Glycemic Index: History and Clinical Application

David J.A. Jenkins

Clinical Nutrition & Risk Factor Modification Center St. Michael’s Hospital;

Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Ontario,

Canada

  Oldways Preservation Trust, Boston, MA – A not for profit organization promoting traditionally “healthy” ways of eating (eg. Mediterranean Diet, etc.) H

  Agriculture and Agrifoods Canada (AAFC) – SAB   Canadian Agriculture Policy Institute (CAPI) – SAB   Canadian Institute of Health Research (CIHR) – G   Canadian Foundation for Innovation (CFI) –G   Pulse Canada - SAB   Saskatchewan Pulse Growers – SAB   Ontario Research Fund (ORF) – G   Advanced Foods and material Network (AFMNet) – G   International Tree Nut Council Nutrition Research and Education Foundation

and the Peanut Institute – G, H   Almond Board of California, Modesto, CA – A branch of the USDA (therefore

“not for Profit”) to promote the use of almonds. C,H,G

C = Consultancies; H = Honorarium; SAB = Scientific Advisory Boards; G = Grants

Conflict of Interest

•  Barilla, Italy – A general food company. Producer of pasta and baked goods. G •  Haine Celestial, CA – One of the largest Health Food companies in the US. G •  Loblaws Supermarkets – Canada’s largest supermarket chain.G, SAB   Sanitarium Company, Sydney, Australia – Australia’s largest health food manufacturing

company and soy food producer. G, SAB   The Coco Cola sugar Advisory Board . C, H,SAB   Griffin Hospital, New Haven- For the development of the Nuval System. C, H, SAB   Abbott Laboratories, Algorithms for Diabetes Management. C, H, SAB   Unilever - Canada – Guidelines for the management of hyperlipidemia. G,C,H   Wife and is a Director of Glycemic Index Laboratories, Toronto, CA – Financial relationship

of a spouse   The California Strawberry Commission, Watsonville, CA – Another USDA not for profit

group to explore possible health benefits and to promote the use of strawberries. SAB   Kellogg’s, Canada – C, H, SAB   Quaker Oats, Canada-C, H, SAB

C = Consultancies; H = Honorarium; SAB = Scientific Advisory Boards; G = Grants

Conflict of Interest

1981 - 1st Glycemic Index Paper1

1995 - 1st International GI Tables2

1997 - Concept of Glycemic Load3,4

(GI x CH2O) 1995- - Demonstration of the importance of 2007 BMI/Insulin resistance as a

determinant of relevance of GI/GL5,6,7,8 1) Jenkins DJ, et al. Am J Clin Nutr. 1981 Mar;34(3):362-6.

2) Foster-Powell K, Miller JB. Am J Clin Nutr. 1995 Oct;62(4):871S-890S. 3) Salmerón J, Manson JE, Stampfer MJ, Colditz GA, Wing AL, Willett WC. JAMA. 1997 Feb 12;277(6):472-7. 4) Salmerón J, Ascherio A, Rimm EB, Colditz GA, Spiegelman D, Jenkins DJ, Stampfer MJ, Wing AL, Willett WC. Diabetes Care. 1997 Apr;20(4):545-50. 5) Wolever TM, Bentum-Williams A, Jenkins DJ. Diabetes Care.1995 Jul;18(7):962-70. 6) Liu S, Willett WC, Stampfer MJ, Hu FB, Franz M, Sampson L, Hennekens CH, Manson JE. Am J Clin Nutr. 2000 Jun;71(6):1455-61. 7) Wolever TM, Mehling C. BJN. 2002 87:477-487. 8) Ebbeling CB, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS. JAMA. 2007 May 16;297(19):2092-102.

GI: Evolution of the Concept

Copyright ©2008 The Endocrine Society

Ford, E. S. et al. J Clin Endocrinol Metab 2008;93:s1-s8

Trends in the prevalence of obesity (BMI >= 30 kg/m2) among U.S. adults aged 18 yr or older, Behavioral Risk Factor Surveillance System (BRFSS)

OBESITY

Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 1990, 1995 and 2001

1990 1995

2001

Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

No Data <4% 4%-6% 6%-8% 8%-10% >10%

DIABETES

Diabetes on the Rise

Current  prevalence  of  Diabetes  worldwide  %  of  Popula7on  with  diabetes  

Diabetes on the Rise

%  of  Popula7on  with  diabetes  Prevalence  of  Diabetes  in  2030  worldwide  

Intensive Glycemic Control in Type 2 Diabetes on CHD Risk

Turnbull FM et al Diabetologia. 2009 (11):2288-98.

Glycemic Index/ Load

Salmeron et al. JAMA 1997;277:472-7

Glycemic Load and Cereal Fiber Intake in Women And Risk of Type II Diabetes

(75,000 Nurses over 10y)

Glycemic Load & T2DM in Adults

Livesey et al. Am J Clin Nutr 2013;97:584–96.

Livesey et al. Am J Clin Nutr 2013;97:584–96.

Adjustments to:

SEX= 50% Men, 50% Women

CORR= Dietary instrument validity centered on a correlation of 0.70

FUY= Follow-up to 10 years

ETH= Ethnicity to 50% European and American 50% other ethnicities

Glycemic Load & T2DM in Adults after adjustments

Pooled Risk Estimate for CHD comparing highest to lowest GL quantiles

Study or Subgroup WeightRelative Risk

IV, Random, 95% CIRelative Risk

IV, Random, 95% CI

Relative Risk

GL & CHD Risk

Mirrahimi A, Jenkins D et. al. JAHA 2012;1:e000752

Ma X, et al. Atherosclerosis; 223 (2012): 491-496

GI and CVD

Barclay et al. Am J Clin Nutr. 2008

Meta-Analysis of GI & Common Cancers

Choi Y, Giovannucci E, and Lee JE. British Journal of Nutrition (2012), 108, 1934–1947

GI and Diabetes-Related Cancers Significant

Choi Y, Giovannucci E, and Lee JE. British Journal of Nutrition (2012), 108, 1934–1947

GI and Diabetes-Related Cancers Non-Significant

Acarbose Viscous Fibers Low glycemic foods

Slow Release Carbohydrate

Chiasson J-L, Josse RG, Hanefeld M, et al. JAMA 2003;346:393.

CVD Events

Acarbose

↓ 49% RR

STOP-NIDDM Trial

STOP-NIDDM Trial

Chiasson J-L, Josse RG, Hanefeld M, et al. JAMA 2003;346:393.

Hypertension

(new cases)

Acarbose

↓ 34% RR

GI & Diabetes Management Meta-analysis

Brand-Miller et al. Diabetes Care. 2003

Favours low GI Favours High GI

Goff L, D.E. Cowland, L. Hooper, G.S. Frost. Nutrition, Metabolism & Cardiovascular Diseases (2013) 23, 1e10

GI & LDL-C

0

5

10

15

20

25

Admission Low GI High GI

PAI-1

act

ivity

(U/m

l)

Jarvi AE, et al. Diabetes Care 1999;22:10-8.

Mean ± sd 22.2 ± 14.7 9.4 ± 11.0 20.2 ± 16.1

** ***

Glycemic Index and Thrombosis PAI-1

Jensen et al. Am J Clin Nutr.2008

GI and Thrombosis PAI-1

Wk0 Wk10 Wk0 Wk10 High GI Low GI

PAI-1 activity (U/mL)

0

2

4

6

8

10

12

14

Liu et al. Am J Clin Nutr 2002;75:492-8

BMI > 25

BMI < 25

Glycemic Load and CRP at High and Low BMI

-0.2

0.0

0.2

0.4

Time×Diet: p=0.084 -3

0

3

6A1c

High GI Low GI Low Carb

0 3 6 9 12

-0.3

0.0

0.3

0.6

Time×Diet: p=0.041 -4

0

4

8Fasting Glucose

Months

Res

idua

ls(%

)(m

mol

/L)

Percentage of B

aseline

High GI & Fiber

Low GI

Low Carb

Wolever et al., Am J Clin Nutr 2008;87:114 –25.

CRP on High and Low GI Diets

SLOTH

GLUTTONY

RX = Diets for Fat People

Liu, Willett, Stampfer, Hu, Franz, Sampson, Hennekens, Manson. Am J Clin Nutr. 2000 Jun;71(6):1455-61.

Multivariate RR of CHD according to body mass index (BMI) and Glycemic load (GL): 10y of

follow-up in the Nurses Health Study (n=65,000)

Ebbeling CB… Ludwig DS. JAMA. 2007 May 16;297(19):2092-102.

Insulin Response Determines Weight Loss

Valtuena S et. al. Am J Clin Nutr 2006;84:136-42

FATTY LIVER (NAFL) and GI

Effect of a Low GL Diet vs. a High Fiber Diet on %HbA1c over 3 Months

Data are presented as ITT mean treatment difference in HbA1c ±SEM, P-values define the significance between treatments using LS means . IR= Insulin Resistance, IR Risk Factors were defined as the following baseline values: HbA1c≥7.2 (median baseline value of the cohort); HDL-C ≤1.3mmol/L for women and ≤1.0mmol/L for men; Triglyceride ≥ 1.7mmol/L; Systolic blood pressure ≥130mmHg or diastolic blood pressure ≥85mmHg ; Waist Circumference ≥88 for women and ≥102 for men; Age ≥ 58 (median age of cohort).

-­‐0.80  

-­‐0.70  

-­‐0.60  

-­‐0.50  

-­‐0.40  

-­‐0.30  

-­‐0.20  

-­‐0.10  

0.00  

All  Par2cipants    ≥1  IR  Risk  Factor    

 ≥2  IR  Risk  Factors    

 ≥3  IR  Risk  Factors    

 ≥4  IR  Risk  Factors    

 ≥5  IR  Risk  Factors    

Betw

een  Treatm

ent  D

ifferen

ce  

(%Hb

A1c  Unit)  

P=  0.076   P=  0.076   P=  0.117  

P=  0.084  

P=  0.017  

P=  0.002  

n=141   n=140   n=121  

n=78  

n=34  

n=18  

Ajala et al. Am J Clin Nutr. 2013

Low GI compared to other diets for T2DM

Collaborators: Dr. Livia Augustin Dr. Russell de Souza Dr. Cyril Kendall Dr. Alexandra Jenkins Dr. John Sievenpiper Dr. Vladimir Vuksan Dr. Thomas Wolever Graduate Students: Laura Chiavaroli Arash Mir-rahimi Stephanie Nishi Kristie Srichaikul

Acknowledgements

Staff: Sonia Blanco Judy Coveney Dorothea Faulkner Christopher Ireland Sandy Mitchell Melanie Paquette Darshna Patel Sandhya Sahye-Pudaruth