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Carbohydrate metabolism and diabetes Nadine R Sahyoun, Amy L Anderson, Frances A Tylavsky, Jung Sun Lee, Deborah Sellmeyer,

Tamara ! "arris, and #or the "ealth, Aging, and !ody Com$osition Study Dietary glycemic inde% and glycemic load and the risk o# ty$e & diabetes in older adults Am J Clin Nutr January 2008 87: 126-131

perspect ive on page 1

Dietary glycemic index and glycemic load and the risk of type 2 diabetes in older adults13

Nadine R Sahyoun, Amy L Ander on, !ran"e A #yla$ %y, Jun& Sun Lee, 'e(orah ) Sellmeyer, and See #amara * +arri ,or the +ealth, A&in&, and *ody correspo and related perspective on page 3. Com-o ition Study nding
in#luence risk, several studies have #ocused on the glycemic inde% +,'- and glycemic load +,L- +/, 7-) Long.term consum$tion o# high.,' #oods has been $ro$osed to increase insulin demand, $romote insulin resistance, im$air $ancreatic .cell #unction, and eventually lead to ty$e & diabetes

ABSTRACT Background: 't is unclear (hether immediate dietary e##ects on blood glucose in#luence the risk o# develo$ing ty$e & diabetes) Objective: The ob*ective o# this study (as to e%amine (hether the dietary glycemic inde% +,'- and glycemic load +,L- (ere associated (ith the risk o# ty$e & diabetes in older adults) Design: The "ealth, Aging, and !ody Com$osition Study is a $ro. s$ective cohort study o# /012 adults (ho (ere 10 314 y old at baseline +n 5646 #or this analysis-) The intakes o# s$eci#ic nutrients and #ood grou$s and the risk o# ty$e & diabetes over a 7.y $eriod (ere e%amined according to dietary ,' and ,L) Results: Dietary ,' (as $ositively associated (ith dietary carbo. hydrate and negatively associated (ith the intakes o# $rotein, total #at, saturated #at, alcohol, vegetables, and #ruit) Dietary ,L (as $ositively associated (ith dietary carbohydrate, #ruit, and #iber and negatively associated (ith the intakes o# $rotein, total #at, saturated #at, and alcohol) 8ersons in the higher 9uintiles o# dietary ,' or ,L did not have a signi#icantly greater incidence o# ty$e & diabetes) Conclusions: These #indings do not su$$ort a relation bet(een dietary ,' or ,L and the risk o# ty$e & diabetes in older adults) !ecause dietary ,' and ,L sho( strong nutritional correlates, the overall dietary $attern should be considered) Am J Clin Nutr &006:61;5&< 3/5) !" #ORDS Diet, glycemic inde%, glycemic load, ty$e & diabetes, older adults

$%TROD&CT$O%

The $revalence o# ty$e & diabetes, a metabolic disorder char. acteri=ed by high blood glucose and insulin resistance, has more than doubled in the >nited States in the $ast & decades, and $ersons <0 y old account #or almost hal# o# the cases +5-) Factors such as obesity, lack o# $hysical activity, and smoking have been linked to the develo$ment o# ty$e & diabetes, but the role o# dietary carbohydrate remains unclear) Little relation has been #ound bet(een total carbohydrate intake and the risk o# ty$e & diabetes +&-) To determine (hether the rates o# digestion and absor$tion o# di##erent carbohydrate sources may

+&, 7 3 <-) "o(ever, studies o# dietary ,' and ,L in relation to insulin resistance and the risk o# ty$e & diabetes have had incon. sistent results) 'n the Framingham ?##s$ring Cohort Study +1-, both dietary ,' and ,L (ere $ositively related to insulin resis. tance, (hereas, in the @ut$hen lderly Study +6-, the 'nsulin Resistance Atherosclerosis Study +4-, the "ealth, Aging, and !ody Com$osition +"ealth A!C- Study +50-, and the 'nter44 Study #rom Denmark +55-, no associations (ere #ound) !oth dietary ,' and ,L (ere $ositively linked to incident ty$e & diabetes in the NursesA "ealth Study +7-, but no relations (ere seen in the Atherosclerosis Risk in Communities +5&-, the 'o(a BomenAs "ealth Study +5/-, and the 'nsulin Resistance Athero. sclerosis Study +57- cohorts) 'n the "ealth 8ro#essionals Follo(.u$ Study +&-, the NursesA "ealth Study '' +2-, and the Celbourne Collaborative Cohort Study +52-, dietary ,' but not ,L (as $ositively associated (ith risk o# ty$e & diabetes) Cost international diabetes organi=ations advocate the use o# the ,' in $revention and management o# diabetes +5<-, but the American Diabetes Association +ADA- does not #ully endorse the use o# the ,' because it considers current evidence insu#. #icient to su$$ort a relation bet(een dietary ,' or ,L and the develo$ment o# diabetes +51, 56-) The &002 >S De$artment o# Agriculture Dietary

,uidelines em$hasi=ed the need #or ad. ditional research on dietary ,L in relation to risk o# ty$e & diabetes +54-) Fe( studies o# dietary ,' and ,L and the risk o# ty$e & diabetes have been conducted in older adults, des$ite the high incidence o# ty$e & diabetes and the evident in#luence o# li#estyle on the risk o# ty$e & diabetes in this age grou$ +&0 3&&-) The $ur$ose o# the
From the De$artment o# Nutrition and Food Science, >niversity o# Cary. land, College 8ark, CD +NRS and ALA-: the De$artment o# 8reventive Cedicine, >niversity o# Tennessee, Cem$his, TN +FAT-: the De$artment o# Foods and Nutrition, >niversity o# ,eorgia, Athens, ,A +JSL-: the Division o# ndocrinology, >niversity o# Cali#ornia, San Francisco, CA +D S-: and the National 'nstitute on Aging, National 'nstitutes o# "ealth, !ethesda, CD +T!"-) & Su$$orted by contracts no) N05.A,.<.&50<, N05.A,.<.&505, and N05. A,.<.&50/ #rom the National 'nstitute on Aging and by the 'ntramural Research $rogram o# the National 'nstitute on Aging, National 'nstitutes o# "ealth) / Re$rints not available) Address corres$ondence to NR Sahyoun, De$art. ment o# Nutrition and Food Science, >niversity o# Caryland, 055& Skinner !uilding, College 8ark, CD &017&) .mail; nsahyounDumd)edu) Received June 5&, &001) Acce$ted #or $ublication August &, &001)
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Am J Clin Nutr &006:61;5&< 3/5) 8rinted in >SA) E &006 American Society #or Nutrition

,LFC C'C 'ND G, ,LFC C'C L?AD, AND TF8 & D'A! T S R'SH

5&1

current study (as to e%amine (hether dietary ,' and ,L (ere associated (ith incident ty$e & diabetes during a 7.y #ollo(.u$ in a cohort o# older adults)
S&B'!CTS (!T)ODS A%D

Stud* population 8artici$ants 10 314 y old (ere recruited #or the "ealth A!C Study, a $ros$ective cohort study, #rom a random sam$le o# Cedicare.eligible residents o# selected areas o# 8ittsburgh, 8A, and Cem$his, TN) 'ndividuals (ere eligible #or the "ealth A!C Study i# they $lanned to remain in the same area #or / y and i# they re$orted no li#e.threatening cancers and no di##iculty (ith basic activities o# daily living, (alking 5I7 mile, or climbing 50 ste$s) Those (ho used assistive devices (ere e%cluded, as (ere $artici$ants in any research studies that involved medications or modi#ication o# eating or e%ercise habits) An intervie( on be. havior, health status, and social, demogra$hic, and economic #actors and a clinical e%amination o# body com$osition, bio. chemical variables +including #asting serum glucose-, (eight. related health conditions, and $hysical #unction (ere adminis. tered in 5441 or 5446) Annual #ollo(.u$ assessments (ere conducted) Results #rom baseline through year < o# the "ealth A!C study (ere used in the current analyses) The sam$le si=e #or this study (as 5646 sub*ects, a#ter the e%clusion o# $artici$ants diagnosed (ith ty$e & diabetes be#ore dietary intake (as assessed +n <<&-,

#oods in the "ealth A!C Study FFJ (ere com$iled #rom the literature by the Clinical Nutrition Research Center at the >ni. versity o# North Carolina +Cha$el "ill, NC-, and they (ere mod. i#ied i# necessary to better match FFJ #oods +5<-) A com$uter $rogram (as (ritten in SAS so#t(are +version 4)5: SAS 'nstitute 'nc, Cary, NC- to calculate the dietary ,' and ,L o# #oods eaten by each $artici$ant) The $rogram #irst determined the amount o# available carbohydrate in one serving o# each #ood by subtracting the amount o# #iber #rom the amount o# total carbohydrate $er serving) To obtain the ,L o# a serving o# the #ood, the amount o# available carbohydrate $er serving (as multi$lied by the #oodAs ,' value, and that $roduct (as divided by 500) To determine the dietary ,L #or each sub*ect, each #oodAs ,L (as multi$lied by the daily #re9uency o# consum$tion o# the #ood, and these $rod. ucts (ere summed over all #oods) The dietary ,' #or each sub*ect (as com$uted by dividing dietary ,L by daily total available carbohydrate intake and multi$lying that value by 500) These methods o# calculating dietary ,' and ,L are endorsed by a *oint re$ort o# the FA?IB"? +&7- and by the &00& international table o# glycemic inde% and glycemic load values +5<-) Diagnosis diabetes o+ t*pe ,

'n this study, ty$e & diabetes (as de#ined by 1- an annual re$ort o# $hysician diagnosis: 2- the re$orted use o# e%ogenous insulin

TAB!1 Characteristics $o$ulation

o#

the

study

those (ith missing in#ormation on ty$e & diabetes in years / through < +n <0-, men (ho re$orted an energy intake o# 600 kcalId or 7000 kcalId and (omen (ho re$orted an energy intake o# 200 kcalId or /200 kcalId +n 1/-, and those (ith

Sociodemogra$hic #actors

5&6
+n Cen 615-

SA"F?>N T AL
Age +y1

Bomen +n 50&1-

incom$lete in#ormation on other relevant behavioral or sociode. mogra$hic #actors +n /6&)

12)/

0)52

12)0

0)53

Bhite +K-.

15)6

</)73

,LFC C'C 'ND G, ,LFC C'C L?AD, AND TF8 & D'A! T S R'SH
ducation +K com$leted high school-. !ehavioral #actors. Smoking +li#etime $ack.years0)13 Any alcohol consum$tion +K8hysical activity +kcalI(k753 !iochemical variables Fasting glucose +mgIdL-1 0)/3 Fasting insulin + >ImL!ody com$osition1
.

5&4
16)2 &2)2 5)0 65)4 55)4 71)63 16&

8artici$ants $rovided (ritten in#ormed consent) 8rotocols (ere a$$roved by institutional revie( boards at the >niversity o# 8ittsburgh and the >niversity o# Tennessee, Cem$his) Dietar* assess.ent Food intake (as measured in year & o# the "ealth A!C Study by using a 506.item #ood.#re9uency 9uestionnaire +FFJbased on the validated !lock 9uestionnaire +!lock Dietary Data Sys.

<&)< 571< 1/

47)7

0)/

45)/

1)1

5/0

0)&

1)4

0)&

SA"F?>N T AL
3 !C' 0)& +kgIm Total body #at +K0)&3 Dietary #actors1 Total calorie intake +kcal563 kcal #rom carbohydrate +K0)/3 kcal #rom $rotein +K0)53 kcal #rom #at +K0)&3 kcal #rom saturated #at +K0)53 Total dietary #iber +g0)&3 Daily servings o# vegetables +n0)5 Daily servings o# #ruit and #ruit *uice +n0)03 >nad*usted dietary glycemic inde% &

tems, !erkeley, CA- +&/-, (hich (as modi#ied s$eci#ically #or the "ealth A!C Study to include an age.a$$ro$riate #ood list) The #ood list (as based on the third National "ealth and Nutrition %amination Survey &7.h recall data #or non. "is$anic (hite and black residents o# the Northeast and South (ho (ere <2 y old) The FFJ (as administered by a trained dietary intervie(er, and intervie(s (ere $eriodically monitored to ensure 9uality and consistency) Bood blocks, models o# actual #oods, and #lash cards (ere used to hel$ $artici$ants estimate $ortion si=es) Nu. trient and #ood grou$ intakes, including daily servings o# vege.

&<)< &4)&

0)5 0)&

&1)0 70)/

&051 && 2/)0 0)/ 57)& 0)5 //)0 0)& 4)< 0)5 56)& /)0 5)6 0)/ 0)5 0)0

5<60 2/)4 57)2 //)& 4)7 5<)1 /)0 &)5

tables and #re9uency o# #ruit and #ruit *uice consum$tion, (ere determined by using !lock Dietary Data Systems) The ,' o# a #ood is de#ined as the &.h incremental area under

+glucose scale>nad*usted dietary glycemic load +glucose scale-

2<)6

0)5

22)6

0)5

,LFC C'C 'ND G, ,LFC C'C L?AD, AND TF8 & D'A! T S R'SH
570)6
1

5)1

55<)1

5)73

5/5

the blood glucose curve a#ter consum$tion o# a #ood $ortion that contains a s$eci#ic amount, usually 20 g, o# available carbohy. drate, divided by the corres$onding area a#ter consum$tion o# a $ortion o# a re#erence #ood, usually glucose or (hite bread, that contains the same amount o# available carbohydrate, and multi. $lied by 500 +to be e%$ressed as a $ercentage-) ,' values #or

Lalues #rom year & o# the "ealth, Aging, and !ody Com$osition +"ealth A!C- Study) 2 / S C +all such values-) 3 Signi#icantly di##erent #rom men, 0 0)02 +StudentAs t test #or con. tinuous variables and chi.s9uare test #or categorical variables-) . Lalues #rom baseline o# the "ealth A!C study)

or oral hy$oglycemic medication, assessed in years &, /, 2, and <: or 3- #asting serum glucose 5&< mgIdL +in accordance (ith current ADA criteria-, measured in years &, 7, and < +&2-) Sociode.ograp/ic variables and li+est*le

Sociodemogra$hic variables including age, se%, sel#. identi#ied racial grou$, and education and li#estyle variables in. cluding smoking status, alcohol consum$tion, and $hysical ac. tivity (ere assessed at baseline o# the "ealth A!C Study) Li#etime $ack.years o# cigarette smoking (ere calculated by multi$lying the number o# $acks o# cigarettes smoked $er day by the number o# years o# smoking) 8hysical activity (as evaluated by a standardi=ed 9uestionnaire s$eci#ically designed #or the "ealth A!C Study) This 9uestionnaire (as derived #rom the leisure.time $hysical activity 9uestionnaire, and it included ac. tivities commonly $er#ormed by older adults +&<-) The #re. 9uency, duration, and intensity o# s$eci#ic activities (ere deter. mined, and a$$ro%imate metabolic e9uivalent unit values (ere assigned to each activity category to estimate (eekly energy e%$enditure) Statistical anal*sis Characteristics o# men and (omen (ere com$ared by using StudentAs t test and the chi.s9uare test) Dietary ,' and ,L (ere ad*usted #or total calorie intake by using the residuals method o# Billett et al +&1-) 8artici$ants (ere grou$ed by 9uintiles o# energy.ad*usted dietary ,' and ,L, and baseline characteristics (ere e%amined according to dietary ,' and ,L) Ceans o# 9uin. tiles & through 2 (ere com$ared (ith those o# 9uintile 5 (ith the
TAB-! , Characteristics o# $artici$ants according to 9uintile +J- o# energy. ad*usted dietary glycemic inde%

use o# DunnettAs test #or continuous variables and a chi. s9uare test #or categorical variables) Linear regression (as used to as. sess trends o# continuous variables in relation to dietary ,' and ,L, and the Cantel."aens=el chi.s9uare test (as used to e%am. ine trends o# categorical variables across 9uintiles o# dietary ,' and ,L) To determine the risk o# develo$ing ty$e & diabetes by 9uintile o# energy.ad*usted dietary ,' and ,L, multivariate logistic re. gression (as used) Covariates included age, se%, race, clinical site, education, $hysical activity, baseline #asting glucose, body mass inde% +in kgIm&-, alcohol consum$tion, total #iber intake, cereal #iber intake, and smoking status) Dietary ,' and ,L (ere also analy=ed as continuous variables in relation to risk) 'nter. actions o# dietary ,' and ,L (ith se%, race, and education (ere tested) Statistical signi#icance (as set at 0 0)02, and analyses (ere $er#ormed (ith SAS so#t(are +version 4)5: SAS 'nstitute 'nc, Cary, NC-)

R!S&TS

Characteristics o# the study $o$ulation are sho(n in Table 1, and characteristics by 9uintiles o# energy.ad*usted dietary ,' and ,L are sho(n in Table , and Table 3) ?n average, sub*ects in the higher 9uintiles o# dietary ,' (ere older: less likely to be #emale or (hite, to have a high school degree, or to consume alcohol: and less $hysically active) They had a higher $ercentage intake #rom carbohydrate: a lo(er $ercentage intake #rom $ro. tein, total #at, and saturated #at: and lo(er consum$tion o# veg. etables and #ruit) Sub*ects (ith a higher dietary ,L also (ere
used #or categorical variables) 2 Lalues #rom year & o# the "ealth, Aging, and !ody Com$osition +"ealth A!C- Study) 3 / S C +all such values-) . Signi#icantly di##erent #rom J5, 0 0)02 +DunnettAs test #or continuous variables and chi.s9uare test #or categorical variables-) 1 Lalues #rom baseline o# the "ealth A!C study) J&

J5 Dietary glycemic inde% Sub*ects +nFemale +KRisk #actors #or ty$e & diabetes Age +y-2 Bhite +K-1 ducation +K com$leted high school- 1 Smoking +li#etime $ack.years-1 Any alcohol consum$tion +K-1 8hysical activity +kcalI(k- 1 Fasting glucose +mgIdL- 2 !C' +kgIm&-2 Dietary #actors2 Total calorie intake +kcalkcal #rom carbohydrate +Kkcal #rom $rotein +Kkcal #rom #at +Kkcal #rom saturated #at +KTotal dietary #iber +gDaily servings o# vegetables +nDaily servings o# #ruit and #ruit *uice +n1 2

20)2 0)5 /14 <5)& 12)0 0)5 <4)5 67)1 56)4 5)7 <7)5 554< 4& 4/)7 0)2 &1)& 0)& 5601 20)6 57)4 //)1 4)1 5<)1 /)5 &)/ // 0)7 0)& 0)7 0)5 0)7 0)5 0)5

27)/ 0)0 /65 22)4 12)0 0)5 15)4 67)/ 5<)< 5)7 <5)7 5&00 4& 4&)4 0)2 &<)1 0)& 566& 2&)6 57)2 //)< 4)< 56)/ /)& &)/ // 0)7 0)& 0)7 0)5 0)7 0)5 0)5

Linear regression (as used #or continuous variables, and the Cantel."aens=el chi.s9uare test #or trend across 9uintiles (as

TAB-! 3 Characteristics o# $artici$ants according to 9uintile +J- o# energy. ad*usted dietary glycemic load

J5 Dietary glycemic load2 Sub*ects +nFemale +KRisk #actors #or ty$e & diabetes Age +y-2 Bhite +K-1 ducation +K com$leted high school- 1 Smoking +li#etime $ack.years-1 Any alcohol consum$tion +K-1 8hysical activity +kcalI(k- 1 Fasting glucose +mgIdL- 2 47)< 0)43 /14 2&)2 17)6 0)5 <6)5 65)6 &/)4 5)7 10)2 5&77 4& 4/)2 0)2

J& 551)5 0)& /65 26)6 12)5 0)5 15)5 65)5 51)2 5)7 26)2. 5022 4& 4&)6 0)2

!C' +kgIm&-2 Dietary #actors2 Total calorie intake +kcalkcal #rom carbohydrate +Kkcal #rom $rotein +Kkcal #rom #at +Kkcal #rom saturated #at +KTotal dietary #iber +gDaily servings o# vegetables +nDaily servings o# #ruit and #ruit *uice +n1

&1)0 &0<5 7/)5 52)& 70)& 55)2 5<)1 /)5 5)1

0)& /5 0)7 0)5 0)/ 0)5 0)7 0)5 0)5

&1)0 5</1 74)4 52)5 /2)< 50)& 52)2 &)4 5)4

0)& /5. 0)&. 0)5 0)/. 0)5. 0)7 0)5 0)5

Linear regression (as used #or continuous variables, and the Cantel."aens=el chi.s9uare test #or trend across 9uintiles (as used #or categorical variables) 2 Lalues #rom year & o# the "ealth, Aging, and !ody Com$osition +"ealth A!C- Study) 3 / S C +all such values-) . Signi#icantly di##erent #rom J5) 0 0)02 +DunnettAs test #or continuous variables and chi.s9uare test #or categorical variables-) 1 Lalues #rom baseline o# the "ealth A!C study)

older: (ere less likely to be (hite, to have a high school degree, or to consume alcohol: and had #e(er li#etime $ack. years o# smoking) They also had a higher $ercentage intake #rom carbo. hydrate: lo(er $ercentage intakes #rom $rotein, total #at, and saturated #at: and higher intakes o# #ruit and #iber) The risk o# develo$ing ty$e & diabetes according to energy. ad*usted dietary ,' and ,L is sho(n in Table 0) Neither dietary ,' nor dietary ,L (as signi#icantly associated (ith risk, either be#ore or a#ter control #or age, se%, race, clinical site, education, $hysical activity, baseline #asting glucose, body mass inde%, alcohol consum$tion, and smoking status) Additional ad*ustment

#or total #iber or cereal #iber intake did not signi#icantly alter results) 'nteractions o# dietary ,' or ,L (ith se%, race, and education (ere #ound not to be signi#icant)
D$SC&SS$ O%

'n this cohort o# (ell.#unctioning older adults, neither dietary ,' nor dietary ,L (as associated (ith the risk o# develo$ing ty$e & diabetes) These #indings su$$ort results o# the Atherosclerosis Risk in Communities Study o# adults 723 <7 y old at baseline, the 'o(a BomenAs "ealth Study o# (omen 22310 y old, and the

TAB-! 0 Relative risk o# ty$e & diabetes according to 9uintile +J- o# energy. ad*usted dietary glycemic inde% and load J5 Dietary glycemic inde% Ty$e & diabetes cases +n?R +42K C'-3 ?R +42K C'-. ?R +42K C'-1 Dietary glycemic load Ty$e & diabetes cases +n?R +42K C'-3 ?R +42K C'-. ?R +42K C'-1
1

J&
2

20)2

0)5 &7 5)0 5)0 5)0 47)< 0)4 51 5)0 5)0 5)0

27)/ 0)0 56 0)1 +0)7, 5)70)1 +0)7, 5)70)6 +0)7, 5)1551)5 0)& && 5)/ +0)1, &)25)/ +0)1, &)<5)2 +0)1, /)0-

Analysis o# dietary glycemic inde% and load as continuous variables) 2 / S C +all such values-) 3 >nad*usted model) . Ad*usted #or age, se%, race, clinical site, and education) 1 Ad*usted #or age, se%, race, clinical site, education, $hysical activity, baseline #asting glucose, !C', alcohol consum$tion, and smoking status)

'nsulin Resistance Atherosclerosis Study o# adults 70 3 <4 y old, (hich also did not sho( associations bet(een dietary ,' or ,L and incident ty$e & diabetes +5&357-) 'n contrast, in the NursesA "ealth Study o# (omen 70 3 <2 y old, those in the highest 9uintile o# dietary ,' or ,L had a risk o# develo$ing ty$e & diabetes that (as 70 320K greater than the risk o# (omen in the lo(est 9uintile, a#ter ad*ustment #or cereal #iber intake +7-) Similar $os. itive relations (ere seen bet(een dietary ,' and ty$e & diabetes risk in the "ealth 8ro#essionals Follo(.u$ Study o# men 70 312 y old +&-, the NursesA "ealth Study '' o# (omen &7 3 77 y old +2-, and the Celbourne Collaborative Cohort Study o# adults 70 3 <4 y old +52-) 'n the $resent study, both dietary ,' and ,L (ere negatively associated (ith the intakes o# saturated #at, total #at, and alcohol, #actors that may adversely a##ect glucose metabolism) Dietary ,' and ,L (ere $ositively associated (ith dietary carbohydrate, and dietary ,L (as also $ositively associated (ith #ruit and #iber intakes, #actors that may bene#it glucose metabolism) Although diets (ith a lo(er ,' or ,L (ere e%$ected to be more health#ul, the higher the dietary ,' or ,L, the better the diet #it current dietary guidelines to limit intake o# saturated #at and, in the case o# dietary ,L, the guideline to consume 57 g #iberI5000 calo. ries and to consume multi$le servings o# #ruit each day +54-) Thus, the #indings o# the $resent study sho( that a lo(er dietary ,' or ,L is not necessarily more com$atible (ith current dietary guidelines than is a higher ,' or ,L) ?ther studies have also #ound strong nutritional correlates o# dietary ,' and ,L +&, 7, 2, 6, 52, &6 3/0-) Schul= et al +&6- $ositively correlated dietary ,' (ith consum$tion o# (hite bread, beer, meat, #ried $otatoes, #at, alcohol, and starchMand thus (ith a less health#ul overall dietMand negatively correlated dietary ,' (ith consum$tion o# #ruit, #iber and lo(.#at milk) ?ther studies also #ound $ositive associations o# dietary ,' (ith consum$tion o# bread and starch and negative associations (ith consum$tion o# #ruit, #iber, and lo(.#at milk +&, 7, 2, 6, 52-) Cost studies, including the $resent study, $ositively associated dietary ,L (ith a more health#ul overall diet, including higher intakes o# #iber and cereal #iber, and negatively associated dietary ,L (ith consum$tion o# #at and alcohol +&, 7, 2, 55-) Summary indicators such as dietary ,' or ,L may not $rovide su##icient in#ormation on the com$osition o# a diet and its e##ect on risk o# ty$e & diabetes) 't has been suggested that dietary ,L $rovides little in#ormation beyond total carbohydrate intake +55, &4-) 'n contrast, dietary ,', (hich does not re#lect total carbo. hydrate intake, is thought to $rovide little insight into the overall insulin demand induced by total carbohydrate intake +&, 7-) There#ore, i# the ,' or ,L is considered in research or in dietary recommendations, it should be considered in con*unction (ith national dietary guidelines +51, &7-) Certain #actors may have in#luenced study #indings) This co. hort included $artici$ants o# similar age and #unctional status and (ith relatively narro( ranges o# dietary ,' and ,L) Dietary ,' 9uintile means ranged #rom 20 to <0) 'n contrast, Cayer.Davis et al +&4- #ound dietary ,' 9uintile means that ranged #rom 12 to 40, as did others +&, 7, 2, 1, 6, 5&-, $erha$s in $art because o# methodologic di##erences in calculating dietary ,' and ,L) Bhereas the current study #ollo(ed methods su$$orted by sev. eral international organi=ations, other studies have used a slightly di##erent

$rocedure +50-) Cean dietary ,L in the current study ranged #rom 42 to 5<0) Cayer.Davis et al #ound dietary ,L 9uintile means o# 40 to /00 +&4-, and others +&, 7, 1- also

#ound larger and higher ranges o# dietary ,L than (ere #ound in the current study) The homogeneity in the $o$ulation o# the current study may have attenuated associations bet(een dietary ,' and ,L and the risk o# ty$e & diabetes +/5-) !ecause the $o$ulation o# the current study consisted o# rel. atively (ell.#unctioning older adults, selection bias, through the e%clusion o# metabolically vulnerable sub*ects, also could have diminished associations bet(een dietary ,' or ,L and risk o# ty$e & diabetes +/&-) Furthermore, as in other studies, the FFJ used in the current study (as not s$eci#ically designed to mea. sure dietary ,' or ,L and may not have ca$tured the total gly. cemic e##ect o# the diet +55-) Strengths o# this study include its longitudinal design, uni9ue age grou$, and the thorough diagno. sis o# ty$e & diabetes that did not rely solely on sel#.re$orted in#ormation) 'n conclusion, this study does not su$$ort a relation bet(een dietary ,' or ,L and the risk o# ty$e & diabetes in older adults) !ecause dietary ,' and ,L each have strong and uni9ue nutri. tional correlates, it may be im$ortant to e%amine the dietary $attern as a (hole in addition to estimating the glycemic e##ect o# dietary carbohydrate (hen evaluating the contribution o# diet to the risk o# a com$le% chronic disease such as ty$e & diabetes)
The authorsA res$onsibilities (ere as #ollo(sMNRS, ALA, and T!"; the study conce$t and research design: ALA and NRS; the dra#ting o# the manu. scri$t: and FAT, JSL, D S, and T!"; critical revie( and revision o# the manuscri$t) None o# the authors had a $ersonal or #inancial con#lict o# interest)

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