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03 Issues & Trends
Cereal Foods World, Vol. 63, No. 4
DOI: https://doi.org/10.1094/CFW-63-4-0158
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Point: Glycemic Index—An Important but Oft Misunderstood Marker of Carbohydrate Quality
Effie Viguiliouk,1,2 Stephanie K. Nishi,1,2 Thomas M. S. Wolever,1–4 and John L. Sievenpiper1–5

1 Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
2 Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St. Michael’s Hospital, Toronto, ON, Canada.
3 Division of Endocrinology and Metabolism, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada.
4 Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada.
5 Corresponding author. Dr. John L. Sievenpiper, MD, PhD, FRCPC, St. Michael’s Hospital, #6138-61 Queen St E, Toronto, ON M5C 2T2, Canada. Tel: +1.416.867.3732; Fax: +1.416.867.7495; E-mail: john.sievenpiper@utoronto.ca


Abstract

The glycemic index (GI) is a measure of carbohydrate quality that is supported by many international health organizations for the management of chronic diseases and is included on food labels in several different countries to help consumers make healthier food choices. Despite its endorsement by various health and governmental organizations, the GI concept remains controversial. The aim of this article is to address the most recent criticisms of the GI related to its accuracy, precision, and role in cardiometabolic disease prevention and management. Many of the criticisms appear to stem from a misunderstanding of the GI and do not undermine the best evidence from prospective cohort studies and randomized controlled trials, which show important clinical and public health benefits of reducing the GI of the diet. 





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References

  1. Jenkins, D. J., Wolever, T. M., Taylor, R. H., Barker, H., Fielden, H., Baldwin, J. M., Bowling, A. C., Newman, H. C., Jenkins, A. L., and Goff, D. V. Glycemic index of foods: A physiological basis for carbohydrate exchange. Am. J. Clin. Nutr. 34:362, 1981.
  2. Augustin, L. S., Kendall, C. W., Jenkins, D. J., Willett, W. C., Astrup, A., et al. Glycemic index, glycemic load and glycemic response: An International Scientific Consensus Summit from the International Carbohydrate Quality Consortium (ICQC). Nutr. Metab. Cardiovasc. Dis. 25:795, 2015.
  3. Atkinson, F. S., Foster-Powell, K., and Brand-Miller, J. C. International tables of glycemic index and glycemic load values: 2008. Diabetes Care 31:2281, 2008.
  4. Dworatzek, P. D., Arcudi, K., Gougeon, R., Husein, N., Sievenpiper, J. L., and Williams, S. L. Nutrition therapy. Can. J. Diabetes 37(Suppl. 1):S45, 2013.
  5. Anderson, T. J., Gregoire, J., Pearson, G. J., Barry, A. R., Couture, P., et al. 2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can. J. Cardiol. 32:1263, 2016.
  6. American Diabetes Association. 4. Lifestyle management: Standards of Medical Care in Diabetes—2018. Diabetes Care 41:S38, 2018.
  7. Colagiuri, S., Dickinson, S., Girgis, S., and Colagiuri, R. National Evidence Based Guideline for Blood Glucose Control in Type 2 Diabetes. Diabetes Australia and the National Health and Medical Research Council, Canberra, Australia, 2009.
  8. The Royal Australian College of General Practitioners. General Practice Management of Type 2 Diabetes: 2016–18. RACGP, East Melbourne, Australia, 2016.
  9. Dyson, P. A., Twenefour, D., Breen, C., Duncan, A., Elvin, E., et al. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet. Med. 35:541, 2018.
  10. Mann, J. I., De Leeuw, I., Hermansen, K., Karamanos, B., Karlstrom, B., et al. Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutr. Metab. Cardiovasc. Dis. 14:373, 2004.
  11. Catapano, A. L., Graham, I., De Backer, G., Wiklund, O., Chapman, M. J., et al. 2016 ESC/EAS guidelines for the management of dyslipidaemias. Eur. Heart J. 37:2999, 2016.
  12. Mitchell, H. L. The glycemic index concept in action. Am. J. Clin. Nutr. 87:244s, 2008.
  13. Standards Australia. Australian Standard: Glycemic Index of Foods. Standards Australia, Sydney, 2007.
  14. Kris-Etherton, P. M., Yu-Poth, S., Sabate, J., Ratcliffe, H. E., Zhao, G., and Etherton, T. D. Nuts and their bioactive constituents: Effects on serum lipids and other factors that affect disease risk. Am. J. Clin. Nutr. 70:504s, 1999.
  15. Heart UK. The portfolio diet. Published online at https://heartuk.org.uk/cholesterol-and-diet/six-super-foods-for-lower-cholesterol/portfolio-diet. Heart UK, Maidenhead, U.K., 2018.
  16. Aziz, A., Dumais, L., and Barber, J. Health Canada’s evaluation of the use of glycemic index claims on food labels. Am. J. Clin. Nutr. 98:269, 2013.
  17. Wolever, T. M. Glycemic index claims on food labels: Review of Health Canada’s evaluation. Eur. J. Clin. Nutr. 67:1229, 2013.
  18. Matthan, N. R., Ausman, L. M., Meng, H., Tighiouart, H., and Lichtenstein, A. H. Estimating the reliability of glycemic index values and potential sources of methodological and biological variability. Am. J. Clin. Nutr. 104:1004, 2016.
  19. Wolever, T. M., Augustin, L. S., Brand-Miller, J. C., Delport, E., Livesey, G., Ludwig, D. S., and Sievenpiper, J. L. Glycemic index is as reliable as macronutrients on food labels. Am. J. Clin. Nutr. 105:768, 2017.
  20. Anderson, G. H. The glycemic index: Clinical and public health significance. Available online at https://pdfs.semanticscholar.org/3821/28f2fcbe9f2d987d2ce8ca365613cd267042.pdf. Carbohydr. News, 2008.
  21. Jones, J. M. Glycemic index: The state of the science, part 1—The measure and its variability. Nutr. Today 47:207, 2012.
  22. Franz, M. J. In defense of the American Diabetes Association’s recommendations on the glycemic index. Nutr. Today 34:78, 1999.
  23. Wolever, T. M. Is glycaemic index (GI) a valid measure of carbohydrate quality? Eur. J. Clin. Nutr. 67:522, 2013.
  24. International Organization for Standardization. ISO 26642:2010. Food products – Determination of the glycaemic index (GI) and recommendation for food classification. ISO, Geneva, 2010.
  25. Wolever, T. M., Brand-Miller, J. C., Abernethy, J., Astrup, A., Atkinson, F., et al. Measuring the glycemic index of foods: Interlaboratory study. Am. J. Clin. Nutr. 87:247s, 2008.
  26. Center for Food Safety and Applied Nutrition. Guidance for industry: Nutrition labeling manual—A guide for developing and using data bases. Published online at www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm063113.htm. Office of Nutritional Products, Labeling, and Dietary Supplements, CFSAN, College Park, MD, 1998.
  27. Canadian Food Inspection Agency. Nutrition labelling compliance test. Available at: www.inspection.gc.ca/english/fssa/labeti/nutricon/nutriconae.shtml#cont. CFIA, Ottawa, ON, 2018.
  28. Sacks, F. M., Carey, V. J., Anderson, C. A., Miller, E. R., 3rd, Copeland, T., et al. Effects of high vs low glycemic index of dietary carbohydrate on cardiovascular disease risk factors and insulin sensitivity: The OmniCarb randomized clinical trial. JAMA 312:2531, 2014.
  29. Eckel, R. H. Role of glycemic index in the context of an overall heart-healthy diet. JAMA 312:2508, 2014.
  30. Brand-Miller, J. C., Astrup, A., and Buyken, A. E. Low vs high glycemic index diet. JAMA 313:1371, 2015.
  31. Bhupathiraju, S. N., Tobias, D. K., Malik, V. S., Pan, A., Hruby, A., Manson, J. E., Willett, W. C., and Hu, F. B. Glycemic index, glycemic load, and risk of type 2 diabetes: Results from 3 large US cohorts and an updated meta-analysis. Am. J. Clin. Nutr. 100:218, 2014.
  32. Ma, X. Y., Liu, J. P., and Song, Z. Y. Glycemic load, glycemic index and risk of cardiovascular diseases: Meta-analyses of prospective studies. Atherosclerosis 223:491, 2012.
  33. Fan, J., Song, Y., Wang, Y., Hui, R., and 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. DOI: https://doi.org/10.1371/journal.pone.0052182. 2012.
  34. Mirrahimi, A., de Souza, R. J., Chiavaroli, L., Sievenpiper, J. L., Beyene, J., Hanley, A. J., Augustin, L. S., Kendall, C. W., and Jenkins, D. J. Associations of glycemic index and load with coronary heart disease events: A systematic review and meta-analysis of prospective cohorts. J. Am. Heart Assoc. DOI: 10.1161/JAHA.112.000752. 2012.
  35. Cai, X., Wang, C., Wang, S., Cao, G., Jin, C., et al. Carbohydrate intake, glycemic index, glycemic load, and stroke: A meta-analysis of prospective cohort studies. Asia-Pac. J. Public Health 27:486, 2015.
  36. Wang, Q., Xia, W., Zhao, Z., and Zhang, H. Effects comparison between low glycemic index diets and high glycemic index diets on HbA1c and fructosamine for patients with diabetes: A systematic review and meta-analysis. Prim. Care Diabetes 9:362, 2015.
  37. Goff, L. M., Cowland, D. E., Hooper, L., and Frost, G. S. Low glycaemic index diets and blood lipids: A systematic review and meta-analysis of randomised controlled trials. Nutr. Metab. Cardiovasc. Dis. 23:1, 2013.
  38. Schwingshackl, L., and Hoffmann, G. Long-term effects of low glycemic index/load vs. high glycemic index/load diets on parameters of obesity and obesity-associated risks: A systematic review and meta-analysis. Nutr. Metab. Cardiovasc. Dis. 23:699, 2013.
  39. Evans, C. E., Greenwood, D. C., Threapleton, D. E., Gale, C. P., Cleghorn, C. L., and Burley, V. J. Glycemic index, glycemic load, and blood pressure: A systematic review and meta-analysis of randomized controlled trials. Am. J. Clin. Nutr. 105:1176, 2017.
  40. Chiasson, J. L., Josse, R. G., Gomis, R., Hanefeld, M., Karasik, A., and Laakso, M. Acarbose for prevention of type 2 diabetes mellitus: The STOP-NIDDM randomised trial. Lancet 359:2072, 2002.
  41. Chiasson, J. L., Josse, R. G., Gomis, R., Hanefeld, M., Karasik, A., and Laakso, M. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: The STOP-NIDDM trial. JAMA 290:486, 2003.
  42. Hanefeld, M., Cagatay, M., Petrowitsch, T., Neuser, D., Petzinna, D., and Rupp, M. Acarbose reduces the risk for myocardial infarction in type 2 diabetic patients: Meta-analysis of seven long-term studies. Eur. Heart J. 25:10, 2004.
  43. van de Laar, F. A., Lucassen, P. L., Akkermans, R. P., van de Lisdonk, E. H., Rutten, G. E., and van Weel, C. Alpha-glucosidase inhibitors for patients with type 2 diabetes: Results from a Cochrane systematic review and meta-analysis. Diabetes Care 28:154, 2005.
  44. Jenkins, D. J., Kendall, C. W., Augustin, L. S., Mitchell, S., Sahye-Pudaruth, S., 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. Arch. Intern. Med. 172:1653, 2012.
  45. Jenkins, D. J., Kendall, C. W., Vuksan, V., Faulkner, D., Augustin, L. S., et al. Effect of lowering the glycemic load with canola oil on glycemic control and cardiovascular risk factors: A randomized controlled trial. Diabetes Care 37:1806, 2014.
  46. Jenkins, D. J., Kendall, C. W., McKeown-Eyssen, G., Josse, R. G., Silverberg, J., et al. Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: A randomized trial. JAMA 300:2742, 2008.
  47. Aziz, A. The glycemic index: Methodological aspects related to the interpretation of health effects and to regulatory labeling. J. AOAC Int. 92:879, 2009.
  48. Pi-Sunyer, F. X. Glycemic index and disease. Am. J. Clin. Nutr. 76:290s, 2002.
  49. Wolever, T. M., Vorster, H. H., Bjorck, I., Brand-Miller, J., Brighenti, F., et al. Determination of the glycaemic index of foods: Interlaboratory study. Eur. J. Clin. Nutr. 57:475, 2003.
  50. Lan-Pidhainy, X., and Wolever, T. M. Are the glycemic and insulinemic index values of carbohydrate foods similar in healthy control, hyperinsulinemic and type 2 diabetic patients? Eur. J. Clin. Nutr. 65:727, 2011.
  51. Wolever, T. M., Jenkins, A. L., Vuksan, V., and Campbell, J. The glycaemic index values of foods containing fructose are affected by metabolic differences between subjects. Eur. J. Clin. Nutr. 63:1106, 2009.
  52. Wolever, T. M. S. Glycemic index: The measure and its variability—The true state of the science. Nutr. Today 47:214, 2012.
  53. Wolever, T. M. The glycemic index: Flogging a dead horse? Diabetes Care 20:452, 1997.
  54. Jenkins, D. J., Wolever, T. M., Jenkins, A. L., Giordano, C., Giudici, S., Thompson, L. U., Kalmusky, J., Josse, R. G., and Wong, G. S. Low glycemic response to traditionally processed wheat and rye products: Bulgur and pumpernickel bread. Am. J. Clin. Nutr. 43:516, 1986.
  55. Joslin Diabetes Center. The glycemic index and diabetes. Published online at www.joslin.org/info/the_glycemic_index_and_diabetes.html. Joslin Diabetes Center, Boston, 2108.
  56. Kalergis, M., Pytka, E., Yale, J. F., Mayo, N., and Strychar, I. Canadian dietitians’ use and perceptions of glycemic index in diabetes management. Can. J. Diet. Pract. Res. 67:21, 2006.
  57. Brown, I. J., Stamler, J., Van Horn, L., Robertson, C. E., Chan, Q., et al. Sugar-sweetened beverage, sugar intake of individuals, and their blood pressure: International study of macro/micronutrients and blood pressure. Hypertension 57:695, 2011.
  58. Goran, M. I., Ulijaszek, S. J., and Ventura, E. E. High fructose corn syrup and diabetes prevalence: A global perspective. Global Public Health 8:55, 2013.
  59. Slavin, J. Basic qualities of carbohydrates and GI/GL concept. In: EB 2010 Symposium: Are We Ready to Adopt Glycemic Index as an Eating Guide, Anaheim, CA, 2010.
  60. Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 36:3821, 2013.
  61. Grant, S., Wolever, T., Josse, R., O’Connor, D., Thompson, A., et al. Evaluation of glycemic index education in people living with type 2 diabetes mellitus: Participant satisfaction, knowledge uptake and application. In: Abstracts from Dietetic Research Event: June 09–11, 2016. Can. J. Diet. Pract. Res. DOI: https://doi.org/10.3148/cjdpr-2016-016. 2016.
  62. Sangeetha, S., Fatimah, A., Rohana, A. G., Norasyikin, A. W., Karuthan, C., Nik, S. S., Mohd, Y. B., and Nor, A. K. Lowering dietary glycaemic index through nutrition education among Malaysian women with a history of gestational diabetes mellitus. Malays. J. Nutr. 19:9, 2013.
  63. Brand Miller, J., Colagiuri, S., and Foster-Powell, K. The glycemic index is easy and works in practice. Diabetes Care 20:1628, 1997.
  64. Diabetes Canada. Glycemic index food guide. Published online at www.diabetes.ca/getmedia/e3c78c79-9b1b-4823-896d-7daae1726b02/glycemic-index.pdf.aspx. Diabetes Canada, Toronto, 2013.
  65. Dietitians of Canada. Glycemic index education: Translating knowledge to action. Available online at www.dietitians.ca/Learn/Distance-Learning/LODStoreProduct.aspx?guid=0efe254d-1f67-43e7-a18f-fb86e1e3cc30. Dietitians of Canada, Toronto, 2017.
  66. Hu, F. B., Stampfer, M. J., Manson, J. E., Rimm, E. B., Colditz, G. A., Rosner, B. A., Speizer, F. E., Hennekens, C. H., and Willett, W. C. Frequent nut consumption and risk of coronary heart disease in women: Prospective cohort study. BMJ 317:1341, 1998.
  67. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, and Cheng, A. Y. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can. J. Diabetes 37(Suppl. 1):S1, 2013.
  68. Sievenpiper, J. L., de Souza, R. J., Mirrahimi, A., Yu, M. E., Carleton, A. J., et al. Effect of fructose on body weight in controlled feeding trials: A systematic review and meta-analysis. Ann. Intern. Med. 156:291, 2012.
  69. Cozma, A. I., Sievenpiper, J. L., de Souza, R. J., Chiavaroli, L., Ha, V., et al. Effect of fructose on glycemic control in diabetes: A systematic review and meta-analysis of controlled feeding trials. Diabetes Care 35:1611, 2012.
  70. Ha, V., Sievenpiper, J. L., de Souza, R. J., Chiavaroli, L., Wang, D. D., et al. Effect of fructose on blood pressure: A systematic review and meta-analysis of controlled feeding trials. Hypertension 59:787, 2012.
  71. Ha, V., Viguiliouk, E., Mirrahimi, A., Sievenpiper, J. L., de Souza, R. J., Kendall, C. W. C., Jenkins, D. J. A., and Wolever, T. M. S. Glycemic index and cardiovascular disease risk prevention and management. In: The Glycemic Index: Applications in Practice. E. Phillippou, ed. Taylor & Francis Group, Abingdon, U.K., 2016.