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Dietary breads: Myth or reality?

Article in Diabetes Research and Clinical Practice · August 2008

DOI: 10.1016/j.diabres.2008.02.010 · Source: PubMed

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 diabetes research and clinical practice 81 (2008) 68–71

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/diabres

Dietary breads: Myth or reality?

Banu Mesci *, Aytekin Oguz 1, Hatice Gul Sagun 2, Mehmet Uzunlulu 3,

Elmas Biberci Keskin 4, Damla Coksert 5
Goztepe Training and Research Hospital, Diabetes Clinic, Turkey

article info abstract

Article history: Aims: To assess the differences in acute effects of whole wheat bread, wheat bran bread and
Received 27 December 2007 rye bread – perceived as dietary(Low caloric!) breads – on glucose and insulin levels in
Accepted 13 February 2008 patients with type 2 diabetes, as compared to white wheat bread.
Published on line 26 March 2008 Methods: One hundred twenty one type 2 diabetic patients were randomized into three
groups as whole wheat, wheat bran and rye bread groups. Each group ate 100 g of bread with
Keywords: water with in 10 min. Blood glucose measurements were made at every 30 min in 2 h. Insulin
Type 2 diabetes was measured at fasting and at the second hour in the patients who do not use insulin. The
Whole wheat bread same processes were repeated on the following day, with white wheat bread for each group.
Wheat bran bread Results: No significant difference was found in either glycemic or insulinemic effects
Rye bread between four types of breads when compared to each other. ( p = 0.093 for glycemic effect
White wheat bread and p = 0.297 for insulinemic effect).
Conclusion: Three different bread types consumed as an alternative to white bread in
Turkey, increase blood glucose levels of diabetic patients similar to white bread.
# 2008 Elsevier Ireland Ltd. All rights reserved.

1. Introduction levels in patients with type 2 diabetes, as compared to white

Bread is one of the main elements in the diet of Turkish people.
It is a common belief that some kinds of bread are more
appropriate for a diabetic diet, as they have less hyperglycemic
effect. Many of the patients visiting our clinic, report that they
eat wheat bran bread, rye bread and whole wheat bread as a
part of their diet, without considering the amount they
consumed. The aim of this study was to explain the acute
effects of whole wheat bread, wheat bran bread and rye bread
– perceived as dietary breads – on blood glucose and insulin
wheat bread.
2. Subjects, materials and methods
The study involved 149 type 2 diabetic patients followed at
Goztepe Training and Research Hospital all reported that they
used to consume 50–100 g of bread at breakfast. Severe
cardiac, liver and renal failure, hypersensitivity reaction to
test foods, chewing and swallowing disorders, malabsorption,

* Corresponding author at: G, Suadiye Kadikoy, Oncu sk. Seher apt. No: 5/10, 34722, Turkey. Tel.: +90 5322923159; fax: +90 2165655526.
E-mail addresses: banualpaslan@gmail.com (B. Mesci), aytekinoguz@yahoo.com (A. Oguz), gulsagun@yahoo.com (H.G. Sagun), meh-
metuzunlu@yahoo.com (M. Uzunlulu), elmasbiberci@yahoo.com (E.B. Keskin), damlacoksert@yahoo.com (D. Coksert).
1
Tel.: +90 5057745929; fax: +90 2165655526.
2
Tel.: +90 5052633312; fax: +90 2165655526.
3
Tel.: +90 5326852744; fax: +90 2165655526.
4
Tel.: +90 53270901989; fax: +90 2165655526.
5
Tel.: +90 5059231359; fax: +90 2165655526.
0168-8227/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.diabres.2008.02.010
 diabetes research and clinical practice 81 (2008) 68–71 69

having fasting blood glucose levels more than 199 mg/dl and
being on intensive insulin treatment were exclusion criteria.
Study protocol was approved by our local ethical committee
(Date of approval: 11 January 2007 and decision no: 34/C) and
designed in accordance with the Helsinki Declaration of 1975
as revised in 1983. Patients giving their written approval for
participation were randomized into three main groups, which
were given whole wheat, wheat bran and rye bread,
respectively. Patients, were invited to the diabetes clinic after
at least 12-h fasting on different days. Fasting blood glucose
was measured from the capillary blood and venous blood was
collected for measurement of fasting plasma insulin only from
the patients who do not use insulin. First group ate 100 g of
whole wheat bread. Second group ate 100 g of wheat bran
bread and third group 100 g of rye bread with 0.5 l of water
within 10 min. Capillary blood glucose was measured in every
half an hour until the second hour from the moment they
started to eat. Venous blood was also collected for blood
insulin level at the second hour from 60 patients (20 patients
from each group) whose fasting insulin levels were measured.
The same processes were repeated on the following day, with
white wheat bread.
White wheat bread used in the study was made of only
white flour, which was separated from wheat’s germ, fine
and coarse bran. Wheat bran bread was made of white flour
with an addition of the fine bran of the wheat grain and did
not include any coarse bran and wheat germ. Whole wheat
bread was made of whole grain wheat flour. In the
manufacturing process of the whole wheat bread whole
wheat is used in the same quantities as in the nature,
including coarse bran, fine bran and wheat germ. Prepara-
tion of the rye bread, made of rye flour containing both the
coarse bran and wheat germ did not exclude any content of
wheat or rye, including the coarse bran and the germ, so the
quantity of bran was adjusted to natural levels. Nutritional
values of the breads are shown in Table 1. Bread used in the
study was prepared as roll bread packages containing
different types of 50-g breads (whole wheat bread, wheat
bran bread, rye bread and white wheat bread).
Blood glucose measurements were made from capillary
blood using glucometer (Johnson & Johnson Company Life
Scan One touch horizon). Insulin values were measured by
Hitachi modular E170 hormon device, Roche insülin kit.
3. Statistical analysis
Glucose and insulin reponses were assessed by the differences
in blood glucose and insulin levels between initial and second
hour measurements. Student’s paired t-test was used to
compare the effects of different kinds of breads on blood
glucose and insulin levels, and one-way ANOVA test was used
to compare glycemic and insulinemic effects of all bread types.
All analyses were conducted through SPSS 13 software.
4. Results
28 of 149 patients were excluded from the study (12 of them for
their absence on the second day, 5 for not eating all of their
bread and 11 for having fasting blood glucose levels above 199
on the second day). The study was completed with 121
patients (77 F, 44 M). The mean age of patients was 57.1 and the
mean duration of diabetes was 6.4 years. Mean blood pressure
levels were found 141.3 mm/Hg systolic, and 83.06 mm/Hg
diastolic. Mean BMI was 31.25 kg/m2. Mean waist circumfer-
ence were 103.3 cm for women and 102.2 cm for men. 90
patients were taking oral antidiabetic drugs, 17 were taking
basal insulin alone or combined with oral hypoglycemic
agents, and 14 were only on a diet. Demographical data for the
participants of the study are shown in Table 2.
For all groups, blood glucose variation during the 2-h period
showed a similar curve. Blood glucose reached the highest
level at the 90 min and then started to decrease (Fig. 1).
The blood glucose differences between second hour
and fasting samples were 75.05 mg/dl with whole wheat
bread and 77.66 mg/dl with white wheat bread in the first
group ( p = 0.414). 94.91 mg/dl with wheat bran bread and

Table 1 – Nutritional values of different types of breads

Nutritional values (in 100 g) Whole wheat bread Wheat bran bread Rye bread White wheat bread

Protein (g) 8.15 9.16 8.82 9

Carbohydrate (g) 40.5 40.4 40 49

Table 2 – Demographic data of the patient group participating in the study

Groups participating N Age BMI Waist circumfer- Treatment
in the study (years) (kg/m2) ence (cm)
a b
M F Diet only OHA BI or BI + OAD

Group 1 39 55.6 30.40 100.6 109.9 8 23 8

Group 2 42 56.1 32.19 101.8 108.9 4 36 2
Group 3 40 59.8 31.10 104 99.8 2 31 7

All groups 121 57.1 31.25 103.3 102.2 14 90 17

a
OHA: oral hypoglycemic agent.
b
BI: basal insulin treatment.
70 diabetes research and clinical practice 81 (2008) 68–71
Fig. 1 – Glycemic effects of different types of bread used in
our study.
78.3 mg/dl with white wheat bread in the second group
( p = 0.153). 103.9 mg/dl with rye bread and 82.72 md/dl with
white wheat bread in the third group ( p = 0.124). The
differences in serum insulin levels between second hour
and fasting samples were 34.56 U with whole wheat bread and
27.35 U with white wheat bread in the first group ( p = 0.441).
29.65 U with wheat bran bread and 25.89 U with white wheat
bread in the second group ( p = 0.496). 40.35 U with rye bread
and 36.15 U with white wheat bread in the third group
( p = 0.569).
No significant difference was found in either glycemic or
insulinemic effects between four types of breads when
compared to each other. ( p = 0.093 for glycemic effect and
p = 0.297 for insulinemic effect) (Table 3).
5. Discussion
This study demonstrated that, in contrast to widely accepted
by public, the effect of white bread on the increase of blood
glucose level of patients with type 2 diabetes mellitus was not
different than other types of bread.
Many studies have shown that diets with lower glycemic
indices and higher fiber content decrease the risk of devel-
oping type 2 diabetes and heart diseases, contribute to a higher
life quality for diabetics and have some preventive and
Table 3 – Comparison of glycemic and insulinemic effects of all bread categories with white wheat bread
a b
Groups Bread type Blood glucose difference (mg/dl)
Group 1 n = 39 Whole wheat bread
White wheat bread 1
Group 2 n = 42 Wheat bran bread
White wheat bread 2
Group 3 n = 40 Rye bread
White wheat bread 3
a
Difference between the second hour blood glucose and fasting blood glucose.
b
Difference between the second hour insulin level and fasting insulin level.
curative effect against insulin resistance and metabolic
syndrome [1–3]. Cereal grains are recommended for diabetic
patients for their diets [4]. The cereal grain consists of
endosperm, embryo and bran. Grinding process separates
the bran and the embryo from the endosperm. The endosperm
is rich in starch content. Other nutrients are concentrated on
the outer layer of the grain. Consequently, nutritional content
of the refined grain decreases and contains more starch. The
major difference between whole grain food and refined grains
is that in whole grain food, the bran and the germ are
protected [5]. Viscous fibers, such as b glucan in oat bread
delays gastric emptying and causes glucose to be released into
the circulation more slowly [6,7]. Be cause of slower digestion
of cereals with high grain content, they may elevate
postprandial blood glucose less in diabetics [8]. Particle size
of whole grain cereals is one of the factors that define their
physiological effects. Unprocessed bran delays gastric empty-
ing and accelerates transit through intestines [9]. In our study,
blood glucose change showed a similar curve for all groups,
peaking at the 90 min. Therefore, no absorption difference as
affected by contents was considered between the compared
bread types.
There are other studies suggesting that different types of
bread do not differ in terms of glycemic effect in single meal
tests. Liljeberg et al. reported that in single meal tests,
glycemic and insulinemic responses to cereal products based
on whole—meal oats or barley were indistinguishable from
those with white bread [10]. Glycemic index value may be
found to vary between individuals, and between measure-
ments repeated for different individuals. We observed inter-
individual variability of glycemic responses for white bread.
Vega-Lopez et al. reported that interindividual variability is
higher than intraindividual reproducibility of glycemic index
values for commercial white bread [11].
The power of our study is that, the number of patient
groups was greater than that of similar studies, and every
patient in each group ate also white wheat bread. Since
patients ate white wheat bread on the day following the very
first day, possibility of any change in lifestyles or metabolic
variation is relatively low.
The weakness of our study, on the other hand, is that
consumed bread types do not suggest any effects other than
short-term glycemic and insulinemic effects. The absence of
any significant difference in postprandial insulin levels
between four type of breads in our study does not exclude
the possible long-term effects of different breads. This study
Blood insulin difference (U)
75.05 p = 0.414 34.56 p = 0.441
77.66 27.35
94.91 p = 0.153 29.65 p = 0.496
78.3 25.89
103.9 p = 0.124 40.35 p = 0.569
82.72 36.15
 diabetes research and clinical practice 81 (2008) 68–71
alone is not enough to comment on effects of different types of
bread on improving of diabetes control.
Although favorable effects of the components contained in
unrefined bread, such as grains, bran, fiber, magnesium, etc. is
shown in a number of studies [12,13], it should be noted that
quantity of bread in the diet of diabetics has to be limited. It
may be a better option to receive needed fiber and vitamins
from cereal grains, vegetables and legumes instead of bread.
Most of the patients in our country believe that consuming
non-white wheat bread is essential for a diabetic diet. This
may lead patients to eat excessive amounts of other breads,
bringing their blood glucose and weight regulations to a
deadlock. This study demonstrates that bread types con-
sumed as an alternative to white wheat bread in our country
for diabetes or obesity, do not have less effect on blood glucose
elevation than white wheat bread and over-consumption of
such kinds of bread in the diets of diabetics could be a factor
that prevents good glycemic control.
Acknowledgments
We thank Doygun Bread Inc. for their support in baking the
breads used in our study. The study does not have any
financial sponsor.
Conflict of interest
The authors state that they have no conflict of interest.
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