Abstract
The nature of carbohydrate is of considerable importance when recommending diets intended to reduce the risk of type II diabetes and cardiovascular disease and in the treatment of patients who already have established diseases. Intact fruits, vegetables, legumes and wholegrains are the most appropriate sources of carbohydrate. Most are rich in nonstarch polysaccharides (NSPs) (dietary fibre) and other potentially cardioprotective components. Many of these foods, especially those that are high in dietary fibre, will reduce total and low-density lipoprotein cholesterol and help to improve glycaemic control in those with diabetes. There is no good long-term evidence of benefit when NSPs or other components of wholegrains, fruits, vegetables and legumes are added to functional and manufactured foods. Frequent consumption of low glycaemic index foods has been reported to confer similar benefits, but it is not clear whether such benefits are independent of the dietary fibre content of these foods or the fact that low glycaemic index foods tend to have intact plant cell walls. Furthermore, it is uncertain whether functional and manufactured foods with a low glycaemic index confer the same long-term benefits as low glycaemic index plant-based foods. A wide range of carbohydrate intake is acceptable, provided the nature of carbohydrate is appropriate. Failure to emphasize the need for carbohydrate to be derived principally from wholegrain cereals, fruits, vegetables and legumes may result in increased lipoprotein-mediated risk of cardiovascular disease, especially in overweight and obese individuals who are insulin resistant.
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References
Ahrens E, Hirsch J, Oette K, Farquhar J, Stein Y (1961). Carbohydrate-induced and fat-induced lipemia. Trans Assoc Am Physicians 74, 134–146.
Anderson JW (2002). Whole-grains intake and risk for coronary heart disease. In: Marquart L, Slavin JL, Fulcher RD (eds). Whole-grain Foods in Health and Disease. American Association of Cereal Chemists. St Paul: Minnesota, USA. pp 187–200.
Anderson JW (2003). Whole grains protect against atherosclerotic cardiovascular disease. Proc Nutr Soc 62, 135–142.
Anderson JW, Hanna TJ, Peng X et al. (2000). Whole grain foods and heart disease risk. J Am Coll Nutr 19, 291S–299S.
Antonis A, Bersohn I (1961). The influence of diet on serum-triglycerides in South African White and Bantu prisoners. Lancet 7, 39.
Appel LJ, Moore TJ, Obarzanek E et al. (1997). For the DASH Collaborative Research Group. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 336, 1117–1124.
Baghurst KI, Record SJ, Baghurst PA (1991). The relationship between refined sugar and micronutrient intakes. Proc Nutr Soc Australia 16, 33.
Basu A, Devaraj S, Jialal I (2006). Dietary factors that promote or retard inflammation. Arterioscler Thromb Vasc Biol 26, 995–1001.
Bazzano LA, He J, Ogden LG, Loria C, Vupputuri S, Myers L et al. (2001). Legume consumption and risk of coronary heart disease in US men and women: NHANES 1 Epidemiologic Follow-up Study. Arch Intern Med 161, 2573–2578.
Brand-Miller J, Hayne S, Petocz P et al. (2003). Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care 26, 2261–2267.
Brunner EJ, Thorogood M, Rees K, Hewitt G (2005). Dietary advice for reducing cardiovascular risk. Cochrane Database of Systematic Reviews 4, Art. No: CD002128.DOl: 10.1002/.
Burr ML, Fehily AM, Gilbert JF, Rogers S, Holliday RM, Sweetnam PM et al. (1989). Effects of changes in fat, fish and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet ii, 757–761.
Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ (2000). Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. N Engl J Med 342, 1392–1398.
Colditz GA, Manson JF, Stampfer MJ, Rosner B, Willett WC, Speizer FF (1992). Diet and risk of clinical diabetes in women. Am J Clin Nutr 55, 1018–1023.
Daly M (2003). Sugars, insulin sensitivity, and the postprandial state. Am J Clin Nutr 78, 865S–872S.
de Lorgeril M, Renaud S, Mamelle N, Salen P, Martin J, Monjaud I et al. (1994). Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet 343, 1454–1459.
DiMeglio DP, Mattes RD (2000). Liquid versus solid carbohydrate: effects on food intake and body weight. Int J Obes Relat Metab Disord 24, 794–800.
Elliott SS, Keim NS, Stern JS, Teff K, Havel PJ (2002). Fructose, weight gain, and the insulin resistance syndrome. Am J Clin Nutr 76, 911–922.
Esmaillzadeh A, Mirmiran P, Azizi F (2005). Whole-grain consumption and the metabolic syndrome: a favorable association in Tehranian adults. Eur J Clin Nutr 59, 353–362.
Flight I, Clifton P (2006). Cereal grains and legumes in the prevention of coronary heart disease and stroke: a review of the literature. Eur J Clin Nutr 60, 1145–1159.
Fried SK, Rao SP (2003). Sugars, hypertriglyceridemia, and cardiovascular disease. Am J Clin Nutr 78 (Suppl 8), 73S–80S.
Fung TT, Hu FB, Pereira MA et al. (2002). Whole-grain intake and the risk of type 2 diabetes: a prospective study in men. Am J Clin Nutr 76, 535–540.
Fung TT, Rimm EB, Spiegelman D, Rifai N, Tofler GH, Willett WC et al. (2001a). Association between dietary patterns and plasma biomarkers of obesity and cardiovascular disease risk. Am J Clin Nutr 73, 61–67.
Fung TT, Willett WC, Stampfer MJ, Manon JE, Fu FB (2001b). Dietary patterns and risk of coronary heart disease in women. Arch Intern Med 161, 1857–1862.
Garcia-Palmieri MR, Sorlie P, Tillotson J, Costas Jr R, Cordero E, Rodriguez M (1980). Relationship of dietary intake to subsequent coronary heart disease incidence: The Puerto Rico Heart Health Program. Am J Clin Nutr 33, 1818–1827.
Garg A (1998). High-monounsaturated-fat diets for patients with diabetes mellitus: a meta-analysis. Am J Clin Nutr 67, 577S–582S.
Giacco R, Parillo M, Rivellese AA et al. (2000). Long-term dietary treatment with increased amounts of fiber-rich low-glycemic index natural foods improves blood glucose control and reduces the number of hypoglycemic events in type 1 diabetic patients. Diabetes Care 23, 1461–1466.
He FJ, Nawson CA, Macgregor GA (2006). Fruit and vegetable consumption and stroke: metaanalysis of cohort studies. Lancet 367, 320–326.
Hjermann I, Byer K, Holme I et al. (1981). Effect of diet and smoking intervention on the incidence of coronary heart disease. Lancet ii, 1303–1310.
Hodge AM, English DR, O’Dea K et al. (2004). Glycaemic Index and dietary fiber and the Risk of type 2 diabetes. Diabetes Care 27, 2701–2706.
Howard BV, van Horn JH, Manson JE et al. (2006) (reprinted) Low-fat dietary pattern and risk of cardiovascular disease: the women's health initiative randomized controlled dietary modification trial. JAMA 295, 655–666.
Hu FB (2003). Plant-based foods and prevention of cardiovascular disease: an overview. Am J Clin Nutr 78 (Suppl 3), 544S–551S. (review).
Hu FB, Rimm EB, Stampfer MJ, Ascherio A, Spiegelman D, Willett WC (2000). Prospective study of major dietary patterns and risk of coronary heart disease in men. Am J Clin Nutr 72, 912–921.
Jacobs Jr DR, Meyer KA, Kushi LH, Folsom AR (1998). Whole-grain intake may reduce the risk of ischemic heart disease death in post-menopausal women: the Iowa Women's Health Study. Am J Clin Nutr 68, 248–257.
Jacobs Jr DR, Pereira MA, Meyer KA, Kushi LH (2000). Fiber from whole grains, but not refined grains, is inversely associated with all-cause mortality in older women: the Iowa women's health study. J Am Coll Nutr 19, 326S–330S.
Jenkins DJ, Kendall CW, Marchie A, Faulkner DA, Wong JM, de Souza R et al. (2003). Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA 290, 502–510.
Jenkins DJA, Kendall CWC, Axelsen M, Augustin LSA, Vuksan V (2000). Viscous and nonviscous fibres, nonabsorbable and low glycaemic indeed carbohydrates, blood lipids and coronary heart disease. Curr Opin Lipidol 11, 49–56.
Jensen MK, Koh-Banerjee P, Hu FB, Franz M, Sampson L, Gronbaek M et al. (2004). Intakes of whole grains, bran, and germ and the risk of coronary heart disease in men. Am J Clin Nutr 80, 1492–1499.
Joshipura KJ, Hu FB, Manson JE et al. (2001). The effect of fruit and vegetable intake on risk for coronary heart disease. Ann Intern Med 134, 1106–1114.
Juntunen KS, Laaksonen DE, Poutanen KS, Niskanen LK, Mykkanen HM (2003). High-fiber rye bread and insulin secretion and sensitivity in healthy postmenopausal women. Am J Clin Nutr 77, 385–391.
Kasim-Karakas SE, Almario RU, Mueller WM, Peerson J (2000). Changes in plasma lipoproteins during low-fat, high-carbohydrate diets: effects of energy intake. Am J Clin Nutr 71, 1439–1447.
Kasim-Karakas SE, Tsodikov A, Singh U, Jialal I (2006). Responses of inflammatory markers to a low-fat, high carbohydrate diet: effects of energy intake. Am J Clin Nutr 83, 774–779.
Kelly S, Frost G, Whittaker V et al. (2004). Low glycaemic index diets for coronary heart disease. Cochrane Database Syst Rev 18, CD004467.
Keys A (1971). Sucrose in the diet and coronary heart disease. Atherosclerosis 14, 193–202.
Kinosian B, Glick H, Preiss L, Puder KL (1995). Cholesterol and coronary heart disease: predicting risks in men by changes in levels and ratios. J Invest Med 43, 443–450.
Knekt P, Reunanen A, Jarvinen R, Seppanen R, Heliovaara M, Aromaa A (1994). Antioxidant vitamin intake and coronary mortality in a longitudinal population study. Am J Epidemiol 139, 1180–1189.
Knowler WC, Barrett-Connor E, Fowler SE, et al., For the Diabetes Prevention Program Research Group (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346, 393–403.
Lau C, Faerch K, Glumer C, Tetens I, Pedersen O, Carstensen B et al. (2005). Dietary glycemic index, glycemic load, fiber, simple sugars, and insulin resistance: the Inter 99 study. Diabetes Care 28, 1397–1403.
Liese AD, Schulz M, Fang F, Wolever TM, D’Agostino RB, Sparks KC et al. (2005). Dietary glycemic index and glycemic load, carbohydrate and fiber intake, and measures of insulin sensitivity, secretion, and adiposity in the Insulin Resistance Atherosclerosis Study. Diabetes Care 28, 2832–2838.
Lindstrom J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J et al. (2003). The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 26, 3230–3236.
Liu S (2002). Intake of refined carbohydrates and whole grain foods in relation to risk of type 2 diabetes mellitus and coronary heart disease. J Am Coll Nutr 21, 298–306.
Liu S, Lee IM, Ajani U, Cole SR, Buring JE, Manson JE (2001). Intake of vegetables rich in carotenoids and risk of coronary heart disease in men: the Physicians’ Health Study. Int J Epidemiol 30, 130–135.
Liu S, Manson JE, Stampfer MJ et al. (2000). A prospective study of whole-grain intake and risk of type 2 diabetes mellitus in US women. Am J Public Health 90, 1409–1415.
Liu S, Manson JE, Stampfer MJ, Rexrode KM, Hu FB, Rimm EG et al. (2000a). Whole grain consumption and risk of ischemic stroke in women: a prospective study. JAMA 284, 1534–1540.
Liu S, Willett WC, Stampfer MJ, Hu FB, Franz M, Sampson L et al. (2000b). A prospective study of dietary glycaemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr 71, 1455–1461.
Mann J (2001). Dietary fibre and diabetes revised. Eur J Clin Nutr 55, 919–921.
Mann J (2004). Free sugars and human health: sufficient evidence for action? Lancet 363, 1068–1070.
Mann JI (1987). Simple sugars and diabetes. Diabet Med 4, 135–139.
Mann JI (2000). Stemming the tide of the diabetes epidemic. Lancet 356, 1454–1455 (editorial).
Mann JI, De Leeuw I, Hermansen K, Karamanos B, Karlström B, Katsilambros N et al. (2004). Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutr Metab Cardiovasc Dis 14, 373–394.
McAuley KA, Hopkins CM, Smith KJ, McLay RT, Williams SM, Taylor RW et al. (2005). Comparisons of high-fat and high-protein diets with a high-carbohydrate diet in insulin-resistant obese women. Diabetologia 48, 8–16.
McAuley KA, Smith KJ, Taylor RW, McLay RT, Williams SM, Mann JI (2006). Long-term effects of popular dietary approaches on weight loss and features of insulin resistance. Int J Obes 30, 342–349.
McGee DL, Reed DM, Yano K, Kagan A, Tillotson J (1984). Ten-year incidence of coronary heart disease in the Honolulu Heart Program: relationship to nutrient intake. Am J Epidemiol 119, 667–676.
Mensink RP, Zock PL, Kester ADM, Katan MB (2003). Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 77, 1146–1155.
Meyer KA, Kushi LH, Jacobs Jr DR, Slavin J, Sellers TA, Folsom AR (2000). Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr 71, 921–930.
Montonen J, Knekt P, Jarvinen R, Aromaa A, Reunanen A (2003). Whole-grain and fiber intake and the incidence of type 2 diabetes. Am J Clin Nutr 77, 622–629.
Morgan LM, Tredger JA, Shavila Y, Travis JS, Wright J (1993). The effect of non-starch polysaccharide supplementation on circulating bile acids, hormone and metabolite levels following a fat meal in human subjects. Br J Nutr 70, 491–501.
Morris JN, Marr JW, Clayton DG (1977). Diet and heart: a postscript. BMJ 2, 1307–1314.
Mozaffarian D, Kumanyika SK, Lemaitre RN, Olson JL, Burke GL, Siscovick DS (2003). Cereal, fruit and vegetable fiber intake and the risk of cardiovascular disease in elderly individuals. JAMA 289, 1659–1666.
Ness AR, Hughes J, Elwood PC, Whiteley E, Smith GD, Burr ML (2002). The long-term effect of dietary advice in men with coronary disease: follow-up of the Diet and Reinfarction trial (DART). Eur J Clin Nutr 56, 512–518.
Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy Jr WS, Brehm BJ et al. (2006). Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 166, 285–293.
Nuttall FO, Gannon MC, Wald JL, Ahmed M (1985). Plasma glucose and insulin profiles in normal subjects ingesting diets of varying carbohydrate, fat, and protein content. J Am Coll Nutr 4, 437–450.
Nuttall FO, Gannon MC (1981). Sucrose and disease. Diabetes Care 4L, 305–310.
Opperman AM, Venter CS, Oosthuizen W et al. (2004). Meta-analysis of the health effects of using the glycaemic index in meal-planning. Br J Nutr 92, 367–381.
Pereira MA, Jacobs Jr DR, Pins JJ, Raatz SK, Gross MD, Slavin JL et al. (2002). Effect of whole grains on insulin sensitivity in overweight hyperinsulinaemic adults. Am J Clin Nutr 75, 848–855.
Pereira MA, O’Reilly E, Augustsson K, Fraser GE, Goldbourt U, Heitmann BL et al. (2004). Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies. Arch Intern Med 164, 370–376.
Peterson DB, Lambert J, Gerring S et al. (1986). Sucrose in the diet of diabetic patients-just another carbohydrate? Diabetologia 29, 216–220.
Poppitt SD, Keogh GS, Prentice AM, Williams DE, Sonnemans HM, Valk EE et al. (2002). Long-term effects of ad libitum low-fat, high-carbohydrate diets on body weight and serum lipids in overweight subjects with metabolic syndrome. Am J Clin Nutr 75, 11–20.
Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V (2006). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP—1). Diabetologia 49, 289–297.
Retzlaff BM, Walden CE, Dowdy AA, McCann BS, Anderson KV, Knopp RH (1995). Changes in plasma triacylglycerol concentrations among free-living hyperlipidemic men adopting different carbohydrate intakes over two years: The Dietary Alternatives Study. Am J Clin Nutr 62, 988–995.
Riccardi G, Rivellese A, Pacioni D, Genovese S, Mastranzo P, Mancini M (1984). Separate influence of dietary carbohydrate and fibre on the metabolic control in diabetes. Diabetologia 26, 116–121.
Rivellese A, Riccardi G, Giacco A et al. (1980). Effect of dietary fibre on glucose control and serum lipoproteins in diabetic patients. Lancet 2, 447–450.
Salmeron J, Ascherio A, Rimm EB et al. (1997b). Dietary fiber, glycemic load, and risk of NIDDM in men. Diabetes Care 20, 545–550.
Salmeron J, Manson JE, Stampfer MJ et al. (1997a). Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA 277, 472–477.
Saris WH, Astrup A, Prentice AM et al. (2000). Randomized controlled trial of changes in dietary carbohydrate/fat ratio and simple vs complex carbohydrates on body weight and blood lipids: the CARMEN study. The Carbohydrate Ratio Management in European National diets. Int J Obes Relat Metab Disord 24, 1310–1318.
Simpson HCR, Carter RD, Lousley S, Mann JL (1982). Digestible carbohydrate—an independent effect on diabetic control in type 11 (non-insulin dependent) diabetic patients? Diabetologia 23, 235–239.
Simpson HCR, Simpson RW, Lousley S et al. (1981). A high cabohydrate leguminous fibre diet improves all aspect of diabetic control. Lancet 1, 1–5.
Slama G, Haardt MJ, Jean-Joseph P et al. (1984). Sucrose taken during mixed meal has no additional hyperglycaemic action over isocaloric amounts of starch in well-controlled diabetes. Lancet 2, 122–125.
Slavin J (2003). Why whole grains are protective: biological mechanisms. Proc Nutr Soc 62, 129–134.
Stone D, Connor W (1963). The prolonged effects of a low-cholesterol, high-carbohydrate diet upon serum lipids in diabetic patients. Diabetes 12, 127–132.
Toeller M, Buyken AE, Heitkamp G, de Pergola G, Giorgino F, Fuller JH (1999). Fiber intake, serum cholesterol levels, and cardiovascular disease in European individuals with type 1 diabetes. EURODIAB IDDM Complications Study Group. Diabetes Care 22 (Suppl 2), B21–B28.
Trowell H (1975). Dietary-fiber hypothesis of the etiology of diabetes mellitus. Diabetes 24, 762–765.
Truswell AS (1987). Sugar and health: a review. Food Technology in Australia 39, 134–140.
Truswell AS (1994). Food carbohydrates and plasma lipids—an update. Am J Clin Nutr 59, 710S–718S.
Truswell AS (2002). Cereal grains and coronary heart disease. Eur J Clin Nutr 56, 1–14.
Tuomilehto J, Lindström J, Eriksson JG et al. (2001). For the Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 334, 1343–1350.
Turley ML, Skeaff CM, Mann JI, Cox B (1998). The effect of a low-fat, high-carbohydrate diet on serum high density lipoprotein cholesterol and triglyceride. Eur J Clin Nutr 52, 728–732.
Van Dam RM, Hu FB, Rosenberg L, Krishnan S, Palmer JR (2006). Dietary calcium and magnesium, major food sources, and risk of type 2 diabetes in US black women. Diabetes Care 29, 2238–2243.
Venn BJ, Mann JI (2004). Cereal grains, legumes and diabetes. Eur J Clin Nutr 58, 1443–1461.
Weickert MO, Mohlig M, Schofl C et al. (2006). Cereal fiber improves whole-body insulin sensitivity in overweight and obese women. Diabetes Care 29, 775–780.
WHO Technical Report Series 916 (2003). Diet, nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert Consultation (Geneva).
Yudkin J (1964). Dietary fat and dietary sugar in relation to ischaemic heart disease and diabetes. Lancet 4, 4–5.
Zhang C, Liu S, Solomon CG et al. (2006). Dietary fiber intake, dietary glycemic load and the risk for gestational diabetes mellitus. Diabetes Care 29, 2223–2230.
Acknowledgements
I thank Professor Kjeld Hermansen, Dr Andrew Neil, Dr Gabriele Riccardi, Dr Angela Rivellese, Dr Monika Toeller, Professor A Stewart Truswell, Dr Rob M van Dam and Dr HH Vorster for the valuable comments they provided on the earlier paper.
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During the preparation and peer-review of this paper in 2006, the author and peer-reviewers declared the following interests.
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Professor Jim Mann: none declared.
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Professor Kjeld Hermansen: none declared. Dr Andrew Neil: none declared. Dr Gabriele Riccardi: none declared. Dr Angela Rivellese: none declared. Dr Monika Toeller: none declared. Professor A Stewart Truswell: none declared. Dr Rob M van Dam: none declared. Dr HH Vorster: member and director of the Africa Unit for Transdisciplinary health Research (AUTHeR), Research grant from the South African Sugar association.
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Mann, J. Dietary carbohydrate: relationship to cardiovascular disease and disorders of carbohydrate metabolism. Eur J Clin Nutr 61 (Suppl 1), S100–S111 (2007). https://doi.org/10.1038/sj.ejcn.1602940
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