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American Journal of Clinical Nutrition, Vol. 87, No. 1, 126-131, January 2008
© 2008 American Society for Nutrition

ORIGINAL RESEARCH COMMUNICATION

Dietary glycemic index and glycemic load and the risk of type 2 diabetes in older adults1,2,3

Nadine R Sahyoun, Amy L Anderson, Frances A Tylavsky, Jung Sun Lee, Deborah E Sellmeyer, Tamara B Harris for the Health, Aging, and Body Composition Study

1 From the Department of Nutrition and Food Science, University of Maryland, College Park, MD (NRS and ALA); the Department of Preventive Medicine, University of Tennessee, Memphis, TN (FAT); the Department of Foods and Nutrition, University of Georgia, Athens, GA (JSL); the Division of Endocrinology, University of California, San Francisco, CA (DES); and the National Institute on Aging, National Institutes of Health, Bethesda, MD (TBH)

See corresponding perspective on page 1 and related perspective on page 3.

2 Supported by contracts no. N01-AG-6-2106, N01-AG-6-2101, and N01-AG-6-2103 from the National Institute on Aging and by the Intramural Research program of the National Institute on Aging, National Institutes of Health.

3 Reprints not available. Address correspondence to NR Sahyoun, Department of Nutrition and Food Science, University of Maryland, 0112 Skinner Building, College Park, MD 20742. E-mail: nsahyoun{at}umd.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: It is unclear whether immediate dietary effects on blood glucose influence the risk of developing type 2 diabetes.

Objective: The objective of this study was to examine whether the dietary glycemic index (GI) and glycemic load (GL) were associated with the risk of type 2 diabetes in older adults.

Design: The Health, Aging, and Body Composition Study is a prospective cohort study of 3075 adults who were 70–79 y old at baseline (n = 1898 for this analysis). The intakes of specific nutrients and food groups and the risk of type 2 diabetes over a 4-y period were examined according to dietary GI and GL.

Results: Dietary GI was positively associated with dietary carbohydrate and negatively associated with the intakes of protein, total fat, saturated fat, alcohol, vegetables, and fruit. Dietary GL was positively associated with dietary carbohydrate, fruit, and fiber and negatively associated with the intakes of protein, total fat, saturated fat, and alcohol. Persons in the higher quintiles of dietary GI or GL did not have a significantly greater incidence of type 2 diabetes.

Conclusions: These findings do not support a relation between dietary GI or GL and the risk of type 2 diabetes in older adults. Because dietary GI and GL show strong nutritional correlates, the overall dietary pattern should be considered.

Key Words: Diet • glycemic index • glycemic load • type 2 diabetes • older adults


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The prevalence of type 2 diabetes, a metabolic disorder characterized by high blood glucose and insulin resistance, has more than doubled in the United States in the past 2 decades, and persons ≥60 y old account for almost half of the cases (1). Factors such as obesity, lack of physical activity, and smoking have been linked to the development of type 2 diabetes, but the role of dietary carbohydrate remains unclear. Little relation has been found between total carbohydrate intake and the risk of type 2 diabetes (2). To determine whether the rates of digestion and absorption of different carbohydrate sources may influence risk, several studies have focused on the glycemic index (GI) and glycemic load (GL) (3, 4).

Long-term consumption of high-GI foods has been proposed to increase insulin demand, promote insulin resistance, impair pancreatic β-cell function, and eventually lead to type 2 diabetes (2, 4-6). However, studies of dietary GI and GL in relation to insulin resistance and the risk of type 2 diabetes have had inconsistent results. In the Framingham Offspring Cohort Study (7), both dietary GI and GL were positively related to insulin resistance, whereas, in the Zutphen Elderly Study (8), the Insulin Resistance Atherosclerosis Study (9), the Health, Aging, and Body Composition (Health ABC) Study (10), and the Inter99 Study from Denmark (11), no associations were found. Both dietary GI and GL were positively linked to incident type 2 diabetes in the Nurses’ Health Study (4), but no relations were seen in the Atherosclerosis Risk in Communities (12), the Iowa Women's Health Study (13), and the Insulin Resistance Atherosclerosis Study (14) cohorts. In the Health Professionals Follow-up Study (2), the Nurses’ Health Study II (5), and the Melbourne Collaborative Cohort Study (15), dietary GI but not GL was positively associated with risk of type 2 diabetes.

Most international diabetes organizations advocate the use of the GI in prevention and management of diabetes (16), but the American Diabetes Association (ADA) does not fully endorse the use of the GI because it considers current evidence insufficient to support a relation between dietary GI or GL and the development of diabetes (17, 18). The 2005 US Department of Agriculture Dietary Guidelines emphasized the need for additional research on dietary GL in relation to risk of type 2 diabetes (19).

Few studies of dietary GI and GL and the risk of type 2 diabetes have been conducted in older adults, despite the high incidence of type 2 diabetes and the evident influence of lifestyle on the risk of type 2 diabetes in this age group (20-22). The purpose of the current study was to examine whether dietary GI and GL were associated with incident type 2 diabetes during a 4-y follow-up in a cohort of older adults.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study population
Participants 70–79 y old were recruited for the Health ABC Study, a prospective cohort study, from a random sample of Medicare-eligible residents of selected areas of Pittsburgh, PA, and Memphis, TN. Individuals were eligible for the Health ABC Study if they planned to remain in the same area for ≥3 y and if they reported no life-threatening cancers and no difficulty with basic activities of daily living, walking 1/4 mile, or climbing 10 steps. Those who used assistive devices were excluded, as were participants in any research studies that involved medications or modification of eating or exercise habits. An interview on behavior, health status, and social, demographic, and economic factors and a clinical examination of body composition, biochemical variables (including fasting serum glucose), weight-related health conditions, and physical function were administered in 1997 or 1998. Annual follow-up assessments were conducted.

Results from baseline through year 6 of the Health ABC study were used in the current analyses. The sample size for this study was 1898 subjects, after the exclusion of participants diagnosed with type 2 diabetes before dietary intake was assessed (n = 662), those with missing information on type 2 diabetes in years 3 through 6 (n = 60), men who reported an energy intake of <800 kcal/d or >4000 kcal/d and women who reported an energy intake of <500 kcal/d or >3500 kcal/d (n = 73), and those with incomplete information on other relevant behavioral or sociodemographic factors (n = 382).

Participants provided written informed consent. Protocols were approved by institutional review boards at the University of Pittsburgh and the University of Tennessee, Memphis.

Dietary assessment
Food intake was measured in year 2 of the Health ABC Study by using a 108-item food-frequency questionnaire (FFQ) based on the validated Block questionnaire (Block Dietary Data Systems, Berkeley, CA) (23), which was modified specifically for the Health ABC Study to include an age-appropriate food list. The food list was based on the third National Health and Nutrition Examination Survey 24-h recall data for non-Hispanic white and black residents of the Northeast and South who were >65 y old. The FFQ was administered by a trained dietary interviewer, and interviews were periodically monitored to ensure quality and consistency. Wood blocks, models of actual foods, and flash cards were used to help participants estimate portion sizes. Nutrient and food group intakes, including daily servings of vegetables and frequency of fruit and fruit juice consumption, were determined by using Block Dietary Data Systems.

The GI of a food is defined as the 2-h incremental area under the blood glucose curve after consumption of a food portion that contains a specific amount, usually 50 g, of available carbohydrate, divided by the corresponding area after consumption of a portion of a reference food, usually glucose or white bread, that contains the same amount of available carbohydrate, and multiplied by 100 (to be expressed as a percentage). GI values for foods in the Health ABC Study FFQ were compiled from the literature by the Clinical Nutrition Research Center at the University of North Carolina (Chapel Hill, NC), and they were modified if necessary to better match FFQ foods (16). A computer program was written in SAS software (version 9.1; SAS Institute Inc, Cary, NC) to calculate the dietary GI and GL of foods eaten by each participant. The program first determined the amount of available carbohydrate in one serving of each food by subtracting the amount of fiber from the amount of total carbohydrate per serving. To obtain the GL of a serving of the food, the amount of available carbohydrate per serving was multiplied by the food's GI value, and that product was divided by 100. To determine the dietary GL for each subject, each food's GL was multiplied by the daily frequency of consumption of the food, and these products were summed over all foods. The dietary GI for each subject was computed by dividing dietary GL by daily total available carbohydrate intake and multiplying that value by 100. These methods of calculating dietary GI and GL are endorsed by a joint report of the FAO/WHO (24) and by the 2002 international table of glycemic index and glycemic load values (16).

Diagnosis of type 2 diabetes
In this study, type 2 diabetes was defined by 1) an annual report of physician diagnosis; 2) the reported use of exogenous insulin or oral hypoglycemic medication, assessed in years 2, 3, 5, and 6; or 3) fasting serum glucose ≥126 mg/dL (in accordance with current ADA criteria), measured in years 2, 4, and 6 (25).

Sociodemographic and lifestyle variables
Sociodemographic variables including age, sex, self-identified racial group, and education and lifestyle variables including smoking status, alcohol consumption, and physical activity were assessed at baseline of the Health ABC Study. Lifetime pack-years of cigarette smoking were calculated by multiplying the number of packs of cigarettes smoked per day by the number of years of smoking. Physical activity was evaluated by a standardized questionnaire specifically designed for the Health ABC Study. This questionnaire was derived from the leisure-time physical activity questionnaire, and it included activities commonly performed by older adults (26). The frequency, duration, and intensity of specific activities were determined, and approximate metabolic equivalent unit values were assigned to each activity category to estimate weekly energy expenditure.

Statistical analysis
Characteristics of men and women were compared by using Student's t test and the chi-square test. Dietary GI and GL were adjusted for total calorie intake by using the residuals method of Willett et al (27). Participants were grouped by quintiles of energy-adjusted dietary GI and GL, and baseline characteristics were examined according to dietary GI and GL. Means of quintiles 2 through 5 were compared with those of quintile 1 with the use of Dunnett's test for continuous variables and a chi-square test for categorical variables. Linear regression was used to assess trends of continuous variables in relation to dietary GI and GL, and the Mantel-Haenszel chi-square test was used to examine trends of categorical variables across quintiles of dietary GI and GL.

To determine the risk of developing type 2 diabetes by quintile of energy-adjusted dietary GI and GL, multivariate logistic regression was used. Covariates included age, sex, race, clinical site, education, physical activity, baseline fasting glucose, body mass index (in kg/m2), alcohol consumption, total fiber intake, cereal fiber intake, and smoking status. Dietary GI and GL were also analyzed as continuous variables in relation to risk. Interactions of dietary GI and GL with sex, race, and education were tested. Statistical significance was set at P ≤ 0.05, and analyses were performed with SAS software (version 9.1; SAS Institute Inc, Cary, NC).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Characteristics of the study population are shown in Table 1Go, and characteristics by quintiles of energy-adjusted dietary GI and GL are shown in Table 2Go and Table 3Go. On average, subjects in the higher quintiles of dietary GI were older; less likely to be female or white, to have a high school degree, or to consume alcohol; and less physically active. They had a higher percentage intake from carbohydrate; a lower percentage intake from protein, total fat, and saturated fat; and lower consumption of vegetables and fruit. Subjects with a higher dietary GL also were older; were less likely to be white, to have a high school degree, or to consume alcohol; and had fewer lifetime pack-years of smoking. They also had a higher percentage intake from carbohydrate; lower percentage intakes from protein, total fat, and saturated fat; and higher intakes of fruit and fiber.


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  		TABLE 1. Characteristics of the study population

 

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  		TABLE 2. Characteristics of participants according to quintile (Q) of energy-adjusted dietary glycemic index

 

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  		TABLE 3. Characteristics of participants according to quintile (Q) of energy-adjusted dietary glycemic load

 
The risk of developing type 2 diabetes according to energy-adjusted dietary GI and GL is shown in Table 4Go. Neither dietary GI nor dietary GL was significantly associated with risk, either before or after control for age, sex, race, clinical site, education, physical activity, baseline fasting glucose, body mass index, alcohol consumption, and smoking status. Additional adjustment for total fiber or cereal fiber intake did not significantly alter results. Interactions of dietary GI or GL with sex, race, and education were found not to be significant.


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  		TABLE 4. Relative risk of type 2 diabetes according to quintile (Q) of energy-adjusted dietary glycemic index and load

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this cohort of well-functioning older adults, neither dietary GI nor dietary GL was associated with the risk of developing type 2 diabetes. These findings support results of the Atherosclerosis Risk in Communities Study of adults 45–64 y old at baseline, the Iowa Women's Health Study of women 55–70 y old, and the Insulin Resistance Atherosclerosis Study of adults 40–69 y old, which also did not show associations between dietary GI or GL and incident type 2 diabetes (12-14). In contrast, in the Nurses’ Health Study of women 40–65 y old, those in the highest quintile of dietary GI or GL had a risk of developing type 2 diabetes that was {approx}40–50% greater than the risk of women in the lowest quintile, after adjustment for cereal fiber intake (4). Similar positive relations were seen between dietary GI and type 2 diabetes risk in the Health Professionals Follow-up Study of men 40–75 y old (2), the Nurses’ Health Study II of women 24–44 y old (5), and the Melbourne Collaborative Cohort Study of adults 40–69 y old (15).

In the present study, both dietary GI and GL were negatively associated with the intakes of saturated fat, total fat, and alcohol, factors that may adversely affect glucose metabolism. Dietary GI and GL were positively associated with dietary carbohydrate, and dietary GL was also positively associated with fruit and fiber intakes, factors that may benefit glucose metabolism. Although diets with a lower GI or GL were expected to be more healthful, the higher the dietary GI or GL, the better the diet fit current dietary guidelines to limit intake of saturated fat and, in the case of dietary GL, the guideline to consume ≥14 g fiber/1000 calories and to consume multiple servings of fruit each day (19). Thus, the findings of the present study show that a lower dietary GI or GL is not necessarily more compatible with current dietary guidelines than is a higher GI or GL.

Other studies have also found strong nutritional correlates of dietary GI and GL (2, 4, 5, 8, 15, 28-30). Schulz et al (28) positively correlated dietary GI with consumption of white bread, beer, meat, fried potatoes, fat, alcohol, and starch—and thus with a less healthful overall diet—and negatively correlated dietary GI with consumption of fruit, fiber and low-fat milk. Other studies also found positive associations of dietary GI with consumption of bread and starch and negative associations with consumption of fruit, fiber, and low-fat milk (2, 4, 5, 8, 15). Most studies, including the present study, positively associated dietary GL with a more healthful overall diet, including higher intakes of fiber and cereal fiber, and negatively associated dietary GL with consumption of fat and alcohol (2, 4, 5, 11).

Summary indicators such as dietary GI or GL may not provide sufficient information on the composition of a diet and its effect on risk of type 2 diabetes. It has been suggested that dietary GL provides little information beyond total carbohydrate intake (11, 29). In contrast, dietary GI, which does not reflect total carbohydrate intake, is thought to provide little insight into the overall insulin demand induced by total carbohydrate intake (2, 4). Therefore, if the GI or GL is considered in research or in dietary recommendations, it should be considered in conjunction with national dietary guidelines (17, 24).

Certain factors may have influenced study findings. This cohort included participants of similar age and functional status and with relatively narrow ranges of dietary GI and GL. Dietary GI quintile means ranged from {approx}50 to 60. In contrast, Mayer-Davis et al (29) found dietary GI quintile means that ranged from {approx}75 to 90, as did others (2, 4, 5, 7, 8, 12), perhaps in part because of methodologic differences in calculating dietary GI and GL. Whereas the current study followed methods supported by several international organizations, other studies have used a slightly different procedure (10). Mean dietary GL in the current study ranged from {approx}95 to 160. Mayer-Davis et al found dietary GL quintile means of {approx}90 to 300 (29), and others (2, 4, 7) also found larger and higher ranges of dietary GL than were found in the current study. The homogeneity in the population of the current study may have attenuated associations between dietary GI and GL and the risk of type 2 diabetes (31).

Because the population of the current study consisted of relatively well-functioning older adults, selection bias, through the exclusion of metabolically vulnerable subjects, also could have diminished associations between dietary GI or GL and risk of type 2 diabetes (32). Furthermore, as in other studies, the FFQ used in the current study was not specifically designed to measure dietary GI or GL and may not have captured the total glycemic effect of the diet (11). Strengths of this study include its longitudinal design, unique age group, and the thorough diagnosis of type 2 diabetes that did not rely solely on self-reported information.

In conclusion, this study does not support a relation between dietary GI or GL and the risk of type 2 diabetes in older adults. Because dietary GI and GL each have strong and unique nutritional correlates, it may be important to examine the dietary pattern as a whole in addition to estimating the glycemic effect of dietary carbohydrate when evaluating the contribution of diet to the risk of a complex chronic disease such as type 2 diabetes.


   ACKNOWLEDGMENTS
 
The authors’ responsibilities were as follows—NRS, ALA, and TBH: the study concept and research design; ALA and NRS: the drafting of the manuscript; and FAT, JSL, DES, and TBH: critical review and revision of the manuscript. None of the authors had a personal or financial conflict of interest.


   REFERENCES
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 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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Received for publication June 12, 2007. Accepted for publication August 2, 2007.


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