Originally published September 14, 2020 by
Healthy eating is the cornerstone of diabetes management. The cost of healthy food combined with the increasing costs of diabetes medications can be a significant barrier for optimal self-care. Patients often tell their providers that they would eat healthier, but it’s just too expensive. Although some studies have reported that healthier diets are more expensive, increasing the consumption of healthy plant-based foods does not need to be economically burdensome. Health care professionals can provide patients with guidelines on healthy plant-based eating that is delicious and affordable.
Plant-based eating has become more popular as a healthy eating pattern for the prevention and treatment of diabetes. The 2015-2020 Dietary Guidelines for Americans endorsed a vegetarian eating pattern as a guide for healthy eating. This “Healthy Vegetarian Eating Pattern” incorporates more legumes (beans and peas), nuts and seeds, soy products and whole grains compared with the “Healthy U.S.-Style Eating Pattern.”
Both observational and interventional studies have reported that plant-based diets reduce diabetes risk as well as improve diabetes outcomes.1 Plant-based eating patterns improve body weight, cardiovascular risk factors, insulin sensitivity, A1C and markers of oxidative stress, and they reduce urinary albumin excretion.1 In addition to clinical outcomes related to diabetes, patients with diabetes following a plant-based diet also have reported improvements in emotional and physical well-being, quality of life and general health.2
In response to clinical evidence, the American Association of Clinical Endocrinologists and the American College of Endocrinology (AACE/ACE) recommend a plant-based eating pattern for lifestyle treatment of type 2 diabetes.3 In a consensus statement, the American Diabetes Association documented that vegetarian and vegan dietary patterns are beneficial for the prevention and treatment of diabetes along with other studied eating patterns.4
The cost of healthy plant-based foods can be a challenge for patients with diabetes who have limited purchasing power. Individuals with food insecurity are more likely to purchase foods that cost less per calorie. These high-calorie foods have added fat, sugar and salt, lowering diet quality and contributing to disparities in nutrition and health.5
Nutrient-dense foods tend to be lower in calories. Price discrepancies between nutrient-dense and energy-dense foods have worsened in recent decades with the price of fruits and vegetables increasing 118% between 1985 and 2000, and the price of soft drinks, fats and oils, and sugars and sweets increasing 20%, 35%, and 46%, respectively.Sup>6 The energy cost of meats, eggs, fish and dairy products is less than fruits and vegetables.5 Animal products do not increase diet quality or reduce incidence of chronic disease in the way plant-based foods (including lower-cost whole grains and legumes) have been reported to do.7,8
Plant-based diets are associated with a higher diet quality, measured by the Alternative Healthy Eating Index (AHEI), when compared with other healthy eating patterns that contain animal products.9 The consumption of fruits, vegetables, legumes (beans, lentils, peas), whole grains, and nuts and seeds is emphasized in plant-based eating patterns, while animal products such as meat, poultry, fish, eggs and dairy are discouraged. High AHEI scores have consistently been associated with lower rates of cardiovascular disease, diabetes, heart failure and certain types of cancer.10
The cost of eating a healthy plant-based diet can be economical depending on the specific food choices. A group of researchers evaluated the amount of money spent on food as it relates to diet quality, measured by the AHEI score, in 78,191 subjects from Nurses’ Health Study.7 Women with the highest diet quality spent 24% more on food. The participants with the highest diet quality also had the lowest rates of angina, diabetes and hypertension. Greater spending on nuts, soy and beans, and whole grains was associated with a higher AHEI score, while spending on refined grains, snacks and sweets, and red and processed meat reduced scores. The authors concluded that AHEI scores could be greatly increased without increasing food costs if individuals purchased and consumed more nuts, soy and beans, and whole grains and spent less on red and processed meats and high-fat dairy.7
A 2015 study compared two seven-day, 2,000-calorie diets. One was a plant-based olive oil (PBOO) diet and the other was the economic version of MyPlate 2010.8 The economic version of the MyPlate meal plan was more expensive at $53.11 per person per week, whereas the PBOO cost was $38.75. The PBOO meal plan provided more servings of vegetables (44.5 vs. 19.33), fruits (34.5 vs. 30.75) and whole grains (34.0 vs. 20.0). The higher cost of the economic MyPlate came from purchasing meat, poultry and seafood. The cost of fruits and vegetables can be offset by reducing animal products. Further, fruits, vegetables and whole grains reduce chronic disease, whereas the consumption of animal products is associated with obesity, type 2 diabetes, heart disease, certain types of cancer and overall mortality.8
The ability to purchase affordable, healthy, plant-based food may be a barrier to reducing diabetes risk, improving glycemic control, and reducing risk of complications in patients who have diabetes. The prevalence of food insecurity in the United States affects one out of nine people.11 Food insecurity is associated with not only a lack of quantity of food but also a low diet quality, which further exacerbates chronic disease risk.12 People with diabetes have more medical costs than the general population, which can worsen economic burden. Patients are often forced to choose between spending money on food or medications. One out of three Americans who has a chronic illness cannot afford to buy food or medicine, or both.13
Food insecurity doubles the risk of type 2 diabetes.6 Patients with diabetes who have food insecurity often have poor glycemic control, which is worsened by intermittent times of food abundance with times of food scarcity, contributing to cycles of hyperglycemia and hypoglycemia. People with food insecurity often select inexpensive, high-calorie foods that have low nutritional quality because it’s more economical in terms of cost per calorie.6 Clinicians should assess patients with diabetes for food insecurity and make proper referrals to food and nutrition resources. See Table 1 for Food Insecurity Resources. Special attention should be paid to prevent fluctuations in blood glucose based on food availability and may include adjusting medications as well as providing education on hypoglycemia awareness and treatment.14
“Within the past 12 months, we worried whether our food would run out before we got money to buy more.” A two-item screening tool is recommended by the ADA Standards of Medical Care in Diabetes-2020:
Recommending a plant-based eating pattern to patients with diabetes who have food insecurity can be done on an individual basis through collaborative and supportive discussions. Patients who have food insecurity may have competing challenges they need to cope with on a day–to–day basis, making it more difficult for them to focus on changing dietary behaviors. However, most patients can make some improvements by increasing plant-based foods and reducing animal products and refined carbohydrates.
Patients with food insecurity may receive assistance from government programs or go to local food pantries (or both) to enhance their food purchasing ability. There are about 45 million Americans on the Supplemental Nutrition Assistance Program (SNAP), which is designed to help families who are living <130% below the poverty level.16 Individuals using SNAP often purchase high-calorie foods that are inexpensive and have a lower diet quality.14 Several longitudinal studies have found that SNAP participants have poorer clinical outcomes, such as higher BMI, waist circumference, triglycerides and fasting glucose, when compared with individuals of similar income who do not participate in the program.16 There are no nutrition requirements for the SNAP program, allowing participants to purchase sodas, candy, doughnuts and other pastries, fatty meat and cheeses, and energy drinks, as well as high-cost luxury food items.16
There have been proposals to improve the diet quality of SNAP. A Healthy Staples proposal was made to increase the diet quality of SNAP participants.16 The plan included enough food to provide 1,800 calories a day per individual with:
The cost of the plan was $121.02 per individual for one month.16 This is less than the average $194 SNAP benefit, which is meant to supplement costs, not cover entire costs. The Healthy Staples plan increased AHEI to levels that align with disease prevention. Compared with the typical American diet, this plan would provide twice as much fiber, iron, vitamin E and folate; almost twice the potassium, calcium and magnesium; almost 40% more vitamin D; and more than five times more beta-carotene.16
A healthy, affordable, plant-based diet is high in carbohydrate. Patients with diabetes are often told to avoid foods high in carbohydrate, as these foods have the greatest effect on post-prandial glucose levels. Yet studies demonstrate that a high intake of carbohydrates, such as whole grains and cereal fibers, are associated with a reduction in diabetes risk, whereas refined carbohydrates increase risk.17 Patients with diabetes have also benefited from increasing unrefined carbohydrates. An eight-week study compared a high-carbohydrate diet with a high-protein diet in patients with type 2 diabetes in which fat was kept at 30% in both groups. Both groups lost similar amounts of weight. The high-carbohydrate group had significant reductions in A1C and fasting glucose, and improvements in insulin sensitivity, none of which improved in the high-protein group.18 It is essential to educate patients adopting a plant-based diet to consume high-quality carbohydrate foods that are high in fiber, vitamins, minerals, antioxidants and phytochemicals, and low in added sugars, fats and sodium. And, initially, more frequent self-monitoring of blood glucose can identify how the new eating pattern may change glycemic responses, resulting in needed adjustments in therapy. Most often, less medication is needed. Several plant-based interventions in which carbohydrate intake increased resulted in reductions in diabetes medications, most likely due to improvements in insulin sensitivity.19,20
Patients with diabetes can benefit from guidance on how to purchase affordable plant-based foods to improve diet quality and health outcomes. Meal planning and making a shopping list are essential skills for patients with diabetes and can control costs, increase diet quality, and improve clinical outcomes. Learning and preparing new plant-based meals initially requires some time and effort. It does not necessarily require more time to prepare plant-based meals. There are many healthy quick-and-easy recipes available. Plant-based diets can be done on a budget while improving diet quality. See Table 2 for Resources for Plant-Based Nutrition Information and Recipes. See Table 3 for Plant-Based Nutrition Shopping on a Budget Guide.
Affordable plant-based meal planning teaching points:
Meal planning is a skill that is often taught by registered dietitian nutritionists. However, all clinicians can teach simple meal-planning skills to their patients. Have your patients create a plan for the week for breakfasts, lunches, dinners and healthy snacks. In the clinic, if a patient can come up with at least three ideas, they have a great start. Remind patients to always eat a meal before shopping to avoid expensive or unhealthy food items.
Eating a high-quality, plant-based eating pattern can be affordable and palatable, and may offer specific benefits in preventing and treating diabetes, including quality of life and psychological health. Frequent consumption of animal products has been associated with obesity, type 2 diabetes, heart disease, certain types of cancer and overall mortality. Patients with diabetes, with or without food insecurity, will benefit from eating more fruits, vegetables, whole grains, legumes, and nuts and seeds. Clinicians are in the ideal position to provide resources, education and support to help their patients eat healthier to improve overall health, diabetes outcomes and quality of life.
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About our expert: Meghan Jardine, MS, MBA, RDN, LD, CDCES, Associate Director of Diabetes Nutrition Education, Physicians Committee for Responsible Medicine
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