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Dr. Katsilambros: Ms. Franz and Dr. Slama, I understand that existing studies in humans comparing low versus high glycemic index (GI) diets do not show any real weight change. However, during the previous discussion I mentioned that there are experimental animal studies that do show a weight change between low and high GI diets. I have found the slide from the study and with your permission I would like to show it.
Ms. Franz: While Dr. Katsilambros gets ready to show the slide, I would like to make a comment on satiety studies. Although subjects may report feeling more satisfied after consuming different meals, this doesn't always translate into eating fewer calories. For example, Stubbs et al.  in a 1-day study reported that although subjective hunger was less after a high protein breakfast compared to a high fat or high carbohydrate breakfast, lunch time intake 5 h later and energy intake for the rest of the day were similar after all three breakfasts. Currently the majority of research on satiety is very short-term and the effect of satiety on future calorie intake is rarely studied. While we wait for the slide does anyone else have a comment or questions?
Dr. Slama: I would like to make three brief comments and ask you one question. To be fair you should quote Razels and Crapo and for European people Otto and Spater who published these results in 1973. They were first published in German and then in French, but they can still be found in Medline. The second thing is you said something which seems wrong to me: you say that adding milk to a portion of cereals will decrease the blood glucose. If you add a portion of skin milk to 50 g cereal, this will increase but not decrease blood glucose, unless you are using caribou milk which is very rich in lipids.
Ms. Franz: Thank you for your comment. What I meant to say is that if you combine a high GI cereal with milk, a low GI food, you lower the GI of the meal. The high GI of the cereal or the low GI of milk is not maintained and instead you have a moderate GI response.
Dr. Slama: My third remark is that we proponents of the low GI do not claim that the GI concept should be substituted by another concept, but it should be added to another concept. So my question is: how as a clinician can you make this claim if you have not tried it yourself?
Ms. Franz: I have used the concept of differing glycemic responses from foods with many patients. For example, when examining food and glucose records you often find glucose responses that do not seem to make sense by just looking at the total amount of carbohydrate eaten. A possible explanation may be that different carbohydrate foods do have differing glucose responses even when the total amount of carbohydrate is the same. If persons with diabetes observe that some foods consistently cause their post-meal glucose response to be higher than other foods, even when keeping the carbohydrate amount consistent, the next time they eat that food they can try eating less of it or, if on insulin, increase their insulin dose. So I agree with the concept that foods with equal amounts of carbohydrate may have differing post-meal glucose responses which can be helpful to patients. They can use their food and glucose test records to make food choices that can beneficially lower their post-meal glucose responses.
Dr Slama: You don't need to explain your concept to the patient. You only have to say eat that rather than that when you have the occasion or the choice. You don't have to explain the area under the curve and the ratio and to multiply by the age. You only have to give some very simple advice.
Ms. Franz: As a clinician, I am reluctant to suggest to patients that they should not eat potatoes because they have a high GI when I am not confident this is true. For example, while potatoes from Australia appear to have a high GI of 87-101, potatoes tested in the US and Canada had a moderate GI of 56-77 . Therefore, my problem with the GI is with the variability and reliability of the published GI values.
Dr. Slama: Try it yourself and you will be convinced.
Dr. Katsilambros: This is a slide published in 2002 and these are rats studied over 32 weeks, not for 1 week. You see an enormous difference in weight, about 75 g at the end of 30 weeks. The upper line is high GI, the lower line is low GI. 75 g in a rat is something like 20 kg in a man. Still I absolutely agree and I expect that in humans this is not the case. But again in humans we are not absolutely sure how strictly the diet can be kept unless it is made in the laboratory and under close supervision. Finally I absolutely agree with you and Dr. Slama that this is an additive dietary treatment, it is not an alternative.
Dr. Mooradian: What was the strain of rats used in the study?
Dr. Katsilambros: I don't remember.
Dr. Mooradian: Because the strain makes a difference in terms of growth. One has to interpret these data as favorable in terms of weight reduction versus stunting of growth.
Ms. Franz: Were the diets comparable in digestible or available carbohydrate and calories?
Dr. Mooradian: I guess to be able to interpret that slide you need to know whether the rats were pair-fed and had exactly the same amount of calorie intake.
Dr. Katsilambros: Yes, I show isoenergetic.
Dr. Eshki: When looking at nutrition tools for diabetes, such as the carbohydrate count, GI and other nutrition tools, I believe all these methods are very effective. When providing consultation to patients, their diet must be customized. For instance, when an individual visits a tailor to have a suit made, the tailor is going to take the measurements and all other factors before customizing the suit. With my patients, I look at several factors, such as culture, lifestyle conditions, the patient's onset, peak and duration of medication and the dietary history, and based on that I customize the proper diet. I see all nutrition tools as useful and don't deny the effectiveness of one over the other. My question is, do you think the GI can be helpful in some way?
Ms. Franz: Yes, as I mentioned previously the GI can be a helpful tool for patients who keep food and blood glucose records. However, as a clinician my first priority is to provide a framework that patients can use to plan food choices and meals and that is based on what the individual with diabetes feels is feasible and realistic for them to implement. In managing diabetes, how much a person eats is more important than what he/she eats. Just because a food has a low GI does not mean people with diabetes can eat unlimited portions of that food without affecting their blood glucose levels. Portions do count! I have found it helpful if patients understand what foods contain carbohydrate; what are average carbohydrate portion sizes, and how many carbohydrate servings to eat for meals or snacks, if desired. To plan food choices and meals people with diabetes can use carbohydrate counting, exchange lists, or experience. People with diabetes use their own experience to determine what works for them and what doesn't, and the GI concept may help explain some of their experiences. If target blood glucose goals are not being met, decisions need to be made to determine if changes in food intake or in medical therapy (i.e. medications) are needed.
Dr. Hill: It is very interesting to have these two talks back to back. While we can change people's diets in the short-term, it is difficult to do this over the long-term. The question in my mind is whether the GI is a useful tool for long-term improvement of diets. Are people following the GI diet eating healthily? Do people know what to do with the message given by the GI? Are people able to stick with this concept more than other concepts? The best example is the recent Atkins diet craze which in the short-term is great at producing weight loss but in the long-term it doesn't seem to be able to do this.
Ms. Franz: There is little, if any, evidence that people with diabetes can in the long-term change the GI of their usual diet. In a 1-year study, children in the low GI group did have significantly better HbAlc levels than the group using a carbohydrate exchange diet . However, the study reported no differences in mean GI between the 2 groups at study end and even the authors stated it was difficult to attribute the difference in HbAlc to diet when there was no apparent difference in the mean GI. The majority of studies comparing low and high GI diets have been short-term. Furthermore, it is likely that most people already eat a moderate GI diet and it is not known if this can be changed long-term to a low GI diet.
Dr. Hill: Some people have suggested putting the GI on food labels. As an educator, how do you think the population would handle that?
Ms. Franz: You would have to ask somebody from a country where GI values are included on a food label as to the usefulness of this information. As an educator, I find the most useful information on the food label to be the serving size expressed in portions that patients can understand and the total grams of carbohydrate in that serving size. Total calories and grams of fat, saturated fat and protein in the serving size are also useful information.
Dr Slama: I would like to make some comments on what has been said. First of all we do not promote chocolate, ice cream, pizza, because they have a low GI. We do not leave people with a list of low GI food, but with a list of low GI healthy food. If time is short one must do what one can, but for me nutritional education is a long running process. I do not tell my patient's right away that now they have to learn what the GI is. I come with it later on when I want to tune the results. So really it is a process which we have to take with precaution and time.
Ms. Franz: I would agree with you. Most patients need support long-term to make and maintain lifestyle changes and part of that support over time may be fine tuning some of their food choices using the GI concept. My concern is when low GI foods are promoted to the public as being healthy food choices, and low GI food become 'good' foods and high GI foods become 'bad' foods.
Dr. Slama: I agree that you have to take care of the amount of carbohydrate. But already diagnosed diabetic people are eating less carbohydrate than they should, and not too much.
Ms. Franz: That is an interesting comment about how much carbohydrate people with diabetes should be and are eating. In this regard, I find the report from the United Kingdom Prospective Diabetes Study on estimated dietary intakes of interest. The intent of the nutrition intervention was to encourage patients to eat 50-55% of their energy intake as carbohydrate, protein 10-15%, and fat 30-35%. Despite the intensive intervention, patients reported a similar proportion of their energy intake as carbohydrate (43%) as the general population, protein intake 21%, and fat 37% . Males reported an estimated energy intake of ~ 1,800 kcal/day and females ~ 1,450 kcal/day. This suggests that people with diabetes eat a moderate carbohydrate diet and do not eat either a high or a low carbohydrate diet.
Dr. Gerasimidi-Vazeou: Regarding type-1 diabetic patients, taking only carbohydrate measurement and GI into consideration and omitting fat consumption is not sufficient to improve glycemic control. This is also true judging from the experience at our center. We live in a real world and our patients do not always follow our suggestions. Perhaps we should also take fat consumption into consideration because we know that in Western countries the latter is over 30% of the daily calorie intake.
Ms. Franz: I certainly agree with you. Patients with both type-1 and type-2 diabetes need also to pay attention to total caloric intake as well as the total meat and fat servings they eat. You can't just focus on carbohydrates.
1 Stubbs RJ, van Wyk MC, Johnstone AM, Harbron CG: Breakfasts high in protein, fat or carbohydrate: effect on within-day appetite and energy balance. Eur J Clin Nutr 1996;50:409-417.
2 Fernandes G, Velangi A, Wolever TM: Glycemic index of potatoes commonly consumed in North America. J Am Diet Assoc 2005;105:557-562.
3 Gilbertson HR, Brand-Miller JC, Thorburn AW, et al: The effect of flexible low glycemic index dietary advice versus measured carbohydrate exchange diets on glycemic control in children with type 1 diabetes. Diabetes Care 2001;24:1137-1143.
4 Eeley EA, Stratton IM, Hadden DR, et al: UKPDS 18: estimated dietary intake in type 2 diabetic patients randomly allocated to diet, sulphonylurea or insulin therapy. UK Prospective Diabetes Study Group. Diabet Med 1996;13:656-662.
Bantle JP, Slama G (eds): Nutritional Management of Diabetes Mellitus and Dysmetabolic Syndrome. Nestlé Nutr Workshop Ser Clin Perform Program, vol 11, pp 73-81, Nestec Ltd., Vevey/S. Karger AG, Basel, © 2006.
Low Glycemic Index Foods Should Play a Role in Improving Overall Glycemic Control in Type-1 and Type-2 Diabetic Patients and, More Specifically, in Correcting Excessive Postprandial Hyperglycemia
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