Original Research Communications-methods

The use of the glycemic index in predicting the

blood glucose response to mixed meals1’2
Thomas MS Wolever, BM, MSc and David JA Jenkins, DM

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ABSTRACT There has been much interest in the use ofthe glycemic index (GI). A recent study
reporting plasma glucose responses to mixed meals containing fat and protein concluded that the
results were totally disparate from what would have been expected from published GI values of the
foods fed. However, this conclusion was based upon an inappropriate assessment of the data using
absolute rather than incremental blood glucose response areas. The present report demonstrates how
data may be analyzed to make use of the GI values of individual foods to predict the GI of mixed
meals(r 0.987; p < 0.02). It is concluded that the GI concept applies well to mixed meals containing
fatand protein. Am J Clin Nutr l986;43: 167-172.

KEY WORDS Glycemic index, diabetic diet, blood glucose, diabetes

Introduction dicted by previously published values for the

glycemic index ofthe foods studied . (8).
. .“

Diabetic patients have been advised recently This conclusion, however, is unjustified, since
to increase their carbohydrate consumption it was based on an incomplete interpretation
in order to decrease fat intake and hopefully of the data. Because of the potentially broad
the risk of cardiovascular disease (1). Little implications of the glycemic index in the
advice has been given as to which specific foods management of diabetes and related condi-
should be eaten to achieve this. However, tions, we present our approach to the use of
common starchy foods produce different gly- such data in assessing the glycemic effects of
cemic responses (2). The glycemic index (GI) mixed meals.
was proposed as a method of ranking foods
on the basis of the incremental blood glucose
responses they produce for a given amount of Methods
carbohydrate (3). It has been suggested that
low GI starchy foods may be beneficial in di- The calculation ofthe GI ofmixed meals is based upon
the sum of the GI contributions of each carbohydrate
abetes (4). Although the concept has received component of the meal.
support (5), there has also been much mis-
understanding about its use (6). It has been
suggested that the GI, based on tests of single
I From the Department ofNutritional Sciences, Faculty
foods, may not apply in the setting of mixed
of Medicine, and Division of Endocrinology and Metab-
meals containing representative amounts of olism, St. Michael’s Hospital, University ofToronto, To-
fat and protein (7, 8). The conclusions of a ronto, Ontario, Canada.
recent study by Coulston et al (8), where blood 2 Address reprint requests to: Dr Thomas MS Wolever,
glucose responses to mixed meals were mea- Department ofNutritional Sciences, Faculty of Medicine,
University of Toronto, Toronto, Ontario, MSS I A8,
sured, was that the GI had minimal clinical Canada.
utility because the results were totally
“. . .
Received February 22, 1985.
disparate from what would have been pre- Accepted for publication June 18, 1985.

The American Journal o[C’linical Nutrition 43: JANUARY 1986, pp 167-172. Printed in USA l67
© 1986 American Society for Clinical Nutrition
 168 WOLEVER AND JENKINS

At (B-A)t (C-B)t
area=-j-+At+ 2 +Bt+ 2 ‘ etc

where A, B, C, D, E, and F represent the blood glucose

increments, ie the differences between the blood glucose
I&1
(1) concentration fasting, and at times t, 2t, 3t, 4t, 4t + T,
0
U and 4t + 2T after the start ofthe meal. t and T represent
-I different time intervals between blood samples (Fig 1).
Ca When, as shown here (Fig 1), the blood glucose con-
0
0
F centration at F is less than the fasting concentration,
the area represented
level, and therefore
only
by the triangle ET is above the fasting
only this portion is included in the
1 -i--rrn fL’f F total area. r represents the portion ofthe time interval T
when the blood glucose level between E and F is above
the fasting level.

. E 1’
TIME Since (E+F)T

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FIG 1 . General blood glucose response curve for illus-
trating the method of calculation of the incremental area ET
Therefore r = (E + F)
under the blood glucose curve.

ET E2T
Therefore - =
2 2(E+FY
Cakulation ofthe GI of individual foods
The overall equation simplifies to:
The GI has been defined (4, 9, 10) as: I D\ (D+E)T E2T
Area=A+B+C+-j)t+ 2
GI

Area under the curve for 50 g If the last blood glucose concentration, F, is above the
carbohydrate from test food fasting level, instead ofbelow as shown here, the last term
= XlOO. in the equation (namely E2T/2(E + F) becomes
Area under the curve for 50 g
carbohydrate from white bread (E + F)T/2. Three examples of incremental area calcu-
lations are shown in Table 1. In example 1 the last blood
The area under the blood glucose curve includes the area glucose value is below the fasting level, in example 2 the
above the fasting level only (3, 4, 9, 10). Any area beneath last value is the same as the fasting level, and in example
3 the last value is above the fasting level.
the fasting level is ignored. The method used to calculate
the incremental area under the blood glucose response
curve is illustrated in Figure 1. It is the sum of the areas Cakulation ofmixed meal GI
ofthe triangles and rectangles, calculated geometrically as Table 2 illustrates the method of applying the GI cal-
follows: culation to a mixed meal containing three carbohydrate

TABLE 1
Exampl e calculations of in cremental area under the blood glucose res ponse curve

Example I Example 2 Example 3

Corresponding
letter on Blood Blood glucose Blood Blood glucose Blood Blood glucose
Time Figure 1 glucose increment glucose increment glucose increment
mm mg/dl mg/dI mg/dI mg/dI mg/dl mg/dI

0 - 100 - 100 -
15 A 120 20 120 20 120 20
30 B 140 40 140 40 140 40
45 C 160 60 160 60 160 60
60 D 150 50 150 50 150 50
90 E 120 20 120 20 120 20
120 F 90 -10 100 0 110 10
202 x 30
Examplel:Area=(20+40+60+25)XlS+(25+l0)X30+ =3425mg-min/dl.
2 X (20 + 10)

Example2:Area=(20+40+60+25)X lS+(25+20+0)X30=3525mg-min/dl.
Example3:Area=(20+40+60+25)XlS+(25+20+S)X303675mg-min/dl.
 GLYCEMIC INDEX AND MIXED MEALS 169

TABLE 2 tils. Plasma glucose was measured fasting and at 30, 60,
Calculation of the GI ofa hypothetical meal 120, and 180 mm after the beginning ofeach test meal.

Carbohydrate Cakulation ofmeal Gis

Meal GI
Propor- contri- The GI values used (Table 4) for the individual foods
Food GI g tion button
were taken from a recently published review incorporating
A GIA A PA MGIA values from five studies carried out in three separate lab-
B GIB gB B MGI oratories (4). The carbohydrate from lettuce (1.5 g) has
C Gk sc Pc MGI been ignored since it represented only 3% ofthe total meal
Total g 1.0 MGI carbohydrate, and the GI oflettuce is not known.

Cakulation ofmeal glycemic response areas

The data available were in the form ofhistograms and
foods, A, B, and C with GIs 0fGIA, GIB, and Gk respec- graphs. The histogram gave values for the mean total areas
tively. The total meal carbohydrate in grams (g) equals under the plasma glucose curve. Since, here, fasting plasma
the sum of the three carbohydrate components: glucose concentration was always below the plasma glucose

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levels between 30 and 180 mm, the fasting levels (estimated
g = g + ga + . from the graph) multiplied by the duration of the test
(3 h) have been subtracted from the total areas (esti-
The proportion ofcarbohydrate from each food is calcu-
mated from the histogram) to give the incremental areas
lated first; for example: (Table 5).
PA (g,jg). The calculated meal GIs were compared with the in-
cremental blood glucose response areas by regression
This value is multiplied by the GI for that food to give analysis using the method ofleast squares (1 1).
the GI contribution ofthat food to the total meal glycemic
index; for example:
Results
MGIA PA X GIA

where MGIA is the GI contribution of food A to the total Meal GIs

meal glycemic index. The GI contributions of each food
The GIs for the baked potato, rice, spaghetti,
(MGIA, MGI, and MGk) are added to give the total
meal glycemic index (MGI): and lentil containing meals were calculated to
be 123.3, 88.7, 77.3, and 62.0 respectively
MGI = MGIA + MGIB + MGI.
(Table 4).
Study to be assessed Incremental plasma glucose areas
Four test meals, each containing 15% of total calories The areas under the plasma glucose curve
as protein, 40% as fat, and 45% as carbohydrate (Table 3), above the fasting level were calculated to be
were given to a group of eight noninsulin-dependent di-
abetic volunteers (8). Approximately 33% of the carbo-
3 13, 247, 195, and 166 mg/dl . h respectively
hydrate in each meal was from white bread and 67% from for the baked potato, rice, spaghetti, and lentil
one offour test foods: baked potato, rice, spaghetti or len- containing meals (Table 5).

TABLE 3
Test meals fed in study being assessed (8)

Test MiT-I M1T-2 M1T-3 MTF-4 Carbohydrate Protein Fat

g g g g g g g
Carbohydrate
Baked potato 194.8 30.0 3.7 0.2
Rice 37.3 30.0 2.5 0.9
Spaghetti 130.4 30.0 4.5 0.6
Lentils 49.9 30.0 12.3 0.6

Constant meal
components
White bread 29.8 29.8 29.8 29.8 15.0 2.6 1.1
Turkey 29.1 29.1 29.1 29.1 8.7 0.9
Margarine 15.0 15.0 15.0 15.0 12.1
Oil 3.5 3.5 3.5 3.5 3.5
Lettuce 50.0 50.0 50.0 50.0 1.5 0.5
170 WOLEVER AND JENKINS

- . I-. ri Regression ofmeal Gis on glycemic

. 2 00
r-i r’
rt response areas

The correlation coefficient for the meal GIs

.
C
. 8 on the under
areas incremental
the curve plasma
for the glucose responsewas
four meals
a- 0 © 0 - 0.987 (p < 0.02). The y-intercept
.
(Fig 2) was
virtually 0 (-4.4 ± 26).
c
u- .

r1 Discussion

- S Using the method of calculation described

here, it can be demonstrated that pooled GI
: : values of individual foods from a number of

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C) laboratories (4) can accurately rank the gly-
cemic responses to mixed meals (10).
. . 8 Much confusion in the past has been caused
i by the lack of application of a standard ap-
proach to estimating the GI of mixed meals
; (8, 12, 1 3). The present results do not negate
se previous findings of an effect of factors such
as fat (14), protein (15, 16), dietary fiber (17),
phytate (1 8), and other antinutrients in influ-
. r encing the glycemic response and the endo-
I
N

: crine background. However, they indicate that

8 the addition of fat and protein to a meal, in
representative amounts, does not obscure the
. - r- e cumulative effect of the component carbo-
3 hydrates (19).
0 0 - We have previously shown that when two
carbohydrate foods ofdiffering GI were mixed
c together in equal proportions in one meal, the
#{128} se blood glucose response in NIDDM patients
. was approximately midway between those of
- meals containing each food alone (9). The
. present results demonstrate how this approach
. a’ rt may be extended to the calculation of the GI
., of mixed meals. This had been borne out by
C analysis of the results of other papers in the
. . . literature notable for their inclusion ofa range
: . i .-: of meals eaten by the same groups of volun-
.. . teers (normal, IDDM, and NIDDM)(l2, 13).
. Here, the correlation coefficients between the
. se t meal GIs and the glycemic responses were sig-
. nificant, being between 0.92 and 0.96 (10).
0 Although this approach allows use to be
; made of GI values in predicting the likely im-
pact of mixed meals on glycemic responses, it
‘E o does not indicate what changes, if any, are to
. .- . . be expected in basal blood glucose levels.
a Nevertheless, high fiber diets which have been
?
. , . -

. . . : . successful in the treatment of diabetes have

I- L) c) -I 1- contained low glycemic index foods (20-26).

 GLYCEMIC INDEX AND MIXED MEALS 171

TABLE 5 It is concluded that use can be made of the

Calculation of incremental plasma glucose response glycemic index concept in ranking the relative
areas from the graphs presented in the study being
glycemic impact of mixed meals containing
assessed (8)
fat and protein. The exact clinical utility of
MiT- I MTT-2 MTT-3 MTF-4
controlling postprandial glycemia remains to
Total area be established. However, the apparent success
(mg/dl - h) 838 735 683 672 of diets containing low glycemic index foods
Fasting blood
suggests that in future studies assessment of
glucose
(mg/dl) 175.0 162.5 162.5 168.8 the GI of the diets used may prove
Fasting blood worthwhile. #{163}3
glucose X3
(mg.dI) 525 488 488 506
Incremental area TW was in receipt of a Nutrition Fellowship from the
(mg/dl-h) 313 247 195 166 Kellogg Company, Battle Creek, MI. This work was sup-
ported by grants from the Natural Sciences and Engi-

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neering Research Council of Canada.

Where studies of high fiber diets have failed References

to reduce the glycemic response (27) or im-
1. Committee ofthe American Diabetes Association on
prove blood glucose control (28, 29) these diets
Food and Nutrition Special Report. Principles on nu-
have relied on high fiber cereal foods where trition and dietary recommendations for individuals
the fiber content does not influence the GI (eg with diabetes mellitus. Diabetes Care 1979;2:520-3.
wholemeal bread). The long-term effects of low 2. Crapo PA, Reaven GM, Olefsky J. Plasma glucose
and insulin responses to orally administered simple
GI foods per se in diabetes requires to be es-
and complex carbohydrates. Diabetes l976;25:
tablished. However, in hyperlipidemic pa- 741-7.
tients, the incorporation oflow GI foods into 3. Jenkins DJA, Wolever TMS, Taylor RH, et al. Gly-
the diet reduced serum triglyceride and cho- cemic index of foods: a physiological basis for car-
lesterol levels (30-32). In order for full use to bohydrate exchange. Am J Clin Nutr 1981:34:
362-6.
be made of GI data in the future, not only
4. Jenkins DJA, Wolever TMS, Jenkins AL, Josse RG,
must it be used appropriately in the calculation Wong GS. The glycaemic response to carbohydrate
ofmeal glycemic effects, but the range of foods foods. Lancet 1984;2:388-91.
classified must be greatly extended to cater for 5. Crapo PA, Olefsky JM. Food fallacies and blood sugar.
varied tastes and individualized diet plans. N EngI J Med l983;309:44-5.
6. O’Dea K. Diabetes and diet. Science l983;221 :214.
7. Coulston AM, Hollenbeck CB, Reaven M. Utility of
studies measuring glucose and insulin responses to
various carbohydrate-containing foods. Am J Clin
Nutr 1984;39: 163-5.
8. Coulston AM, Hollenbeck CB, Liu GC, et al. Effect
of source of dietary carbohydrate on plasma glucose,
100 insulin, and gastric inhibitory polypeptide responses
to test meals in subjects with noninsulin-dependent
5, diabetes mellitus. Am J Clin Nutr l984;40:965-70.
9. Jenkins DJA, Wolever TMS, Wong GS, et al. Gly-
cemic responses to foods: possible difference between
insulin-dependent and non-insulin-dependent dia-
i 50
betics. Am J Clin Nutr 1984:40:971-81.
10. Wolever TMS, Nuttall FQ, Lee R, et al. Prediction
ofthe relative blood glucose response ofmixed meals
using the white bread glycemic index. Diabetes Care
l985;8:4 18-28.
1 1. Snedecor GW, Cochran WG. Statistical methods. 7th
ed. Ames, IA: Iowa State University Press, 1980.
0 100 200 300 12. Nuttall FQ, Mooradian AD, DeMarais R, Parker S.
INCREMENTAL PLASMA GLUCOSE AREA (mg/dI.h) The glycemic effect of different meals approximately
isocaloric and similar in protein, carbohydrate, and
FIG 2. Correlation between calculated meal GIs and fat content as calculated using the ADA exchange lists.
incremental blood glucose response areas for the study Diabetes Care l983;6:432-5.
being assessed (8): r = 0.987; p < 0.02. 13. Bantle JP, Lame DG, Castle GW, Thomas JW,
 I72 WOLEVER AND JENKINS

Hoogwerf BJ, Goetz FC. Post-prandial glucose and diets for insulin treated men with diabetes mellitus.
insulin responses to meals containing different car- Am J Clin Nutr 1979;32:23l2-2l.
bohydrates in normal and diabetic subjects. N Engl J 23. Albrink MJ, Newman T, Davidson PC. Effect of high-
Med 1983;309:7-12. and low-fiber diets on plasma lipids and insulin. Am
14. Collier G, O’Dea K. The effect of coingestion of fat J Clin Nutr l979;32: 1486-91 .
on the glucose, insulin and gastric inhibitory poly- 24. Rivellese A, Riccardi G, Giacco A, et al. Effect of
peptide responses to carbohydrate and protein. Am J dietary fibre on glucose control and serum lipo-pro-
Clin Nutr 1983;37:94l-4. teins in diabetic patients. Lancet l980;2:447-50.
15. Estrich D, Ravnick A, SchlierfG, Fukayama G, Kin- 25. Simpson HCR, Simpson RW, Lousley 5, et al. A high
sell L. Effects ofco-ingestion of fat and protein upon carbohydrate leguminous fibre diet improves all as-
carbohydrate-induced hyperglycemia. Diabetes pects ofdiabetic control. Lancet 198 1; 1:1-5.
1967;l6:232-7. 26. Kinmouth A-L, Angus RM, Jenkins PA, Smith MA,
16. Nuttall FQ, Mooradian AD, Gannon MC, Billington Baum JD. Whole foods and increased dietary fibre
C, Krezowski P. Effect of protein ingestion on the improve blood glucose control in diabetic children.
glucose and insulin response to a standardized oral Arch Dis Child l982;57:l87-94.
glucose load. Diabetes Care 1984;7:465-70. 27. Ullrich IH, Albrink MJ. Lack ofeffect ofdietary fiber
17. Levitt NS, Vinik Al, Sive AA, Child PT, Jackson on serum lipids, glucose, and insulin in healthy young

Downloaded from ajcn.nutrition.org at BOSTON UNIVERSITY on July 4, 2017

WPU. The effect ofdietary fiber on glucose and hor- men fed high starch diets. Am J Clin Nutr l982;36:
mone responses to a mixed meal in normal subjects 1-9.
and in diabetic subjects with and without autonomic 28. Manhire A, Henry CL, Hartog M, Heaton KW. Un-
neuropathy. Diabetes Care l980;3:5 15-9. refined carbohydrate and dietary fibre in treatment of
18. Collier G, McLean A, O’Dea K. Effect of co-ingestion diabetes mellitus. J Hum Nutr 198 l;35:99-lOl.
offat on the metabolic responses to slowly and rapidly 29. Lindsay AN, Hardy S, Jarrett L, Rallinson ML. High-
absorbed carbohydrates. Diabetologia 1984;26:50-4. carbohydrate, high-fiber diet in children with type 1
19. Yoon JH, Thompson LU, Jenkins DJA. The effect diabetes mellitus. Diabetes Care 1984;7:63-7.
of phytic acid on in vitro rate of starch digestibility 30. Jenkins DJA, Wong GS, Patten R, et al. Leguminous
and blood glucose response. Am J Clin Nutr l983;38: seeds in the dietary management of hyperlipidemia.
835-42. Am J Clin Nutr l983;38:567-73.
20. Kiehm TG, Anderson JW, Ward K. Beneficial effects 31. Jenkins DJA, Wolever TMS, Kalmusky J, et al. Low
ofa high carbohydrate high fiber diet in hyperglycemic . glycemic index carbohydrate foods in the management
men. Am J Clin Nutr 1976;29:895-9. ofhyperlipidemia. Am J Clin Nutr l985;42:604-l7.
21. Anderson JW, Ward K. Long-term effects ofhigh car- 32. Andersen E, Hellstrom P. Karlander 5-0, Hellstrom
bohydrate, high fiber diets on glucose and lipid me- K. Effects of a rich-rich versus a potato-rich diet on
tabolism: A preliminary report on patients with dia- glucose, lipoprotein, and cholesterol metabolism in
betes. Diabetes Care l978;l:77-82. noninsulin-dependent diabetics. Am J Clin Nutr
22. Anderson JW, Ward K. High carbohydrate, high fiber 1984;39:598-606.