Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2005) / Chapter Skim
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6. Dietary Carbohydrates: Sugars and Starches
6. Dietary Carbohydrates: Sugars and Starches
Pages 265-338
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From page 265... ...
Due to a lack of sufficient evidence on the prevention of chronic diseases in generally healthy indi viduals, no recommendations based on glycemic index are made. BACKGROUND INFORMATION Classification of Dietary Carbohydrates Carbohydrates can be subdivided into several categories based on the number of sugar units present.
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From page 266... ...
has defined "added sugars" for the purpose of analyzing the nutrient intake of Americans using nationwide surveys, as well as for use in the Food Guide Pyramid. The Food Guide Pyramid, which is the food guide for the United States, translates recommendations on nutrient intakes into recommendations for food intakes (Welsh et al., 1992)
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From page 267... ...
. Table 6-1 shows the amounts of added sugars that could be included in diets that meet the Food Guide Pyramid for three different calorie levels.
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From page 268... ...
Definition of Glycemic Response, Glycemic Index, and Glycemic Load Foods containing carbohydrate have a wide range of effects on blood glucose concentration during the time course of digestion (glycemic response) , with some resulting in a rapid rise followed by a rapid fall in blood glucose concentration, and others resulting in a slow extended rise and a slow extended fall.
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. Utilization of the Glycemic Index Several food characteristics that influence GI are summarized in Table 6-2.
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A number of research groups have reported a significant relationship between mixed-meal GI predicted from individual food items and either the GI measured directly (Chew et al., 1988; Collier et al., 1986; Gulliford et al., 1989; Indar-Brown et al., 1992; Järvi et al., 1995; Wolever and Jenkins, 1986; Wolever et al., 1985, 1990) or metabolic parameters such as high TABLE 6-3 Glycemic Index (GI)
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From page 271... ...
For instance, coingestion of dietary fat and protein can sometimes have a significant influence on the glucose response of a carbohydratecontaining food, with a reduction in the glucose response generally seen with increases in fat or protein content (Gulliford et al., 1989; Holt et al., GI Meal ed Mix Incremental Plasma Glucose Area (mg/dl-h) FIGURE 6-1 Correlation between calculated glycemic index (GI)
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Finally, varied experimental design and methods for calculating the area under the blood glucose curve can result in a different glycemic response to meals of a similar predicted GI (Coulston et al., 1984; Wolever and Jenkins, 1986)
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in the brush border membrane (Díez-Sampedro et al., 2001)
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Glycogen is present in the muscle for storage and utilization and in the liver for storage, export, and maintenance of blood glucose concentrations. Glycogenesis is activated in skeletal muscle by a rise in insulin concentration following the consumption of carbohydrate.
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This immediate rise in plasma insulin concentration minimizes the extent of hyperglycemia after a meal. The effects of insulin deficiency (elevated blood glucose concentration)
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In the absence of dietary carbohydrate, de novo synthesis of glucose requires amino acids derived from the hydrolysis of endogenous or dietary protein or glycerol derived from fat. Therefore, the marginal amount of carbohydrate required in the diet in an energy-balanced state is conditional and dependent upon the remaining composition of the diet.
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From page 277... ...
The endogenous glucose production rate in a postabsorptive state correlates very well with the estimated size of the brain from birth to adult life. However, not all of the glucose produced is utilized by the brain (Bier et al., 1977; Felig, 1973)
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From page 278... ...
The glycerol released from the hydrolysis of triacylglycerols stored in fat cells becomes a significant source of substrate for gluconeogenesis, but the conversion of amino acids derived from protein catabolism into glucose is also an important source. Interestingly, in people who consumed a protein-free diet, total nitrogen excretion was reported to be in the range of 2.5 to 3.5 g/d (35 to 50 mg/kg)
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From page 279... ...
Glucose utilization by the brain has been determined either by measuring arteriovenous gradients of glucose, oxygen, lactate, and ketones across the brain and the respiratory quotient (Kety, 1957; Sokoloff, 1973) , or with estimates of brain blood flow determined by different methods (e.g., NO2 diffusion)
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The brain utilizes approximately 60 percent of the infant's total energy intake (Gibbons, 1998)
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The lower limit of dietary carbohydrate compatible with life or for optimal health in infants is unknown. Human milk is recognized as the optimal milk source for infants throughout at least the first year of life and is recommended as the sole nutritional milk source for infants during the first 4 to 6 months of life (IOM, 1991)
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282 DIETARY REFERENCE INTAKES TABLE 6-4 Total Carbohydrate Content of Human Milk Total Total Total Reference Stage of Carbohydrate Lactose Glucose Lactation Content (g/L) Content (g/L)
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for older infants is carbohydrate intake from human milk and complementary foods (see Chapter 2)
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. As for adults, the EAR is the same for both genders since differences in brain glucose utilization are small.
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of 15 percent based on the variation in brain glucose utilization. The RDA is defined as equal to the EAR plus twice the CV to cover the needs of 97 to 98 percent of the individuals in the group (therefore, for carbohydrate the RDA is 130 percent of the EAR)
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From page 286... ...
were also used, which correlated weight of the brain with body weight. The average rate of brain glucose utilization in the postabsorptive state of adults based on several studies is approximately 33 µmol/100 g of brain/min (5.5 mg/100 g of brain/min or 8.64 g/100 g of brain/d)
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. The carbohydrate requirement is modestly greater than the potential glucose that can be derived from an amount of ingested protein required for nitrogen balance in people ingesting a carbohydrate-free diet (Azar and Bloom, 1963)
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The amount of dietary protein required approaches the theoretical maximal rate of gluconeogenesis from amino acids in the liver (135 g of glucose/24 h) (Brosnan, 1999)
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. Carbohydrate EAR and RDA Summary, Ages 19 Years and Older EAR for Men 1930 years 100 g/d of carbohydrate 3150 years 100 g/d of carbohydrate 5170 years 100 g/d of carbohydrate > 70 years 100 g/d of carbohydrate EAR for Women 1930 years 100 g/d of carbohydrate 3150 years 100 g/d of carbohydrate 5170 years 100 g/d of carbohydrate > 70 years 100 g/d of carbohydrate The RDA for carbohydrate is set by using a CV of 15 percent based on the variation in brain glucose utilization.
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Several doubly labeled water studies indicate a progressive increase in total energy expenditure over the 36 weeks of pregnancy (Forsum et al., 1992; Goldberg et al., 1993; Kopp-Hoolihan et al., 1999) (Table 5-27)
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If nonglucose sources (largely ketoacids) supply 30 percent of the fuel requirement of the fetal brain, then the brain glucose utilization rate would be 23 g/d (32.5 g × 0.70)
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RDA for Pregnancy 1418 years 175 g/d of carbohydrate 1930 years 175 g/d of carbohydrate 3150 years 175 g/d of carbohydrate Lactation Evidence Considered in Estimating the Average Requirement The requirement for carbohydrate is increased during lactation. The lactose content of human milk is approximately 74 g/L; this concentration changes very little during the nursing period.
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The EAR during lactation is the sum of the carbohydrate intake necessary to replace the carbohydrate secreted in human milk (60 g/d) and the EAR for adolescent girls and women (100 g/d)
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Department of Agriculture food consumption survey data, nondiet soft drinks were the leading source of added sugars in Americans' diets, accounting for one-third of added sugars intake (Guthrie and Morton, 2000)
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Less than 5 percent of Canadian men and women consumed more than 65 percent of energy from carbohydrate. Data from the Third National Health and Nutrition Examination Survey shows that the median intake of added sugars widely ranged from 10 to 30 tsp/d for adults, which is equivalent to 40 to 120 g/d of sugars (1 tsp = 4 g of sugar)
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by measurement construct following meta-analysis of 23 studies on the effect of sugar intake on behavior and cognition. Reprinted, with permission, from Wolraich et al.
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published an exhaustive review of carbohydrate-induced hypertriacylglycerolemia and concluded that it is more extreme if the carbohydrate content of a high carbohydrate diet consists primarily of monosaccharides, particularly fructose, rather than oligo- and polysaccharides. Purified diets, whether based on starch or monosaccharides, induce hypertriacylglycerolemia more readily than diets higher in fiber in which most of the carbohydrate is derived from unprocessed whole foods, and possibly result in a lower glycemic index and reduced postprandial insulin response (Jenkins et al., 1987b)
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From page 298... ...
: 30% starch 0.981.98 to 2.76 to 4.50 30% sucrose 1 female (starch to fructose) : 30% fructose 1.321.78 to 2.302.58 Dunnigan et al., 9 men and women, 4-wk 1970 crossover 31% sucrose 1.05a sucrose-free 1.04a Mann and 9 men, 2-wk Truswell, crossover 1972 23% sucrose 1.10a 23% starch 1.11a Mann et al., 9 men, 2-wk 1973 crossover 17% sucrose 1.66a 34% sucrose 1.84b 34% sucrose + 1.50a polyunsaturated fatty acids Rath et al., 6 men, 2- to 5-wk Significant increase with 1974 crossover 52% sucrose 17% sucrose 52% sucrose Hayford et al., 8 men, 10-d 1979 crossover 45% sucrose 0.87a 65% sucrose 1.31b 45% glucose 0.80a 65% glucose 1.33b Reiser et al., 19 men and women, Men Women 1979a 6-wk crossover Baseline 6 wk Baseline 6 wk 30% starch 1.28a 1.42a 1.06a 0.98a 30% sucrose 1.54a 1.86b 1.06a 1.23b Hallfrisch 12 men, 5-wk crossover et al., 1983 0% fructose, 15% starch 0.97a 7.5% fructose, 7.5% starch 1.07a 15% fructose, 0% starch 1.04a Bossetti et al., 8 men and women, 140-d 1984 crossover Baseline 14 d 1116% sucrose 0.60a 0.63a 1116% fructose 0.80a 0.56a
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DIETARY CARBOHYDRATES: SUGARS AND STARCHES 299 Low Density Lipoprotein High Density Lipoprotein Cholesterol Concentration Cholesterol Concentration (mmol/L) (mmol/L)
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300 DIETARY REFERENCE INTAKES TABLE 6-7 Continued Study Population/ Reference Dietary Intervention Triacylglycerol Concentration (mmol/L) Crapo and 11 men and women, 14-d No significant difference Kolterman, crossover 1984 24% sucrose 24% fructose Albrink and 6 men per group, 11 d Significant increase when fed 36% or Ullrich, 1986 0% sucrose 52% sucrose and a diet containing 18% sucrose less than 14 g of fiber 36% sucrose 52% sucrose Yudkin et al., 14 men, 14-d crossover 1986 18% sucrose 1.02a 37% sucrose 1.11a 19% sucrose 1.09a 26 men, 14-d crossover 23% sucrose 1.33a 9% sucrose 1.05b 24% sucrose 1.23a Reiser et al., 11 men, 5-wk crossover 1989 20% fructose 0.84a 20% starch 0.70b Swanson et al., 14 men and women, 4-wk 1992 crossover Baseline 4 wk 19% fructose, 25% starch 1.16a 0.96a < 3% fructose, 39% starch 1.02a 0.94a Surwit et al., 42 women, 6-wk 1997 intervention 4% sucrose 1.05a 43% sucrose 1.08a Marckmann 20 women, 2-wk crossover et al., 2000 2.5% sucrose, 59% 0.81a carbohydrate 23.2% sucrose, 59% 0.96b carbohydrate Saris et al., 390 adults, 6-mo parallel 2000 18.8% sugar, 52% 1.29a carbohydrate 29.5% sugar, 56% 1.46a carbohydrate a,bDifferent lettered superscripts within each study indicate that values were significantly different.
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Significant reduction in high density lipoprotein concentration with fructose Significant decline observed for Significantly lower for 18%, 0% and 18% sucrose diets 36%, and 52% sucrose diets 1.27a 1.07b 1.42a 1.30a 1.27a 1.26a 3.06a 1.16a 2.73b 1.11a Baseline 4 wk Baseline 4 wk 2.62a 2.73a 1.28a 1.30a 2.65a 2.46b 1.32a 1.22a 2.38a 1.03a 2.60b 1.06a 2.43a 1.34a 2.72b 1.38a 3.68a 1.20a 3.61a 1.15a
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Both serum homocysteine and HDL cholesterol concentrations are independent risk factors for cardiovascular disease (Aronow and Ahn, 1998; Boushey et al., 1995)
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from consuming naturally occurring or added sugars (Bolton-Smith and Woodward, 1994a; Kushi et al., 1985; Liu et al., 1982, 2000; McGee et al., 1984) (see Table 11-7)
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304 DIETARY REFERENCE INTAKES TABLE 6-8 Controlled Studies of Low Glycemic Index (GI) Diets on Carbohydrate and Lipid Metabolism in Healthy, Diabetic, and Hyperlipidemic Subjects Type of Change in Glycated Reference Study Design Diet GI Proteins Healthy subjects Jenkins et al., 6 men, 2 wk 41 Fructosamine 1987a Kiens and Richter, 7 young men, 30 d 24 Not reported 1996 Frost et al., 25 women, 3 wk 18 Not reported 1998 Diabetic subjects Collier et al., 7 type I children, 12 Albumin 1988 6 wk Fontvieille et al., 8 type I men 14 Fructosamine 1988 and women, 3 wk Jenkins et al., 8 type II men 23 HbA1c 1988a and women, 2 wk Fructosamine Brand et al., 16 type II men 14 HbA1c 1991 and women, 12 wk Fontvieille et al., 18 type I and II 26 Fructosamine 1992 men and women, 5 wk Wolever et al., 15 type II men 27 Fructosamine 1992a and women, 2 wk Wolever et al., 6 type II over- 28 Fructosamine 1992b weight men and women, 6 wk
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From page 305... ...
Commentsb 7c,d 15c,d TC 32%c,e urinary C-peptide excretion 13c,d LDL-C 10%c,e creatinine clearance during the day Not reported Not reported Euglycemic hyperinsulinemic clamp showed no difference in glucose uptake between high and low GI diets at low plasma insulin, but glucose uptake was reduced at high plasma insulin with low GI diet Not reported Not reported Using short insulin tolerance test, in vivo insulin sensitivity improved after low GI diet 19c,d 14c,d TC Reduced postprandial glucose response to standard test meal with low GI diet 18.1c,d 5.8c,d TAG 8.9%c,d plasma phospholipids 6.1%c,d daily insulin needs 6.6c,d 5.8c,d TC 30%c,d fasting blood glucose 6.6c,d 11c,e Not significant 11%c,e plasma glucose response to standard meal 12.1c,e 21.1c,e TAG 11%c,e fasting blood glucose 13.3%c,e mean daily blood glucose 3.4c,e 7c,e TC 30%c,e urinary C-peptide excretion 29%c,e postbreakfast blood glucose TAG rose on high GI diet (p = 0.027) and fell on low GI diet, but the difference between the two diets was not significant 8c,e 6.8c,e TC 22.4%c,e TAG for the 5 subjects with TAG > 2.2 mmol/L continued
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. Data from the Nurses' Health Study illustrated a significant association between the dietary glycemic index and risk of type 2 diabetes that was significant both with and without an adjustment for
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Several studies have been conducted to determine the relationship between total (intrinsic plus added) and added sugars intake and energy intake (Table 6-10)
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, and Cancer and Its Association with High Density Lipoprotein Cholesterol (HDL-C) Concentration and Glucated Hemoglobin (HbAlc)
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, and TAG 6.59 was positively associated with GI 6.55 (p for trend = 0.01) Significant association between GL and risk of diabetes (p trend < 0.001)
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Study reported a significant decrease in energy intake with increased total sugar intake (Nicklas et al., 1996)
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1.29 1.37 OR of colon and p for trend < 0.001 rectum cancer Similar findings for glycemic load 1.0 1.3 1.6 1.5 1.7 et al., 1990) (Table 6-11)
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. Increased added sugars intakes have been shown to result in increased energy intakes for children and adults (Bowman, 1999; Gibson 1996a, 1997; Lewis et al., 1992)
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From page 313... ...
Based on the above data, it appears that the effects of increased intakes of total sugars on energy intake are mixed, and the increased intake of added sugars are most often associated with increased energy intake. There is no clear and consistent association between increased intake of added sugars and BMI.
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From page 314... ...
Gibson, 1996a 1,087 men and 1,110 women < 10 Dietary and Nutritional 1013 Survey of British Adults 1416 1720 > 20 Gibson, 1997 1,675 boys and girls, 1.54.5 y < 12 U.K. National Diet and 1216 Nutrition Survey of 1620 Children 2025 > 25 Bowman, 1999 Continuing Survey < 10 of Food Intakes by 1018 Individuals > 18 (19941996)
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From page 315... ...
DIETARY CARBOHYDRATES: SUGARS AND STARCHES 315 Energy Intake (kcal) Boys Girls 1011 y 1415 y 1011 y 1415 y 1,954a 2,401a 1,753a 1,819a 2,095b 2,526b 1,838b 1,961b 2,066b 2,549b 1,871b 1,901a,b 2,291 2,245 2,274 2,016 2,249 2,286 2,144 2,061 High consumers of added sugars had greater energy intakes than consumers of moderate and low added sugars Men Women 2,219a 1,438a 2,430b 1,681b 2,455b,c 1,738b 2,549b,c 1,773b 2,596c 1,774b Boys Girls 1,129a 1,097a 1,168a,b 1,102a 1,187a,b 1,139a 1,188a,b 1,115a 1,217b 1,116a 1,860a 2,040b 2,049b
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From page 316... ...
Total sugars Dunnigan et al., 9 men and women, 31% sucrose 1970 4-wk crossover sucrose-free Fehily et al., 1984 493 men, 4559 y 7-d weighed dietary record Dreon et al., 1988 155 obese men, 3059 y 13.7 ± 8.4 g/1,000 7-d dietary record kcal Miller et al., 1990 107 men and 109 women, 1871 y 24-h recall and 2-d dietary questionnaire Gibson, 1993 2,705 boys and girls Department of Health Survey of British School Children < 20.7 20.725.2 < 25.2 Bolton-Smith and 11,626 men and women, Quintile Woodward, 1994b 2564 y 1 Scottish Heart Health 2 and MONICA studies 3 4 5 Gibson, 1996b 1,087 men and 1,110 women, Quintile 1664 y 1 Dietary and Nutritional Survey 2 of British Adults 3 4 5
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DIETARY CARBOHYDRATES: SUGARS AND STARCHES 317 BMI (kg) 62.4 63.8 Significant negative association between sucrose intake and BMI Significant negative correlation between sucrose intake and BMI Significant negative correlation between sugar intake and percentage of body fat for women; no association for men Boys Girls 1011 y 1415 y 1011 y 1415 y 18.6a 20.2a 18.2a 21.2a 17.9a,b 20.0a,b 18.1a 20.2b 17.5b 19.2b 17.9a 19.8b Men Women 27.0 26.5 26.4 26.0 26.0 25.5 25.5 25.1 24.7 24.4 Significant negative correlation between sugar intake and BMI Men Women 24.9 25.4 25.3 24.7 25.2 24.5 24.8 23.8 24.4 24.4 Weak negative association between sugar intake and BMI continued
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From page 318... ...
Bolton-Smith and 11,626 men and women, Quintile Woodward, 1994b 2564 y 1 Scottish Heart Health and 2 MONICA studies 3 4 5 Gibson, 1996a 1,087 men and 1,110 women, 1664 y < 10 Dietary and Nutritional 1013 Survey of British Adults 1416 1720 > 20 Ludwig et al., 2001 Planet Health intervention and evaluation project a,b,c,dDifferent lettered superscripts within each study indicate that values were significantly different. Physical Activity Although consumption of high GI test foods increases glucose oxidation and suppresses the availability of free fatty acids (Ritz et al., 1991)
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From page 319... ...
Lung Cancer One case-control study in Uruguay (463 cases and 465 controls) suggested that foods rich in sugars, total sucrose intake, sucrose-to-dietary fiber ratio, and GI were associated with increased risk of lung cancer (De Stefani et al., 1998)
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From page 320... ...
Meal 100) estT = of test w-GI lo of Consumption After e (consumption Intak Energy Preload y or oluntarV Test Meal/Preload FIGURE 6-4 Summary of data from crossover studies examining the effects of the glycemic index (GI)
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From page 321... ...
. Colorectal Cancer The World Cancer Research Fund and American Institute for Cancer Research (1997)
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From page 322... ...
Dietary GI and glycemic load have relatively predicable effects on circulating glucose, hemoglobin A1c, insulin, triacylglycerol, HDL cholesterol, and urinary C-peptide concentrations, particularly in individuals with diabetes and hyperlipidemia. Although the data are lacking in healthy individuals, on theoretical grounds, these effects would be expected to result in reduced risks of type 2 diabetes and cardiovascular disease in individuals consuming low GI versus high GI carbohydrates.
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From page 323... ...
While it is recognized that hypertriglyceridemia can occur with increasing intakes of total (intrinsic plus added) sugars, total sugars intake can be limited by minimizing the intake of added sugars and consuming naturally occurring sugars present in nutrient-rich milk, dairy products, and fruits.
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From page 324... ...
1983. Length of gestation and nutritional composition of human milk.
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1999. Diets of individuals based on energy intakes from added sugars.
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1988. Application of glycemic index to mixed meals.
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2000. Preexercise carbohydrate ingestion, glucose kinetics, and muscle glycogen use: Effect of the glycemic index.
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2001. Glycemic index and serum high-density lipoprotein choles terol concentration among US adults.
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1989. Differential effect of protein and fat ingestion on blood glucose responses to high- and low-glycemic-index carbo hydrates in noninsulin-dependent diabetic subjects.
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1999. Improved glycemic control and lipid profile and normalized fibrinolytic activity on a low-glycemic index diet in type 2 diabetic patients.
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1985. Low glycemic index carbohydrate foods in the management of hyperlipidemia.
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1992. Nutrient intakes and body weights of persons consuming high and moderate levels of added sugars.
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1999. High glycemic index foods, overeating, and obesity.
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1999. Glycemic index, cardiovascular disease, and obesity.
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2000b. High-glycemic index foods, hunger, and obesity: Is there a connection?
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2000. A low-glycemic index diet in the treatment of pediatric obesity.
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1986. The use of the glycemic index in predicting the blood glucose response to mixed meals.
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1985. Prediction of the relative blood glucose response of mixed meals using the white bread glycemic index.
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