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Asia Pacific J Clin Nutr (1997) 6(2): 80-83

Glycaemic response to selected Kerala breakfast
items in people with diabetes

Latha Vijayan MSc and S Sumathi PhD

Department of Foods and Nutrition, Andhra Pradesh Agricultural University, India

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The glycaemic response (index) to four commonly consumed breakfast items of Kerala, namely puttu, idiappam, appam and tapioca was studied in six non-insulin dependent diabetic Malayalee men. All the breakfast items were isoenergetic and had almost similar nutrient composition. The glycaemic response to breakfast items as compared to that of glucose was determined by comparing the areas under the 2 hour glucose response curves.

The mean peak rise over fasting levels was significantly lower (P<0.05) only after puttu consumption whereas the mean area under curve was significantly lower (P<0.05) after consumption of puttu, idiappam and tapioca when compared to the oral glucose tolerance test. The mean glycaemic response to puttu was found to be the lowest (0.79) of the breakfast items tested, followed by that of idiappam and appam. Tapioca elicited a glycaemic response almost similar to that of glucose load. The differences observed in the glycaemic response to different breakfast items may be due to differences in carbohydrate chemistry or physical form of food (particle size) and also dependant on method of processing.

Key words: Diabetes, non-insulin dependent, carbohydrate foods, glycaemic response, glycaemic index, Kerala, India, puttu, idiappam, appam, tapioca, breakfast

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Introduction

Diabetes mellitus - a complex metabolic disorder- is a common disease affecting 2-4% of the Indian population, and a majority of them (90%) are diagnosed as non-insulin dependent diabetes mellitus (NIDDM)¹. In the management of NIDDM, diet has been recognised as a cornerstone of therapy.

During the past few decades, dietary modification in the treatment of diabetes mellitus has advanced from alterations in nutrient constituents (mainly carbohydrate, CHO) of a meal to alterations in the whole meal itself. Recent studies^2,3 have suggested that not only should the carbohydrates ingested be considered when planning a diet for those with diabetes, but also the biological equivalents (that is, quantities of food yielding the same effect on blood glucose) or the glycaemic response (index) of a food. For an effective dietary management of diabetes, it is better to modify the diet appropriate to the individual lifestyle, taking into consideration traditional eating patterns for better and longer compliance. The glycaemic responses of common Indian breakfast items have been studied^4-6, but there is a paucity 1000 of data on the glycaemic responses of the typical cereal (rice) based preparations of Kerala. Hence, this study assessed the glycaemic response of some breakfast items commonly consumed by Keralites in non-insulin dependent diabetic subjects.

Materials and methods

Six non-insulin dependent Malayalee men with diabetes aged between 40-51 years taking oral hypoglycaemic drugs and free from any other major complications participated in the study. Internationally accepted ethical practices in the conduct of human research have been adhered to during the experimental period. The four breakfast items tested namely puttu, idiappam, appam and tapioca were isoenergetic (~390 Kcal) and had similar nutrient contents. The first three breakfast items are rice based with a difference only in the method of preparation and the fourth one is a root vegetable. The preparative methods are in Table 1. All the rice-based breakfast items were served with bengal gram curry. A cup of tea was served with the breakfast items. Nutrient composition of breakfast items computed on the basis of Nutritive Value of Indian Foods⁷ is given in Table 2.

Table 1. Breakfast items - ingredients and preparation.

Item	Ingredients	Raw weight (g)	Preparation	Cooked weight (g)
Puttu	Rice flour Tender coconut	75 25	Moisten flour, steam over boiling water	150
Idiappam	Rice flour Tender coconut	75 25	Make dough with warm water, extrude & steam	200
Appam	Rice flour Tender coconut	75 25	Make a thin batter, ferment, cook in a frying pan	180
Curry	Bengal gram (whole) Onions Oil	20 10 5	Cook gram, saute onions and add seasonings	100
Boiled tapioca	Tapioca Oil (for seasoning)	190 10	Cut into small cylindrical pieces and cook, season	190
Tea	Skim milk Tea	50 50	-	-

Table 2. Nutritive value of breakfast items.

Breakfast items	Energy (Kcal)	CHO (g)	Protein (g)	Fat (g)	Fibre (g)
Puttu Curry	269.0 122.0 391.0	60.2 13.3 73.5	5.3 3.4 8.8	0.7 6.1 6.8	0.2 0.8 1.0
Idiappam Curry	269.0 122.0 391.0	60.2 13.3 73.5	5.3 3.4 1000 8.8	0.7 6.1 6.8	0.2 0.8 1.0
Appam Curry	267.9 122.0 389.9	58.9 13.3 72.2	5.2 3.4 8.6	0.7 6.1 6.8	0.2 0.8 1.0
Boiled tapioca (seasoned)	388.3	72.2	1.3	10.4	1.1
Tea*	15	2.3	1.2	-	-

* Served with each breakfast

The subjects were requested to avoid taking drugs 24 hours prior to the test. An interval of at least two days was given between two successive test preparations. The breakfast items were prepared independently for each subject after weighing the required ingredients. The time taken for consumption of the entire breakfast item was 10 minutes. On the first visit, an oral glucose tolerance test was conducted using 75g glucose load as recommended by the WHO Expert Committee⁸. Fasting and post-prandial blood samples at half-hourly intervals for 2 hours were drawn intravenously after consumption of each breakfast item/glucose. The blood samples (3 ml) were collected into test tubes containing 50 mg of NaF, centrifuged immediately for separation of plasma and stored at 4°C. Plasma glucose was estimated by glucose-oxidase-peroxidase method using Boehringer Mannheim kit.

The area under the 2-hour glucose stimulation curve (AUC) was calculated for each subject by summing up the four glucose values obtained after stimulation and similarly for each test meal⁵. Glycaemic response of each food item was calculated as follows ⁵.

Glycaemic response (GR) =
AUC of breakfast item
AUC of glucose

Statistical analysis used the paired t-test. This differs from the "glycaemic index (GI)" of foods where respo 1000 nse to the same amount of carbohydrate from a reference food is used to calculate the index, although, in reality, breakfasts contained 72-74g CHO, compared to 75g glucose load on reference.

Results

The mean plasma glucose responses of the subjects fed different breakfast items are presented in Table 3.

Table 3. Mean plasma glucose values of the subjects in response to the different breakfast items. Mean± S.D

Plasma glucose (mg/dl)
Items tested (n = 6)	Fasting	1/2hr	1hr	1 1/2hr	2 hrs	Mean peakrise over fasting blood glucose levels (mg/dl)	Glycaemic response
Glucose	186±37	319±92	358±96	386±109	338±72	210.18a±71.27	1.00
Puttu	163±42	233±66	327±84	302±91	260±99	164.2b±47.77	0.79±0.11
Idiappam	182±57	262±64	357±119	324±109	284±99	174.53a±75.95	0.86±0.10
Appam	189±47	252±53	362±105	337±61	308±55	191.7a±56.1	0.90±0.11
Tapioca	193±53	277±62	377±86	339±74	321±76	183.57a±52.96	0.93±0.04

Values with different superscripts are significantly different (P<0.05). All values are compared with glucose.

The mean plasma glucose values at each time point following the intake of puttu were not significantly different (P>0.05) compared to glucose. However, for the two breakfast items, idiappam and appam, 1000 the values at almost all the time points except at 1 hour (when peak was observed) were lower. The glycaemic response of tapioca was very similar to that of glucose.

The mean total AUC or the overall glycaemic stimulus was significantly lower (P<0.05) following the stimulation of only puttu and idiappam compared to glucose and is represented in Figure 1. Also, the mean peak rise over fasting was significantly lower after administration of puttu when compared to that of glucose (Table 3). The values obtained after consumption of other breakfast items were, however, not significantly lower (P>0.05) than that of glucose.

The glycaemic response of puttu was found to be the lowest (0.79± 0.11) of the four breakfast items tested followed by idiappam (0.86± 0.10). The glycaemic responses of appam and tapioca were found to be the highest and almost similar to that of glucose. No significant difference (P>0.05) was found in the glycaemic responses among the different breakfast items themselves.

Figure 1. Comparative areas under 2-hour glucose response curve (AUC) for food items.

Discussion

In the present study, the mean glycaemic response (GR) to puttu was found to be the lowest of the four breakfast items tested. All the breakfast items were isoenergetic (~390 Kcal) and had similar CHO content. Thus, differences observed in GR will be mainly due to type and form of CHO available from each food item and to the presence of non-CHO constituents, that is, fats, proteins and non-digestible (non-glycaemic) CHOs. The breakfast items tested had relatively low protein contents (less than 10g) and thus unlikely to impact on GR since it is protein at intakes greater than 25g that seems to blunt the rate of increase in blood glucose^9,10. The fat content of the breakfast items was low and unlikely to have influenced GR . The dietary fibre content of the test items also seems to have had little effect on the rate of food digestion and absorption, and hence on the GR, as all the breakfast items elicited mean peak glucose levels at the same time point (1 hr); this is despite the presence of Bengal gram in the breakfasts based on puttu, iddiapam and appam. So, in this study, the nature and form of CHO seems to have affected GR. Tapioca elicited a higher GR though it had a slightly low CHO content (72g) than others (73.5g) probably due to the type of CHO in tapioca. Similarly, the high GR of appam among the rice based breakfast items highlights the probable importance of physical form in the physiological response to a food.

The rice based breakfast items differed only in the processing method and the particle size of rice flour, with the ingredients being almost the same (rice flour, coconut and bengal gram curry). Puttu, which elicited the lowest GR among the breakfast items tested, is prepared by moistening the coarse rice flour and steaming over boiling water. Idiappam is made from finer rice flour, which is worked into a soft dough. The extruded dough is then steamed. Appam, the breakfast item that elicited a higher GR, is prepared by pan frying a fermented batter of rice, coconut milk and toddy (a naturally fermented, non-alcoholic drink obtained from the palm or coconut palm tree).

The larger particle size of the moistened rice flour of puttu could have affected the degree of gelatinisation of starch while cooking, with a relatively complete gelatinisation in idiappam, thus increasing the rate of digestion and absorption and hence an increased GR. Similar results were reported by Susan et a 1000 l¹¹, who found that glycaemic index correlates positively with degree of gelatinisation and with the amount of starch digested. O’Donnell et al¹² demonstrated the effect of particle size on GR. They reported that bread made from coarse flour resulted in lower plasma glucose and insulin concentration than that made from fine flour. It should be noted, however, that if gelatinised starch is cooled it becomes more resistant to digestion ("resistant starch").

Idiappam is a preparation that is comparable to spaghetti because it undergoes similar processing. Jenkins et al¹³ have reported that flour in the form of spaghetti raises blood glucose levels significantly less than when the same amount of CHO is eaten as bread. Thus, idiappam may lower GR due to processing, for example, to resistant starch formation.

The relatively higher GR of appam could be attributed to the wet grinding and fermentation of rice prior to cooking, leading to complete gelatinisation of starch and enhanced rate of starch digestion of the product. It has been reported that fermentation of pearl millet sprouts, green gram and sorghum significantly increases protein and starch digestibility^14,15. Various other studies have also demonstrated that there is no significant difference in the metabolic responses to ground brown rice (complex CHO) and glucose (simple CHO)^16,17 In the present study too, the mean AUC of appam was not significantly different from that of glucose.

Tapioca (a root vegetable) and appam (a rice product) elicited similar GRs. In the preparation of appam, the physical process of breaking the rice starch into smaller particles seems to have eliminated the factors intrinsic to the whole food which would have led to different glycaemic potencies in these two different sources of CHOs. Similar findings have been reported by Crapo and Henry¹⁸, namely that differences in metabolic responses to two common starches (rice and potato) could be eliminated by altering the physical form (blended to form a slurry). They suggested that differences in glycaemic potencies of different starch containing foods are not due only to variations in the starch molecule per se, but rather to the way it is presented to the gastro intestinal tract digestive and absorptive process. Blending leads to dispersion and hydration of starch, which could be an important factor in absorption and hence, determination of GR.

These data thus provide information helpful in the design of diets for people with diabetes which contain unrefined CHO in a form which is digested and absorbed slowly. However, food culture and preference would still need to be considered despite the overall beneficial impact of the glycaemic response differences.

Conclusion

The differences observed in the glycaemic response to different breakfast items in subjects with NIDDM in the present study may have been due to differences in CHO chemistry, physical form of food or the method by which it was processed.

Puttu had a comparatively lower GR (0.79) compared to glucose than did other breakfast items from Kerala and is therefore more suitable for those with diabetes. Thus, even traditionally used cereal based food items may be chosen to contribute to lower GR in diabetes.

References

1. Raghuram TC, Swaran Pasricha and Sharma RD. Diet and Diabetes. National Institute of Nutrition, Indian Council of Medical Research, Hyderabad. 1991;l-5.
2. Jenkins DJA, Wolever TMS, Taylor RH, Barker HM, Fieldon H, Baldwin JM, Bowling AC 1000 , Newman HC, Goff DV and Jenkins AL. Glycaemic index of foods: A physiological basis for carbohydrate exchange. Am J Clin Nutr 1981; 34: 362-366.
3. Crapo PA, Reaven G, Olefsky J. Post-prandial plasma glucose and insulin responses to different complex carbohydrates. Diabetes 1977; 26:1178-83.
4. Raghuram TC, Swaran Pasricha, Upadhyaya AC and Krishnaswamy K. Glycaemic index of Indian foods, Diabetes Bull 1987; V 7 : 1-2.
5. Vishwanathan M, Snehalatha C,Ramachandran A, Mohan V, Revathy M, Paul S, Indira S and Kymal PK. Glycaemic and insulin responses to some breakfast items in diabetic subjects. Nutrition Reports International 1988; 37(a): 409-418.
6. Vimala CKW and Easwaran PP. Glycaemic indices of selected South Indian breakfast items. The Indian Journal of Nutrition and Dietetics 1988; 25: 1-6.
7. Narsinga Rao BS, Deosthale YG and Pant KC. Nutritive value of Indian Foods. Indian Council of Med Research, Hyderabad. 1991.
8. World Health Organisation. Expert Committee report on diabetes mellitus. Technical Report Series 1980; No.646 WHO Geneva.
9. Seino Y, Seino S, Ikeda M, Matsukura S and Imura H. Beneficial effects of high protein diet in the treatment of mild diabetics. Human Nutrition : Applied Nutrition 1983; 37A: 226-230.
10. Seino Y, Ikeda M, Matsukura S and Imura H. Blood glucose and plasma insulin of mild diabetic patients in response to high protein divided meals. Human Nutrition: Applied Nutrition 1983; 37A(3): 222-225.
11. Ross SW, Brand JC, Thornburn AW and Truswell AS. Glycaemic index of processed wheat products. Am J Clin Nutr 1987; 46: 631-635.
12. O’Donnell LJD, Emmett PM, Heaton KW. Size of flour particles and its relation to glycemia, insulinaemia and colonic disease. British Medical Journal 1989; 298(6688): 1616-1617.
13. Jenkins DJA, Wolever TMS, Jenkins AL, Thorne MJ, Lee R, Reichert R and Wong GS. The glycaemic index of foods tested in diabetic patients: A new basis for carbohydrate exchange favouring the use of legumes. Diabetologia 1983; 24: 257-264.
14. Chavan VD, Chavan JK and Kadam SS. Effect of fermentation on soluble proteins and invitro protein digestibility of sorghum, green-gram and their blends. J of Food Science 1988; 53(5): 1574-1575.
15. Khetarpaul N and Chauhan BM. Effect of germination and fermentation on invitro starch and protein digestibility of pearl millet. Journal of Food Science 1990; 55(3): 883-884.
16. O’Dea K, Snow P and Nestel PJ. Rate of starch hydrolysis in vitro as a predictor of metabolic responses to complex carbohydrate in vivo. Am J Clin Nutr 1981; 34: 1991-1993.
17. Collier G and O’Dea K. Effect of physical form of carbohydrate on the postprandial glucose, insulin and gastric inhibitory polypeptide responses in type-2 diabetes. Am J Clin Nutr 1982; 36:10-14.
18. Crapo PA and Henry R. Postprandial metabolic responses to the influence of food form. Am J Clin Nutr 1988; 48: 560-564.

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Glycaemic response to selected Kerala breakfast items in people with diabetes
Latha Vijayan and S Sumathi
Asia Pacific Journal of Clinical Nutrition (1997) Volume 6, Number 2: 80-83

Glycaemic response to selected Kerala breakfast items in people with diabetes
Latha Vijayan and S Sumathi
Asia Pacific Journal of Clinical Nutrition (1997) Volume 6, Number 2: 80-83

Copyright © 1997 [Asia Pacific Journal of Clinical Nutrition]. All rights reserved.
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