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CARBOHYDRATES The basis of Mediterranean style eating

CARBOHYDRATES The basis of Mediterranean style eating

The Double Food & Environmental Pyramid

The “Double Food/Environmental Pyramid” combines nutritional information from the Food Pyramid with findings about the impact that individual foods have on the environment. The model was created by the Barilla Center for Food & Nutrition (BCFN) to show that the foods that we have recommended to eat regularly also have the lowest environmental impact and vice versa. To learn more visit: www.barillacfn.com

FOOD AND NUTRITION: A HISTORY OF COMMITMENT AND PASSION

For over 130 years, the Italian family business of Barilla has considered eating as a moment to be shared, to be rich in experience and taste, and to help people live better.

Barilla is the company that helps maintain and improve the well-being of people, communities and the planet on which we live: • turning high quality ingredients into good wholesome foods, that are safe, nutritionally sound and meet the daily nutritional requirements of the whole family • developing products according to the Mediterranean Food Model and respecting the environment • promoting a healthy lifestyle through educational projects, activities, and events for young people and families Barilla firmly believes that the dual objective of taking care of both people and the planet is achievable. The Mediterranean Food Model is not only an

important reference point for promoting good and healthy eating habits, but also states that the foods which are good for us are the ones with the lowest environmental impact. This is shown by the Double Pyramid, which was developed in 2009 by the Barilla Center for Food & Nutrition, a non-profit think tank.

Barilla’s ambition is to double its business by 2020 through the promotion of positive and healthy eating habits, while continuing to reduce our environmental impact, in order to be “Good for You, Good for the Planet”.

CARBOHYDRATES: THE BASIS OF MEDITERRANEAN STYLE EATING

[Adaptation by Barilla from Oldways Preservation and Exchange Trust]

The Mediterranean Food Pyramid: a modern, tasty and healthy way of eating.

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Vegetables, fruit, legumes, cereals, and pasta: foods that add to the beneficial effects of Mediterranean style eating are also our main sources of carbohydrates.

ScientiďŹ c evidence from the past 50 years has shown that following a Mediterranean Diet helps protect us against the risk of developing cardiovascular disease1, can prevent certain tumors2-4, reduces the likelihood of a stroke5, seems to promote a long life6, improves brain performance7 and helps maintain good health8. In 2011, UNESCO declared the Mediterranean Diet as an Intangible Cultural Heritage of Humanity.

WHERE ARE CARBOHYDRATES FOUND? Natural sources of carbohydrates are foods such as: cereals, pasta, bread fruit and fruit juices vegetables milk and dairy products Other foods such as sweets and drinks that contain added sugars.

Typical foods in the Mediterranean Diet include vegetables, legumes, cereals, fresh and dried fruit9 and all sources of carbohydrates. The basis of the Mediterranean style diet is therefore made up of carbohydrates, as shown by the two largest segments of the well-known Food Pyramid.

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THE MAIN TYPES OF CARBOHYDRATES

In food there are different types of carbohydrates, simple and complex, depending on the type and number of molecules of which they are composed.

Carbohydrates are the main source of energy in our food. Our body uses carbohydrates to obtain glucose, the “fuel” that provides the energy needed for it to function. The body can either consume it immediately or store it in the liver to use when necessary.

Depending on the type and number of molecules of which they are composed carbohydrates can be categorized as either simple or complex.

SIMPLE CARBOHYDRATES Simple carbohydrates, commonly known as sugars, are monosaccharides and disaccharides, made up of one or two molecules of simple sugars.

MONOSACCHARIDES Glucose: an ingredient of both table sugar, sucrose, and complex carbohydrates.

Fructose: the sweetest sugar and found in honey and fruit.

Galactose: the most similar to glucose, is not very sweet and found in milk and dairy products.

DISACCHARIDES Disaccharides are made up of two types of monosaccharides: Sucrose: made up of glucose and fructose, known as common table sugar.

Lactose: (galactose + glucose) is found in milk and dairy products.

Maltose: made up of two glucose molecules and found in flour.

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COMPLEX CARBOHYDRATES OR POLYSACCHARIDES Complex carbohydrates are made up of long chains of interconnected monosaccharides.

The main complex carbohydrates are:

Foods:

Grams per 100g of product

Corn flakes (low-sodium)

88.8

White rice (uncooked)

79.15

Whole wheat pasta (uncooked)

75.03

Kidney beans (uncooked)

60.0

White bread

50.0

Glycogen: an energy reserve for animals and humans, present in the liver and in the muscles.

Wholemeal bread

42.71

Rice noodles (cooked)

24.01

Dietary fibers: non-digestible complex carbohydrates. They are divided into soluble fibers, such as pectin, and insoluble fibers, such as cellulose and lignin.

Vanilla Ice cream

23.60

Potatoes (boiled)

20.13

Apples (unpeeled)

13.80

Onions (boiled)

10.15

Red cabbage (raw)

7.37

Sweet pepper (raw)

6.03

Mozzarella (whole milk)

2.19

Starch: an energy reserve for plants and has a granular shape, with size and dimensions depending on plants from which it derives. Its digestibility is inversely proportional to the size of the granules.

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Carbohydrate content of certain foods 10

The Magic of Starch Take a handful of spaghetti and throw it into boiling water. The rigid pieces quickly become softer, bend and increase in volume. We take this behavior of pasta for granted when it’s added to hot water, but what exactly happens to the structure of the spaghetti to cause this change? The ďŹ rst answer is that pasta, like rice, potatoes or bread, contains a large amount of starch.

But what is starch? Starch is a storage compound that accumulates in the seeds of plants. The starch is made up of long chains of glucose and is granular in structure. The raw starch granules are so dense that they are difďŹ cult to digest. This source of essential energy can only be accessed once cooked, making it easier to digest.

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HOW WE USE CARBOHYDRATES Carbohydrates, consumed via foods, are the main source of energy for the body

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A proper diet must satisfy two needs: provide energy, in particular through carbohydrates and fats, and provide all the nutrients (protein, vitamins and minerals) needed for the body to function.

CARBOHYDRATES, A SOURCE OF ENERGY All carbohydrates are used to produce energy. Glucose itself is one of the main sources of energy used by all body cells, as well as being the only source for red blood cells and the nervous system. Its availability is crucial for the correct functioning of these tissues. A lack of glucose can have serious consequences for one’s health. It has been calculated that, under normal circumstances, an adult needs about 180 grams of glucose per day, from any source, in order to meet the body’s energy needs. (FAO, 1980) BUT HOW DO WE OBTAIN GLUCOSE? Glucose is derived by the digestive system through the absorption of carbohydrates in foods.

For carbohydrates to be absorbed, they must first be digested, broken down into single units or monosaccharides. Once ingested, carbohydrates undergo the digestion process by various enzymes.

These are proteins capable of reducing more complex substances (such as starch) into simple units (such as maltose), so it becomes available for the body’s needs.

Carbohydrates contained in food

Digestion and absorption Storage of glycogen Gluconeogenesis from enzyme activity

Amino acids

Number of enzymes

Liver

Muscles

Glycerol

Fat Glucose

Protein degradation Protein synthesis Glucose usage Insulin sensitivity

Glucose usage Insulin sensitivity Lipolysis

Metabolism of carbohydrates taken with food and the destination of glucose.11

The process of digesting carbohydrates begins in the oral cavity and is completed in the duodenum, which “transforms” carbohydrates into simple sugars or monosaccharides.

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FROM FOOD TO GLYCEMIC RESPONSE: A 6 STEP JOURNEY

The body is able to use or store glucose through a series of complex metabolic processes in which insulin plays a key role.

1. Monosaccharides such as glucose are absorbed to a small extent by the stomach and for the most part by the small intestine, where they pass into the bloodstream through the intestinal villi.

2. Through the bloodstream, glucose is able to reach all areas of the body (brain, red blood cells, skeletal muscle, cardiac muscle, etc.) and be used by the cells of these organs and tissues to produce energy. The amount of glucose in the blood and its use by the cells is regulated by insulin, a hormone produced by the endocrine part of the pancreas.

3. Insulin works as a door allowing glucose to enter the cells, as it binds to specific structures present on the cell wall (insulin receptors). In this way, the glucose is literally “taken out of circulation”, reducing its level in the blood (glycemia or blood sugar). Without insulin, the glucose continues to circulate, increasing blood sugar levels and depriving cells of their primary source of energy.

4. Glucose in excess of the energy needed by the body is captured mainly by the liver and the muscles and stored there, thanks to insulin. The individual glucose molecules are added to the polysaccharide chains glycogen, already present in the liver and in the muscles, and forms an energy store (the so-called medium-term energy reserves). The additional carbohydrates in excess of caloric needs are instead converted into fat and stored in the fat tissue (long-term energy reserves).

5. After the intake of food containing carbohydrates, the glucose level detected in the blood (blood sugar) is adjusted. This is called the glycemic response.

6. With continued overeating, the body’s cells gradually lose their sensitivity to insulin (insulin resistance). The “door” no longer functions and the glucose can no longer enter the cells, but remains in circulation, resulting in a permanent increase in glucose levels in the blood. This condition is often seen in obese people. It’s been found that excess weight reduces the sensitivity of the tissues to insulin.

(Source: Nutrition Foundation of Italy12)

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NOT ALL CARBOHYDRATES ARE THE SAME

When chosing carbohydratecontaining foods, we have to consider that all carbohydrates are not the same.

Increased importance is now placed on the quality of carbohydrates, as it influences the effect carbohydrates have on the body.

WHAT DEFINES THE QUALITY OF CARBOHYDRATES? The quality of carbohydrates comes from: 1. Absorption rate, defined by the glycemic index 2. Content of dietary fiber and whole grains.

1. Absorption rate The glycemic index allows us to distinguish between: • Slowly absorbed carbohydrates that have a lower glycemic response, causing glucose levels to rise slowly and helping induce a feeling of satiety = low glycemic index (GI).

• Rapidly absorbed carbohydrates that raise glucose and insulin levels in the blood very quickly = high glycemic index.

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The best foods for glucose metabolism and for health, such as pasta cooked “al dente”, vegetables (but not potatoes) and fruit, are absorbed more slowly and correspond to a low glycemic index (GI): less than 55.

Foods with a high glycemic index (greater than 70) cause insulin levels in the blood to rise, leading to an increase in fat storage, higher levels of triglycerides in the blood, increased appetite and, over time, resistance to insulin.

2. Fiber content in food A diet high in carbohydrates and fiber (more than 30 grams of fiber per day) gives positive glycemic control.13 The foods richest in fiber are: • fruits, legumes and oats (sources of soluble fiber) • foods made from whole grains, wheat bran and vegetables.

GLYCEMIC INDEX (GI) Determines the value of carbohydrates, with a scale ranging from 0 to 100, in order to distinguish those that are digested, absorbed or metabolized rapidly (high GI) from those which are slowly digested (low GI).

The GI quantifies specific physiological properties of carbohydrates-containing foods, including delayed gastric emptying and a reduction in the digestion and absorption rate of the intestine.

GLYCEMIC LOAD (GL) Determines the quality of carbohydrate (and therefore its GI) and the amount present in the average portion of a certain food (a slice of wholemeal bread), a recipe (for example, pasta with vegetables) or a complete meal. It is calculated by multiplying the grams of available carbohydrate in an average portion of food by the glycemic index of that food and dividing it by 1000 kJ. It’s the best predictor of glycemic response to food.

GLYCEMIC RESPONSE Describes how the levels of glucose detected in the blood are changed after eating carbohydrate-containing foods. Glycemic response varies from person to person and is influenced both by individual foods as well as lifestyle (physical activity, metabolism etc...)

(Source: Nutrition Foundation of Italy14)

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The glycemic index (GI) of certain foods 14 Food:

GI (g)

Sugar

100

Potatoes

87

Cornakes White bread

72

Pizza

62

Ripe bananas

62

Oranges

45

Pasta

36-51

Beans

30-43

Lentils

22-30

Tomatoes

16

72-78

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As with food composition tables, it has been suggested that a low glycemic index be indicated on food packaging.12

Glycemic response 15

High GI

Blood glucose level

Major international organizations, including the World Health Organization, recommend that both the glycemic index and the glycemic load be included in national dietary guidelines.

Low GI

1 Time/hours Levels of glucose in the blood after eating foods that have a high or low glycemic index.15

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What the experts say An international committee of experts, the “Carbohydrate Quality Consortium” (CQC), met in Stresa on June 6-7, 2013 to discuss the importance of the quality and quantity of carbohydrates on an individual’s health.

Here are the key findings:12 Carbohydrates found in foods have, among other things, an important effect on blood sugar after a meal, the reduction of which is recognized as being beneficial.

One way to reduce high blood sugar after a meal is to eat slowly absorbed carbohydrates (with a low GI) and by reducing the glycemic load (GL).

The quality of carbohydrates, defined by the glycemic index and the glycemic load, is particularly important for people who are sedentary, overweight and at risk for developing type 2 diabetes.

There is convincing scientific evidence that low-GI diets: • Improve glycemic control in patients with type 2 diabetes.

• Reduce the risk of type 2 diabetes.

• Reduce the risk of coronary heart disease.

PASTA? BETTER “AL DENTE” Cooking foods that are rich in starch for a longer time in water speeds up the digestion of carbohydrates and heightens the glycemic peak after

meals. In practice, foods cooked longer have a higher glycemic index. So, for pasta and rice, it’s much better to cook them “al dente”, as do the Italians.

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THE ROLE CARBOHYDRATES PLAY IN STAYING HEALTHY

All the experts agree: carbohydrates are good for us and necessary for life. It is important to give preference to those that are complex, as found in whole grains, legumes, vegetables and fruit.

Maintaining an adequate amount of glucose in the blood (blood sugar) after meals is one of the requirements for staying healthy and preventing many diseases. For this reason, both the quantity and quality of carbohydrates taken in through food are very important.

CARBOHYDRATES ARE NECESSARY For healthy eating, carbohydrates are necessary.

All the experts agree: a reasonable percentage of our energy needs should be derived from carbohydrates. In practice, more than half (55%) of our total calorie intake should come from carbohydrates. In a diet that provides 2,000 calories per day, it is therefore recommended to have between 225g and 325g of carbohydrates, with less than 50g of this coming from added sugars. Additionally, our daily diet should include between 25g and 38g of foods that are rich in fiber.16

HOW TO KEEP YOUR ENERGY IN BALANCE Energy or caloric balance is one of the key factors for maintaining good health, eating food in the right quantity and quality. Just like a balance sheet, with energy there is the difference between input and output, between the amount of energy taken in and that used up for normal bodily functions and day-to-day activities. When energy expenditure (measured in kilocalories) is equal to energy taken in, the energy is in balance. That’s why carbohydrates play such an important role. They are the body’s fuel, because, once consumed, carbohydrates are transformed into the glucose that gives us energy.17

Consumption

Absorption

Physical activity

Fats

Thermogenesis

Carbohydrates

Resting metabolism

Proteins

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Be careful with ‘low-carb’ diets Reducing, or worse, completely removing foods containing complex carbohydrates is not good for a healthy heart or for our metabolism. Moreover, any weight loss achieved by reducing essential food components, such as complex carbohydrates, undermines us in the long run and instead increases cardiovascular risk factors.

It’s better to “tailor” our food model based on personal preferences and our metabolism, as recommended by the Mediterranean Diet.18 Some high-protein low-carb diets19

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Scarsdale

A low-calorie diet (850 kcal to 1200 kcal per day), low in carbohydrates and fats.

Distribution of macronutrients: protein 43%, carbohydrate 34.5%, fat 22.5%.

By excluding certain foods, you are likely to run into nutritional deficiencies.

Atkins

Based on the principle of ketogenesis, producing energy from protein and fat, with a strong limitation of carbohydrates. It’s a way of eating that is difficult to maintain as a healthy and balanced diet.

Dukan

A ketogenic and low-calorie diet, where the first phase is limited to protein foods only. It’s likely to induce improper eating habits that can lead to health risks.

Paleo Diet

Based on the nutrition that primitive cavemen would have followed before the discovery of agriculture, it’s centered on the regular consumption of lean meats, fish, dried fruit, fresh fruit and vegetables. In the long term, can lead to health risks because the intake of carbohydrates and proteins are unbalanced.

South Beach

Involves eating eggs, fish and lean meats, low fat dairy products, some legumes, vegetables (but not all), a little dried fruit and sweeteners. Fruit is not allowed.

Promotes bad food habits that are not nutrionally healthy.

WHAT SHOULD WE DO: THE 12 RULES OF MEDITERRANEAN STYLE EATING

1 23 4 5 6 7 8 9 10 11 12

A healthy lifestyle includes a healthy diet, based on the Mediterranean Food Model, with the right amount of carbohydrates and fiber, but also regular physical activity:

Vary the ingredients: choose the quantity and quality of food to be consumed during the week, following the Food Pyramid.

Consume between 225g and 325g of carbohydrates per day, focusing on whole grains, vegetables and fruits. For example: 1 serving of cooked mixed vegetables (peppers, onions, peas = 50g) + 1 portion of pasta (about 45g) + 2 slices of wholemeal bread (48g) + 1 portion of fruit (apples = 16g), which equals 180g.10,20 Do not exceed the 50g of carbohydrates coming from added sugars, such as sucrose.

For example, 1 portion of snacks + 1 portion of sweetened cereal + 1 portion of biscuits + 1 ice cream does not exceed 42g of sugars.21 Include 25g to 38g of dietary fiber in your daily diet. For example, 3 slices of wholemeal bread a day contain a little under 20g of fiber, 1 portion of boiled artichokes contains about 8g.

Eat less but more often, according to the 1+2+2 formula: five meals a day including breakfast, two snacks and two main meals.

Spread different types of foods between the two main meals.

Use extra virgin olive oil.

Limit meat consumption (no more than 3-5 times per week) and give priority to eating fish (at least 2-3 times a week).

Limit added salt to food during cooking or seasoning.

Limit the intake of alcoholic beverages.

Choose water over sugary drinks.

Do at least 30 minutes of physical activity each day (walking briskly, cycling, etc.).10,13,22

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It is important to focus on complex carbohydrates (whole grains, vegetables and fruits) and limit intake of simple sugars (in soft drinks and sugary foods)

THE BENEFITS OF PHYSICAL ACTIVITY Nutrition and exercise are two fundamental aspects for the prevention of diseases, such as obesity, diabetes and cardiovascular disease. A common characteristic of healthy nutrition and physical exercise is establishingg a routine, which is essential for maintaining a correct rrect long-term lifestyle. Those who are in the habit of walking or cycling at least 4-5 times

per week (and not smoking) have almost half the risk of a heart attack.22 Movement is one of the most important things for good health, as it helps keep the energy balance under control. Physical y activityy is needed to burn calories, release stress, and improve mood m and 23 psychological well-being.

1-2 times per week a more intense and demanding activity FOR A SPORTIVE LIFESTYLE Aerobics, tennis, football, running

2-4 times per week FOR A MORE ACTIVE LIFESTYLE Gymnastics, swimming, dancing, volleyball, cycling, jogging, about an hour at a time

TO COMBAT A SEDENTARY LIFESTYLE At least 6 times a week: 30 minutes walk TO IMPROVE YOUR LIFESTYLE Park farther away, use public transportation, use the stairs instead of the elevator, walk to work, do the housework, walk the dog

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REFERENCES AND SOURCES

1. Estruch R, Ros E, Salas-Salvadó J et al. N Engl J Med. 2013 Feb 25.

2. Couto E, Boffetta P, Lagiou P et al. Br J Cancer. 2011 Apr 5.

3. Agnoli C, Grioni S, Sieri S, et al. Int J Cancer. 2012 Jul 23.

4. Kyriacou K. BMC Cancer. 2012 Mar 23;12(1):113.

5. Kastorini CM, Milionis HJ, Ioannidi A et al. Am Heart J 2011; Oct;162(4):717-24. Epub 2011 Sep 14.

6. Tognon G, Rothenberg E, Eiben G et al. Age (Dordr). 2011; 33(3):439–450.

7. McMillan L, Owen L, Kras M, Scholey A. Appetite. 2010 Nov 26. [Epub ahead of print].

8. Panunzio MF, Caporizzi R, Antoniciello A et al. Ann Ig. 2011;23(1):13-25.

9. Sofi F, Abbate R, Gensini GF, et al. Eur J Nutr. 2011 May 4. [Epub ahead of print].

10. USDA, National Nutrient Database. http://ndb.nal.usda.gov/ndb/search/list [Ult. acc. 12.11.2013].

11. Barret KE, Boitano S, Barman SM, Beooks HL. Ganong’s Review of Medical Physiology; pagg. 349 e segg. Piccin 2011.

12. NFI. Glycemic index, glycemic load and glycemic response: an international scientific consensus summit. Stresa, June 2013.

13. BCFN. Healthy growth and nutrition in children Parma 2010.

14. NFI. Carbohydrates and glycemic index. http://www.nutrition-foundation.it/monografie/Carboidrati-ed-indice-glicemico.aspx (ult. acc.

10.12.2013) (ult. acc. 18.09.2013) 15. Glycemic index Foundation. http://www.gisymbol.com/about/glycemic-index/. Ult. acc. 12.11.2013.

16. SINU. Carbohydrates and dietary fiber. http://www.sinu.it/larn/carboidr.asp. Ult. acc. 12.06.2013.

17. Mannhart C, Mäder U, Sportwissenschaftliches Institut, Bundesamt für Sport, Magglingen. www.suissebalance.ch_logicio_client_ suissebalance_fi le_Grundlagen_Energiebilanz_it.pdf.

18. Wylie-Rosett J, Aebersold K, Conlon B et al. Curr Diab Rep. 2012 Dec 25. [Epub ahead of print].

19. Altroconsumo, April 2013. http://www.altroconsumo.it/alimentazione/dimagrire/speciali/diete.

20. SINU. Calculating Portions. http://www.sinu.it/larn/annesso2.asp. Ult. acc. 16.06.2013.

21. Altroconsumo. http://www.altroconsumo.it/alimentazione/dimagrire/speciali/zucchero-energia-e-calorie. Ult. acc. 12.06.2013.

22. FIPC, Know your numbers, 2008.

23. BCFN. Double Pyramid 2012. Enabling sustainable food choices. Parma 2012.

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