Glycemic Index, Glycemic Load and Glycemic Response: Scientific Consensus Statement

Stresa, Italy • June 7, 2013

This Consensus Statement was the culmination of the International Scientific Consensus Summit on Glycemic Index, Glycemic Load and Glycemic Response, organized June 6-7, 2013 in Stresa, Italy.  Another outcome of the Summit was that the participating international panel of experts formed the “Carbohydrate Quality Consortium (CQC)” to meet and discuss the importance of carbohydrate quality in addition to quantity.

  1. Carbohydrates present in different foods have distinct physiological effects, including effects on post-prandial glycemia (PPG), also known as the glycemic response1, with different implications for health.
  1. Reducing PPG is recognized as a beneficial physiological effect (Ceriello and Colagiuri 2008, Levitan et al. 2004, Coutinho et al. 1999, EFSA 2011).
  1. Ways to reduce PPG include slowing carbohydrate absorption by consuming low glycemic index (GI)2 and glycemic load (GL)3 foods to reduce the dietary GI and GL (Jenkins et al. 1981, Salmeron et al. 1997).
  1. The GI methodology is a sufficiently valid and reproducible method for differentiating foods based on their glycemic response (Wolever 2013, Brouns et al. 2005). 
  1. The GI quantifies specific physiological properties of carbohydrate-containing foods as influenced by the food matrix. These characteristics extend beyond their chemical composition of food and include delaying gastric emptying and reducing the rate of digestion and small intestinal absorption.
  1. When considering the macronutrient composition, the GL/1000kJ (the product of GI and available‚Äč4 carbohydrate content) is the single best predictor of the glycemic response of foods (Bao et al. 2011).
  1. There is convincing evidence from meta-analyses of controlled dietary trials that diets low in GI improve glycemic control in people with type 2 and type 1 diabetes (Giacco et al. 2000, Brand-Miller et al. 2003, Livesey et al. 2008, Thomas and Elliot 2010, Jenkins et al. 2012).
  1. There is convincing evidence from meta-analyses of prospective cohort studies that low GI/GL diets reduce the risk of type 2 diabetes Barclay et al. 2008, Livesey et al. 2013).
  1. There is convincing evidence from a large body of prospective cohort studies that low GI/GL diets reduce the risk of coronary heart disease (Liu et al. 2000, Mirrahimi et al. 2012, Fan et al. 2012).
  1. The proof of principle for the concept of slowing carbohydrate absorption is the use of alpha-glucosidase inhibitors (acarbose etc.) to reduce progression to type 2 diabetes and coronary heart disease (Chiasson et al. 2002, Chiasson et al. 2003).
  1. The quality of carbohydrate-rich foods as defined by GI/GL is particularly important for individuals who are sedentary, overweight and at increased risk of type 2 diabetes (Salmeron et al. 1997, Ludwig et al. 2002).
  1. Potential mechanisms for reduction of type 2 diabetes include evidence that low GI/GL diets improve insulin sensitivity and beta-cell function in people with type 2 diabetes and those at risk for type 2 diabetes (Rizkalla et al. 2004, Solomon et al. 2011).
  1. Potential mechanisms for reduction of coronary heart disease include evidence that low GI/GL diets improve blood lipids and inflammatory markers including C-reactive protein (CRP) (Frost et al. 1999, Liu et al. 2001, Wolever et al. 2008, Shikany et al. 2010. Goff et al. 2013).
  1. Probable evidence exists for low GI/GL diets in reducing total body fat mass and in weight management (Larsen et al. 2010, Murakami et al. 2013, Bouché et al. 2002, McMillan-Price et al. 2006, Ebbeling et al. 2005).
  1. The GI complements other ways of characterizing carbohydrate-foods, such as fiber and whole grain content (Riccardi et al. 2008, Slavin 2008).
  1. Low GI and Low GL should be considered in a context of a healthy diet.
  1. Given the rapid rise in diabetes and obesity there is a need to communicate information on GI/GL to the general public and health professionals.
  1. This should be supported by inclusion of GI/GL in dietary guidelines and in food composition tables.
  1. In addition package labels and low GI/GL symbols on healthy foods should be considered.
  1. More comprehensive high-quality food composition tables need to be developed for GI/GL at the national level.
Footnotes:
1. Glycemic response: is the simple term for the post-prandial blood glucose concentration (PPG) elicited by a food or a meal.
 
2. Glycemic Index (GI): Conceptually, GI is the glycemic response elicited by a portion of a carbohydrate-rich food containing 50g (or in some cases 25g) available carbohydrate expressed as a percentage of that elicited by 50g (or 25g) glucose. GI is precisely defined by the ISO (International Organization for Standardization) method 26642:2010 (http://www.iso.org/iso/home/store/catalogue_tc/catalogue_detail.htm?csnu...)
 
3. Glycemic load (GL): is the product of GI and the total available carbohydrate content in a given amount of food (GL = GI x available carbohydrate/given amount of food). Available carbohydrates can have different modes of expression: g per serving, g per 100g food, g per day intake, and g per 1000 kJ or 1000 calories, dependent on the context in which GL is used. Thus GL has corresponding units of g per serving, g per 100 g food, and g per 1000 kJ or 1000 calories.
 
4. Available carbohydrate: Is the carbohydrate in foods that is digested, absorbed and metabolised as carbohydrate. Available carbohydrate is sometimes referred to as glycemic carbohydrate.
 
References:
Bao J, Atkinson F, Petocz P, Willett WC, Brand-Miller JC. Prediction of postprandial glycemia and insulinemia in lean, young, healthy adults: glycemic load compared with carbohydrate content alone. Am J Clin Nutr. 2011;93(5):984-96.
 
Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, Brand-Miller JC. Glycemic index, glycemic load, and chronic disease risk--a meta-analysis of observational studies. Am J Clin Nutr 2008;87: 627-37.
 
Bouché C, Rizkalla SW, Luo J, Vidal H, Veronese A, Pacher N, Fouquet C, Lang V, Slama G. Five week low-glycemic index diet decreases total fat mass and improves plasma lipid profile in moderately overweight non diabetic subjects. Diabetes Care 2002;25:822-828
 
Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care 2003;26:2261-7.
 
Brouns F, Bjorck I, Frayn KN, Gibbs AL, Lang V, Slama G, Wolever TM. Glycaemic index methodology. Nutr Res Rev. 2005;18(1):145-71.
Ceriello A, Colagiuri S. International Diabetes Federation guideline for management of postmeal glucose: a review of recommendations. Diabet Med. 2008;25:1151-6.
 
Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial. JAMA. 2003;290(4):486-494.
 
Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M; STOP-NIDDM Trial Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP- NIDDM randomised trial. Lancet 2002;359(9323):2072-7.
 
Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relationship between glucose and incident cardiovascular events. A metaregression analysis of published data from 20 studies of 95,783 individuals followed for 12.4 years. Diabetes Care 1999;22:233–40.
 
Ebbeling CB, Leidig MM, Sinclair KB, Seger-Shippee LG, Feldman HA, Ludwig DS. Effects of an ad libitum low-glycemic load diet on cardiovascular disease risk factors in obese young adults. Am J Clin Nutr. 2005;81(5):976-82.
 
European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition and Allergies (NDA). Scientific opinion on the substantiation of a health claim related to “slowly digestible starch in starch-containing foods” and “reduction of post-prandial glycaemic responses” pursuant to Article 13(5) of Regulation (EC) No 1924/20061. EFSA Journal 2011;9(7):2292.
 
Fan J, Song Y, Wang Y, Hui R, Zhang W. Dietary glycemic index, glycemic load, and risk of coronary heart disease, stroke, and stroke mortality: a systematic review with meta-analysis. PLoS One. 2012;7(12):e52182.
 
Frost G, Leeds AA, Dore CJ, Madeiros S, Brading S, Dornhorst A. Glycaemic index as a determinant of serum HDL-cholesterol concentration. Lancet. 1999;353:1045-8.
 
Giacco R et al, Long-Term Dietary Treatment With Increased Amounts of Fiber-Rich Low–Glycemic Index Natural Foods Improves Blood Glucose Control and Reduces the Number of Hypoglycemic Events in Type 1 Diabetic Patients, Diabetes Care 2000;23:1461-6.
 
Goff LM, Cowland DE, Hooper L, Frost GS. Low glycaemic index diets and blood lipids: a systematic review and meta-analysis of randomised controlled trials. Nutr Metab Cardiovasc Dis. 2013;23(1):1-10.
 
International Standards Organisation. ISO 26642-2010. Food products - Determination of the glycaemic index (GI) and recommendation for food classification. International Standards Organisation; 2010.
 
Jenkins DJ, Kendall CW, McKeown-Eyssen G, et al. Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: a randomized trial. JAMA. Dec 17 2008;300(23):2742-2753.
 
Jenkins DJ, Kendall CW, Augustin LS, Mitchell S, Sahye-Pudaruth S, Blanco Mejia S, Chiavaroli L, Mirrahimi A, Ireland C, Bashyam B, Vidgen E, de Souza RJ, et al. Effect of legumes as part of a low glycemic index diet on glycemic control and cardiovascular risk factors in type 2 diabetes mellitus: a randomized controlled trial. Archives of internal medicine 2012;172:1653-60.
 
Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, et al. Glycemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr. 1981;34:362–6.
 
Larsen TM, Dalskov SM, van Baak M, Jebb SA, Papadaki A, Pfeiffer, AF, Martinez JA, Handjieva-Darlenska T, Kunesova M, Pihlsgard M, et al. Diets with high or low protein content and glycemic index for weight-loss maintenance. N Engl J Med 2010;363:2102- 13.
 
Levitan EB, Song Y, Ford ES, Liu S. Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? A meta-analysis of prospective studies. Arch Intern Med. 2004;164:2147–55.
 
Livesey G, Taylor R, Hulshof T, Howlett J. Glycemic response and health--a systematic review and meta-analysis: relations between dietary glycemic properties and health outcomes. Am J Clin Nutr. 2008;87:258S-68S.
 
Livesey G, Taylor R, Livesey H, Liu S. Is there a dose-response relation of dietary glycemic load to risk of type 2 diabetes? Meta-analysis of prospective cohort studies. Am J Clin Nutr 2013;97:584-596.
 
Liu S, Willett WC, Stampfer MJ, et al. A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr. Jun 2000;71(6):1455-1461.
 
Liu S, Manson JE, Stampfer MJ, Holmes MD, Hu FB, Hankinson SE, Willett WC. Dietary glycemic load assessed by food-frequency questionnaire in relation to plasma high- density-lipoprotein cholesterol and fasting plasma triacylglycerols in postmenopausal women. Am J Clin Nutr. 2001;73(3):560-6.
 
Liu S, Manson JE, Buring JE, Stampfer MJ, Willett WC, Ridker PM. Relation between a diet with a high glycemic load and plasma concentrations of high-sensitivity C-reactive protein in middle-aged women. Am J Clin Nutr. 2002;75:492–8.
 
Ludwig DS. The glycemic index: physiological mechanisms relating to obesity, diabetes, and cardiovascular disease. JAMA. 2002;287(18):2414-2423.
 
McMillan-Price J, Petocz P, Atkinson F, O'neill K, Samman S, Steinbeck K, Caterson I, Brand-Miller J. Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial. Arch Intern Med. 2006;166(14):1466-75.
 
Mirrahimi A, de Souza RJ, Chiavaroli L, Sievenpiper JL, Beyene J, Hanley AJ, Augustin LS, Kendall CWC, Jenkins DJA. Associations of Glycemic Index, Load and their Dose with CHD events: A Systematic Review and Meta-analysis of Prospective Cohorts. J Am Heart Assoc. 2012;1(5):e000752.
 
Murakami K, McCaffrey TA, Livingstone MB. Associations of dietary glycaemic index and glycaemic load with food and nutrient intake and general and central obesity in British adults. Br J Nutr. 2013:1-11.
 
Riccardi G, Rivellese AA, Giacco R. Role of glycemic index and glycemic load in the healthy state, in prediabetes, and in diabetes. Am J Clin Nutr 2008;87(suppl):269S-74S.
 
Rizkalla SW, Laika T, Laromiguiere M, Huet D, Boillot J, Rigoir A, Slama G. Improved plasma glucose control, whole body glucose utilization and lipid profile on a low glycemic index diet in type 2 diabetic men: A randomized-controlled trial. Diabetes Care 2004;27:1866-72
 
Salmeron J, Manson JE, Stampfer MJ, Colditz GA, Wing AL, Willett WC. Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA. Feb 12 1997;277(6):472-477.
 
Shikany JM, Tinker LF, Neuhouser ML, Ma Y, Patterson RE, Phillips LS, Liu S, Redden DT. Association of glycemic load with cardiovascular disease risk factors: the Women's Health Initiative Observational Study. Nutrition 2010;26(6):641-7.
 
Slavin JL. Position of the American Dietetic Association: health implications of dietary fiber. J Am Diet Assoc. 2008;108:1716–31.
 
Solomon TP, Haus JM, Kelly KR, Cook MD, Filion J, Rocco M, Kashyap SR, Watanabe RM, Barkoukis H, Kirwan JP. A low-glycemic index diet combined with exercise reduces insulin resistance, postprandial hyperinsulinemia, and glucose-dependent insulinotropic polypeptide responses in obese, prediabetic humans. Am J Clin Nutr. 2010;92(6):1359- 68.
 
Thomas DE, Elliott EJ. The use of low-glycaemic index diets in diabetes control. Br J Nutr. 2010;104(6):797-802.
 
Wolever TMS. Is glycaemic index (GI) a valid measure of carbohydrate quality? Eur J Clin Nutr 2013;67:522-31.
 
Wolever TM, Brand-Miller JC, Abernethy J, Astrup A, Atkinson F, Axelsen M, et al. Measuring the glycemic index of foods: interlaboratory study. Am J Clin Nutr. 2008;87:247S-57S.

 


 

 

Scientific Consensus Committee:

Chairs:

David J.A. Jenkins, MD, PhD, DSc, University Professor and Canada Research Chair in Nutrition  and Metabolism,  Department of Nutritional Sciences,  Faculty of Medicine, University of Toronto, Director, Risk Factor Modification Centre, St. Michael’s Hospital (Toronto, Canada)

Walter C. Willett, MD, DrPH, Fredrick John Stare Professor of Epidemiology and Nutrition, Chair, Department of Nutrition, Harvard School of Public Health (Boston, USA)

 

Members:

Livia Augustin, PhD,  Research Fellow, Risk Factor Modification Centre, St. Michael’s Hospital (Toronto, Canada)

Sara Baer-Sinnott, President, Oldways (Boston, USA)

Alan W. Barclay, PhD, Head of Research, Australian Diabetes Council; Chief Scientific Officer Glycemic Index Foundation (Sydney, Australia),

Inger Björck, PhD, Professor and Managing Director Antidiabetic Food Centre, Lund University (Lund, Sweden)

Jennie C. Brand-Miller, PhD, Professor, Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney (Sydney, Australia)

Furio Brighenti, DrPH, Professor of Human Nutrition, Department of Food Science University of Parma (Parma, Italy)

Anette E. Buyken, PhD, Research Associate, Department of Nutritional Epidemiology, University of Bonn (Bonn, Germany).

Antonio Ceriello, MD, Head of Research at the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (Barcelona, Spain)

Cyril W.C. Kendall, PhD, Research Associate, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto (Toronto, Canada) and Adj. Professor College of Pharmacy and Nutrition, University of Saskatchewan (Saskatoon, Canada)

Carlo La Vecchia, MD, Chief, Department of Epidemiology, Mario Negri Institute, and Professor of Epidemiology, University of Milan, (Milan, Italy)

Geoff Livesey, PhD, Director, Independent Nutrition Logic (Wymondham, UK)

Simin Liu, MD, ScD, Professor, Departments of Epidemiology and Medicine, Brown University (Providence, USA)

Andrea Poli, MD, Scientific Director, Nutrition Foundation of Italy (Milan, Italy)

Gabriele Riccardi, MD, Full Professor of Endocrinology and Metabolic Diseases, Department of Clinical Medicine and Surgery, Federico II University (Naples, Italy)

Salwa W. Rizkalla, MD, PhD, DSc, Senior Researcher, National Institute of Health and Medical Research (INSERM) U 872, team 7, Research centre in human nutrition, ICAN Institute of Cardiometabolism & Nutrition, University Pierre et Marie Curie-Paris 6, Centre of Research in Human Nutrition, Pitié Salpêtrière Hospital (Paris, France).

John L. Sievenpiper, MD, PhD, Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital (Toronto, Canada), Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University (Hamilton, Canada).

Antonia Trichopoulou, MD, PhD, Professor and Director, World Health Organization  Collaborating Centre for Food & Nutrition,  Department of Hygiene and Epidemiology, University of Athens Medical School, and Vice President, Hellenic Health Foundation (Athens, Greece)

Thomas M.S. Wolever MD, PhD, Professor, Department of Nutritional Sciences, University of Toronto (Toronto, Canada)

 

                                          

This International Scientific Consensus Summit was co-organized by the Nutrition Foundation of Italy and Oldways.

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