CHAPTER 87
Glycemic Index and
In the past, carbohydrates have been classified as either
simple or complex based on the number of simple sugars
per molecule. Simple carbohydrates can be categorized as
a single sugar (monosaccharides), which include glucose,
fructose, and galactose, or double sugars (disaccharides),
which include sucrose, lactose, and maltose. Complex car-
bohydrates, also known as polysaccharides, are starches
formed by longer saccharide chains, which means they take
longer to break down. It has been assumed that starchy
foods cause smaller increases in blood glucose than simple
sugars. However, this system is too simplistic and is not
predictable because the changes in blood glucose and insu-
lin levels after consuming complex carbohydrates can be
very different.1 For example, complex carbohydrates refer
to any starches, including the highly refined starches found
in white bread, pastries, and cakes, which induce a very
different blood glucose and insulin response than whole
grains and starchy vegetables, such as sweet potatoes. As
a result, a concept known as the glycemic index (GI) was
introduced in the early 1980s. It has become a very useful
nutritional concept that allows new insight into the rela-
tionship between carbohydrate-rich foods and health.2
GLYCEMIC INDEX
The GI measures the rises in blood glucose and insu-
lin triggered by a specific food compared with a control
food, such as white bread or glucose (Fig. 87.1).
To determine the GI of a specific food, test subjects
are given a test food and a control food (white bread or
glucose) on separate dates, each food containing 50 g of
3.0
Glucose (mmol/l Blood)
2.5
2.0
1.5
1.0
0.5
0.0
0 20 40 60 80
Time (Minutes)
FIG. 87.1 □ Mean incremental blood glucose responses to differ-
ent foods in healthy subjects.
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Glycemic Load
Consumption of white bread
Spaghetti 1.8 mm
Thin linguine 2.2 x 1.2 mm
Thin linguine w/egg
Thick linguine 2.2 x 3.3 mm
100 120 140 160 180
Yue Man Onna Lo, MD, ABIHM
available carbohydrates, and changes in blood glucose and
insulin are measured every 2 hours. The GI is calculated
as the area under the curve of the test food divided by the
area under the curve of the control food, then multiplied
by 100 to represent a percentage of the control food.3 For
example, a baked potato has a GI of 94 relative to glu-
cose, which means that the blood glucose response to the
carbohydrate in a baked potato is 94% of the blood glu-
cose response to the same amount of carbohydrate in pure
glucose. In contrast, sweet potato, which is also a com-
plex carbohydrate, has a GI of 44 relative to glucose and
induces a much lower blood glucose response in compari-
son with pure glucose.2 Therefore, you can say that not
all carbohydrates or calories are created equal (Fig. 87.2).
High-GI foods can stimulate the reward and food craving
areas of the brain seen with other addictions. The rebound
hypoglycemia (Fig. 87.3) can exacerbate cravings for high-
GI foods, which leads to a vicious cycle that can increase
insulin, inflammation, and triglyceride levels.4
GLYCEMIC LOAD
The concept of glycemic load (GL) was introduced later
as an additional tool to more accurately assess the impact
of eating carbohydrates on blood sugar. It gives a more
complete picture than GI alone because GI only indicates
how rapidly a particular carbohydrate turns into sugar,
while GL indicates the amount of carbohydrate in a serv-
ing.2 Serving sizes can be different based on cultural and
Glucose Insulin Glucose Insulin
High glycemic Low glycemic
index food index food
FIG. 87.2 □ The effect of high glycemic index food versus low
glycemic food on glucose and insulin. (From Rakel, D: Glycemic
index and glycemic load: http://www.fammed.wisc.edu/files/
webfm-uploads/documents/outreach/im/handout_glycemic_
index_patient.pdf. Accessed 12/25/2016.
863
864 PART III Tools for Your Practice

Breakfast Lunch Dinner

Blood sugar and insulin levels

= high carb/glycemic index meal

= low carb/glycemic index meal

Spikes in insulin and blood sugar trigger production of triglycerides from the
liver to help store excess sugar.
Troughs of hypoglycemia is also associated with negative health outcomes.
FIG. 87.3 □ Blood sugar and insulin levels.

TABLE 87.1 Calculating Glycemic Load TABLE 87.2 How to Interpret Glycemic Index
(GI) and Glycemic Load (GL)
Example: Watermelon
Glycemic index (GI) = 72 (high) Foods that have a low GL almost always have a low GI.
Glycemic load (GL) = 4 (low) Foods with an intermediate or high GL range from a very
Amount of carbohydrates per serving: 6 g (low) low to very high GI.5

Calculating Glycemic Load (GL) Glycemic Index Glycemic Load

GL = (GI) × (carbohydrates per serving in grams)/100
GL for watermelon = 72 × 6/100 = 4 The smaller the number, the The smaller the number, the
less impact the food has less impact the food has
on your blood sugar on your blood sugar per
serving size
dietary practices. GL helps patients to account for both the 55 or less = low 10 or less = low
56–69 = moderate 11–19 = moderate
quantity and the quality of their carbohydrates at the same 70 or higher = high 20 or more = high
time. For example, the GI of watermelon is high; however,
most of watermelon is water, and the amount of carbohy-
drates per serving size is low, which results in a low GL.
Therefore, consuming one to two servings of watermelon GI than just baked potatoes and nonsourdough breads,
will not raise blood glucose or insulin significantly when respectively. Combining high-GI foods with low-GI
compared with other foods that have a high GI and GL. foods will also decrease blood sugar rise.
Table 87.1 shows the calculations for GL.5 5. Food variety—Certain varieties of vegetables, grains,
The GL is calculated by using the amount of avail- and fruits have different GIs than their counterparts,
able carbohydrates in grams per serving size for a certain e.g., short grain rice versus long grain rice and russet
food multiplied by the GI value of that food, then divided potatoes versus red potatoes.7
by 100.1 The higher the GL, the greater the expected 6. An individual’s metabolism and digestion—GI is rela-
elevation in blood glucose and insulin effect of the food.2 tive to a person’s age, metabolism, and digestive health.7
Table 87.2 shows the interpretation of GI and GL values.

What Can Affect the Glycemic Index in Food? Practical Guidelines

1. Ripeness and storage time—The GI of many fruits
such as bananas goes up as they ripen.
2. Cooking time—The longer the cooking time for
certain grains and starches, like pasta, the higher the
GI. Pasta cooked “al dente,” where it is slightly under-
cooked and is more firm, has a lower GI.
3. Processing method—The finer a food is chopped,
mashed, or juiced, the higher the GI, e.g., whole pota-
toes versus chopped potatoes.6
4. Combination with other foods or dressings—Add-
ing fat, fiber, and acid (such as lemon juice or vinegar)
lowers the GI since they help slow down the absorp-
tion of sugar into the bloodstream. For example, baked
potatoes with butter and sourdough bread have lower
1. Increase consumption of fruits, vegetables, and
legumes.
2. Eat multicolored, unprocessed, whole foods.
3. Decrease consumption of “white foods” (e.g., potatoes,
fluffy breads, pasta).
4. Consume grain products that are less processed or not
overcooked (e.g., steel-cut oats, al dente pasta, stone-
ground breads).
5. Always combine your meal with fiber (vegetables and
fruits), fats (oils), and proteins (beans and nuts).
6. Eat low-GI foods regularly and high-GI foods rarely
and only in small quantities, preferably with a meal.
7. Eat healthy portions. Excessive consumption of low-
GI foods can still trigger a hyperglycemic response.8,9

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DISEASE PREVENTION AND
MANAGEMENT
Diabetes and Blood Sugar Control
Medical nutrition therapy is the first line of treatment
for the prevention and management of type 2 diabetes
and plays an essential part in the management of type
1 diabetes. Although the American Diabetes Associa-
tion still recommends carbohydrate counting as a main
strategy for diabetes management, the Diabetic Associa-
tions in Europe, Canada, and Australia have all recom-
mended high-fiber, low-GI foods for individuals with
diabetes as a means of improving postprandial glycemia
and weight control.2,10,11 Many studies have shown that
low dietary GI and GL is effective in the prevention12-16
and management of diabetes by improving insulin sen-
sitivity and lowering glycated hemoglobin A1c (HbA1c)
levels and fructosamine in diabetic patients.14,17-19 In a
recent cohort study in Hawaii, a high-GL diet showed an
increased incidence of diabetes.13 In a randomized, open-
label, crossover study, a low-GI diet for 3 months pro-
duced greater weight loss, body fat reduction, and body
mass index (BMI) reduction than a standard diabetes
diet.17 There were also fewer reported episodes of hypo-
glycemia and hyperglycemia in patients on a low-GI diet
compared with those on a carbohydrate exchange diet.19
Weight Management and Cardiovascular
Disease (CVD) Prevention
A low-GL/GI diet has been found to improve weight
loss, decrease fat composition, and increase high-density
lipoprotein (HDL) cholesterol in obese and overweight
subjects.20 It has also been shown to reduce C-reactive
protein (CRP), an emerging CVD risk factor.21 There
are also a number of cohort studies that show a significant
association between the consumption of high-GL/GI
diets and increased CVD risk in women,22,23 especially in
those with higher fat composition, who are overweight or
obese,24 or have diabetes. However, this association has
not been established in men.21 Increases in dietary GL,
but not GI, have also been associated with increased risk
of stroke and diabetes in both men and women.22,21
Among overweight or obese subjects, dietary GL was
associated with increased risk of coronary heart disease
(CHD).22 Among healthy, postmenopausal women,
dietary GL has been found to be associated with HDL
and triglyceride levels.26
Inflammation and Oxidative Stress
Oxidative stress and inflammation have been linked to
insulin resistance and cardiometabolic disorders.9 Post-
prandial glucose surges correlate directly with an increase
in free radicals, resulting in oxidative stress.27 A blood
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87 Glycemic Index and Glycemic Load 865
glucose spike after an excessively high-GL food consump-
tion significantly reduces the mitochondria’s capacity for
oxidative phosphorylation, driving an increase in free rad-
icals.8 High-GI foods or meals with a high GL also cause
an increase in postprandial inflammatory mediators and
markers such as CRP, cytokines, and endothelin-1.8 On
the contrary, minimally processed low-GI foods or meals
with a low GL do not result in adverse inflammatory
effects.9 One study showed a strong association between
a high dietary GL and elevated CRP levels in 244 mid-
dle-aged women where CRP levels almost doubled in the
low versus high dietary GL groups.28 Therefore it is not
surprising that most antiinflammatory diets, such as the
Mediterranean diet, advocate plant-based, nonprocessed
food approaches that are low in GL.
Cancer
A number of prospective cohort studies have shown
that diets high in GI and GL are both associated with
an increased risk of breast cancer29,30 and colorectal
cancers.31 The same association was also demonstrated
in a case-control study in Italy for ovarian cancer.32 A
positive association has also been noted in studies with
dietary GL, but not GI, on gastric cancers33 and endo-
metrial cancers.34-36 In a large prospective cohort study
in Italy of 47,749 subjects, results showed that a high-
GI diet was associated with an increased rate of colorec-
tal cancer, especially in those with a higher waist-to-hip
ratio.31 However, there are currently no strong associa-
tions found for pancreatic cancers.37,38
Other Conditions
High-carbohydrate diets with a high glycemic response
may exacerbate the metabolic consequences of an insu-
lin-resistance syndrome. Two studies have found a posi-
tive association between high GI and GL values and
symptomatic gallstone disease in men and women.39,40
This hyperinsulinemia effect also initiates an increase
in insulin-like growth factor 1 activity, which is known
to stimulate acne pathogenesis,41 which was confirmed
when 43 male acne patients in a randomized controlled
trial showed improvement of acne on a 12-week low GI/
GL diet when compared to a high GI/GL diet.42
CONCLUSION
The consumption of low-GI and low-GL foods is posi-
tively associated with the prevention of diabetes, CVD,
cancer, gallbladder disease, and acne. More information
on the GI/GL diet and its effects on hormones, meta-
bolic responses, and cellular changes is emerging. It is
certainly a simple, useful tool to offer our patients facing
such health issues. Table 87.3 lists GI and GL values for
common foods.
866 PART III Tools for Your Practice

TABLE 87.3 Glycemic Index and Glycemic Load Values for Select Foods
Glycemic Index Available Carbohy- Glycemic Load
Food Item (glucose = 100) Serving Size (g) drates (g/serving) (per serving)
Bakery Products
Angel food cake 67 50 29 19
Pound cake 54 53 28 15
Apple muffin (no sugar) 48 ± 10 60 19 9
Bran muffin 60 57 24 15
Oatmeal 69 50 35 24
Pancakes 67 ± 5 80 58 39
Waffles 76 35 13 10
Beverages
Coca-Cola 63 250 mL 26 16
Smoothie drink, soy, banana 30 ± 3 250 mL 22 7
Apple juice, pure, cloudy, unsweetened 37 ± 3 250 mL 28 10
Cranberry juice cocktail 68 ± 3 250 mL 36 24
Orange juice 50 ± 4 250 mL 26 13
Tomato juice, canned, no sugar 38 ± 4 250 mL 9 4
Gatorade 78 ± 13 250 mL 15 12
Breads
Bagel (white) 72 70 35 25
Baguette (white) 95 ± 15 30 15 15
Oat bran bread 44 30 18 8
Rye-kernel bread (whole-grain pumpernickel) 46 30 11 5
Wheat bread (80% intact kernels and 20% 52 30 20 10
white-wheat flour)
Wonder enriched white bread 73 ± 2 30 14 10
Healthy Choice Hearty 7-Grain bread 55 ± 6 30 14 8
Breakfast Cereals and Related Products
All-Bran 38 30 23 9
Cheerios 74 30 20 15
Cornflakes 92 30 26 24
Muesli 66 ± 9 30 24 17
Pop-Tarts, double chocolate 70 ± 2 50 36 25
Raisin Bran 61 ± 5 30 19 12
Special K 69 ± 5 30 21 14
Cereal Grains
Sweet corn 60 150 33 20
Taco shells, cornmeal 68 20 12 8
White rice, boiled 64 ± 7 150 36 23
Parboiled white rice (high amylose) 35 ± 4 150 39 14
Brown rice, steamed 50 150 33 16
Cracked wheat, bulgur 48 ± 2 150 26 12
Semolina (roasted or steamed) 55 ± 1 150 11 6
Cookies
Graham wafers 74 25 18 14
Vanilla wafers 77 25 18 14
Crackers
Breton crackers (wheat) 67 25 14 10
Corn thins 87 ± 10 25 20 18
Rice cakes (low amylose) 91 ± 7 25 21 19
Rye crispbread 63 25 16 10
Stoned wheat thins 67 25 17 12

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 87 Glycemic Index and Glycemic Load 867

Key Web
TABLE 87.3 Resources
Glycemic Index and Glycemic Load Values for Select Foods—cont’d
Glycemic Index Available Carbohy- Glycemic Load
Food Item (glucose = 100) Serving Size (g) drates (g/serving) (per serving)

Dairy Products and Alternatives

Milk 27 ± 4 250 12 3
Milk, condensed, sweetened 61 ± 6 250 136 83
Ice cream 61 ± 7 50 13 8
Yogurt 36 ± 4 200 9 3
Soy milk 44 ± 5 250 17 8
Tofu-based frozen dessert with 115 ± 14 50 9 10
high-fructose corn syrup
Fruit and Fruit Products
Apple (raw) 40 120 13 6
Apple juice (unsweetened) 40 250 mL 29 12
Banana (ripe) 51 120 25 13
Cranberry juice cocktail 68 ± 3 250 mL 35 24
Fruit cocktail (canned) 55 120 16 9
Grapes (raw) 43 120 17 7
Orange (raw) 48 120 11 5
Orange juice (reconstituted from 57 ± 6 250 mL 26 15
frozen)
Pineapple (raw) 39 ± 15 120 12 5
Strawberry (raw) 40 ± 7 120 3 1
Strawberry jam 51 ± 10 30 20 10
Watermelon (raw) 72 ± 13 120 6 4
Legumes
Black-eyed beans 42 ± 9 150 30 13
Chickpeas (garbanzo beans) 28 ± 6 150 30 8
Kidney beans 28 ± 4 150 25 7
Lentils (green) 22 150 18 4
Lentils (red) 26 ± 4 150 18 5
Mung beans 31 150 17 5
Pigeon peas 22 150 20 4
Pinto beans 39 150 26 10
Soya beans 18 ± 3 150 6 1
Pasta and Noodles
Fettuccine (egg) 40 ± 8 180 46 18
Linguine (thick, durum wheat) 46 ± 3 180 48 22
Mung bean noodles (Lungkow) 26 180 45 12
Macaroni 47 ± 2 180 48 23
Rice noodles (dried) 61 ± 6 180 39 23
Rice noodles (fresh) 40 ± 4 180 39 15
Rice pasta (brown rice) 92 ± 8 180 38 35
Spaghetti (white) 32 180 48 15
Spaghetti (durum wheat) 64 ± 15 180 43 27
Spaghetti (whole meal) 32 180 44 14
Nuts
Cashew nuts (salted) 22 ± 5 50 13 3
Peanuts 14 ± 8 50 6 1
Sport Bars
PowerBar (chocolate) 56 ± 3 65 42 24
Ironman PR Bar (chocolate) 39 65 26 10
Continued

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868 PART III Tools for Your Practice

TABLE 87.3 Glycemic Index and Glycemic Load Values for Select Foods—cont’d
Glycemic Index Available Carbohy- Glycemic Load
Food Item (glucose = 100) Serving Size (g) drates (g/serving) (per serving)

Vegetables
Beetroot 64 ± 16 80 7 5
Carrots (raw) 16 80 8 1
Corn (sweet, boiled) 60 80 18 11
Green peas 48 ± 5 80 7 3
Parsnips 97 ± 19 80 12 12
Baked potato (in skin) 60 150 30 18
Yam (peeled, boiled) 37 ± 8 150 36 13

Modified from Foster-Powell K, Holt SHA, Brand-Miller JC. International table of glycemic index and glycemic load values: 2002. Am J Clin
Nutr. 2002;76:5–56.

Key Web Resources

The official website for the glycemic index (GI) and interna- http://www.glycemicindex.com
tional GI database, which is based at the Human Nutrition
Unit, School of Molecular Bioscience, University of Sydney
The University’s GI Group. The Group publishes a
monthly e-newsletter with the latest GI research from
around the world
A comprehensive food list with GIs http://www.mendosa.com/gilists.htm
Patient handout on glycemic index/load from the University http://www.fammed.wisc.edu/sites/default/files//webfm-
of Wisconsin Integrative Medicine uploads/documents/outreach/im/handout_glycemic_in-
dex_patient.pdf
International Table of Glycemic Index and Glycemic Load http://www.ajcn.org/content/76/1/5/T1.expansion
Values from the American Journal of Clinical Nutrition

REFERENCES
References are available online at ExpertConsult.com.

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868.e1