By Nora Saul, MS, RD, and Melinda D.

Maryniuk, MEd, RD, CDE

USING THE GLYCEMIC INDEX

IN DIABETES MANAGEMENT
Consider carbohydrate quality to achieve blood glucose control.

lthough nutritional management is well

recognized as the cornerstone of diabetes treatment, theres no consensus on
the type of diet or the nutrient composition thats most effective for glycemic
control.1-5 Until recently, most American health care
providers have focused on keeping carbohydrate intake consistent while downplaying the influence of
carbohydrate quality. Exactly how different types of
carbohydrate foods affect blood glucose and whether
the differences are clinically significant have been the
subjects of much debate. This article summarizes
the findings of a recent Cochrane Collaboration review of the efficacy of using the glycemic index (GI)
to modulate blood glucose response.6
The term glycemic index refers to the relative ranking of different carbohydrate foods according to
how they affect the blood glucose level.7 To determine a foods GI, its effect on blood glucose levels
in healthy volunteers is compared with that of 50 g
of glucose. First healthy volunteers ingest a portion
of the food containing 50 g of digestible carbohydrate. Blood glucose levels are measured every half
hour for two hours and a glucose response curve is
calculated. The GI of the food is calculated by dividing the area under the curve for the food by that for
glucose, which is valued at 100. A foods GI is then
ranked as high (70 or more), medium (56 to 69), or
low (55 or less). Carbohydrates with high GI values
cause blood glucose levels to rise more quickly than
those with low GI values. For example, eating a boiled
white potato, which has a GI of 96, raises blood glucose more rapidly than eating a serving of black
beans, which has a GI of 30. However, there can be
variability in GI values within the same food category
depending on where the food was grown, how it was
cooked, and slight differences in the plant itself. In general, foods that have higher fiber or fat content have
lower GI values, but this doesnt always apply. A baked
potato with skin is a good fiber source, yet it doesnt
have a low GI.
The GI value doesnt take into account the amount
of carbohydrate in different standard food portions.
68

AJN July 2010

Vol. 110, No. 7

This can lead to confusion about the relative effects

of certain foods on glycemic control. For example,
the University of Sydneys online GI database (available at www.glycemicindex.com) reports that although watermelon has a GI of 72, a standard portion
contains very little carbohydrate and therefore doesnt
significantly raise blood glucose levels. To resolve this
discrepancy, researchers developed a secondary measure called the glycemic load (GL). Its calculated by
multiplying a foods GI by the number of grams of
carbohydrate present in a standard portion and dividing that by 100. A GL of 20 or more is high, 11 to 19
is medium, and 10 or less is low. For example, the GL
of watermelon, which has 6 g of carbohydrate in a
120 g portion, is calculated as:
72 6 / 100 = 4.3
This is then rounded to a GL of 4. Table 17 presents
the GIs and GLs of a variety of foods.
The most recent recommendations on nutrition
released by the American Diabetes Association
(ADA)8 state, The use of glycemic index and load
may provide a modest additional benefit [for glycemic control] over that observed when total carbohydrate is considered alone. The ADA considers
the evidence for this to be supportive rather than
clear, indicating that additional research in this area
is needed.
The Cochrane Collaboration review looked at 10
randomized controlled studies comparing low GI
with high GI diets. An 11th study compared a low
GI diet with a measured carbohydrate exchange program. The trials varied in length from four weeks to
one year.6 The primary end point in studies of longer
than six weeks was glycemic control as measured by
glycosylated hemoglobin (HbA1c). In studies of less
than six weeks in length, glycemic control as measured by fructosamine level (which measures changes
in blood glucose control over a two-to-three-week
period) or glycated serum albumin level (a measure
of the binding of the glucose molecule to serum albumin) was the primary end point. The review included
402 participants between the ages of 10 and 63 with
ajnonline.com

Table 1. Glycemic Index and Glycemic Load of Selected Carbohydrate Foods7

Glycemic Index
Glycemic Load

Low (55 or less)

Medium (5669)

Low (10 or less)

Whole wheat bread, rye bread, sourdough

bread, Kelloggs All-Bran cereal, green
peas, kidney beans, apple, grapefruit,
strawberries

Vanilla yogurt, cantaloupe,

French bread, whole wheat
pita

White bread, watermelon

Medium (1119)

Oatmeal, banana, chickpeas

Shredded wheat cereal,

sweet corn

Boiled red potato, bran flakes

High (20 or more)

Pasta (white flour)

Bagel, raisins, brown rice

Boiled white potato, white rice

either type 1 or type 2 diabetes. Six studies including 247 participants reported HbA1c values. Among
these participants, HbA1c decreased by 0.5% (95%
confidence interval of 0.8 0.2)a significant effect comparable to that produced by the less potent
oral antihyperglycemic agents. The studies reviewing
fructosamine and glycated serum albumin also attributed positive results to low glycemic diets. The study
that compared a low GI diet to a measured carbohydrate exchange diet didnt report statistical differences; however, compared to the exchange group,
twice the percentage of participants in the low GI
group reached acceptable HbA1c levels.
Since none of the studies reported the total carbohydrate content of the diets or whether this parameter
was controlled for, its difficult to analyze their outcomes. In addition, each of the studies defined high
and low GI diets differently and sometimes ones low
GI value was anothers high value and vice versa
although there was a significant difference between the
high and low GI values within each study.
Many factors affect a foods glycemic effect: its soluble fiber content, the type of starch it contains, its fat
and protein content, its acid content, its physiologic
state (liquid versus solid), the cooking method used,
and the glycemic condition of the person eating it.
The GI focuses on one parameter onlyhow quickly
blood glucose rises in response to a particular food
and provides no guidance in terms of serving size or
nutrient balance, two parameters that many patients
lack the skill to consider when they plan their meals.
The ADA recommends that a registered dietitian play
the primary role in teaching patients about nutrition
care.8 When patients are interested in moving beyond
basic meal planning, a registered dietitian can help
them use the GI to fine-tune their dietary patterns to
improve their metabolic control.
Nora Saul is manager of nutrition services at the Joslin
Diabetes Center in Boston, where Melinda D. Maryniuk is
director of clinical education programs in strategic initiatives.
Contact author: Nora Saul, nora.saul@joslin.harvard.edu.
ajn@wolterskluwer.com

High (70 or more)

PATIENT RESOURCES
Brand-Miller J, et al. The New Glucose Revolution: Low GI
Eating Made Easy. New York: Marlowe; 2005.
Brand-Miller J, Foster-Powell K. The New Glucose Revolution
Shoppers Guide to GI Values 2009. Cambridge, MA: Da
Capo Press; 2008.
Brand-Miller J, et al. Low GI Diet Cookbook: 100 Simple,
Delicious Smart-Carb Recipes. Cambridge, MA: Da Capo
Press; 2005.
Brand-Miller J, et al. The New Glucose Revolution: The
Authoritative Guide to the Glycemic IndexThe Dietary
Solution for Lifelong Health. Cambridge, MA: Da Capo Press;
2006.
Harvard School of Public Health. The Nutrition Source:
carbohydrates: the bottom line. http://bit.ly/11YpSq.

REFERENCES
1. Gerhard GT, et al. Effects of a low-fat diet compared with
those of a high-monounsaturated fat diet on body weight,
plasma lipids and lipoproteins, and glycemic control in type 2
diabetes. Am J Clin Nutr 2004;80(3):668-73.
2. Esposito K, et al. Effects of a Mediterranean-style diet on
the need for antihyperglycemic drug therapy in patients with
newly diagnosed type 2 diabetes: a randomized trial. Ann
Intern Med 2009;151(5):306-14.
3. Kodama S, et al. Influence of fat and carbohydrate proportions on the metabolic profile in patients with type 2 diabetes: a meta-analysis. Diabetes Care 2009;32(5):959-65.
4. Parker B, et al. Effect of a high-protein, high-monounsaturated fat weight loss diet on glycemic control and lipid levels in type 2 diabetes. Diabetes Care 2002;25(3):425-30.
5. Brehm BJ, et al. One-year comparison of a highmonounsaturated fat diet with a high-carbohydrate diet in
type 2 diabetes. Diabetes Care 2009;32(2):215-20.
6. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database
Syst Rev 2009(1):CD006296.
7. Atkinson FS, et al. International tables of glycemic index
and glycemic load values: 2008. Diabetes Care 2008;
31(12):2281-3.
8. Bantle JP, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American
Diabetes Association. Diabetes Care 2008;31 Suppl 1:
S61-S78.

AJN July 2010

Vol. 110, No. 7

69