Blood sugar management becomes imperative
When being diagnosed with diabetes mellitus, it becomes imperative to deal with raised blood sugar levels. Blood sugar levels are elevated either because the body does not respond properly to insulin, as for instance in early type 2 diabetes mellitus or in case of gestational diabetes first diagnosed during pregnancy. Or they result from insufficient insulin production, when the pancreas gland of the body has lost its ability to produce sufficient insulin in early years (type 1 diabetes mellitus) or later in life (type 2 diabetes mellitus).
In all these cases, dealing with high blood sugar levels is essential to minimize diabetic complications such as cardiovascular disease, damage to the eyes (retinopathy), chronic kidney disease (diabetic nephropathy) or the diabetic foot, and to maintain the quality of life.
Dietary planning and blood glucose control
Dietary management is a first line treatment for diabetes mellitus, together with exercise and insulin supplementation in type-1 or advanced type-2 diabetes mellitus. While diabetic people are advised to follow the recommendations for a healthy diet, strict meal planning is needed to manage and normalize blood sugar levels and to lower long-term blood glucose control parameters such as glycated haemoglobin (HbA1c) and fasting glucose, which are increased with permanently abnormal blood glucose levels and which are risk factors for diabetic complications. Also improvements in blood pressure and cholesterol levels are foreseen, and people with diabetes are advised to achieve and maintain their body weight goals (Evert et al 2019).
Research sees benefits of low GI diets
Giving preference to carbohydrate foods with low or reduced glycaemic properties is beneficial for healthy people, but especially important for diabetics and related benefits in the management of diabetes mellitus (Augustin et al 2015). The American Diabetes Association agrees that emphasis shall be given on the quality of carbohydrate foods with respect to their composition and fiber content (Evert et al 2019). Also the use of the Glycemic Index (GI) and Glycemic Load (GL) to rank carbohydrate foods according to their effects on glycaemia is seen of interest for people with diabetes and those at risk.
Several systematic reviews of GI research see benefits of low GI diets for diabetic blood glucose control.
For instance, Ojo et al (2018) concluded from their meta-analysis that low GI diets result in greater improvements in glycaeted haemoglobin and fasting blood glucose compared to high GI diets or control in patients with type-2 diabetes. Compared with other diabetic diets, the low GI diet achieved equivalent control of HbA1c using less medication. Similarly, the review of Thomas and Elliott (2010) concluded that lowering the GI of foods can improve glycated haemoglobin in patients with diabetes.
Earlier reviews by Brand-Miller (2003), Wolever (2003) or Oppermann et al (2004) have proven small but clinically useful improvements on medium-term glycaemic control in diabetes; “comparable to that offered by pharmacological agents” (Brand-Miller et al 2003), or more specifically “comparable with a 10% improvement in glycaemic control obtained with intensive drug therapy in type-2 diabetics and a ~20% improvement with intensive insulin therapy in type-1 diabetes” (Wolever 2003).
Encouraging people with diabetes to adhere to low glycaemic diets supports them to maintain those larger short-term achievements and continue improving blood glucose control long-term.
Isomaltulose – the better sugar for people with diabetes
Isomalulose can serve as the “better sugar” for people with diabetes due to its low effect on blood glucose levels, different incretin response and potential to improve glucose flux in people with diabetes (Maresch et al 2016).
Lower blood glucose responses with isomaltulose have been observed in adults with non-insulin dependent type 2 diabetes mellitus, in comparison to sucrose (Kawai et al 1989, Keyhani-Nejad et al 2016) or in adults with type 1 diabetes mellitus, in comparison to dextrose (West et al 2011a, Bracken et al 2012). For instance, when Pfeiffer and co-workers provided type 2 diabetic with 50 g isomaltulose or sucrose in solution after an overnight fast in cross-over design, isomaltulose showed a 20% lower blood glucose peak concentration, a 55% lower insulin release, and a different incretin response compared to sucrose: GIP release in the upper small intestine was about 40% lower, and the GLP-1 secretion in the lower intestine was overall 6.3 fold higher with isomaltulose (Keyhani-Nejad et al 2016). Incretin hormones play a role in blood glucose regulation, insulin release and related long-term effects in developing insulin resistance and type 2 diabetes (Pfeiffer et al 2018). These findings illustrate that the type of sugar used makes a difference to the blood glucose management of people with type 2 diabetes.
Isomaltulose improves glucose flux in diabetics
Blood sugar levels are maintained on constant level. On one side glucose appearance from food consumption feeds into blood sugar levels, as well as the body own glucose production or mobilization from glycogen stores. On the other side, blood sugar disappears when glucose is taken up by body cells for use as fuel or for glycogen storage. Whether a carbohydrate supplies glucose fast, like sucrose, or more slowly, like isomaltulose, is likely to influence the overall glucose flux. This was investigated by Ang and Linn (2014), who compared the effects of isomaltulose and sucrose on postprandial glucose flux in 11 adults with type-2 diabetes in randomised, double-blind cross-over design, using dual isotope technique in combination with an underlying 3-h euglycaemic-hyperinsulinaemic clamp. The intestinal glucose absorption from isomaltulose was prolonged, and the resulting glucose appearance from isomaltulose in the blood was extended in comparison with sucrose. The different incretin pattern from isomaltulose – with lower GIP release and higher GLP-1 release – contributed to a general shift in the insulin-to-glucagon ratio, lowered the body’s own glucose production and enhanced glucose uptake by liver cells. The result was an overall lower glucose flux with isomaltulose in comparison with rapidly absorbed sucrose in type-2 diabetics.
Figure: Blood sugar regulation by the liver.
Isomaltulose and long-term blood glucose control
Longer-term studies investigated the effects of isomaltulose on markers of blood glucose control and insulin sensitivity. Those studies show improvements in blood glucose control and lipid metabolism upon regular consumption of isomaltulose when compared with other carbohydrates such as sucrose, maltodextrin, or glucose. Reductions in fasting blood glucose and improvements in insulin resistance (HOMA-IR) in healthy persons or those with poor insulin sensitivity have been observed as well as reductions in fasting triglyceride levels (e.g. Oizumi et al 2007, Yamori et al 2007, Okuno et al 2010, Sakuma et al 2009, Fujiwara et al 2007, Brunner et al 2012, Keller et al 2016).
Diabetes & sports: Nutrition strategies for stable blood sugar levels
When diabetics seek to engage in sports, a common worry is the maintaining of stabilized blood glucose control during the exercise and thereafter. A series of studies from Swansea University, UK, sought to find ways to improve blood glucose management in people with type 1 diabetes mellitus during exercise, and to create solutions for overcoming barriers that prevented these individuals from engaging in physical activity.
The researchers observed that in people with type-1 diabetes, the intake of isomaltulose instead of dextrose as a carbohydrate load before exercise showed to improve their glycaemic control and protected against hypoglycaemia, while running performance was maintained (West et al 2010; West et al 2011a, b; Bracken et al 2012; Campbell et al 2014). When exercise was timed during evenings, blood glucose levels were further stabilized overnight with the consumption of a low GI evening meal and a low GI bed time snack, both containing isomaltulose (Campbell et al 2014, 2015). Nutritional strategies for the blood sugar management of diabetics during sports that resulted from this research have been formulated. [Read more]
References
Ang M, Linn T (2014) Comparison of the effects of slowly and rapidly absorbed carbohydrates on postprandial glucose metabolism in type 2 diabetes mellitus patients: a randomized trial. Am J Clin Nutr 100(4):1059–1068. http://ajcn.nutrition.org/content/early/2014/07/16/ajcn.113.076638.full.pdf+html
Augustin LS, Kendall CW, Jenkins DJ et al (2015) Glycemic index, glycemic load and glycemic response: An International Scientific Consensus Summit from the International Carbohydrate Quality Consortium (ICQC). Nutr Metab Cardiovasc Dis 25(9):795-815. doi: 10.1016/j.numecd.2015.05.005.
Bracken RM, Page R, Gray B, Kilduff LP, West DJ, Stephens JW, Bain SC (2012) Isomaltulose improves glycemia and maintains run performance in type 1 diabetes. Med Sci Sports Exerc 44(5):800–808. http://www.ncbi.nlm.nih.gov/pubmed/22051571
Brand-Miller J, Haye S, Petocz P, Colagiuri S (2003) Low glycemic index diets in the management of diabetes: A meta-analysis of randomised controlled trials. Diabetes Care 26, 2261-2267. http://care.diabetesjournals.org/content/26/8/2261.long
Brunner S, Holub I, Theis S, Gostner A, Melcher R, Wolf P, Amann-Gassner U, Scheppach W, Hauner H (2012) Metabolic Effects of Replacing Sucrose by Isomaltulose in Subjects With Type 2 Diabetes: A randomized double-blind trial. Diabetes Care 35(6):1249–1251. http://www.ncbi.nlm.nih.gov/pubmed/22492584
Campbell MD, Walker M, Bracken RM, Turner D, Stevenson EJ, Gonzalez JT, Shaw JA, West DJ (2015) Insulin therapy and dietary adjustments to normalize glycemia and prevent nocturnal hypoglycemia after evening exercise in type 1 diabetes: a randomized controlled trial. BMJ Open Diabetes Res Care 3(1):e000085. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442134/pdf/bmjdrc-2015-000085.pdf
Campbell MD, Walker M, Trenell MI, Stevenson EJ, Turner D, Bracken RM, Shaw JA, West DJ (2014) A low-glycemic index meal and bedtime snack prevents postprandial hyperglycemia and associated rises in inflammatory markers, providing protection from early but not late nocturnal hypoglycemia following evening exercise in type 1 diabetes. Diabetes Care 37:371–379. http://www.ncbi.nlm.nih.gov/pubmed/24784832
Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, Mitri J, Pereira RF, Rawlings K, Robinson S, Saslow L, Uelmen S, Urbanski PB, Yancy WS Jr (2019) Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care 42(5):731-754. doi: 10.2337/dci19-0014.
Fujiwara T, Naomoto Y, Motoki T et al (2007) Effects of a novel palatinose based enteral formula (MHN-01) carbohydrate-adjusted fluid diet in improving the metabolism of carbohydrates and lipids in patients with esophageal cancer complicated by diabetes mellitus. J Surg Res 138(2):231–240. http://www.ncbi.nlm.nih.gov/pubmed/17254607
Holub I, Gostner A, Theis S, Nosek L, Kudlich T, Melcher R, Scheppach W (2010) Novel findings on the metabolic effects of the low glycaemic carbohydrate isomaltulose (Palatinose™). Br J Nutr 103(12):1730–1737. http://www.ncbi.nlm.nih.gov/pubmed/20211041
Kawai K, Yoshikawa H, Murayama Y, Okuda Y, Yamashita K (1989) Usefulness of palatinose as a caloric sweetener for diabetic patients. Horm Metab Res 21(6):338–340. http://www.ncbi.nlm.nih.gov/pubmed/2673967
Keller J, Kahlhöfer J, Peter A, Bosy-Westphal A (2016) Effects of Low versus High Glycemic Index Sugar-Sweetened Beverages on Postprandial Vasodilatation and Inactivity-Induced Impairment of Glucose Metabolism in Healthy Men. Nutrients 8(12):802. www.mdpi.com/2072-6643/8/12/802/pdf
Keyhani-Nejad F, Kemper M, Schueler R, Pivovarova O, Rudovich N, Pfeiffer AF (2016) Effects of Palatinose and Sucrose Intake on Glucose Metabolism and Incretin Secretion in Subjects With Type 2 Diabetes. Dia Care 39(3):e38-e39. http://www.ncbi.nlm.nih.gov/pubmed/26721819
Maresch CC, Petry SF, Theis S, Bosy-Westphal A, Linn T (2017) Low Glycemic Index Prototype Isomaltulose-Update of Clinical Trials. Nutrients 9(4). http://www.mdpi.com/2072-6643/9/4/381
Oizumi T, Daimon M, Jimbu Y, Kameda W, Arawaka N, Yamaguchi H, Ohnuma H, Sasaki H, Kato T (2007) A palatinose-based balanced formula improves glucose tolerance, serum free fatty acid levels and body fat composition. Tohoku J Exp Med 212(2):91–99. http://www.ncbi.nlm.nih.gov/pubmed/17548953
Ojo O, Ojo OO, Adebowale F, Wang XH (2018) The Effect of Dietary Glycaemic Index on Glycaemia in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 10(3) pii: E373. doi: 10.3390/nu10030373.
Okuno M, Kim MK, Mizu M, Mori M, Mori H, Yamori Y (2010) Palatinose-blended sugar compared with sucrose: different effects on insulin sensitivity after 12 weeks supplementation in sedentary adults. Int J Food Sci Nutr 61(6):643–651. http://www.ncbi.nlm.nih.gov/pubmed/20367218
Opperman AM, Venter CS, Oosthuizen W, Thompson RL, Vorster HH (2004) Meta-analysis of the health effects of using the glyceamic index in meal-planning. British Journal of Nutrition 92, 367-381. https://doi.org/10.1079/BJN20041203
Pfeiffer AFH, Keyhani-Nejad F (2018) High glycemic index metabolic damage – a pivotal role of GIP and GLP-1. Trends Endocrinol Metab 29(5):289-299. https://www.cell.com/trends/endocrinology-metabolism/fulltext/S1043-2760(18)30046-8
Sakuma M, Arai H, Mizuno A, Fukaya M, Matsuura M, Sasaki H, Yamanaka-Okumura H, Yamamoto H, Taketani Y, Doi T, Takeda E (2009) Improvement of glucose metabolism in patients with impaired glucose tolerance or diabetes by long-term administration of a palatinose-based liquid formula as a part of breakfast. J Clin Biochem Nutr 45(2):155–162. http://www.ncbi.nlm.nih.gov/pubmed/19794923
Thomas DE, Elliott EJ (2010) The use of low-glycaemic index diets in diabetes control. Br J Nutr 104(6):797-802. doi: 10.1017/S0007114510001534.
West DJ, Morton RD, Bain SC, Stephens JW, Bracken RM (2010) Blood glucose responses to reductions in pre-exercise rapid-acting insulin for 24 h after running in individuals with type 1 diabetes. J Sports Sci 28(7):781-8. doi: 10.1080/02640411003734093.
West DJ, Morton RD, Stephens JW, Bain SC, Kilduff LP, Luzio S, Still R, Bracken RM (2011) Isomaltulose improves postexercise glycemia by reducing CHO oxidation in T1DM. Med Sci Sports Exerc 43(2):204–210. http://journals.lww.com/acsm-msse/Fulltext/2011/02000/Isomaltulose_Improves_Postexercise_Glycemia_by.2.aspx
West DJ, Stephens JW, Bain SC, Kilduff LP, Luzio S, Still R, Bracken RM (2011b) A combined insulin reduction and carbohydrate feeding strategy 30 min before running best preserves blood glucose concentration after exercise through improved fuel oxidation in type 1 diabetes mellitus. J Sports Sci 29(3):279–289. http://www.ncbi.nlm.nih.gov/pubmed/21154013
Wolever TMS (2003) Carbohydrate and the regulation of blood glucose and metabolism. Nutrition Reviews 61, S40-48. https://doi.org/10.1301/nr.2003.may.S40-S48
Yamori Y, Mori H, Mori M, Kashimura J, Sakamua T, Ishikawa PM, Moriguchi E, Moriguchi Y (2007) Japanese perspective on reduction in lifestyle disease risk in immigrant japanese brazilians: a double-blind, placebo-controlled intervention study on palatinose. Clin Exp Pharmacol Physiol 34(S5-S7). http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1681.2007.04759.x/abstract