Dietary glycemic load and glycemic index and risk of coronary heart disease and stroke in Dutch men and women: the EPIC-MORGEN study

The association between glycemic index, glycemic load and total carbohydrate intake and risk of premature coronary artery disease: Iran Premature Coronary Artery Disease Study (IPAD) - A Case-Control Study

BACKGROUND AND AIMS

The association between glycemic index (GI), glycemic load (GL), total carbohydrate intake, and risk of cardiovascular diseases has been controversial. Premature coronary artery disease (PCAD) is characterized by the age of onset lower than 55 and 65 respectively in men and women. The aim of the current study is to investigate the relationship between GI, GL and carbohydrate levels and the risk of PCAD in Iran.

METHODS AND RESULTS

In total, 419 healthy people and 553 patients struggling with PCAD have participated in this case-control study. Dietary GI and GL were calculated using a validated food frequency questionnaire at the baseline. Crude and multivariable logistic regression were used to assess the relationship between GI, GL, and total carbohydrate intake and risk of PCAD. The mean age of participants was 51.13 ± 6.90 and 46 % of them were women. A significant direct relationship was observed between higher carbohydrate intake (OR: 1.74, 95%CI: 1.27-2.38) and GL levels (OR: 1.56, 95 % CI:1.14-2.14) and risk of PCAD. These associations were not significant after adjusting for potential variables. No significant association has been observed between GI and odds of PCAD even after controlling for all covariates.

CONCLUSION

We found no significant association between GI, GL, and total carbohydrate intake and risk of premature coronary heart disease. Further observational and clinical trials are required to assess this relationship.

Carbohydrate Intake and Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Prospective Studies

The purpose of this study is to understand the conflicting results from previous studies on the association between carbohydrate intake and cardiovascular disease (CVD) by conducting a systematic review and meta-analysis to summarize the most recent scientific evidence. A systematic review used three electronic databases to gather literature on the association between carbohydrate intake and CVD. Considering the discrepancies, either fixed or random effect models were chosen to determine the effect size, and sensitivity analysis results, as well as publication bias, were also presented. The meta-analysis found that individuals with the highest carbohydrate intake had a 1.15-fold increased risk of CVD compared to those with the lowest intake (hazard ratio, HR: 1.15, 95% confidence interval, CI: 1.07–1.23). Further subgroup analysis revealed that this association was only present in Asia, with a 1.52-fold increased risk (HR: 1.52, 95% CI: 1.17–1.97), while no associations were seen in the Americas, Europe, and Oceania. The relationship between carbohydrate intake and CVD was non-linear, with a marked escalation beyond 60% of total energy from carbohydrates. Our findings suggest that a high-carbohydrate diet may raise the risk of CVD, particularly in Asian populations. This association may be due to the higher carbohydrate consumption and genetic variations found in Asia.

Dietary carbohydrate quantity and quality and risk of cardiovascular disease, all-cause, cardiovascular and cancer mortality: A systematic review and meta-analysis

BACKGROUND & AIMS

Evidence remains conflicted on the association between dietary carbohydrate quantity and quality and risk of cardiovascular disease, all-cause, cardiovascular and cancer mortality, and such meta-analyses are lacking. The study aimed to conduct a systematic review and meta-analysis to synthesize the knowledge about their associations and to explore the dose-response relations.

METHODS

We comprehensively searched PubMed, EMBASE, and Web of Science up to March 2022 for observational studies investigating the associations in adults. Random effect model was used to estimate the summary relative risks (RRs) and 95% confidence intervals (CIs) and the dose-response association was explored by restricted cubic splines.

RESULTS

We obtained the data from 41 eligible studies. Compared with participants with lowest dietary carbohydrate intake, those with highest intake had an RR of 1.10 (95% CI 1.03-1.17, I2 = 52.8%) for cardiovascular disease, 1.10 (0.98-1.24, I2 = 65.5%) for coronary heart disease (CHD), 1.20 (1.08-1.34, I2 = 0) for stroke, 1.07 (1.00-1.14, I2 = 61.9%) for all-cause mortality, 1.02 (0.92-1.14, I2 = 51.3%) for cardiovascular mortality, and 1.01 (0.89-1.13, I2 = 56.7%) for cancer mortality. For each 5 %E increase in dietary carbohydrate intake, the summary RR was 1.02 (1.00-1.04, I2 = 66.8%) for cardiovascular disease, 1.04 (1.01-1.06, I2 = 0) for stroke but not significant for other outcomes. Restricted cubic splines showed linear associations with risk of cardiovascular disease (Pnon-linearity = 0.143), CHD (Pnon-linearity = 0.508), stroke (Pnon-linearity = 0.654) and non-linear associations with all-cause mortality (Pnon-linearity = 0.008) and cardiovascular mortality (Pnon-linearity = 0.055). Limited studies were found on the association of cardiovascular disease and mortality with dietary carbohydrate quality using a multidimensional and integrated indicator.

CONCLUSIONS

Increased consumption of dietary carbohydrate intake is associated with increased risk of cardiovascular disease, stroke, and all-cause mortality. Linear relation was found for cardiovascular disease and stroke but non-linear relation for all-cause mortality. More studies are warranted to investigate the association of dietary carbohydrate quality using a combined indicator and cardiovascular disease and mortality.

Low-carbohydrate diet score and the risk of stroke in older people: Guangzhou Biobank Cohort Study and meta-analysis of cohort studies

OBJECTIVES

To our knowledge, evidence regarding the association of a low-carbohydrate diet (LCD) with the risk for stroke is limited. The aim of this study was to examine the association between an LCD and stroke in a population with relatively high-carbohydrate intake and risk for stroke and use a meta-analysis to update the evidence.

METHODS

The study included 19 850 participants aged ≥50 y without stroke history at baseline in the Guangzhou Biobank Cohort Study. LCD score was calculated based on the percentage of energy from carbohydrate, protein, and fat (range 0-30 points), with a higher score indicating a lower intake of carbohydrate and a higher intake of fat and protein.

RESULTS

During an average follow-up of 13.1 y, 1661 stroke events and deaths occurred, including 1255 ischemic strokes. The second, versus the lowest quartile of animal-based LCD scores, were associated with lower risks for all stoke and ischemic stroke (hazards ratio [HR], 0.87; 95% confidence interval [CI], 0.77-0.997, and HR, 0.83; 95% CI, 0.72-0.97). Non-significant associations of plant-based or total LCD scores with the risk for stoke were found.

CONCLUSIONS

In a population consuming high levels of carbohydrates and low levels of protein and fat, a moderate level of animal-based LCD, but not plant-based LCD, was associated with a lower risk for stroke.

Relative validity of a glycemic index extended food-frequency questionnaire

BACKGROUND AND AIMS

The dietary glycemic index (GI) and glycemic load (GL) are increasingly recognized as important for the prevention and management of diabetes mellitus. To extend the portfolio of assessment methods for large-scale epidemiological studies, we propose a GI-specific addition to an already established FFQ.

METHODS AND RESULTS

The German version of the EPIC-FFQ was extended by GI-specific questions for major carbohydrate sources varying notably in GI (breakfast cereals, bread, pasta, rice, potato etc.). We performed relative validation analyses comparing the GI-extended FFQ to three to four 3-day weighted dietary records (3-d WDR) in 100 middle-aged individuals with diabetes mellitus participating in the German Diabetes Study (GDS). Level of agreement between the two methods was assessed by correlation and cross-classification analyses as well as Bland-Altman-Plots, conducted separately for women and men. Spearman correlation analysis for female participants suggested good agreement between the GI-extended FFQ and 3-d WDRs for energy adjusted dietary GL (r = 0.52, p = 0.0004). For both women and men, agreement with the estimations of dietary GI, GL (for men) and carbohydrates from low and higher-GI food sources from the GI-extended FFQ was acceptable (r: 0.28-0.45). Classification of the dietary GI and GL in the opposite quartile was <10% comparing the GI-extended FFQ and 3-d WDR. Bland-Altman plots suggested a tendency for an overestimation of the dietary GI from the GI-extended FFQ in the lower GI-ranges, particularly for men.

CONCLUSION

Compared to the 3-d WDR, the GI-extended FFQ showed a moderate to good relative validity for parameters of carbohydrate quality.

Current WHO recommendation to reduce free sugar intake from all sources to below 10% of daily energy intake for supporting overall health is not well supported by available evidence

Sugar is widely consumed over the world. Although the mainstream view is that high added or free sugar consumption leads to obesity and related metabolic diseases, controversies exist. This narrative review aims to highlight important findings and identify major limitations and gaps in the current body of evidence in relation to the effect of high sugar intakes on health. Previous animal studies have shown that high sucrose or fructose consumption causes insulin resistance in the liver and skeletal muscle and consequent hyperglycemia, mainly because of fructose-induced de novo hepatic lipogenesis. However, evidence from human observational studies and clinical trials has been inconsistent, where most if not all studies linking high sugar intake to obesity focused on sugar-sweetened beverages (SSBs), and studies focusing on sugars from solid foods yielded null findings. In our opinion, the substantial limitations in the current body of evidence, such as short study durations, use of supraphysiological doses of sugar or fructose alone in animal studies, and a lack of direct comparisons of the effects of solid compared with liquid sugars on health outcomes, as well as the lack of appropriate controls, seriously curtail the translatability of the findings to real-world situations. It is quite possible that "high" sugar consumption at normal dietary doses (e.g., 25% daily energy intake) per se-that is, the unique effect of sugar, especially in the solid form-may indeed not pose a health risk for individuals apart from the potential to reduce the overall dietary nutrient density, although newer evidence suggests "low" sugar intake (<5% daily energy intake) is just as likely to be associated with nutrient dilution. We argue the current public health recommendations to encourage the reduction of both solid and liquid forms of free sugar intake (e.g., sugar reformulation programs) should be revised due to the overextrapolation of results from SSBs studies.

Tolerable upper intake level for dietary sugars

Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50-75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15-50% probability) and very low for hypertension (0-15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

Longitudinal association of dietary carbohydrate and the risk cardiovascular disease: a dose-response meta-analysis

Previous findings on the association of dietary carbohydrate with cardiovascular disease (CVD) events and mortality are inconsistent. We aimed to assess the relationship between dietary carbohydrate and the incidence of cardiovascular events and mortality. A comprehensive literature search of MEDLINE (PubMed), Scopus, ISI Web of Science, and EMBASE, was performed up to June 2019. Prospective cohort studies which examined dietary carbohydrate in relation to fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, heart failure, and sudden cardiac death were included in our study. Summary HRs and 95% CIs were estimated using a random-effects model. A total of 19 cohort studies including 15,663,111 participants were identified. Combining 27 effect sizes with 1,577,225 CVD cases led to a significant association between dietary carbohydrate and total CVD events (HR= 1.05, 95% CI: 1.00, 1.10; I² = 38.5%), but no association was observed between dietary carbohydrate and CVD mortality (HR = 1.02; 95% CI: 0.91, 1.14; I²=27.1%, derived from 8 effect sizes with 106,412 events), and CHD events (HR = 1.03, 95% CI: 0.98, 1.09; I² = 46.6%, derived from 18 effect sizes with 1,549,281 events). Moreover, using 8 effect sizes with 6,829 cases, higher carbohydrate intake was associated with increased risk of stroke (HR = 1.13; 95% CI: 1.01, 1.27; I²= 0.0%). In subgroup analysis by sex, higher carbohydrate intake increased the risk of total CVD events (HR: 1.10; 95% CI: 1.03, 1.17; I² = 0.0%), and CHD (HR: 1.10; 95% CI: 1.01, 1.20; I²= 15.0%), but not stroke and CVD mortality in women. No significant association was found in men. Low- to very-low-certainty evidence suggests that higher carbohydrate intake is directly but slightly associated with CVD and stroke risk, while no association was found for CHD and CVD mortality. We also found sex-specific associations.

Investigating the associations of glycemic load and glycemic index with lung cancer risk in the Southern Community Cohort Study

PURPOSE

Diets with a high glycemic load (GL) or glycemic index (GI) may increase cancer risk. Findings from prior studies on the relationship between GL, GI, and lung cancer risk are inconsistent. We investigated this relationship in a large prospective cohort.

METHODS

We analyzed data from the Southern Community Cohort Study, a prospective cohort that includes diverse racial groups predominantly low-income adults aged 40-79 in 12 southeastern states of the USA. We estimated dietary GL and GI values using data collected from food frequency questionnaires at baseline. Dietary GL and GI were energy adjusted by residual method and categorized into sex-specific quintiles. Cox proportional hazard regression was used to assess the associations between dietary GL, GI, and lung cancer risk. We further performed stratified analyses by various factors.

RESULTS

Intakes of individual food items or food groups that commonly contribute to GL were similar between blacks and whites in the cohort. After excluding the first two years of follow-up, 947 incident lung cancers were ascertained among 55,068 participants. Neither dietary GL nor GI was significantly associated with incident lung cancer risk in the overall population (GL: Q5 vs. Q1, HR = 0.88, 95% CI 0.72-1.07, p_trend = 0.29; GI: Q5 vs. Q1, HR = 1.06, 95% CI 0.86-1.30, p_trend = 0.71), nor in subgroups of populations (p_trend > 0.05), in multivariable-adjusted analyses.

CONCLUSION

Dietary GL and GI were not independently associated with incident lung cancer risk in a large understudied population.

The Impact of Dietary Glycemic Index and Glycemic Load on Postprandial Lipid Kinetics, Dyslipidemia and Cardiovascular Risk

Many recent studies have acknowledged postprandial hypetriglyceridemia as a distinct risk factor for cardiovascular disease. This dysmetabolic state is the result of the hepatic overproduction of very low-density lipoproteins (VLDLs) and intestinal secretion of chylomicrons (CMs), which leads to highly atherogenic particles and endothelial inflammation. Postprandial lipid metabolism does not only depend on consumed fat but also on the other classes of nutrients that a meal contains. Various mechanisms through which carbohydrates exacerbate lipidemia have been identified, especially for fructose, which stimulates de novo lipogenesis. Glycemic index and glycemic load, despite their intrinsic limitations, have been used as markers of the postprandial glucose and insulin response, and their association with metabolic health and cardiovascular events has been extensively studied with contradictory results. This review aims to discuss the importance and pathogenesis of postprandial hypertriglyceridemia and its association with cardiovascular disease. Then, we describe the mechanisms through which carbohydrates influence lipidemia and, through a brief presentation of the available clinical studies on glycemic index/glycemic load, we discuss the association of these indices with atherogenic dyslipidemia and address possible concerns and implications for everyday practice.

Carbohydrate quality, glycemic index, glycemic load and cardiometabolic risks in the US, Europe and Asia: A dose-response meta-analysis

BACKGROUND AND AIMS

Despite the proven evidence of high glycemic index (GI) and glycemic load (GL) diets to increase cardiometabolic risks, knowledge about the meta-evidence for carbohydrate quality within world geographic regions is limited. We conducted a meta-analysis to synthesize the evidence of GI/GL studies and carbohydrate quality, gathering additional exposures for carbohydrate, high glycemic carbohydrate, total dietary fiber, and cereal fiber and risks for type 2 diabetes (T2DM), coronary heart disease (CHD), stroke, and mortality, grouped into the US, Europe, and Asia. Secondary aims examined cardiometabolic risks in overweight/obese individuals, by sex, and dose-response dietary variable trends.

METHODS AND RESULTS

40-prospective observational studies from 4-Medline bibliographical databases (Ovid, PubMed, EBSCOhost, CINAHL) were search up to November 2019. Random-effects hazard ratios (HR) and 95% confidence intervals (CI) for highest vs. lowest categories and continuous form combined were reported. Heterogeneity (I²>50%) was frequent in US GI/GL studies due to differing study characteristics. Increased risks ((HR_GI,T2DM,US=1.14;CI:1.06,1.21), HR_GL,T2DM,US=1.02 (1.01, 1.03)), HR_GI,T2DM,Asia=1.25;1.02,1.53), and HR_GL,T2DM,Asia=1.37 (1.17, 1.60)) were associated with cardiometabolic diseases. GI/GL in overweight/obese females had the strongest magnitude of risks in US-and Asian studies. Total dietary fiber (HR_T2DM,US = 0.92;0.88,0.96) and cereal fiber (HR_T2DM,US = 0.83;0.77,0.90) decreased risk of developing T2DM. Among females, we found protective dose-response risks for total dietary fiber (HR_{5g-total-dietary-fiber,T2DM,US} = 0.94;0.92,0.97)_, but cereal fiber showed better ability to lower T2DM risk (HR_{5g-cereal-fiber},_T2DM,US = 0.67;0.60,0.74). Total dietary-and cereal fibers' dose-response effects were nullified by GL, but not so for cereal fiber with GI.

CONCLUSIONS

Overweight/obese females could shift their carbohydrate intake for higher cereal fiber to decrease T2DM risk, but higher GL may cancel-out this effect.

Relation of Total Sugars, Sucrose, Fructose, and Added Sugars With the Risk of Cardiovascular Disease: A Systematic Review and Dose-Response Meta-analysis of Prospective Cohort Studies

OBJECTIVE

To determine the association of total and added fructose-containing sugars on cardiovascular (CVD) incidence and mortality.

METHODS

MEDLINE, EMBASE and Cochrane Library were searched from January 1, 1980, to July 31, 2018. Prospective cohort studies assessing the association of reported intakes of total, sucrose, fructose and added sugars with CVD incidence and mortality in individuals free from disease at baseline were included. Risk estimates were pooled using the inverse variance method, and dose-response analysis was modeled.

RESULTS

Eligibility criteria were met by 24 prospective cohort comparisons (624,128 unique individuals; 11,856 CVD incidence cases and 12,224 CVD mortality cases). Total sugars, sucrose, and fructose were not associated with CVD incidence. Total sugars (risk ratio, 1.09 [95% confidence interval, 1.02 to 1.17]) and fructose (1.08 [1.01 to 1.15]) showed a harmful association for CVD mortality, there was no association for added sugars and a beneficial association for sucrose (0.94 [0.89 to 0.99]). Dose-response analyses showed a beneficial linear dose-response gradient for sucrose and nonlinear dose-response thresholds for harm for total sugars (133 grams, 26% energy), fructose (58 grams, 11% energy) and added sugars (65 grams, 13% energy) in relation to CVD mortality (P<.05). The certainty of the evidence using GRADE was very low for CVD incidence and low for CVD mortality for all sugar types.

CONCLUSION

Current evidence supports a threshold of harm for intakes of total sugars, added sugars, and fructose at higher exposures and lack of harm for sucrose independent of food form for CVD mortality. Further research of different food sources of sugars is needed to define better the relationship between sugars and CVD. REGISTRATION: clinicaltrials.gov, NCT01608620.

Nutritional Challenges in Metabolic Syndrome

Metabolic Syndrome (MetS) is a combination of risk factors for the development of cardiovascular disease (CVD) and type 2 diabetes. Different diagnostic criteria were proposed, but a consensus was reached in 2009 based on values of waist circumference, blood pressure, fasting glycemia, triglycerides, and high-density lipoprotein (HDL)-cholesterol levels. The main underlying etiologic factor is insulin resistance. The quality and quantity of individual macronutrients have an influence on the development and resolution of this syndrome. However, the main treatment goal is weight loss and a decrease in insulin resistance. A controlled energy dietary recommendation, together with moderate levels of physical activity, may positively change the parameters of MetS. However, there is no single dietary or exercise prescription that works for all patients. Dietary patterns such as Mediterranean-style, dietary approaches to stop hypertension (DASH), low-carbohydrate, and low-fat diets can ameliorate insulin resistance and MetS. Long-term adherence to a healthy lifestyle is key in assuring that individuals significantly reduce the risk of CVD and diabetes mellitus.

Modulation of the Gut Microbiota by Resistant Starch as a Treatment of Chronic Kidney Diseases: Evidence of Efficacy and Mechanistic Insights

Chronic kidney disease (CKD) has been associated with changes in gut microbial ecology, or "dysbiosis," which may contribute to disease progression. Recent studies have focused on dietary approaches to favorably alter the composition of the gut microbial communities as a treatment method in CKD. Resistant starch (RS), a prebiotic that promotes proliferation of gut bacteria such as Bifidobacteria and Lactobacilli, increases the production of metabolites including short-chain fatty acids, which confer a number of health-promoting benefits. However, there is a lack of mechanistic insight into how these metabolites can positively influence renal health. Emerging evidence shows that microbiota-derived metabolites can regulate the incretin axis and mitigate inflammation via expansion of regulatory T cells. Studies from animal models and patients with CKD show that RS supplementation attenuates the concentrations of uremic retention solutes, including indoxyl sulfate and p-cresyl sulfate. Here, we present the current state of knowledge linking the microbiome to CKD, we explore the efficacy of RS in animal models of CKD and in humans with the condition, and we discuss how RS supplementation could be a promising dietary approach for slowing CKD progression.

Coronary Heart Disease and Dietary Carbohydrate, Glycemic Index, and Glycemic Load: Dose-Response Meta-analyses of Prospective Cohort Studies

Objective

To clarify the role of dietary carbohydrate, glycemic index (GI), and glycemic load (GL) in progression from health to coronary heart disease (CHD) by determining disease-nutrient risk relation (RR) values needed for intake ranges within jurisdictions and across the globe.

Methods

We performed a literature search of MEDLINE and EMBASE for prospective cohort studies that used truly valid dietary instruments in heathy adults published from January 1, 2000, to June 5, 2018. Relevant observations were extracted by 2 reviewers independently. We used dose-response meta-analysis accounting for nonindependence of results within studies. Bradford-Hill criteria were used to assess causality.

Results

Eligible studies had a mean follow-up of 11 years (range, 5-19 years), were conducted in North America, Europe, and East Asia, and yielded combined RRs of 1.44 (95% CI, 1.25-1.65) per 65 g/d GL (11 studies) and 1.24 (95% CI, 1.12-1.38) per 10 U GI (10 studies) (glucose scale). The CHD-carbohydrate RR on GI was 1.66 (95% CI, 1.23-2.25) per 98 g/d of carbohydrates per 10 units GI. The 65 g/d GL, 10 U GI, and 98 g/d carbohydrate values corresponded to oral intakes from the 10th to the 90th percentiles within sampled populations. Inconsistencies were minor (I²≤20%), as were small-study effects (P=.61 for GL and P=.26 for GI). Funnel plots were symmetric. Cubic spline dose-response meta-analysis yielded RRs as follows: across the global range for GL (55-290 g/d), 5.5 (95% CI, 3.1-9.8) (I²=0); for GI (47-82 U), 2.71 (95% CI, 1.47-4.40) (I²=0); and for the CHD-carbohydrate dependence on GI (50-80 U), 4.57 (95% CI, 1.86-11.4) (I²=16%). Bradford-Hill criteria indicated that these relations were probably causal.

Conclusion

Strong and probably causal CHD-GL and GI RRs exist within populations. The RRs were remarkably higher across global exposures. The results support the consideration of these markers of carbohydrate food quality in dietary guidelines for general populations.

Trial Registration

PROSPERO Identifier: CRD42013004504

Associations of Biomarker-Calibrated Intake of Total Sugars With the Risk of Type 2 Diabetes and Cardiovascular Disease in the Women's Health Initiative Observational Study

The inconsistent findings from epidemiologic studies relating total sugars (TS) consumption to cardiovascular disease (CVD) or type 2 diabetes (T2D) risk may be partly due to measurement error in self-reported intake. Using regression calibration equations developed based on the predictive biomarker for TS and recovery biomarker for energy, we examined the association of TS with T2D and CVD risk, before and after dietary calibration, in 82,254 postmenopausal women participating in the Women's Health Initiative Observational Study. After up to 16 years of follow-up (1993-2010), 6,621 T2D and 5,802 CVD incident cases were identified. The hazard ratio for T2D per 20% increase in calibrated TS was 0.94 (95% confidence interval (CI): 0.77, 1.15) in multivariable energy substitution, and 1.00 (95% CI: 0.85, 1.18) in energy partition models. Multivariable hazard ratios for total CVD were 0.97 (95% CI: 0.87, 1.09) from energy substitution, and 0.91 (95% CI: 0.80, 1.04) from energy partition models. Uncalibrated TS generated a statistically significant inverse association with T2D and total CVD risk in multivariable energy substitution and energy partition models. The lack of conclusive findings from our calibrated analyses may be due to the low explanatory power of the calibration equations for TS, which could have led to incomplete deattenuation of the risk estimates.

Relevance of the Glycemic Index and Glycemic Load for Body Weight, Diabetes, and Cardiovascular Disease

Despite initial enthusiasm, the relationship between glycemic index (GI) and glycemic response (GR) and disease prevention remains unclear. This review examines evidence from randomized, controlled trials and observational studies in humans for short-term (e.g., satiety) and long-term (e.g., weight, cardiovascular disease, and type 2 diabetes) health effects associated with different types of GI diets. A systematic PubMed search was conducted of studies published between 2006 and 2018 with key words glycemic index, glycemic load, diabetes, cardiovascular disease, body weight, satiety, and obesity. Criteria for inclusion for observational studies and randomized intervention studies were set. The search yielded 445 articles, of which 73 met inclusion criteria. Results suggest an equivocal relationship between GI/GR and disease outcome. The strongest intervention studies typically find little relationship among GI/GR and physiological measures of disease risk. Even for observational studies, the relationship between GI/GR and disease outcomes is limited. Thus, it is unlikely that the GI of a food or diet is linked to disease risk or health outcomes. Other measures of dietary quality, such as fiber or whole grains may be more likely to predict health outcomes. Interest in food patterns as predictors of health benefits may be more fruitful for research to inform dietary guidance.

High Dietary Glycemic Load is Associated with Poor Functional Outcome in Patients with Acute Cerebral Infarction

Background and Purpose

Elevated postprandial blood glucose is a critical risk factor for stroke. The dietary glycemic load (GL) and glycemic index (GI) are frequently used as markers of the postprandial blood glucose response to estimate the overall glycemic effect of diets. We hypothesized that high dietary GL, GI, or total carbohydrate intake is associated with a poor functional outcome in patients with acute ischemic stroke.

Methods

We prospectively included 263 first-ever ischemic stroke patients who completed a semiquantitative food-frequency questionnaire. The dietary GL, GI, and total carbohydrate intake were investigated by examining the average frequency of intake during the previous year based on reference amounts for various food items. Poor functional outcome was defined as a score on the modified Rankin Scale (mRS) of ≥3 at 3 months after stroke.

Results

The patients were aged 65.4±11.7 years (mean±standard deviation), and 58.2% of them were male. A multivariate analysis adjusted for age, sex, marital status, prestroke mRS score, diabetes mellitus, hyperlipidemia, body mass index, triglycerides, low-density lipoprotein, hemoglobin A1c, stroke classification, and National Institutes of Health Stroke Scale score, early neurological deterioration, and high-grade white-matter hyperintensities revealed that the dietary GL and total carbohydrate intake were associated with a poor functional outcome, with odds ratios for the top quartile relative to the bottom quartile of 28.93 (95% confidence interval=2.82–296.04) and 36.84 (95% confidence interval=2.99–453.42), respectively (p for trend=0.002 and 0.002, respectively). In contrast, high dietary GI was not associated with a poor functional outcome (p for trend=0.481).

Conclusions

Increased dietary GL and carbohydrate intake were associated with a poor short-term functional outcome after an acute ischemic stroke.

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study

BACKGROUND

The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear.

METHODS

The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering.

FINDINGS

During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], p_trend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], p_trend<0·0001; saturated fat, HR 0·86 [0·76-0·99], p_trend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], p_trend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], p_trend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], p_trend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality.

INTERPRETATION

High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.

FUNDING

Full funding sources listed at the end of the paper (see Acknowledgments).

What is the appropriate upper limit for added sugars consumption?

Dramatic increases in obesity and diabetes have occurred worldwide over the past 30 years. Some investigators have suggested that these increases may be due, in part, to increased added sugars consumption. Several scientific organizations, including the World Health Organization, the Scientific Advisory Council on Nutrition, the Dietary Guidelines Advisory Committee 2015, and the American Heart Association, have recommended significant restrictions on upper limits of sugars consumption. In this review, the scientific evidence related to sugars consumption and its putative link to various chronic conditions such as obesity, diabetes, heart disease, nonalcoholic fatty liver disease, and the metabolic syndrome is examined. While it appears prudent to avoid excessive calories from sugars, the scientific basis for restrictive guidelines is far from settled.

Dietary glycemic index, glycemic load, and refined carbohydrates are associated with risk of stroke: a prospective cohort study in urban Chinese women

BACKGROUND

Epidemiologic evidence on dietary carbohydrates and stroke risk remains controversial. Very few prospective cohort studies have been conducted in Asian populations, who usually consume a high-carbohydrate diet and have a high burden of stroke.

OBJECTIVE

We examined dietary glycemic index (GI), glycemic load (GL), and intakes of refined and total carbohydrates in relation to risks of total, ischemic, and hemorrhagic stroke and stroke mortality.

DESIGN

This study included 64,328 Chinese women, aged 40-70 y, with no history of cardiovascular disease, diabetes, or cancer. A validated, interviewer-administered food-frequency questionnaire was used to assess usual dietary intakes at baseline and during follow-up. Incident stroke cases and deaths were identified via follow-up interviews and death registries and were confirmed by review of medical records and death certificates.

RESULTS

During mean follow-ups of 10 y for stroke incidence and 12 y for stroke mortality, we ascertained 2991 stroke cases (2750 ischemic and 241 hemorrhagic) and 609 stroke deaths. After potential confounders were controlled for, we observed significant positive associations of dietary GI and GL with total stroke risk; multivariable-adjusted HRs (95% CIs) for high compared with low levels (90th compared with 10th percentile) were 1.19 (1.04, 1.36) for GI and 1.27 (1.04, 1.54) for GL (both P-linearity < 0.05 and P-overall significance < 0.05). Similar linear associations were found for ischemic stroke, but the associations with hemorrhagic stroke appeared to be J-shaped. Similar trends of positive associations with stroke risks were suggested for refined carbohydrates but not for total carbohydrates. No significant associations were found for stroke mortality after multivariable adjustment.

CONCLUSION

Our results suggest that high dietary GI and GL, primarily due to high intakes of refined grains, are associated with increased risks of total, ischemic, and hemorrhagic stroke in middle-aged and older urban Chinese women.

Short-term benefits of an unrestricted-calorie traditional Mediterranean diet, modified with a reduced consumption of carbohydrates at evening, in overweight-obese patients

The Mediterranean diet (MeD) is believed to promote health; nevertheless, changes in the nutritional patterns in the Mediterranean area (increased intake of refined carbohydrates/saturated fats; reduced fibers intake; main calorie load shifted to dinner) led to reduced MeD benefits in recent decades. We retrospectively investigated the effects of a MeD with a low intake of refined carbohydrates in the evening ("MeDLowC") on body weight (BW) and metabolic profile of overweight/obese subjects. According to their adherence to MeDLowC, subjects were classified into 44 (41%) individuals with "excellent" adherence and 63 (59%) with "poor" adherence. Nutritional counseling induced an improvement in BW, glucose metabolism and liver transaminases in both groups, with an increased magnitude of these effects in the "Excellent" adherence group. "Excellent" adherence to MeDLowC improved insulin sensitivity and lipid metabolism. In conclusion, MeD with a restriction of carbohydrates in the evening significantly ameliorates obesity and associated metabolic complications.

The association of ideal cardiovascular health with incident type 2 diabetes mellitus: the Multi-Ethnic Study of Atherosclerosis

AIMS/HYPOTHESIS

Levels of ideal cardiovascular health (ICH) and incident type 2 diabetes mellitus have not been examined in a multiethnic population. We assessed the total and race/ethnicity-specific incidence of diabetes based on American Heart Association (AHA) ICH components.

METHODS

Incident diabetes was assessed among 5341 participants in the Multi-Ethnic Study of Atherosclerosis without prevalent diabetes between 2002 and 2012. ICH components (total cholesterol, BP, dietary intake, tobacco use, physical activity and BMI) were assessed at baseline and participants were categorised as having ideal, intermediate or poor cardiovascular health, as defined by the AHA 2020 impact goals. We developed a scoring system based on the number of ICH components (0-1 'poor', 2-3 'intermediate', and ≥4 'ideal'). HRs were calculated using Cox models.

RESULTS

During a median follow-up of 11.1 years, we identified 587 cases of incident diabetes. After multivariable adjustment, participants with 2-3 and ≥4 ICH components vs 0-1 components had a 34% lower (HR 0.66; 95% CI 0.54, 0.80) and a 75% lower (HR 0.25; 95% CI 0.18, 0.35) diabetes incidence, respectively. There were significant differences by race/ethnicity: African-American and Hispanic-American participants with ≥4 ICH components had diabetes incidence rates per 1000 person-years of 5.6 (95% CI 3.1, 10.1) and 10.5 (95% CI 6.7, 16.4), respectively, compared with 2.2 (95% CI 1.3, 3.7) among non-Hispanic white Americans.

CONCLUSIONS/INTERPRETATION

Meeting an increasing number of AHA 2020 impact goals for dietary intake, physical activity, smoking, BP, cholesterol and BMI was associated with a dose-dependent lower risk of diabetes with significant variation by race/ethnicity.

Relation of Dietary Glycemic Index and Glycemic Load to Coronary Artery Calcium in Asymptomatic Korean Adults

The relation between glycemic index, glycemic load, and subclinical coronary atherosclerosis is unknown. The aim of the study was to evaluate the associations between energy-adjusted glycemic index, glycemic load, and coronary artery calcium (CAC). This study was cross-sectional analysis of 28,429 asymptomatic Korean men and women (mean age 41.4 years) without a history of diabetes or cardiovascular disease. All participants underwent a health screening examination between March 2011 and April 2013, and dietary intake over the preceding year was estimated using a validated food frequency questionnaire. Cardiac computed tomography was used for CAC scoring. The prevalence of detectable CAC (CAC score >0) was 12.4%. In multivariable-adjusted models, the CAC score ratios (95% confidence intervals) comparing the highest to the lowest quintile of glycemic index and glycemic load were 1.74 (1.08 to 2.81; p trend = 0.03) and 3.04 (1.43 to 6.46; p trend = 0.005), respectively. These associations did not differ by clinical subgroups, including the participants at low cardiovascular risk. In conclusion, these findings suggest that high dietary glycemic index and glycemic load were associated with a greater prevalence and degree of CAC, with glycemic load having a stronger association.

How do high glycemic load diets influence coronary heart disease?

Background

Diet has a significant relationship with the risk of coronary heart disease (CHD). Traditionally the effect of diet on CHD was measured with the biomarker for low-density lipoprotein (LDL) cholesterol. However, LDL is not the only or even the most important biomarker for CHD risk. A suitably integrated view of the mechanism by which diet influences the detailed CHD pathogenetic pathways is therefore needed in order to better understand CHD risk factors and help with better holistic CHD prevention and treatment decisions.

Methods

A systematic review of the existing literature was conducted. From this an integrated CHD pathogenetic pathway system was constructed. CHD biomarkers, which are found on these pathways, are the only measurable data to link diet with these CHD pathways. They were thus used to simplify the link between diet and the CHD mechanism. Data were systematically analysed from 294 cohort studies of CHD biomarkers constituting 1 187 350 patients.

Results and discussion

The resulting integrated analysis provides insight into the higher-order interactions underlying CHD and high-glycemic load (HGL) diets. A novel “connection graph” illustrates the measurable relationship between HGL diets and the relative risks attributed to the important CHD serological biomarkers.

The “connection graph” vividly shows that HGL diets not only influence the lipid and metabolic biomarkers, but also the inflammation, coagulation and vascular function biomarkers in an important way.

Conclusion

A focus primarily on the low density lipoprotein cholesterol biomarker for CHD risk has led to the traditional guidelines of CHD dietary recommendations. This has however inadvertently led to HGL diets. The influence of HGL diets on the other CHD biomarkers is not always fully appreciated. Thus, new diets or other interventions which address the full integrated CHD impact, as shown in this paper, are required.

Glycemic load and coronary heart disease in a Mediterranean population: the EPIC Greek cohort study

BACKGROUND AND AIMS

High glycemic load (GL) has been associated with increased coronary heart disease (CHD) risk. We evaluated whether preference of low-GL foods conveys incremental benefits with respect to CHD, especially to people adhering to the traditional Mediterranean diet (MD).

METHODS AND RESULTS

We analyzed data from the Greek European Prospective Investigation into Cancer and Nutrition, including 20,275 participants free of cardiovascular diseases, cancer, or diabetes at baseline and without incident diabetes. Subjects completed a validated, semi-quantitative food frequency questionnaire at enrollment. We calculated a 10-point MD adherence score and the dietary GL, and estimated hazard ratios (HRs) for CHD incidence and mortality through Cox proportional hazard regression. After a median follow-up of 10.4 years, 417 participants developed CHD, and 162 died from the disease. A significant positive association of GL with CHD incidence emerged (HR for the highest versus the lowest tertile = 1.41, 95% confidence interval, CI: 1.05-1.90). HRs for CHD mortality exceeded unity but were not statistically significant. The association with GL was stronger among subjects with higher body mass index. High adherence to MD with low/moderate GL was associated with lower risk of CHD incidence (HR = 0.61, CI: 0.39-0.95) and mortality (HR = 0.47, 95% CI: 0.23-96).

CONCLUSION

High dietary GL increases the risk of CHD. Compared to a high GL diet with suboptimal adherence to the traditional Mediterranean pattern, a low/moderate GL diet that also conforms to the traditional MD principles could lead to a 40% reduced risk for CHD, and over 50% reduced risk for death from CHD.

Carbohydrate Intake, Glycemic Index, Glycemic Load, and Stroke

The objective of this study was to investigate associations between carbohydrate intake/glycemic index (GI)/glycemic load (GL) and stroke risk. A literature search of MEDLINE, Embase, Web of Science, and CBM databases was performed to retrieve eligible studies published up to March 2014. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were used to evaluate the strength of this association. Publication bias was assessed by the Egger’s regression asymmetry test and Begg’s rank correlation test with Begg’s funnel plot. All analyses were conducted using software STATA 12.0 (StataCorp LP, College Station, TX) and SAS version 9.1 (SAS Institute Inc, Cary, NC). We identified 7 prospective studies that met the inclusion criteria and processed data from cohort studies to update available evidence. There were 25 independent estimates and 225 000 participants free of diabetes from 6 different countries; 3046 stroke events were included; and the follow-up range was 5 to 18 years. High GI was not associated with risk of stroke events (pooled RR = 1.10; 95% CI: 0.99-1.21); GL was a risk factor for stroke (pooled RR = 1.19; 95% CI: 1.05-1.36). There was no significant association between high carbohydrate intake and stroke risk (RR = 1.12; 95% CI: 0.93-1.35). A daily high GL diet is the risk factor of stroke event, and further researches need to verify the meta-analyses results and study associated mechanisms.

A high dietary glycemic index increases total mortality in a Mediterranean population at high cardiovascular risk

OBJECTIVE

Different types of carbohydrates have diverse glycemic response, thus glycemic index (GI) and glycemic load (GL) are used to assess this variation. The impact of dietary GI and GL in all-cause mortality is unknown. The objective of this study was to estimate the association between dietary GI and GL and risk of all-cause mortality in the PREDIMED study.

MATERIAL AND METHODS

The PREDIMED study is a randomized nutritional intervention trial for primary cardiovascular prevention based on community-dwelling men and women at high risk of cardiovascular disease. Dietary information was collected at baseline and yearly using a validated 137-item food frequency questionnaire (FFQ). We assigned GI values of each item by a 5-step methodology, using the International Tables of GI and GL Values. Deaths were ascertained through contact with families and general practitioners, review of medical records and consultation of the National Death Index. Cox regression models were used to estimate multivariable-adjusted hazard ratios (HR) and their 95% CI for mortality, according to quartiles of energy-adjusted dietary GI/GL. To assess repeated measures of exposure, we updated GI and GL intakes from the yearly FFQs and used Cox models with time-dependent exposures.

RESULTS

We followed 3,583 non-diabetic subjects (4.7 years of follow-up, 123 deaths). As compared to participants in the lowest quartile of baseline dietary GI, those in the highest quartile showed an increased risk of all-cause mortality [HR = 2.15 (95% CI: 1.15-4.04); P for trend  = 0.012]. In the repeated-measures analyses using as exposure the yearly updated information on GI, we observed a similar association. Dietary GL was associated with all-cause mortality only when subjects were younger than 75 years.

CONCLUSIONS

High dietary GI was positively associated with all-cause mortality in elderly population at high cardiovascular risk.

The role of glycemic index and glycemic load in cardiovascular disease and its risk factors: a review of the recent literature

A number of meta-analyses of cohort studies have assessed the impact of glycemic load (GL) and glycemic index (GI) on cardiovascular outcomes. The picture that emerges is that for women, a significant association appears to exist between the consumption of high GL/GI diets and increased cardiovascular disease (CVD) risk. This association appears to be stronger in those with greater adiposity and possibly in those with diabetes, although these findings are not uniform. There is also an indication that raised CRP levels may be reduced, which has special implications for women whose CRP levels, as an emerging CVD risk factor, may be higher than men. For men, the situation is not as clear-cut. Although some studies show association, the meta-analyses have not demonstrated a significant direct association with CVD, despite current evidence that risk factors, including LDL-C, may be reduced on low-GI diets. Moreover, in a recent meta-analysis, increases in dietary GL have been associated with increased risk of diabetes, another CVD risk factor, in both men and women. Studies in men expressing relative risk of CVD in relation to GL and GI, with corresponding confidence intervals, are needed to provide the necessary power for future meta-analyses on this topic.

Dietary glycaemic load associated with cognitive performance in elderly subjects

PURPOSE

Ageing is associated with loss of cognitive function and an increased risk of dementia which is expected to place growing demands on health and long-term care providers. Among multiple causative factors, evidence suggests that cognitive impairment in older subjects may be influenced by diet. The objective of this study was to examine the association between dietary patterns, dietary glycaemic load (GL) and cognition in older Irish adults.

METHODS

Community-dwelling subjects (n 208; 94 males and 114 females; aged 64-93 years) were analysed. Dietary intake was assessed using a validated semi-quantitative food frequency questionnaire. Cognitive capacity was tested using the Mini-Mental State Examination (MMSE). The data were clustered to derive patterns of dietary intake. Multivariable-adjusted logistic and Poisson regression models were used to examine the relationship between dietary GL and MMSE score.

RESULTS

Elderly subjects consuming 'prudent' dietary patterns (high in fruit, vegetables, fish, low-fat dairy and salad dressings and low in red meat and white bread) had higher MMSE scores (better cognitive function) than those consuming 'Western' dietary pattern (high in red meat and white bread and low in fruit and vegetables; P < 0.05). Logistic and Poisson regression analyses both indicated that the MMSE score was inversely associated with the GL of the diet (P < 0.05) even after adjusting for age, gender, diabetes, hypertension, healthy food diversity, nutritional status, residential property price, cardiovascular medications and energy intake.

CONCLUSION

In this community-dwelling elderly Irish cohort, consumption of a high glycaemic diet is associated with poorer cognitive performance as assessed by the MMSE.

Carbohydrate nutrition and development of adiposity during adolescence

OBJECTIVE

To examine the prospective association between glycemic index, glycemic load (GL) of diets and intakes of carbohydrates, sugars, fiber, and the main carbohydrate containing food groups (e.g., soft drinks) with changes in percent body fat, body mass index (BMI), and waist circumference among adolescents.

DESIGN AND METHODS

Students aged 12 at baseline (n = 856) were examined both in 2004-2005 and 2009-2011. A semiquantitative food frequency questionnaire was administered. Anthropometric parameters were measured and defined using standardized protocols.

RESULTS

After multivariable adjustment, in girls, each 1-SD increase in dietary GL was associated with concurrent 0.77 kg/m2 and 1.45 cm increase in BMI and waist circumference, respectively (both P = 0.01). Conversely, each 1-SD increase in dietary fiber intake was associated with a concurrent 0.44 kg/m2 decrease in mean BMI in girls (P = 0.02) and 1.45 cm decrease in waist circumference in boys (P = 0.002). Girls who consumed soft drinks once or more per day versus those who never/rarely consumed soft drinks, had a 4.45% increase in percent body fat after 5 years (Ptrend = 0.01).

CONCLUSIONS

High-GL foods might adversely influence development of body composition, particularly in girls, whereas fiber-rich diets could limit excess weight during adolescence.

Dietary glycemic load and glycemic index and risk of cerebrovascular disease in the EPICOR cohort

BACKGROUND

Studies on the association of stroke risk to dietary glycemic index (GI) and glycemic load (GL) have produced contrasting results.

OBJECTIVE

To investigate the relation of dietary GI and GL to stroke risk in the large EPIC-Italy cohort (EPICOR) recruited from widely dispersed geographic areas of Italy.

DESIGN

We studied 44099 participants (13,646 men and 30,453 women) who completed a dietary questionnaire. Multivariable Cox modeling estimated adjusted hazard ratios (HRs) of stroke with 95% confidence intervals (95%CI). Over 11 years of follow-up, 355 stroke cases (195 ischemic and 83 hemorrhagic) were identified.

RESULTS

Increasing carbohydrate intake was associated with increasing stroke risk (HR = 2.01, 95%CI = 1.04-3.86 highest vs. lowest quintile; p for trend 0.025). Increasing carbohydrate intake from high-GI foods was also significantly associated with increasing stroke risk (HR 1.87, 95%CI = 1.16-3.02 highest vs. lowest, p trend 0.008), while increasing carbohydrate intake from low-GI foods was not. Increasing GL was associated with significantly increasing stroke risk (HR 2.21, 95%CI = 1.16-4.20, highest vs. lowest; p trend 0.015). Dietary carbohydrate from high GI foods was associated with increased both ischemic stroke risk (highest vs. lowest HR 1.92, 95%CI = 1.01-3.66) and hemorrhagic stroke risk (highest vs. lowest HR 3.14, 95%CI = 1.09-9.04). GL was associated with increased both ischemic and hemorrhagic stroke risk (HR 1.44, 95%CI = 1.09-1.92 and HR 1.56, 95%CI = 1.01-2.41 respectively, continuous variable).

CONCLUSIONS

In this Italian cohort, high dietary GL and carbohydrate from high GI foods consumption increase overall risk of stroke.

Short-term impact of sugar consumption on hunger and ad libitum food intake in young women

The hypothesis of this study was that greater sugar consumption at breakfast promotes a stronger sensation of hunger and a later increase in energy consumption. The objective was to assess the relation between sugar consumption in a meal and the subsequent sensations of hunger and ad libitum food consumption. Sixteen women consumed a breakfast accompanied by 2 drinks sweetened ad libitum with sugar. After 3 h, a lunch was offered to evaluate ad libitum food consumption. During the period from breakfast to lunch, hunger sensations were evaluated at 30 min intervals. Women were divided according to the median amount of sugar used to sweeten the breakfast drinks (20 g). The group who consumed sugar above the median showed a greater hunger sensation in the preprandial period, and a greater ad libitum intake at lunch (390 ± 130 g × 256 ± 67 g, P = 0.002), compared to the group who had a lower sugar consumption. The amount of sugar consumed at breakfast was correlated positively with the sensation of preprandial hunger and food intake at lunch. We concluded that foods with a high glycemic index can modulate the appetite within a short period of time.

Glycaemic index, carbohydrate substitution for fat and risk of CHD in men

We have examined the associations between dietary glycaemic index (GI), substitutions of total, low-, medium- and high-GI carbohydrates for fat and the risk of CHD. The study consisted of 21 955 male smokers, aged 50-69 years, within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. The diet was assessed at baseline using a validated FFQ. During a 19-year follow-up, 4379 CHD cases (2377 non-fatal myocardial infarctions and 2002 CHD deaths) were identified from national registers. Relative risks (RR) and CI for CHD were analysed using Cox proportional hazards modelling, and multivariate nutrient density models were applied to examine the associations between the substitutions of macronutrients and the risk of CHD. Dietary GI was inversely associated with CHD risk: multivariate RR in the highest v. lowest quintile was 0·89 (95 % CI 0·81, 0·99). Replacement of higher-GI carbohydrates with lower-GI carbohydrates did not associate with the risk. Replacing saturated and trans-fatty acids with carbohydrates was associated with decreased CHD risk: RR for substitution of 2 % of energy intake was 0·97 (95 % CI 0·94, 0·99). On the contrary, replacing MUFA with carbohydrates was associated with an increased risk: RR for substitution of 2 % of energy intake was 1·08 (95 % CI 1·01, 1·16). We conclude that in the present study population, contrary to the hypothesis, a lower GI does not associate with a decreased risk of CHD. The associations of carbohydrates with CHD risk depend on the fatty acid composition of the diet.

Effect of added carbohydrates on glycemic and insulin responses to children&#8217;s milk products

Powdered milk products for children (Growing Up Milk Powders or GUMPs) containing added carbohydrates such as glucose and sucrose are now well established in parts of Asia. We surveyed GUMPs in Malaysia and Indonesia to determine the content of added carbohydrates. The ingredient lists and nutrition information panels were used to calculate the percentage of declared carbohydrates contributed by added carbohydrates and a subset of seven products was tested for their glycemic index (GI) and insulin responses in healthy adults. The glycemic load for each product was calculated. In total, 58 products (n = 24 in Malaysia and n = 34 in Indonesia) were surveyed. Added carbohydrate content (excluding fibre) ranged from 0 to 21.5 g per serve. Milk powders without added sources of carbohydrate had similar GI values to standard liquid whole milk. Products containing maltodextrins, corn or glucose syrups increased the GI by more than 2-fold, and glycemic load (GL) by 7-fold compared to milk powders with no added carbohydrates. Insulin responses were significantly but not strongly correlated with glucose responses (r = 0.32, p < 0.006). Children’s milk powders containing higher levels of added carbohydrate ingredients elicit higher glucose and insulin responses than liquid or powdered whole milk.

Dietary glycemic index, glycemic load, and risk of coronary heart disease, stroke, and stroke mortality: a systematic review with meta-analysis

BACKGROUND

The relationship between dietary glycemic index, glycemic load and risk of coronary heart disease (CHD), stroke, and stroke-related mortality is inconsistent.

METHODS

We systematically searched the MEDLINE, EMBASE, and Science Citation Index Expanded databases using glycemic index, glycemic load, and cardiovascular disease and reference lists of retrieved articles up to April 30, 2012. We included prospective studies with glycemic index and glycemic load as the exposure and incidence of fatal and nonfatal CHD, stroke, and stroke-related mortality as the outcome variable. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated using random-effects models.

RESULTS

Fifteen prospective studies with a total of 438,073 participants and 9,424 CHD cases, 2,123 stroke cases, and 342 deaths from stroke were included in the meta-analysis. Gender significantly modified the effects of glycemic index and glycemic load on CHD risk, and high glycemic load level was associated with higher risk of CHD in women (RR=1.49, 95%CI 1.27-1.73), but not in men (RR=1.08, 95%CI 0.91-1.27). Stratified meta-analysis by body mass index indicated that among overweight and obese subjects, dietary glycemic load level were associated with increased risk of CHD (RR=1.49, 95%CI 1.27-1.76; P for interaction=0.003). Higher dietary glycemic load, but not glycemic index, was positively associated with stroke (RR=1.19, 95% CI 1.00-1.43). There is a linear dose-response relationship between dietary glycemic load and increased risk of CHD, with pooled RR of 1.05 (95%CI 1.02-1.08) per 50-unit increment in glycemic load level.

CONCLUSION

High dietary glycemic load is associated with a higher risk of CHD and stroke, and there is a linear dose-response relationship between glycemic load and CHD risk. Dietary glycemic index is slightly associated with risk of CHD, but not with stroke and stroke-related death. Further studies are needed to verify the effects of gender and body weight on cardiovascular diseases.

Associations of glycemic index and load with coronary heart disease events: a systematic review and meta-analysis of prospective cohorts

Background

Glycemic index (GI) and glycemic load (GL) have been associated with coronary heart disease (CHD) risk in some but not all cohort studies. We therefore assessed the association of GI and GL with CHD risk in prospective cohorts.

Methods and Results

We searched MEDLINE, EMBASE, and CINAHL (through April 5, 2012) and identified all prospective cohorts assessing associations of GI and GL with incidence of CHD. Meta-analysis of observational studies in epidemiology (MOOSE) methodologies were used. Relative measures of risk, comparing the group with the highest exposure (mean GI of cohorts=84.4 GI units, range 79.9 to 91; mean GL of cohorts=224.8, range 166 to 270) to the reference group (mean GI=72.3 GI units, range 68.1 to 77; mean GL=135.4, range 83 to 176), were pooled using random-effects models, expressed as relative risk (RR) with heterogeneity assessed by χ² and quantified by I². Subgroups included sex and duration of follow-up. Ten studies (n=240 936) were eligible. Pooled analyses showed an increase in CHD risk for the highest GI quantile compared with the lowest, with RR=1.11 (95% confidence interval [CI] 0.99 to 1.24) and for GL, RR=1.27 (95% CI 1.09 to 1.49), both with evidence of heterogeneity (I²>42%, P<0.07). Subgroup analyses revealed only a significant modification by sex, with the female cohorts showing significance for GI RR=1.26 (95% CI 1.12 to 1.41) and for GL RR=1.55 (95% CI 1.18 to 2.03).

Conclusions

High GI and GL diets were significantly associated with CHD events in women but not in men. Further studies are required to determine the relationship between GI and GL with CHD in men.

Dietary fiber, carbohydrate quality and quantity, and mortality risk of individuals with diabetes mellitus

BACKGROUND

Dietary fiber, carbohydrate quality and quantity are associated with mortality risk in the general population. Whether this is also the case among diabetes patients is unknown.

OBJECTIVE

To assess the associations of dietary fiber, glycemic load, glycemic index, carbohydrate, sugar, and starch intake with mortality risk in individuals with diabetes.

METHODS

This study was a prospective cohort study among 6,192 individuals with confirmed diabetes mellitus (mean age of 57.4 years, and median diabetes duration of 4.4 years at baseline) from the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at baseline (1992-2000) with validated dietary questionnaires. Cox proportional hazards analysis was performed to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality, while adjusting for CVD-related, diabetes-related, and nutritional factors.

RESULTS

During a median follow-up of 9.2 y, 791 deaths were recorded, 306 due to CVD. Dietary fiber was inversely associated with all-cause mortality risk (adjusted HR per SD increase, 0.83 [95% CI, 0.75-0.91]) and CVD mortality risk (0.76[0.64-0.89]). No significant associations were observed for glycemic load, glycemic index, carbohydrate, sugar, or starch. Glycemic load (1.42[1.07-1.88]), carbohydrate (1.67[1.18-2.37]) and sugar intake (1.53[1.12-2.09]) were associated with an increased total mortality risk among normal weight individuals (BMI≤25 kg/m(2); 22% of study population) but not among overweight individuals (P interaction≤0.04). These associations became stronger after exclusion of energy misreporters.

CONCLUSIONS

High fiber intake was associated with a decreased mortality risk. High glycemic load, carbohydrate and sugar intake were associated with an increased mortality risk in normal weight individuals with diabetes.

Maternal diets with low healthy eating index or Mediterranean diet adherence scores are associated with high cord-blood insulin levels and insulin resistance markers at birth

BACKGROUND/OBJECTIVES

Few studies have used healthy eating index (HEI) and mediterranean diet adherence (MDA) scores to evaluate the diet quality during pregnancy. To determine the relationship between first trimester diet quality and insulin sensitivity/resistance biomarkers at birth.

SUBJECTS/METHODS

Cord-blood insulin sensitivity/resistance biomarkers of the offspring of 35 women whose diets were 'adequate' or 'inadequate' according to their HEI score (>70 or ≤ 70, respectively) and their 13-point MDA score (≥ 7 or <7, respectively).

RESULTS

Low HEI-score diets contained less (g/1000 kcal) carbohydrates (CHO; P=0.027) and fibre (P=0.011), and more fats (P<0.001) and cholesterol (P<0.001), and contributed (percentage contribution to total energy (%En)) fewer CHO (P=0.005), more fats (P=<0.001) and saturated fatty acid (SFA; P=0.002) than their high HEI-score counterparts. Low MDA-score diets contained less (g/1000 kcal) fibre (P<0.001) and more cholesterol (P=0.05), had lower polyunsaturated fatty acids+monounsaturated fatty acid/SFA (PUFA+MUFA/SFA; P=0.05) and higher SFA/CHO (P=0.021) and ω-6/ω-3 PUFA ratios (P=0.044) than their respective counterparts. Women consuming the low HEI- or low MDA-score diets had low-fasting glycaemia (P=0.016 or P=0.025, respectively) but delivered infants with high insulinaemia (P=0.048 or P=0.017, respectively), homeostatic model assessment for insulin resistance (HOMA-IR; P=0.031 or P=0.049, respectively) and glycaemia (P=0.018 or P=0.048, respectively). The relative risk (RR) of high-neonatal glycaemia and insulinaemia were 7.6 (P=0.008) and 6.7 (P=0.017) for low vs high HEI-score groups. High HOMA-IR and high glucose RR were, respectively, 3.4 (P=0.043) and 3.9 (P=0.016) in neonates from the <7 MDA- vs ≥ 7 MDA-score group. These RRs were not affected by potential confounders.

CONCLUSION

Maternal diets with low HEI- or MDA-scores during the first trimester of pregnancy negatively affect insulin resistance markers at birth.

The NutriChip project – translating technology into nutritional knowledge

Advances in food transformation have dramatically increased the diversity of products on the market and, consequently, exposed consumers to a complex spectrum of bioactive nutrients whose potential risks and benefits have mostly not been confidently demonstrated. Therefore, tools are needed to efficiently screen products for selected physiological properties before they enter the market. NutriChip is an interdisciplinary modular project funded by the Swiss programme Nano-Tera, which groups scientists from several areas of research with the aim of developing analytical strategies that will enable functional screening of foods. The project focuses on postprandial inflammatory stress, which potentially contributes to the development of chronic inflammatory diseases. The first module of the NutriChip project is composed of three in vitro biochemical steps that mimic the digestion process, intestinal absorption, and subsequent modulation of immune cells by the bioavailable nutrients. The second module is a miniaturised form of the first module (gut-on-a-chip) that integrates a microfluidic-based cell co-culture system and super-resolution imaging technologies to provide a physiologically relevant fluid flow environment and allows sensitive real-time analysis of the products screened in vitro. The third module aims at validating the in vitro screening model by assessing the nutritional properties of selected food products in humans. Because of the immunomodulatory properties of milk as well as its amenability to technological transformation, dairy products have been selected as model foods. The NutriChip project reflects the opening of food and nutrition sciences to state-of-the-art technologies, a key step in the translation of transdisciplinary knowledge into nutritional advice.