Victor Tambunan

Department of Nutrition Faculty of Medicine Universitas Indonesia

References
Brand-Miller J et al. The New Glucose Revolution 2003 American Diabetes Association. Diabetes Care 2003 The Diabetes and Nutrition Study. Eur J Clin Nutr 2000 Canadian Diabetes Association. Clinical Practice Guidelines Expert Committee 2003 Shils ME et al. Modern Nutrition in Health and Disease 10th ed., 2006 Mahan LK et al. Krauses Food and the Nutrition Care Process 13th ed., 2013
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In 1981: Jenkins defined a glycemic index (GI) to rank different dietary carbohydrates (CHOs) on their ability to blood glucose levels as compared with a reference food Glycemic indexing of food was developed to compare the physiologic effects of CHOs on blood glucose glycemic response

CHOs in foods have traditionally been classified as:

Simple CHOs (sugars): mono & disaccharides Complex CHOs (starches): polysaccharides

How to choose the CHOs?

Low vs moderate or high CHOs Simple vs complex CHOs

Low vs high GI CHOs

Definition

is an incremental area under blood glucose response curve of a 50 g CHO portion of a test food expressed as a percentage of the response to the same amount of CHO from a reference food (glucose or white bread) taken by the same subject

Glycemic index (GI) provides little

clinical assistance in designing meals for diabetic patients

Various studies suggest that the GI of a diet:

Has a predictable effect on blood glucose levels and May have use in the dietary management of diabetes & hyperlipidemia

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Calculation of the incremental area under a glycemic response curve (IAUC). The IAUC equals the sum of the area of the triangles & trapezoids: A + B + C + D + F

Blood glucose (mg/dL)

Test food White bread

Time (minutes)

Glycemic response of healthy individuals to white bread or a test food that contains 50 g CHO
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Postprandial glycemia following (A) Slow absorption of starchy fiber-rich meals (B) Rapid absorption of refined, fiber-depleted CHO foods

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Low versus high GI of CHOs

Not all CHOs are created equal when compared to their effects on plasma glucose GI is an attempt to measure the differences in the amount of glucose converted in the plasma from various foods GI ranks foods according their ability to blood glucose Low-GI foods release their glucose to the bloodstream slowly, over a prolonged period of time High-GI foods release their glucose all at once
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Classification
High : GI >90 Intermediate: GI 7090 Low : GI <70
(Anderson JW, 1999; Foster-Powell K et al, 2002)
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Glycemic Index Ranking of Selected Starchy Foods

Higher: GI >90* Intermediate: GI 7090 Lower: GI <70

Most dry cereals Most breads

Most crackers White rice, boiled Most cakes Most potatoes Pancakes & waffles

Oat bran All bran cereals Whole-wheat bread Oatmeal, muesli, pumpernickel bread Most muffins Most pasta Long-grain rice Barley Most cookies New potatoes Yams Sweet corn Most dry beans & lentils

GI, glycemic index *Using bread as 100 for reference

(Anderson JW, 1999; Foster-Powell K et al, 2002)
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Glycemic Load
The glycemic load (GL) of foods & meals is calculated by multiplying the GI by the amount of CHO in each food and then totaling the values for all foods in a meal

GL = GI x g CHO in a serving of the food

GL: glycemic load GI: glycemic index CHO: carbohydrate
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Glycemic load

(contd)

The higher the GL, the greater the expected elevation in blood glucose & in the insulinogenic effect of the food

Long-term consumption of a diet with a relatively high GL is associated with an risk of: type 2 diabetes coronary heart disease
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Factors Influence the Glycemic Response to Foods

Rate of ingestion

Food form
Food components Methods of cooking and processing Physiologic effects
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Factors Influence the Glycemic Response

Rate of ingestion
Ingestion time Raw apple vs apple juice
Highly processed foods are digested faster & tend to have a higher GI rating

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Factors Influence (contd)

Food form
Nature of the monosaccharides component:
- Glucose - Fructose - Galactose

Nature of the starch:

Amylose Amylopectin Starch-nutrient interaction Resistant starch

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Factors Influence (contd)

Food components
Fat content Fiber content Protein content Starch characteristics

Food ingredients
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Factors Influence (contd)

Methods of cooking & processing
Degree of starch gelatinization

Particle size Food form Cellular structure

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Factors Influence (contd)

Physiologic effects
Pregastric hydrolysis Gastric hydrolysis Gastric emptying rate Intestinal response Intestinal hydrolysis & absorption Pancreatic & gut hormone responses Colonic effects
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Effect of Low-GI Diets on DM Management

Improve the management of DM blood glucose levels

Prevent hypoglycemia

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Low-glycemic index foods

Healthy choices for persons with diabetes Meta-analyses of some randomized clinical trials (RCTs): low-GI diets compared with high-GI diets significantly:
Fasting

plasma glucose Hemoglobin A1c (A1c) Fructosamine

in diabetic patients
(Brand-Miller J et al. Diabetes Care 2003;26:22617, Anderson JW et al. J Am Coll Nutr 2004;23:517)
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Low-GI Diets
in the Management of Diabetes
CONCLUSIONS:
Choosing low-GI foods in the place of conventional or high-GI foods has a small but clinically useful effect on medium- term glycemic control in patients with diabetes

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ADA Recommendation
Low-GI foods reduce postprandial hyperglycemia Not sufficient evidence of long-term benefit to recommend low-GI as a primary strategy

American Diabetes Association. Diabetes Care 2003

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EASD Recommendation
Substitution of low-GI foods for high-GI foods

The Diabetes and Nutrition Study. Eur J Clin Nutr 2000

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The EURODIAB study

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The EURODIAB study: a cross-sectional study involving nearly 3,000 subjects with type 1 diabetes in 31 clinics throughout Europe, in which the GI of self-selected diets was positively & independently related to A1C levels

Lower GI food

Lower HbA1C

Buyken AE et al. Am J Clin Nutr 2001;73:57481

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Canadian Diabetes Association

Clinical Practice Guidelines Expert Committee People with diabetes should choose low-GI foods in the place of high-GI foods within the same category of foods more often to help optimize glycemic control

[Grade B, Level 2]

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Making the Change to a Low-GI Diet

The GI is not intended to be used in isolation There is no need to eat only low-GI foods
Consider both the GI value of the food & the amount of CHO it contains Begin with a healthy, balanced-diet based on a variety of foods Substitute low -GI alternatives for CHO foods with high -GI values
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