Glycemic Index and Glycemic Load of Carbohydrates
in the Diabetes Diet
Kate Marsh & Alan Barclay & Stephen Colagiuri &
Published online: 11 January 2011
# Springer Science+Business Media, LLC 2011
Abstract Medical nutrition therapy is the first line of
treatment for the prevention and management of type 2
diabetes and plays an essential part in the management of
type 1 diabetes. Although traditionally advice was focused
on carbohydrate quantification, it is now clear that both the
amount and type of carbohydrate are important in predict-
ing an individual’s glycemic response to a meal. Diets
based on carbohydrate foods that are more slowly digested,
absorbed, and metabolized (i.e., low glycemic index [GI]
diets) have been associated with a reduced risk of type 2
diabetes and cardiovascular disease, whereas intervention
studies have shown improvements in insulin sensitivity and
glycated hemoglobin concentrations in people with diabetes
following a low GI diet. Research also suggests that low GI
diets may assist with weight management through effects
on satiety and fuel partitioning. These findings, together
with the fact that there are no demonstrated negative effects
of a low GI diet, suggest that the GI should be an important
consideration in the dietary management and prevention of
Keywords Glycemic index.Glycemic load.Diabetes.
Medical nutrition therapy (MNT) plays an important role in
managing existing diabetes (type 1, type 2, and gestational
diabetes) and in preventing or reducing the progression of
impaired glucose tolerance and diabetes-related complica-
tions . Current nutrition recommendations limit the
amount of saturated and trans faty acids but encourage
moderate amounts of carbohydrate from fruits, vegetables,
whole grains, legumes, and low-fat milk to assist with
glycemic control. The American Diabetes Association
(ADA) recommendations also state that the use of glycemic
index (GI) and glycemic load (GL) may provide a modest
additional benefit over that observed when total carbohy-
drate is considered alone . Despite consensus in some
areas, the optimal diet and macronutrient composition for
people with diabetes remains controversial. The quantity
and quality of the carbohydrates is one of those areas of
controversy and is the focus of this review.
The amount of carbohydrate is an important determinant of
the glycemic effect of a given food or meal. However, even
J. Brand-Miller (*)
School of Molecular Bioscience and Boden Institute of Obesity,
Nutrition and Exercise, The University of Sydney,
Sydney, NSW 2006, Australia
Northside Nutrition & Dietetics,
74/47 Neridah Street,
Chatswood, NSW 2067, Australia
Australian Diabetes Council,
26 Arundel Street,
Glebe, NSW 2037, Australia
Metabolic Health, Faculty of Medicine, Boden Institute of
Obesity, Nutrition and Exercise, The University of Sydney,
Sydney, NSW 2006, Australia
Curr Diab Rep (2011) 11:120–127
in equal amounts, the carbohydrates in some foods have
much greater effects on postprandial glycemia than others.
For this reason, the concept of GI was introduced in early
1981 as a method for classifying food carbohydrates
according to their effect on postprandial glycemia . The
GI is the blood glucose response of a 50-g (or 25-g)
carbohydrate portion of food, expressed as a percentage of
the same amount of carbohydrate from a reference food—
either glucose or white bread . Essentially, the GI ranks
the glycemic potential of the carbohydrates in different
foods, gram for gram of carbohydrate (Table 1).
The GI of a food is influenced by many different factors
including the type of sugar (e.g., fructose vs glucose), the
type of starch (e.g., amylose vs amylopectin), the gelatini-
zation of the starch, the type of fiber (e.g., soluble vs
insoluble), the processing of a food, and the presence of fat
or protein in a mixed meal. It cannot be easily predicted nor
measured in vitro, which is a measure of carbohydrate
digestibility rather than the true in vivo response of a food
on blood glucose levels.
There is now a significant body of evidence demonstrat-
ing the benefits of healthy low GI diets. Although a high
carbohydrate diet has been shown to worsen many of the
features of insulin resistance, including postprandial glyce-
mia and insulinemia, fasting hypertriglyceridemia, low
high-density lipoprotein (HDL) levels and fibrinolysis, this
is not seen when the carbohydrate comes from low GI
sources. Many studies show that low and high GI foods
have significantly different effects on metabolism .
High GI meals result in a rapid increase in blood glucose
and insulin levels followed by reactive hypoglycemia,
counterregulatory hormone secretion, and elevated free
fatty acid concentrations, which may then lead to β-cell
dysfunction, dyslipidemia, and endothelial dysfunction .
Over time this could be expected to increase the risk of
obesity, type 2 diabetes, cardiovascular disease (CVD), and
some types of cancer and there is now an increasing amount
of evidence from both clinical and epidemiologic studies to
support this hypothesis [6•].
Although the GI predicts the potential of a food’s
carbohydrate to raise blood glucose levels, the overall
blood glucose response to a food or meal is determined by
both the quantity and quality (GI) of the carbohydrate
consumed . Thus the concept of glycemic load—defined
as the GI multiplied by the amount of carbohydrate per
serving of food in grams—was introduced as a measure of
the overall effect of a food on blood glucose and insulin
levels. Dietary GL can be reduced in two ways: either by
lowering the GI of the carbohydrate or by reducing the total
carbohydrate in the diet, but the metabolic effects of these
changes are likely to be different .
Defects in carbohydrate metabolism, which characterize
diabetes, mean that the GI and GL of a food or meal are
particularly relevant to the management of this condition.
GI in the Nutritional Management of Diabetes
According to the ADA, the goals of MNT for individuals
with diabetes are :
1. To achieve and maintain blood glucose levels in the
normal range or as close to normal as is safely possible,
a lipid and lipoprotein profile that reduces the risk for
vascular disease, and blood pressure levels in the
normal range or as close to normal as is safely possible.
2. To prevent, or at least slow, the rate of development of
the chronic complications of diabetes by modifying
nutrient intake and lifestyle.
3. To address individual nutrition needs, taking into
account personal and cultural preferences and willing-
ness to change.
4. To maintain the pleasure of eating by only limiting food
choices when indicated by scientific evidence.
In those who are overweight, MNT should also aim to
achieve moderate weight loss (5–7% of body weight) .
A healthy low GI diet is easily able to achieve these goals,
perhaps better than other dietary interventions. It is for this
professional organizations including the Canadian Diabetes
Association, Diabetes UK, and Diabetes Australia and the
European Association for the Study of Diabetes as playing an
important role in the management of diabetes [9–15].
Improved Glycemic Control
A large number of studies have now been published
investigating the effects of low GI diets in the management
High GI food Lower GI alternative
Bread (white or whole meal)
Puffed and flaked breakfast cereals
Plain biscuits or crackers
Most types of rice
Dense, whole-grain breads
Unrefined cereals (e.g., rolled oats or natural muesli)
Biscuits made with dried fruit, oats, and whole grains
Baby new potatoes, sweet potatoes, and corn
Basmati rice, pearled barley, quinoa, cracked wheat, pasta, noodles
Table 1 Substituting high GI
foods for low GI alternatives
GI glycemic index.
Curr Diab Rep (2011) 11:120–127 121
of diabetes. An earlier meta-analysis of 14 studies involving
356 subjects with type 1 and type 2 diabetes found that low
GI diets can improve blood glucose control to a similar
extent as that seen with medications that target postmeal
blood glucose levels . A second meta-analysis of 16
studies investigating the effect of low versus high GI diets
on markers for carbohydrate and lipid metabolism found
that low GI diets significantly reduced fructosamine and
hemoglobin A1c (HbA1c) levels in people with type 2
diabetes . More recently, a Cochrane systematic review
incorporating the findings of 11 randomized controlled
trials (RCTs) for 4 weeks or longer, found that a low GI diet
can improve glycemic control in diabetes while reducing
the risk of hypoglycemic events . This finding is
significant because improving blood glucose levels is
usually associated with an increased risk of hypoglycemia
and this is the greatest barrier to achieving optimal
glycemic control, particularly in individuals with type 1
diabetes . The authors have recently published an
updated review incorporating an additional large-scale
RCT, and report a significant improvement in HbA1c(a
weighted mean difference of −0.4% in seven studies) and
fructosamine (a weighted mean difference of −0.23 mmol/L
in four shorter-term studies) with a low GI compared with a
control diet [20•]. These changes are clinically significant
and are of sufficient magnitude to contribute to a reduction
in the risk of diabetes complications .
Nutrition recommendations for those with type 1
diabetes receiving intensive treatment is focused mainly
on matching carbohydrate intake to insulin; however,
consideration of GI may also be of benefit. Although
longer-term studies are needed, a low GI meal has been
shown to reduce postprandial glucose excursions in
children with type 1 diabetes treated with both intensive
multiple daily injection of insulin or insulin pump therapy
In women with gestational diabetes, a low GI diet has been
shown to halve chances of needing insulin [24•]. Of the 63
women in the study, who were randomized to follow either a
low GI diet or a conventional high-fiber (~ 28 g/day; and
higher GI) diet, only 29% of those following the low GI diet
met the criteria for commencement of insulin (a fasting
blood glucose of 5.5 mmol/L [99 mg/dL] or greater, or a 1-
h postprandial blood glucose of 8.0 mmol/L [144 mg/dL] or
greater, more than once per week) compared with 59% of
those on the conventional diet. Of the latter group, almost
half (9/19) were able to avoid insulin by switching to a low
GI diet [24•].
In addition to reducing postprandial glycemia, a low GI
diet has been shown to improve insulin sensitivity after 3–
4 weeks [25, 26]. A high GI diet, in contrast, has been
shown to worsen insulin resistance in individuals with and
without diabetes [27–29]. Animal studies have also shown
a worsening of insulin resistance on a high versus a low GI
diet [30, 31]. A worsening of insulin resistance would be
expected to increase blood glucose levels and medication
needs in those with type 2 diabetes and increase insulin
requirements in people with type 1 diabetes.
In both epidemiologic studies and clinical trials, low GI
diets have been shown to reduce triglycerides, total and
low-density lipoprotein (LDL) cholesterol and improve
the total cholesterol/HDL ratio in individuals with and
without diabetes [29, 32–45]. For example, the RISCK
(Reading, Imperial, Surrey, Cambridge, and Kings) study,
a five-center, parallel design RCT, fed four different diets
with high and low GI and high and low monounsaturated
fat content to people at risk of the metabolic syndrome for
up to 24 weeks . Consumption of the low GI diet led
to the most significant decreases in total and LDL
cholesterol concentrations compared with the other dietary
Effect of Low GI Diets on Blood Pressure
Research has also shown that in the setting of weight
reduction, a low GI diet can achieve greater reductions in
blood pressure than a higher GI eating plan . Further
research is needed to determine whether a low GI diet,
independent of weight loss, is also effective at lowering
blood pressure. Furthermore, the most successful dietary
intervention for hypertension has been the DASH (Dietary
Approaches to Stopping Hypertension) diet, which is high
in fruit, vegetables, whole grains, and low-fat dairy
products and therefore likely to be relatively low GI .
The DASH dietary intervention has also been shown to
improve insulin sensitivity .
The Effect of GI on Diabetes Complications
Although there are no studies looking specifically at the
effect of a low GI diet in reducing the risk of diabetes-
related complications, the improvements in glycemic
control and cardiovascular risk factors seen with a low GI
diet can be predicted to reduce the risk and progression of
Individuals with diabetes have a significantly greater risk
of developing CVD, estimated to be two to four times
higher than those without diabetes . Strategies to reduce
CVD risk are therefore important. In addition to improve-
ments in lipids and blood pressure, a low GI diet has been
found to improve inflammatory markers including plasmin-
ogen activator inhibitor-1 [44, 51, 52] and C-reactive
protein levels [53, 54].
122 Curr Diab Rep (2011) 11:120–127
Most studies looking at the association between dietary
GI and CVD risk have found higher HDL, lower
triglyceride, or lower coronary heart disease risk in those
with lowest compared with highest dietary GI and GL [55–
60]. A meta-analysis of observational studies found a
significant positive relationship between dietary GI and
coronary heart disease risk, with the degree of protection
similar to that of higher fiber or whole-grain intakes [6•].
More recently, a high GI diet has been associated with
increased risk of myocardial infarction in a large cohort of
Danish men and women , and coronary heart disease in
a large cohort of Italian women .
A high GI diet has also been associated with higher risk
of hemorrhagic stroke in women, with a stronger relation-
ship in those who are overweight , in a cohort of older
(49+ years) Australians ; also, in postmenopausal
women, high GI diets have been linked to greater
atherosclerotic progression .
In addition to traditional risk factors, there are a number
of reasons that may explain the possible reduction in risk of
CVD with a low GI diet. One such reason is the reduction
in postprandial hyperglycemia seen with a lower GI diet.
Postprandial hyperglycemia is now recognized as an
important risk factor for CVD regardless of diabetes status
[66–70] and a positive linear relationship between post-
challenge blood glucose levels and CVD risk has been
found, even in the nondiabetic range . One study found
postchallenge glucose and glycemic spikes to be more
strongly associated with carotid intima-media thickness and
risk factors for atherosclerosis than fasting blood glucose or
HbA1c . Another reason is the positive association
between high GI diets and levels of oxidative stress ,
which has been implicated in the pathogenesis of CVD
. Research suggests that oxidative stress may be an
important factor in the link between hyperglycemia and
increased cardiovascular risk . High GI diets may also
increase CVD risk by increasing insulin levels in patients
with type 2 diabetes. Excessive insulinemia can worsen
blood pressure, lipids, coagulation factors, inflammatory
mediators, and endothelial function .
Address Individual Nutrition Needs
Unlike many other dietary modifications, adopting a
healthy low GI diet is neither difficult nor restrictive. It
does not require the elimination of any food groups but
simply requires the substitution of low GI for high GI
choices within food groups/categories as illustrated in
Table 1. It can easily accommodate different personal
and cultural dietary preferences and fits closely with
general healthy eating recommendations including eating
more fruits, vegetables and whole-grain breads and
One study in children with type 1 diabetes comparing a
measured carbohydrate exchange diet versus a more
flexible low GI eating plan found that quality of life
improved on the low GI diet and twice as many parents in
the low GI group reported that their child had no difficulties
selecting their own meals at the end of the 12-month study
. Similarly, in a study of women during pregnancy,
those assigned to the low GI arm reported that the diet was
“easier” to follow compared with those assigned to the
conventional (low-sugar/high-fiber) diet .
Evidence-based Nutrition Advice
The GI has shown us that the previous belief that “starchy”
foods raised blood glucose levels more slowly than sugars
was in fact incorrect and that there are many different
factors that affect the glycemic response to carbohydrates in
food . It is only since the discovery of GI that the strict
avoidance of refined sugar, once the focus of dietary
management for diabetes, was found to be unnecessary. It
is now recognized that there is no need for an individual
with diabetes to completely avoid sugars and that foods
high in sugars can be substituted for other carbohydrates in
the diet provided they are matched with insulin or other
glucose-lowering medication. Added refined sugars (and
starches) are best included as part of an overall healthy
eating plan and care should be taken to avoid excessive
consumption to limit unnecessary energy intake .
Obesity is a major risk factor for type 2 diabetes and weight
loss in those who are overweight or obese is an important
part of the nutritional management of diabetes. Even
moderate weight loss (5–10% of initial body weight) in
combination with increased activity can improve insulin
sensitivity and glycemic control in individuals with type 2
diabetes and prevent the development of type 2 diabetes in
those at high risk .
Diets with a lower GI or GL may assist in weight
management by influencing appetite and fuel partition-
ing. Short-term feeding studies have generally found low
GI foods to increase satiety, reduce hunger, or lower
subsequent voluntary food intake, whereas high GI foods
are associated with increased appetite and higher energy
intake [78–83]. In a review of 16 studies, low GI foods
were found to increase satiety, delay the return of hunger,
or reduce ad libitum food intake in all but one . Two
studies have found a smaller reduction in energy expen-
diture with weight loss on a low GI versus high GI diet
A number of medium-term intervention trials have
also demonstrated a benefit of a low GI diet in weight
Curr Diab Rep (2011) 11:120–127 123
loss. A meta-analysis of six RCTs found that overweight
or obese individuals lost more weight and had greater
improvement in lipid profiles on a low GI compared with
a control diet .
Observational studies also demonstrate a relationship
between dietary GI and weight. Ma et al.  found body
mass index to be positively associated with the dietary GI
but not with carbohydrate intake or GL. Similarly, in the
EURODIAB Complications Study of nearly 3000 adults
with type 1 diabetes, dietary GI was inversely associated
with waist-to-hip ratio and waist circumference in men,
independent of carbohydrate, fat, and fiber . In women,
a high GI diet has been found to be positively associated
with an increase in body weight, body fat, and waist
circumference . In the Nurses’ Health Study, weight
gain was inversely associated with the intake of high fiber,
whole-grain foods (reflective of a low GI diet) but
positively associated with the intake of refined grains .
Prevention of Type 2 Diabetes
In addition to its benefits in the management of existing
diabetes, a low GI diet may also help to prevent type 2
diabetes. Although there have been no long-term interven-
tion studies looking at the effects of a low GI diet in
diabetes prevention, two large epidemiologic studies in men
and women have associated low GI diets with reduced risk
of type 2 diabetes [90, 91]. In both studies, the risk of
developing diabetes was 37% higher in the highest quintiles
of GI after adjusting for confounding factors including
cereal fiber intake. A high dietary GL was also found to
increase the risk of diabetes and was related to GI and not
the amount of dietary carbohydrate. A recent meta-analysis
found that a high GI diet was associated with a 40%
increased risk of type 2 diabetes and a high GL diet with a
27% increased risk [6•]. More recently, the EPIC-NL
(European Prospective Investigation into Cancer and
Nutrition-Netherlands) study found that after adjusting for
confounding factors, GL and to a lesser extent GI were
positively associated with type 2 diabetes risk .
However, not all studies have found an association
between the GI, GL, and the risk of diabetes. The Iowa
Women’s Health Study, for example, found no relationship
between dietary GI or GL and diabetes risk . A limitation
of all observational studies published to date is that none of
the food frequency questionnaires have been specifically
designed to assess the GI and until recently, few were
validated against another method of dietary assessment such
as 24-hour recalls or diet records. In some cases, such as the
Iowa Women’s Health Study , the ability to estimate
carbohydrate intake was poor (due to poor correlation
coefficients for total carbohydrate), automatically calling
into question the accuracy of any GI or GL estimation.
The increased risk of type 2 diabetes with a high GI diet
is likely to be a result of the effects on hyperinsulinemia,
insulin resistance, β-cell demand, and β-cell function .
In rats, a high GI diet over 18 weeks led to significantly
higher areas under the curve for blood glucose and insulin
after oral glucose, lower plasma adiponectin concentrations,
higher triglyceride levels, and severe disruption to islet cell
architecture, together which likely to increase the chances
of developing type 2 diabetes .
There is now a large body of evidence from animal models,
clinical trials, and epidemiologic studies supporting the
benefits of a low GI diet in the prevention and management
of diabetes. Low GI diets have been shown to be associated
with reduced type 2 diabetes risk, improve blood glucose
control in patients with both type 1 and type 2 diabetes, and
may help to reduce the risk of diabetes-related complica-
tions, particularly CVD. Moreover, the benefits of a low GI
diet in improving glycemic control are similar to that which
may be obtained by some medications and sufficient to
significantly reduce the risk of diabetes-related complica-
tions. With respect to prevention, the reduction in risk seen
with a low GI diet is similar to or greater than that for
increasing intake of fiber and whole grains. Finally, there is
no evidence to suggest any negative effect of following a
low GI diet. A low GI diet is consistent with healthy eating
recommendations aimed at weight control and reducing
chronic disease risk, and easily meets all of the goals of
MNT recommended for people with diabetes.
Conflicts of interest
Australia as a co-author of three books on low GI diets; A. Barclay: is a
board member and a consultant for Glycemic Index Ltd., is an employee
for the Australian Diabetes Council, and receives royalties from the New
Glucose Revolution for diabetes for book sales; S. Colagiuri: none; J.
Brand-Miller: receives book royalties for The New Glucose Revolution
series, is the director of a glycemic index testing service at the University
of Sydney, and is the president of the Glycemic Index Foundation.
K. Marsh: receives royalties from Hachette
Papers of particular interest, published recently, have been
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