Relationship of Nutrition to

Blood Glucose Control

Arline McDonald, Ph.D.

December 4, 2001

1
 Blood Glucose Responses to Diet

Long-term=Adaptive
Response to Diet/Exercise

Short-term=
Postprandial
response

2
 Blood Glucose Abnormalities

Abnormality Diet-Induced Underlying Associations

Hyperinsulinemia
Normoglycemia Yes Rapidly absorbed sugars
Obesity, hypertension,
Hyperglycemia Yes hyperlipemia
Hypoglycemia
Fasting Yes Absence of food > 8 hrs
Rapidly absorbed sugars,
Postprandial Yes alcohol
Idiopathic High insulin sensitivity +
reactive
No reduced glucagon
3
 Conditions Requiring Dietary
Management for Blood Glucose Control
– Diabetes mellitus – Trauma
 Type I – Sepsis
 Type II
– Treatment with:
– Hypertension
 Hydrochlorothiazide
– Hyperlipidemia  Chlorpropamide
– Liver disease  Propranolol
– Renal disease  Prednisone
– Cancer  Sulfonylureas
– Obesity

4
 Diabetes Prevention Program
3-year Incidence of Type II Diabetes

35

30

25

20
15

10

5
Percentage of Group
0
Placebo Metformin Diet + Exercise
New Engl J Med 2001; 344:1343
5
 Relationship of Source of Energy
to Incidence of Type I Diabetes1

0.8
0.6 Total
0.4 **** Plant
** ***
0.2 Cereals
NS Animal
0
Dairy
-0.2 * Meat
-0.4 ***
regression coefficient
-0.6
-0.8
1
40 countries ecologic data *p<0.05 **p<0.01 ***p<0.001
****p<0.0001
AJCN 2000;71:1525-9.
6
 The Postprandial Plasma Glucose
Response (Glucose Tolerance)
200
180
Plasma Glucose mg/dL

160
140
120
100 Area Under Curve
80
60
0 15 30 45 90 120 150 180

Ingestion Minutes

7
 Plasma Glucose Response to
Different Carbohydrate Sources
220
200 Standard
180 Simple Sugar
160 Soluble Fiber + Sugar
Starch
140
120
100
80 glucose (mg/dL)
Blood
60
0 15 30 45 90 120 150 180
Minutes

8
 Fate of Dietary Carbohydrate
CO2

15-20 g

2g Glucose 20 g
Glycogen
90 g
Adipose
20-45 g 20 g ATP
Tissue
25 g
Glycogen
Triglyceride Muscle

9
 Proposed Etiology of Diet-Induced
Insulin Resistance
Repeated high
Rapid absorption High insulin peak insulin peaks
& rise in glucose
to high peak
concentrations
Insulin secretion in
Downregulation
concentration to
of tissue insulin
restore blood
receptors
glucose to fasting
Available glucose levels
from soluble, rapidly
digested CHO with
Glucose
high energy density
Insulin

10
 Receptor Modification in
Insulin Resistance
 Receptor number Downregulation
 dietary glycemic index
 dietary fat
 body fat

 Receptor activity Composition of dietary fat

Post-receptor defect Stress Response

• Enzyme activation  counterregulatory
• Glucose transporters hormones
11
 Metabolic Consequences of
Insulin Resistance
Stimulation of SNS activity  Blood pressure

Altered smooth muscle cell Ca++  Vascular tone

transport

Increased renal sodium

reabsorption/retention  Plasma Volume

Mitogenic stimulation of vascular

smooth muscle cells  Atherogenesis

Increased plasminogen activator  Fibrinolysis

inhibitor-type 1 activity

12
 Metabolic Consequences of
Hyperglycemia
Thickening of capillary Microvascular Disease
basement membrane

Retinal ischemia/vascular Retinopathy

changes & RBC aggregation

Glomerular injury from Nephropathy

protein denaturation

Glycosylated Hgb/ O2 Infection

 Microbial growth

?? Relationship to Neuropathy
blood glucose Macrovascular Disease

13
 Glycemic Index

 Describes the incremental increase in blood

glucose from fasting levels over a defined
time interval following ingestion of CHO
(AUC) relative to a standard
 Property of food sources of digestible CHO
 Function of efficiency of digestion and
rate of absorption

14
 Glycemic Indexes of Foods
AUC mg/L at ⎫Standard
Food
3 hours x 100
W hite bread 866 100
W hole w heatbread 811 94
R ice 652 75
C ornflakes 954 110
O atm eal(coarse) 424 49
Spaghetti 583 67
Potatoes (boiled) 638 74
Lentils 263 30
C hickpeas 263 30
K idney beans 258 30

15
 Primary Determinants
of Glycemic Index

 Amount of Carbohydrate
– Portion size
– Energy density
 Availability of Carbohydrate
– Solubility
– Digestibility
– Extent of processing
– Type of processing

16
 High Glycemic Index Carbohydrates

Simple Sugars Starches

 highly soluble  highly digestible
 liquid form – amylopectin > amylose
 low fiber content
– amylose > resistant starch
– refined starch > simple
 high energy content
sugars with fiber
 high Na+ content

17
 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

18
 Simple Sugar (SS) with and
without Soluble Fiber (SDF)
220
200 Standard
180 SS
160 SS & SDF
140
120
100
80 glucose (mg/dL)
Blood
60
0 15 30 45 90 120 150 180
Minutes

19
 Starch With and Without
Soluble Dietary Fiber (SDF)

200
180 Standard
160 Starch
140 Starch & SDF

120
100
80
Blood glucose (mg/dL)
60
0 15 30 45 90 120 150 180
Minutes
20
 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
21
 Effects of Dietary Fat on
Blood Glucose Control

Total Amount Fatty Acid Composition

 Determines gastric  Saturated fat

emptying   membrane fluidity &

receptor function
 Inhibits insulin   number of glucose
clearance by transporters
increased FFA in  Monounsaturated fat
portal circulation – promotes insulin secretion
 Contributes to body  -6:3 PUFA ratio
fat stores – membrane fluidity

22
 Relationship of Fasting Insulin to
Dietary Polyunsaturated Fat-C20-22
25 r=-0.68; p< 0.001
Fasting Insulin (U/mL)

20

15

10

5
New Engl J Med 1993;328:238

12 14 16 18 20 22 24 26
C20-22 PUFA (% Total Fatty Acids)
23
 Relationship of Fasting Insulin to Ratio
of C20:4 (arachidonic) to C20:3 (eicosapentanoic)

25
r=-0.55; p= 0.003
Fasting Insulin (U/mL)

20

15

10 New Engl J Med 1993;328:238

4 6 8 10 12
Ratio of C20:4 to C20:3
24
 Glucose Response
to Monounsaturated Fatty Acids

12

10

6 Starch
mmoL/L MUFA
4

0
Fasting Postprandial
CHO/Fat= 60:20 for starch and 40:40 for MUFA
Diabetes Care 1993; 14:1115.
25
 Insulin Response to
Monounsaturated Fatty Acids

12

10

6 Starch
umoL/L MUFA
4

0
Fasting Postprandial
CHO/Fat= 60:20 for starch and 40:40 for MUFA
Diabetes Care 1993; 14:1115.
26
 Effects of Energy Intake on
Blood Glucose Control

 Relates to amount of carbohydrate and fat

 Provides excess or deficiency of micronutrients
that 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)

27
 Relationship of Intake* to Storage
Capacity for Dietary CHO and Fat

120
100
100

80

60 CHO
40
Intake
20 as % of Stores
Protein Fat
1.67 0.57
0
*Based on Intake of 40% CHO, 40% Fat, and 20% Protein
Bray, 1993
28
 Obesity and Insulin Resistance

Abdominal vs Gluteal
Apple-shape:
 high portal free fatty acid Abdominal
concentration inhibits Fat Deposits
hepatic insulin clearance Android Pattern
 higher insulin level
required to facilitate
glucose uptake
Pear-shape:
Gluteal/Femoral
Fat Deposits
Gynoid Pattern
29
 Effects of Physical Activity
on Blood Glucose Control

 prevents weight gain

 increases muscle mass/fat mass ratio
 Promotes mobilization of free fatty acids
from abdominal adipocytes
 reduces km of skeletal muscle glucose
transporters
 enhances glycogenesis for up to 48 hours
post-activity

30
 Effects of Distribution of Energy
Intake on Blood Glucose Control

Low Glycemic High Glycemic

Index Index
Variable
+ - + -

Frequency of 5-6 0 5-6 1-2

Eating
Energy Density/ High/Low High/ Low/ High/
Portion Size Small Large Small Large

Timing Prior to or No issues After Before

after activity activity activity

31
 Effects of Dietary Protein
on Blood Glucose Control

 Minimal effect on postprandial blood glucose

response

Alanine
Glycine Glucose Glucose

32
 Effects of Micronutrients on
Blood Glucose Control

 Insulin Response  Carbohydrate

– Chromium Metabolism
– Zinc – Potassium
– Vitamin E – Magnesium

33
 Summary of Dietary Effects on
Postprandial Glucose Response
Sources Available Carbohydrate
Fat Physical form
Solubility
Viscous
Fiber Gastric Emptying Time
Chemical
Digestibility properties
Rate of glucose absorptionInsulin
Activity
Sodium resistance
Rate of insulin release
Obesity
Interval to restoration of fasting glucose levels
34
 Summary

 Short-term insulin response is dependent on

amount and digestibility of CHO, food matrix,
and other components of the meal
 Insulin resistance can develop as an
adaptive response to chronic intake of high
glycemic loads
 Dietary modifications can facilitate insulin
effectiveness
35
 Predicting the Postprandial
Plasma Glucose Response
200
Plasma Glucose mg/dL

180
160
140
120
100
80
60
0 15 30 45 90 120 150 180

Minutes from Ingestion

36
 What has been ingested?
90
Plasma Glucose mg/dL

85

80
75 High protein drink
70

65
60
0 15 30 45 90 120 150 180

Minutes from Ingestion

37
 What has been ingested?

220
200
Plasma Glucose mg/dL

180
160
140
120
100
80
High energy=refined sugar + starch
60
40
0 15 30 45 90 120 150 180
Minutes from Ingestion

38
 Predicting the Postprandial
Plasma Glucose Response
130
Plasma Glucose mg/dL

120
110
100
90
80
High Soluble Fiber + Starch
70
60
0 15 30 45 90 120 150 180

Minutes from Ingestion

39