Associations of the glycaemic index and the glycaemic load with risk of type 2 diabetes in 127 594 people from 20 countries (PURE): a prospective cohort study

Victoria Miller; David A Jenkins; Mahshid Dehghan; Kristie Srichaikul; Sumathy Rangarajan; Andrew Mente; Viswanathan Mohan; Sumathi Swaminathan; Rosnah Ismail; Maria Luz Diaz; Rekha M Ravindran; Katarzyna Zatonska; Ahmad Bahonar; Yuksel Altuntas; Rasha Khatib; Patricio Lopez-Jaramillo; Afzalhussein Yusufali; Karen Yeates; Jephat Chifamba; Romaina Iqbal; Rita Yusuf; Elizabeth Catherina Swart; Hu Bo; Guoliang Han; Xiaocong Li; Khalid F Alhabib; Annika Rosengren; Alvaro Avezum; Fernando Lanas; Salim Yusuf; Prospective Urban and Rural Epidemiology (PURE) study investigators

doi:10.1016/S2213-8587(24)00069-X

Associations of the glycaemic index and the glycaemic load with risk of type 2 diabetes in 127 594 people from 20 countries (PURE): a prospective cohort study

Lancet Diabetes Endocrinol. 2024 May;12(5):330-338. doi: 10.1016/S2213-8587(24)00069-X. Epub 2024 Apr 5.

Authors

Victoria Miller¹, David A Jenkins², Mahshid Dehghan³, Kristie Srichaikul⁴, Sumathy Rangarajan³, Andrew Mente⁵, Viswanathan Mohan⁶, Sumathi Swaminathan⁷, Rosnah Ismail⁸, Maria Luz Diaz⁹, Rekha M Ravindran¹⁰, Katarzyna Zatonska¹¹, Ahmad Bahonar¹², Yuksel Altuntas¹³, Rasha Khatib¹⁴, Patricio Lopez-Jaramillo¹⁵, Afzalhussein Yusufali¹⁶, Karen Yeates¹⁷, Jephat Chifamba¹⁸, Romaina Iqbal¹⁹, Rita Yusuf²⁰, Elizabeth Catherina Swart²¹, Hu Bo²², Guoliang Han²², Xiaocong Li²², Khalid F Alhabib²³, Annika Rosengren²⁴, Alvaro Avezum²⁵, Fernando Lanas²⁶, Salim Yusuf²⁷; Prospective Urban and Rural Epidemiology (PURE) study investigators

Affiliations

¹ Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada. Electronic address: victoria.miller@phri.ca.
² Department of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada; Clinical Nutrition Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, ON, Canada.
³ Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
⁴ Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
⁵ Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
⁶ Department of Diabetology, Madras Diabetes Research Foundation & Dr Mohan's Diabetes Specialties Centre, Chennai, India.
⁷ St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India.
⁸ Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan, Kuala Lumpur, Malaysia.
⁹ Estudios Clinicos Latino America, Rosario, Argentina.
¹⁰ Department of Health Sciences, Government of Kerala, Kerala, India; Health Action by People, Trivandrum, Kerala, India.
¹¹ Social Department of Wroclaw Medical University, Wroclaw, Poland.
¹² Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
¹³ University of Health Sciences Turkey, Faculty of Medicine, Istanbul Sisli Hamidiye Etfal Health Training Research Hospital, Clinic of Endocrinology and Metabolism, Sisli/Istabul, Türkiye.
¹⁴ Advocate Aurora Research Institute, Milwaukee, WI, USA; Institute of Community and Public Health, Birzeit University, Birzeit, Palestine.
¹⁵ Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia.
¹⁶ Tamani Foundation, Matemwe, Zanzibar, Tanzania.
¹⁷ Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada.
¹⁸ Department of Biomedical Sciences, University of Zimbabwe, Harare, Zimbabwe.
¹⁹ Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
²⁰ Center for Health, Population and Development, Independent University, Dhaka, Bangladesh.
²¹ Department of Dietetics and Nutrition, University of the Western Cape, Bellville, South Africa.
²² Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
²³ Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyaadh, Saudi Arabia.
²⁴ Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden.
²⁵ International Research Center, Hospital Alemão-Oswaldo Cruz & UNISA, São Paulo, SP Brazil.
²⁶ Universidad de la Frontera, Temuco, Chile.
²⁷ Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.

PMID: 38588684
DOI: 10.1016/S2213-8587(24)00069-X

Abstract

Background: The association between the glycaemic index and the glycaemic load with type 2 diabetes incidence is controversial. We aimed to evaluate this association in an international cohort with diverse glycaemic index and glycaemic load diets.

Methods: The PURE study is a prospective cohort study of 127 594 adults aged 35-70 years from 20 high-income, middle-income, and low-income countries. Diet was assessed at baseline using country-specific validated food frequency questionnaires. The glycaemic index and the glycaemic load were estimated on the basis of the intake of seven categories of carbohydrate-containing foods. Participants were categorised into quintiles of glycaemic index and glycaemic load. The primary outcome was incident type 2 diabetes. Multivariable Cox Frailty models with random intercepts for study centre were used to calculate hazard ratios (HRs).

Findings: During a median follow-up of 11·8 years (IQR 9·0-13·0), 7326 (5·7%) incident cases of type 2 diabetes occurred. In multivariable adjusted analyses, a diet with a higher glycaemic index was significantly associated with a higher risk of diabetes (quintile 5 vs quintile 1; HR 1·15 [95% CI 1·03-1·29]). Participants in the highest quintile of the glycaemic load had a higher risk of incident type 2 diabetes compared with those in the lowest quintile (HR 1·21, 95% CI 1·06-1·37). The glycaemic index was more strongly associated with diabetes among individuals with a higher BMI (quintile 5 vs quintile 1; HR 1·23 [95% CI 1·08-1·41]) than those with a lower BMI (quintile 5 vs quintile 1; 1·10 [0·87-1·39]; p interaction=0·030).

Interpretation: Diets with a high glycaemic index and a high glycaemic load were associated with a higher risk of incident type 2 diabetes in a multinational cohort spanning five continents. Our findings suggest that consuming low glycaemic index and low glycaemic load diets might prevent the development of type 2 diabetes.

Funding: Full funding sources are listed at the end of the Article.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Aged
Blood Glucose / analysis
Cohort Studies
Diabetes Mellitus, Type 2* / blood
Diabetes Mellitus, Type 2* / epidemiology
Diet
Female
Glycemic Index* / physiology
Glycemic Load*
Humans
Incidence
Male
Middle Aged
Prospective Studies
Risk Factors

Substances

Blood Glucose