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Glycemic Index, Glycemic Load and Their Association with Glycemic Control Among Patients with Type 2 Diabetes

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Glycemic Index, Glycemic Load and Their Association with Glycemic Control Among Patients with Type 2 Diabetes European Journal of Clinical Nutrition (2014) 68, 459–463 & 2014 Macmillan Publishers Limited All rights reserved 0954-3007/14 www.nature.com/ejcn ORIGINAL ARTICLE Glycemic index, glycemic load and their association with glycemic control among patients with type 2 diabetes Maryam S Farvid1, F Homayouni2, M Shokoohi1, A Fallah1 and Monir S Farvid3 BACKGROUND/OBJECTIVES: The aim was to investigate the associations of glycemic index (GI), glycemic load (GL), carbohydrate and fiber intakes with hyperglycemia in type 2 diabetic patients. SUBJECTS/METHODS: In a cross-sectional study of 640 type 2 diabetic patients aged 28–75 years, usual dietary intakes were assessed by validated food frequency questionnaire. We used published international and Iranian tables of GI based on the white bread. Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CI). RESULTS: High-GL diet was associated with higher risk of hyperglycemia in type 2 diabetic patients after controlling for potential confounders. In multivariable model, OR (95% CI) for the highest vs the lowest quartile of GL was 2.58 (1.08–6.15) for elevated fasting serum glucose (FSG) (4130 mg/dl) (Ptrend ¼ 0.02) and was 3.05 (1.33–7.03) for elevated HbA1c (48.6%) (Ptrend ¼ 0.008). After additional adjusting for dietary fiber and protein intakes, the relation of GL with elevated FSG and HbA1c was stable. GI was not significantly associated with either elevated FSG or HbA1c. In multivariable model, OR (95% CI) for the highest vs lowest quartile of the substitution of dietary carbohydrate for fat intake was 2.32 (1.37–3.92) for elevated HbA1c (Ptrend ¼ 0.001). Higher intake of dietary fiber was associated with lower risk of elevated FSG (highest vs lowest quartile: OR, 0.53; 95% CI: 0.28–0.99; Ptrend ¼ 0.04), but not with lower risk of elevated HbA1c. CONCLUSIONS: GL and carbohydrate intake were positively associated with the risk of hyperglycemia in type 2 diabetic patients; but the benefit in pursuing a low-GI diet without considering carbohydrate and energy intakes in these patients should be further investigated. European Journal of Clinical Nutrition (2014) 68, 459–463; doi:10.1038/ejcn.2013.288; published online 19 February 2014 Keywords: glycemic index; glycemic load; carbohydrate; fiber; hyperglycemia INTRODUCTION counting, the use of GI and GL may provide a modest additional 3 Diabetes is a chronic metabolic disease associated with long-term benefit in achieving blood glucose goals. On the other hand, the complications resulting from chronic hyperglycemia.1 Nutrition concept of the GI is considered as an important issue in the therapy is an integral part of diabetes care, and carbohydrate guidelines suggested by the European Association for the Study of intake has the greatest impact on improving glycemic control.2 Diabetes that recommends the substitution of low-GI foods with 15 On the basis of American Diabetes Association’s (ADA) high-GI foods. Therefore, the aim of this study was to examine recommendations,3 there is no ideal percentage of energy from the potential association between dietary GI, GL, carbohydrate carbohydrate and other macronutrients for all diabetic patients. and fiber intakes, and the risk of hyperglycemia in men and ADA proposes diabetic patients to monitor total carbohydrate women with type 2 diabetes. intake via carbohydrate counting, exchanges or estimation.2 Foods containing equal amounts of carbohydrate induce a MATERIALS AND METHODS 4,5 different effect on the postprandial blood glucose. The We conducted a cross-sectional study of 751 patients with type 2 diabetes glycemic index (GI), which quantifies the postprandial blood who were randomly recruited via phone call from registered patients with glucose and insulin responses to carbohydrate composition of diabetes at three major diabetes clinics located in Tehran: the Charity diet,6 may have beneficial effects in addition to carbohydrate Foundation for Special Diseases, the Institute of Endocrinology and counting. On the other hand, the concept of glycemic load (GL), Metabolism, and the Iran Diabetes Association. Eligible participants were which represents both the quality and quantity of carbohydrate 25 years old and above with physician-diagnosed type 2 diabetes at least intake,7 has been developed to better represent overall glycemic 1 year before data collection. We did not measure islet cell autoantibodies. effects of a particular food item.8 The effectiveness of low GI Therefore, anyone with diabetes diagnosed before the age of 25 and taking only insulin therapy was considered to be having type 1 diabetes and GL diets in glycemic control has been examined in 9–14 and was excluded from our sample. epidemiological, clinical trials and meta-analysis. However, in Data on medical history, smoking addiction and medication were obtained some studies, diets with low GI or GL had no benefits in the from personal interview. We excluded those who did not meet the following 13,14 management of diabetes. On the basis of the current criteria: taking insulin, altering medication regimen or dietary intake during 3 evidence, the ADA states that combined with carbohydrate months before the study and having abnormal hepatic tests (n ¼ 30). We also 1Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2Paramedical School, Jundishapur University of Medical Sciences and Health Services, Ahvaz, Iran and 3Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Correspondence: Dr Maryam S Farvid, Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 19395-4741, Iran. E-mail: [email protected] Received 20 May 2013; revised 28 October 2013; accepted 14 November 2013; published online 19 February 2014 GI and GL and glycemic control Maryam S Farvid et al 460 excluded patients who did not live in Tehran (n ¼ 4), did not complete the GL quartiles. Variables were compared across quartile categories of GI and food frequency questionnaire (FFQ) (n ¼ 48), those (n ¼ 11) who reported a GL by one-way analysis of variance with Tukey’s post hoc comparisons total daily energy intake outside the range of 800–4200 kcal and those for quantitative variables and w2-tests for qualitative variables. Logistic (n ¼ 18) who had missing data for confounding variables. After these regression models were used to estimate odds ratio (OR) and 95% exclusions, 640 type 2 diabetic patients aged 28–75 years remained. confidence intervals (CI) for each category using the lowest quartile of Written informed consent was obtained from all participants. The intake as the reference category, while controlling for potential confound- research protocol was approved by the Ethics Committee of National ing variables. FSG o130 mg/dl is recommended as a target of glycemic Nutrition and Food Technology Research Institute. control by ADA2 and the expected HbA1c levels for normal glucose values We collected 20 ml blood samples from each participant between 0800 are 6–8.6% by the commercial HbA1c kit.22 Therefore, we defined and 1000 hours, before taking any oral hypoglycemic agent(s) and after hyperglycemia with cutoff values of 130 mg/dl for FSG and 8.6% for 12–14-h overnight fasting. Aliquots of serum and red pack cells were HbA1c. All models were adjusted for age, sex and energy intake. transferred to polystyrene tubes that were immediately stored at À 70 1C Multivariable models included additional terms for duration of diabetes, until analysis. Fasting serum glucose (FSG) concentration was measured by smoking, physical activity, BMI, vitamin/mineral supplementation, total the glucose oxidase method. HbA1c was measured by a chromatography hypoglycemic medication, blood pressure-lowering drug and lipid- method using the commercial kit (Globe Diagnostics, Rome, Italy). lowering drug. In additional analyses, we further adjusted for dietary The dietary intake of patients was assessed by interview using a 1-year protein and fiber intakes (multivariable model 2). Multivariable model 1 for validated 168-item semi-quantitative FFQ.16 It consisted of a list of foods total carbohydrate intake was fit without adjusting for protein and fat with standard serving sizes according to Iranian meal patterns, and was intake to simulate the substitution of carbohydrate for the average designed to obtain information on usual food intake during the previous mixture of protein and fat in the study population and with the adjustment year. The reported frequency for each food item was then converted to a for protein (multivariable model 2) to simulate the substitution daily intake. Information on frequency of intake and portion size was of carbohydrate with total fat intake.23 To examine whether the converted to the number of grams of each food item consumed on associations between GL and elevated FSG or HbA1c were modified by average per day. To determine the total dietary carbohydrate, protein, fat, other measures of diabetes risk factors, a cross-product term for the level fiber and energy compositions of Iranian foods, we used the United States of each factor and intake of GL expressed as a continuous variable was Department of Agriculture database17 and Iranian food composition tables. included in the multivariable model. P-values for tests for interactions were The validity and reproducibility of dietary GI and GL were similar to those obtained from a likelihood ratio test with 1 degree of freedom. IBM SPSS of nutrients commonly studied in epidemiologic studies with the use of 21 was used for all analyses. All P-values were two-sided. FFQs.18 Of the 168 food and beverage items included in the FFQ, 30 items (17.8%) contain no available carbohydrate. The calculation of dietary GL and GI was thus based on the remaining 138 items with GI values ranging from 10 to 123.
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