Fermented Dairy Intake in Relation to Glycemic and Insulinemia

Thomas MS Wolever, BA, MA, MSc, PhD, DM (Oxon)

Department of Nutritional Sciences,University of Toronto, Toronto, ON, Canada.

Keenan Research Centre of Li Ka Shing Knowledge Institute,St. Michael's Hospital, Toronto, ON, Canada.

Glycemic Index Laboratories, Inc.20 Victoria St., Suite 300, Toronto, ON, Canada.

www.gilabs.com

Disclosures for Thomas Wolever

AFFILIATION/FINANCIAL INTERESTS (past 12 months)

CORPORATE ORGANIZATION

Grants/Research Support: None

Scientific Advisory Board/Consultant: Glycemic Index Laboratories,

Inc. (GI Labs), a CRO

Speakers Bureau: None

Stock Shareholder: No Food Companies

Other GI Labs: my wife and I are

part owners and employees

Objectives

• Describe the role of glycemic index (GI) in reducing risk for type 2 diabetes.

• Review the effect of yogurt on:– Acute glycemic responses– Acute insulin responses

• Show how yogurt can be used to reduce dietary GI.

Association of High Yogurt Intake with Reduced Risk for Type 2 Diabetes

<1/wk

1-4/

wk

5-10

/wk

>1.5/

day

<1/wk

1-4/

wk

5-10

/wk

>1.5/

day

<1/wk

1-4/

wk

5-10

/wk

>1.5/

day

0.4

0.6

0.8

1.0

1.2

Yogurt Yogurt BMI≤25 Yogurt BMI>25

p<0.001p<0.001p<0.001

Rel

ativ

e R

isk

of T

2DM

Chen M, et al. BMC Medicine 2014;12:215.

Why Does Yogurt Reduce Risk for Type 2 Diabetes?

• Good source of– Vitamin D (D2d study)– Calcium– Conjugated linoleic acid

• Influence on microbiome

• Low glycemic response

1 2 3 4 5 1 2 3 4 5

0.2

0.6

1.0

1.4Glycemic Index

Glycemic Loadp<0.0001 p=0.02

Quintiles of GI or GL

Rel

ativ

e R

isk

of T

2DM

Glycemic Index / Load and Risk for Type 2 Diabetes: 2014

SN Bhupathiraju et al. AJCN 2014;100:218.

49 52 585554

Fully adjusted models: age, race, smoking, hormone/contraceptive use, physical activity, family history, BMI, and intakes of energy, alcohol, coffee, cereal fiber, PUFA, SFA and trans-fat (and for GI, protein)

What is the GI of Yogurt?www.glycemicindex.com

10

≤>

10

-15

>1

5-2

0

>2

0-2

5

>2

5-3

0

>3

0-3

5

>3

5-4

0

>4

0-4

5

>4

5-5

0

>5

0-5

5

>5

5-6

0

>6

0-6

5

>6

5-7

0

>7

0-7

50

5

10

15

Glycemic Index

Num

ber

n Mean SD Minimum Maximum

93 34.1 13.2 11 67

High GI(≥70)

Low GI(≤55)

Carbohydrate Content of Yogurts in GI Database

5 ≤

>5

-10

>10

-15

>15

-20

>2

0-2

5

>2

5-3

0

>3

0-3

5

>35

-40

>40

-45

>4

5-5

00

10

20

30

Carbohydrate g/Serving

Num

ber

2 ≤>

2-4

>4

-6

>6

-8

>8-

10

>1

0-1

2

>1

2-1

4

>14

-16

>1

6-1

8

>1

8-2

0

>2

0-2

2

>2

2-2

40

10

20

30

Carbohydrate g/100gN

umbe

r

PlainYogurt

SweetenedYogurt

g/100g Skimmed Milk Plain Yogurt Sweetened Yogurt

Carbohydrate 5.2 6.9 14.3

Sugars 5.2 3.4 12.0

Protein 3.6 4.0 3.4

Fat 0 0 0

GI of Plain vs Sweetened Yogurt

Plain Yogurts

(n=43)Sweetened Yogurts

(n=50)p

Glycemic Index 26.6±10.9 40.5±11.4 <0.0001

Serving Size 192±29 195±31 ns

Carbohydrate (g/serving) 12.4±2.4 30.6±6.3 <0.0001

Glycaemic Load 3.4±1.7 12.6±4.5 <0.0001

Carbohydrate (g/100g) 6.5±1.2 15.6±2.3 <0.0001

GIPlain Yogurts Sweetened Yogurts

% of CHO GI×%/100 % of CHO GI×%/100

Lactose 48 100% 48 42% 19

Sucrose 61 0% 0 58% 36

Calculated GI of CHO 48 55

10

≤>

10

-15

>1

5-2

0

>2

0-2

5

>2

5-3

0

>3

0-3

5

>3

5-4

0

>4

0-4

5

>4

5-5

0

>5

0-5

5

>5

5-6

0

>6

0-6

5

>6

5-7

0

>7

0-7

50

5

10

15

Glycemic Index

Num

ber

High GI(≥70)

Low GI(≤55)

www.glycemicindex.com

+15%

+52%

Amount of Protein and Fat Consumed for GI Testing Yogurt

Portion Size for GI Testing

Plain Yogurt Sweetened Yogurt

Weight (g) 769 321

Carbohydrate 50 50

Protein 29 12

Fat ? 0 - 62 0 - 20

Protein /g CHO 0.58 0.24

Fat /g CHO 0 – 1.2 0 - 0.44

g/100g Skimmed Milk Plain Yogurt Sweetened Yogurt

Carbohydrate 5.2 6.9 14.3

Sugars 5.2 3.4 12.0

Protein 3.6 4.0 3.4

Fat 0 0 0

Dose-Response Effect of Fat and Protein on Glycemic Response

(n=20) 50g Glucose plus:Corn OilSoy Pro

0g 5g 10g 30g

0g 0:0 0:5 0:10 0:30

5g 5:0 5:5 5:10 5:30

10g 10:0 10:5 10:10 10:30

30g 30:0 30:5 30:10 30:30

(n=25) 50g Glucose plus:Canola OilWhey Pro

0g 5g 30g

0g 0:0 0:5 0:30

5g 5:0 5:5 5:30

30g 30:0 30:5 30:30

(n=12) 25g Glucose +

Whey Protein

0g

4.5g

9g

18g

Moghaddam et al.J Nutr 2006;136:2506

Lan-Pidhainy & WoleverAJCN 2010;91:98.

Gunnerud et al.EJCN 2013;67:749.

0.0 0.2 0.4 0.6 0.80

20

40

60

80

100Moghaddam 2006Lan-Pidhainy 2010

Fat Intake (g/gCHO)

AU

C (

Mea

n±

SE

M)

(% o

f C

ontr

ol)

Small Effect of Fat on Glycemic Response

Slope -14% per 1g fat/gCHO

GI of Milk

Whole Skimmed0

10

20

30

40

50

Gly

cem

ic I

ndex

Whole Skim

Mean GI 31.1 34.7

Fat g/gCHO 0.78 0

% reduction 10%

34.7×0.9 = 31.2

Effect of Protein Amount and Source on Glycemic Response

Soy protein: slope -65% per 1g pro/gCHO

Whey: slope -76% per 1g pro/gCHO

0.0 0.2 0.4 0.6 0.80

20

40

60

80

100

Gunnerud 2013Moghaddam 2006Lan-Pidhainy 2010

Protein Intake (g/gCHO)

AU

C (

Mea

n±

SE

M)

(% o

f C

ontr

ol)

Plain Sweetened0

20

40

60

Observed GI±95% CICalculated CHO GIProtein Adjusted

PlainYogurt

SweetenedYogurt

Protein/g CHO 29/50 = 0.58 12/50 = 0.24

% reduction dueto dairy protein

44% 18%0.0 0.2 0.4 0.6 0.80

10

20

30

40

50

Protein (g/gCHO)

Gly

cem

ic I

ndex

Lactic Acid:Little or no effect on Glycemic Response

0 60 120 180

0

1

2

BreadBread & Lactic Acid(0.28 mmol/g CHO)

Time (min)

∆ B

lood

Glu

cose

(m

mol

/L)

0 60 120 180

0

1

2

BreadBread & Lactic Acid(0.26 mmol/g CHO)

Time (min)∆

Blo

od G

luco

se (

mm

ol/L

)

HGM Liljeberg et al.J Nutr 1995;125:1503

HGM Liljeberg & BjörckAm J Clin Nutr 1996;64:886

Insulinemic Impact of Dairy Foods

0 40 80 1200

40

80

120

Glycaemic Index

Insu

linae

mic

Ind

ex

MilkYogurtLactoseFermented Milk

148 140

Non-Dairy Dairy

IIGI

Mean±SD 0.97±0.21 3.58±2.0*

(Range) (0.6-1.6) (0.9-6.5)

ProCHO

Mean±SD 0.078±0.056 0.66±0.17*

(Range) (0.00-0.19) (0.33-0.81)

Brand-Miller et al.Brit J Nutr 1995;73:613.

● Non-dairy Foods

0.0 0.2 0.4 0.6 0.80

50

100

150

Gunnerud 2013Lan-Pidhainy 2010

Protein Intake (g/gCHO)

AU

C (

Mea

n±

SE

M)

(% o

f C

ontr

ol)

Whey Protein and Insulin Response:Size and Mechanism of Effect

Lan-Pidhainy & WoleverAJCN 2010;91:98.

Slope = +91% per1g protein/g CHO

0.0 0.2 0.4 0.6 0.80

100

200

300

Protein Intake (g/gCHO)

100 ×

RIR

:RG

R

Slope = +294% per1g protein/g CHO

Conclusions 1: Glycemic and insulinemic impact of yogurt

• Yogurt has a low GI:– Lactose is its available CHO.

• GI of plain/artificially sweetened < sweetened– Due to higher content of protein per CHO

• Relative to other CHO foods, dairy foods elicit a disproportionately high insulin response:– Explained by high protein content– Not due to increased insulin secretion– Very few data on insulinemic impact of yogurt (from 1995)

• Low-fat fruit yogurt sweetened with sugar: GI=33, II=28• Low-fat yogurt aspartame sweetened: GI=14, II=63

• Would this be a problem?

Meals with and without dairyProtein Fat Carb

Bread, butter, orange juice and beef 31 20 42

Bread, margarine, milk, yogurt and cheese 31 21 42

Turner et al. Am J Clin Nutr 2016;103:71.

Reported (netAUC)

My Estimate (incAUC)

Glucose Insulin Glucose Insulin I:G

Beef 0.88 160 68 472 6.98

Dairy 2.33 167 71 496 6.94

0 60 120 180

-0.5

0.0

0.5

1.0

1.5

2.0 DairyMeat

Time (min)

∆ B

lood

Glu

cose

(m

mol

/L)

Serving 90g 79g 2 cookies

Kcal 60 70 71

Fat 0 0 2

Avail Carb 12 16 12

Protein 3 1 1

GI 33 53 69

II 57 53 69

2/3

Estimated Glycemic & Insulinemic Impact of Yogurt vs Other Snacks

??

II/GI increases 294% per gPro/gCHO

RGR = 1.64×GI×(1-e-0.0191g) RIR = II×g/50

Data from: Lee & Wolever EJCN 1998;52:924.

2/3

Estimated Glycemic & Insulinemic Impact of Yogurt vs Other Snacks

Glucose Insulin0

5

10

15

20

25

Yogurt Banana Cookies

Rel

ativ

e to

50g

Glu

cose

Yogurt to Reduce Diet GISample Menu Yogurt Substituted

Breakfast

Cornflakes and 1%milk Granola and Fruit Yogurt

Toast, Jam, Orange Juice Toast, Butter, Orange Juice

Lunch

PB and Jam Sandwich, Banana PB and Jam Sandwich, Banana

Afternoon snack

Cheese & crackers Vanilla Yogurt and Apple

Dinner

Chicken, Rice and Vegetables Chicken, Rice and Vegetables

Apple Pie and Ice Cream Plain Yogurt and Blueberries

Kcal Protein Fat CHO GI

Sample Menu 1840 74 47 265 64

Yogurt Substituted 1740 75 37 270 56

30-35% risk reduction for T2DM

Summary• Yogurt associated with reduced risk for T2DM• Low diet GI associated with reduced risk for T2DM• Yogurt has a low GI

– Due to its lactose and protein content• Plain/artificially sweetened: 27 (SD=11)• Sweetened: 41 (SD=11)

• Few data on insulinemic impact of yogurt– Even assuming a disproportionately high insulin

response, yogurt, whether consumed alone or as a part of mixed meals, likely elicits similar or lower insulin response than other meals/snacks

• Yogurt can replace other foods as a healthy way to reduce diet GI and reduce risk for T2DM.

Thank you!

DC Greenwood et al. Diabetes Care 2013;36:4166.©2013 by American Diabetes Association

Glycemic Index / Load and Risk for Type 2 Diabetes: 2013

1.08 (1.02, 1.15)

1.08 (1.02, 1.15)

1.03 (1.00, 1.05)

1.03 (1.00, 1.05)

0.97 (0.90, 1.06)

0.97 (0.90, 1.06)

HighGI

LowGI

Meals with and without dairyProtein Fat Carb GI

Cereal, milk & fruit 10 3 50 65 S1

Cereal, milk & fruit 11 3 42 35 S2

Bread & vegetable omelette 18 10 20 66 S3

Bread & vegetable omelette 17 10 16 40 S4

Cereal, sugar, milk, banana & OJ 7 2 47 55 S5

Muffin, peanut butter 5 15 27 56 S6

Wolever et al.Am J Clin Nutr 2006;83:1306.

0 40 80 1200

4

8

12

16

20 DairyNon-Dairy

Glucose AUC (mmol×min/L)

Insu

lin A

UC

(nm

ol×m

in/L

)

Mean±SD I:G ratio Dairy: 0.13±0.021Non-dairy: 0.12±0.014