Diabetology: Type 2 Diabetes Mellitus Viswanathan Mohan, Ranjit Unnikrishnan
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Diet-based Management and Treatment of Diabetes

Christiani J Henry MSc PhD FIFST (UK),
Functional Food Centre,Oxford, United Kingdom jeya_henry@sics.a-star.edu.sgClinical Nutrition Research Centre, Singapore Institute for Clinical SciencesSingapore
Bhupinder Kaur MSc
Clinical Nutrition Research Centre, Singapore Institute for Clinical SciencesSingapore

ABSTRACT

A diet rich in refined carbohydrates is believed to be a major factor contributing to the rising incidence of type 2 diabetes mellitus in Indians. Understanding the role of refined carbohydrates on blood glucose excursions is necessary for the proper selection and formulation of foods. This review presents simple and practical ways in which Indian dietaries may be modified not only to lower blood glucose response, but also to enable consumers to enjoy the diverse variety of Indian foods. Practical recommendations are provided that will enable diabetics to consume nutritious and highly palatable foods. The time has come for both consumers and food manufacturers to appreciate the importance of consuming low glycemic foods in order to abate the escalating incidence of type 2 diabetes.
 
INTRODUCTION
Asia is emerging as the epicenter of the diabetes epidemic with China and India leading the world with the greatest number of people with diabetes. An estimated 61.3 million individuals are affected by diabetes in India, and this number is expected to increase to a staggering 101.2 million by the year 2030.1 Population studies have shown that diabetes affects both rural and urban populations in India with the numbers increasing at an alarming rate.2,3 This has been attributed to changes in diet and lifestyle patterns with the latter having a profound role in the etiology of diabetes. With the increasing prevalence of diabetes and related chronic diseases, greater research attention is necessary to curb its further escalation. Dietary interventions have, therefore, gained considerable interest in diabetes 2management and treatment. Their primary aim is to maintain a modest and stable postprandial blood glucose concentration when consuming a carbohydrate-rich diet.4 Whilst pharmacological intervention has been the bedrock of diabetes management for several decades, there is increased support for the use of diet in the management and treatment of diabetes.
 
ETIOLOGY OF TYPE 2 DIABETES IN INDIANS
Indians are more prone to insulin resistance, developing metabolic syndrome and have an increased risk for developing type 2 diabetes compared to other ethnic groups.5 Higher insulin levels to a given glucose load was observed in Asian Indians compared to Europeans with hyperinsulinemia.6 Euglycemic clamp studies demonstrated that insulin resistance was greater among Asian Indians compared to Europeans who were similar in age, sex, and body mass.710
The Indian diet is generally characterized as one that is high in carbohydrate content. In India where the two most common staples are rice and wheat-based chapati, their consumption is associated with a rapid rise in blood glucose. Refined grains such as white rice have been linked with the risk of type 2 diabetes and metabolic syndrome among urban South Asian Indians.11,12 The degree of blood glucose excursion after a carbohydrate diet can be described by the glycemic index (GI).
The GI is a very useful methodology in assessing the quality of carbohydrate in the diet. An understanding of the GI concept can be of particular benefit in subjects with diabetes and impaired glucose tolerance. Dietary management of diabetes involves a reduction in postprandial hyperglycemia and adequate glycemic control. This may be achieved through the consumption of low GI foods as part of the Indian diet.
 
ROLE OF GLYCEMIC INDEX IN TYPE 2 DIABETES
Jenkins et al. were the first to develop the GI concept, where it was shown to be an important and innovative discovery in nutritional science.13 The GI is defined as a measure of the blood glucose raising ability of the available carbohydrate in foods. It is expressed as a percentage of the incremental area under the glycemic response curve (AUC) elicited by a portion of food containing 50 g available carbohydrate in comparison with the AUC elicited by 50 g glucose in the same subject. The principle is that the slower the rate of carbohydrate absorption, the lower the rise of blood glucose level and the lower the GI value.14 A GI value of greater than or equal to 70 is considered high, a GI value 56–69 inclusive is medium and a GI value less than or equal to 55 is low, where glucose is equal to 100.15 The glycemic load (GL) is a product of the GI and available carbohydrate content per serving 3of the food. Both high GI and GL have shown to increase the risk of type 2 diabetes in both Western and Asian populations1619 although some studies have reported no association with diabetes risk.2022 The large amount of refined grain consumption (mostly high GI) in the Indian diet, therefore, leads to a higher dietary GL.
An important body of evidence exists to support the preventive and therapeutic potential of low GI diets in diabetes.14,23 Low GI foods may reduce insulin demand and lipid concentrations, improve blood glucose control and reduce body weight, thus preventing diabetes-related cardiovascular events.17,18,24,25 A meta-analysis by Brand-Miller et al. demonstrated that choosing low GI foods in place of conventional or high GI foods exhibited a small but clinically important effect on medium-term glycemic control in patients with diabetes. This diet-based intervention was similar to the effects seen using pharmacological agents.15 There have been numerous studies providing useful information on the GI of various Indian foods and their effect on blood glucose and lipid levels2631 although a bulk of GI research has been conducted on Western foods.
One of the main impediments in the use of GI tables worldwide has been the uncertainty of the applicability and consistency of international tables to different ethnic groups. One study examined the role of ethnicity on GI when subjects were resident of their own countries.32 The glycemic response to common foods (sweet biscuits and breakfast cereals) was higher in Asian Indian subjects compared to United Kingdom (UK) Caucasian subjects, but no significant differences in GI values for the test foods between the two group of subjects was observed.32 This suggests the potential of the applicability of Western GI tables with the Indian population.
 
GLYCEMIC INDEX OF COMMONLY CONSUMED INDIAN STAPLES
A typical Indian diet is high in carbohydrates with cereal-based foods, such as rice and wheat providing the bulk of the energy. Whole grains, such as millet, sorghum, amaranth and barley were commonly used in ancient Indian cooking prior to the “Green Revolution” in 1951, after which refined rice and wheat became popular.33 Per capita consumption of refined grains tripled in India and the country became the world's foremost exporter of rice and wheat.33 Traditional cereal-based Indian diets were not only rich in dietary fiber, but also in other micro- and phytonutrients.34 With modernization, mechanical milling led to an increased total rice yield but produced a highly refined rice grain with starchy endosperm.11 Polished rice and other highly refined cereals, such as white flour, finger millet and semolina are mostly high GI (Table 1).4
Table 1   Glycemic Index (GI) of Common Staples (Cereals and Legumes) in the Indian Diet35
Food
Glycemic index (GI)
Cereals
White rice (Oryza sativa), boiled (India)
69
Parboiled rice, eaten as part of a traditional Indian meal (India)
99
Sona Masuri (India)
72
Ponni rice (India)
70
Surti Kolam (India)
77
Basmati, white, boiled (Mahatma brand, Sydney, Australia)
58
Brown basmati rice
75
White and brown basmati rice (60% white basmati, 40% brown basmati)
59
Basmati with wild rice (83% easy-to-cook basmati) and 17% North American wild rice
63
Easy-to-cook basmati rice
80
Chapati (unleavened bread made from refined wheat flour and water)
64
Whole wheat flour chapati/roti
45
Naan (leavened bread made from white flour, water and yeast)
80
Finger millet/ragi
84
Pearl millet/bajra
55
Sorghum/jowar (roasted bread made from sorghum flour)
77
Semolina, steamed, and gelatinized (India)
84
Idiyappam or string hoppers (steamed fresh vermicelli made from red or white rice flour)
103 (red)
Legumes
Bengal gram/chickpeas
33
Kidney beans
28
Black beans
20
Green lentils
30
Red lentils
26
Moong beans
42
Peas
22
Split peas, yellow, boiled
32
Majority of the Indian diet consists of these cereal-based staples. Understanding the GI of these staples is necessary for proper selection and modifications of foods that may be of particular benefit to Indians who are more insulin-resistant and/or have diabetes.6,8 Almost half of the daily caloric intake of South Indians is derived from refined grains, particularly white rice and rice products12 whilst 5wheat consumption is higher in Northern India.36 From an epidemiological study, a typical South Indian meal was found to have more rice and less of other foods, such as legumes, fruits, vegetables, and dairy products.12 The greater quantity of rice eaten and its associated GL is regarded as a major contributing factor to a higher prevalence of diabetes and associated complications. Therefore, Southern regions of India were found to have a higher prevalence of diabetes than Northern regions.3,11
The GI of foods is influenced by several factors, such as the nature of starches, macronutrients, fiber, the cooking/preparation method, cooking time, particle size as well as processing conditions. An analysis of these factors will be useful in making food choices and modifications necessary to develop diabetic foods for Indians.
 
Glycemic Response of Rice
Rice variety significantly influences GI. This varietal effect on GI appears to be mainly mediated by its amylose content. Basmati rice is a popular rice in the Indian diet. White basmati rice with intermediate amylose content (20–25%) has been shown to have a GI of 5837 and 50.38 Some studies show that parboiling reduces the GI of rice.38,39 A reduced glycemic response was observed in healthy subjects who consumed parboiled Sri Lankan rice compared to the unparboiled version.40
Other factors may also influence the digestibility and GI of rice. Indian rice varieties Sona Masuri (medium grain rice), Ponni (medium grain rice), and Surti Kolam (polished short grain rice) have shown to be high GI (72, 70, and 77, respectively) when they were cooked under similar conditions.41 These three types of rice were fully polished rice, void of fiber and high in starch, resulting in a higher rate of digestion, therefore, leading to poor glycemic control. Other studies have shown that brown rice has a lower GI than white rice42 while some have shown it to be high GI. It seems that the GI of brown rice types is affected by the bran constituents (perhaps micronutrients) and not just the bran alone. It is therefore not possible to assume that brown rice has low GI. White rice as opposed to brown rice is more often consumed by Indians due to its taste, consistency and shorter cooking time. Therefore, white rice has been more desirable in Indian dishes. Basmati rice and parboiled rice may be good options for an Indian rice-based meal.
 
Glycemic Response of Flatbreads
Flatbreads made using wheat flour (chapati) contribute a major portion of energy notably in North Indian diets. Compared to rice, less work has been done on the effects of different flatbreads on blood glucose responses. North Indian meals 6traditionally have a form of flatbread, either unleavened or leavened. Most GI studies have examined the glycemic responses of bread consumed in the Western diet but few studied the breads in Asian diets. A study by Radhika et al. showed that whole wheat flour used to make chapati has a low GI.43 Whole wheat flour chapati with the wheat bran and germ present is typically low-to-medium GI but if refined wheat flour (i.e. white flour) is used, the GI is higher due to the removal of bran (Table 1). Furthermore, α-amylase inhibitors present in wheat can withstand cooking temperature and were found to be effective in reducing blood glucose response.44 More recently, a study evaluated the glycemic and insulin responses of different South Asian flatbreads. Flatbread, such as naan and refined chapati were reported to be high GI.45 Other flatbreads, such as chickpea flour chapati was of medium GI and whole wheat chapati was of low GI.45
 
Glycemic Response of Other Cereals
Other popular grains include millet or ragi which can be processed to make porridges, idli (Indian fermented steamed cake), dosa (Indian fermented fried pancake), and roti (unleavened bread). A recent detailed review by Shobana et al. highlighted that finger millet was a cereal grain that possesses components that were likely to lower GI.46 A study comparing the glycemic response of pearl millet (bajra), barley and maize in healthy and type 2 diabetic individuals showed that the glycemic response to pearl millet and barley, but not maize, was significantly lower than the glycemic response to white bread, particularly in individuals who were healthy.47
 
Glycemic Response of Legumes
Besides cereals, legumes also form a major source of protein and carbohydrates intake in the Indian diet. It is usually consumed as an accompaniment (dal) to a cereal staple or processed to make snacks. Generally most legumes are low GI (Table 1). Their low GI has been attributed to the high-fiber and polyphenol content, and the slow-digesting starch characteristics. In an early study, Jenkins et al. have showed that dietary fiber in legumes and dals (dehusked and split legumes) are more viscous than the fiber content of cereals and millets.48 A number of researchers investigated the blood glucose responses of leguminous seeds in the Indian diet. Indian snacks are traditionally made using dehusked legumes. The glycemic response of cheela, an Indian snack was studied by Batra et al.49 Whole legumes (green gram and Bengal gram) showed a GI lowering effect. In addition, green gram produced a lower GI than Bengal gram, because of the higher protein and crude fiber content in the former.49 The presence of protein and viscous fiber helps to lower glycemic response. A systematic review and meta-analysis showed 7that pulses were able to reduce blood glucose and insulin in both normal and diabetic subjects.50 The use of pulses with low GI diets was reported to reduce the amount of glycosylated hemoglobin and fructosamine that are markers of long-term maintenance of blood glucose.50
Overall, wholegrain foods and legumes showed a lowering of blood glucose response. However, the GI of most Indian wholegrain foods and legumes have not been tested using standardized methodology.32,43
 
Processing Techniques Affecting Glycemic Index
Processing techniques, such as puffing, instantiation and fermentation have shown to affect GI and increase starch digestibility. Instant (easy-to-cook) basmati rice, which is pregelatinized rice, results in a significantly higher GI than raw basmati rice. Puffing of finger millet is commonly used to make Indian snacks. An in vitro study showed puffed finger millet had an increase in rapidly digestible starch content and lower slowly digestible starch content, with a decrease in resistant starch content of finger millet.51 The fermentation process of finger millet in making dosa was found to increase the starch digestibility.52 Idiyappam (string hoppers), which are steamed fresh rice vermicelli, have high GI.53 Certain processes disrupt the structure of rice, promote gelatinization and therefore increase the GI.
 
Cooking Method and Cooking Time Affecting Glycemic Index
Cooking method also affects GI. Carbohydrate foods that had been roasted or baked showed significantly higher blood glucose responses, and therefore a higher GI than the same foods that had been boiled or fried (Bahado-Singh et al. 2006). Cooking time has also shown to influence starch gelatinization and therefore GI. Basmati rice cooked for longer times elicited greater glycemic responses.38 White basmati rice cooked for 10 min had a GI of 50 (low), but basmati and wild rice, brown and white basmati rice cooked for 25 min had high GI.38
 
MANIPULATING THE GLYCEMIC INDEX OF INDIAN FOODS
The consumption of large carbohydrate rich meals is common in the Indian diets. The addition of ingredients to staples and supplementing these staples with accompaniments could lower the GI and overall GL of a traditional Indian meal.
 
The Potential of Adding Ingredients to Reduce Glycemic Response
Barley β-glucan is a natural soluble dietary fiber that has shown to lower glycemic response when incorporated into carbohydrate foods. High molecular weight 8barley β-glucan was able to reduce the GI of chapati when tested in healthy subjects.54 The GI values for chapati (Indian flatbreads) with 4 g and 8 g β-glucan were 43–47% less than the control chapatis made of whole wheat flour. The functional properties of β-glucans have always been attributed to their ability to delay carbohydrate digestion and absorption from the gut by increasing the viscosity of the stomach and intestinal contents and forming a protective layer incorporating readily digestible carbohydrates.55 Another study also found that moderate amounts of β-glucan (∼3 g) along with a low GI breakfast have lipid-lowering effects in type 2 diabetics.56
The GI of rotis (unleavened flatbread) made of whole wheat flour was reduced with a newly developed “atta mix” containing Bengal gram, psyllium husk, and debittered fenugreek flour in healthy nondiabetic subjects.43 The therapeutic effects of Bengal gram (legume), psyllium/ispaghula husk, and debittered fenugreek powder on lowering postprandial glucose levels are likely to be due to high viscous soluble fiber, the galactomannans (polysaccharides) that are not hydrolyzed by the digestive enzymes. Soluble fiber results in high viscous intestinal contents with gelling properties that could delay gastric emptying and also intestinal absorption.43
Mani et al. investigated the glycemic response in type 2 diabetics subjects who were given 50 g portions of five different conventional meals containing semolina cooked by two different methods, or combinations of semolina and pulse (black gram dal, green gram dal or Bengal gram dal)28 (Table 2). There were no significant differences in GI among the meals except for roasted semolina and semolina-black gram dal meals. But meals based on steam-cooked semolina and semolina-Bengal gram dal elicited a significantly lower blood glucose response at 1 hour postprandially and semolina-black gram dal at 2 hours postprandially. The cooking method had an influence on the GI by affecting starch digestion and therefore postprandial blood glucose response.57,58
Table 2   Glycemic Index (GI) of Semolina Meals28
Ingredients
Glycemic index (GI)
Semolina-steamed with gelatinization
55
Semolina + black gram dal
46
Semolina + green gram dal
62
Semolina + Bengal gram dal
54
Semolina-roasted at 105° with resultant gelatinization when water is added
76
All dals were soaked for 4 hours, ground to paste and fermented. Meals were cooked 20 min, 400 mL water added during cooking and 5 g groundnut oil. Meals were approximately isocaloric.
9
Finger millet (20%) incorporated into idli, dosa, chapati, rice string hoppers and kozhukattai (steamed rice balls), fed to type 2 diabetics (n = 6) for a month, showed a significant decrease in postprandial blood glucose, but the limitation of the study was the small sample size.59 Finger millet incorporated into noodles also showed a lower GI when compared to refined wheat flour-based noodles.60
A study examined the glycemic response of four formulations (popped rice, expanded rice, wheat and finger millet) combined with legumes in normoglycemic subjects showed that the wheat-based formulation had the lowest GI of = 55.61 The other formulations were high GI. The finger millet-based formulation, which used polished finger millet, had a GI of 93. The rice-based formulation that used popped rice had a GI of 105 and expanded rice had a GI of 109. This showed that processing techniques and low dietary fiber content had a considerable effect on increasing the GI of foods, even if legumes were present.
 
Spices and Herbs
Several spices and herbs, such as curry leaf, turmeric, fenugreek and cinnamon are used by Indians to add characteristic flavor and aroma to dishes. Many of these spices and herbs provide beneficial effects on glycemic control by possessing antidiabetic or blood glucose lowering properties based on successful in vitro and in vivo studies, where mostly has been investigated using animal models.62 The constituents of spices have insulin-stimulating and hypoglycemic effects.63 Fenugreek (methi) is known to play a role in glycemic control, delaying gastric emptying and regulating insulin secretion due to the presence of soluble fiber.64 Incorporating fenugreek in the form of seeds and flour into Indian foods lowered postprandial glucose levels in type 2 diabetics.6568 Cinnamon is known for its potential role on insulin action and was found to improve blood glucose profiles in diabetics.69 Several other researchers reported the effectiveness of cinnamon in controlling blood sugar in type 2 diabetics.70,71 Turmeric is a widely used spice in Indian cooking where it functions as a coloring and flavoring agent. Curcumin is an active polyphenol present in turmeric. Human clinical trials have shown dietary curcumin to possess anti-hyperglycemic effects in type 2 diabetics72 and significantly reduce type 2 diabetes development in prediabetics.73 Due to curcumin's poor absorption in the digestive system,74 its beneficial effects on type 2 diabetes still remains to be elucidated. Curry leaf (Murraya koenigii) is a popular aromatic herb known to be used in curry and chutney. A selection of studies have shown hypoglycemic properties of curry leaf powder in controlling the fasting and postprandial blood glucose level among type 2 diabetics.75 Overall, spices and herbs used in Indian foods potentially have strong antidiabetic and glucose lowering effects in diabetics but much remains to be researched using more long-term human intervention trials.10
 
Meal Accompaniments
The conventional meal pattern of most Indians is the use of a staple, for example, boiled white rice or refined wheat chapati, accompanied by a constellation of dishes, such as legumes, vegetables and yogurt. Some of these accompaniments play a crucial role in lowering the GI of a carbohydrate staple. Table 3 represents a selection of accompaniments that can be practically adopted to lower the glycemic response of carbohydrate-rich foods.
Table 3   Glycemic Index (GI) of Indian Staple Foods with/without Accompaniments26,29,35,53,76
Food
Glycemic index (GI)
With accompaniment
Glycemic index (GI)
Rice-based
White rice; low-amylose
Medium-to-high
Rice with lentil and cauliflower curry
60
White rice; high-amylose
Low-to-medium
Rice, boiled served with Lagenaria vulgaris (bottle gourd) and (Lycopersicon esculentum) tomato curry
69
Brown rice
50
Parboiled rice with green leaf curry (Amaranthus)
58
Basmati rice
47
Parboiled rice with gravy (soya meat)
56
Parboiled rice with green leaf curry and gravy
55
Red rice with lentil curry, boiled egg + Centella asiatica (gotu kola) salad and coconut gravy (Kiri hodi)
63
Red rice with lentil curry, boiled egg + Centella asiatica (gotu kola) salad and coconut gravy (kiri hodi) and Lasia spinosa (kohila) salad
57
Red rice with lentil curry, boiled egg + Centella asiatica (gotu kola) salad, coconut gravy and Trichosanthes cucumerina (snake gourd) salad
61
Red rice with lentil curry: Red rice (82% starch), Lentils curry (18% starch)
60
Red rice with coconut gravy
99
Rice roti
103
Dosa (parboiled and raw rice, soaked, ground, fermented and fried) with chutney
77
String hopper (wheat flour) with coconut sambol, egg and coconut gravy
104
String hopper (red rice flour) with coconut sambol, egg and coconut gravy
103
Pongal (rice and roasted green gram dal, pressure cooked)
90
Pongal with sambar
54
Continued
11
Idiyappam (steamed rice flour dough with tender coconut) eaten with Bengal gram curry
86
Idli (parboiled and raw rice + black dal, soaked, ground, fermented and steamed) with chutney
77
Puttu (rice flour, steamed with tender coconut) eaten with Bengal gram curry
79
Appam (thin pancake made from fermented rice flour batter with tender coconut) eaten with Bengal gram curry
90
Wheat-based
Chapati
64
Chapati, wheat, served with bottle gourd and tomato curry
66
Chapati with green gram dal
44
Chapati (maize flour)
59
Chapati and dal
Naan
80
Semolina-based
Semolina, steamed and gelatinized
54
Uppittu (roasted semolina and onions, cooked in water)
67
Semolina, roasted then gelatinized with water
55
Millet products
Millet/ragi
84
Upma kedgeree (millet, legumes, fenugreek seeds; roasted and cooked in water)
18
Other Indian foods
Dhokla (chickpea-based + wheat semolina)
35
Punjabi meal
68
Uttapam with chutney
63
South Indian meal
63
Curd rice with curry leaves chutney
65
Adai with chutney
70
Bengali meal
70
Rasam rice with papad
78
Gujarati meal
83
Sambar rice
83
12
Legumes accompanied with a carbohydrate staple have shown a blood glucose lowering effect in several studies. White bread with a GI of 100 when given with lentils moong (Phaseolus mungo) had a GI of 45 and with mash (Phaseolus aureus) a GI of 56.77 In conventional Indian foods, rice combined with legumes (Bengal gram, peas and green gram) and a combination of rice-dal (green gram dal and red gram dal, both dehusked and split) was studied to determine the GI in type 2 diabetic subjects.78 Rice and rice plus peas showed a higher GI while all other rice combinations produced lower glycemic indices. Overall, all the foods with leguminous seeds were able to significantly lower blood glucose response postprandially.78 Bengal gram dal and rajma (kidney beans; Phaseolus vulgaris) in a carbohydrate meal would be most effective in reducing postprandial plasma glucose levels than wheat and rice alone.31 Green gram and Bengal gram promote insulin secretion due to the protein content and form a complex with starch to decrease susceptibility to amylolytic digestion. A comparison of the glycemic responses of three Sri Lankan bread-lentil meals had no significant differences in GI (white sliced bread = 77, wholemeal bread = 77, ordinary white bread = 80 and wholemeal bread + lentil curry = 61).53 However, including legumes to bread helped reduce the GI of bread and lower postprandial glucose concentrations. Yogurt, where it is called dahi in Hindi, has been shown to significantly reduced the GI of the rice when consumed together (prior to or after a carbohydrate meal).79
 
Indian Snacks
Popular traditional Indian snack foods include upma and dhokla. Upma is made from semolina and dhokla from chickpea, both mostly eaten in South India and Gujarat, respectively. The GI of the snacks were low (GIs: upma 18, dhokla 35).29 The higher GI of dhokla compared to upma was attributed to the fermentation process, which resulted in rapid digestion of carbohydrate and absorption of sugar, compared to upma.80 The study demonstrated that these two food products had a hypoglycemic effect in diabetic subjects. A study by Krishnamoorthy et al. investigated the GI of seven traditional Indian snacks modified in composition and preparation to determine their glycemic and insulinemic response in type 2 diabetics.81 The snacks were standardized in terms of weight. Exclusion of starchy ingredients from the original recipe, such as potatoes, refined flour, and inclusion of whole and split lentils (with intact husk) lowered the GI of Indian vegetarian snacks which are commonly medium-to-high GI (Table 4). In addition, vegetables, such as radish, cabbage, carrot, bottle gourd were included for fiber that also contributed to lowering the GI of the snacks by suppressing the postprandial glycemic response.81 This study provided a new insight into how Indian snacks could be modified to be suitable for diabetics without causing hyperglycemic effects.13
Table 4   Indian Snacks and Modifications81
Modified Indian vegetarian snacks for reduced glycemic response
Modifications necessary
Poha (rice flakes and ground nuts) and lemon tea
Excluded potato
Sprouted and cooked lentils (moth bean, Bengal gram whole) and buttermilk
Used moth bean, Bengal gram whole
Broken wheat upma (broken wheat, green gram whole) and chutney
Used medium sized broken wheat (in place of semolina) and whole green gram dal
Thalipeeth (wheat flour, Bengal gram dal flour, green gram dal flour) and chutney
Included whole green gram flour, Bengal gram dal flour (in place of chana dal and urad dal)
Brown idli (parboiled rice, black gram dal) and sambhar (red gram dal)
Included intact black gram dal (in place of dehusked black lentils)
Raddish paratha (wheat flour, moth bean flour, Bengal gram dal flour) and curd
Included moth bean flour and Bengal gram flour
Dhokla (parboiled rice, Bengal gram dal, green gram dal) and chutney
Used parboiled rice, Bengal gram dal and green gram dal (in place of chickpea flour)
Krishnamoorthy et al. further investigated their systematic study of modifying Indian foods by looking at mixed meals and their effects on glycemic and lipidemic responses.82,83 The redesigned meals included five to six low GI items, with each meal having a GL ranging from 15.58 to 23.8 g, and energy content ranging from 403 to 502 calories.82 The low GI of each meal was attributed to the whole grains, lentils and pulses (husk intact), with each meal showing good postprandial glycemic control in both normal and type 2 diabetics. The next study by the authors was the first to report improved blood glucose, glycosylated hemoglobin (HbA1c) and lipid profiles in type 2 diabetics after consuming low GI and low-to-medium GL Indian diets (vegetarian mixed meals and snacks) in type 2 diabetics over a period of 4 weeks.83 Several combined dietary factors, such as multigrain carbohydrate sources, high fiber, high amylose rice variety, legumes, inclusion of more vegetables (no starchy tubers) and spices were beneficial in bringing about the hypoglycemic effect of the meals. These systematic studies have provided significant evidence on how simple modifications of the Indian diet could improve blood glucose control in diabetics.
Fruits are rich in carbohydrates and produce different glycemic responses. Brand-Miller et al. reported that tropical fruits may produce higher responses of postprandial blood glucose than temperate fruits (Brand-Miller, et al. 1997). However, fruits, such as jackfruit, guava, plum, unripe papaya and pomegranate are reported to be lower GI.84,85 When raw jackfruit was cooked with its flesh and seeds together with coconut and onions, it showed a lowering of postprandial 14blood glucose.86 Larger and more defined studies are required to establish the benefits of several tropical fruits in prevention/treatment of obesity and diabetes. More preliminary data are needed when recommending a full range of tropical fruits for diabetics.
William et al. (1995) studied the effect of Indian vegetables (bitter gourd, curry leaves and drumstick leaves) in a meal on the blood glucose response in diabetics. The meals with vegetables had produced significantly lower blood glucose response compared to the standard meal without vegetables and a glucose standard. A detailed review by Kaushik et al. also highlighted vegetables commonly used in Indian cooking, such as cabbage, bottle gourd, bitter gourd and green leafy vegetables to have an antidiabetic effect.87
 
CONCLUDING REMARKS AND RECOMMENDATIONS
If there is one scientific point that the reader can take home from this article is that all carbohydrates do not elicit the same blood glucose response.
zoom view
Figure 1: Suggestions to reduce glycemic response to a carbohydrate-rich Indian diet.
15
All carbohydrates do not produce similar physiological response. The recognition that the carbohydrates we consume may be classified into low and high GI foods has dramatically altered our dietary management of type 2 diabetes. Cereal staples like rice and wheat contribute largely to the diets of the Indian population. Consumers would gain great benefit by selecting low GI foods in their battle to reduce the risk of developing type 2 diabetes. In Indian, where type 2 diabetes is a major affliction, the time has come for consumers to demand for low GI products and for manufacturers to develop them (Figure 1).
REFERENCES
  1. Sicree R, Shaw J, Zimmet P. Diabetes and impaired glucose tolerance. International Diabetes Federation: Diabetes Atlas, 3rd edition. International Diabetes Federation.  Brussels, Belgium:  2006; pp. 15–103.
  1. Mohan V, Shanthirani S, Deepa R, Premalatha G, Sastry NG, Saroja R, et al. Intra-urban differences in the prevalence of the metabolic syndrome in southern India—the Chennai Urban Population Study (CUPS No. 4). Diabet Med. 2001;18:280–7.
  1. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al. High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia. 2001;44:1094–101.
  1. Jenkins DJ, Wolever TM, Jenkins AL, Josse RG, Wong GS. The glycaemic response to carbohydrate foods. Lancet. 1984;2:388–91.
  1. Mohan V. Why are Indians more prone to diabetes? J Assoc Physicians India. 2004;52:468–74.
  1. Mohan V, Sharp PS, Cloke HR, Burrin JM, Schumer B, Kohner EM. Serum immunoreactive insulin responses to a glucose load in Asian Indian and European type 2 (non-insulin-dependent) diabetic patients and control subjects. Diabetologia. 1986;29:235–7.
  1. Chandalia M, Abate N, Garg A, Stray-Gundersen J, Grundy SM. Relationship between generalized and upper body obesity to insulin resistance in Asian Indian men. J Clin Endocrinol Metab. 1999;84:2329–35.
  1. Sharp PS, Mohan V, Levy JC, Mather HM, Kohner EM. Insulin resistance in patients of Asian Indian and European origin with non-insulin dependent diabetes. Horm Metab Res. 1987;19:84–5.

  1. 16 Raji A, Seely EW, Arky RA, Simonson DC. Body fat distribution and insulin resistance in healthy Asian Indians and Caucasians. J Clin Endocrinol Metab. 2001;86:5366–71.
  1. Laws A, Jeppesen JL, Maheux PC, Schaaf P, Chen YD, Reaven GM. Resistance to insulin-stimulated glucose uptake and dyslipidemia in Asian Indians. Arterioscler Thromb. 1994;14:917–22.
  1. Mohan V, Radhika G, Sathya RM, Tamil SR, Ganesan A, Sudha V. Dietary carbohydrates, glycaemic load, food groups and newly detected type 2 diabetes among urban Asian Indian population in Chennai, India (Chennai Urban Rural Epidemiology Study 59). Br J Nutr. 2009;102:1498–506.
  1. Radhika G, Van Dam RM, Sudha V, Ganesan A, Mohan V. Refined grain consumption and the metabolic syndrome in urban Asian Indians (Chennai Urban Rural Epidemiology Study 57). Metabolism. 2009;58: 675–81.
  1. Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, et al. Glycemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr. 1981;34:362–6.
  1. Brand JC, Colagiuri S, Crossman S, Allen A, Roberts DC, Truswell AS. Low-glycemic index foods improve long-term glycemic control in NIDDM. Diabetes Care. 1991;14:95–101.
  1. Brand-Miller J, Foster-Powell K, Miller JB, Holt S. The New Glucose Revolution Complete Guide to Glycemic Index Values. Marlowe & Company.  New York, USA:  2003.
  1. Hu EA, Pan A, Malik V, Sun Q. White rice consumption and risk of type 2 diabetes: meta-analysis and systematic review. BMJ. 2012;344:e1454.
  1. Salmerón J, Ascherio A, Rimm EB, Colditz GA, Spiegelman D, Jenkins DJ, et al. Dietary fiber, glycemic load, and risk of NIDDM in men. Diabetes Care. 1997;20:545–50.
  1. Salmerón J, Manson JE, Stampfer MJ, Colditz GA, Wing AL, Willett WC. Dietary fiber, glycemic load, and risk of noninsulin-dependent diabetes mellitus in women. JAMA. 1997;277:472–7.
  1. Villegas R, Liu S, Gao YT, Yang G, Li H, Zheng W, et al. Prospective study of dietary carbohydrates, glycemic index, glycemic load, and incidence of type 2 diabetes mellitus in middle-aged Chinese women. Arch Intern Med. 2007;167:2310–6.
  1. Meyer KA, Kushi LH, Jacobs DR, Slavin J, Sellers TA, Folsom AR. Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr. 2000;71:921–30.
  1. Lundgren H, Bengtsson C, Blohmé G, Isaksson B, Lapidus L, Lenner RA, et al. Dietary habits and incidence of noninsulin-dependent diabetes mellitus in a population study of women in Gothenburg, Sweden. Am J Clin Nutr. 1989;49:708–12.
  1. Stevens J, Ahn K, Juhaeri, Houston D, Steffan L, Couper D. Dietary fiber intake and glycemic index and incidence of diabetes in African-American and white adults: the ARIC study. Diabetes Care. 2002;25:1715–21.
  1. Frost G, Wilding J, Beecham J. Dietary advice based on the glycaemic index improves dietary profile and metabolic control in type 2 diabetic patients. Diabet Med. 1994;11:397–401.
  1. Rizkalla SW, Taghrid L, Laromiguiere M, Huet De, Boillot J, Rigoir A, et al. Improved plasma glucose control, whole-body glucose utilization, and lipid profile on a low-glycemic index diet in type 2 diabetic men: a randomized controlled trial. Diabetes Care. 2004;27:1866–72.
  1. Liu S, Willett WC, Stampfer MJ, Hu FB, Franz M, Sampson L, et al. A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr. 2000;71:1455–61.
  1. Mani UV, Mani IU, Iyer UM, Prakash B, Manivannan S, Campbell S, et al. Glycemic and lipemic response to various regional meals and South Indian snacks. Int J Diab Dev Countries. 1997;17:75–81.
  1. Mani UV, Prabhu BM, Damle SS, Mani I. Glycemic index of some commonly consumed foods in Western India. Asia Pac J Clin Nutr. 1993;2:111–4.
  1. Mani UV, Pradhan SN, Mehta NC, Thakur DM, Iyer U, Mani I. Glycemic index of conventional carbohydrate meals. Br J Nutr. 1992;68:445–50.
  1. Pathak P, Srivastava S, Grover S. Development of food products based on millets, legumes and fenugreek seeds and their suitability in the diabetic diet. Int J Food Sci Nutr. 2000;51:409–14.
  1. Mitra A, Basu B, Mukherjee S. Significance of different dietary habits in sections of Indian diabetics. J Hum Ecol. 2009;26:89–98.

  1. 17 Dilawari JB, Kamath PS, Batta RP, Mukewar S, Raghavan S. Reduction of postprandial plasma glucose by Bengal gram dal (Cicer arietinum) and rajmah (Phaseolus vulgaris). Am J Clin Nutr. 1981;34:2450–3.
  1. Henry CJ, Lightowler HJ, Newens K, Sudha V, Radhika G, Sathya RM, et al. Glycaemic index of common foods tested in the UK and India. Br J Nutr. 2008;99:840–5.
  1. Dixit AA, Azar KM, Gardner CD, Palaniappan LP. Incorporation of whole, ancient grains into a modern Asian Indian diet to reduce the burden of chronic disease. Nutr Rev. 2011;69:479–88.
  1. Mohan V, Radhika G, Vijayalakshmi P, Sudha V. Can the diabetes/cardiovascular disease epidemic in India be explained, at least in part, by excess refined grain (rice) intake. Indian J Med Res. 2010;131:369–72.
  1. Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values: 2002. Am J Clin Nutr. 2002;76:5–56.
  1. Chatterjee S, Rae A, Ray R. Food consumption and calorie intake in contemporary India. eSocial Sciences Working Paper. September: 1–14, 2007.
  1. Bhattacharjee P, Singhal RS, Kulkarni PR. Basmati rice: a review. Int J Food Sci Technol. 2002;37:1–12.
  1. Ranawana DV, Henry CJ, Lightowler HJ, Wang D. Glycaemic index of some commercially available rice and rice products in Great Britain. Int J Food Sci Nutr. 2009;60:99–110.
  1. Wolever TM, Jenkins DJ, Kalmusky J, Jenkins A, Giordano C, Giudici S, et al. Comparison of regular and parboiled rices: explanation of discrepancies between reported glycemic responses to rice. Nutr Res. 1986;6:349–57.
  1. Pathiraje PM, Madhujith WM, Chandrasekara A, Nissanka SP. The effect of rice variety and parboiling on in vivo glycemic response. Trop Agricultural Res. 2010;22:26–33.
  1. Shobana S, Kokila A, Lakshmipriya N, Subhashini S, Ramya Bai M, Mohan V, et al. Glycaemic index of three Indian rice varieties. Int J Food Sci Nutr. 2012;63:178–83.
  1. Miller JB, Pang E, Bramall L. Rice: a high or low glycemic index food? Am J Clin Nutr. 1992;56:1034–6.
  1. Radhika G, Sumathi C, Ganesan A, Sudha V, Jeya Kumar Henry C, Mohan V. Glycaemic index of Indian flatbreads (rotis) prepared using whole wheat flour and 'atta mix'-added whole wheat flour. Br J Nutr. 2010;103:1642–7.
  1. Urooj A, Puttaraj S. Glycemic index of foods-new concepts in carbohydrate bioavailability. Arogya-J Health Sci. 1988;14:7–23.
  1. Khawaja KI, Fatima A, Mian SA, Mumtaz U, Moazzum A, Ghias M, et al. Glycaemic, insulin and ghrelin responses to traditional South Asian flatbreads in diabetic and healthy subjects. Br J Nutr. 2012;108:1810–7.
  1. Shobana S, Krishnaswamy K, Sudha V, Malleshi NG, Anjana RM, Palaniappan L, et al. Finger millet (ragi, Eleusine coracana L.): a review of its nutritional properties, processing, and plausible health benefits. Adv Food Nutr Res. 2013;69:1–39.
  1. Shukla K, Narain JP, Puri P, Gupta A, Bijlani RL, Mahapatra SC, et al. Glycaemic response to maize, bajra and barley. Indian J Physiol Pharmacol. 1991;35:249–54.
  1. Jenkins DJ, Wolever TM, Leeds AR, Gassull MA, Haisman P, Dilawari J, et al. Dietary fibres, fibre analogues, and glucose tolerance: importance of viscosity. Br Med J. 1978;1:1392–4.
  1. Batra M, Sharma S, Seth V. The glycaemic index of fermented and non-fermented legume based snack foods. Asia Pac J Clin Nutr. 1994;3:151–4.
  1. Sievenpiper JL, Kendall CW, Esfahani A, Wong JM, Carleton AJ, Jiang HY, et al. Effect of non-oil-seed pulses on glycaemic control: a systematic review and meta-analysis of randomised controlled experimental trials in people with and without diabetes. Diabetologia. 2009;52:1479–95.
  1. Roopa S, Premavalli KS. Effect of processing on starch fractions in different varieties of finger millet. Food Chem. 2008;106:875–82.
  1. Lakshmi Kumari P, Sumathi S. Effect of consumption of finger millet on hyperglycemia in non-insulin dependent diabetes mellitus (NIDDM) subjects. Plant Foods Hum Nutr. 2002;57:205–13.
  1. Hettiaratchi UP, Ekanayake S, Welihinda J. Do Sri Lankan meals help decrease blood glucose response? Ceylon Med J. 2009;54:39–43.
  1. Thondre PS, Monro JA, Mishra S, Henry CJ. High molecular weight barley b-glucan decreases particle breakdown in chapattis (Indian flat breads) during in vitro digestion. Food Res Int. 2010;43:1476–81.

  1. 18 Lazaridou A, Biliaderis CG. Molecular aspects of cereal b-glucan functionality: Physical properties, technological applications and physiological effects. J Cereal Sci. 2007;46:101–18.
  1. Kabir M, Oppert JM, Vidal H, Bruzzo F, Fiquet C, Wursch P, et al. Four-week low-glycemic index breakfast with a modest amount of soluble fibers in type 2 diabetic men. Metabolism. 2002;51:819–26.
  1. Wong S, O'Dea K. Importance of physical form rather than viscosity in determining the rate of starch hydrolysis in legumes. Am J Clin Nutr. 1983;37:66–70.
  1. Behall KM, Scholfield DJ, Canary J. Effect of starch structure on glucose and insulin responses in adults. Am J Clin Nutr. 1988;47:428–32.
  1. Geetha C, Parvathi EP. Hypoglycemic effect of millet incorporated breakfast items on selected non-insulin dependent diabetic patients. Indian J Nutr Diet. 1990;27:316–20.
  1. Shukla K, Srivastava S. Evaluation of finger millet incorporated noodles for nutritive value and glycemic index. J Food Sci Technol. 2011;1–8.
  1. Shobana S, Kumari SR, Malleshi NG, Ali SZ. Glycemic response of rice, wheat and finger millet based diabetic food formulations in normoglycemic subjects. Int J Food Sci Nutr. 2007;58:363–72.
  1. Modak M, Dixit P, Londhe J, Ghaskadbi S, Paul A Devasagayam T. Indian herbs and herbal drugs used for the treatment of diabetes. J Clin Biochem Nutr. 2007;40:163–73.
  1. Tapsell LC, Hemphill I, Cobiac L, Patch CS, Sullivan DR, Fenech M, et al. Health benefits of herbs and spices: the past, the present, the future. Med J Aust. 2006;185:S4–24.
  1. Sauvaire Y, Ribes G, Baccou JC, Loubatieères-Mariani MM. Implication of steroid saponins and sapogenins in the hypocholesterolemic effect of fenugreek. Lipids. 1991;26:191–7.
  1. Madar Z, Abel R, Samish S, Arad J. Glucose-lowering effect of fenugreek in non-insulin dependent diabetics. Eur J Clin Nutr. 1988;42:51–4.
  1. Madar Z, Shomer I. Polysaccharide composition of a gel fraction derived from fenugreek and its effect on starch digestion and bile acid absorption in rats. J Agricultural Food Chem. 1990;38:1535–9.
  1. Sharma RD, Raghuram TC. Hypoglycaemic effect of fenugreek seeds in non-insulin dependent diabetic subjects. Nutr Res. 1990;10:731–9.
  1. Sharma RD, Sarkar A, Hazra DK, Mishra B, Singh JB, Sharma SK, et al. Use of fenugreek seed powder in the management of non-insulin dependent diabetes mellitus. Nutr Res. 1996;16:1331–9.
  1. Khan A, Safdar M. Role of diet, nutrients, spices and natural products in diabetes mellitus. Pakistan J Nutr. 2003;2:1–12.
  1. Soni R, Bhatnagar V. Effect of cinnamon (Cinnamomum cassia) intervention on blood glucose of middle aged adult male with non-insulin dependent diabetes mellitus (NIDDM). Studies on Ethno-Medicine. 2009;3:141–4.
  1. Anuradha V, Devi A. Hypoglycemic effect of cinnamon and cumin seed powder on type 2 diabetes. Indian J Nutr. 2004;41:370–4.
  1. Srinivasan M. Effect of curcumin on blood sugar as seen in a diabetic subject. Indian J Med Sci. 1972;26: 269–70.
  1. Chuengsamarn S, Rattanamongkolgul S, Luechapudiporn R, Phisalaphong C, Jirawatnotai S. Curcumin extract for prevention of type 2 diabetes. Diabetes Care. 2012;35:2121–7.
  1. Maradana MR, Thomas R, O'Sullivan BJ. Targeted delivery of curcumin for treating type 2 diabetes. Mol Nutr Food Res. 2013;57:1550–6.
  1. Kirupa LS, Kavitha R. Hypoglycemic effect of Murraya koenigii (curry leaf) in type 2 diabetes mellitus. Int J Food Sci Nutr. 2012;2.
  1. Urooj A, Puttaraj S. Glycaemic responses to cereal-based Indian food preparations in patients with non-insulin-dependent diabetes mellitus and normal subjects. Br J Nutr. 2000;83:483–8.
  1. Akhtar MS, Asim AH, Wolever T. Blood glucose responses to traditional Pakistani dishes taken by normal and diabetic subjects. Nutr Res. 1987;7:696–706.
  1. Mani UV, Bhatt S, Mehta NC, Pradhan SN, Shah V, Mani I. Glycemic index of traditional Indian carbohydrate foods. J Am Coll Nutr. 1990;9:573–7.
  1. Sugiyama M, Tang AC, Wakaki Y, Koyama W. Glycemic index of single and mixed meal foods among common Japanese foods with white rice as a reference food. Eur J Clin Nutr. 2003;57:743–52.

  1. 19 Wolever TM. The glycemic index. World Rev Nutr Diet. 1990;62:120–85.
  1. Krishnamoorthy G, Pande AS, Moulick ND. Traditional Indian snacks modified to attain low glycaemic index and confirmed suitable to be consumed without hyperglycaemic effect in type 2 diabetics. J Indian Med Assoc. 2011;109:222–9.
  1. Pande A, Krishnamoorthy G, Moulick N. Effect of redesigned Indian mixed meals on blood glucose and insulin levels in normal versus type 2 diabetic subjects—a comparative study. Int J Food Sci Nutr. 2011;62:881–92.
  1. Pande A, Krishnamoorthy G, Moulick ND. Hypoglycaemic and hypolipidaemic effects of low GI and medium GL Indian diets in type 2 diabetics for a period of 4 weeks: a prospective study. Int J Food Sci Nutr. 2012;63:649–58.
  1. Fatema K, Rahman F, Sumi N, Kobura K, Afroz A, Ali L. Glycemic and insulinemic responses to pumpkin and unripe papaya in type 2 diabetic subjects. Int J Nutr Metab. 2011;3:1–6.
  1. Fatema K, Sumi N, Rahman F, Kobura K, Ali L. Glycemic index determination of vegetable and fruits in healthy Bangladeshi subjects. Malays J Nutr. 2011;17:393–9.
  1. Hettiaratchi UP, Ekanayake S, Welihinda J. Nutritional assessment of a jackfruit (Artocarpus heterophyllus) meal. Ceylon Med J. 2011;56:54–8.
  1. Kaushik G, Satya S, Khandelwal RK, Naik SN. Commonly consumed Indian plant food materials in the management of diabetes mellitus. Diabetes Metab Syn Clin Res Rev. 2010;4:21–40.