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Assessing Glycaemic Index Utility: from Bench to Bedside

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Assessing Glycaemic Index Utility: from Bench to Bedside ASSESSING GLYCAEMIC INDEX UTILITY: FROM BENCH TO BEDSIDE by Shannan Melissa Grant A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Nutritional Sciences University of Toronto © Copyright by Shannan Melissa Grant 2015 I Assessing Glycaemic Index Utility: From Bench to Bedside Shannan Melissa Grant Doctor of Philosophy Department of Nutritional Sciences University of Toronto 2015 Abstract Glycaemic index (GI) categorizes carbohydrate-containing food according to postprandial glycaemic effect. The Canadian Diabetes Association supports integration of GI-education into standard care for type 2 diabetes mellitus (T2DM). Notwithstanding, most Canadian RDs identify as “non-users”; citing a need for studies examining GI-mechanism and GI-efficacy and a lack of reliable educational materials as barriers to GI-utility. These barriers highlight practice- based research opportunities spanning bench-to-bedside, such as: The examination of novel metabolic pathways and evaluation of low GI-education/ diet effectiveness using established markers of utility. The overall purpose of this dissertation was to address, experimentally, gaps in the literature, highlighted by educators as barriers to GI-utility. METHODS: Three studies were completed. Study one examined the effect of slowing carbohydrate absorption on postprandial oxidative stress (novel GI-mechanism) in overweight/obese participants (n=18). Study two involved the development and evaluation of a questionnaire designed to evaluate an evidence-based GI-education platform for DM (n = 29), using a one-armed pre/post-intervention pre-test design. Study three (RCT; n=99) was performed to evaluate the effect of the low GI-education platform on glycaemic control in women with GDM using the questionnaire pre-tested in study two. II RESULTS: Sipping 75g dextrose solution slowly over 3.5h reduced postprandial oxidative stress compared to consuming it over 5min. Studies two and three showed that participants who received GI-education were satisfied with the education, showed a significant increase in GI- knowledge score (36%; p<0.05) and a significant decrease in dietary GI (4-6 units; p≤0.001). Moreover, low GI-education decreased average postprandial blood glucose compared to standard care (6.02±0.03 vs. 6.10±0.02 mmol/L; p=0.041) in women with GDM. CONCLUSIONS: The experimental work reported in dissertation provides insight into a novel GI-mechanism, demonstrates the acceptability and efficacy of the GI education platform and provides evidence that a low GI diet improves glycaemic control in women with GDM. Therefore, this work has successfully achieved its goal of addressing educators’ perceived barriers to GI-utility. Whether or not these efforts will increase knowledge translation to the end-user remains to be determined. III "It is the tension between creativity and skepticism that has produced the stunning and unexpected findings in science." ~ Carl Sagan IV Dedications I dedicate this dissertation to my family and friends; most notably my husband Michael Trumbull and parents Albert and Imelda Grant. I will never be able to thank you enough for the support you have given me during my formal education. I would never have been able to do this without your support. I dedicate the first study of this research program to Dr Marian Naczk, former faculty of St Francis Xavier University, who did not live to see me become Dr Grant, but continues to inspire me daily. I also dedicate this dissertation to Canadians living with or caring for someone with diabetes mellitus or cardiovascular disease. We do what we do for you. V Acknowledgements “No man is an Iland, intire of itselfe; every man is a peece of the Continent, a part of the maine…”* John Donne, MEDITATION XVII Devotions upon Emergent Occasions I have been blessed to work with amazing people in various capacities; many of whom my husband (Michael) and I consider our Ontario family. The next six pages will highlight the key players in my Ontario-based academic life from 2009 to 2015. Only the tip of the iceberg, this list is not exhaustive. I could easily write a thesis just of acknowledgments. If you are not included here, please know you are acknowledged and I am grateful for the role you have played in my professional development to date. First and foremost, I would like to thank my Supervisor, Dr Thomas Wolever. His respect of self-directed learning and my prior learning made the decision to come back to school, to complete my PhD, easy. Over the past six years, I have developed scientific knowledge and skill beyond what I could have imagined when I returned to the Department of Nutritional Sciences in 2009. As a result of my experiences in his laboratory, I have accumulated knowledge on glycaemic index that has made me a nationally recognized “expert” on the topic; with members of national and professional organizations seeking my input on education and knowledge translation (KT). I have improved a number of my professional skills because of the experiences he and our colleagues have offered me. My relationship with Tom has been and is one of the most rewarding of my life. I had the good fortune of having an excellent committee during my graduate studies at the University of Toronto; including Dr Pauline Darling, Dr Deborah O’Connor, and Dr Robert Josse. They, with Tom, challenged me to speak with conviction about my work and to believe in myself as a scientist, Dietitian and a change-agent. I would like to thank them for the invaluable * “No man is an island entire of itself; every man is a piece of the continent, a part of the main…” Old English version is provided above. VI feedback they provided on the scientific and statistical methodology employed during the writing of this thesis. I would also like to thank them for their efforts to highlight the balance between independence and asking for help; key to self-directed learning. Pauline and Tom were the first mentors I had when I arrived in Toronto in 2004 to partake in the Combined Dietetic Internship and Masters of Science offered through St Michael’s Hospital Dietetic Internship and the Department of Nutritional Sciences, University of Toronto. I am thankful for their unfailing and enthusiastic support of me and my ideas and for their openness to innovation. I am very thankful for the opportunity to work with them for so many years. Debbie and Bob have also been a big part of this journey. They have known me for the majority of my time spent contributing to the Ontario research community and have provided me with unquantifiable mentorship and support. I finish this thesis acknowledging that I am honoured and privileged to have had four world-class Clinician Scientists observe and guide me for over a decade. Although there were a number of unofficial members of my committee (including study collaborators, co-investigators, hospital-based PIs etc.), there are three members that truly stand out in the context of the work included in this dissertation; including Edward Barre, PhD, Department of Health Studies and Emergency Management, Cape Breton University (and his laboratory technician Kaz), Denice Feig, MD, MSc, FRCPC, Diabetes and Endocrinology in Pregnancy Program, Mount Sinai Hospital, and Kevin Thorpe, M.Math, Applied Health Research Centre, St. Michael's Hospital. The training and support provided by each of them, during my degree, has made this document possible. The nature of the work conducted as part of my PhD brought me to work in a number of clinical settings and often required that I be in multiple locations at once. This ability to transcend time and space was made possible by a group of professionals I like to call my “dream team”; including Alexandra Thompson, RD, IBCLC, MSc, Rebecca Noseworthy, RD, MPH, Andrea Glenn, RD, MSc, and Maxine Seider, MSc. Each research site provided a different learning environment and set of colleagues to share experiences, skills and knowledge with. At GI Labs, I had the pleasure to work with Alexandra Jenkins, RD, PhD, Katherine Corbett, MBA, Janice Campbell, MSc, and Adish Ezatagha, MSc, and Laura Chiavaroli, MSc, PhD(c). I also had the pleasure of working with Koidula Aedna, Clinical Research Assistant, Phil Ciglen, Laboratory Technician, Slobodanka Nojkova, Immunoassay Laboratory Technician, Ana Baniska, VII Laboratory Supervisor, and the infamous intravenous (IV) team (composed of seasoned Registered Nurses). Each day in the clinic, I worked with one member of the IV team. Although all of the RNs were amazing and have become good friends of mine, I would like to give special thanks to Celine Hanrahan. Her extreme enthusiasm, altruism, grace, passion for experience and professionalism continue to inspire me daily. At the hospital sites, we had six site Principal Investigators; Dr Joel Ray, Dr Thomas Wolever, Dr Meera Luthra, Mary Beth Neibert, RN, Dr Denice Feig and Dr. Julia Lowe. They, their health care teams and administrative staff were an endless source of scientific discussion, logistical information, support and inspiration. Alex, Rebecca, Andrea, Maxine and I felt very much a part of the health care teams at all hospital sites; St Michael’s Hospital, Mount Sinai Hospital, and Sunnybrook Health Sciences Centre, in Toronto, and St Joseph’s Healthcare Hamilton, Hamilton. Although not directly involved in my research, I would like to acknowledge the following members of the Department of Nutritional Sciences, University of Toronto who certainly played a significant role in my PhD experience: The administrative staff, including Louisa Kung, Emelia D’Souza, Vijay Chetty, Lucile Lo and (most recently) Slavica Jovanovic. The role you play in student life in the department is noteworthy and appreciated. Thank you for your support, guidance, patience and friendship. Dr Anthony Hanley (or Tony) must be acknowledged for his ongoing mentorship and friendship – the work we have done together impacts how I approach every project I am asked to contribute to.
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