then can a quality carbohydrate definition be a truly valuable tool in helping consumers choose the right foods that promote their health.

The Need for Nuance: Nutrition Researchers Dig into What’s Needed for Future Carbohydrate Guidance

Carbohydrates are a diverse group of compounds, ranging from simple monosaccharides – such as glucose and fructose – to various types of polysaccharides, like starch and dietary fiber. And, the foods that contain them are even more diverse – from highly nutrient-dense and health-promoting, to energy-dense and potentially detrimental to human health. Despite this diversity, the role that carbohydrates play in human health and nutrition is often overly reduced to a source of calories, frequently assumed to have the same function in the body and the same impact on health – and without consideration of other important determinants of health like food access, cost and cultural acceptance.

The Alliance for Potato Research and Education interviewed a select group of carbohydrate experts to better understand how the carbohydrate debate got to where it is today, and what the research community and health professionals can do to provide clarity and enhance understanding of the nutritional role carbohydrates play in our diet.

Nuanced carbohydrate guidance is needed

According to Jamie Baum, PhD, a nutrition scientist from the University of Arkansas, “There is a wide knowledge gap between what nutritional scientists understand about carbohydrates, and what consumers believe about carbohydrates. There is a need to educate consumers about nutrient-dense carbohydrate foods that contain high amounts of fiber, vitamins and minerals, and food sources that contain a lot of added sugar and refined carbohydrates with little-to-no additional nutrients.”

Part of this knowledge gap stems from a lack of nuance in current carbohydrate guidance. While the Dietary Guidelines for Americans recommends people consume nearly two-thirds of calories from carbohydrates, with some advice around fiber and added sugar specifically, in general, the advice is simplistic. The research and public health communities have more nuanced recommendations for the other macronutrients (protein, fat), usually including specific guidance on the subtype of macronutrient (i.e., unsaturated vs. saturated fat, complete vs. incomplete protein) and the food sources of these macronutrients (i.e., plants, animals). Such detailed advice does not yet exist for carbohydrate-containing foods.

Dr. Baum suggests we think of carbohydrate quality in a similar way to how we think about protein – in terms of the nutritional value. Indeed, nutrition is a foundational pillar for any definition that identifies quality sources of carbohydrates, but other non-nutritive social determinants of food decisions and health should also be considered as well.

Current carbohydrate indicators need to be reexamined

Several different sources of data and contextualizing factors are required to understand carbohydrate’s role in the diet and provide dietary guidance. The current scientific dialogue focuses on just a few and, some would argue, flawed sources and indicators of carbohydrate quality. In fact, a recently published article outlines at least 20 factors that should be taken into consideration when defining carbohydrate quality, including the nutritional value of the food in question, the biological and metabolic changes it promotes, and the cost and accessibility of the food. Brooke Devlin, PhD, the clinical research officer at the Australian Catholic University in Australia, emphasized that she doesn’t “[think] there is necessarily one metric that is most meaningful in defining carbohydrate quality. We need to take into consideration several factors.”

However, carbohydrate dietary guidance often relies on a single metric, the measurement of a food’s Glycemic Index – which does not consider the multitude of ways a carbohydrate-containing food can impact health. Nick Bellissimo, PhD, a nutrition scientist at Ryerson University, questions the over-reliance on GI, a measurement of how one food consumed in isolation impacts glycemic changes in the hours following consumption of that food, to develop food-based guidance. “The field must move beyond a GI-based approach for judging carbohydrate quality,” suggests Dr. Bellissimo. Instead, he proposes we take a different approach. “Food and function studies (e.g., satiety, cognition, performance) are needed that investigate carbohydrates first in isolation, secondly within mixed meals, and then followed by studies investigating a dietary patterns approach on functional markers of interest.” See more detail on the limitations of GI here.

The current dialogue has created confusion about carbohydrate sources, like the potato

As one example, Dr. Devlin notes that potatoes are often the victim of reductionist carbohydrate guidance. “Despite being a vegetable, potatoes are sometimes associated negatively with carbohydrates.” Dr. Baum agrees, suggesting that the nutritional value of white potatoes is misunderstood, as is the myriad of ways that potatoes can be prepared and consumed. The white potato is a nutrient-rich vegetable, an excellent source of vitamin C and a good source of potassium. It is also a high-quality source of carbohydrates, like resistant starch, as well as a source of high-quality protein, on par with many animal proteins. While white potatoes have a reputation for negatively impacting glycemic response, Dr. Bellissimo explains that “recent experimental trials show benefits of consuming potatoes on many functional outcomes that are uncoupled from their glycemic response; and glycemic response to various forms of potatoes has been shown to be low-to-moderate in both young and elderly adults.”

Where do we go from here?

So how do we ensure that consumers know which carbohydrate-containing foods are the most nutritious and the highest quality? Adding more nuance to carbohydrate guidance while needed, is a big undertaking, requiring multi-stakeholder input and support. More importantly, it must be led by a multicultural diverse group of researchers who are experts in nutrition, carbohydrates and diverse populations so that realistic and relevant guidance is developed.

Recent Review Shows Potatoes are a Top Source of Resistant Starch

A recent narrative review was published in the Journal of the Academy of Nutrition and Dietetics that identified food sources of resistant starch, an indigestible fiber linked with numerous health benefits.  Potatoes were identified as a top source, especially when cooked and then chilled. The authors also found that the enrichment of processed foods with resistant starch may be one way to improve intake and enhance a foods’ nutritional profile, without losing sensory appeal. The database the authors developed is intended to help health practitioners support patients who would benefit from increasing their resistant starch intake and to assist researchers in developing resistant starch dietary interventions.

Citation: Resistant Starch Content in Foods Commonly Consumed in the United States: A Narrative Review. Patterson, Mindy A. et al. Journal of the Academy of Nutrition and Dietetics, Volume 120, Issue 2, 230-244.