Glycemic responses to foods: possible differences ...

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addition of fat and protein as peanut butter. Insulin-dependent diabetics tended to respond similarly to noninsulin-dependent diabetics but their greater variability.
Glycemic responses differences between noninsulin-dependent

to foods: possible insulin-dependent and diabetics1-3

David JA Jenkins, DM, Thomas MS Anne Kenshole, MD, Robert G Josse, Kah Yun Lam, MSc

Wolever, BM MSc, Gerald MD, Lilian U Thompson,

S Wong, MD, PhD, and

KEY WORDS betics, diabetic

diet,

Glycemic legumes,

index, noninsulin-dependent fat, protein

Introduction Certain differences exist in the conventional dietary advice given to insulin-dependent (IDDM) and noninsulin-dependent diabetics (NIDDM). Emphasis has been placed on evenness of carbohydrate distribution throughout the day for the former and caloric restriction for the overweight majority of the latter (1-3). Recently there has been a move internationally to increase the carbohydrate content of the diabetic diet (1-3), the case for which has been well argued (3). Despite this, it was only specifically stated by the ADA that carbohydrate intakes of IDDM should be increased (4). Nevertheless, successful studies of increased carbohydrate intakes (especially in the context of high-fiber diets) have been carried out on both IDDM and NIDDM volunteers (5-10). However, in addition such studies often involved changes The American Journal of Clinical Nutrition 40: NOVEMBER © 1984 American Society for Clinical Nutrition

diabetics,

insulin-dependent

dia-

in terms of the amount of fat and the nature of the protein content of the diet. The question therefore arises as to whether different dietary advice should be given to IDDM and NIDDM. To provide further insights into this question we have looked for possible differences between IDDM and NIDDM in their responses to different carbohydrate foods and different proportions of these foods within the same meal. We have also studied the effects of adding fat and protein on the blood glucose response to the meal. I

From

the

Department

of

Nutritional

Sciences

(DJAJ, TMSW, LUT), Faculty of Medicine, Departments of Medicine, St. Michael’s Hospital (DJAJ, TMSW, GSW, RGJ), and Women’s College Hospital (AK), University of Toronto, Toronto, Canada. 2Supported by grants from the Natural Sciences and Engineering Research Council. 3Address reprint requests to: David JA Jenkins, Department of Nutritional Sciences, Faculty of Medicine, Toronto University, Toronto, Canada M5S 1A8. Received November 28, 1983. Accepted for publication May 15, 1984. 1984,

pp

971-981.

Printed

in USA

971

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ABSTRACT The effect on the blood glucose response of varying the amount (25 or 50 g) and type (bread or beans) of carbohydrate (CH2O) in test meals and of adding fat and protein was examined in a group of insulin dependent and noninsulin dependent diabetic volunteers. With noninsulin-dependent diabetics, the blood glucose area after a half bread portion was 48% that of the full bread meal (p < 0.001). White pea beans (50 g CH2O) gave a blood glucose response of 41 ± 5% (p 10 or F < 10, respectively).

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Seventeen compliant diabetic volunteers were selected for study, six IDDM (three men, three women, 47 ± 6 yr, 107 ± 5% ideal body weight (IBW), insulin dose 37 ± 6 U/day, duration of diabetes 15 ± 4 yr, Tables 1 and 2) and 1 1 NIDDM (seven men, four women, 61 ± 5 yr. 136 ± 11% IBW, nine taking insulin 30± 6 U/day, duration of diabetes II ± 2 yr, Tables 1 and 2). The patients were classified as IDDM or NIDDM according to their fasting and 90 mm postprandial C-peptide levels (11). Patients defined as IDDM had fasting and postprandial C-peptide levels below 0.6 ng/ml. NIDDM had fasting C-peptide levels above 1.0 ng/ml which either rose or at least remained above 4 ng/ml postprandially (Table 2). The mean fasting value of our own healthy controls was 1.2 ± 0.2 ng/mI (range 0.6 to 1.9 ng/ml; n = 8) with a value at 60 mm post bread of 4.8 ± 0.7 ng/ml (range 2.7 to 7.9 ng/ml). Our results agree well with published values [fasting 1.3 ± 0.3 ng/ml peaking at 60 mm at 4.4 ± 0.8 ng/ml after glucose challenge (12)]. Other studies have demonstrated that C-peptide levels decline much more slowly than insulin (13, 14) and for this reason the 90mm value was selected for the diabetics as coinciding with the mean peak glucose value, and the 60-mm value was chosen for the controls. The majority of patients was free from evidence of neurological complications apart from those whose duration of diabetes was more than 15 yr (Table 1). The volunteers attended the Diabetic Day Care Unit of St Michael’s Hospital, Toronto, or the University Nutritional Sciences Department for approved studies after overnight fasts on at least three occasions (mean 6.4 ± 0.6) each 1 or more wk apart. Test meals were eaten at approximately 9:00 AM after routine medications (insulin or oral agents) had been taken. Capillary blood samples were obtained with autolet lancets (Owen Mumford, Woodstock, Oxford, England) both fasting, before medications, and at 30-mm intervals for 3 h after the start of the meal. On one occasion (after a standard bread meal) venous blood samples were also obtained at 0 and 90 mm from those patients on insulin for measurement of C-peptide concentrations.

ET

GLYCEMIC TABLE Patients

RESPONSES

TO

1 studied Mean

Patient

Sex

Age

Desirable WI

Treatment

yr

3F

IDDM AC AB RW HC

±6 F 57 F 45 M 36 M 71

Duration

diabetes

of Neurological status

36

92

LH

F

34

116

Mean±SEM

3M

47

107

NIDDM

4F

±5

±11

±6 21 U lente 23 U lente 26Ulente l6Ulente 40 U regular 36 U lente AM 14 U lente AM 30U NPH AM 20 U NPH PM

±4 8 8 21 32

NAD NAD P, R

17

o,r

5.7±

NAD

9.4

37

15 ±2

8

±

18

NAD

±0.7 10.5

0.32

2a,b,c,d,e

1.7

0.08

0.10

2a, b, c, d, e

0.23

0.27

±0.6 1.05

±0.9 1.35

l5Ulente 25 U lente

I

NAD

5.0 ± 0.2

WL

M

75

121

24Ulente

15

NAD

10.1 ± 0.5

4 U regular SUlente

1

NAD

6

NAD

15 3 5

NAD NAD NAD

11 23

P P

RH

F

37

144

BS RS VB

M M F

65 30 59

131 104 233

PM

M M

76 77

124 111

JH

M

72

122

WT

*

±

SEM

Abbreviations:

7 M 61 NSNS a, white

10mg glyburide S0Ulente 30 U lente 5mg glyburide SSUlente 10mg glyburide bd 3OUlente

136 30 NS NS bread; b, #{189} white

20

5.5±0.1 12.1

±

12.7 ±0.2 8.8 ± 0.6

9.2

11 9.0 NS NS bread; c, white pea beans;

±

2.4

2a, b, c, d, e, f, i,

1.55

4.6

5.0

6.0

3.65

9.8

2a,b,c,d,e,f, h,j, k 2a, b, c, d, e, f, k, 1

2.95 5.3

4.8 4.3

2a, b, c, d 2a, c, d 2a,h

3.8

2a,h 2a, f,g, j, k

2.7

2a, h

1.2

8.7 ± 0.9 7.2 ± 0.9 9.6±1.0

R

2a,b,c,d,f,g 2a, b, c, d, e 2a,b,c,d,e 2a, b, c, d, e

0.53

0.6

±

±0.08 0.32 0.38 0 0.51

1.5

9.0

±6

done

ng/ml

165 106

130

90 mm

1.3

53 61

71

Fasting

±0.08 9.7± 1.2 0.10 11.9 ± 2.2 0.32 12.7±1.5 0 4.5 ± 0.2 0.36 ±

F F

M

concentration T

Fasting blood glucose

AM KM

Ww

C-peptide

3.2

1.1

2a, b, c, d, f,g, h, i,j 2a, b, c, d, f,g, i,

3.0 4.7