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Glycemic Index And Glycemic LoadGlycemic load and childrens health -
Chronic non-communicable diseases, which until very recently were considered typical of adult and elderly population, have been increasingly common in young individuals. Obesity, type 2 diabetes, dyslipidemias and hypertension have been reported in children and adolescents in several reports [3,4].
Eating habits exert an important influence on the cause of these diseases, which have insulin resistance as a common starting point. Childhood is a crucial stage in the development of healthy dietary habits. Nevertheless, high consumption of high-sugar, processed foods, low in fiber and micronutrients, including candies, processed juice, salty snacks, sweets, cake, and refined cereals, all with a high glycemic index GI , has been reported during this age.
Since glucose levels are directly related with insulin production, GI was created as a tool to help control diet quality, and thereby prevent or delay the progression of chronic diseases associated with altered insulin production and insulin resistance, such as diabetes mellitus [5,6], metabolic syndrome [7], obesity [8] and some cancers [9].
Nevertheless, the standardized method to calculate GI, i. Thus, since in a real-life situation, neither the amount of carbohydrate consumed nor the time for its ingestion is controlled, another parameter, named glycemic load GL , was proposed [11] to estimate blood glucose response to carbohydrate consumption, considering food serving portions typically consumed in daily life [12].
Clinical studies have suggested an important role of GI in energy metabolism [5,13]. Consumption of high GL and GI foods induces a high glycemic and insulin response, resulting in greater cellular glucose uptake and fall in circulating glucose level, which may be associated with higher hunger sensation and consequently greater food consumption [].
Besides, consumption of high GI and high GL diets can alter lipid profile and favor the development of cardiovascular diseases. Insulin resistance has been suggested as the triggering event for LDL uptake from the blood, body weight gain, and peripheral vascular resistance, common in diabetes mellitus, obesity, hypertension and dyslipidemias [5,16,17].
On the other hand, low GI diets have been associated with slower glucose removal rates and hence lower glucose fluctuation, which in turn, leads to a better glycemic control. In type 2 diabetes, low GI diets were associated with lower glycated hemoglobin and fructosamine levels, two key biomarkers of glycemic control [16,18].
In addition, consumption of low GI foods leads to the release of counterregulatory hormonescortisol, growth hormone and glucagon. Body fat mass regulation associated with the consumption of low GI diets seems to be correlated with the activation of some genes.
For example, these diets seem to decrease the expression of ob gene, resulting in lower postprandial insulin secretion [13, 19]. In a review article [20], the adoption of a low GL diet is suggested as a dietetic strategy to prevent metabolic syndrome. Several studies have investigated the impact of GI and GL on health [13,16,19,21].
However, despite their established importance, the use of these parameters is not a consensus and results of clinical studies are still conflicting [10,13,21]. Glucose absorption is also influenced by other dietary components, including lipid, protein and fiber.
In addition to its chemical composition, other factors such as the size of carbohydrate particles and food processing methods may also affect carbohydrate digestion and absorption rates [23]. In general, high GI diets are rich in refined carbohydrates, and poor in fiber, protein and micronutrients, in contrast to low GI diets, rich in micronutrients and fibers.
This makes it practically impossible to conduct comparative studies on diets with the same amounts of these nutrients and different GI and GL [24].
In another study involving adults in Spain, GL was positively correlated with lower BMI [26]. Go to Mini Review Abstract Introduction Conclusion References Conclusion Nationwide studies on GI and GL diets in children and adolescents have been conducted in few countries and are still scarce [].
More attention should be addressed to the theme to clarify whether the adoption of low GI and GL diets in children could actually contribute to stopping the expansion of diabetes and obesity in the world. Go to Mini Review Abstract Introduction Conclusion References References World Health Organization WHO Global database on body mass index an interactive surveillance tool for monitoring nutrition transition.
Althoff T, Socič R, Hicks JL, King AC, Delp SL, et al. Nature : Hannom TS, Rao G, Arslanian SA Childood obesity and type 2 diabetes mellitus. Pediatr 2 : Xue Y, Gao Y Childhood type 2 diabetes: Risks and complications Review.
Exp Ther Med 12 4 : Macdonald IA A review of recent evidence relating to sugars, insulin resistance and diabetes. Eur J Nutr 55 suppl 2 : SS Akash H, Rehman K, Liagat A Tumor necrosis factor-alpha: Role in development of insulin resistance and pathogenesis of type 2 diabetes mellitus.
J Cell Biochem 1 : Barba G, Sieri S, Russo MD, Donatiello E, Formisano A, et al. Nutr, Metab Cardiov Diseas 22 1 : Kyungjoon L, Jackson KL, Sata Y, Head GA Factors responsible for obesity-related hypertension. Curr Hypertens Rep 19 7 : Twarock S, Reichert C, Peters U, Gorski DJ, Röck K, et al.
Int J Cancer 4 : Sacks FM, Carey VJ, Anderson CAM, Miller III ER, Copeland T, et al. JAMA 23 : Salmeron J Dietary Fiber, Glycemic Load, and risk of non-insulin- dependent diabetes mellitus in women. JAMA 6 : Barclay AW, Brand Miller JC, Wolever TM Glycemic index, glycemic load, and glycemic response are not the same.
Diabetes Care 28 7 : Silva FM, Kramer CK, Crispim D, Azevedo MJ A high-glycemic index, low fiber breakfast affects the postprandial plasma glucose, insulin, and ghrelin responses of patientes with Type 2 Diabetes in a randomized clinical trial.
J Nutr 4 : Tsilas CS, Souza RJ, Mejia SB, Mirrahimi A, Cozma AI, et al. From the Division of Endocrinology Drs Ebbeling and Ludwig, Mr Leidig, and Ms Sinclair , Department of Medicine Drs Ebbeling and Ludwig, Mr Leidig, and Mss Sinclair and Hangen , and the Optimal Weight for Life Program Mss Sinclair and Hangen and Dr Ludwig , Children's Hospital Boston, and the Department of Pediatrics Drs Ebbeling and Ludwig , Harvard Medical School, Boston, Mass.
Background The incidence of type 2 diabetes increases markedly for obese children after puberty. However, the effect of dietary composition on body weight and diabetes risk factors has not been studied in adolescents. Objective To compare the effects of an ad libitum, reduced—glycemic load GL diet with those of an energy-restricted, reduced-fat diet in obese adolescents.
Design Randomized control trial consisting of a 6-month intervention and a 6-month follow-up. Main Outcome Measures Body composition body mass index [BMI; calculated as weight in kilograms divided by the square of height in meters] and fat mass and insulin resistance homeostasis model assessment were measured at 0, 6, and 12 months.
Seven-day food diaries were used as a process measure. Results Fourteen subjects completed the study 7 per group. Conclusions An ad libitum reduced-GL diet appears to be a promising alternative to a conventional diet in obese adolescents. Large-scale randomized controlled trials are needed to further evaluate the effectiveness of reduced-GL and —glycemic index diets in the treatment of obesity and prevention of type 2 diabetes.
Although many studies have evaluated obesity treatments in children, 5 , 6 relatively little attention has been directed toward adolescents. Treatments evaluated in a few adolescent studies have incorporated a reduced-fat diet in combination with varying exercise prescriptions and behavioral strategies.
Recently, the novel dietary factors glycemic index GI and glycemic load GL have been linked to the risk for obesity or type 2 diabetes mellitus on experimental and theoretical grounds. One-day feeding studies have consistently reported increased hunger or voluntary food intake in subjects after eating highcompared with low-GI foods.
Slabber et al 17 reported greater weight loss after 3 months among obese women who were counseled to eat low-GI foods compared with those who did not receive this advice. Bouche et al 18 found that fat mass decreased significantly more in overweight men after 5 weeks of a lowcompared with a high-GI diet.
Spieth et al 19 retrospectively observed a greater reduction in body mass index BMI; calculated as weight in kilograms divided by the square of height in meters with a reduced-GL, compared with a reduced-fat diet prescription in children and adolescents who were followed up for an average of 4 months.
In addition, 2 large-scale, prospective observational studies found a direct association between GL and risk for type 2 diabetes mellitus, after controlling for the effects of BMI and other potential confounders. The aims of this work were 1 to develop a reduced-GL diet for use in an adolescent population; 2 to determine whether adolescents following this diet will successfully achieve long-term reduction of GL; and 3 to compare the long-term effects of a reduced-GL diet with those of a conventional reduced-fat diet in a pilot study involving obese adolescents.
Development and testing of novel dietary treatment for obesity is arguably of major public health significance, in view of the continuing debate regarding the efficacy of conventional reduced-fat diets for weight control.
Subjects were randomly assigned to experimental reduced GL or conventional reduced fat dietary treatment. Both groups received similar behavioral therapy, physical activity recommendations, and treatment intensity. The study, conducted in the General Clinical Research Center of Children's Hospital Boston, Boston, Mass, consisted of a 6-month intensive intervention 12 dietary counseling sessions and a 6-month follow-up 2 dietary counseling sessions.
Body composition and insulin resistance were measured at 0, 6, and 12 months. The protocol was approved by the Institutional Review Board at Children's Hospital Boston. Written informed consent was obtained from subjects 18 years or older and from the parents of minors; assent was obtained from minors.
After screening for study eligibility, 16 obese patients 5 male and 11 female patients; 13 white and 3 nonwhite aged 13 to 21 years were enrolled and randomized between December 1, , and September 30, Figure 1. Obesity was defined as a BMI that exceeded sex- and age-specific 95th percentiles.
The reduced-GL prescription emphasized selection of carbohydrate-containing foods eg, nonstarchy vegetables, fruits, legumes, nuts, and dairy that are characterized by a low to moderate GI.
The prescription was not energy restricted. Rather, subjects were advised to eat to satiety and to snack when hungry.
An ad libitum approach was used in light of preliminary evidence that suggests greater satiety and decreased voluntary energy intake occurs among children and adolescents consuming reduced-GL diets.
The reduced-fat prescription was based on current recommendations for weight loss and diabetes prevention, 25 , 26 with emphasis on limiting dietary fat intake and increasing the intake of grains, vegetables, and fruits. Energy requirements were estimated using the Harris-Benedict equation, 27 with an activity factor of 1.
Social cognitive theory provided a conceptual framework for the educational and behavioral components of treatment that was consistent between intervention groups.
Counseling focused on enhancing self-efficacy for dietary change using the concepts of behavioral capability knowledge and skill and self-control. Written materials included topic modules, food choice lists, and a select-a-meal menu.
The topic modules were the primary mechanism for presenting nutrition intervention messages and facilitating self-assessment, goal setting, and problem solving.
These modules were designed to promote dialogue between the patient and study dietitian. Food choice lists were used to enhance practical application of intervention messages presented in the topic modules. For the experimental group, lists corresponded to food groups delineated by a reduced-GL food pyramid.
One topic module was devoted to physical activity, with subjects in both groups receiving information based on current recommendations. The treatment process was evaluated from the perspectives of interventionist adherence to nutrition education and counseling protocols, and subject participation and adherence to diet prescriptions.
Interventionist adherence may be conceptualized as treatment fidelity, a term encompassing integrity and differentiation.
Several strategies were used to maximize treatment fidelity in the present study. First, written materials for the experimental and conventional groups were developed specifically for the pilot study such that the format and quality were completely parallel. The materials differed only with regard to the specific intervention messages pertaining to GL and dietary fat.
Second, the interventionist was a dietitian M. trained in the science underlying each intervention and given precise instructions regarding use of written materials to ensure differentiation of the intervention messages.
Third, to prevent shifts in implementation, the dietitian completed a tracking form and progress note immediately after each session. The project director C. met with the study dietitian on a regular basis to review tracking forms and progress notes and to discuss treatment of individual subjects.
Subject participation was evaluated on the basis of session attendance, and adherence was assessed by means of self-report of dietary intake.
All subjects received extensive instruction and practice in keeping food diaries. Three-dimensional food models, plates, bowls, glasses, and measuring cups and spoons were used to educate them regarding accurate appraisal of portion sizes.
The diaries were reviewed with the subject at the time of receipt to obtain clarification, as necessary, on recorded foods and beverages.
Food Processor Plus software Version 7. The GI of individual foods was assigned according to published values. Data from 7-day food diaries were used to evaluate process outcomes at baseline, during the intervention period months 3 and 6 , and at the end of the follow-up month In addition, self-monitoring of food intake was encouraged throughout the intervention period to enhance self-control and facilitate problem solving.
The study dietitian reviewed self-reported intake after each individual counseling session to identify deviations from diet prescriptions and made corrective recommendations to the subject when necessary.
Total body mass and fat mass were measured by dual-energy x-ray absorptiometry using Hologic instrumentation Model QDR ; Hologic, Inc, Bedford, Mass. Height was measured using a wall-mounted stadiometer Holtain Limited, Crymych, Wales. Plasma glucose level was measured using a Hitachi analyzer Model ; Roche Diagnostics, Indianapolis, Ind , and serum insulin level was measured using an Elecsys system Model ; Roche Diagnostics.
We conducted statistical analyses using SAS software Release 8. Repeated-measures analysis of variance was performed using the mixed linear model procedure.
Component contrasts were estimated from the fitted model for preplanned comparisons within treatment group changes over time and differences between groups for changes over time. The time intervals of interest were 0 to 6 months and 0 to 12 months.
Change in insulin resistance was adjusted for change in BMI. Results are presented as mean ± SEM. We conducted simple linear regression using the general linear models procedure , pooling data from both groups, to explore whether changes in dietary GL or fat intake average of values obtained at 3 and 6 months independently predicted change in body fat.
When exploring relationships between dietary variables and body fat, we eliminated 1 outlier from regression analyses, although data from this outlier are displayed. The outlier was a young woman who matriculated in medical school during participation in the study. On the basis of previous research, we speculated that apparent underestimation of dietary intake by this subject may be attributed, in part, to expression of a social desirability bias.
Fourteen subjects finished the study 7 per group , yielding a completion rate of There were no group differences in session attendance, with subjects in the experimental and conventional groups completing 9.
All 14 subjects attended the 2 scheduled sessions during the follow-up. At baseline, we found no differences between the experimental and conventional groups for age However, fat mass was lower for the experimental group compared with the conventional group Changes in dietary variables are presented in the Table 1.
Of interest, there was no weight regain between 6 and 12 months for the experimental group. Changes over time for study outcomes. Figure 3 depicts results of bivariate linear regression analysis, using dietary GL or fat intake during the intervention period as the independent variable and change in body fat from 0 to 6 months as the dependent variable.
Changes in dietary glycemic load GL or fat intake as predictors of change in body fat. Black circles indicate subjects in the experimental group; white circles, subjects in the conventional group. Treatment of obesity in adolescents is characterized by modest weight loss and substantial relapse.
In this pilot study, we investigated the independent effects of an experimental reduced-GL diet vs a conventional reduced-fat diet, using similar behavioral strategies, physical activity prescriptions, and treatment intensity in both groups.
Although both groups showed the intended changes in targeted dietary factors, measures of adiposity decreased significantly more in the reduced-GL group.
This result is of particular interest, in that the reduced-GL diet was prescribed in an ad libitum fashion, whereas the reduced-fat diet was energy restricted, consistent with conventional practices. The potential flexibility of such a diet may have particular behavioral benefits for adolescents who have a strong desire for autonomy.
In a previous study, children with type 1 diabetes mellitus were more easily able to select their own foods when prescribed a low-GI diet compared with a regimented meal plan based on an exchange system without consideration for GI.
At the end of the study, children expressed an overall preference for the low-GI diet compared with the regimented plan. We also examined insulin resistance, as prevention of type 2 diabetes mellitus is a primary goal of obesity treatment in adolescents.
In contrast, insulin resistance did not change in the reduced-GL group. Moreover, the group effect remained significant after adjustment for change in BMI. These findings are consistent with epidemiological data 11 , 20 that show lower risk for diabetes among individuals consuming a low-GL diet, after controlling for BMI.
Thus, reducing dietary GL may protect against diabetes through weight-dependent and weight-independent mechanisms, as previously hypothesized. Adherence to diet prescriptions, regardless of group assignment, was likely affected by intrapersonal, interpersonal, and environmental influences.
Although most participating parents were well intentioned, not all provided adequate support with regard to provision of recommended foods, transportation to counseling sessions, and encouragement. Adolescents who participated in the pilot study often enjoyed socializing with peers at food courts and fast-food restaurants, where they were challenged to make reduced-GL or reduced-fat food choices.
Research is needed to develop novel strategies for motivating obese adolescents to change their eating behaviors and for motivating parents to provide appropriate support in environments that pose challenges to adherence.
Several issues pertaining to study design should be noted. Strengths of the study include careful attention to treatment fidelity, a well-defined conceptual framework to promote behavior change, a relatively long follow-up, and high subject retention.
Study limitations include a small sample size and reliance on self-report for dietary assessment. Underreporting of energy intake is a recognized source of measurement error when assessing adolescent diets. Furthermore, we cannot definitely attribute treatment effects exclusively to changes in GL, as other dietary factors such as fiber or palatability may mediate or confound the relationship between changes in GL and changes in adiposity to some degree an issue in all long-term outpatient dietary studies.
Our results suggest that reducing dietary GL may have greater benefits than reducing dietary fat when treating adolescent obesity to lower the risk for type 2 diabetes mellitus. Although findings must be considered preliminary, this study provides relevant pilot data to inform future research.
Large-scale randomized controlled trials are needed to evaluate the effectiveness and public health applications of reduced-GL and -GI diets. Corresponding author: David S.
Ludwig, MD, PhD, Division of Endocrinology, Longwood Ave, Children's Hospital Boston, Boston, MA e-mail: david. ludwig tch. This study was supported by grants 1R01DK and 1K01DK, from the National Insitute of Diabetes and Digestive Kidney Diseases Bethesda, Md ; the Charles H.
Hood Foundation Boston, Mass ; pilot and feasibility project grant DK from the Boston Obesity and Nutrition Research Center Boston ; and grant M01 RR awarded by the National Institutes of Health Bethesda to support the General Clinical Research Center at Children's Hospital Boston, Boston.
We thank Janet Washington, MPH, RD, for her contribution to intervention development; Suzanne Muggeo and Eve Callahan, MS, RD, for performing the dual-energy x-ray absorptiometry scans; Catherine Murphy, RN, and Linda Lynch, RN, for help with patient care; and Irena Clark, MHP, Erica Garcia-Lago, and Gina Masse for technical assistance.
Adolescent obesity increases the risk for a wide range of serious complications, including type 2 diabetes mellitus. Given the current obesity epidemic, novel treatment strategies are needed urgently. No previous studies have evaluated the effects of diet composition per se on treatment outcomes in obese adolescents.
The results of this study indicate that a reduced-GL diet may yield greater benefits than a conventional reduced-fat diet.
These pilot data, derived from a relatively long-term intervention study, provide strong rationale for conducting large-scale randomized controlled trials to evaluate the effectiveness of a reduced-GL diet in the treatment of obesity and prevention of diabetes mellitus.
This line of investigation has the potential to change clinical practice and public health guidelines. Ebbeling CB , Leidig MM , Sinclair KB , Hangen JP , Ludwig DS. A Reduced—Glycemic Load Diet in the Treatment of Adolescent Obesity. Arch Pediatr Adolesc Med. Artificial Intelligence Resource Center.
The body jealth down most cyildrens Body toning transformation the foods we eat jealth converts them to childrebs type of sugar called Heart health tips. Glucose is the chjldrens source of fuel for our cells. Herbal metabolic boosting drink eating, the time it takes for the body to convert carbohydrates and release glucose into the bloodstream varies, depending on the type of carbohydrate and the food that contains it. Some carbohydrate-containing foods cause the blood glucose level to rise rapidly; others have a more gradual effect. The glycemic index measures how fast and how much a food raises blood glucose levels.
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