Food Order Behavioral Intervention in Prediabetes
If you’re one of the many people in the US trying to prevent or manage elevated blood sugar, a small tweak in your meals may move the needle.
Previous studies on people with overweight or obesity in combination with prediabetes or type 2 diabetes have shown that eating non-starchy vegetables and high-protein foods before high-carbohydrate foods resulted in lower postprandial blood sugars over 180 minutes, compared to eating the same combination of foods in reverse order.
To further evaluate this effect, researchers evaluated the impact of a behavioral intervention (carbohydrate-last food order) on glucose tolerance (GT), HbA1c, weight, and nutritional intake in adult subjects with prediabetes over a 16-week study.
A small sample of 45 adults with overweight/obesity and prediabetes were randomized to receive 4-monthly standard nutrition counseling sessions, or standard nutrition counseling sessions plus counseling on carbohydrate-last food order (FO).
Subjects in the FO group showed a decrease in body weight (13.6 ± 5.7 pounds) and a trend toward lower HbA1c (-0.1 ± 0.2; p = 0.054). The control group’s weight trended lower (-2.6 ± 6.8 lbs, p = 0.102) without a change in HbA1c (-0.03 ± 0.3, p = 0.605).
No change in glucose tolerance (GT) was seen in either group after 16 weeks. Weight changes, HbA1c, and GT were similar within the groups.
Sensitivity analysis of pre-COVID subjects indicated more weight loss in the FO group (-5.9 ± 5.3 lbs, p = 0.003) but not in the control group (-1.0 ± 6.8 lbs, p = 0.608).
The control group reduced its daily intake of calories, fat, protein, and grains after 16 weeks, while the FO group increased its intake of vegetables and protein.
In the FO group, 94% (17 subjects) reported high intervention compliance, and 72% (13) reported that eating protein and vegetables before carbohydrates was easy to follow.
The behavioral intervention of advising a carbohydrate-last food order is a simple method to improve diet quality, specifically increasing intake of protein and vegetables.
Below are some strategies to suggest to clients with prediabetes or diabetes:
· Add roasted vegetables to breakfast, or add in omelets. Enjoy toast or breakfast potatoes last.
· Order a salad before your meal when eating out.
· Put the pasta, potatoes, or rice on your plate after eating your vegetables and protein.
· Double the vegetables in your bowls and limit grains.
· Enjoy hummus with raw vegetables and a smaller serving of crackers or bread.
· Air fry or roast vegetables instead of potatoes and serve with lean poultry, beef, or seafood.
· Keep quick protein sources on hand for snacks like nuts, seeds, or string cheese in place of processed chips or pretzels.
· Pair carbs with protein for better blood sugar management (fruit with Greek yogurt, peanut butter on an apple, or grapes with cheese).
· Limit the use of ultra-processed meat sticks as a protein source, given their link with diabetes, heart disease, and colorectal cancer. 2
· Choose whole grains over refined grains when possible for more fiber, vitamins, and minerals.
Lisa Andrews, MEd, RD, LD
References:
1. Shukla AP, Karan A, Hootman KC, Graves M, Steller I, Abel B, Giannita A, Tils J, Hayashi L, O'Connor M, Casper AJ, D'Angelo D, Aronne LJ. A Randomized Controlled Pilot Study of the Food Order Behavioral Intervention in Prediabetes. Nutrients. 2023 Oct 20;15(20):4452. doi: 10.3390/nu15204452. PMID: 37892527; PMCID: PMC10610476.
Li-Hua P, Bajinka O. Processed Meat Health Risks: Pathways and Dietary Solutions. J Nutr. 2025 Nov;155(11):3584-3594. doi: 10.1016/j.tjnut.2025.08.030. Epub 2025 Sep 4. PMID: 4091