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Glycemic Index and Glycemic Load Yue Man Onna Lo, MD, ABIHM CHAPTER 87 GLYCEMIC INDEX AND GLYCEMIC LOAD Yue Man Onna Lo, MD, ABIHM 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 serv- ing.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 Downloaded for Aman Shah ([email protected]) at Elsevier - Demonstration Account from ClinicalKey.com by Elsevier on December 21, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. 864 PART III TOOLS FOR YOUR PRACTICE 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 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. 1. Increase consumption of fruits, vegetables, and legumes. 2. Cooking time—The longer the cooking time for 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 Downloaded for Aman Shah ([email protected]) at Elsevier - Demonstration Account from ClinicalKey.com by Elsevier on December 21, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. 87 GLYCEMIC INDEX AND GLYCEMIC LOAD 865 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.
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