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Yeasts are the major producers of CO 2 in sourdough [ 20 ], so they are primarily responsible for leavening [ 15 ]. The final pH is about 4. The sourdough fermentation of wheat flour lowers the GI of bread, reducing starch digestibility, mostly through the formation of organic acids [ 22 , 23 ].
The mechanism responsible for the slow absorption of starch in the presence of lactic acid is the inhibition of amylolytic enzymes [ 24 ] or a reduction of starch bioavailability, because of the interaction between starch and gluten [ 25 ], whereas acetic acid delays the gastric emptying rate [ 26 ]. The whole wheat bread average GI is 71, and the glycemic load GL for a g serving size is nine [ 27 ]; the white wheat flour bread GI is 71, and the GL of a g serving size is 10 [ 27 ]; while the GI of sourdough wheat bread is 54, and its GL for a g serving size is eight [ 27 ]. Whole wheat bread and white wheat bread give the same postprandial response of glucose and insulin in type 2 diabetic patients [ 29 , 30 ]; however, the inclusion of a high percentage of intact or partially milled cereal kernels in the flour reduces the glycemic response of bread [ 31 , 32 , 33 ].
These data have a possible biological and technical explanation: Standard wholemeal flour not stone ground meal flour is a reconstituted flour after passage through the roller mill. Therefore, wholemeal flour is hydrolyzed at a rate identical to white flour [ 34 ].
Scazzina evaluated the metabolic effects of four breads prepared from two different wheat flours whole or white through two different leavening techniques sourdough and Saccharomyces cerevisiae. Both sourdough fermented breads gave glycemic responses significantly lower than the corresponding breads leavened with Saccharomyces cerevisiae in eight healthy volunteers. The presence of fiber did not influence the glycemic potential of breads [ 35 ]. Accordingly, the plasma insulin response of sourdough bread showed significantly lower values at 30 min and a significantly smaller incremental area under the curve at 0—30 min [ 36 ].
The sourdough wholemeal wheat breads resulted in the lowest postprandial glucose and insulin response among four tested breads white wheat bread, wholemeal wheat bread, sourdough wholemeal bread and wholemeal bread made with xylanase [ 37 ]. Phytate, which is widely represented in whole grains and legumes, but also in oil seeds and nuts [ 40 ], strongly bound to metal cations of Ca, Fe, K, Mg, Mn and Zn, making them insoluble and, thus, unavailable as nutritional factors [ 41 ]. Furthermore, Katina et al. Since many fruits and vegetables, beans, pasta, dairy foods and nuts have a low GI [ 27 , 43 ], the Mediterranean traditional diet with sourdough wholemeal bread can be qualified as a low GI diet.
This type of diet can also be a good guide to get a low GL diet, if the intake of starchy foods is controlled. As regards the effects of high GI diets on body weight, this type of diet raises glucose and insulin in the early postprandial period 0—2 h more than low GI diets, and the excess of insulin lowers blood glucose in the postprandial period 3—5 h , thus leading to excessive hunger.
The decrease of plasma glucose and the increased hunger have been associated with increased activity in specific brain regions related to food intake, reward and craving in overweight or obese men. The assessment was done by using arterial spin-labeling functional magnetic resonance imaging [ 44 ]. In 14 healthy subjects, an activation of limbic-striatal brain regions with a concomitant increasing desire for high-calorie foods was evident when a mild hypoglycemia occurred during hyperinsulinemic euglycemic-hypoglycemic clamp [ 45 ].
In non-diabetic subjects aged 20—70 of the Health Worker Cohort Study, the adjusted odds ratios in the highest versus the lowest quartile of dietary GL were 1. In two studies [ 52 , 53 ], high dietary GI was positively associated with both lower HDL-cholesterol and higher triglyceride concentrations. In the late postprandial period 4—6 h after the meal , the counter-regulatory hormones restore normal glycemia and cause a marked increase in free fatty acid concentration [ 56 ]. Elevated glucose, insulin and free fatty acids induce insulin resistance [ 56 ].
High GL diets have been associated with an increased risk of developing T2DM in several large prospective studies. A recent systematic review and meta-analyses of 24 prospective cohort studies with 7. The progressively higher glucose levels induced by a high GL depend on the degree of underlying insulin resistance being more evident in obese, inactive or genetically susceptible people [ 58 ].
Four systematic reviews and meta-analyses [ 59 , 60 , 61 , 62 ], including an Italian prospective study [ 63 ], showed that high dietary GL significantly increases the risk of coronary heart disease in women, but not in men. Furthermore, the hazards ratio for coronary heart disease is higher in diabetic women than in men [ 65 ]. Interestingly, in the EPICOR long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients study, increasing carbohydrate intake from high GI foods was significantly associated with greater risk of coronary heart disease in women, whereas increasing carbohydrate intake from low GI foods was not [ 63 ].
The dietary GI can influence the risk of coronary heart disease through inflammation and oxidative stress. Low GI diets are associated with lower C-reactive protein [ 53 ] and lipid peroxidation markers [ 66 ] in comparison to high GI diets in cross-sectional studies. Chronic hyperinsulinemia may promote cancer through abnormal stimulation of multiple cellular signaling cascades and increasing the bioactivity of insulin-like growth factor 1. Insulin, by reducing sex hormone binding globulin levels, increases the estrogens bioavailability that, in turn, can promote cellular proliferation and inhibit apoptosis in breast epithelium and endometrium [ 68 ].
Moreover, hyperinsulinemia increases proinflammatory cytokines and oxidative stress that, in turn, can promote malignancy and neoplastic progression [ 68 ]. Systematic reviews and meta-analysis showed conflicting results regarding the involved cancer sites [ 69 , 70 , 71 , 72 , 73 ].
However, a large nationwide population-based case-control study showed that GI was positively associated with the risk of prostate cancer, and a high GL significantly increased the risk of colorectal and pancreatic cancers [ 74 ]. Another peculiarity of wholemeal sourdough bread should be considered, that is its richness in fiber.
High intake of cereal fiber reduces the risk of coronary heart disease [ 75 ], T2DM [ 76 ], obesity [ 77 ] and colorectal cancer [ 78 ]. Cereal fiber reduces inflammatory markers [ 79 , 80 ] and improves insulin sensitivity [ 81 ]. Whole grain cereals, but not refined grains, reduce the risk of coronary heart disease, gastrointestinal cancer [ 82 ] and T2DM [ 82 , 83 ]. The protective mechanisms of whole grain cereals against the risk of developing chronic diseases depend on bioactive compounds and dietary fiber, mainly contained in the bran and germ fractions, that are lost in the milling process [ 84 ].
Interestingly, fiber and oligosaccharides of whole grain wheat have also a prebiotic effect on gut microbiota [ 85 , 86 ] involved in systemic low-grade inflammation and progression of chronic metabolic diseases [ 87 ]. As a result of the above considerations, it can be said that at the base of the Mediterranean diet pyramid there should be low GI, fiber-rich cereals, such as wholemeal wheat sourdough bread, stone ground wheat bread, wholemeal pasta, brown rice and whole kernel cereal grains.
At the top of the pyramid, there should be cereal foods with high GI and that are poor in fiber, such as white bread, white rice, white couscous and potatoes and even a food with low GI, but that is poor in fiber, such as white pasta Figure 2. Wholemeal sourdough pizza with low-fat cheese and wholemeal couscous could be placed also at the base of the pyramid, if a low GI for these meals is demonstrated in the future.
In conclusion, we state that the Italian Mediterranean diet pyramid presented during the third CIISCAM conference in Parma [ 6 ] Figure 1 should be modified as far as the position of cereal foods is concerned, because they are a heterogeneous category if we consider their effects on health, as has been shown above. The proposed new pyramid Figure 2 can help Italian people avoid the risk of many common chronic diseases, as it is based not only on our cultural heritage and traditions, but also on scientific evidence.
There are many problems for the implementation of the proposed pyramid, because of the low availability of the suggested types of cereal foods. However, we have a long tradition in making sourdough bread; there are more than different types of traditional bread manufactured throughout Italy, and almost one-third of them are leavened with sourdough [ 88 ]. A nutrition policy that acts by increasing the availability of wholemeal possibly from stone ground flour sourdough bread through the activity of artisan bakeries is essential and needs to be supported by politicians.
The adoption of the traditional Mediterranean diet could impede the increase of and even reduce many of these risk factors, above all, the main cardiovascular risk factors [ 16 ]. Even a little reduction of these risk factors by adopting the traditional Mediterranean diet at a population level can reduce cardiovascular disease more than pharmacological interventions in people at high risk [ 93 ]. Furthermore, the traditional Mediterranean diet is a sustainable diet, as it has a low environmental impact and is healthy for consumers, while the current Mediterranean dietary patterns are not sustainable [ 94 ].
Is our past diet the future of our health? Giovanni De Pergola helped to review the manuscript. Both authors read and approved the final version of the manuscript. National Center for Biotechnology Information , U. Journal List Nutrients v. Published online Oct Author information Article notes Copyright and License information Disclaimer.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license http: This article has been cited by other articles in PMC. Abstract Bread was a staple in the traditional Mediterranean diet of the early s, as well as nowadays; however, it was a stone ground sourdough bread in Nicotera and probably in the Greek cohorts of the Seven Countries Study.
Mediterranean diet pyramid adult, sourdough bread, glycemic index, glycemic load. Introduction In , the United States Department of Agriculture reported nutritional recommendations for the American population in the form of pyramid [ 1 ], helping people to make good dietary choices with the aim of reducing the risk of chronic diseases. Open in a separate window. Cereal Foods in the Traditional Mediterranean Diet of the Early s Fruit, vegetables and cereals are the basis of the Mediterranean diet. Traditional Mediterranean Diet of the Early s as a Low GI and GL Diet Since many fruits and vegetables, beans, pasta, dairy foods and nuts have a low GI [ 27 , 43 ], the Mediterranean traditional diet with sourdough wholemeal bread can be qualified as a low GI diet.
Proposal of Mediterranean Diet Pyramid for Italian People As a result of the above considerations, it can be said that at the base of the Mediterranean diet pyramid there should be low GI, fiber-rich cereals, such as wholemeal wheat sourdough bread, stone ground wheat bread, wholemeal pasta, brown rice and whole kernel cereal grains. Proposal of the Mediterranean diet pyramid for Italian people. Conclusions In conclusion, we state that the Italian Mediterranean diet pyramid presented during the third CIISCAM conference in Parma [ 6 ] Figure 1 should be modified as far as the position of cereal foods is concerned, because they are a heterogeneous category if we consider their effects on health, as has been shown above.
Acknowledgments We acknowledge Giovanni Misciagna for his criticism. Conflicts of Interest The authors declare no conflict of interest. Dietary Guidelines for Americans. A cultural model for healthy eating. The Oldways Mediterranean Diet Pyramid. Supreme Scientific Health Council. Ministry of Health and Welfare Dietary guidelines for adults in Greece.
Mediterranean diet pyramid today. Science and cultural updates. Food intake patterns and year mortality from coronary heart disease: Cross-cultural correlations in the Seven Countries Study. Food consumption patterns in the s in seven countries. The diets of middle-aged men in two rural areas of Greece. Dietary Studies and Epidemiology of Heart Diseases. Dietary studies on two rural italian population groups of the Seven Countries Study.
Trend of food and nutrient intake from to Dieta Mediterranea Italiana di Riferimento. La dieta di Nicotera nel Dieta Mediterranea Italiana di riferimento; pp. Pietanze di un Tempo. Saperi e Sapori Della Cucina Nicoterese. Biodiversity and metabolic interactions. Lactobacilli in sourdough fermentation. La Dieta Mediterranea; pp. What is so special about the diet of Greece? Urban and rural dietary patterns in Greece in the years —; an economic analysis. Alimentary expenditure of the different socio-vocational classes of the population in Greece — A description of the dietary models.
Interactions between ingredients and microbial species diversity. Importance of dietary fibre and other food properties. Sourdough and cereal fermentation in a nutritional perspective. Sourdough fermentation or addition of organic acids or corresponding salts to bread improves nutritional properties of starch in healthy humans.
On the effect of lactic acid on blood glucose and insulin responses to cereal products: Mechanistic studies in healthy subjects and in vitro. Delayed gastric emptying rate may explain improved glycaemia in healthy subjects to a starchy meal with added vinegar. International tables of glycemic index and glycemic load values: Glycemic, insulinemic, and appetite responses of patients with type 2 diabetes to commonly consumed breads. Wholemeal versus wholegrain breads: Proportion of whole or cracked grain and the glycaemic response.
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