ABSTRACT Title of document: OBSERVATIONS REGARDING CONSUMPTION OF PERUVIAN NATIVE GRAINS (QUINOA, AMARANTH AND KAÑIWA), WEIGHT STATUS, AND PERCEPTIONS OF POTENTIAL RISK FACTORS, WARNING SIGNS AND SYMPTOMS OF TYPE 2 DIABETES AMONG PERUVIAN ADULTS: A CASE STUDY Katherine A Sanchez, Master of Science, 2012 Directed by: Retired Associate Professor and Extension Specialist Dr. Mark A Kantor, Nutrition and Food Sciences Department Wheat flour-based foods and rice have replaced native cereals in the diets of many urban- living Peruvians. Urban areas have also seen increases in overweight, obesity, and type 2 diabetes mellitus prevalence in recent years. The focus of this research is to describe observations regarding consumption of quinoa, amaranth and kañiwa cereals; weight status; and self-described experiences of potential risk factors and warning signs for, and symptoms that may represent complications of, type 2 diabetes mellitus in Peruvian adults living in the city of Arequipa. A survey instrument was developed and administered to 110 subjects (22 diabetics, 88 non-diabetics), middle-aged and over. Participants with normal BMIs consumed quinoa, amaranth, and kaniwa more frequently than overweight or obese participants. Diabetics reported more frequent consumption of Andean cereals, particularly amaranth, and less frequent consumption of white flour than non-diabetics. Most participants reported eating a diet high in carbohydrates and leading a sedentary lifestyle. OBSERVATIONS REGARDING CONSUMPTION OF PERUVIAN NATIVE GRAINS (QUINOA, AMARANTH AND KAÑIWA), WEIGHT STATUS, AND PERCEPTIONS OF POTENTIAL RISK FACTORS, WARNING SIGNS AND SYMPTOMS OF TYPE 2 DIABETES AMONG PERUVIAN ADULTS: A CASE STUDY By Katherine A Sanchez Thesis submitted to the Faculty of the Graduate School of the University of Maryland, College Park, in partial fulfillment of the requirements for the degree of Master of Science 2012 Advisory Committee: Mark Kantor, PhD, Chair Nadine Sahyoun, PhD, RD Mira Mehta, PhD © Copyright by Katherine A Sanchez 2012 Dedication To Pachamama, Tata Inti, Wayra, Uno and the many Apus close to my heart in Peru and the US. To the wise and generous spirit of the Inka people and their many descendents in Tawantinsuyo, especially the Q’eros—and to Native peoples around the world—thank you. To my amazing family—especially my husband, Ricardo, and sons, Max and Nico; and to my mom and dad, Virginia and James McCall, and mother and father-in-law, Samuel Sanchez and Betty Pérez de Sánchez—you inspire me. ii Acknowledgements There are many people who have been instrumental in bringing this thesis to fruition, and to whom I am most grateful. Above all, I’d like to thank the Divine Creator for answering every request for help and for the many blessings bestowed every day on all of us. I am also blessed to have benefited from the excellent guidance of my advisory committee, headed by Dr. Mark Kantor, along with Dr. Nadine Sahyoun and Dr. Mira Mehta, who generously shared their exceptional experience, knowledge and wisdom with me. Many thanks to the wonderful, resourceful, and generous people who helped me do the groundwork for this thesis in Peru, especially Dr. Sonia Medina Quiroga de Hijar, head of the Nutrition Department and the Universidad San Augustín, Professor Evaristo Pfuture Consa, Lic. Dina Varges Guillen, Lic. Saulo Ramón Cuno Montalvo, Lic. Alexander Alberto Zuñiga Quiroz, Dr. Ronald Sánchez Pérez, MD, Mrs. Betty Pérez de Sánchez, Mrs. Dayana Sánchez de Peralta, Mrs. Margot Cabrera de Sánchez, Dr. Walter Medina Rueda, MD, and the gracious, helpful, professional staff at the diabetes patient education center in the Hospital Regional Honorio Delgado in Arequipa. In the US, I’m grateful for the tremendous help and data processing and analysis support from Kylie Wheelock, as well as the sound advice from Lic. E. Noelia Williams, food scientist. Finally, I am eternally grateful for my wonderful husband, Ricardo Sánchez Pérez, for his support and help in every phase of this project. iii Table of Contents I. Introduction 1 II. Literature review A. Peru and the people of Arequipa 3 B. Peru’s history and shifts in dietary patterns 4 C. Macronutrient content of the typical Peruvian diet 7 D. Epidemiological and nutrition transitions 11 E. Peru’s nutrition transition experience 14 F. Health and chronic disease in Peru 17 G. Overview of type 2 diabetes mellitus 24 H. Diet and diabetes 28 I. Carbohydrates and diabetes 31 J. Whole grains, weight status and diabetes 35 K. Importance of quinoa in Peru and the Andes region of South America 40 L. Nutritional composition and properties of amaranth 55 M. Nutritional composition and properties of kañiwa 62 N. Summary 67 III. Objectives 69 IV. Research methods A. Recruitment of study participants 70 B. Survey instrument and data collection 73 V. Results and discussion A. Participant characteristics 78 B. Weight status measures 83 C. Cereal and tuber consumption 84 D. Self-described experiences of potential diabetes risk factors and warning signs in non-diabetics 92 E. Andean cereal consumption frequency and self-described experiences of potential diabetes risk factors and warning signs in non-diabetics 95 F. Self-described experiences of symptoms that may represent diabetes complications in diagnosed diabetics 97 G. Andean cereal consumption frequency and self-described experiences of symptoms that may represent diabetes complications in diabetic participants 99 VI. Strengths, limitations and lessons learned 100 VII. Conclusions 114 VIII. Future research 116 iv IX. Appendix 120 X. References 129 v Figures Figure 1: Phytonutrient content of whole grains 36 Figure 2: Average antioxidant content of vegetables, fruits and cereals 39 Figure 3: Health effects of whole grains due to interactions with microflora 40 Figure 4: Self-reported specific risk factors or warning signs for diabetes among non-diabetics 94 Figure 5: Distribution of symptoms in diabetics 98 Tables Table 1: Composition of whole quinoa seed 43 Table 2: Amino acid composition of dehulled quinoa flour 44 Table 3: Comparison, Protein quality of casein & dehulled quinoa flour 46 Table 4: Fatty acid composition of crude fat from quinoa seeds 49 Table 5: Nutrition facts: cooked quinoa versus cooked white rice 53 Table 6: Nutrition facts: cooked amaranth versus cooked wheat berries 56 Table 7: Nutrition facts: raw kañiwa versus raw Peruvian corn 63 Table 8: Mean soluble phenolic acid and flavanoid content of Andean cereals 66 Table 9: Selected characteristics of study participants 81 Table 10: Consumption of native Peruvian grains and other carbohydrate sources 85 Table 11: Potential risk factors and warning signs in non-diabetic participants 93 Table 12: Number of participants affected by symptoms that may represent complications from diabetes 98 vi I. Introduction Quinoa, amaranth and kañiwa are among the most important “grains” of the Andean region of South America. For centuries, they were so vital to the local food supply that the Inka culture considered them to be sacred; indeed, the Quechua name for quinoa means “mother grain.” Quinoa, amaranth and kañiwa have long been—and still are today—major sources of protein for people in the region, sometimes replacing meat in the diet. Although they are used like grains in Andean cooking, quinoa, amaranth and kañiwa are technically not grains; they are actually seeds, which is why they are sometimes called “pseudo-grains” or “pseudocereals.” While true cereals are botanically classified as grasses, pseudocereals are considered to be broadleaf plants (non-grasses). Seeds are generally better sources of high-quality protein than true cereal grains, such as wheat, rice and corn. Compared to popular refined grain products, (e.g., white bread, cooked white rice and regular pasta), foods made from quinoa, amaranth and kañiwa generally have higher levels of fiber, essential fatty acids, antioxidants, and other phytochemicals, defined as bioactive, non-nutritive plant compounds. Among the health benefits of these components, the fiber content of quinoa, amaranth and kañiwa may help control appetite and induce satiety. Nevertheless, the popularity of these traditional pseudo-grains has waned in the past five or six decades, due to their association with indigenous cultures and the perception that only people of low socioeconomic status eat them. Instead, foods made from refined wheat flour, white rice and other refined grains have become more dominant on the Andean plate. This is especially true in urban areas of Peru such as Lima and 1 Arequipa, where wheat-based foods and rice are customarily purchased, served and eaten. Because these foods were brought to Peru by the Spaniards, Peruvians associate them with European origins and “whiteness.” Thus, regularly consuming such foods confers a higher social status, whereas purchasing, serving and consuming quinoa, amaranth and kañiwa have become associated with a low socioeconomic class. This attitudinal shift set the stage for the replacement of native grains with refined grains in the staple diets of many Peruvians (Martínez-Zuñiga, 2007). In recent years, Peru’s urban population has experienced an increase in overweight, obesity, and the prevalence of type 2 diabetes and other chronic diseases (Ministerio de Salud, Peru, 1996). Given the evidence that whole grain intake may lower the risk of overweight, obesity and some chronic diseases, it is important to explore the nutritional consequences of the trend toward decreased consumption of traditional