Glycemic Index and Glycemic Load Yue Man Onna Lo, MD, ABIHM

CHAPTER 87

In the past, carbohydrates have been classified as either available carbohydrates, and changes in blood glucose and simple or complex based on the number of simple sugars insulin are measured every 2 hours. The GI is calculated per molecule. Simple carbohydrates can be categorized as as the area under the curve of the test food divided by the a single sugar (monosaccharides), which include glucose, area under the curve of the control food, then multiplied fructose, and galactose, or double sugars (disaccharides), by 100 to represent a percentage of the control food.3 For which include sucrose, lactose, and maltose. Complex car- example, a baked potato has a GI of 94 relative to glu- bohydrates, also known as polysaccharides, are starches cose, which means that the blood glucose response to the formed by longer saccharide chains, which means they take carbohydrate in a baked potato is 94% of the blood glu- longer to break down. It has been assumed that starchy cose response to the same amount of carbohydrate in pure foods cause smaller increases in blood glucose than simple glucose. In contrast, sweet potato, which is also a com- sugars. However, this system is too simplistic and is not plex carbohydrate, has a GI of 44 relative to glucose and predictable because the changes in blood glucose and insu- induces a much lower blood glucose response in compari- lin levels after consuming complex carbohydrates can be son with pure glucose.2 Therefore, you can say that not very different.1 For example, complex carbohydrates refer all carbohydrates or calories are created equal (Fig. 87.2). 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 High-GI foods can stimulate the reward and food craving grains and starchy vegetables, such as sweet potatoes. As areas of the brain seen with other addictions. The rebound a result, a concept known as the glycemic index (GI) was hypoglycemia (Fig. 87.3) can exacerbate cravings for high- GI foods, which leads to a vicious cycle that can increase introduced in the early 1980s. It has become a very useful 4 nutritional concept that allows new insight into the rela- insulin, inflammation, and triglyceride levels. tionship between carbohydrate-rich foods and health.2

GLYCEMIC INDEX GLYCEMIC LOAD

The GI measures the rises in blood glucose and insu- The concept of glycemic load (GL) was introduced later lin triggered by a specific food compared with a control as an additional tool to more accurately assess the impact food, such as white bread or glucose (Fig. 87.1). of eating carbohydrates on blood sugar. It gives a more To determine the GI of a specific food, test subjects complete picture than GI alone because GI only indicates are given a test food and a control food (white bread or how rapidly a particular carbohydrate turns into sugar, glucose) on separate dates, each food containing 50 g of while GL indicates the amount of carbohydrate in a serving.2 Serving sizes can be different based on cultural and

3.0 Consumption of white bread Spaghetti 1.8 mm 2.5 Thin linguine 2.2 x 1.2 mm 2.0 Thin linguine w/egg Thick linguine 2.2 x 3.3 mm l Blood) 1.5 1.0 0.5 Glucose Insulin Glucose Insulin 0.0 High glycemic Low glycemic Glucose (mmol/ index food index food

020406080 100 120 140 160 180 FIG. 87.2 □ The effect of high glycemic index food versus low Time (Minutes) glycemic food on glucose and insulin. (From Rakel, D: Glycemic index and glycemic load: http://www.fammed.wisc.edu/files/ FIG. 87.1 □ Mean incremental blood glucose responses to differ- webfm-uploads/documents/outreach/im/handout_glycemic_ ent foods in healthy subjects. index_patient.pdf. Accessed 12/25/2016. 863

Breakfast Lunch Dinner

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

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

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

TABLEKey Web 87.3 ResourcesGlycemic 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

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) andinterna - 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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