Received: 21 December 2021 | Accepted: 30 March 2022

DOI: 10.1111/jhn.13029

OBESITY AND WEIGHT MANAGEMENT

Low glycaemic index and glycaemic load diets in adults with

excess weight: Systematic review and meta‐analysis of randomised
clinical trials

Lisiane Perin1 | Isadora G. Camboim1,2 | Alexandre M. Lehnen1

1
Instituto de Cardiologia do Rio Grande do
Sul, Fundação Universitária de Cardiologia,
Porto Alegre, Rio Grande Grande do Sul,
Brasil
2
Universidade Federal de Ciências da Saúde de
Porto Alegre, Porto Alegre,
Rio Grande Grande do Sul, Brasil
Correspondence
Alexandre M. Lehnen, Instituto de Cardiologia
do Rio Grande do Sul, Unidade de Pesquisa,
3° andar, Av. Princesa Isabel, 395 Santana,
90620‐001 Porto Alegre, RS Brazil.
Email: amlehnen@gmail.com
Funding information
Coordenação de Aperfeiçoamento de Pessoal
de Nível Superior
Abstract
Background: To compare the effects of low and high glycaemic index/
glycaemic load (GI/GL) diets on body weight in adults with excess weight.
Methods: We searched for randomised controlled trials comparing low GI/GL
vs. high GI/GL diets from Medline (via PubMed), Embase, Scopus and Web
of Science. The variables of interest were anthropometric measurements,
fasting glucose and fasting insulin levels and lipid profile, and 10 studies were
included in the meta‐analysis.
Results: The sample size ranged from 19 to 203 participants. Low GI/GL is not
superior to high GI/GL diets on body weight reduction in adults with excess
weight (body mass index [BMI] ≥ 25 kg m–2). However, low GI/GL diets show
greater body weight reductions in adults with BMI ≥ 30 kg m–2 (−0.93 kg; 95%
confidence interval [CI] = −1.73 to −0.12; p = 0.045). Compared with high
GI/GL diets, low GI/GL diets may also help reduce fasting glucose (−1.97 mg
dl–1; 95% CI = −3.76 to 0.19; p = 0.030) and fasting insulin (−0.55 μU ml–1;
95% CI = −0.95 to –0.15; p = 0.007). No differences in fat mass, fat‐free mass,
waist circumference and lipid profile were observed between low GI/GL and
high GI/GL diets. The risk of bias for body weight was classified as ‘low risk’
(25% of the studies) and ‘some concerns’ for all domains of RoB 2 tool in most
studies.
Conclusions: When compared with high GI/GL diets, low GI/GL diets appear
to more effectively reduce fasting glucose and insulin and promote greater
body weight reduction in adults with obesity (BMI ≥ 30 kg m–2).

KEYWORDS
glucose, glycaemic index, glycaemic load, insulin, weight loss

Key points
• Compared with high index/glycaemic (GI/GL) load diets, low GI/GL diets
reduce fasting glucose and insulin in adults with excess weight.
• In turn, low GI/GL load diets promote reductions in body weight only in
adults with body mass index ≥ 30 kg m–².
• However, further research is needed to determine whether these benefits are
maintained over the long run and can be incorporated into lifestyle.

1124 | © 2022 The British Dietetic Association Ltd. wileyonlinelibrary.com/journal/jhn J Hum Nutr Diet. 2022;35:1124–1135.

PERIN ET AL.
INTRODUCTION
Unhealthy eating habits along with sedentary behaviour
are major modifiable factors that contribute to weight
gain.1 The major contribution of dietary macronutrients
to body weight gain has been a continuing matter of
debate in the literature and habitual consumption
of carbohydrate‐rich foods has gained attention because
of the risk of developing obesity.2
Carbohydrates are usually classified as ‘simple’ or
‘complex’ chemical structure. However, the effects of
dietary carbohydrates are more effectively related to the
stimulus for insulin secretion and post‐prandial glucose
levels, determined by different types of carbohydrates.2
Thus, the rate of glucose‐stimulated insulin secretion is
associated with the glycaemic index (GI) of foods,3 which
can be found in global tables.4–6 GI ranks carbohydrate‐
containing foods and is expressed as the percentage of
response to the reference amount of food (e.g., 50 g of
glucose or white bread).7 A single food item can be
classified as high GI, medium GI or low GI.8 In turn, the
glycaemic load (GL) is a product of GI and the quantity
of carbohydrate consumed. Thus, GL of a given food
item is used to quantify the glycaemic effect of the food
by the carbohydrate content9 (classified as low, GL ≤ 10
g; intermediate, GL between 11 and 19 g; high, GL ≥ 20
g). Furthermore, a ‘daily GL’ is considered low if <80 g
or high if >120 g.8
Several meta‐analyses of randomised controlled trials
(RCTs) have investigated the effects of low GI and GL
(low GI/GL) diets compared with high GI and GL (high
GI/GL) diets.10–12 Although low GI/GL diets apparently
have positive effects on body composition, lipid profile,
fasting insulin and C‐reactive protein, most RCTs
evaluated in these meta‐analyses did not provide
information on either GI and/or GL or macronutrient
composition of foods (carbohydrates, proteins and
lipids), and on whether the study interventions were
supervised and documented using dietary assessment
tools. These are limitations to the validity of the findings
regarding low GI diet protocols.
The present study aimed to evaluate the effects of low
GI/GL diets compared with high GI/GL diets on body
weight in adults with excess weight (overweight or
obesity). In addition, we compared the effects of both
dietary strategies on other anthropometric measure-
ments, fasting glucose and insulin and lipid profile. We
postulated that low GI/GL diets have beneficial effects
on all parameters considered compared to high GI/GL
diets.
METHODS
The protocol for this systematic review and meta‐analysis
was registered in the International Prospective Register
of Systematic Reviews (PROSPERO) (registration ID:
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| 1125
CRD42018108684). The study design and conduction
followed the recommendations of the Cochrane Hand-
book for Systematic Reviews of Interventions13 and the
Preferred Reporting Items for Systematic Reviews and
Meta‐analyses (PRISMA).14
Eligibility criteria
Inclusion criteria for the meta‐analysis were: (a)
randomised controlled design; (b) 1 month of dietary
intervention or more; (c) evaluation of selected
parameters: body weight, fat mass, fat‐free mass,
waist circumference, fasting glucose and/or fasting
insulin, total cholesterol, low‐density lipoprotein
(LDL) cholesterol, high‐density lipoprotein choles-
terol (HDL) and triglycerides; (d) adult participants
18 years of age or more; (e) body mass index
(BMI) ≥25 kg m– ²; and (f) comparison of selected
parameters between low GI/GL diet (experimental)
vs. high GI/GL diet (control). It should be noted that
GI and GL classifications were defined by the authors
of each eligible RCT.
There were excluded studies where: (a) macronutrient
composition (carbohydrates, proteins and lipids) and GI
and/or GL of the diets were not properly reported; (b)
the intervention was not under direct supervision or not
documented using dietary assessment tools; (c) the
intervention consisted only of general diet recommenda-
tions to increase intake of low GI foods or to reduce GL;
(d) the diets were not prescribed to reduce body weight;
and (e) participants included individuals with type 1 or
type 2 diabetes mellitus, vegetarians, vegans or pregnant
women.
Literature searches
Searches were conducted in the electronic databases
Medline (via PubMed), Embase, Scopus, and Web of
Science. PubMed search strategy is detailed in the
supplementary material (see Supporting information,
Figure S1). This same strategy was adjusted for Embase,
Scopus and Web of Science searches. Articles in any
language with no date of publication limits were all
eligible.
Study selection
Two reviewers (LP and IGC) independently read the
titles and abstracts of every publication found in the
literature search and recorded the data in a standard
form. When it was unclear, they reviewed the full‐text
publication retrieved. Disagreements between reviewers
were resolved by consensus and otherwise by consulta-
tions with a third reviewer (AML).

1126 | SYSTEMATIC REVIEW AND META‐ANALYSIS
Data extraction and risk of bias assessment
The same two reviewers independently extracted infor-
mation on study population, intervention and outcomes
from every RCT selected. The data were entered into an
Excel (Microsoft Corp.) form as: first author's last name;
year of publication; sample size; participants' age, race/
ethnic group, BMI; study design; duration of interven-
tion; characteristics of dietary interventions; differences
between GI and GL; diet adherence; study dropout rate;
and post‐intervention outcome values or mean difference
(MD) between the two groups over time and related
dispersion measures (standard deviation or standard
error of the mean or 95% confidence interval [95% CI])
for intervention and control groups. A meta‐analysis was
performed for each outcome measure of interest to
determine the pooled effect of the intervention through
MDs of post‐intervention values or MDs between low
GI/GL and high GI/GL groups. When MD of post‐
intervention values was not available, we calculated MDs
between low GI/GL and high GI/GL groups.
The reviewers then independently reviewed full‐text
studies for methodological quality. They used the recom-
mended Cochrane Risk‐of‐Bias (Rob 2) tool for rando-
mised trials (17). For each study result of interest, the risk
of bias was evaluated on the following five domains: (i)
randomisation process; (ii) deviations from the intended
intervention; (iii) missing outcome data; (iv) measurement
of the outcome; and (v) selection of the reported result. For
each outcome assessed we assigned an overall risk of bias,
which is the least favourable assessment across the domains
of bias. The values were produced using the robvis tool
(https://www.riskofbias.info).15
Disagreements between the two reviewers in data
extraction or risk of bias assessment were resolved by
consensus or otherwise by consultation with a third
reviewer (AML) by examining the original data.
Statistical analysis
Heterogeneity of results was tested using a chi‐squared
test. I2 statistic was used to measure the extent of
inconsistencies: I² = [(Q−df)]/Q×100%, where Q is the χ²
statistic and df is its degree of freedom. I2 > 50% was
considered to represent substantial heterogeneity.16 A
random‐effects model was used in the analyses with the
R software version 3.5.1 (The R Foundation for
Statistical Computing) because of substantial heteroge-
neity of the data.
We used forest plots to show the specific effect sizes
of the meta‐analyses along with 95% CIs. We conducted
subgroup analyses for BMI (≥30 vs. <30 kg m–2) and
study duration (≥6 vs. <6 months).
The RCTs included in this systematic review used
different specific GI or GL values for the interventions.
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We carried out a random effects meta‐regression to
detect any potential dose–response relationships
among inter‐study variability of low GI/GL and high
GI/GL characteristics, as well as changes in all
outcomes evaluated. We generated funnel charts to
assess potential publication bias and the Egger's
regression test and Begg's rank test were also
used.17,18
In particular, the study by McMillan‐Price et al.19
compared GI/GL diets using two different interventions:
low or high GI/GL diets with high‐carbohydrate (CHO)
content and low or high GI/GL diet with high‐protein
(PTN) content. Both dietary interventions were included
in the meta‐analysis as separate comparisons (low GI/
GL/CHO vs. high GI/GL/CHO and low GI/GL/PTN vs.
high GI/GL/PTN) because this strategy minimises the
potential confounding effect of high CHO and high PTN
compared to the diets of interest (low GI/GL and high
GI/GL).
p < 0.05 (two‐tailed) was considered statistically
significant.
RESULTS
Literature searches
Of 2516 articles retrieved in the literature search, 225
articles were excluded because of duplicate publication.
We then examined titles, abstracts and/or keywords of
the remaining 2291 articles and 2248 were screened out.
All 43 articles remaining were read in full and 33 were
excluded (Figure 1). In total, 10 studies fully met the
inclusion criteria for the meta‐analysis.
Study characteristics
All studies included in the meta‐analysis were parallel
RCTs with 2–18‐month dietary interventions (mean
6.9 months) for a total of 801 participants (70.1% females
and 29.9% males). The most commonly used dietary
interventions had similar macronutrient and fibre com-
position, but their contents varied among the studies
(40–60% carbohydrates; 12–30% proteins; 20–39% lipids;
and 14–45 g fibres). The studies also used different
caloric restriction strategies, and they were most com-
monly 10–30% reductions of total energy. GI values
ranged from 8 to 42 and GL values ranged from 27 to
176. The most frequently used food assessment tool to
assess adherence to dietary interventions was 3–7‐day
food records. Only two studies explicitly reported the
dietary adherence rate. Notably the longest study showed
the highest dropout rate (39%). Table 1 summarises the
overall characteristics of the studies included in this
meta‐analysis.

PERIN ET AL.
F I G U R E 1 Flowchart of study selection. GI,
glycaemic index; GL, glycaemic load
Effect size for the outcomes evaluated
There were no differences in body weight reduction
among the participants with excess weight (BMI ≥ 25 kg
m–2) with the dietary strategies evaluated. We found an
effect size of −0.39 kg (95% CI = −1.08 to 0.31; p = 0.270;
I2 = 87%) (Figure 2). No differences were found for fat
mass, fat‐free mass and waist circumference either
(Table 2). Yet, the sensitivity analysis for BMI showed
that low GI/GL diets appear to increase body weight
reduction among those with BMI ≥ 30 kg m–² compared
to control volunteers with BMI < 30 kg m–², with a
difference of −0.93 mg dl–1 for low GI/GL (95% CI =
−1.73 to −0.12; p = 0.045) (Table 3). The benefits of low
GI/GL diets for body weight reduction were more often
seen when interventions lasted <6 months (Table 4).
With regard to glycaemic and lipid profiles, no
differences were seen between low and high GI/GL diets
(Table 2) for total cholesterol (−7.15 mg dl–1; 95% CI =
−16.39 to 2.09; p = 0.130; I2 = 98%), LDL (−5.56 mg dl–1;
95% CI = −11.91 to 0.79; p = 0.090; I2 = 98%), HDL
(−0.10 mg dl–1; 95% CI = −1.74 to 1.95; p = 0.910;
I2 = 86%) and triglycerides (2.05 mg dl–1; 95% CI = −9.71
to 13.80; p = 0.730; I2 = 93%).
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| 1127
By contrast, when we compared low GI/GL diets
with high GI/GL dietary protocols, we found reductions
in both fasting glucose of −1.97 mg dl–1 (95% CI = −3.76
to 0.19; p = 0.030; I2 = 95%) and fasting insulin with an
effect size of −0.55 μU ml–1 (95% CI = −0.95 to −0.15;
p = 0.007; I2 = 0%) (Figure 3).
Heterogeneity and risk of bias assessment
There was moderate to substantial heterogeneity among
the studies regarding body weight in most outcomes
assessed (Table 2). A random‐effects meta‐regression was
used to examine any associations between low GI‐GL
and high GI/GL dietary characteristics and outcome
changes, but we found no dose‐response relationship.
However, a dose‐response relationship was seen between
GL and HDL (p = 0.013) (see Supporting information,
Figure S2A) and GL and triglycerides (p < 0.001) (see
Supporting information, Figure S2B). Every one point of
GL was associated with a relative risk reduction of 2.3%
in HDL and 14.5% in triglycerides. Thus, GL explained
84.3% and 96.5% of early heterogeneity seen in HDL and
triglycerides, respectively.
 TABLE 1 Overall characteristics of randomised clinical trials included in the meta‐analysis.
| 1128

Dietary intervention
Duration of
Participant dietary Energy GI and GL Changes in Dropout
Authors, country characteristics intervention composition (%) Energy restriction values Reference GI GI and GL Dietary records rate (%)
Abete et al.20 32 subjects 2 months LGI: 30% LGI: NA GI: 20 3‐day weighed food record None
Spain 43.8% women CHO, 50.2; PTN, GI, 40–45 GL: NA Dietary adherence rate: NA
Age: 36.0 ± 7.0 18.3; LIP, 31.5; HGI:
years FIB, 24.9 GI, 60–65
Race: NA HGI:
BMI: 32.5 ± 4.4 CHO, 47.8. PTN,
19.6; LIP, 32.6;
FIB, 18.5

Armendáriz‐ 54 subjects 6 months LGL: 500 kcal LGL: NA GI: 8 3‐day food record 44.4
Anguiano 66.7% women CHO, 50; PTN, 19; GI, 51; GL, 76 GL: 27 Dietary adherence rate: NA
et al.21 Age: 35.4 ± 8.6 LIP, 31; FIB 23 HGL:
Mexico years HGL: GI, 59;
Race: NA CHO, 51; PTN, 21; GL, 103
BMI: 31.6 ± 25.7 LIP, 28; FIB 14

Buscemi et al.22 40 subjects 3 months LGI: 20 kcal/kg LGI: NA GI: 10.3 3‐day food record 14.9
Italy 52.5% women CHO, 55; PTN, 20; GI, 43.8; GL: 28.5 Dietary adherence rate: >90%
Age: 49.9 ± 8.0 LIP, 25; FIB, 32 GL, 95.5 in both groups
years HGI: HGI:
Race: NA CHO, 57; PTN, 19; GI, 54.1;
BMI: 34.4 ± 5.8 LIP, 24; FIB, 33 GL, 124

Cheatham et al.23 46 subjects 6 months LGL: 10% or 30% LGL: NA GI: NA Food record 8.7
USA 73.81% women CHO, 40; PTN, 30; GL, 45 g/ GL: 71 Dietary adherence rate: NA
Race: NA LIP, 30; FIB, 1000 kcal
Age: 34.74 ± 4.93 15 g/1000 kcal HGL:
years HGL: GL, 116 g/
BMI: 27.80 ± 1.54 CHO, 60; PTN, 20; 1000 kcal
LIP, 20; FIB,
15 g/1000 kcal

Das et al.24 34 subjects 12 months LGL: 30% LGL: NA GI: 33.2 Weighted non‐consumed foods 14.7
USA 76.47% women CHO, 40; PTN, 30; GI, 52.4; GL, GL: 102.9 Dietary adherence rate: NA
Age: 34.5 ± 5.5 LIP, 30; FIB, 45.4 g/
years 15.1/1,000 kcal 1000 kcal
Race: NA HGL: HGL:
BMI: 27.6 ± 1.4 CHO, 60; PTN, 20; GI, 85.6; GL,
LIP, 20; FIB, 118.3 g/
15.3/1000 kcal 1000 kcal

Goss et al.25 69 subjects 4 months LGL: All energy‐ LGL: Glucose GI: NA 4‐day food record 14.5
USA 55.07% women restricted diets: GL ≤ 45 g/ GL: 30 Dietary adherence rate: NA
1000 kcal 1000 kcal
SYSTEMATIC REVIEW AND META‐ANALYSIS

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 TABLE 1 (Continued)
PERIN

Dietary intervention
Duration of
ET AL.

Participant dietary Energy GI and GL Changes in Dropout

Authors, country characteristics intervention composition (%) Energy restriction values Reference GI GI and GL Dietary records rate (%)
Race: 52.17% CHO, 43; PTN, 18; HGL:
white LIP, 39; GL ≥ 75 g/
Age: 35.18 ± 8.33 FIB, NA 1000 kcal
years HGL:
BMI: 32.62 ± 4.34 CHO, 59; PTN, 18;
LIP, 27;
FIB, NA

Karl et al.26 46 subjects 12 months LGL: 10% or 30% LGL: NA GI: NA 7‐day food record 15.22
USA 76.92% women CHO, 40; PTN, 30; GL, 45 g/ GL: 71 Dietary adherence rate: NA
Race: NA LIP, 30; 1000 kcal
Age: 35 ± 4.49 FIB, NA HGL:
years HGL: GL, 116 g/
BMI: 27.95 ± 1.60 CHO, 60; PTN, 20; 1000 kcal
LIP, 20;
FIB, NA

McMillan‐Price 129 subjects 3 months LGI and high CHO: 1400 kcal day–1 for LGI and Glucose High CHO 3‐day food record 10.1
et al.19 75.96% women CHO, 55; PTN, 15; females high CHO: GI: 27 Dietary adherence rate: NA
Australia Age: 31.8 ± 8.7 LIP, 30; FIB, 37 1900 kcal day–1 for GI, 40; GL, 75 GL: 52
years HGI and high CHO: males HGI and High PTN
Race: NA CHO, 55; PTN, 15; high CHO: GI: 23
BMI: 31.2 ± 4.4 LIP, 30; FIB, 34 GI, 67; GL: 33
LGI and high PTN: GL, 127
CHO, 45; PTN, 25; LGI and
LIP, 30; FIB, 35 high PTN:
HGI and high PTN: GI, 34; GL, 54
CHO, 45; PTN, 25; HGI and
LIP, 30; FIB, 33 high PTN:
GI, 57; GL, 87

Raatz et al.27 19 subjects 3 months LGI: −0.7 kg week–1 LGI: Glucose GI: 30 5‐day food record None
USA 73.68% women CHO, 60; PTN, 15; GI, 33; GL: 94 Dietary adherence rate: NA
Race: NA LIP, 25; FIB, GL, 178
Age: 17.0–70.0 16.7 g/4184 kJ HGI:
years HGI: GI, 63;
BMI: 35.60 ± 4.98 CHO, 60; PTN, 15; GL, 272
LIP, 25; FIB,
9.1 g/4184 kJ

Sichiery et al.28 203 women 18 months LGI: 100–300 kcal LGI: White bread GI: 42 Food frequency questionnaire 39.4
Brazil Age: 37.4 ± 5.5 GI, 30; GL: 176 Dietary adherence rate (>10
years GL, 104 sessions): higher in LGI
|

(Continues)
1129

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1130 | SYSTEMATIC REVIEW AND META‐ANALYSIS

The risk of bias in the studies included in this meta‐

Abbreviations: BMI, body mass index; CHO, carbohydrates; FIB, fibres; GI, glycaemic index; GL, glycaemic load; HGI, high glycaemic index; HGL, high glycaemic load; LGI, low glycaemic index; LGL, low glycaemic load;
analysis varied for body weight and fasting glucose and

rate (%)
Dropout
fasting insulin. We assessed the risk of bias using the
RoB 2 tool and found that most studies showed high risk
of bias arising from reported outcome results (D5) and of
group (61%) compared with bias arising from missing outcome data (D4) (see
Supporting information, Figures S3A and S4A). The
overall risk of bias was classified as ‘low risk’ (approxi-
HGI group (46%)

mately 25% of the studies) and ‘some concerns’ for all

domains assessed in most studies (see Supporting
Dietary records

information, Figures S3B and Figure S4B).

The funnel plots (see Supporting information,
Figure S5) generated to assess publication bias of body
weight and fasting glucose and insulin showed moderate
asymmetry suggesting that publication bias cannot be
Reference GI GI and GL
Changes in

completely ruled out as a factor influencing the results of

this meta‐analysis. In addition, the Begg's and Egger's
tests did not show any evidence of publication bias
(Table 2).

DISCUSSION
This systematic review and meta‐analysis provide evi-
GL, 280
GI and GL

dence showing that low GI/GL diets have no benefits of

GI, 72;

body weight reduction compared to high GI/GL diets in

Note: Data on age, BMI, amount of energy, LGI, LGL, HGI and HGL are given as mean values unless otherwise specified.
values
HGI

individuals with excess weight (BMI ≥ 25 kg m–²). How-

ever, low GI/GL diets improved lipid profile and reduced
Energy restriction

fasting glucose and insulin in adults with excess weight

compared to high GI/GL diets. In those with obesity
(BMI ≥ 30 kg m–²), low GI/GL diets showed benefits of
body weight reduction compared to high GI/GL diets.
Thus, we reject our hypothesis that low GI/GL diets can
promote more favourable changes in anthropometric
Dietary intervention

measurements and lipid profile, but our findings support

13.3; LIP, 27.2;

12.3; LIP, 26.1;

CHO, 59.5; PTN,

CHO, 61.6; PTN,

composition (%)

the benefits of these diets for fasting glucose and insulin.

FIB, 44.5

Overweight and obesity in adults presents a major

FIB, 36

challenge with serious adverse health consequences

Energy

HGI:

around the world. Both fat mass and waist circumference

are indicators of excess body weight and risk factors for
the development of cardiometabolic diseases.29 Lifestyle
modifications aimed to weight loss are important for
Duration of

intervention

primary and secondary prevention of overweight or

dietary

obesity30 and dietary strategies with low GI/GL may

provide greater health benefits. Our systematic review
LIP, lipids; NA, not available; PTN, proteins.

and meta‐analysis showed that low GI/GL diets promote

body weight reduction in volunteers with BMI ≥ 30 kg
BMI: 26.8 ± 1.9
characteristics
Race: 53.24%

m–² compared to high GI/GL dietary protocols even

Participant

white

though the effect size was modest (Table 3). Yet, when
the analysis involved overweight participants (i.e., BMI ≥
(Continued)

25 kg m–²), there was no longer any difference between

low and high GI/GL diets. Given that foods with low
Authors, country

GI/GL have higher fibre content than high GI/GL

diets, low GI/GL strategies appear more advantageous
TABLE 1

because of the amount of soluble fibre and because

they are associated with reduced post‐prandial glycae-
mic response, delayed gastric emptying and satiety and
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PERIN ET AL.
| 1131

F I G U R E 2 Mean differences (MD) of body weight between low glycaemic index/glycaemic load diets (experimental) vs. high glycaemic index/
glycaemic load diets (control). CI, confidence interval

TABLE 2 Pooled effect size estimates.

Outcomes Studies (n) Sample size MD 95% CI p Value I² Egger's test Begg's test
Body weight (kg) 11 536 −0.39 −1.08 to 0.31 0.270 87% p = 0.824 p = 0.815

Fat mass (kg) 8 332 −0.52 −1.90 to 0.87 0.460 98% p = 0.413 p = 0.805

Fat‐free mass (kg) 7 303 −0.01 −0.87 to 0.85 0.990 97% p = 0.227 p = 0.177

Waist circumference (cm) 5 225 0.15 −0.17 to 0.46 0.360 7% p = 0.591 p = 0.327

Fasting glucose (mg dl–1) 7 273 −1.97 −3.76 to −0.19 0.030 95% p = 0.704 p = 0.652

Fasting insulin (mUI/ml) 7 273 −0.55 −0.95 to −0.15 0.007 0% p = 0.704 p = 0.177
–1
Total cholesterol (mg dl ) 7 377 −7.15 −16.39 to 2.09 0.130 98% p = 0.925 p = 0.652
–1
LDL (mg dl ) 7 377 −5.56 −11.91 to 0.79 0.090 98% p = 0.450 p = 0.453
–1
HDL (mg dl ) 7 377 0.10 −1.74 to 1.95 0.910 86% p = 0.618 p = 0.881
–1
Triglycerides (mg dl ) 8 396 2.05 −9.71 to 13.80 0.730 93% p = 0.423 p = 0.322

Abbreviations: CI, confidence interval; HDL, high density lipoprotein; I², inconsistency; LDL, low‐density lipoprotein; MD, mean difference.

TABLE 3 Sensitivity analysis of body mass index (BMI).

BMI < 30 kg m–² BMI ≥ 30 kg m–² p value between

Outcomes Studies (n) MD 95% CI Studies (n) MD 95% CI groups
Body weight (kg) 4 0.28 −0.59 to 1.14 7 −0.93 −1.73 to −0.12 0.045

Fat mass (kg) 1 −1.12 −1.18 to −1.06 7 −0.46 −2.21 to 1.30 0.460

Fat‐free mass (kg) – – – 7 −0.01 −0.87 to 0.85

Waist circumference (cm) – – – 5 0.15 −0.17 to 0.46

–1
Fasting glucose (mg dl ) 1 −2.3 −2.65 to −1.95 6 −1.17 −5.00 to 2.65 0.560
–1
Fasting insulin (mUI ml ) 1 −0.67 −1.13 to −0.21 6 −0.20 −0.99 to 0.60 0.310
–1
Total cholesterol (mg dl ) 2 −2.85 −4.23 to −1.46 5 −9.68 −28.75 to 9.39 0.480
–1
LDL (mg dl ) 2 −0.78 −1.63 to 0.06 5 −8.69 −23.01 to 5.64 0.280
–1
HDL (mg dl ) 2 0.15 −2.20 to 2.50 5 0.12 −3.15 to 3.39 0.990
–1
Triglycerides (mg dl ) 2 −4.28 −10.68 to 2.13 6 4.97 −10.50 to 20.45 0.280

Abbreviations: BMI, body mass index; CI, confidence interval; HDL, high density lipoprotein‐cholesterol; LDL, low‐density lipoprotein‐cholesterol; MD, mean
difference.
 1365277x, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jhn.13029 by CAPES, Wiley Online Library on [18/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1132 | SYSTEMATIC REVIEW AND META‐ANALYSIS

TABLE 4 Sensitivity analysis of intervention duration.

<6 months ≥6 months

p value between
Outcomes Studies (n) MD 95% CI Studies (n) MD 95% CI groups
Body weight (kg) 6 −0.91 −1.75 to −0.06 5 0.20 −0.63 to 1.03 0.070

Fat mass (kg) 6 −0.31 −2.19 to 1.56 2 −1.12 −1.18 to −1.06 0.400

Fat‐free mass (kg) 6 −0.06 −0.97 to 0.84 1 0.60 −1.51 to 2.71 0.570

Waist circumference (cm) 4 0.13 −0.29 to 0.56 1 −1.70 −7.75 to 4.35 0.550

Fasting glucose (mg/dl) 5 −1.25 −5.24 to 2.75 2 −2.30 −2.65 to −1.95 0.610
–1
Fasting insulin (mUI ml ) 5 −0.04 −0.90 to 0.82 2 −0.69 −1.14 to −0.24 0.190
–1
Total cholesterol (mg dl ) 4 −9.18 −29.16 to 10.81 3 −2.86 −4.24 to −1.47 0.540

LDL (mg dl–1) 4 −8.34 −23.54 to 6.86 3 −0.79 −1.64 to 0.05 0.330

HDL (mg dl–1) 4 0.08 −3.27 to 3.43 3 0.17 −2.03 to 2.38 0.960
–1
Triglycerides (mg dl ) 5 5.01 −10.68 to 20.70 3 −5.01 −9.29 to −0.72 0.230

Abbreviations: CI, confidence interval; HDL, high density lipoprotein‐cholesterol; LDL, low‐density lipoprotein‐cholesterol; MD, mean difference.

F I G U R E 3 Mean differences (MD) of fasting glucose (a) and fasting insulin (b) between low glycaemic index/glycaemic load diets (experimental)
vs. high glycaemic index/glycaemic load diets (control). CI, confidence interval

regulation of intestinal microbiota.31 Another impor-
tant aspect is that weight loss is apparently achieved
irrespective of the macronutrient distribution and
(either low or high) GI/GL as long it is a reduced‐
energy diet.32,33
Calorie restriction was comparable in both groups
studied, but we did not find any body weight reduction.
The amount of calories appears more relevant than
carbohydrate composition (high or low GI/GL) for
weight loss. The same has been reported with other
nutritional strategies.34 Intermittent fasting, for example,
does not appear more effective for weight loss than
dividing calorie intake into several meals throughout the
day.35 Likewise, low‐carbohydrate diets are a strategy
that is almost or as effective as traditional carbohydrate
diets (45%–65% of total energy) for body weight
reduction.36 Thus, calorie restriction appears to be the
most important aspect for weight loss.
Obesity has been associated with increased risk of
insulin resistance and type 2 diabetes mellitus and clinical
outcomes such as fasting glucose and insulin should be
evaluated and monitored in dietary interventions in this

PERIN ET AL.
population.37 Our findings show that, compared with
high GI/GL diets, low GI/GL diets were superior in
lowering fasting glucose, even though the effect size was
modest (−1.97 mg dl–1). In their meta‐analysis, Zafar
et al.12 found that high GI diets were not associated with
lower fasting glycaemia compared to high GI diets,
which corroborates our results. However, low GI diets
were superior to diets specific for diabetes mellitus
(p = 0.010), although no information was available on
macronutrient composition and/or energy restriction of
both diets assessed in this meta‐analysis. Considering
that diabetes diets are specifically prescribed to indivi-
duals with diabetes, we assumed in the subgroup meta‐
analysis that the subset of studies achieving a reduction
in GI of at least 20 points would be more pronounced in
those with type 2 diabetes mellitus. However, the
observed reduction in fasting glucose (standardised MD
of −0.15) was not significant (p = 0.130) with low GI diets
compared with a control diet in this population.
Insulin resistance can be assessed using the hyper-
insulinaemic‐euglycaemic clamp technique, but it is not
widely used because it is an expensive invasive method.
An alternative to this technique is the homeostatic model
assessment (HOMA) of insulin resistance.38 Despite its
limitations, the HOMA is a surrogate marker to assess
insulin resistance and its use was reported in five
studies19–22,27 of this meta‐analysis. We found a reduc-
tion in fasting insulin with low GI/GL diets compared to
high GI/GL diets, with a modest effect size of −0.55 μU
ml–1. Consistent with our findings, a meta‐analysis by
Schwingshackl et al.11 reported that fasting insulin
benefits were more pronounced with low GI/GL diets.
Chronic low‐grade inflammation is typically associated
with obesity and insulin resistance and thus low GI/GL
diets would also be expected to reduce the levels of
inflammatory markers as reported by Schwingshackl
et al.11 The findings of the present meta‐analysis point to
beneficial effects of dietary interventions with low GI/GL
on fasting insulin which may help prevent excess body
weight in adults.
As for intervention duration, dietary patterns in
overweight and obese adults were compared using a
network meta‐analysis. We found that, over a 6‐month
period, most diets promoted modest body weight loss.
Interestingly, these nutritional approaches promoted
significant improvement in blood pressure. Yet, over a
12‐month period, these effects appeared to largely
disappear.32 Low GI/GL diets were associated with body
weight reduction with short‐term dietary strategies (up to
6 months), suggesting that dietary interventions should
be longer than 2 months to drive body weight loss.
Our findings also demonstrated that low GI/GL diets
did not exert any effect on lipid profiles compared to high
GI/GL diets (Table 2). This is corroborated by the
findings of a meta‐analysis by Clar et al.39 that reported
low GI diets were not associated with changes in total
1365277x, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jhn.13029 by CAPES, Wiley Online Library on [18/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 1133
cholesterol, LDL, HDL or triglycerides. It is of note that
these authors39 used a fixed‐effect model in their meta‐
analysis and eligible interventions involved recommen-
dations on diets or dietary carbohydrates and prescribed
diet plans. By contrast, Goff et al.40 showed in their
meta‐analysis that low GI diets were associated with
reductions in total cholesterol and LDL, although this
benefit was not seen in triglycerides. Contrasting with
our study, these authors40 included parallel and cross-
over RCTs reporting at least one meal replacement a day
during the intervention period and results for at least one
type of lipid profile (total cholesterol, LDL, HDL, or
triglycerides).
Our study has some limitations. The main limitation
was the difficulty of comparing nutritional intervention
studies because of heterogeneous aspects and different
study protocols. The small number of articles reviewed
was not enough to allow a meta‐regression analysis of
confounding factors or secondary meta‐analyses which
could have further supported our findings. To improve
the power of dietary intake assessments for the analysis,
we used data from 3‐ or 7‐day food records, weighed
food records and food frequency questionnaires. How-
ever, differences in GI and GL are potential confounders
of outcome measures. Lastly, the funnel plots showed
moderate asymmetry suggesting that publication bias
cannot be completely ruled out as a confounder in the
present meta‐analysis (e.g., lack of published studies with
inconclusive results).
We conclude that low GI/GL diets may favour
reductions in fasting glucose and insulin in adults with
excess weight. They also promote increased reductions in
body weight only in adults with BMI ≥ 30 kg m–² (but not
in individuals with excess weight, BMI ≥ 25 kg/m41).
Despite these benefits, low GI/GL diets did not show
any other benefits on lipid profile compared to high GI/
GL diets. Further research is needed to determine
whether the reduction in fasting glucose, fasting insulin
and body weight is maintained over the long run and can
be incorporated into lifestyle.
AUTHOR CONTRI BUTI ONS
Lisiane Perin and Alexandre M. Lehnen contributed to
the study concept and design. Lisiane Perin and Isadora
G. Camboim collected the data and organised the
database. Lisiane Perin conducted the statistical analy-
ses. Lisiane Perin and Isadora G. Camboim drafted the
manuscript. Alexandre M. Lehnen conducted the critical
review, and all authors provided input and approved the
final manuscript submitted for publication.
A C K N OW L E D GE M E N T S
This work was carried out with the support of the
Coordination for the Improvement of Higher Education
Personnel—Brazil (CAPES)—Financing Code 001.
PROSPERO registration number: CRD42018108684.

1134 | SYSTEMATIC REVIEW AND META‐ANALYSIS
CONFLI CT OF I NTE RES T
The authors declare no conflict of interest.
ORCID
Alexandre M. Lehnen http://orcid.org/0000-0002-
5912-8020
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| 1135

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