Glycemic intake influences the rise in blood glucose concentration following consumption of a carbohydrate containing meal, known as the postprandial glycemic response. The glycemic response is a result of both the type and amount of carbohydrate foods consumed and is commonly measured as the glycemic index (GI) or glycemic load (GL), where the GI is a ranking in comparison to glucose and the GL is an absolute value encompassing both the GI and amount of carbohydrate consumed. Evidence from controlled trials in rat models suggests that glycemic intake has a role in development of insulin resistance, however trials and observational studies of humans have produced conflicting results. As insulin resistance is a precursor to type 2 diabetes mellitus, lifestyle factors that could prevent development of this condition have important public health implications. Previous observational studies have used food frequency questionnaires to assess usual diet, which could have resulted in a lack of precision in assessment of individual serve sizes, and have been limited to daily measures of glycemic intake. Daily measures do not take fluctuations in glycemic intake on a per meal basis into account, which may be a more relevant measure for investigation in relation to disease outcomes. This PhD research was conducted in a group of Brisbane women aged 42 to 81 years participating in the multidisciplinary Brisbane Longitudinal Assessment of Ageing in Women (LAW study). Older women may be at particular risk of insulin resistance due to age, hormonal changes, and increases in abdominal obesity associated with menopause, and the LAW study provided an ideal opportunity to study the relationship between diet and insulin resistance. Using the diet history tool, we aimed to assess the glycemic intake of the population and hypothesised that daily GI and daily GL would be significantly positively associated with increased odds of insulin resistant status. We also hypothesised that a new glycemic measure representing peaks in GL at different meals would be a stronger predictor of insulin resistant status than daily measures, and that a specially designed questionnaire would be an accurate and repeatable dietary tool for assessment of glycemic intake. To address these hypotheses, we conducted a series of studies. To assess glycemic intake, information on usual diet was obtained by detailed diet history interview and analysed using Foodworks and the Australian Food and Nutrient (AUSNUT) database, combined with a customised GI database. Mean ± SD intakes were 55.6 ± 4.4% for daily GI and 115 ± 25 for daily GL (n=470), with intake higher amoung younger participants. Bread was the largest contributor to intakes of daily GI and GL (17.1% and 20.8%, respectively), followed by fruit (15.5% and 14.2%, respectively). To determine whether daily GI and GL were significantly associated with insulin resistance, the homeostasis model assessment of insulin resistance (HOMA) was used to assess insulin resistant status. Daily GL was significantly higher in subjects who were insulin resistant compared to those who were not (134 ± 33 versus 114 ± 24 respectively, P<0.001) (n=329); the odds of subjects in the highest tertile of GL intake being insulin resistant were 12.7 times higher when compared with the lowest tertile of GL (95% CI 1.6-100.1, P=0.02). Daily GI was not significantly different in subjects who were insulin resistant compared to those who were not (56.0 ± 3.3% versus 55.7 ± 4.5%, P=0.69). To evaluate whether a new glycemic measure representing fluctuations in daily glycemic intake would be a stronger predictor of insulin resistant status than other glycemic intake measures, the GL peak score was developed to express in a single value the magnitude of GL peaks during an average day. Although a significant relationship was seen between insulin resistant status and GL peak score (Nagelkerke’s R2=0.568, P=0.039), other glycemic intake measures of daily GL (R2=0.671, P<0.001) and daily GL per megajoule (R2=0.674, P<0.001) were stronger predictors of insulin resistant status. To develop an accurate and repeatable self-administered tool for assessment of glycemic intake, two sub-samples of women (n=44 for the validation study and n=52 for the reproducibility study) completed a semi-quantitative questionnaire that contained 23 food groupings selected to include the top 100 carbohydrate foods consumed by the study population. While there were significant correlations between the glycemic intake questionnaire and the diet history for GL (r=0.54, P<0.01), carbohydrate (r=0.57, P<0.01) and GI (r=0.40, P<0.01), Bland-Altman plots showed an unacceptable difference between individual intakes in 34% of subjects for daily GL and carbohydrate, and 41% for daily GI. Reproducibility results showed significant correlations for daily GL (r=0.73, P<0.001), carbohydrate (r=0.76, P<0.001) and daily GI (r=0.64, P<0.001), but an unacceptable difference between individual intakes in 25% of subjects for daily GL and carbohydrate, and 27% for daily GI. In summary, our findings show that a significant association was observed between daily glycemic load and insulin resistant status in a group of older women, using a diet history interview to obtain precise estimation of individual carbohydrate intake. Both the type and quantity of carbohydrate are important to consider when investigating relationships between diet and insulin resistance, although our results suggest the association is more closely related to overall daily glycemic intake than individual meal intake variations. A dietary tool that permits precise estimation of carbohydrate intake is essential when evaluating possible associations between glycemic intake and individual risk of chronic diseases such as insulin resistance. Our results also suggest that studies using questionnaires to estimate glycemic intake should state degree of agreement as well as correlation coefficients when evaluating validity, as imprecise estimates of carbohydrate at an individual level may have contributed to the conflicting findings reported in previous studies.

Pães integrais são alimentos de consumo habitual da população brasileira, porém há poucas informações a respeito da resposta glicêmica pós-prandial, O presente trabalho teve como objetivo avaliar a resposta glicêmica produzida, em indivíduos saudáveis, após o consumo de pães de fôrma rotulados como integrais. Oito pães de fôrma integrais de três categorias (clássico, light e com grãos) foram avaliados, após o consumo de porcão equivalente a 25 g de carboidratos disponíveis, através do índice glicêmico (IG) e carga glicêmica (CG). Os voluntários (n=15) compareceram ao laboratório em jejum (10 a 12 horas), pela manhã, em onze ocasiões (três dias para o consumo do pão controle e um dia para cada tipo de pão de fôrma integral). A glicemia foi determinada em jejum (t=0) e após o consumo de cada pão nos tempos: 15; 30; 45; 60; 90 e 120 minutos. A curva de resposta glicêmica, a área sob a curva (ASC) e o cálculo do IG e CG para cada um dos pães foram realizados. Considerando a glicose como referência, os pães integrais clássicos (n=2) apresentaram alto IG (71 %); os light (n=2), IG baixo (50 %) e médio (58 %) e; os com grãos (n=4), IG baixo (44 e 49 %) e médio (57 e 60 %). Os pães de fôrma light e com grãos apresentaram IG menor que os do tipo clássico (p<0,05), os quais apresentaram IG igual ao pão francês (controle). Como foi consumida a mesma quantidade de carboidratos disponíveis, a menor proporção de açúcar solúvel na categoria light parece ter sido o fator que induziu ao menor IG observado. Em relação à CG, um pão de fôrma integral light (CG=10) e outro com grãos (CG=7) foram classificados como baixa CG; os demais pães integrais (n=6) foram classificados como média CG (11 a 16). Todos os pães integrais apresentaram CG inferior a do pão controle (CG=18) (p<0,05) e entre os integrais novamente os da categoria light e com grãos foram os que apresentaram menor CG. Assim, foi observada variação na resposta glicêmica após o consumo de pães de fôrma integrais, sendo que a redução no conteúdo de açúcares solúveis, para os pães light, e a adição de grãos integrais, nos pães com grãos, favoreceram menor elevação da resposta glicêmica pós-prandial. / Whole meal breads are part of the habitual daily diet of the Brazilian population, but there is little information on the postprandial glycaemic response. The aim of this work was to evaluate the glycaemic response produced, in healthy volunteers, following the consumption of breads labeled as whole meal. Eight whole meal breads of three different categories (classic, light and grains) were evaluated, after the consumption of a portion containing approximately 25 g of available carbohydrates, using the glycaemic index (GI) and glycaemic load (GL). The subjects (n=15) attended to the laboratory after an overnight fasting (10 to 12 hours), in eleven different occasions (three days for the consumption of the control bread and a day for each whole meal bread). In every occasion, a portion of bread containing 25 g of available carbohydrate was consumed. Capillary blood samples were taken immediately before (t=0) and 15, 30, 45, 60, 90 and 120 minutes after the consumption of test breads. The glycaemic response curve, area under the curve (AUC), GI and GL for each bread were obtained. Considering glucose as reference, the classic breads (n=2) had high GI (71 %); the light (n=2), low (50 %) and medium (58 %) GI; and grains (n=4), low (44 and 49 %) and medium (57 and 60 %) GI. The light and grain breads had lower GI than the classic (p<0,05), which presented GI similar to white bread (control). As the same amount of available carbohydrates was consumed, the reduced proportion of soluble sugars in the light category breads seems to be a factor that induced the lower GI observed. In relation to the GL, one light bread (GL=10) and a grain bread (GL=7) were classified as low GL; the other whole meal breads (n=6) were classified as medium GL (11 to 16). All whole meal breads had lower GL than the control bread (GL=18) (p<0,05), and among the whole meal breads the ones in both light and grain categories presented the lower GL. Therefore, it was possible to observe variation on the glycaemic responses following the consumption of whole meal breads, the reduction in soluble sugar content, in the light breads, and the addition of whole grains, in the grain breads, favored lower elevation in the postprandial glycaemic response.