December 2013 The Pure Prairie Eating Plan: A Mediterranean Diet for the Prairies Written by Catherine B. Chan, PhD and Rhonda C. Bell, PhD Key Messages The Pure Prairie Eating Plan (PPEP) is a four week structured menu plan for a well-balanced diet, initially developed for people with type 2 diabetes. PPEP emphasizes foods that are locally grown or produced, readily available and acceptable to people living on the prairies. PPEP provides supporting resources such as recipes, weekly grocery lists and cooking tips to make it very practical. Initial research findings indicate that following PPEP results in good blood-sugar control and improvements in cardiovascular risk and nutrient intakes. Introduction Healthy eating is a key factor in preventing and treating chronic diseases such as heart disease, stroke, cancer and diabetes. According to the World Health Organization, good nutrition is one of four key factors that could help postpone or avoid ninety per cent of the cases of type 2 diabetes and up to eighty per cent of the cases of coronary heart disease. 1 The Mediterranean Diet has gained popularity as one approach to a healthy diet 2, but evidence gathered through research on Alberta products (canola, flax, barley, pulses, berries, dairy and meat) demonstrates that many Albertagrown foods have similar nutritional qualities and would be acceptable and more accessible to Albertans. 3-7 Evidence also exists that, in addition to providing adequate nutritional quality, food should be accessible, acceptable and available (the 4A Framework) to facilitate healthy eating. 8-10 The Pure Prairie Eating Plan (PPEP) was conceived to develop, test and demonstrate the potential health benefits of a dietary pattern based on foods that are commonly grown and consumed in Alberta. How was PPEP Developed? PPEP was first developed as a nutritional approach to be used in a set of practically-oriented studies designed to help people with type 2 diabetes improve their adoption and adherence to physical activity and eating patterns that match treatment recommendations from the Canadian Diabetes Association (CDA). Initial studies conducted by the Physical Activity and Nutrition for Diabetes in Alberta (PANDA) team examined the barriers to adhering to a healthy, diabetes-friendly diet, according to diabetes patients and diabetes educators. Next, a consensus conference was held with diabetes experts and patients to facilitate knowledge exchange, identify issues and collaboratively develop recommendations for programs that they believed would support
long-term adherence to a high quality, healthy diet among people with diabetes. 11,12 This multi-disciplinary, multi-faceted, collaborative approach provided the framework for PPEP. Originally, PPEP was called The Alberta Diet as a play on The Mediterranean Diet, but it was re-branded to reflect planning as an important component of this approach to facilitate a healthy diet and to recognize the rich diversity of healthy food choices available in the Canadian Prairies. PPEP integrates knowledge across several areas of research: consumer behavior, behavior change and the nutritional quality of dairy, meat, canola, pulses and grains. What is PPEP? PPEP is a structured menu plan that outlines 28 days of healthy food choices for three meals and three snacks per day in portion sizes and a dietary pattern that meets Canada s Food Guide and the Nutrition Therapy recommendations from the CDA. It emphasizes foods that are locally grown or produced, readily available and acceptable to people living on the prairies. See Figure 1 for a sample menu plan. PPEP also contains approximately 100 recipes, tips for healthy eating, pantry and grocery lists and other helpful information about the foods described. When followed, the menus average approximately 2000 kcal/day with a macronutrient distribution consistent with health recommendations. The menus provide between 25 and 50 grams of total fibre per day. The recipes are for foods that meet the 4A Framework: they are nutritionally adequate, locally available, acceptable and accessible to Albertans. All are quick, tasty and easy to prepare. Many of the recipes have been obtained from our provincial agricultural commodity groups: Alberta Milk, Alberta Canola Commission, Alberta Pulse Growers, Alberta Barley as well as Canada Beef and Dairy Farmers of Canada. Additional recipes were developed specifically for the guide by well-known cookbook author and chef, Nancy Hughes. Along with Dr. s Chan and Bell, many bright and enthusiastic nutrition students at the University of Alberta helped to define and refine PPEP. Research Studies Using PPEP In the first set of implementation and evaluation studies, PPEP was pilot-tested for 12 weeks with 15 people with type 2 diabetes. Each participant met one-on-one with a program facilitator who oriented them to PPEP and evaluated the following: how participants used the menu plan, what participants liked about the PPEP concept, meals, snacks and format, what they thought could be improved, biological markers of diabetes control and cardiovascular risk. Results from this first study produced promising results summarized below: 13 Participants implemented PPEP in different ways. For example, some adhered rigorously to the menus and did all cooking from scratch, while others used the menus as a guide to their dietary pattern. They liked the flexibility of the menu plan. All participants liked the PPEP concept and approach. Participants followed PPEP ~5 days/week and about 60% of them continued to follow PPEP 8 weeks after the study had concluded. Participants were pleased with the variety of food choices and liked the taste of the recipes. Many were not used to cooking from scratch and cited time as a barrier to using the menu plan more. The benefits of PPEP that participants described included: more structure in their diets, increased frequency of snacking, increased awareness of food choices, aided purchasing of healthier foods, better portion control. Blood-sugar control (measured as A1c) improved by 1%; body weight and levels of good (HDL) cholesterol for Health Educators 2
also improved. These effects were clinically and statistically significant. Next, funding was secured through the Alberta Diabetes Institute to conduct a 24-week intervention with a larger group of participants with type 2 diabetes. The revised version of PPEP was paired with a fiveweek curriculum that emphasized building practical skills in food selection and food preparation. The PPEP and curriculum were delivered in a small group setting with a facilitator. Quantitative markers of diabetes control (A1c) and cardiovascular risk (body mass index, waist circumference and blood pressure) along with three-day food records were collected. A total of 73 participants enrolled and 63 (86%) completed all aspects of the program. On average, there were decreases in A1c (-1%), body mass index (-0.6 kg/ m2) and waist circumference (-2 cm). 14 Analysis of nutrient intakes showed decreases in total energy intake (-127 kcal/day), total fat (-7 g/day), total sugar (-25 g/day) and sodium (-469 mg/ day). 14 All of these findings were statistically significant. Additional information about PPEP and Figure 1: A Sample Menu Plan from PPEP Week 1, Day 1 Meal Ingredients Per Serving Canada s Food Guide Servings Breakfast Breakfast Parfait Morning Snack Fresh Raspberry Muffin with Roasted Almonds Lunch Tuna Caesar Sandwich Afternoon Snack Five Minute Hummus & Crackers Dinner Roasted Apple Pork Tenderloin with Roasted Potatoes Evening Snack Cinnamon Raisin Toast Good to Know Nutrition facts of the day Calories: 2350 Fat: 59 g Saturated fat: 14 g Carbohydrate: 334 g Fibre: 46 g Protein: 132 g 1 serving Breakfast Parfait 1 cup (250 ml) coffee/tea 2 Tbsp (30 ml)1% milk (optional) 1 tsp (5 ml) granulated sugar (optional) 1 Fresh Raspberry Muffin 1 tsp (5 ml) non-hydrogenated magarine 1 Tbsp (15 ml) roasted almonds 1 Tuna Caesar Sandwich 1 cup (250 ml) 1% milk 1/2 cup (125 ml) peaches (in water) 1 serving Five Minute Hummus 6 whole wheat Melba toast 1/4 cup (60 ml) chopped tomatoes 1 serving Roasted Apple Pork Tenderloin 2/3 cup (150 ml) roasted potatoes 1/2 cup (125 ml) green beans 1 small whole grain dinner roll 1 tsp (5 ml) non-hydrogenated margarine 1/2 cup (125 ml)1% milk 1 slice toasted raisin bread 1 tsp (5 ml) each margarine, cinnamon 1/2 cup (125 ml) 1% milk Total Servings Adjusting today s menu 2 Vegetables and Fruit 1 Milk and Alternatives 1/4 Meat and Alternatives 2 1/2 Vegetables and Fruit 2 Grain Products 1 Meat and Alternatives 1 Milk and Alternatives 1/2 Vegetables and Fruit 1 1/2 Grain Products 1/2 Meat and Alternatives 2 Vegetables and Fruit 1 1/2 Meat and Alternatives 1/2 Milk and Alternatives 1/2 Milk and Alternatives 7 Vegetables and Fruit 7 1/2 Grain Products 3 1/4 Meat and Alternatives 3 Milk and Alternatives 4 Oils and Fats To cut about 200 calories: have only 1/2 cup (125 ml) of yogurt at breakfast (saves 50 kcal) omit margarine at morning snack and dinner (saves 70 kcal) make an open faced sandwich for lunch (saves 70 kcal) To add about 200 calories: have 2 Tbsp (30 ml) almonds at morning snack (adds 100 kcal) drink 1 cup of milk with your dinner (adds 100 kcal) Calorie intakes for PPEP average 2000 kcal/day over each week. 3 for Health Educators
curriculum acceptability, accessibility and acceptability was also collected and is still being analyzed. The Evolution of PPEP While the original purpose of PPEP was to help people with type 2 diabetes adhere to the nutrition recommendations of the Canadian Diabetes Association, it is clear that a healthy diet for people with diabetes is a healthy diet for everyone. This concept was reinforced in the consensus conference. People living with type 2 diabetes and members of the expert panel felt strongly that a diabetes diet is not and should not be different from the diets of others. The promising and positive outcomes regarding the acceptability of the menu plan and improvements in health, along with the encouragement we ve received from a number of Alberta agricultural commodity groups, led us to make the Pure Prairie Eating Plan (PPEP): Fresh Food, Practical Menus and a Healthy Lifestyle, widely available. PPEP will be available for purchase late in December 2013. Proceeds from its sale will be used to further research into improving the lifestyle behaviours of Albertans. PPEP will be available initially as a book via our website www.pureprairie.ca and in e-book format in the near future. The supporting website features sample menus, new recipes, information about our research and links to our sponsors. Our Sponsors We would like to acknowledge the financial support of Alberta Livestock and Meat Agency, Alberta Crop Industry Development Fund, Alberta Canola Producers Commission, Alberta Diabetes Institute and Alberta Diabetes Foundation, Alberta Pulse Growers Commission, Alberta Barley Commission, Alberta Wheat Commission, Canada Beef, Alberta Milk and Alberta Potato Growers. About the Authors Rhonda Bell and Catherine Chan are professors of human nutrition at the University of Alberta. They are both members of the Physical Activity and Nutrition for Diabetes in Alberta (PANDA) research team. Archived issues of our newsletter can be found on our website. The team of Alberta Milk registered dietitians are: Jaclyn Chute, RD Lee Finell, MHSA, RD Colinda Hunter, RD Cindy Thorvaldson, MSc, RD Nutrition File is a free quarterly research newsletter for health educators, funded by the dairy producers of Alberta. If you are a new reader and would like to add your name to our distribution list, please contact Alberta Milk at nutrition@ albertamilk.com or phone 1-877-361-1231. for Health Educators 4
A Recipe from PPEP: Chickpea and Feta Bulgur Salad Serves 4 Serving Size: 1 ½ cups (375 ml) This recipe, featuring whole grains, pulses, veggies and cheese, can be served for lunch by itself or as a side dish at dinner. Developed for PPEP by chef Nancy Hughes. Ingredients 2 cups (500 ml) water 1 cup (250 ml) dry bulgur 1 medium cucumber, diced 1/2 of a 16 ounce (450 ml) can chickpeas, rinsed and drained 1/2 cup (125 ml) diced red onion 1/2 cup (125 ml) finely chopped fresh flat leaf parsley 1/2 cup (125 ml) finely chopped fresh mint 3 Tbsp (45 ml) cider vinegar 2 Tbsp (30 ml) canola oil 2 medium garlic cloves, minced 1/2 tsp (2 ml) salt 2 oz (60 g) feta cheese, crumbled Directions 1. Bring the water to a boil in a medium saucepan over high heat. Add the bulgur, reduce the heat to medium low, cover and simmer 12 minutes or until most of the water has been absorbed. 2. Meanwhile, combine the remaining ingredients, except the cheese in a large bowl. 3. Drain the bulgur in a fine mesh sieve and run under cold water to cool quickly. Shake off excess liquid and add to the cucumber mixture. Stir until well mixed. 4. Add the cheese and stir until just mixed. Let stand 10 minutes to absorb flavours. Nutrition Information per serving 308 kcal 11 g fat 3 g saturated fat 44 g carbohydrate 11 g fibre 11 g protein Eating Well with Canada s Food Guide servings 1.5 Vegetables and Fruit 1.5 Grain Products 0.5 Milk and Alternatives 0.5 Meat and Alternatives