Glycemic index, glycemic load and glycemic response: An International Scientific Consensus Summit from the International Carbohydrate Quality Consortium (ICQC).

BACKGROUND AND AIMS: The positive and negative health effects of dietary carbohydrates are of interest to both researchers and consumers. METHODS: International experts on carbohydrate research held a scientific summit in Stresa, Italy, in June 2013 to discuss controversies surrounding the utility of the glycemic index (GI), glycemic load (GL) and glycemic response (GR). RESULTS: The outcome was a scientific consensus statement which recognized the importance of postprandial glycemia in overall health, and the GI as a valid and reproducible method of classifying carbohydrate foods for this purpose. There was consensus that diets low in GI and GL were relevant to the prevention and management of diabetes and coronary heart disease, and probably obesity. Moderate to weak associations were observed for selected cancers. The group affirmed that diets low in GI and GL should always be considered in the context of diets otherwise understood as healthy, complementing additional ways of characterizing carbohydrate foods, such as fiber and whole grain content. Diets of low GI and GL were considered particularly important in individuals with insulin resistance. CONCLUSIONS: Given the high prevalence of diabetes and pre-diabetes worldwide and the consistency of the scientific evidence reviewed, the expert panel confirmed an urgent need to communicate information on GI and GL to the general public and health professionals, through channels such as national dietary guidelines, food composition tables and food labels.

Metabolizable energy of macronutrients.

I describe recent advances in assessing the amount of energy available from diets of varied composition. Empirical models of food energy prediction have grown in preference to factorial models over the past 20 y and knowledge of the quantitative aspects of energy salvage in the colon have modified our thoughts on how to best calculate food energy values. In contrast, food regulatory practices have been limited mostly to changes in the way in which carbohydrate is defined or measured and there has been little change in the basic approach to energy evaluation or the energy conversion factors used with food components. The empirical systems have advantages over factorial models of food energy assessment and it is proposed that such empirical systems should be used in food regulations, food tables and databases, and in nutritional studies in which knowledge of metabolizable energy intake is desirable but cannot be determined directly.

Energy values of unavailable carbohydrate and diets: an inquiry and analysis.

To determine digestible-energy values (DEVs) for unavailable carbohydrate (UC), an analysis was made of published data on 29 human diets with UC from several sources and intakes ranging from 4 to 93 g/d. A distinction was made between apparent DEVs, derived from UC intake and fecal loss, and partial DEVs, derived from energy intake and fecal loss. By use of a proposed calculation, partial DEVs ranged from -20 to +10 kJ/g (-4.8 to +2.4 kcal/g) in different diets; all values were below the corresponding apparent DEVs. Factors explaining this range, including analytical problems, are considered. Rather than finding discrepancies, both the partial DEVs and the energy available from the whole diet were found to be related to the apparent digestibility of UC (r = 0.88), the proportion of the diet estimated as UC (r = 0.73), and both combined (r = 0.98). Several food-energy evaluation systems are also assessed for accuracy and the implications of these observations for food-energy evaluation are discussed.

Theory and validity of indirect calorimetry during net lipid synthesis.

A critical examination is made of the validity of indirect calorimetry when the nonprotein respiratory quotient is greater than 1. The different published stoichiometries for lipogenesis from glucose are excluded as a source of uncertainty in the interpretation of gaseous exchange measurements. The validity of indirect calorimetry is proved independently by an algebraic approach which, in contrast to previous attempts, makes minimal assumptions about stoichiometries. Although equations relating the respiratory quotient to the heat equivalent of oxygen are found valid, there is uncertainty in using these equations to predict accurately carbohydrate utilization and fat oxidized or synthesized. Reference tables interrelating respiratory data, the heat equivalent of oxygen, and net fuel utilization or synthesis for specified fuels are provided. A suggested framework for calculating energy expenditure in terms of ATP gain is given as an appendix.

Estimation of energy expenditure, net carbohydrate utilization, and net fat oxidation and synthesis by indirect calorimetry: evaluation of errors with special reference to the detailed composition of fuels.

Sources of error in the interpretation of respiratory data are evaluated and reviewed with special reference to the detailed composition of foods. Estimates of fuel utilization or synthesis are 12-fold more sensitive to errors in the nonprotein respiratory quotient than is the heat equivalent of oxygen. Estimates of protein oxidation from nitrogen excretion can be in error from +14 to -39% of the true value. Heat equivalents of oxygen, respiratory quotients, and urinary nitrogen-to-oxygen conversion ratios are considered for 60 artificial and 101 conventional food proteins, 36 artificial and 125 conventional food fats, and the different carbohydrates contained in these foods. It is concluded that there is considerable uncertainty when the mix of fuels utilized is assessed accurately. Accuracy is best within 5% of the true values. This analysis is completed with descriptions of some physiological sources of error in an appendix.

Energy balance and expenditure while consuming guar gum at various fat intakes and ambient temperatures.

We devised a new model to evaluate whether dietary composition affects whole-body energy metabolism in rats. Dietary guar gum, but not corn starch, elevates both fecal energy excretion and energy expenditure. Neither ambient temperature (21 vs 28 degrees C) nor fat content of the basal diet (15% vs 33% metabolizable energy) has a marked effect on guar gum's thermogenic stimulus. Starch and guar gum each contribute 17.5 kJ/g to gross energy intake. This energy is fully available from the starch but guar gum contributes only 9-13 kJ/g to digestible energy intake on the low-fat diet (15% of energy), only 6 kJ/g to digestible energy on the higher-fat diet (33% of energy) (because of a fat-gum interaction), decreases urinary energy loss by 1.4-2.7 kJ/g gum, and elevates energy expenditure by 11.6-14.8 kJ/g. The thermogenic effect of the guar gum is highly reproducible. Several potential mechanisms to explain such elevated energy expenditure are considered. The model used to quantify the thermogenic stimulus is highly sensitive and could be applied to the trial of potentially thermogenic drugs as well as dietary ingredients.

Energy expenditure and net substrate utilization in men ingesting usual and high amounts of nonstarch polysaccharide.

BACKGROUND: Diets intrinsically high in nonstarch polysaccharides (NSPs) are frequently advised for body weight regulation and health, but the consequences for energy expenditure and fuel selection are undetermined. OBJECTIVE: We determined whether energy expenditure and fuel selection differ when men consume a diet intrinsically higher in NSP than a usual mixed diet. DESIGN: A randomized crossover design was used in which 12 healthy men were fed a maintenance diet for approximately 3 wk in a metabolic suite. By judicial choice of food exchanges, the usual- and high-NSP diets were similar in protein, fat, and carbohydrate contents. Twenty-four-hour, indirect, open-circuit calorimetry was performed, including measurements of total hydrogen gas and methane. Participants were weight stable (within 2 kg for 3 wk), entered an 11-m3 calorimetry chamber for 36 h with measurements taken in the last 24 h, and underwent a strictly controlled program of moderate physical activity (1.3 x basal metabolic rate). RESULTS: The mean total 24-h energy expenditure and percentages from protein, fat, and carbohydrate metabolism were 10 MJ/d and 16%, 35%, and 48%, respectively. Differences (mean+/-SEM) between the 2 diets were only -0.005+/-0.130 MJ/d, -0.3+/-1.3%, -0.2+/-2.0%, and 0.6+/-2.2%, respectively, and were nonsignificant (P> 0.2). CONCLUSIONS: There was no thermogenic response to the high-NSP diet, which would be advantageous for body weight control, and no short-term influence on body composition, as may be judged from a lack of change in protein, fat, or carbohydrate metabolism.

Energy balance and thermogenesis in rats consuming nonstarch polysaccharides of various fermentabilities.

BACKGROUND: The equivalents of dietary protein, fat, and available carbohydrate as fuels for maintenance (kJ apparent metabolizable energy/kJ maintenance requirement) are known from classical experiments and are similar across species; that for nonstarch polysaccharide (NSP) is undetermined. OBJECTIVES: Our objectives were to determine the energy equivalent of NSP and the thermic responses to NSP. DESIGN: In a randomized block design, 120 rats were treated in groups of 10 for 28 d with a basal diet (control) supplemented with starch and 10 different NSP treatments in amounts between 38 and 92 g/kg basal diet. Cellulose and starch were references. Thermic responses, deduced from body-composition changes and modeling of energy disposition, and energy and substrate excretion were determined. RESULTS: NSP had fermentabilities between 0.01 and 0.93 g/g intake. Fermentability, partial digestible energy, and net metabolizable energy values of NSP were closely related. Generally, 51% of apparent metabolizable energy from NSP (fermentable gross energy) met maintenance requirements. Diet (energy)-induced thermogenesis (DIT) was evident from whole diets. Fermentable NSP supplied net metabolizable energy and caused DIT. After DIT and fermentation were accounted for, NSP-induced thermogenesis was generally -2+/-4% (x+/-SEM) of gross NSP energy, except for an outlying pectic preparation, which was 33% (P< 0.1). CONCLUSIONS: The energy equivalent of NSP was 196 (100/51) kJ/kJ, compared with 128, 105, and 100 for protein, fat, and glucose, respectively, from the classical experiments. With the exception of pectic NSP, NSP does not induce thermogenesis in excess of that associated with DIT and fermentation.

Influence of the physical form of barley grain on the digestion of its starch in the human small intestine and implications for health.

It has been suggested that incomplete digestion of cereal starch explains the low energy values of certain cereals of large particle size. We used human subjects with ileostomies to investigate the digestion of barley and to determine whether the physical form of barley affects stomal excretion of starch, glucooligosaccharides, nitrogen, fat, and calculated energy. Only 2 +/- 1% of starch remained undigested after finely milled barley was eaten, but after flaked barley was eaten 17 +/- 1% resisted digestion, partly as oligosaccharides (G1-G10) but largely as intact unpitted starch granules bound by intact cell walls. The calculated energy excretion from the stoma was three times higher after flaked than after milled barley [51.5 decreasing to 15.3 kJ/g nonstarch polysaccharide (NSP, P < 0.001]. NSP, starch, and fat made almost equal contributions to the higher energy excretion. It is concluded that possibly the botanical source of cereals and certainly processing, other than retrogradation of the starch, are important determinants of starch digestibility and energy value. Possible clinical implications are introduced.

The influence of the colon on postprandial glucagon-like peptide 1 (7-36) amide concentration in man.

Glucagon-like peptide (7-36) amide (GLP-1) is an incretin hormone of the enteroinsular axis released rapidly after meals despite the fact that GLP-1 secreting cells (L-cells) occur predominantly in the distal gut. The importance of these colonic L-cells for postprandial GLP-1 was determined in healthy control subjects and in ileostomy patients with minimal small bowel resection (<5 cm). Subjects were fed a high complex carbohydrate test meal (15.3 g starch) followed by two carbohydrate-free, high fat test meals (25 g and 48.7 g fat respectively). Circulating levels of glucose, insulin, glucagon, glucose insulinotrophic peptide (GIP) and GLP-1 were measured over a 9-h postprandial period. For both subject groups the complex carbohydrate test meal failed to elicit a rise in either GIP or GLP-1. However, both hormones were elevated after the fat load although the GLP-1 concentration was significantly reduced in the ileostomist group when compared with controls (P=0.02). Associated with this reduction in circulating GLP-1 was an elevation in glucagon concentration (P=0.012) and a secondary rise in the plasma glucose concentration (P=0.006). These results suggest that the loss of colonic endocrine tissue is an important determinant in the postprandial GLP-1 concentration. Ileostomists should not be assumed to have normal enteroinsular function as the colon appears to have an important role in postprandial metabolism.

The energy cost of triglyceride-fatty acid recycling in nonobese subjects after an overnight fast and four days of starvation.

The basal blood glycerol concentration was determined and the rate of glycerol turnover was assessed by a nonradioactive infusion technique in six healthy nonobese adults after an overnight fast and again after four days of total starvation. Simultaneously, estimates of total energy expenditure and net fat oxidation were made from measurements of oxygen consumption, carbon dioxide production, and urinary nitrogen excretion. The data were combined to provide quantitative estimates of the activity of the triglyceride/fatty acid cycle. The basal concentration of glycerol in venous blood rose from a mean value of 54 +/- 8 mumol/L (SEM) before starvation to 154 +/- 5 mumol/L on day 4 of starvation. Glycerol turnover rates correlated well with the basal blood glycerol concentration (r = .95) and increased from a mean value of 115 +/- 17 mumol/min before starvation (equivalent to mobilization of about 3.95 kJ triglyceride/min) to 304 +/- 20 mumol/min (equivalent to mobilization of about 18.41 kJ/min). The estimated rate of net fat oxidation was 3.00 +/- 0.47 kJ/min before starvation and 4.00 +/- 0.14 kJ/min on day +4 of starvation. The rate of triglyceride energy recycling or rate of deposition of triglyceride energy into fat stores was calculated from the difference in the rate of fat energy mobilization and the rate of energy released during net fat oxidation. The values were found to be 0.94 +/- 0.26 kJ/min before starvation and 6.29 +/- 0.54 kJ/min on day +4 of starvation.(ABSTRACT TRUNCATED AT 250 WORDS)

Food energy values of artificial feeds for man.

The gross and metabolizable energy values of artificial enteral and parenteral feeds have been calculated from detailed composition data for amino acid, fatty acid, saccharide and other oxidizable substrates and compared with similar values calculated for conventional foods. The background to the derivation and application of calorie conversion factors is briefly reviewed. There is evidence of widespread inappropriate application of calorie conversion factors for carbohydrates and amino acid mixtures. Appropriate digestibility or availability factors for the oxidizable fractions of artificial feeds is discussed for normal adult man and the intrinsic difficulty of obtaining availability values for subjects with varying types of malabsorption or urinary and tissue losses is emphasized. The nitrogen:protein conversion ratio and the availability of energy at a biochemical level (i.e. net ATP yield per calorie) is also considered. Finally, a more uniform and appropriate approach to calculating energy values for artificial feeds for the purposes of labelling, product description and estimating energy intake of patients is called for.

Calculating the energy values of foods: towards new empirical formulae based on diets with varied intakes of unavailable complex carbohydrates.

A statistical analysis has been made by generalised linear regression of the relationship between the availability of digestible energy (DE) and the intakes of dietary gross energy (E) and of dietary 'fibre' or unavailable complex carbohydrate (U), for published observations on 43 human diets with varied intakes and sources of U (2-93 g daily) and varied intakes of E (7598-15104 kJ or 1816-3610 kcal daily). Simple formulae were devised also for the availability of metabolizable energy (ME) assuming urinary energy losses of 30 kJ or 7 kcal/g nitrogen (N) intake. For the calculation of DE and ME in mixed human diets with accuracy greater than obtained with previously published methods, the following linear formulae are proposed and their limitations discussed: DE (kJ) = 0.96E(kJ)-9U(g) ME (kJ) = 0.96E(kJ)-9U(g)-30N(g) DE (kcal) = 0.96E(kcal)-2U(g) ME (kcal) = 0.96E(kcal)-2U(g)-7N(g) The equations devised are used to identify atypical observations on faecal energy excretion, and their possible causes are considered. In particular diets high in whole-grain cereal cause faecal energy losses greater than predicted by these equations which is possibly explained by more carbohydrate reaching the colon than expected from current compositional analytical methods.

Is the rat a suitable model for humans on studies of cereal digestion?

OBJECTIVES: To compare the extent of starch digestion from barley flake and flour in humans and rat. Is the rat a useful model? DESIGN: Four healthy male ileostomy volunteers consumed, in random order, flapjacks containing flaked barley on one occasion and barley flour on another. Ileostomy fluid was collected for analysis of starch and nonstrach polysaccharide (NSP) hourly for 12 h. The ratio of starch to NSP in ileostomy fluid was compared with that in the terminal ileum of eight randomly selected male rats consuming the flaked barley flapjack and another eight rats consuming the barley flour flapjack. RESULTS: After consuming flaked barley the terminal ileal starch-NSP ratio was 20 times lower in rats than in ileostomists and was 0.04 (s.e.m. 0.006) g/g compared with 0.89 (s.e.m. 0.05) g/g respectively. By contrast the starch-NSP ratio was very low after consuming the barley flour in both species; however the ratio was still lower in rats than in ileostomists and was 0.02 (s.e.m. 0.01) g/g compared with 0.05 (s.e.m. 0.01) g/g respectively. Using the NSP as an indigestible marker, starch from barley flake that resisted small intestinal digestion was calculated to be 0.7 (s.e.m. 0.02)% in rats compared with a higher value of 17 (s.e.m. 1)% in ileostomists. CONCLUSION: The cell walls of barley flake limit the extent of starch digestion in humans but in rats this appears not to be a limiting factor. In the present instance it was not possible to extrapolate results from rats to humans.

Circadian patterns of total 24-h hydrogen and methane excretion in humans ingesting nonstarch polysaccharide (NSP) diets and the implications for indirect calorimetric and D2 18O methodologies.

OBJECTIVES: To quantify the relationship between substrate fermentation and total 24-h H2 and CH4 excretion on mixed diets and to assess errors incurred in the calculation of energy expenditure and fuel selection by the exclusion of these gases from standard calculations. DESIGN AND SUBJECTS: Twelve healthy, lean men were studied over two consecutive dietary periods of 3 weeks. Measurements of total H2 and CH4 excretion were made during 24h within a whole body calorimeter. Subjects were fed a diet containing 16 g or 38 g of nonstarch polysaccharide (NSP) and 16 g or 19 g resistant starch (RS). Colonic fermentation was measured by balance techniques during the two dietary treatments. RESULTS: There was an inverse non-linear relationship between H2 and CH4 excretion on both diets (r2 = 0.53; P < 0.001), but absolute excretion did not increase significantly as the intake of NSP and RS (from 28 +/- 3 and 48 +/- 4 g/day) increased. No relationship was found between daytime and 24-h measurements of H2 and CH4. H2 and CH4 excretion introduces an error of less than 0.2% and 1% in calculations of energy expenditure and CO2 production from the standard human equations used in indirect calorimetric (IC) and doubly labelled water (DLW) methodologies respectively, and less than 2% in fuel utilisation calculated as % non-protein energy expenditure from IC. CONCLUSIONS: This study provides evidence that neither daytime nor total 24-h rates of H2 or CH4 excretion accurately predict degree of fermentation of NSP+RS in either individual subjects or groups of subjects, probably because of changes in the stochiometry of the fermentation process.

'Determination' of sugar alcohol and Polydextrose absorption in humans by the breath hydrogen (H2) technique: the stoichiometry of hydrogen production and the interaction between carbohydrates assessed in vivo and in vitro.

The production of hydrogen from substrates and substrate mixture of sugar alcohols and Polydextrose was determined, both in vivo using the breath hydrogen test, and in vitro, using human faecal microorganisms in anaerobic culture. One objective was to test a previous assumption that the stoichiometry of hydrogen production from different alternative carbohydrates is similar. Another objective was to discover whether hydrogen responses from mixtures of substrates were simply additive, or whether interactions occurred. The breath tests were performed in a 10 subject x 10 substrate factorial design with substrates and substrate mixtures (5-11 g) administered in 42 g chocolate confectionery. Incorporation of the alternative carbohydrates lactitol (L), Isomalt (I) and Polydextrose (P) into otherwise conventional confectionery increased breath hydrogen production by approximately 112, 73 and 11%/g respectively. There was no interaction between L and I or between P and I, but a combination of L and P approximately doubled the breath hydrogen anticipated from their individual contributions (P < 0.05). Anaerobic cultures showed a sixfold range in the efficiency of converting individual substrates and mixtures to hydrogen gas (0.003-0.018 kJ H2 per kJ carbohydrate). The positive interaction between L and P, and the lack of interaction between L and I, and between P and I, found in vivo were reproduced in vitro. The work showed that interpretation of the hydrogen breath test is confounded by differing stoichiometries for hydrogen production, by interaction between substrates and by an uncertain extent to which small intestinal hydrolysis yielding species with a fermentation stoichiometry that differs from the parent substrate.

The absorption of stearic acid from triacylglycerols: an inquiry and analysis.

Although stearic acid is a saturated fatty acid, its influence on plasma cholesterol acid other health variables is neutral; possibly owing in part to poor absorption. Reduced absorption of stearic acid from particular triacylglycerols, cocoa butter and novel fats formulated with short- and long-chain acid triacylglycerol molecules (Salatrims) has been attributed to high intakes. However, the circumstances and causes of poor stearic acid digestion from triacylglycerols are unclear; published data were therefore collected and analysed, with emphasis on human studies. Of twenty-eight studies conducted in adults, most are in men (>90%). The assertion that reduced absorption is due to a high intake of stearoyl groups is not supported: dietary intakes of stearoyl of 0.05-0.65 g stearic acid equivalent/kg body weight (cf typical intake of 0.2 g stearic acid equivalent/kg body weight in the Western diet) indicate that the 'true' digestibility of stearoyl is 0.98 (SE 0.01) g/g, with apparent digestibility less than this value at low intakes owing to endogenous stearic acid excretion and to inter-publication variation of unidentified cause. The neutral health impact of stearic acid must be due to factors other than availability. Exceptions include cocoa butter, Salatrims and tristearin, for which digestibility is an additional factor. The efficiency with which human subjects digest stearoyl from cocoa butter still remains uncertain, while the digestion of total long-chain fat from this source is 0.89-0.95 g/g, high in comparison with 0.33 g/g for Salatrim 23CA and 0.15 g/g for tristearin in their prepared states. Salatrims contain the highest proportion of long-chain fatty acids that are stearic acid-rich other than tristearin, which is the main component of fully-hydrogenated soyabean and rapeseed oil. Analysis shows that apparent digestibility of stearic acid is associated with stearoyl density within the triacylglycerol molecule and that, in Salatrims, the occurrence of short-chain fatty acids in place of long-chain fatty acids increases this density. Soap formation appears not to be a major factor in the reduced digestion of stearic acid from tristearin under regular dietary circumstances, but both microcrystallinity and reduced digestibility of tri-, di- and monostearoylglycerols appears to be important. Solubilisation of high-melting-point tristearin in low-melting-point oils improves the digestibility of its stearic acid, particularly when emulsified or liquidized at above melting point. However, without such artificial aids, the digestive tracts of the rat, dog and man have a low capacity for emulsifying and digesting stearic acid from tristearin. Reduced digestibility of stearic acid from Salatrim 23CA also appears to be attributable to reduced digestibility of di- and monostearoylglycerols and is particularly due to remnants with the 1- or 3-stearoylglycerol intact after initial hydrolytic cleavage. Short-chain organic acid in Salatrim 23CA, which is readily hydrolysed, leaves such remnants. Unlike tristearin, Salatrim 23CA melts at body temperature and mixing it with low-melting-point oils is not expected to cause further disruption of microcrystalline structures to aid digestibility of its stearoyl groups. The low digestibility of stearoyl in Salatrim 23CA, together with the occurrence of short-chain organic acids in this product, account for its relatively low nutritional energy value (about 20 kJ (5 kcal)/g) compared with traditional fats (37 kJ (9 kcal)/g) and low fat value (<20:37 kJ/kJ; <5:9 kcal/kcal) relative to traditional fats. In part these differences are because of minor effects of Salatrim 23CA on the excretion of other fat and protein, due to the bulking properties of this poorly-digestible fat.