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Letters to the Editor Letters to the Editor Glycemic index and body weight found a difference in RAG after adjustment for dry matter, this is not normal practice and can be questioned. Last, the hypothesis that low-GI diets may aid weight control Dear Sir: because they are more satiating and reduce overall energy intake cannot be realistically assessed in a study in which the subjects are Some readers of the Journal have expressed surprise at the deci- compelled to eat a specified amount of the starchy foods provided sive title and conclusion of the paper by Sloth et al (1), which and to minimize the amount of sugar and other highly palatable foods appeared in the August issue. Body weight, body fat, and cardiovas- consumed. Indeed, more than one-half the subjects complained that cular disease risk factors were compared during 10 wk of ad libitum the quantity of starchy foods was far too high and was associated with intake of a low-glycemic-index (GI) diet and during consumption of nausea and discomfort in the first half of the study. Hence, Sloth et a macronutrient-matched high-GI diet. The authors reported a 2.5- al’s study could be criticized on the grounds that it is not a truly ad fold difference in total body fat mass change (1.0 compared with 0.4 libitum and realistic comparison of high-GI versus low-GI diets. In kg; P ҃ 0.20) and significant difference in LDL cholesterol favoring this context, it may be informative to undertake an intention-to-treat the low-GI diet (P 0.05). Although the difference in fat mass analysis in which all subjects recruited to the study are included and change was not significant, one could argue that the 0.6 kg difference the last reported data point is carried forward. Downloaded from might be directly related to the observed difference in LDL choles- Sloth et al’s article is undoubtedly a useful addition to the litera- terol. For example, Bouché et al (2) found that an Ȃ700 g decrease ture on GI and obesity. However, the limitations outlined above in total fat mass even in the absence of changes in body weight was suggest that the conclusions should be tempered. In particular, the associated with an improved lipid profile and changes in the en- title of the paper should not have been as definitive. zymes and genes controlling fat metabolism. JB-M serves on the board of directors of Glycemic Index Limited, a With 22–23 subjects per group, the study by Sloth et al may have not-for-profit company that administers the Glycemic Index Symbol food www.ajcn.org been underpowered to detect differences in body fat. With the use of labeling program in Australia (Internet:www.gisymbol.com.au). She is also the SD data reported, sample size calculations suggest that Ȃ90 the director of a not-for-profit glycemic index testing service at the University subjects in each group would be necessary to lower the probability of of Sydney (Internet:www.glycemicindex.com) and the co-author of a series of books under the general title The New Glucose Revolution (published by a type 2 error to acceptable levels (ie, to achieve acceptable power). by on April 1, 2009 Alternatively, had the study continued for longer than 10 wk, the Marlowe and Co in North America) that explains the theory and practice of difference might continue to widen, as suggested by the trends in the glycemic index to the lay public. body weight loss in Figure 1 of the article. It may be possible for Sloth and her colleagues to reanalyze their dual-energy X-ray ab- Jennie Brand-Miller sorptiometry measurements to estimate changes in trunk fat mass specifically. Similarly, changes in waist circumference may be more School of Molecular and Microbial Biosciences indicative of visceral fat changes than is the waist-to-hip ratio. University of Sydney A major limitation of the study design is the failure to demonstrate Sydney differences in glycemic and insulin day profiles during the low-GI NSW 2006 compared with the high-GI diet. Without that evidence, a negative Australia study will always be subject to the doubt that a real difference in E-mail: [email protected] overall GI was actually achieved. Although Sloth et al offer in vitro assays of the rate of carbohydrate digestion [rapidly available glu- cose (RAG) and slowly available glucose (SAG)] as evidence of the REFERENCES low- or high-GI nature of their diets, in vitro assays are at best 1. Sloth B, Krog-Mikkelsen I, Flint A, et al. No difference in body weight approximate and at worst clearly wrong. We have reported several decrease between a low-glycemic-index and a high-glycemic-index diet instances of large discrepancies in the results of in vivo versus in but reduced LDL cholesterol after 10-wk ad libitum intake of the low- vitro estimates of GI values (3). Readers should bear in mind that the glycemic-index diet. Am J Clin Nutr 2004;80:337–47. GI is fundamentally defined by its in vivo nature. Studies that cannot 2. Bouché C, Rizkalla S, Luo J, et al. Five-week, low–glycemic index diet decreases total fat mass and improves plasma lipid profile in moderately show actual differences in day profiles or other measure of glycemia overweight nondiabetic men. Diabetes Care 2003;2:822–8. (eg, hyperglycemic events in persons with diabetes) can be chal- 3. Brand-Miller J, Holt S. Testing the glycaemic index of foods: in vivo not lenged. Moreover, because in vitro RAG estimates were the same for in vitro. Eu J Clin Nutr 2004;58:700–1. the high- and low-GI diet, it is conceivable that Sloth et al did not 4. Englyst K, Englyst H, Hudson G, Cole T, Cummings J. Rapidly available achieve a marked difference in glycemic or insulin profile. RAG has glucose in foods: an in vitro measurement that reflects the glycemic been found to be a stronger predictor of postprandial glycemia than response. Am J Clin Nutr 1999;69:448–54. 5. Araya H, Contreras P, Alvina M, Vera G, Pak N. A comparison SAG (4–6). According to Englyst et al (4), the SAG fraction does not between an in vitro method to determine carbohydrate digestion rate contribute to the glycemic response over and above that which can and the glycemic response in young men. Eur J Clin Nutr 2002;56: already be accounted for by the RAG fraction. Although Sloth et al 735–9. 722 Am J Clin Nutr 2005;81:722–9. Printed in USA. © 2005 American Society for Clinical Nutrition LETTERS TO THE EDITOR 723 6. Englyst K, Vinoy S, Englyst H, Lang V. Glycaemic index of cereal found a mean difference of 34.5 units. However, we do agree that it products explained by their content of rapidly and slowly available is difficult to predict the glycemic index of a mixed diet from the glucose. Br J Nutr 2003;89:329–39. glycemic index values of the individual food items from table values. Last, we argue that the significant difference in LDL cholesterol between the 2 groups is a good marker for a true difference between the 2 groups of test foods, because the study was designed so that everything other than the glycemic index was similar in the 2 groups. Reply to J Brand-Miller As reported in our paper, some subjects found the amounts of test food too high (not “far too high” as stated by Brand-Miller). This was Dear Sir: not a complaint that continued throughout the study period, but a statement made mostly during the first week of the study period, and We were surprised to read that Brand-Miller finds our title and for most subjects, it was only addressed when specifically requested. conclusion too decisive, because we merely stated the findings of our It is not unusual for overweight subjects to complain about quantities study (both the pros and the cons of low-glycemic-index diets) and of food when they are served low-fat, high-carbohydrate diets that specifically pointed out the time frame of 10 wk. Furthermore, we have a high dietary fiber content because these diets are probably stated that more studies are needed to substantiate our findings. more satiating than the subjects’ habitual diets (6). We deal with the questions raised by Brand-Miller as follows: The dietary instructions were necessarily strict because we We found a significant 10% decrease in LDL cholesterol in the wanted to control the glycemic index and macronutrient composi- low-glycemic-index group compared with a 2% increase in the high- tion of the subjects’ diets to effectively compare the effects on energy glycemic-index group. This difference cannot be explained by intake of a low-fat, high-carbohydrate diet with either a low or a high changes in fat mass, as suggested by Brand-Miller, because we glycemic index. However, energy intake was not restricted; we observed no correlation between changes in fat mass and changes in merely supplied the subjects with carbohydrate-rich test foods com- LDL cholesterol (total fat mass: r ҃ 0.17, P ҃ 0.27; trunk fat: r ҃ prising Ȃ49% of their estimated total energy intake. Dietary record 0.09, P ҃ 0.56). Nor does inclusion of changes in total or trunk fat data from weeks 5 and 10 clearly show that the test foods provided Downloaded from mass in the covariance analysis change the significance of the diet were only part of the subjects’ diets, as intended.
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