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Special Communication | Clinician's Corner

The Glycemic Index:  Physiological Mechanisms Relating to Obesity, Diabetes, and Cardiovascular Disease

David S. Ludwig, MD, PhD
JAMA. 2002;287(18):2414-2423. doi:10.1001/jama.287.18.2414.
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Published online

The glycemic index was proposed in 1981 as an alternative system for classifying carbohydrate-containing food. Since then, several hundred scientific articles and numerous popular diet books have been published on the topic. However, the clinical significance of the glycemic index remains the subject of debate. The purpose of this review is to examine the physiological effects of the glycemic index and the relevance of these effects in preventing and treating obesity, diabetes, and cardiovascular disease.

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Figure 1. Glycemic and Insulinemic Responses After Ingestion of Carbohydrates
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Responses were measured after ingestion of 50 g of carbohydrate as white bread or spaghetti made from identical ingredients.5 Qualitatively similar results were obtained after consumption of these foods as part of mixed meals,22 although nutrient interactions can modulate the magnitude of these responses to some degree.17,18 Adapted with permission from the European Journal of Clinical Nutrition.5
Figure 2. Sequence of Physiological Events After Ingestion of a High–Glycemic Index Meal Compared With a Low–Glycemic Index Meal
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Vertical outlined arrows indicate direction and magnitude of change from baseline (preprandial) state indicated by horizontal outlined arrows. Early postprandial period: rapid absorption of carbohydrate after a high–glycemic index meal results in a relatively high blood glucose level and a high insulin-to-glucagon ratio. Middle postprandial period: blood glucose level decreases to below preprandial level, and free fatty acid concentration remains suppressed after a high–glycemic index meal. Late postprandial period: counterregulatory hormones after a high–glycemic index meal restore euglycemia and cause a marked increase in free fatty acid concentration.
Figure 3. High–Glycemic Index Diet and Risk for Type 2 Diabetes Mellitus
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The hypothetical model relates a high–glycemic index diet to increased risk for type 2 diabetes mellitus.
Figure 4. Interventional Studies Examining the Effects of Dietary Glycemic Index on Serum Lipids
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The data are depicted as percentage of change in lipid concentration after a low– compared with a high–glycemic index diet. LDL indicates low-density lipoprotein; HDL, high-density lipoprotein.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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