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Relationship of Nutrition toBlood Glucose Control
Arline McDonald, Ph.D.December 4, 2001
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Blood Glucose Responses to Diet
Short-term=Postprandial
response
Long-term=AdaptiveResponse to Diet/Exercise
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Blood Glucose Abnormalities
Abnormality Diet-Induced Underlying Associations
Hyperinsulinemia
Normoglycemia Yes Rapidly absorbed sugars
Hyperglycemia Yes Obesity, hypertension,hyperlipemia
Hypoglycemia
Fasting Yes Absence of food > 8 hrsPostprandial Yes Rapidly absorbed sugars,
alcohol
Idiopathicreactive
No High insulin sensitivity +reduced glucagon
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Conditions Requiring DietaryManagement for Blood Glucose Control
Diabetes mellitusType IType II
Hypertension Hyperlipidemia Liver disease Renal disease Cancer Obesity
Trauma
Sepsis Treatment with:HydrochlorothiazideChlorpropamidePropranololPrednisoneSulfonylureas
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Diabetes Prevention Program3-year Incidence of Type II Diabetes
0
5
10
15
20
2530
35
Placebo Metformin Diet + Exercise
New Engl J Med 2001; 344:1343
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Relationship of Source of Energyto Incidence of Type I Diabetes 1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.40.6
0.8
TotalPlantCerealsAnimalDairyMeat
1 40 countries ecologic data
AJCN 2000;71:1525-9.
*
***
***
****
**
*p
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The Postprandial Plasma GlucoseResponse (Glucose Tolerance)
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0 15 30 45 90 120 150 180
Plasma Glucosemg/dL
MinutesIngestio
n
Area Under Curve
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Plasma Glucose Response toDifferent Carbohydrate Sources
6080
100
120140160180
200220
0 15 30 45 90 120 150 180
Minutes
Standard
Simple Sugar Soluble Fiber + Sugar
Starch
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Fate of Dietary Carbohydrate
Glucose90 g
Glycogen20 g
Adipose Tissue
Triglyceride
2 g
CO 2
15-20 g
MuscleGlycogen25 g
ATP20 g20-45 g
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Proposed Etiology of Diet-InducedInsulin Resistance
GlucoseInsulin
Available glucosefrom soluble, rapidlydigested CHO with
high energy density
Rapid absorption& rise in glucose
to high peakconcentrationsInsulin secretion in
concentration torestore blood
glucose to fasting
levels
Downregulationof tissue insulin
receptors
High insulin peakRepeated highinsulin peaks
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Receptor Modification inInsulin Resistance Receptor number
Receptor activity
Post-receptor defect Enzyme activation Glucose transporters
Downregulation dietary glycemic index dietary fat body fat
Composition of dietary fat
Stress Response counterregulatoryhormones
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Metabolic Consequences of Insulin Resistance
Stimulation of SNS activity
Altered smooth muscle cellCa ++ transport
Increased renal sodiumreabsorption/retention
Mitogenic stimulation of vascular smooth musclecells
Increased plasminogenactivator inhibitor-type 1activity
Blood pressure
Fibrinolysis
Vascular tone
Plasma Volume
Atherogenesis
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Metabolic Consequences of Hyperglycemia
Microvascular Disease
Retinopathy
Nephropathy
Infection
NeuropathyMacrovascular Disease
Thickening of capillarybasement membrane
Retinal ischemia/vascularchanges & RBC aggregation
Glomerular injury fromprotein denaturation
Glycosylated Hgb/ O2 Microbial growth
?? Relationship toblood glucose
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Glycemic Index
Describes the incremental increase in bloodglucose from fasting levels over a definedtime interval following ingestion of CHO(AUC) relative to a standardProperty of food sources of digestible CHO
Function of efficiency of digestion andrate of absorption
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Glycemic Indexes of Foods
FoodAUC mg/L at
3 hours
100
866 100 811 94 652 75 954 110 () 424 49
583 67 () 638 74 263 30 263 30 258 30
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Primary Determinants
of Glycemic Index
Amount of Carbohydrate
Portion size Energy density
Availability of Carbohydrate Solubility Digestibility Extent of processing Type of processing
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Simple Sugars
highly solubleliquid formlow fiber contenthigh energy content
high Na + content
Starches
highly digestible amylopectin > amylose amylose > resistant starch refined starch > simple
sugars with fiber
High Glycemic Index Carbohydrates
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Effects of Soluble (Viscous) Dietary
Fiber on Blood Glucose Control
Direct Effects decreases rate of digestion
impedes access to digestive enzymes decreases rate of absorption
slows rate of diffusion across unstirred layer
Indirect Effects decreases absorption of dietary fat
inds bile acids regulates appetite
Ileal brake-second-meal effect
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Simple Sugar (SS) with andwithout Soluble Fiber (SDF )
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80
100
120
140
160180
200
220
0 15 30 45 90 120 150 180
Minutes
StandardSS
SS & SDF
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Starch With and WithoutSoluble Dietary Fiber (SDF )
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0 15 30 45 90 120 150 180
Minutes
StandardStarchStarch & SDF
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Noncarbohydrate Influences
On Glycemic Index
Dietary fat
Slows gastric emptying (short-term) Decreases insulin clearance (long-term)
Dietary sodium Facilitates glucose transport via
Na+-linked transporter Physical Activity Increases insulin sensitivity
improved skeletal muscle glucose transport kinetics
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Effects of Dietary Fat on
Blood Glucose Control
Total Amount
Determines gastricemptyingInhibits insulinclearance by
increased FFA inportal circulationContributes to bodyfat stores
Fatty Acid Composition
Saturated fatmembrane fluidity &receptor functionnumber of glucosetransporters
Monounsaturated fat promotes insulin secretion -6: 3 PUFA ratio membrane fluidity
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Relationship of Fasting Insulin to
Dietary Polyunsaturated Fat-C20-22
12 14 16 18 20 2224 26
25
20
15
10
5
r=-0.68; p< 0.001
C20-22 PUFA (% Total Fatty Acids)
F a s t
i n g
I n s u
l i n
( U / m L )
New Engl J Med 1993;328:238
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Relationship of Fasting Insulin to Ratioof C20:4 (arachidonic) to C20:3 (eicosapentanoic)
4 6 8 1012
25
20
15
10
5
r=-0.55; p= 0.003
Ratio of C20:4 to C20:3
F a s t
i n g
I n s u
l i n
( U / m L )
New Engl J Med 1993;328:2
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Glucose Response
to Monounsaturated Fatty Acids
0
2
4
6
810
12
Fasting Postprandial
StarchMUFA
Diabetes Care 1993; 14:1115.
CHO/Fat= 60:20 for starch and 40:40 for MUFA
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Insulin Response to
Monounsaturated Fatty Acids
0
2
4
6
810
12
Fasting Postprandial
StarchMUFA
CHO/Fat= 60:20 for starch and 40:40 for MUFA
Diabetes Care 1993; 14:1115.
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Effects of Energy Intake on
Blood Glucose Control
Relates to amount of carbohydrate and fat
Provides excess or deficiency of micronutrientsthat influence effectiveness of insulin Zinc, potassium, magnesium, chromium, vitamin E
Contributes to body fat If not balanced with expenditure Preferentially deposited in abdomen (age, gender)
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Relationship of Intake* to Storage
Capacity for Dietary CHO and Fat
100
1.67 0.570
20
40
60
80
100
120
CHO
Protein Fat
*Based on Intake of 40% CHO, 40% Fat, and 20% Protein
Bray, 1993
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Obesity and Insulin Resistance
Abdominal vs Glutealhigh portal free fatty acidconcentration inhibitshepatic insulin clearancehigher insulin levelrequired to facilitateglucose uptake
Pear-shape:Gluteal/Femoral
Fat DepositsGynoid Pattern
Apple-shape:Abdominal
Fat DepositsAndroidPattern
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Effects of Physical Activity
on Blood Glucose Control
prevents weight gain
increases muscle mass/fat mass ratioPromotes mobilization of free fatty acidsfrom abdominal adipocytesreduces km of skeletal muscle glucosetransportersenhances glycogenesis for up to 48 hourspost-activity
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Effects of Distribution of Energy
Intake on Blood Glucose Control
Variable Low GlycemicIndex
High GlycemicIndex
+ - + -Frequency of Eating
5-6 0 5-6 1-2
Energy Density/
Portion Size
High/Low
Small
High/
Large
Low/
Small
High/
Large
Timing Prior to orafter
activity
Noissues
Afteractivity
Beforeactivity
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Effects of Dietary Protein
on Blood Glucose Control
Minimal effect on postprandial blood glucoseresponse
AlanineGlycine Glucose Glucose
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Effects of Micronutrients on
Blood Glucose Control
Insulin Response
Chromium Zinc Vitamin E
CarbohydrateMetabolism Potassium Magnesium
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Summary of Dietary Effects on
Postprandial Glucose Response
Fat
Chemicalproperties
ViscousFiber
Physical form
Sources Available Carbohydrate
Interval to restoration of fasting glucose levels
Rate of glucose absorption
Rate of insulin release
Digestibility
SolubilityGastric Emptying Time
SodiumInsulin
resistance Obesity
Activity
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Summary
Short-term insulin response is dependent on
amount and digestibility of CHO, food matrix,and other components of the mealInsulin resistance can develop as anadaptive response to chronic intake of highglycemic loadsDietary modifications can facilitate insulineffectiveness
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Predicting the Postprandial
Plasma Glucose Response
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Plasma Glucosem
g/dL
Minutes from Ingestion
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What has been ingested?
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Plasma Glucosem
g/dL
Minutes from Ingestion
High protein drink
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What has been ingested?
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Plasma Glucosem
g/dL
Minutes from Ingestion
High energy=refined sugar + starch
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Predicting the Postprandial
Plasma Glucose Response
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0 15 30 45 90 120 150 180
Plasma Glucosem
g/dL
Minutes from Ingestion
High Soluble Fiber + Starch