Co-authors: Muneer Hussain E Meena.V Thulasi Ramudu Mahesh Ram

1. EFFECT OF LOW GLYCAEMIC INDEX FOODS ON SUBJECTS
OF TYPE 2 DIABETES MELLITUS
Thesis
Submitted
By
P. Madhumathi
Under the guidance of
Dr. A. Jyothi
Professor
DEPARTMENT OF HOME SCIENCE
SRI PADMAVATI MAHILA VISVAVIDYALAYAM
TIRUPATI- 517502
2020

2. INTRODUCTION
Diabetes mellitus is the most common metabolic disorder affecting the present generations all
over the world. Diabetes is a chronic disease that occurs either when the pancreas does not produce
enough insulin, a hormone that regulates blood sugar, or when the body cannot effectively use the insulin
it produces. It is a complex illness, characterized by hyperglycaemia with disturbances in the metabolism
of carbohydrate, fat and protein (WHO,2006). The status of diabetes has changed from being considered
as a mild disorder of elderly to one of the major causes of morbidity and mortality affecting the youth and
middle aged people, between 35 and 65 years of age (Mohan et al., 2007). Diabetes is a major cause of
blindness, kidney failure, heart attacks,stroke and lower limb amputation (WHO,2006).
According to the International Diabetes Federation, in 2019 diabetes affects 463million (9.3%)
adults globally, and it is estimated to rise to 578 million (10.2%) by 2030 and 700 million (10.9%) by
2045. (Saeediet al., 2019). In the South East Asia region 82 million people have diabetes and by 2045, it
may rise to 151 million (IDF 2018). According to the IDF, there were 73 million cases of diabetes in
India in 2017, i.e., nearly about 8.8% in adults. In 2015 an estimated 1.6 million deaths were directly
caused by diabetes and another 2.2 million deaths were attributable to high blood glucose in 2012, WHO
projects that diabetes will be the 7th leading cause of death in 2030.
The ADA (2017) has classified diabetes mellitus into Type 1 diabetes mellitus, Type 2 diabetes
mellitus, Gestational diabetes mellitus and specific types of diabetes due to other causes. Among these,
Type 2 diabetes, earlier called as Non Insulin Dependent diabetes mellitus (NIDDM),constitutes more
than 90 per cent of diabetic population, growing constantly and leading to multiple health problems. The
symptoms of Type 2 diabetes are frequent urination (polyurea), excessive thirst (polydypsia), increased
hunger (polyphagia), weight loss, tiredness, lack of interest and concentration, a tingling sensation or
numbness in the hands or feet,blurred vision, frequent infection, slow wound healing, vomiting and
stomach pain (IDF,2017). Diagnostic criteria by the American Diabetes Association includes a fasting
plasma glucose (FPG) level of 126 mg/dL or higher, a 2-hour plasma glucose (PPG) level of 200 mg/dL
or higher during a 75 g oral glucose tolerance test (OGTT). HbA1c is a widely used biomarker for the
adequacy of glycaemic management, reflecting average blood glucose levels over a two to three months
period of time
WHO has identified India as capital of diabetes for its high prevalence rate, for which, factors
such as urbanization, consumption of energy dense food and changes from traditional active life to
modern sedentary and stressful life are some of the major underlying causes. Family history, overweight
and obesity (BMI≥25 kg/m2
) , higher waist circumference, unhealthy diet, physical inactivity, increasing
age, high blood pressure,ethnicity, history of gestational diabetes, poor nutrition during pregnancy are the
possible risk factors associated with Type 2 diabetes (WHO, 2016). Several studies have confirmed that
unhealthy personal habits, such as smoking and excess intake of alcohol, can make diabetes and its
complications worse.
If it is not treated,diabetes can damage the blood vessels, eyes (retinopathy), kidneys
(nephropathy) and nerves (neuropathy) and increase the risk of heart disease and stroke (WHO, 2016).
Hypertension and dyslipidaemia, which includes high triglyceride and low HDL cholesterol, are common

3. in type 2 diabetes and contribute significantly to the incidence of coronary heart disease. Due to lack of
knowledge and awareness of the disease among the diabetics, they remain undiagnosed until major
complications set in and it may lead to further serious complications (Kanojia, 2017).
Diabetes cannot be cured but it is a disorder that can be kept under control through proper
management strategies. The primary goal of management of diabetes is maintaining near normal blood
glucose levels to prevent long term complications. Oral antidiabetic drug is the first line treatment for
type 2 diabetes for controlling the hyperglycaemia. The progressive nature of type 2 diabetes requires a
combination of two or more oral agents in the long term and insulin may also be used as an intermittent or
permanent therapy in some advanced cases of type 2 diabetes mellitus (Ramachandran et al., 2010). But
there are limitations in the use of anti-hyperglycaemic medications, because of the side effects,high cost,
limited action and secondary failure rates (Omodanisi et al., 2017).
A life-time management using anti diabetic drugs alone is expensive and the economic burden
due to diabetes at personal, societal and national levels is huge (Ramachandran et al., 2010). So it is an
urgent need to identify the most appropriate and cost-effective approach for the easy management of the
disease and reduction of disease burden. Well designed randomized control trials have shown that life
style interventions including dietary changes have a vital role in preventing the progression of type 2
diabetes (Esposito et al., 2015). Life style measures include reduced alcohol intake, reduced intake of salt,
reduced sugar intake, increasing physical activity and control of overweight.
For the effective implementation of life style modifications and improvement of quality of life,
knowledge about the disease, risk factors, complications and management of the disease is essential. In
India, studies on diabetes awareness revealthat urban people have more knowledge of diabetes than rural
residents. Several studies have suggested that educating the patient with life style modifications is an
important component of management of type 2 diabetes.
In addition to pharmacotherapy and increased physical activity, nutrition therapy makes an
important component of the overall treatment plan of type 2 diabetes. The nutrition therapy should aim at
delaying and preventing complications of diabetes and also consider blood pressure,serum lipid profile
and body weight goals (ADA, 2015). Dietary prescription should be individualized considering the age,
weight, gender, dietary pattern, habitual eating and regional availability of the foods to achieve better
meal adherence. For achieving metabolic goals, multiple meal planning approaches like carbohydrate
counting, simplified meal plans, exchange lists and glycaemic index are effective (Evert et al., 2014).
Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and
it is the primary macronutrient of the concern in glycaemic management. But there is difference in blood
glucose response after ingestion of the same amount of carbohydrates from different foods (Wolever,
2001). Based on this, the concept of glycaemic index (GI) was first proposed by Jenkins et al in 1981. It is
a system of ranking (0 to 100) of foods which contain carbohydrate, based on their glycaemic response
(Perlstein et al., 1997). Glycaemic Index is defined as the incremental area under the blood glucose
response curve of a 50 g carbohydrate portion of a test food expressed as a percent of the response to the
same amount of carbohydrate from a standard food taken by the same subject (FAO/WHO, 1998).
Glucose has been used as the reference food for international standardization of GI values. The WHO has
classified the foods according to their GI values as low GI foods (GI 55 or less), medium GI (56-69) and
high GI (70 or more). GI data for foods could be used to make priorities for food selection within food
groups as a part of dietary management (Brouns et al., 2005). The GI is acknowledged by a number of
major diabetes associations, including those in UK,Canada, Australia, Europe, and the USA, as a useful
tool for differentiating between carbohydrates (Venter, 2005).
The glycemic response to an ingested food was found to depend not only on the GI but also on
the total amount of carbohydrates ingested, and this led to the concept of Glycaemic Load (GL) (Eleazu,
2016). GI gives ranking of foods based on their blood glucose response,where as the GL takes into
account the amount of available carbohydrate also being consumed in the portion of food.

4. Consumption of high glycaemic index foods like some refined foods, sugars and rapidly digested
starch,induces a rapid increase in blood glucose, thus results in high demand for insulin which could
eventually lead to type 2 diabetes (Maki and Phillips, 2005). Conversely low glycaemic index foods have
slower glycaemic response which may facilitate better glycaemic control and lipid profiles in people with
diabetes (Perlstein, 1997). A reduction in postprandial glucose and insulin concentrations in the blood is
considered beneficial in the prevention and treatment of diabetes mellitus. Evidence from prospective
studies shows that low GI diets are associated with reduced risk of diabetes, CVD,cancer and metabolic
syndrome (Venter,2005).
.
Clinical trials have shown that low Glycaemic Index diets improve glycaemic control in
diabetes, increase insulin sensitivity and beta cell function, reduce food intake and body weight, influence
memory and may improve blood lipids (Venter,2005). In addition to this, satiating effect of lower GI
foods and also reducing episodes of nocturnal hypoglycaemia may be useful for diabetics (Perlstein et al.,
1997). Patients with type 2 diabetes will have a 2 to 3 fold higher risk of CVD and premature mortality
than the generalpopulation. Low GI foods may reduce CVD risk through effects on oxidative stress,
blood Pressure,serum lipids and coagulation factors (Radulian et al., 2009). One more advantage of
ingesting a low GI food is that the postprandial response to the subsequent meal will be attenuated
(Jenkins, 2007).
Several studies stated that cereals like whole wheat, brown rice, finger millet, barley and maize
are having low glycaemic Index. Pulses which are good sources of protein and fibre are also considered as
low GI foods. Many prospective GI studies consider the carbohydrate content of legumes as a slow
releasing which makes them low glycaemic (Mirmiran et al., 2014). Green leafy vegetables, vegetables
and some fruits are having low glycemic index. Studies found many other low GI spices like fenugreek,
kalonji, beneficial for the management of diabetes. The glycaemic index of the foods is affected by some
factors like nature of carbohydrate in the food, seasonalfactors,type of starch present in the food,
physical form of food, cooking and processing, fibre, antinutrients, fat and protein, speed of eating the
food and acidity (Perlstein et al., 1997). These parameters should be considered while calculating the
glycaemic index of foods for better functional quality.
Glycaemic Index in the context of a meal is referred as ‘mixed meal’ and substituting low GI
foods for high GI foods in a meal will reduce the glycaemic response to the meal (Perlstein et al., 1997).
Recent dietary guidelines recommend inclusion of two low GI foods daily or inclusion of one low GI
food at each meal or the replacement of 50% of carbohydrate with low GI choices (FAO/WHO,1998).
The diabetic diet should provide 50-60% of total calories from carbohydrates,25-35% from dietary fat
and 10-15% from protein (Alwan, 1994). Cereals and millets are prime source of carbohydrate, but a
combination of cereal,millet and pulse is found to be more effective with rich energy value, dietary fibre,
protein, minerals and vitamins than the only cerealdiet. So a combination of different low GI foods in
proper proportions, in the form of a composite meal is a better choice instead of selecting them
individually. So it is necessary to educate people about the importance of low GI foods and how to
incorporate them into the diet for the prevention and management of type 2 diabetes. One of the
limitations of following a low GI diet is a lack of acceptable low GI foods and most of the palatable foods
are high GI foods. Therefore the demand for the food industry is to produce foods that are not only
palatable and fast to prepare but also slow to digest (Jenkins, 2007). As the magnitude of type 2 diabetes
is reported high in India in both urban and rural areas,in middle income groups and among
underprivileged people and at lower BMI levels (Nanditha et al., 2016), there is a need to develop and
popularize such therapeutic dietary multigrain products with locally available low glycaemic index foods,
which are cost effective and easily accessible to the people without compromising the palatability.
With this background, the present study has been undertaken as an attempt to make use of the
therapeutic and hypoglycaemic quality of some indigenous foods in the formulation of a multi grain
product for the effective management of type 2 diabetes with the following objectives:

5. 1. To develop and standardize a low glycaemic index multigrain mix,
2. To analyze the nutrient composition and shelf life of the developed low glycaemic index multi
grain mix,
3. To evaluate the glycaemic index and sensory evaluation of the developed low glycaemic index
multigrain mix,
4. To study the effect of supplementation of the developed low glycaemic index multigrain mix on
type 2 diabetics, and
5. To assess the effect of nutrition counseling on type 2 diabetics.
*****

6. 2. Review of literature
Diabetes is now one of the most common global metabolic disorders affecting the young
adults also. Because of the drastic increase in prevalence rate, Type 2 Diabetes Mellitus has
become a high priority public health problem in the world. It is the fifth leading cause of death in
many countries. Complications from diabetes like coronary artery and peripheral vascular
disease, stroke, diabetic neuropathy, amputations, renal failure and blindness, are resulting in
increasing disability, reduced life expectancy and huge health cost for every affected individual
and the society. Diet and life style approaches for prevention and treatment of diabetes should be
given much attention equal to drug therapies. Therefore, an effective preventive and control
protocol for type 2 diabetes mellitus are inevitable in the management of the disease. The scientific
review and expert committee reports may provide a scientific guidance for clinical and self-care practice
recommendations in patient care. The scientific literature related to diabetes and its management
strategies are reviewed here in the following aspects.
2.1. Definition of diabetes mellitus,
2.2. Types of diabetes and diagnostic criteria,
2.3. Risk factors of diabetes mellitus,
2.4. Symptoms and complications of Type 2 diabetes,
2.5. Prevalence of diabetes and projections,
2.6. Management of diabetes,
2.7. Dietary management,
2.8. Effect of individual nutrient in the diet on diabetes:
2.9. Glycaemic index,
2.10. Glycaemic Load,
2.11. Low glycaemic index formulations for diabetes,
2.12. Food ingredients of the developed low glycaemic index multigrain mix,
2.13. Whole grains and diabetes,
2.14. Nutrition counseling.
2.1. Definition of diabetes mellitus:
The name diabetes mellitus has been known for centuries, which was said to derive from its
symptoms, i.e., diabetes, from the Greek diabainein, meaning “to pass through,” describes the frequent
urination, and mellitus, from the Latin meaning “sweetened with honey,” refers to sugar in the urine. It is
called as ‘Madhumeham” in the local language Telugu, in the states of Telangana and Andhra Pradesh.
World Helath Organization (WHO, 2016) defined diabetes mellitus as a chronic disease caused
by inherited or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of
the insulin produced and this deficiency results in increased concentrations of glucose in the blood, which
in turn damage many of the body's systems, in particular the blood vessels and nerves.
Diabetes is a disorder of carbohydrate metabolism characterized by impaired ability of
the body to produce or respond to insulin and maintain proper levels of glucose in the blood
(“Diabetes Mellitus”, n.d.). American Diabetes Association (ADA, 2017) defines diabetes as a
group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion,
insulinaction,orboth.

7. Indian Council of Medical Research (ICMR, 2018) defines diabetes mellitus as a syndrome of
multiple etiologies characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and
protein metabolism resulting from defects in insulin secretion, insulin action or both is often associated
withlongtermcomplications,involvingorganslikeeyes,kidneys,nerves,heartandbloodvessels.
2.2. Types of diabetes mellitus anddiagnosis criteria:
The classification and diagnosis of diabetes are complex but it is now widely accepted
that there are three main types of diabetes, type 1 diabetes, type 2 diabetes and gestational
diabetes (GDM) (IDF (2008). Type 1 diabetes was earlier called as Juvenile-onset diabetes or
insulin dependent diabetes mellitus (IDDM) and type 2 diabetes was called as maturity-onset
diabetes or non-insulin-dependent diabetes (NIDDM). The immune pathogenesis of early onset
diabetes was recognized in the 1970s, and it was acknowledged that both type 1 diabetes and
type 2 diabetes, adopted in the 1990s, are two different diseases (Diapedia, 2013).
Diabetes is diagnosed based on plasma glucose level criteria either Fasting Blood Glucose (FBG),
2 hours postprandial blood glucose (PPG), value after 75g oral glucose tolerance test (OGTT), or A1c
criteria. All the four are equally appropriate for diagnostic tests (ADA,2017).
The diagnosticcriteriafordiabetesbyWHO/IDF(2006) are given intable.1.
Table.1. DiagnosticcriteriaforType 2 diabetesmellitus*byWHO
Diabetesshouldbe diagnosedif
one or more of the following
criteriaare met
Impairedglucose tolerance (IGT)
shouldbe diagnosedif bothof
the followingcriteriaare met
Impairedfastingglucose (IFG)
shouldbe diagnosedif bothof
the followingcriteriaare met
Fastingplasmaglucose ≥7.0
mmol/L(126 mg/dL) or
Fastingplasmaglucose <7.0
mmol/L(126 mg/dL) and
Fastingplasmaglucose 6.1-6.9
mmol/L(110 to 125 mg/ dL),and
Two-hourplasmaglucose ≥11.1
mmol/L(200 mg/dL) followinga
75g oral glucose load,or
Two-hourplasmaglucose ≥7.8
11.1mmol/L (≥140 to <200
mg/dL) followinga75g oral
glucose load
Two-hourplasmaglucose
<7.8mmol/L (140mg/dL)
followinga75g oral glucose load
A randomglucose > 11.1 mmol/L
(200 mg/ dL) or HbA1c ≥ 48
mmol/mol (equivalentto6.5%)…
*Source:WHO/IDF (2006)
The diagnosticcriteriagivenbyIndianCouncil of Medical Research(ICMR,2018) for Indiansare
furnishedin table.2.
Table. 2. DiagnosticcriteriafordiabetesandprediabetesbyICMR**
Parameter Normoglycemia Prediabetes Diabetes
FBG < 110 mg/dl 110-125 mg/dl (IFG) ≥ 126 mg/dl
2- h PG < 140 mg/dl 140-199 mg/dl (IGT) ≥ 200 mg/dl
HbA1c < 5.7% 5.7-6.4% ≥ 6.5%
Randomplasma
glucose*
- - ≥ 200 mg/dl (with
symptomsof diabetes)
*Individualswithrandomplasmaglucose between140-199mg/dl are recommendedtoundergoOGTT

8. ** Source: ICMR (2018).
International Expert Committee 2009 reported that HbA1c is a widely used marker of chronic
glycaemia, reflecting average blood glucose levels over a 2 to 3 months period of time. It is widely used
as the standard biomarker for the adequacy of glycaemic management, with a threshold of ≥ 6.5%. It has
got several advantages over Fasting Blood Glucose and Postprandial Glucose because it is convenient, no
fasting is required, has got greater preanalytical stability and less day-to-day deviations during stress and
illness. But it involves greater cost,limited availability of testing facility in all places. There may be
imperfect correlation between A1c and average glucose insome individuals(ADA,2017).
2.3. Risk factors of diabetes mellitus:
The increasing prevalence of diabetes emphasizes the need for understanding various risk
factors which account for type 2 diabetes mellitus. This helps in preventing or delaying the onset
of type 2 diabetes.
Diabetes results when the beta cells of the pancreas are no longer able to meet the body’s
requirement for insulin which may be increased by obesity or other factors. (Diapedia, 2013).
WHO reported that type 2 diabetes can be determined by interplay of genetic and metabolic
factors. The factors that increase the risk are ethnicity, family history of diabetes, previous gestational
diabetes combined with older age, overweight and obesity, unhealthy diet, physical inactivity and
smoking. Higher waist circumference and higher BMI are associated with increased risk of Type 2
diabetes. (WHO, 2016 and Diapedia, 2013). Ramachandran (2005) stated that the prevalence of
diabetes is more in urban India and the scenario is occurring in rural areas also due to the socio-
economic transition. Ramachandran et al. (2010) reported that the sharp increase in the prevalence
of diabetes in South East Asia regions is observed both in urban and rural areas, which is
associated with the life style transitions towards urbanization and industrialization. This process
of rapid transition from a traditional to an affluent lifestyle is referred to as 'Coca-Colonisation.
(Diapedia, 2013). Psychological stress also is one of the risk factors for type 2 diabetes for the
present day generations with the changed life style.
2.3.1. Age and diabetes:
The risk of Type 2 diabetes mellitus increases with rising age, especially between 40 and 59 years
of age (Gupta et al., 2015) which probably due to less physical exercise, decreasing muscle mass and
gaining body weight with the increasing age. But various studies demonstrated that the adult-onset type 2
diabetes is also increasing dramatically among children, adolescents and younger adults in developed as
well as developing countries due to changed life style, high level of mental stress, consumption of diets
rich in fat and calories and sedentary life style. Htike et al. (2015) reviewed to explore the magnitude
of the evolving problem of type 2 diabetes in younger adults and challenges facing by healthcare workers
in managing this high risk group. In this review it was recognized from the literature that the age of
onset of T2DM has decreased in the last two decades and an increase in obesity along with sedentary
life style have contributed to the downward shift in age of onset of T2DM. Early detection of risk
individuals would help in preventing or postponing the onset of diabetes (Gupta et al., 2015).
2.3.2. Overweight/obesity and diabetes:
Obesity is defined simply as a condition of abnormal or excessive fat accumulation in
adipose tissue, to the extent that health may be impaired (WHO, 2014). Obesity and diabetes
mellitus have a complex relationship and several studies revealed that obese people are more

9. prone to develop type 2 diabetes mellitus. This close relationship led to the connotation ‘diabesity’,
highlighting the fact that the majority of individuals with diabetes are overweight or obese (Leitner et al.,
2017). In obese individuals, the amount of non-esterified fatty acids, glycerol, hormones, cytokines, pro-
inflammatory markers, and other substances which are involved in the development of insulin
resistance, is increased. The pathogenesis in the development of diabetes is based on the fact that the
β-isletcellsof the pancreasare impaired,causingalack of control of bloodglucose (Al-Goblan ., 2014).
Quetelet Index or BMI provides most useful measure of overweight and obesity for both the
genders and for all ages of adults. The article on three decades of research on epidemiology of
diabetes in India by Ramachandran et al. (2014) stated that Indians have a genetic phenotype
characterized by low BMI with high upper body adiposity, high body fat percentage and high
level of insulin resistance. Weight reduction is one of the important therapeutic goals of disease
management for obese diabetics. The classification of BMI according to both WHO and Indian
criteria is given in table.3.
Table.3. Classification of BMI as per WHO and Indian standards
WHO criteria
(BMI kg/m2
)*
BMI Category Indian criteria
(BMI kg/m2
)**
< 18.5 Underweight < 18.5
18.5-24.99 Normal 18.5-22.99
25-29.99 Overweight 23-24.99
≥30 Obesity ≥25
(* WHO, 2000) (**Misra et al., 2009)
Broca’s index isthe easiestmethodtocalculate the ideal bodyweightforheightwhichis
determinedasHeight(incm) – 100. Mundodanet al.(2019) studiedtoidentifynormal range forBroca’s
index thatcorrespondstothe normal range for BMI andto determine the predictiveaccuracyforcut-off
pointsthusobtained.The studyobservedthatBroca’sindex ratiohadstrong correlationwiththe BMI
value andit wasconcludedthatthe individualscanbe advisedontheirideal weight(asperBroca’s
index),withthe upperlimitbeingaround5% lessthanthe calculatedvalue.
The elevated waist circumference with more than 80 cm for women and more than 94 cm for men
in the Caucasian population also shows the accumulation of abdominal fat which may lead to non-
communicable diseases like type 2 diabetes, CVD and stroke (Leitner et al., 2017). Abdominal fat is
considered more lipolytic than subcutaneous fat, and it does not respond easily to the antilipolytic action
of insulin, which causes insulin resistance,and thus type 2diabetes (Al-Goblan ., 2014).
2.3.3. Familyhistory of diabetes:
In the Inter Act case-cohort study, Scott et al. (2012) investigated the association of family
history of diabetes among different family members with incidence of T2D and the extent to which
genetic, anthropometric and lifestyle risk factors mediated this association. It was concluded that family
history remains a strong, independent and easily assessed risk factor for Type 2 diabetes mellitus and

10. prominent lifestyle, anthropometric and genetic risk factors explained only a marginal proportion of the
family history-associated excess risk.
Ramachandran and Snehalatha (2009) mentioned that nearly 75percent of type 2 diabetes patients
in India have first degree family history, indicating a strong familial aggregation in the population.
Sakurai et al. (2013) in a cohort study among 3,517 middle aged men and women
Japanese participants, investigated the relationship between family history of diabetes, the
incident risk of type 2 diabetes and the interaction of these variables with other factors. It was
found that family history of diabetes was associated with the incident risk of diabetes, and these
associations are independent of other risk factors, such as obesity, insulin resistance, and lifestyle
factors in men and women.
Bener et al. (2013) in a cross sectional study, observed the parental transmission of type 2
diabetes mellitus in a highly endogamous population and evaluated its influence on the clinical
characteristics. It was found that the prevalence of diabetes was higher among patients with
a diabetic mother and maternal aunts or uncles when compared to that with a diabetic father
and paternal aunts or uncles. The family history of diabetes mellitus was higher in patients of
consanguineous parents (38.5%) than those of non-consanguineous parents (30.2%). The
development of complications of type 2 diabetes mellitus was higher in patients with either a
paternal or maternal history of diabetes.
Shankar (2016) in a study conducted on 5,444 residents of Dilshad Garden in east Delhi to
understand the socio-economic and demographic factors among patients of Type 2 diabetes mellitus. The
study noted that the prevalence was significantly higher in joint families than in nuclear families.
2.3.4. Personalhabits and diabetes:
The personal habits including the food habits, tobacco usage and alcohol consumption show little
or more effect on onset and management of type 2 diabetes mellitus.
Food habits play an important role in maintaining the blood sugar levels. Healthy eating habits
keep the blood glucose level under control and prevent diabetes complications. Various experimental
studies have proven that vegetarian diet reduces the risk of diabetes. The prevalence of type 2 diabetes
among the vegetarians was compared to that among the non-vegetarians in a hospital-based survey by
Sarwar et al. (2010) among 724 people in the Bijapur district of Karnataka. The study showed that the
BMI is high (29.2 kg/m2
) among the non-vegetarians when compared to that of vegetarians and the
prevalence of diabetes is high among the non-vegetarians.
Various observational studies demonstrated that personal habits like smoking and alcohol
consumption aggravate the disease condition. WHO (2016) reported that active smoking increases
the risk of type 2 diabetes with the highest risk among heavy smokers. Chang (2012) in a review
about the various smoking effects on diabetes mellitus, diabetic complications, and diabetic incidence,
reported that smoking has harmful effects on patients with diabetes and it increases diabetic incidence and
aggravates glucose homeostasis and chronic diabetic complications. In microvascular complications, the
onset and progression of diabetic nephropathy is highly associated with smoking and in macrovascular
complications, smoking is associated with a 2 to 3 times higher incidence of CHD and mortality.
Alcohol consumption, another habit people get addicted to, is considered as a potential
risk factor for the type 2 diabetes, as it influences glucose metabolism in several ways. ICMR
(2018) recommended to avoid alcohol as far as possible and if used, should be taken in

11. moderation without considering it as part of the meal plan. Alcohol provides calories (7 kcal/ g),
which are considered as “empty calories” and in fasting state, alcohol may produce
hypoglycaemia.
A review by Engler et al. (2013) on effect of alcohol consumption by diabetics reported
that self-care adherence is negatively impacted by alcohol use and also negatively alters diabetes
course leading to increased morbidity and mortality.
2.3.5. Lipid profile and diabetes:
Dyslipidemia and hypertension are major modifiable risk factors for type 2 diabetes
mellitus among the Caucasian population and Asian Indians. Lipid abnormalities in patients with
type 2 diabetes, often termed “diabetic dyslipidemia”, are characterized by high total cholesterol,
high triglycerides, low high density lipoprotein cholesterol (HDL-C) and increased levels of Low
density lipoprotein cholesterol (LDL-C). This may cause an increase in the risk of developing
cardiovascular disease in type 2 diabetics. The insulin resistance or deficiency affects the key
enzymes and pathways in lipid metabolism which causes lipid abnormalities in type 2 diabetes
mellitus. In diabetes the associated hyperglycemia, obesity and insulin changes highly accelerate
the progression to atherosclerosis (Bhowmik et al., 2018). The storage of triglycerides in nonadipose
tissues is called ectopic fat storage which is associated with insulin resistance in obese patients with type
2 diabetes mellitus. The mechanisms of ectopic fat depositions in the liver, skeletal muscle, and in and
around the heart, its consequences and the effects of diet and exercise on ectopic fat depositions were
reviewed by Snel et al. (2012)
2.3.6. Occupationanddiabetes:
The literature on the association between occupation of the patient and diabetes is limited where
statistically significant outcomes were found. It depends on the factors like the nature of work, the
physical activity and the stress involved in the work. Work-related stress is thought to be a major risk
factor for type 2 diabetes.
Heden et al. (2014) conducted a study to assess whether low occupational class was an
independent predictor of Type 2 diabetes in men in Sweden over a 35-year follow-up, after adjustment for
both conventional risk factors and psychological stress. It was found that men with unskilled and semi-
skilled manual occupations had a significantly higher risk of diabetes than higher officials. The study
concluded that a low occupational class suggests a greater risk of Type 2 diabetes, independently of
conventional risk factors and psychological stress.
A collaborative study undertaken by Solja et al. (2014) examined whether stress at work, defined
as job strain, is associated with incident of type 2 diabetes independent of lifestyle factors and the findings
from this large pan-European data-set suggested that job strain is a risk factor for type 2 diabetes in men
and women independent of lifestyle factors.
2.4. Symptoms and complications of type 2 diabetes:

12. Apart from the classic symptoms polyuria, polydypsia and polyphagia, the other common
symptoms of type 2 diabetes mellitus are extreme fatigue, blurred vision, weight loss, lack of
interest, recurring infections, slow healing of wounds, tingling, pain, or numbness in the hands or
feet, skin problems and sexual problems (ADA, 2016). Hyperglycaemia is the common effect of
uncontrolled diabetes, and over time can damage the heart, blood vessels, eyes, kidneys, and
nerves (WHO, 2016). Early detection and treatment of diabetes can decrease the risk of
developing long term complications like diabetic neuropathy, nephropathy and retinopathy.
Acute complications like hypoglycaemia and ketoacidosis are also common which are to be
attended to immediately. Dyslipidaemia is also common which increases the risk of heart disease
and stroke in type 2 diabetes. With high levels of serum cholesterol and triglycerides, 50 percent
of people with diabetes die of cardiovascular disease (WHO, 2016).
2.5. Prevalence ofdiabetes and projections:
1. Global prevalence
2. Indian scenario
2.5.1. Globalprevalence:
According to IDF, the current data on global prevalence of diabetes revealed that, in 2019 it is
estimated to be 9.3 percent (463 million people), rising to 10.2 percent (578 million) by 2030 and 10.9
percent (700 million) by 2045 (Saeedi et al., 2019).
The information by WHO (2018) revealed that the number of people with diabetes had
increased from 108 million in 1980 to 422 million in 2014. The global prevalence of diabetes among
adults above 18 years of age had increased from 4.7 percent in 1980 to 8.5 percent in 2014. It reports that
the prevalence of diabetes is increasing rapidly in middle and low income countries. According to WHO,
in 2016, an estimated 1.6 million deaths were directly caused by diabetes and another 2.2 million deaths
were attributed to high blood glucose level in 2012. It was projected by WHO that diabetes will be the 7th
leading cause of death in 2030 and the deaths due to high blood glucose levels occur before the age of 70
years.
International Diabetes Federation (IDF) has been giving data on the prevalence of diabetes and
the projections nationally, regionally and globally, since the year 2000. The worldwide and South East
Asian region which is consisting of India, Srilanka, Bangladesh, Bhutan, Mauritius and Maldives,
data on prevalence and projections for a decade from 2009 to 2018 are shown in Table.4. It was estimated
that in 2009 the global prevalence of diabetes was 285 million, increasing to 366 million in 2011, 382
million in 2013, 415 million in 2015 and 425 million in 2017 (Saeedi et al., 2019).
The figures in the table.4.are showing that, every year the projections had been increasing, based
on the current data and this information gives a conclusion that the rate of prevalence of diabetes is
rapidly increasing. This presents a huge social, financial and health care burden across the world.
Table.4. Global and South East Asian (SEA) prevalence and Prediction of diabetes (in Millions) for a
decade from the year 2009-2018*
Period Worldwide South East Asian
Prevalence Prediction-year prevalence Prediction-year
2009-10 285 438 (2030) 58 101 (2030)
2011-12 366 552 (2030) 71 120 (2030)

13. 2013-14 382 592 (2035) 72 123 (2035)
2015-16 415 642 (2040) 78 140 (2040)
2017-18 425 693 (2045) 82 151 (2045)
*Source IDF Atlas
Figure.1. Worldwide actuals and projections of prevalence of diabetes during a decade (2009-2019)
Figure.1 shows that the actualprevalence (451 million) of diabetes during 2017-18 had crossed
the projections made (438 million) for 2030 in the year 2009, which shows the rapid increase in the
prevalence rate of diabetes worldwide.
The prevalence of diabetes and the number of people of all ages with diabetes for years 2000 and
2030 was estimated by Wild et al. (2004) and reported the prevalence of diabetes for all age-groups
worldwide was estimated to be 2.8 percent in 2000 and 4.4 percent in 2030. It was also reported that
India, China and United Stated of America are the ‘top three’ countries identified with high prevalence of
diabetes. The analysis presented that globally the prevalence of diabetes is similar in men and women but
slightly higher in men less than 60 years of age and in women at older ages. The analysis also reported
that urban population in developing countries is projected to double between 2000 and 2030 and the most
important demographic change to diabetes prevalence across the world appears to be the increase in the
proportion of people above 65 years of age.
Shaw et al. (2010) carried out a meta analysis to estimate the age and sex specific diabetes
prevalence worldwide for all 216 countries for the years 2010-2030 by considering studies from 91
countries, based on WHO and ADA,for age group 20-79 years range. The results revealed that the world
prevalence of diabetes among adults will be 6.4 percent, affecting 285 million adults in 2010 and will
increase to 7.7 percent affecting 439 million adults in 2030, with an increase of 69 percent in number of
adults with diabetes in developing countries and a 2 percent increase in developed countries.
Whiting et al. (2011) reported in an analysis on global estimates of prevalence of diabetes for
2011-2030 from IDF diabetes atlas, considering total 565 data sources that in 2011 there were 366 million
people with diabetes and is expected to rise to 552 million by 2030.
285
366 382
415
451
438
552
592
642
693
2009-10 2011-12 2013-14 2015-16 2017-18
Worldwide actuals and projections in
millions Actuals Projections

14. Ramachandran et al. (2014) reported that 95 percent of people with diabetes have type 2
diabetes mellitus. According to a meta analysis by Nanditha et al. (2016) more than 80 percent of
the people live with type 2 diabetes in the developing countries and the rise in T2DM in South
Asia is estimated to be more than 150 percent between 2000 and 2035. The meta analysis also
stated that out of 60 percent people living with diabetes in Asia, one half contributes from China
and India combined.
Nordstrom et al. (2016) in a study investigated the associations between body fat estimates,
plasma glucose level and the prevalence of diabetes in elderly men and women in relation to
objectively assessed visceral fat volume on a population-based sample of 705 men and 688 women,
all age 70 years. It was found that the higher prevalence of type 2 diabetes in older men (14.6%)
than in older women (9.1%) was associated with larger amount of visceral fat in men.
In another meta analysis from 540 data sources on global estimates for the prevalence of diabetes
for 2015-2040 from IDF diabetes atlas seventh edition, Ogurtsova et al. (2017) reported that in 2015,
about 415 million people aged 20-79 years were with diabetes and predicted to rise to 642 million by
2040. The study also stated that 75 percent of those with diabetes were living in low and middle income
countries. The prevalence of diabetes for South East Asia was reported as 78.3 million in the year 2015
and predicted to rise to 140.2 million in 2040. In the year 2015, about 5.0 million deaths were attributed
to diabetes.
Cho et al. (2017) reported from the IDF diabetes atlas that in 2017 it was estimated that almost
half of all people (49.7%) living with diabetes are undiagnosed. There was an estimated 374 million
people with impaired glucose tolerance (IGT) and it was projected that about 21.3 million live births to
women were affected by some form of hyperglycaemia in pregnancy. In 2017, approximately 5 million
deaths worldwide were attributable to diabetes in the age group of 20-99 years and the global healthcare
expenditure on people with diabetes was estimated to be USD 850 billion.
According to the International Diabetes Federation (IDF, 2018) the figures showed that India
was in the second position worldwide with 72.9 million people with diabetes in 2017 and China was in
top position with 114.4 million. But it is predicted that India may surpass China with 134.3 million people
and reach the top position globally by 2045, leaving China to the second position with 119.8 million.
2.5.2. Indian Scenario:
It is very alarming to know the increasing trend in the prevalence of type 2 diabetes among the
Indian population. In India the first national study on the prevalence of type 2 diabetes was done between
1972 and 1975 by the Indian Council Medical Research (ICMR) and the prevalence among the
individuals above 14 years of age was 2.1 percent in urban population and 1.5 percent in the rural
population while in individuals above 40 years of age, the prevalence was 5 percent in urban and 2.8
percent in rural areas (Mohan et al., 2007).
Purty et al. (2009) stated that according to the population studies, the prevalence had
risen five-fold from 2.1 percent in 1975 to 12.1 percent in 2000. The study furnished the
prevalence rate of diabetes of different surveys as, CURES (Chennai Urban Rural Epidemiology
Study) (age standardized prevalence rate)-14.3 percent, CUPS (Chennai Urban Population

15. Study) (age standardized) -9.3 percent. The overall prevalence in CUPS was 12 percent, in
ADEPS (Amrita diabetes and Endocrine Population Study) from Kerala was 9 percent and a
study from Kashmir showed 1.9 percent.
Ramachandran et al. (2001) illustrated that according to the national urban diabetes
survey (NUDS), the prevalence of diabetes is high in urban India and a large pool of subjects
with impaired glucose tolerance are at high risk of conversion to diabetes.
Reddy et al (2002) reported that there was 24 percent prevalence of diabetes in Andhra
Pradesh (joint state) and 28 percent hypertension on assessing a unique sample of 3307 in Andhra
Pradesh.
Mohan et al. (2007) reported that in the National Urban Diabetes Survey (NUDS),a population
based study conducted in six metropolitan cities across India recruiting 11,216 subjects aged 20 years and
above representative of all socio-economic strata, that the prevalence of type 2 diabetes was 12.1 percent.
This study also revealed that the prevalence in the Southern part of India to be higher with 13.5 percent in
Chennai, 12.4 percent in Bangalore and 16.6 percent in Hyderabad,compared to Eastern India (Kolkatta)
11.7 percent, Northern India (New Delhi) 11.6 percent and Western India (Mumbai), 9.3 percent.
Anjana et al. (2011) reported that India would be 62.4 million people with diabetes and
77.2 million people with prediabetes. The studies also reported from the results of the first phase
of national study ICMR-INDIAB (2008-2011) to determine the prevalence of diabetes and
prediabetes in three states and one union territory of India that the prevalence of diabetes in
Tamilnadu was 10.4 percent, Maharashtra-8.4 percent, Jarkhand-5.3 percent and Chandigarh
13.6 percent. The prevalence of prediabetes was reported as 8.3 percent in Tamilnadu, 12.85
percent in Maharashtra, 8.15 percent in Jarkhand and 14.6 percent in Chandigarh.
Anjana et al. (2015) presented the incidence of diabetes and prediabetes and the
predictors of progression in a population based Asian Indian cohort in an article on 10 years
follow-up of the Chennai Urban Rural Epidemiology Study (CURES) and concluded that Asian
Indians have one of the highest incidence rates of diabetes with rapid conversion from
normoglycaemia to dysglycaemia.
According to IDF (2015) reports, Indian had 69.1 million cases of diabetes in 2015, with
8.7 percent adults (20-79 years). According to a meta analysis by Nanditha et al. (2016) India has
more than 65.1 million people with diabetes, occupying the second position next to China in the
IDF global list of top 10 countries for people with diabetes and also mentioned that occurrence of
type 2 diabetes at a younger age is observed among South Asians. ICMR (2018) reports that as per the
International Diabetes Federation (IDF) estimates, there were 72.9 million people with diabetes
in India in 2017, which is projected to rise to 134.3 million by the year 2045. The prevalence of
diabetes in urban India, especially in large metropolitan cities has increased from 2 percent in the
1970s to over 20 percent at present and the rural areas are also fast catching up.
2.6. Managementofdiabetes:
Diabetes cannot be cured completely, but it is to be managed with proper diet, physical
activity and healthy life style along with the medication prescribed by the physician for leading a

16. healthy normal life. American Diabetes Association suggested that early detection and
hypoglycaemic medication are considered as the primary care for the type 2 diabetes patients.
Literature related to the dietary management and the role of physical exercise and nutrition
counseling in the management of diabetes is presented in the following text.
2.7. Dietary management:
The diabetes diet generally is planned with unnecessary restrictions, inclusion of certain
monotonous food items such as roti for rice eaters, ragi porridge etc., which might be due to
misconceptions, unawareness of the disease and role of diet in its management. In contrast, over
enthusiasm among the literates about the dietary management of diabetes is leading to
unnecessary confusion in the choice of foods and diet plans. This results in either over-nutrition
or under-nutrition of the diabetics. Any restriction on food for a patient will have negative effect
on the psychological aspects of the patient so it is necessary to bring awareness among the
people with type 2 diabetes about their diet for better choice of food. In India any modification
in diet should consider the regional influences on lifestyle, diversity in culinary practices,
economic issues and local cultivation considerations to improve the acceptance among people
with Type 2 Diabetes. The evidence based literature on the role of diet in the management of
diabetes and various dietary approaches to reach the primary goal of achieving normal blood
glucose levels and to promote overall nutritional well being is furnished in the following text.
Before planning a diet, it is necessary to set the goals of planning a diet for people with
type 2 diabetes. The goals of nutrition therapy for type 2 diabetic patients set by American
Diabetes Association id presented in table.5..
Table.5. Goals of nutrition therapy for type 2 diabetes mellitus* as per American Diabetes
Association
S.No Biochemical parameter Goal
1 HbA1c <7%
2 Blood pressure <140/80mmHg
3 LDL-C <100 mg/DL
4 Triglycerides <150 mg/DL
5
HDL-C
>40 mg/Dl for Men
6 >50 mg/Dl foe women
*American Diabetes Association.
ICMR had suggestedtargetsformetaboliccontrol indiabetesforAsianIndiansinthe guidelinesfor
diabetes,whichmayslightlydifferfromthatof international targets.The ideal targetssuggestedby
ICMR for AsianIndiandiabeticsforthe managementof type 2 diabetesare shownintable.6.
Table.6. Ideal targetsfor the managementof diabetesforIndiansbyICMR*
S.No Parameter Ideal target
1 FastingPlasmaGlucose (mg/dl) 80 -110
2 2 hourPostprandial Glucose (mg/dl) 120 – 140
3 Bloodpressure (mmHg) < 130/80

17. *Source ICMR (2018).
Bhupathiraju et al. (2014) on discussing the results of a large US cohort and an updated meta
analyses on well designed RCTs as the diabetic prevention programmes observed that following a healthy
dietary pattern along with life style modification are as effective as or even better than pharmacologic
interventions in preventing type 2 diabetes. Existing guidelines of WHO (2016) for dietary management
of type 2 diabetes recommended a lower calorie intake for overweight and obese patients, and replacing
saturated fats with unsaturated fats,intake of dietary fibre equal to or higher than that recommended for
the generalpopulation and avoiding added sugars, tobacco use and excessive use of alcohol. Education of
patients in groups is a cost-effective strategy.
Kam et al. (2016) in a review on dietary interventions for type 2 diabetes explained the
importance of intervention of diet for diabetics, as to control the fluctuation of blood glucose
which causes various health complications.
2.8. Effectof individual nutrient in the diet on diabetes:
The chemical composition of foods (eg., fat, sugars, dietary fibre content) should be an
important factor influencing food choice, but simply knowing the chemical nature of the
carbohydrate in foods does not indicate their actual physiological effect (FAO/WHO, 1998).The
effect of each nutrient in the diet of a diabetes patient on glycaemic control is discussed further.
2.8.1. Energy:
Various studies explained the pathophysiology as the gradual accumulation of fat in pancreas
affects the functioning of beta cells and results in type 2 diabetes. Weight loss may not be the goal for
every diabetic but reducing the calorie intake may rectify the resulting hyperglycaemia.
A review by Asif (2014) on prevention and control of the type 2 diabetes by changing life
style and dietary pattern, mentioned the following recommended daily energy intake (Kcal/day)
for diabetics:
a) Non-obese diabetic-Between 1500-2500, average allowance 2000 Kcal/day
b) Overweight diabetic-between 800-1500,
c) Under weight diabetics- at least 2500 (including growing children and adolescents).
Various studies have reported that the distribution of total calories from macro nutrients is also to
be considered while planning a diet for people with type 2 diabetes. ADA (2015) reported that
according to various studies, type 2 diabetic people eat on an average 45 percent of calories from
carbohydrates, 36-40 percent from fat and 16-18 percent from protein. There are numerous
4 BodyMass Index (kg/m2) 20 – 23
5
Waistcircumference (cms)
Men < 90
Women< 80
6 GlycatedHaemoglobin(HbAlc])(%) < 7
7 Total Cholesterol (mg/dl) < 200
8
HDL Cholesterol (mg/dl)
> 40 formen
> 50 forwomen
9 LDL Cholesterol (mg/dl) < 100
10 Non-HDLCholesterol(mg/dl) < 130
11 Triglycerides(mg/dl) < 150

18. international guidelines available for the management of Type 2 Diabetes, but following the
country-specific guidelines will show better treatment outcomes in diabetes. The
recommendations by Research Society for the Study of Diabetes in India (RSSDI) and Indian Council
of Medical Research (ICMR) for medical nutritional therapy (MNT) in India for the management of type
2 diabetes mellitus are shown in brief in table.7 (Viswanathan et al., 2019).
Table.7. Recommendations for Medical Nutritional Therapy in India for type 2 diabetes mellitus.
S.No Nutrient RSSDI ICMR
1 carbohydrates 45–65% of total daily
calories (minimum intake:
130 g/day)
55–60% of total daily
calories.
2 Fibre High fiber diet: increased
intake of soluble and
insoluble fibers
Intake of fiber-rich
foods
3 Protein Recommended intake:
10–15% of total daily
calories
Recommended intake:
10–15% of total daily
calories
4 Fat Recommended calorie
intake: no specified ideal
intake
Recommended calorie
intake: 20–25% total
daily calories
5 Sugars Reduced intake of refined
sugars
Avoidance of sugar,
honey, jiggery
Fig. 2. Distribution of calories recommendedby RSSDI
cho
65%
pro
15%
fat
20%
Distribution of calories as-RSSDI

19. Fig. 3. Distribution of calories recommendedby ICMR
Figures.2 and 3 are showing the distribution of calories from the macronutrients
recommended by RSSDI and ICMR respectively.
2.8.2. Carbohydrate:
Several studies have reported that insulin needs are more closely correlated with the
carbohydrate intake than with the total calorie intake. Studies support to have most complex
carbohydrates in the form of polysaccharides like whole grains than rapidly absorbed mono and
disaccharides like sugars for type 2 diabetics. ADA reported that the total amount of
carbohydrate in meals and snacks will be more important than the source or the type, as a
number of factors influence glycemic responses to foods, including the amount of carbohydrate,
type of sugar (glucose, fructose, sucrose, lactose), nature of the starch (amylose, amylopectin,
resistant starch), cooking and food processing (degree of starch gelantinization, particle size)
food form, and other food components (fat and natural substances). Sahay (2012) mentioned that
carbohydrate content of the diet has to provide 50-60 percent of the calories and most of this is to
be in the form of complex carbohydrates with a high fiber content and low glycemic index.
All carbohydrate containing food items do not raise blood glucose to a similar extent
within the same period of time and quantification of these differences has been lead to
introduction of concept of glycemic index by Jenkins et al. (1981). While reviewing the selected
dietary approaches as interventions for the prevention and management of type 2 diabetes, Maki
and Phillips (2015) reported that the dietary carbohydrate is the primary nutrient that influences
postprandial blood glucose and insulin secretion and Glycaemic Index is a tool which allows for
the quantification of the postprandial blood glucose response to dietary carbohydrate from foods.
2.8.3. Protein:
carbohydrates
60%
Protein
15%
fat
25%
Distribution of calorires-ICMR

20. Protein is another important component of dietary strategies for type 2 diabetics and
various clinical trials reported that amino acid leucine has some positive influence on diabetic
patients. Protein intake of 0.8mg/kg is recommended, so as to contribute to 12-20 percent of the
calories. Vegetable proteins are preferable due to their high fiber content and absence of
saturated fat which is present in animal proteins (Sahay, 2012).
In a review, Venn and Green (2007) mentioned that combining foods does influence GI
and addition of protein and fat to a carbohydrate containing meal can reduce the glycaemic
response. The article on dietary substitution for refined carbohydrate for reducing risk of type 2
diabetes by Maki and Phillips (2015) illustrated that low GI and high protein was associated
with less weight gain, when compared with low protein -low GI, low protein-high GI and high
protein-high GI diets.
Kam et al. (2016) mentioned in a review that protein influences the rate of starch
digestion and can improve postprandial glycaemia in type 2 diabetics. ICMR (2018) suggested
the supplementation of foods like cereal and pulse in 4:1 ratio, e.g. idli,dosa, Missi roti, Khichdi,
Dhokla, Khandvi etc., improves the protein quality and also gives satiety.
2.8.4. Fats in the diet:
Fats are essential part of healthy diet but problem arises when consumed in excess,
especially in diabetic patients, there is a risk of blocking of vessels. ICMR (2018) recommended
that fats should provide 20-30 percent of total energy intake for people with diabetes. Goals
should be individualized as evidence is inconclusive for an ideal quantity of total fat intake for
people with diabetes and quality of fat is as important as the quantity.
The findings of a study by Frost et al. (1999) revealed that the GI of a diet is a stronger
predictor of serum HDL-C concentration than dietary fat intake. Sahay (2012) mentioned that fat
content of the diet should be 20-25 percent of the total calories distributed in the ratio of 1:1:1
among saturated fatty acids, mono unsaturated fatty acids (MUFA) and polyunsaturated fatty
acids (PUFA) for diabetics in India.
2.8.5. Fibre content in the diet:
The total dietary fibre (TDF) includes soluble dietary fibre (SDF) and insoluble dietary
fibre (IDF). The plant foods contribute to dietary fibre requirements in the diet but individual
intake is influenced by the nature of source, maturity moisture, proportion in the diet and mode
of processing and preparation of the foods. Various experimental studies revealed that high
dietary fibre in the diet can reduce blood glucose levels, serum cholesterol, avoid constipation
and makes the food low GI. This was supported by a study by Chandalia et al. (2000) that an
increase in the intake of dietary fibre (soluble type) by Type 2 diabetes patients improved
glycaemic control and decreased hyperinsulinaemia in addition to expected lowering of plasma
lipid concentration. The study also suggested that guidelines for patients with diabetes should
increase dietary fibre through the consumption of unfortified foods rather than the use of fibre
supplements. In contrary, the Meta analysis by Wheeler et al. (2012) on macro nutrients, food
groups and eating patterns in the management of diabetes, summarized that the majority of the
reviewed evidence indicated that adding fibre supplement in moderate amounts (4-19 g) to a
daily diet will show little improvement in glycaemia and CVD risk factors.

21. A study was conducted by Jenkins et al. (1982) to observe the relationship between rate
of digestion of foods and postprandial glycaemia. The in vitro study showed a significant
relationship between the glycaemic index and the food fibre content and between the GI and
glucose tapping capacity of foods. It was found that legumes as a group liberated 56 percent less
sugars and oligosaccharides than the 8 cereal foods over 5 hours.
Chandalia et al. (2000) compared the effects of two diets, one with foods containing
moderate amount of fibre (total 24 g with 8 g soluble and 16 g insoluble) and another diet with
high fibre (total 50 g with 25 g soluble and 25 g insoluble) foods on glycaemic control and
plasma lipid concentrations. It was concluded that a high intake of dietary fibre particularly of
soluble type improves glycaemic control, decreases hyperinsulinaemia and lowers plasma lipid
concentrations in patients with Type 2 Diabetes mellitus.
A cohort study by Schulze et al. (2004) with 91,249 young women, to examine the
association between GI, GL and dietary fibre and the risk of Type 2 diabetes, concluded that a
diet high in rapidly absorbed carbohydrates and low in cereal fibre is associated with an
increased risk of type 2 diabetes.
In a meta analysis by Post et al. (2012) reviewed the studies on the effect of
supplementation of 15 g/day dosage of fibre in the diet on HbA1c and FBG in patients with type
2 diabetes and found that there was statistically significant improvement in FBG and HbA1c. It
was stated that the fibre content decreases the glycaemic index of food; the decreased GI would
lead to smaller increases in blood glucose and thus reduced blood glucose and HbA1c.
A review on dietary approaches for the prevention and control of type 2 diabetes by Maki
and Phillips (2015) reported that in the Nurse’s health study, women aged 45-60 years the
combination of high GL and low cereal fibre intake produced a greater risk of type 2 diabetes
when compared with participants in both the low GL and the highest cereal fibre. It was reported
that the mechanism by which fibre decreases the risk of Type 2 diabetes might be a result of
colonic fermentation, short chain fatty acid production and effect of these fatty acids on insulin
sensitivity.
2.8.6. Calcium:
Abnormalities related to calcium are common in adult patients with type 2 diabetes.
Insulin secretion is said to be a calcium dependent process and alterations in calcium flux may
affect the insulin secretion.
Pittas e al. (2007) in a review on role of altered vitamin D and calcium homeostasis in the
development of type 2 diabetes stated from the overall evidence that vitamin D alone probably has no
effect in healthy individuals, but combined vitamin D and calcium supplementation may have a role in the
prevention of Type 2 diabetes mellitus especially in populations those with glucose intolerance. The
vitamin D and calcium deficiency influences post-prandial glycemia and insulin response while
supplementation may be beneficial in optimizing these processes. In relation to calcium intake for type 2
diabetes, the evidence suggested that intakes above 600 mg/day are desirable but intakes above 1200 mg
may be optimal.

22. 2.9. Glycaemic index (GI):
There is a dietary notion that carbohydrate-rich foods have deleterious health effects in
type 2 diabetics and so the consumption should be limited. But several evidence-based studies
have demonstrated that not all carbohydrates are equal and the variations in the physiochemical
properties of complex carbohydrates have been shown to elicit different physiological effects
when consumed. Perlstein et al. (1997) while reviewing the Glycaemic Index in diabetes
management explained the history of GI that, from as long ago as 1550 BC, carbohydrate has
been the main focus of diabetes nutrition management. Since 1930-the scientists have challenged
simple and complex carbohydrates, in 1970- examined the glycaemic impact of range of
carbohydrate containing foods and in 1981- Jenkins et al. (1981) proposed the Glycaemic Index,
initially as a tool for the dietary management of type 1diabetes and later dyslipidaemia. The
scientific literature on GI in relation to dietary management of type 2 diabetes is discussed with
the following sub-headings.
1. Definition of GI,
2. Role of low GI in diabetes diet,
3. Methodology of Calculating GI of foods,
4. Factors affecting GI,
5. Limitations of GI,
6. Suggestions on GI.
2.9.1. Definitionof GI:
The Glycemic Index (GI) is a relative ranking of carbohydrate in foods according to how
they affect blood glucose levels. According to Perlstein et al.(1997) GI is a system of classifying
foods which contain carbohydrate, based on their glycaemic response with the review that the
slower flatter response may facilitate better glycaemic control and lipid profiles in people with
diabetes. The GI is defined as the “incremental area under the blood glucose response curve of a
50 g carbohydrate portion of a test food expressed as percent of the response to the same amount
of carbohydrate from a standard food taken by the same subject” (FAO/WHO, 1998).
ADA defined that it measures how a carbohydrate-containing food raises blood glucose.
Glycaemic index values are grouped into three categories viz., low GI (GI < 55), medium GI (GI
56-69) and high GI (GI >70) (FAO/WHO, 1998) Foods containing carbohydrates that are
quickly digested have the highest glycemic index since the blood sugar response is fast and high.
Slowly digested carbohydrates have a low glycemic index, since they release glucose gradually
into the bloodstream (Brand-Miller et al., 2003). Good scientific evidence is available to suggest
that low GI foods may help to control blood glucose levels and minimize fluctuations in blood
glucose levels for people with Type 2 diabetes, which can help reduce the risk of complications
of diabetes such as heart and kidney problems.
2.9.2. Role ofLow GI in the diabetes diet:
In 1997 a committee of experts was brought together by FAO and WHO to review the
importance of carbohydrate in human nutrition and health. The committee endorsed the use of
the GI method for classifying carbohydrate rich foods and recommended that the GI values of
foods be used in conjunction with information about food composition to guide food choices

23. (Foster-Powel et al., 2002). But in choosing the foods, both GI and food composition must be
considered. Some low GI foods may not always be good because they are high in fat.
Conversely some high GI foods may be a good choice because of convenience or because they
have low energy and high nutrient content (FAO/WHO, 1998). Insulin sensitivity and
concentrations of HDL-Cholesterol, the two metabolic predictors of CHD are influenced by diet.
Dietary carbohydrate with high GI cause a high postprandial glycaemia and insulin response and
are associate with decreased insulin sensitivity and an increased risk of CHD. (Frost et al., 1999).
Brand et al. (1991) compared a low GI diet (eg., porridge, pastas) with a high diet (eg.,
processed cereals and potatoes) on 16 subjects in the treatment of NIDDM (Type 2 diabetics).
The GI of low GI diet was 15 percent lower than that of high GI diet in the study. Results
showed that the glycaemic control was improved on the low GI diet compared with high diet. It
was concluded that low GI diet gives a modest improvement in long term glycaemic control but
not plasma lipids in normolipidaemic well controlled subjects with NIDDM.
The glycaemic index was considered as the beginners’ guide by some researchers.But GI has
proven to be a more nutritional concept than is the chemical classification of carbohydrate (as
simple, complex or sugars or starches or as available or unavailable) permitting new insights into
the relation between physiological effects of carbohydrate rich foods and health (Foster-Powel et
al., 2002). Brand-Miller et al. (2003) opined that low GI dietary advice seems to improve
glycemic control same as newer pharmacological agents which gives patients a choice as well as
reduces the size of the health care burden.
The GI is useful to rank foods by developing exchange lists of categories of low GI foods
such as legumes, pearled barley, lightly refined grains (e.g, whole grain pumpernickel bread or
breads made from coarse flour) pasta etc (FAO/WHO, 1998). In a meta analysis by Bjorck et al.
(2000) on low GI foods, it was indicated that certain low GI breakfasts, capable of maintaining a
net increment in blood glucose and insulin at the time of the next meal, reduced postprandial
glycaemia and insulinaemia significantly following a standardized lunch meal, where as others
had no second meal impact.
Venter (2005) in an editorial mentioned that, clinical trials have shown that low GI diets
improve glycaemic control in diabetes, increase insulin sensitivity and beta cell function, reduce
food intake and body weight, influence memory and may improve blood lipids. The hypothesis
for the underlying mechanism of action that leads to low GI foods is that the carbohydrate in
those foods is absorbed slowly (Jenkins, 2007).
Jenkins et al. (2008) conducted a study to test the effects of low GI diets on glycaemic
control and cardio vascular risk factors in Type 2 Diabetes patients and concluded that 6
months treatment with a low GI diet resulted in moderately lower HbA1C levels compare with a
high cereal fibre diet.
A meta analysis of RCTs was performed by Brand Miller et al. (2003) to determine
whether low GI diets compared with conventional or high GI diets, improve overall glycaemic
control in individuals with diabetes. The results showed that low GI diets reduced HbA1c by
0.43 percent points over and above that produced by high GI diets. The analysis concluded that

24. choosing low GI foods in place of high GI foods or conventional foods has a small but clinically
useful effect on medium term control in patients with diabetes.
A meta analysis was done by Opperman et al. (2004) to critically analyze the scientific
evidence that low GI diets have beneficial effects on carbohydrate and lipid metabolism
compared with high GI diets and found that low GI diets reduced HbA1c by 0.27percent, total
cholesterol by 0.33 mmol/l and LDL- cholesterol by 0.15 mmol/l in type 2 diabetics. The
analysis found no changes in HDL- cholesterol and triglycerides, compared with high GI diets.
Results of this analysis supported the use of GI as a scientifically based tool to enable selection
of carbohydrate containing foods to reduce total cholesterol and to improve overall metabolic
control of diabetes.
Aston (2006) discussed the association of low GI diets with various metabolic risk factors
and opined that low GI foods may increase satiety and delay the return of hunger compared with
high GI foods, which could translate into reduced energy intake at a later time points. He also
expressed that there is much interest in GI from scientists, health professionals and the public but
more research is needed for drawing conclusion about the relationship with metabolic disease
risk.
Jenkins (2007) in a review on 25 years of research on GI, concluded that it allows foods
to be ranked on the basis of the postprandial glyceamia these foods produce and consumption of
low GI diets has been associated with reduced incidence of heart disease, diabetes and also some
forms of cancer. Venn and Green (2007) concluded in a review that high GI carbohydrates
suppress short term (1 hour) food intake more effectively than a low GI carbohydrate, where as a
low GI carbohydrate appeared to be more effective over longer periods (6hours).
A pilot study by Ma et al. (2008) concluded that a low GI diet is viable alternative to the
standard ADA diet and low GI diet achieved equivalent control of HbA1c using less diabetic
medication. Thomas and Elliott (2009) assessed the effect of low GI and GL diet on glycaemic
control in people with diabetes and concluded that a low GI diet can improve glycaemic control
in diabetics without compromising hypoglycaemic events. A thematic review on metabolic effect
of low GI diet by Radulian et al. (2009) concluded that long term compliance to low GI diets
acutely induce favourable effects like rapid weight loss, decrease of fasting glucose and insulin
levels, reduction of circulating triglyceride levels and improvement of blood pressure. The
reduced hyperinsulinaemia associated with a low GI diet may reduce CVD risk through effects
on oxidative stress, blood pressure, serum lipids, coagulation factors, inflammatory mediators,
endothelial function and thrombolytic function.
A study by Jenkins et al. (2012) tested the effect of increased intake of legumes (1 cup/day) as
part of low GI diet in the treatment of Type 2 Diabetes, on glycaemic control, serum lipid levels and
blood pressure. The results showed a reduction in HbA1c by 0.5 percent and a relative reduction in
systolic blood pressure. Wolever et al. (1992) compared the effect of low GI diet (GI-58) with high GI
(GI-86) diet on 6 overweight NIDDM subjects with a randomized cross over design for 6 week duration

25. and found that in low GI diet, the mean serum fructoseamine level was lower than high GI diet by 8
percent and total cholesterol was lower by 7 percent. The study concluded that in overweight patient s
with NIDDM,a low GI diet will improve overall blood glucose and lipid control. Pande et al. (2012)
conducted a prospective study to report significant hypoglycaemic and hypolipidaemic effects in type 2
diabetic subjects who were on complete diet plan with low glycaemic index (GI) and low-medium
glycaemic load (GL) Indian vegetarian snacks and mixed meals for 4 continuous weeks. The results
showed a positive decrease in blood glucose levels and improvement in lipid profile.
In an interventional study, to investigate the effect of a low glycemic index-low glycemic load
(GL = 67–77) diet on lipids and blood glucose of poorly controlled diabetic patients, Afaghi et al. (2012)
administered a low GL diet (energy = 1800–2200 kcal, total fat = 36%, fat derived from olive oil and nuts
15%, carbohydrate = 41%, protein = 22%) to 100 poorly controlled diabetic patients for 10 weeks. The
results showed that HbA1c percentage was reduced by 12 percent and body weight significantly reduced
from 74.0 kg to 70.7 kg. The study demonstrated that low GL diet having lower carbohydrate amount and
higher fat content is an appropriate strategy in blood lipid and glucose response control of type 2 diabetic
patients.
The updated analyses from three large US cohorts and meta analyses by Bhupathiraju et
al. (2014) on the association of glycaemic index and glycaemic load with type 2 diabetes mellitus
provided evidence that higher GI and GL are associated with increased risk of type 2 diabetes
mellitus. The study also showed that the participants who consumed diets that are low in cereal
fibre but with a high GI or GL have an elevated risk of type 2 diabetes.
The studies reviewed by Maki and Phillips (2015) explained that the consumption of high
GI foods which are rich in refined carbohydrates induces a rapid increase in blood glucose
concentration and thus a high demand for pancreatic insulin production, which could lead to
exhaustion of pancreatic β cells and development of type 2 diabetes.
The effect of consumption of desserts with low glycemic index and low glycemic load on
anthropometric and biochemical parameters in patients with type 2 diabetes mellitus was examined by
Argiana et al. (2015) and found a positive impact on arterial blood pressure,fasting blood glucose and
glycosylated hemoglobin at endpoint. It was also observed that anthropometric measurements like body
weight, body mass index and waist circumference were reduced significantly.
A randomized, controlled crossover non blind design, by Kaur et al. (2016) was done to
simultaneously investigate glucose excursion and substrate oxidation in a whole body calorimetre in 12
healthy Chinese male adults attended two sessions consisting of either four low or high glycaemic
meals. The results revealed that, after Low GI meals in the whole body calorimetre, IAUC for glucose
was lower compared to the High GI session. The investigators concluded that the consumption of low GI
meals may be a strategic approach in improving overall glycaemia and increasing fat oxidation in Asians
consuming a high carbohydrate diet.
In a systematic review and meta analysis of Randomized Controlled Trials, Ojo et al. (2018)
concluded that the low GI diet is more effective in controlling HbA1c ( improvement by 0.5%) and
fasting blood glucose level when compared with a high GI diet in patients with type 2 diabetes.
2.9.3. Methodologyofcalculating GI of foods:

26. The GI of food is determined by comparing the acute glycaemic response of a test food to
a standard food in individual subjects. Initially glucose was used as the standard food but
because of the concerns of excessive sweetness and the osmotic effect of glucose solutions, it
was suggested that white bread of known composition be utilized. In this case a conversion
factor is used to compare the results. If white bread is used, it can be multiplied by a conversion
factor of 0.7 to compare it to a glucose standard or if glucose is used as the standard, it can be
multiplied by a conversion factor of 1.4 to compare it to a white bread standard. (Perlstein et al.,
1997).
The glycemic index of a food is defined as the incremental area under the two-hour blood glucose
response curve (AUC) following a 12- hour fast and ingestion of a food with a certain quantity of
available carbohydrate (usually 50 g). The Area under the curve (AUC) of the test food is divided by the
AUC of the standard (either glucose or white bread) and multiplied by 100. Both the standard and test
food must contain an equal amount of available carbohydrate. The result gives a relative ranking for each
tested food (Brouns et al., 2005). The review elaborated the methodology of GI calculation of foods.
The study by Jenkins et al. (1981) was to determine the effect of different foods on the
blood glucose. Sugars and 62 commonly eaten foods were fed individually to groups of 5 to 10
healthy fasting volunteers and blood sugar levels were measured over 2 hours. It was expressed
as percentage of the area under the glucose response curve when the same amount of
carbohydrate was taken as glucose.
The study by Radhika et al.(2010) elaborated the procedure to evaluate the glycaemic
index (GI) of newly developed 'atta mix' roti with whole wheat flour roti in 18 healthy non-
diabetic subjects, who consumed 50 g available carbohydrate portions of a reference food
(glucose) and two test foods in random order after an overnight fast. The reference food was
tested on three separate occasions, while the test foods were each tested once. Capillary blood
samples were measured from finger-prick samples in fasted subjects (- 5 and 0 min) and at 15,
30, 45, 60, 90 and 120 minutes from the start of each food. For each test food, the incremental
area under the curve and GI values were determined. The results showed that the GI of atta mix
roti (27.30) was considerably lower than the whole wheat flour roti (45.1) and concluded that
development of foods with lower dietary glycaemic could help in the prevention and control of
diabetes in South Asian populations, which habitually consume very high glycaemic load diets.
Premakumari et al. (2013) evaluated the glycaemic index of recipes with rice bran to see
the effect of plant fibre in the diets of diabetics on postprandial glycaemia. The GI test was done
in 10 healthy volunteers (adult men and women) of age 20-40 years, by taking glucose as the
reference food.
A study was undertaken by Aston et al.(2007) to determine the glycaemic index (GI) of
various staple carbohydrate-rich foods including various breads, breakfast cereals, pasta, rice and
potatoes, all of which were commercially available in the UK diet and to consider the factors
influencing the GI in 42 healthy adult volunteers. The GI values of 33 foods were measured

27. according to the WHO/FAO recommended methodology. It was stated that the results illustrated
a number of factors which are important in influencing the GI of a food, highlighting the
importance of measuring the GI of a food, rather than assuming a previously published value for
a similar food and concluded that this is useful both to researchers analyzing dietary surveys or
planning intervention studies, and also to health professionals advising individuals on their diets.
2.9.4. Factors affecting GI:
Report of a Joint FAO/WHO Expert Consultation (1998) detailed the factors that influence the
glycaemic properties of foods as, amount of carbohydrate, nature of monosaccharide components
(glucose, fructose, galactose),nature of starch (amylase, amylopectin, starch-nutrient interaction, resistant
starch), cooking or food processing (degree of starch gelatinization, particle size, food form, cellular
structure), other food components (fat and protein, dietary fibre, antinutrients, organic acids).
The analysis on GI in diabetes management by Perlstein et al. (1997) revealed that GI of the food
is affected by factors like nature of carbohydrate, seasonalfactors, type of starch present in the food,
physical form of food and processing, fibre, anti-nutrients, fat and protein content. In addition to these,
Eleazu (2016) in a review on low GI and GL also mentioned some more factors like amylose-amylopectin
ratio, gelatinization, insulin response, variety, particle size and acidity that have an effect on GI of foods.
This will help in making foods low glycaemic by adding protein or fibre with minimum
processing and also in planning low glycaemic formulations for people with type 2 diabetes
mellitus.
2.9.5. Limitations of GI:
Several studies have pointed out that low GI diets have got certain limitations. Mostly the
concept of GI is misused by people in relation to its numerical figures and many health
professionals and people with diabetes view these figures as the sole factor in determining the
suitability of food e.g., Chocolate as low GI –suitable and potato as high GI-unsuitable (Perlstein
et al., 1997).
Venter (2005) in an editorial, mentioned that there is a significant scientific
disagreement among academicians and clinicians as to whether there is true physiological benefit
in consuming a reduced GI or GL diet and lack of data promote controversy.
Venn and Green (2007) consolidated the weak points questioned by several studies on the
usefulness of GI in a review as GI fails to consider the insulin response, there may be the intra
and inter subject variation in glucose response to a food, a loss of discriminating power when
foods are combined in a mixed meal, foods with a high sugar content and those containing both
carbohydrate and fat may have a low GI but may not be regarded as particularly appropriate
choices because of their energy density and nature of dietary fat.
Jenkins (2007) while looking back into 25 years of research on GI found that the major
limitations of following a low GI diet are a lack of acceptable low GI foods. This review also
suggested that food industry must look into production of foods that are not only palatable and
fast to prepare but also slow to digest. The literature concerning GI and GL in individuals with

28. diabetes is complex, although demonstrated a reduction in A1C of 0.2 percent to 0.5 percent in
some studies (ADA, 2015).
2.9.6. Suggestions on Glycaemic Index :
Perlstein et al. (1997) suggested that the GI concept should be incorporated into the client
education because it is an unfamiliar concept to both health professionals and to people with
diabetes and its use may be complicated by old beliefs. The analysis also recommended for a
future research and development in the areas of GI and diabetes prevention, GI and food
industry, resource materials and teaching methods and health professional training.
The joint committee of FAO and WHO (1998) expressed that there is a need to study a large
number of subjects under standard conditions to obtain more precise estimates of the GI and GL of
individual foods.
Brouns et al. (2005) suggested that RCTs on low GI diets will decide the role and value of the GI
as a therapeutic modality and they should be with reasonable number and duration (months and years
rather than weeks and days). Wheeler et al. (2012) in the meta analysis on eating patterns also suggested
for the development of standardized definitions of low GI and to address the low retention rates on lower
GI diets.
A study by Evert et al.(2014) on nutrition therapy for the adults with diabetes recommended
multiple meal planning approaches and eating patterns for achieving metabolic goals and suggested for
future research,to develop standardized definitions for high and low GI diets for evaluation of their
impact on glycaemic control.
2.10. Glycaemic Load(GL):
The glycaemic response to an ingested food not only depends on the GI but also on the
total amount of carbohydrates ingested, and this led to the concept of Glycaemic Load. GL
accounts for how much of carbohydrate is in the food and how each gram of carbohydrate in the
food raises blood glucose levels.
Mathematically, GL = GI × available carbohydrate (g) /100
Where available carbohydrate = total carbohydrate - dietary fiber. GL is classified as: low (< 10),
intermediate (11–19) and high (> 20). GL is a metric used as a basis for weight loss or diabetes
control. (Eleazu, 2016).
The concept of GI had been extended to take into account the effect of the total amount
of carbohydrate consumed. Thus the glycaemic load, a product of GI and quantity of
carbohydrate consumed provides an indication of glucose available.
Eleazu (2016) in a review on the concept of low GI and GL foods, the author suggested that in
view of discrepancies on the results of GI versus GL of foods, any assay on the GI and GL of a food could
be balanced with glycated hemoglobin assays before they are adopted as useful antidiabetic foods.
2.11. Low GI Formulations for diabetes:

29. Many views had been expressed on the role GI in a diet in the management of diabetes and
severalsuggestions had been made to the diabetic diets. Various studies had shown that different foods
raise the blood sugar to variable extent and exhibit different glycemic responses,but when the individual
food is used in a mixed meal or in mixture of certain foods, it exhibits glycemic response in a different
way. This helps in formulating low GI mixtures for nutrition interventions, emphasizing a variety of
locally available manually processed nutrient dense foods, in appropriate proportions and portion sizes for
the individuals with diabetes as practical tools for day-to-day food plan.
In the last 20 years nearly 300-400 separate foods and mixed meals have been subjected to GI
testing in both normal and diabetic individuals all around the world but methodological differences
created confusion regarding clinical interpretation of GI of foods, so the results of different studies have
not been directly comparable. (Venn and Green, 2007).
Itagi (2003) conducted a study to exploit the nutritional and clinical efficacy of a millet based
diabetic composite food among local people and popularize the product. A composite diabetic mix was
developed from regional millets like foxtail and little millet (80%) along with wheat (10%) and black
gram dal (10%) and spice mixture (8%). These millets increased four times its volume after cooking thus
providing 19-22 per cent of dietary fibre. The glycaemic index was noted in six non diabetics when
tested against 50 g carbohydrate load. Intervention study of four weeks (80 g mix/day) revealed that the
blood glucose in six non-diabetics and nine diabetics reduced to 17 and 19 percent and HDL cholesterol
increased to 2 and 6 per cent respectively. Besides, intervention with foxtail millet mix exhibited
considerable reduction in triglycerides without apparent changes in total cholesterol values in
experimental volunteers as compared to little millet mix. In feeding trial (4 weeks),60 per cent of
diabetics switched over to normal ratio at TC;HDL and LDL.HDL cholesterol along with maintenance of
body weight. As part of the study, the therapeutically potential diabetic mix was popularized through print
media exhibitions, melas, displays and seminars in many diabetic centres,health clubs and clinics.
Jenkins et al. (2007) in a review on research over 25 years opined that GI has potential
therapeutic utility and to make it a practical reality, the food industry would be instrumental in developing
a wider range of readily available and acceptable low GI foods.
Jenkins et al. (2008) included low GI breads (including pumpernickel, Rye pita, quinoa and flax
seeds),breakfast cereals (Large flake oat meal, oat bran and bran buds), pasta,parboiled rice, beans, peas,
lentils and nuts in the low GI diet while testing the effects of low GI diet on glycaemic control and
cardiovascular risk factors in T2 DM patients.
Ankita (2005) conducted an experiment to develop a composite flour with wheat,bajra, maize,
flaxtail millet, Bengal gram and barley and evaluate quality of the low glycaemic composite flour for
missi roti. GI was evaluated in both diabetic and non-diabetics. It was found that the composite flour
made with wheat, Bengal gram and barley in 3:1:1 ratio was acceptable with the lowest GI (50±21.29)
and so suggested for diabetic patients in place of plain flour.
A study was conducted by Rajvinder.et al.(2008) to find out the impact of indigenous fibre rich
therapeutic premix containing locally available ingredients like wheat, Bengal gram, dried peas, defatted
soya flour, barley and fenugreek seeds in different proportions, on blood glucose levels of 30 type 2
diabetics (41-50 years of age). The premix was given as chapathi in the breakfast for 90 days to the
selected subjects. The results revealed that there was a significant reduction in FBG and PPGafter 90
days. It was also observed that the there was a decrease in the diabetic symptoms among the subjects and
dosage of hypoglycaemic drug was reduced after the supplementation.

30. Ankita et al. (2010) had undertaken an investigation to make use of the therapeutic quality of
wheat in the formulation of supplementary foods for the better and effective management of type 2
diabetes. Glycaemic index, Rheological feasibility, sensory acceptability and other functional properties
of three products, chapati, dhalia and noodles prepared with dicoccum wheat as base ingredient along
with some suitable functional ingredients were done and found that inclusion of hypoglycaemic
ingredients made all the three designed foods into low glycaemic category with dhalia (35.20) having
lowest, followed by chapati (41.49) and noodles (43.58). The glycaemic load calculated, also followed the
similar trend with designed dhalia (6.04) having lowest followed by chapati (7.38), and noodles (8.25)
compared to the control ones. The study suggested to include the enriched dicoccum wheat chapatiin the
diet for the management of diabetes more effectively and to avoid further secondary complications.
Ijarotimi et al. (2015) in a study, formulated and evaluated nutrient compositions and
antidiabetic potentials of multi-plant based functional foods from locally available food materials.
In the study, the food materials were processed as raw,blanched and fermented flour samples and
blended to obtain nine different samples and the glycaemic index and anti-diabetic potentials were
determined using rat models. The findings of the study showed that these functional foods contain
appreciable amount of protein, fiber, carbohydrate content within the recommended value for diabetic
patients, low glycaemic index and glycaemic load properties and with antidiabetic activities which were
statistically comparable to metformin (a synthetic anti-diabetic drug). The study recommended the
formulated functional foods for individuals at risk of diabetes or diabetic patients.
Ahmed and Urooj (2015) compared in vitro hypoglycemic effects and starch digestibility
characteristics of wheat based composite functional flour for diabetics. In the study, two composite flours
were formulated using wheat,psyllium, barley and oat at two different levels [product I with wheat flour
(75 %), psyllium (5 %),oat (10 %) and barley (10 %) and product II with wheat flour (60 %),psyllium
(10 %), oat (15 %) and barley (15 %)]. Chapathies were prepared from all formulations and various
starch fractions were analyzed using controlled enzymatic digestion. Product-I showed better starch
digestibility characteristics with significantly lower starch digestibility index. It was suggested that
consumption of the composite flours might be helpful in establishing stable blood glucose pattern due to
the redistribution of nutritionally important starch fractions and inhibition of carbohydrate digestion in the
gastrointestinal tract.
Hossain et al. (2018) developed a low Glycemic index multi wholegrain flour for diabetic persons
as well as for people of all age groups and assessed for glycaemic index and compared with the market
flours. The product was found to be a high energy value supplementary food source with high nutrition.
The study reported that the results of this study were highly inspiring the people to utilize multi
wholegrain flour in food preparation particularly in the preparation of bread.
2.12. Food ingredients of the developed low GI multigrain mix:
The medicinal effects and health benefits of foods have been recognized in India since many
centuries. The present day planning of therapeutic diets based on functional foods can be applied to many
Indian traditional foods like whole grains, legumes, oilseeds, nuts, vegetables, fruits, spices, condiments,
and many fermented products. Consumption of such foods on a regular basis not only provides required
nutrients in adequate quantities but also improves health, immunity and also prevents some disorders. The

31. nutritive value and health benefits of following ingredients used in the formulation of the low glycaemic
index multigrain mix in the present study are discussed here.
1. Barley
2. Wheat
3. Finger millet
4. Soya bean
5. Kalonji
6. Drumstick leaf powder
2.12.1.Barley(Hordeum vulgare L):
National barley food council (NBFC, 2017) recommended barley (Plate No.1) as a smart choice
for type 2 diabetes and pre-diabetes, because it contains essential vitamins, minerals and excellent source
of dietary fibre particularly β-glucan which promotes healthy blood sugar by slowing down the glucose
absorption. Referring to findings of a clinical trial, the council mentioned that subjects who ate muffins or
cookies enriched with barley β-glucan experienced significant reductions in glucose and insulin responses
compared to that with corn starch or whole wheat flour.
Plate.No.1. Barley seeds
NBFC explained very clearly in comparison with other grains that, regardless of the form of
grain, whether whole grain or processed, barley supplies a ready source of β-glucan soluble fibre
throughout the kernel. Barley is a great source of dietary fibre, both soluble and insoluble fibre. The
soluble fibre is effective in reducing the risk of heart disease by lowering blood cholesterol and reduces
the risk of type 2 diabetes by slowing down the absorption of sugar. The insoluble fibre helps in lowering
the risk of colon cancer by maintaining regular bowel movement.
NBFC also mentioned that a serving of barley contains less than half gram of fat and only 100
calories with plenty of vitamins and mineral like niacin, thiamine, selenium, iron, magnesium, zinc,
phosphorus and copper. Barley is rich in antioxidants and phytochemicals also which help decrease the
risk of certain diseases such as CVD, diabetes and cancer.
Robyn (2010) called barley as a ‘secret weapon to help control diabetes’, which has a unique
profile of nutrients to make it a great defender and was once known as a ‘food of the gladiators’. The
author explained that the soluble fibre present in barley has the ability to form a gel when it is mixed with
liquids in the stomach, and the gel slows down the emptying of the stomach which prevents carbohydrates
from being absorbed too quickly and raising the blood glucose levels. The articles had given the nutritive
value of barley as one cup of cooked whole grain barley contains 14 g of total fibre (Soluble fibre-3g and
insoluble fibre-11g), one cup of cooked pearl barley contains 6 g of total fibre (soluble fibre-2 g and

32. insoluble fibre-4g). GI is 25 and rich in magnesium, a mineral which acts as a co-factor in more than 300
enzymes in the body including those involved in the production and secretion of insulin and the use of
glucose.
Mishra et al. (2010) in an analytical review of plants for anti diabetic activity explained that the
chemical constituents of barley are saponin, tannin and lignin and the effect of it on diabetes is by
decreasing plasma triglyceride level and insulin sensitizing activity.
Mirmiram et al. (2014) reviewed several studies on the effects of barley and its products on
glucose tolerance and insulin resistance index and attributed the beneficial effects of barley to its high
content of β-glucan. The review stated that in a randomized cross over study, cooked barley with white
rice reduced area under the curves of plasma glucose and insulin concentrations and also increased
satiety. It also mentioned the investigations on the hypolipidaemic properties, antioxidant and anti-
inflamatory activities of barley products.
2.12.2.Wheat(Triticum aestivum):
Wheat (Plate No.2) is a worldwide staple food and the most common food preferred to have, in
place of rice, by most of the individuals with type 2 diabetes mellitus in India. The major wheat species
grown throughout the world is Triticumaestivum,usually called ‘common’ or ‘bread’ wheat. Wheat is not
only a major source of starch and energy but also provides a number of components which are essential or
beneficial for health like protein, vitamins, dietary fiber, and phytochemicals. Various studies on the
potentials of wheat in the treatment and dietary management of diabetes are discussed here.
Plate.No.2. Whole wheat grains
Kumar et al. (2011) in a review on the nutritional contents and medicinal properties of wheat
opined that, it is essential to understand the molecular and genetic control of various aspects of plant
growth of wheat, to enhance the quality as well as the quantity of proteins, starches and the content of
vitamins, essential amino acids, minerals and other healthy components of wheat. It was mentioned that
the whole wheat,which includes bran and wheat germ, provides protection against diseases like diabetes
by improving insulin sensitivity and decreasing the disordered insulin function.
The results of a review on functional foods based diet for the management of type 2 diabetes by
Mirmiram et al. (2014) showed that wheat bran and whole wheat are rich sources of magnesium which is
a cofactor of enzymes involved in glucose metabolism and insulin secretion, potassium, dietary fibre,
phenolic acids, tocopherols, carotenoids and antioxidants. The analysis reported that whole wheat could
improve postprandial glucose response, HbA1C, lipid disorders and other CVD risk factors in diabetes
patients

33. According to a case report presented by Eapen (2017) when a diabetic patient incorporated wheat
porridge for his breakfast and dinner along with other food, the PPGcame down and shot up when the
patient stopped taking wheat porridge. This had drawn a conclusion that the diet modification with whole
grains and legumes had protective role in lowering the postprandial glycaemia. The review by
Visvanathan et al. (2019) recommended to fortify wheat flour with soluble viscous fibre and legume flour
(eg., gaur gum, chick pea flour, barley etc) for people with type 2 diabetes.
2.12.3.Fingermillet (Ragi)((Eleusine coracana L) :
Finger millet (Plate No.3) is grown extensively in various parts of India and Africa. In India, after
wheat,rice, maize, sorghum, and bajra, ragi ranks sixth position in production. Ragi has high content of
calcium (0.38%), dietary fibre (18%) and protein (6%–13%) with vitamin A, vitamin B and phosphorus.
Ragi is considered as an ideal food for diabetics because of its low sugar content and slow release of
glucose into the blood. (Priyanka et al., 2017).
Plate.No.3. Finger Millet
LakshmiKumari and Sumathi (2002) studied the effect of consumption of finger millet based
diets on hyperglycemia in six type 2 diabetic subjects. All the experimental diets were planned to contain
75 g equivalent of carbohydrate load to compare glycemic response with a 75 g glucose load. The results
revealed that the consumption of finger millet based diets significantly lowered the plasma glucose levels,
mean peak rise, and area under the curve which was attributed to the higher fiber content of finger millet
and the presence of antinutritional factors in whole finger millet flour, known to reduce starch
digestibility and absorption, when compared to that of rice and wheat.
The analysis on millets by Kam et al. (2016) mentioned that there are evidences to support that
millet protein can increase insulin sensitivities and reduce blood glucose and triglyceride levels. Also
mentioned that millets are high in nutritional content, gluten free,have low GI, high energy, high dietary
fibre and protein with balanced amino acid profile. The review mentioned a study on diabetic rats which
demonstrated that finger millet may help reduce subcapsular cataract and may reverse
hypercholesteraemia.
2.12.4.Soya bean(Glycine max):
The soya bean (Plate No.4), native to East Asia, is a species of legume widely grown for
its edible bean. It is the most important bean economically, providing vegetable protein for

34. millions of people in the world and ingredients for many chemical products. Soya bean has got
several uses like soya milk, from which tofu and tofu skin are made. Fermented soya foods
include soya sauce, fermented bean paste. Defatted soya bean meal is a fat-free cheap source of
protein for animal feeds and many packaged meals. Soya bean products, such as textured
vegetable protein (TVP), are used as meat and dairy substitutes.
Soya chunks (Plate No.5) are defatted soya flour product, a by-product of extracting soya
bean oil. It is often used as a meat analogue or meat extender. It is quick to cook, with
protein content comparable to certain meats. It is a low cost, high protein content with long shelf
life. Soya beans contain significant amounts of phytic acid, dietary minerals like calcium, iron,
magnesium, phosphorus, potassium and B vitamins thiamin. The seeds contain 17 percent oil and
63 percent meal, 50 percent of which is protein (“Soyabean”, n.d.) Because soya beans contain
no starch, they are a good source of protein for diabetics.
Plate No.4. Soya bean seeds
Plate.No.5. Defatted soya chunks
In a study by Anderson et al. (1998) substituted soya protein as half of the daily protein
intake, for animal protein to observe the therapeutic value in diabetic nephropathy with resultant
slowing of deterioration of renal function and decreasing proteinuria, in 8 type 2 diabetes