Public Health Nutrition: 14(12A), 2316–2322
Wholegrain cereals and bread: a duet of the Mediterranean
diet for the prevention of chronic diseases
Angel Gil1,*, Rosa M Ortega2and Jose ´ Maldonado3
1Department of Biochemistry and Molecular Biology II, Centre for Biomedical Research (CIB), Institute of
Nutrition and Food Technology, University of Granada, Avda. del Conocimiento s/n, 18100 Armilla, Granada,
Spain:2Department of Nutrition, School of Pharmacy, Complutense University of Madrid, Spain:3Department of
Paediatrics, School of Medicine, University of Granada, Spain
Submitted 13 May 2011: Accepted 7 September 2011
Objective: The promotion of healthy lifestyles is one of the major goals of
governments and international agencies all over the world. Wholegrain cereals
are rich in nutrients and many phytochemical compounds, with recognised
benefits for health, including dietary fibre, a number of phenolic compounds,
lignans, vitamins and minerals and other bioactive components. The aim of the
present work is to review the fundamental studies that support the consumption
of wholegrain cereals and bread to prevent chronic diseases.
Design: Descriptive review considering human studies.
Setting and subjects: Subjects included in randomised intervention trials and
cohort studies from different countries published up to 2010.
Results: Several studies show consistently that subjects who ingest three or more
portions of foods per day based on wholegrain cereals have a 20–30% lower risk
of CVD than subjects who ingest low quantities of cereals. This level of protection
is not observed with the ingestion of refined cereals, these being even higher
than with the intake of fruit and vegetables. Likewise, high intake of wholegrain
cereals and their products, such as whole-wheat bread, is associated with a
20–30% reduction in the risk of type 2 diabetes. Finally, protection against the risk
of colorectal cancer and polyps, other cancers of the digestive tract, cancers
related to hormones and pancreatic cancer has been associated with the regular
consumption of wholegrain cereals and derived products.
Conclusions: The regular intake of wholegrain cereals can contribute to reduction
of risk factors related to non-communicable chronic diseases.
Foods based on wholegrain cereals, including bread, play
an important part in health and well-being. Thus, research
consistently indicates that the regular consumption of
wholegrain cereals reduces the risk of CVD, type 2 diabetes
mellitus (DM2) and certain types of cancer, as well as several
Wholegrain cereals, those containing all the parts of the
grain (bran, germ and endosperm), are rich in nutrients and
phytochemical compounds, with recognised benefits for
health, such as dietary fibre, antioxidants, including phenolic
compounds, phytoestrogens including lignans, vitamins and
minerals. In fact, the advantages of wholegrain cereals are
related not only to greater fibre content but also to higher
content of essential fatty acids, vitamin-B complex, vitamin
E, Fe, K, Mg, Zn, Se and other bioactive components(2,6).
Most of the substances that promote health in whole-
grain cereals are found in the germ and bran. It is believed
that these compounds exert an additive, synergetic effect on
health when consumed together(7). In particular, cereals
contain various non-amylaceous polysaccharides, namely
cellulose, pentosans and b-glucans. These compounds are
hydrolysed by endogenous digestive enzymes and, being
cell-wall constituents, abound in the external parts of the
grain. Therefore, their content is greater in wholegrain or
less processed flours.
The major compound in bread is starch. Starch is
classified into rapidly digestible starch (RDS), slowly
digestible starch (SDS) and resistant starch (RS)(8)
according to the rate of glucose release and its absorption
in the gastrointestinal tract. SDS, which leads to a slower
entry of glucose into the blood stream and a lower
glycaemic response, is digested completely in the small
intestine at a lower rate as compared to RDS, whereas RS
is the starch portion that cannot be digested in the small
intestine, but is fermented in the large intestine. Experi-
mentally, each starch fraction can be quantified on the
*Corresponding author: Email firstname.lastname@example.org
r The Authors 2011
basis of the in vitro Englyst method(8,9): starch digested
within 20min belongs to RDS, whereas SDS represents the
digested starch between 20 and 120min, and the remaining
fraction is RS. Bread has a variable proportion of SDS and
of RS, according to the variety of grain. In white breads,
the proportion of RS is high, reaching 5?6–8?1% due to the
incomplete gelatinisation of the starch in the crust. Starch in
bread tends to retrograde, so that from the moment the
bread is made, the portion of resistant starch increases over
time, this being more pronounced in pre-cooked breads(10).
Some varieties of French bread (the traditional baguette)
have lower insulinaemic index in healthy subjects, and
lower glycaemic index (GI) in type 2 diabetic subjects, than
that of the other varieties; these results might be due to
bread processing difference rather than fibre content(11).
Soluble fibres present in bread are partially hydrolysed
and used as a substrate by the intestinal microbiota,
augmenting the mass of colon bacteria and the synthesis
of volatile fatty acids – acetic, propionic and butyric acids –
as well as gases such as nitrogen and methane. These fatty
acids can be used by the colonocyte as an energy source. Its
ingestion in the appropriate quantity is associated with
lower levels of plasma cholesterol and TAG as well as a
lower postprandial peak of glucose and insulin(9).
The aim of the present study is to review the fundamental
studies, concerning both epidemiology as well as inter-
vention, which support the consumption of wholegrain
cereals and bread to prevent CVD, DM2, colorectal cancer
and other cancers, as well as certain gastrointestinal
There is ample epidemiological and clinical evidence that
relates the consumption of wholegrain cereals with a
reduced risk of coronary disease(10,11). Subjects who
ingest three or more rations of foods per day based on
integral cereals have a 20–30% lower risk than subjects
who ingest low quantities of cereals, and this level of
protection is not observed with the ingestion of refined
cereals, these being even higher than with the intake of
fruits and vegetables(1,6,12–16).
Morris et al.(17), after studying 337 subjects for 10–20
years, concluded that the reduction in the risk of CVD
was attributable to a greater consumption of cereal fibre,
whereas other sources of soluble fibre such as pectin and
guar gum did not present the same effect. In addition, an
analysis of several cohort studies on dietary fibre and
coronary disease risk showed that the consumption of
dietary fibre from cereals and fruits was inversely asso-
ciated with the risk of coronary disease(18). Other large
surveys have found a moderate association between the
intake of wholegrain cereal and the lowering of CVD risk.
In an extensive prospective health study in Iowa (USA),
34492 postmenopausal women aged 55–69 years and
free of CVD were tracked to determine the occurrence
of mortality by CVD (n 387) from 1986 to 1994(15). The
lowering of the risk in the highest quintile of wholegrain
cereal intake was controlled for more than fifteen vari-
ables and was not explained by the adjustment of the
consumption of dietary fibre. This suggests that other
components of wholegrain cereal that are not dietary
fibre may reduce the risk of CVD.
A Finnish study of 21930 men who smoked (50–69
years of age) was monitored for 6?1 years(16). The lower
risk of CVD was associated with the increase in the intake
of products containing rye. Rimm et al.(19)examined the
association between cereal consumption and the risk of
myocardial infarction (MI) in 43757 health professionals
in the USA, aged 40–75 years. Cereal fibre was the factor
most strongly associated with a reduced risk of MI, with a
0?71 decline in the risk per 10g increase in the ingestion
of cereal fibre.
The Nurses’ Health Study, an extensive prospective
cohort study tracking women in the USA for 10 years, was
also used to examine the relationship between cereal
consumption and cardiovascular risk(1). A total of 68782
women aged between 37 and 64 years without prior
diagnosis of angina, MI, apoplexy, cancer, hypercholes-
terolaemia or diabetes were examined at the beginning of
the study. The authors controlled for age, cardiovascular
risk factors, dietary factors and the use of multivitamin
supplements. For an increase of 10g/d in the total con-
sumption of fibre, the risk of CVD was 0?81 (95% CI 0?66,
0?99). Among the different sources of dietary fibre (cereal,
vegetables and fruit), only cereal fibre proved to be
strongly associated with a lower risk of CVD.
As wholegrain cereals are a major source of dietary
fibre in many countries, it is difficult to separate the
protection of dietary fibre from that of wholegrain cereals.
In a study tracking health professionals, Jensen et al.(6)
examined the consumption of wholegrain cereals, bran
and germ in relation to the risk of coronary disease from
the data on food consumption frequency. Added germ
was not associated with CVD risk, leading the authors to
conclude that the study supported the association of the
benefits described between the consumption of whole-
grain cereals and the reduction of CVD, suggesting that
the bran of wholegrain cereal could be a key factor in this
relation. The regular consumption of foods that include
wholegrain cereals appears to protect against CVD. Van
Dam et al.(20)reported that the consumption of refined
diets that did not include wholegrain cereals was associated
with higher levels of blood cholesterol and lower con-
sumption of micronutrients. Prudent eating habits, including
the intake of wholegrain cereals, was associated with a
lower level of reactive protein C and endothelial dysfunc-
tion, an early step in the development of atherosclerosis(21).
The consumption of foods based on wholegrain cereals was
also associated with lower reactive protein-C concentrations
in the Nurses’ Health Study(22). In addition, a prospective
Wholegrain cereals, bread and chronic diseases2317
cohort study of post-menopausal women found that the
consumption of cereal fibre and the ingestion of whole-
grain cereal reduced the progression of atherosclerosis
in the coronary artery(23). In a subsample of the Study
Tracking Health Professionals and the Nurses’ Health
Study II, a broad range of biomarkers related to CVD(24)
was measured. Greater consumption of wholegrain cereal
was associated with lower homocisteine and total cho-
lesterol. Thus, these results suggest a lower risk of cardiac
disease in persons who consume diets high in whole
grains. In this sense, Sayoun et al.(25), have published a
significant inverse trend between the intake of whole-
grain cereal and mortality by CVD, independently of
demography, lifestyle or dietary factors. In addition, glucose
while fasting and the BMI diminished as the quartiles
increased in the category of wholegrain consumption.
Type 2 diabetes mellitus
Nutrition is considered by health professionals to be a
basic tool to control the blood glucose levels and there-
fore to treat diabetes. Several epidemiological studies
have shown that the high intake rates of wholegrain
cereals and their products, such as whole-wheat bread,
are associated with a 20–30% reduction in the risk of
DM2(25,26). Furthermore, evidence from observational and
interventional studies indicates that the consumption of
wholegrain cereals improves the plasma glucose levels as
well as insulinaemia, reducing tissue resistance to insu-
lin(2,26). On the other hand, the data available indicate
that the components of wholegrain cereals overall are
responsible for the lowering of risk, as the fibre from fruit
and vegetables does not exert the same effects(27). In fact,
Montonen et al.(27)found an inverse relation between the
intake of total fibre, especially cereal fibre, and the risk of
type 2 diabetes, whereas fibre derived from fruit or vege-
tables did not have an effect on diabetes risk. Adjustment for
cereal fibre considerably weakened the association between
wholegrain consumption and type 2 diabetes risk, which
suggests that the relation of whole grain may be due to
cereal fibre or to factors related to cereal fibre intake.
With the exception of a few foods, most contain carbo-
hydrates in different proportions. However, from the nutri-
tional standpoint, not only the quantity is important but also
the speed with which it is absorbed, this being influenced
by a number of factors such as the type of carbohydrate
(glucose, fructose, sucrose, lactose), the nature of the starch
(amylose, amylopectin, RS), the method of preparation
(manner and time of cooking, quantity of heat used), the
degree of processing of the foods (degree of gelatinisation
of the starch, particle size, the form of the food) and other
components (e.g. natural substances that slow down
digestion like pectins, phytates and tannins)(8,11).
With the aim of comparing the effects of specific foods
in the blood sugar response, in 1981 the concept of GI
was introduced. For this index to be established, healthy
volunteers who had fasted for the night had their gly-
caemia levels measured after ingesting a set quantity of
the food in question (the quantity of food was adjusted
to provide 50g of glycaemic or biologically available
carbohydrate). The glycaemia was measured in pre-
viously established time intervals up to a maximum of
120min. These measurements were compared with those
of a reference product such as glucose (50g), to which an
index of 100 was arbitrarily assigned. The quotient
between the areas of the respective curves was called the
GI(3). Initially, the reference product for the determina-
tion of the GI was white bread, but the bread generated a
variable glycaemic curve, depending on its composition
and preparation, especially the variable content of RS.
In fact, traditional white breads can vary their GI with
respect to glucose from 74% to 100%(8).
The concept of GI appears to be a useful tool for
glycaemic tracking in diabetic patients. In addition, diets
with a low GI have the capacity to reduce the secretion
of insulin and diminish blood lipid concentrations, as
demonstrated in several clinical tests(28). Diabetic patients
who ingested bread having a low GI and made with the
addition of fibre from wholegrain cereals registered a
reduction in the blood glucose values(29)as well as in the
cholesterol and TAG levels, compared with those who
followed a diet with a high GI(5,30). However, the GI did not
take into account the quantity of carbohydrates consumed,
an important determinant of the glycaemic response. For
example, most fruits have a high GI and would appear
not to be a good choice as part of a diet with a low GI.
Nevertheless, fruit usually have a low content of carbo-
hydrates, and therefore their glycaemic effect is minimal.
Given that foods differ in carbohydrate content, Willett et al.
defined the glycaemic load (GL) in 1997 as the arithmetic
product of GI and the quantity of carbohydrates ingested(3).
Another important concept is that of the glycaemic
glucose equivalent (GGE) of a food. The GGE refers to
the relative tendency of a given quantity of food con-
sumed at a single time, such as a portion, to induce a
postprandial glycaemic response. The GGE is measured
directly by the quantity of reference glucose necessary to
give the same glycaemic response as a relevant quantity
of a given food(31).
Bread belongs to a group of foods that increase the
insulin response, as its main carbohydrate is gelatinised
starch, easily digested by human amylases, and therefore
usually gives rise to high glycaemic responses. Whole-
grain breads have a lower GL than do corresponding
white breads and therefore offer better control for post-
Breads made with wholegrain cereals, for reasons dis-
cussed for the whole grains in terms of their content of
fibre and resistant starches, present lower GI values. The
incorporation of soluble fibre in great quantities (bread
made of oat bran) augments viscosity of the bolus, limits
2318A Gil et al.
the access of amylotic enzymes and diminishes the diffusion
of the glucose through the mucosa, giving these products
a far lower GI. In addition, rye breads made with sour
dough, due to the presence of organic acids, appear to
diminish postprandial glycaemia and insulinaemia. In
addition, flatbread has a more compact structure and
therefore slower digestion and a lower GI. For all the
above, breads made traditionally with high fibre contents
are useful for controlling postprandial glycaemia in sub-
jects with intolerance to glucose and with diabetes(8).
It has been reported that the ingestion of fibre from
wholegrain cereals is inversely related to DM2. In a long-
term study of almost 90000 women(31), and in a similar
study of nearly 45000 men(32), it was found that those
who consumed more cereal fibre had an approximately
30% lower risk of developing DM2, compared with those
with lower consumption. In addition, in the study on
women’s health in Iowa (USA), it was found that the
consumption of dietary fibre and wholegrain cereal pro-
tected against DM2(33). In another study, individuals who
consumed mainly refined cereals and little wholegrain
cereal had a 57% greater risk of DM2 than those who
consumed higher quantities of wholegrain cereals(34). In
the Study Tracking Health Professionals, one part monitor-
ing 42898 men consuming approximately three rations of
wholegrain cereal per day associated this consumption with
a 37% lower risk of DM2(35). In addition, when the data
were brought together for prospective cohort studies, the
consumption of wholegrain cereal was found to reduce the
relative risk of DM2 by 30%(36,37).
Pereira et al.(38), studying hyperinsulinaemic subjects
who were overweight or obese, tested the hypothesis that
the consumption of wholegrain cereal improves the tissue
sensibility of the insulin in overweight and obese adults.
Eleven adults followed two diets, each for 6 weeks. The
two diets were identical except that in one of them the
products of refined cereal, mainly bread, were replaced
by wholegrain products. The insulin during fasting
proved 10% lower during the diet with the integral cereal.
Thus, the authors concluded that sensitivity to insulin may
be an important mechanism by which foods based on
whole grains reduce the risk of DM2 and cardiac disease.
Juntunen et al.(39)evaluated the factors affecting
plasma glucose and the insulin response after the inges-
tion of cereal products. Several subjects consumed dif-
ferent cereal products: bread with wholegrain rye,
wholegrain rye bread with a b-glucan concentrate from
oats, pasta made of dark Durum wheat and wheat bread
made from white wheat flower. The glucose responses
and the index of gastric emptying after the consumption
of the two rye breads and the pasta did not differ from
those after the consumption of white wheat bread.
However, the insulin, the glucose-dependent insulino-
tropic polypeptide and the peptide analogous to type-1
glucagon were lower after the consumption of the rye
breads and dark pasta than after the consumption of
white wheat bread. Thus, the postprandial insulin responses
to cereal products may be determined by the form of the
food and the botanical structure more than by the quantity
of fibre or the type of cereal in the food. McKeown et al.(40)
have reported that the consumption of wholegrain cereal in
the Framingham Children’s Study is inversely associated
with the index of body mass and insulin during fasting.
Juntunen et al.(41), studying postmenopausal women
who consumed high-fibre rye bread and white wheat
bread, measured the glucose and insulin metabolism. The
acute response of insulin significantly augmented more
during the period of consuming rye bread than during that
of consuming white wheat bread. This suggests that high-
fibre rye bread favours the secretion of insulin. In another
study, foods based on rye and wheat was offered to middle-
aged overweight men(42). The men consumed cereals low in
fibre that provided 5g of dietary fibre in the diet of refined
cereals and 18g of fibre in the diet of the wholegrain cereal,
whether high in rye or wheat. All this was additional to a
basal diet that contained 14g of fibre. The postprandial
insulin fell 46–49% and postprandial glucose dipped
16–19% after the consumption of the wholegrain diet.
Qi et al.(43), examining whether the ingestion of whole-
grain cereals and dietary fibre was associated with inflam-
matory indicators among 902 diabetic women in the Nurses’
Health Study, suggested that the wholegrain cereals and a
diet with a low GI could reduce systemic inflammation
among women with DM2. In addition, Jensen et al.(24)
found in 938 healthy men and women that the consumption
of wholegrain cereal was inversely related more strongly to
the plasma markers of glycaemic control (insulin during
fasting, glycosylated Hb A1c, peptide C and leptin).
The consumption of wholegrain cereals has in several
studies been associated with a reduced risk of some types
of gastrointestinal cancer. In a meta-analysis on the con-
sumption of wholegrain cereals and cancer that analysed
all the studies conducted up to 1998 indicated protection
against the risk of colorectal cancer and polyps, other
cancers of the digestive tract, cancers related to hormones
and pancreatic cancer(44). In addition, a systematic review
of case–control studies carried out using a common
protocol in northern Italy between 1983 and 1996 indi-
cated that a greater frequency in the consumption of
wholegrain cereal is associated with a lower risk of cancer(45).
Wholegrain cereal is consumed primarily as wholegrain
bread and some as wholegrain pasta. Cohort studies have
shown a lower risk for specific cancers, such as colorectal
in women(46), stomach(47), mouth/throat and the upper
digestive tract(48)and endometrium(49).
A review of forty studies on gastrointestinal cancer has
found a reduction in cancer risk from 21% to 43% in
subjects with high consumption of wholegrain cereals
Wholegrain cereals, bread and chronic diseases2319
compared to those with low consumption(2). In addition,
in more recent cohort studies, the intake of wholegrain
cereals has been associated with a moderate reduction
in colorectal cancer risk(50,51). Furthermore, in a recent
meta-analysis, it was shown that the intake of products
having a low GI and GL, including products based on
cereals with a high fibre content, was associated with a
lower risk of colorectal, pancreatic, endometrium and
breast cancer(52). However, a recent study published
jointly between the World Cancer Research Fund and the
Institute for Cancer Research on the relative risk of different
types of cancer in relation to different lifestyles found no
association between the specific consumption of cereals
and colorectal cancer(53). On the other hand, another meta-
analysis indicated that the consumption of foods with a low
GI or GL was not associated with a reduction in colorectal or
pancreatic cancer(54). However, the studies that examine the
association of the consumption of cereals with hormone-
dependent cancers are very limited.
Several mechanisms have been proposed for the action
of cereals in relation to cancer. The fibre and certain
resistant starches found in cereals and their products, as
in the case of bread, ferment in the colon and contribute
to reduction of the intestinal transit and improvement of
intestinal health. Cereals also contain antioxidants that
can protect against oxidative damage, which can play a
fundamental role in the development of cancer. Other
bioactive compounds in wholegrain cereals may affect
the hormonal levels and probably the hormone-dependent
cancers. The potential mechanisms include shifts in
the plasma-glucose values and weight loss(2). In addition,
the lowering of insulin levels by wholegrain cereals can
be an indirect way by which cancer risk is reduced, given
that several epidemiological studies have suggested that
higher levels of insulin are associated with a greater risk
of colon, breast and possibly other types of cancer.
Dietary factors, such as the intake of fibre, vegetables,
fruits, antioxidants, vitamin B6and phytoestrogen, as well
as lifestyle factors such as exercise, smoking and alcohol
intake, which are controlled for in most epidemiological
studies, do not explain the apparent protective effect of
wholegrain cereals against cancer, again suggesting that it
is the complete package of the wholegrain cereal that is
Various theories have been proposed to explain the
protective effects of wholegrain cereals. Thus, the
increase in the faecal mass and the decrease in transit time
give less opportunity to the faecal mutagens to interact
with the intestinal epithelium. Secondarily, it is thought
that the sequestration by fibre of the bile acids, which
promote cell proliferation, can diminish the frequency of
mutations. Wholegrain cereals also contain anti-nutrients,
such as protease inhibitors, phytic acid, phenolic com-
pounds and saponins, which until recently were thought
to have only a negative nutritional consequence. Some of
these anti-nutrient compounds may act as cancer inhibitors
by preventing the formation of carcinogens and blocking
the interaction of carcinogens with cells. Other potential
mechanisms of wholegrain cereals to lower cancer risk
include effects of lignans. Lignans are compounds that have
a 2,3-dibenzylbutane structure, and there are minority con-
stituents of many plants that form construction blocks to
create lignin in the cell wall of the plant. Owing the relation
of the excretion of lignans with fibre consumption, it is
assumed that vegetal lignans are contained in external layers
of the grain. Concentrated sources of lignans include whole
wheat, whole oats and whole rye. Seeds are also a con-
centrated source of lignans, including flax seeds (the most
concentrated source), pumpkin seeds, caraway seeds and
Cereals and other foods rich in fibre increase the
urinary excretion of lignans, an indirect measure of the
lignan content in food(55,56). In addition, they are posi-
tively related to the consumption of products based on
wholegrain cereals(57). Similar results were found in a
study in the USA(58)in which the subjects consumed
either wholegrain-based foods or refined-grain foods
(especially bread) for 6 weeks. Most of the increase in
serum enterolactone occurred when the subjects con-
sumed the diet based on wholegrain bread. Serum
enterolactone has been associated not only with a decline
in the risk of cancer, but also with a lower CVD related to
all the causes of mortality in middle-aged Finnish men(59).
The components of wholegrain cereals, including fibre, RS
and oligosaccharides, play a fundamental role in the main-
tenance of intestinal homeostasis. Several studies have sug-
gested that the dietary fibre from grains and whole cereals
augments the weight of the stool and absorb water, and the
partial fermentation of the fibre in the colon as well as of the
oligosaccharides promotes the growth of beneficial bacteria
in the faeces(2,27). RS is not digested in the same way as
ordinary starch, passing through the intestine to the colon,
where it is fermented, and behaving in all senses like soluble
dietary fibre. The main content of faecal residue facilitates
intestinal peristalsis and defecation. All this helps alleviate
symptoms of constipation and contributes to lowering the
risk of developing diverticulosis and diverticultitis(60).
McIntosh et al.(42)offered foods based on rye and
wheat to overweight middle-aged men and measured
markers of intestinal health. The food based on rye and
wheat with high fibre content increased the faecal eva-
cuation by 33–36% and diminished the activity of faecal
b-glucuronidase by 29%.
The regular intake of wholegrain cereals may contribute
to reduction of the risk factors related to non-communicable
2320 A Gil et al.
chronic diseases, particularly those of CVD, DM2 and
certain types of cancer, as well as several gastrointestinal
A.G. and J.M. are funded in part by the Instituto de Salud
Carlos III del Ministerio de Ciencia e Innovacio ´n. Red
SAMID RETIC n. RD08/0072. The authors have no conflict
of interest to declare related to the topic and content of
the article. The authors thank the Mediterranean Diet
Foundation for its valuable comments and suggestions.
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