Cited by 162Nutritional Studies and DietFood composition and propertiesDiet, Metabolism, and Disease

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Associations of Glycemic Index and Load With Coronary Heart Disease Events: A Systematic Review and Meta‐Analysis of Prospective Cohorts

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Abstract

Background: Glycemic index ( GI ) and glycemic load ( GL ) have been associated with coronary heart disease ( CHD ) risk in some but not all cohort studies. We therefore assessed the association of GI and GL with CHD risk in prospective cohorts. Methods and Results: We searched MEDLINE , EMBASE , and CINAHL (through April 5, 2012) and identified all prospective cohorts assessing associations of GI and GL with incidence of CHD . Meta‐analysis of observational studies in epidemiology ( MOOSE ) methodologies were used. Relative measures of risk, comparing the group with the highest exposure (mean GI of cohorts=84.4 GI units, range 79.9 to 91; mean GL of cohorts=224.8, range 166 to 270) to the reference group (mean GI =72.3 GI units, range 68.1 to 77; mean GL =135.4, range 83 to 176), were pooled using random‐effects models, expressed as relative risk ( RR ) with heterogeneity assessed by χ 2 and quantified by I 2 . Subgroups included sex and duration of follow‐up. Ten studies (n=240 936) were eligible. Pooled analyses showed an increase in CHD risk for the highest GI quantile compared with the lowest, with RR =1.11 (95% confidence interval [ CI ] 0.99 to 1.24) and for GL , RR =1.27 (95% CI 1.09 to 1.49), both with evidence of heterogeneity (I 2 >42%, P <0.07). Subgroup analyses revealed only a significant modification by sex, with the female cohorts showing significance for GI RR =1.26 (95% CI 1.12 to 1.41) and for GL RR =1.55 (95% CI 1.18 to 2.03). Conclusions: High GI and GL diets were significantly associated with CHD events in women but not in men. Further studies are required to determine the relationship between GI and GL with CHD in men.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis of 10 prospective cohorts found that high glycemic load was significantly associated with increased coronary heart disease risk, while high glycemic index was not significant overall. The associations were significant in women but not in men.

Key findings

  • Across 10 studies (n=240,936 for GL; n=233,655 for GI), 6 to 25 years of follow-up yielded 6,940 coronary events.
  • Highest versus lowest GI exposure: RR=1.11 (95% CI 0.99 to 1.24), P=0.09, with heterogeneity I²=45%, P=0.05; removing the Grau et al. report on men gave RR=1.14 (95% CI 1.02 to 1.26), P=0.02, I²=30%.
  • Highest versus lowest GL exposure: RR=1.27 (95% CI 1.09 to 1.49), P=0.002, with heterogeneity I²=43%, P=0.06.
  • Sex significantly modified associations: women had GI RR=1.26 (95% CI 1.12 to 1.41) and GL RR=1.55 (95% CI 1.18 to 2.03); men had GI RR=0.96 (95% CI 0.84 to 1.11) and GL RR=1.08 (95% CI 0.93 to 1.26). Duration of follow-up was not a significant modifier.

Methods

  • Systematic review and meta-analysis of prospective cohorts in healthy adults, following MOOSE guidelines; MEDLINE, EMBASE, and CINAHL were searched through April 5, 2012, for studies assessing GI or GL and incident CHD, MI, or CHD death.
  • Eligible studies included 10 cohorts with 12 GI reports and 12 GL reports; all used Cox proportional hazards models except one study using restricted cubic spline models.
  • Natural log-transformed relative risks comparing highest versus reference exposure were pooled using random-effects generic inverse variance models; heterogeneity was assessed by Cochrane’s Q and I², with a priori subgroups for sex and follow-up duration and publication bias tested by Begg’s and Egger’s tests.

Limitations

  • The paper states limitations including the limited number of studies, inability to include potentially relevant studies because of missing data, heterogeneity in overall analyses, likely underpowered analyses in men, potential residual confounding or overadjustment, combining dietary data from multiple instruments, and a predominantly white population limiting racial diversity.
  • The text makes evident that observational design cannot establish causality, and the sex-specific findings may be influenced by the larger female sample and underpowered male cohorts.
  • One included study used restricted cubic splines and was identified as an outlier and contributor to heterogeneity, which the authors note may affect pooled estimates.

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Integrity signals

Registry

Crossref · 10.1161/jaha.112.000752

Cites

65 of 65 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Figure 1. Literature search and review flow. CHD indicates coronary heart disease; GI, glycemic index.*The Hardy et al study, for which data were unavailable, only reported a rate of change in risk of CHD per 5 and 30 units of GL.
Figure 1. Literature search and review flow. CHD indicates coronary heart disease; GI, glycemic index.*The Hardy et al study, for which data were unavailable, only reported a rate of change in risk of CHD per 5 and 30 units of GL.CC BY · PubMed Central
Figure 2. Pooled risk estimate of all prospective cohorts investigating the association of highest GI exposure with CHD events (including death and myocardial infarctions) relative to the reference exposure (ΔGI between mean of highest exposure and mean of reference=12.1±1.1 SE). The figure is stratified by sex-specific subgroups with subtotal boxes in 2.1.1 and 2.1.2 summarizing the pooled analysis for women28,31,33,36,42,43 and for men,29,30,33,35,43 respectively. The total analysis box represents the overall pooled analysis for both men and women. P values in circles are based on generic inverse variance (IV) methods in random-effects models and represent the significance for association of high-GI diets with CHD. The P value in a rectangle depicts the significance of differences between the subgroups. Interstudy heterogeneity was tested by Cochrane's Q (χ2) at a significance level of P<0.10 and quantified by I2.38 CHD indicates coronary heart disease; GI, glycemic index.
Figure 2. Pooled risk estimate of all prospective cohorts investigating the association of highest GI exposure with CHD events (including death and myocardial infarctions) relative to the reference exposure (ΔGI between mean of highest exposure and mean of reference=12.1±1.1 SE). The figure is stratified by sex-specific subgroups with subtotal boxes in 2.1.1 and 2.1.2 summarizing the pooled analysis for women28,31,33,36,42,43 and for men,29,30,33,35,43 respectively. The total analysis box represents the overall pooled analysis for both men and women. P values in circles are based on generic inverse variance (IV) methods in random-effects models and represent the significance for association of high-GI diets with CHD. The P value in a rectangle depicts the significance of differences between the subgroups. Interstudy heterogeneity was tested by Cochrane's Q (χ2) at a significance level of P<0.10 and quantified by I2.38 CHD indicates coronary heart disease; GI, glycemic index.CC BY · PubMed Central
Figure 3. Pooled risk estimate of all prospective cohorts investigating the association of highest GL exposure with CHD events (including death and myocardial infarctions) relative to the reference exposure (ΔGL between mean of highest exposure and mean of reference=89.4±9.5 SE). The figure is stratified by sex-specific subgroups with subtotal boxes in 3.1.1 and 3.1.2 summarizing the pooled analysis for women31,33,34,36,42,43 and for men,29,30,33,35,43 respectively. The total analysis box represents the overall pooled analysis for both men and women. P values in circles are based on generic inverse variance (IV) methods in random-effects models and represent the significance for association of high-GL diets with CHD. The P value in a rectangle depicts the significance of differences between the subgroups. Interstudy heterogeneity was tested by Cochrane's Q (χ2) at a significance level of P<0.10 and quantified by I2.38 CHD indicates coronary heart disease; GI, glycemic index.
Figure 3. Pooled risk estimate of all prospective cohorts investigating the association of highest GL exposure with CHD events (including death and myocardial infarctions) relative to the reference exposure (ΔGL between mean of highest exposure and mean of reference=89.4±9.5 SE). The figure is stratified by sex-specific subgroups with subtotal boxes in 3.1.1 and 3.1.2 summarizing the pooled analysis for women31,33,34,36,42,43 and for men,29,30,33,35,43 respectively. The total analysis box represents the overall pooled analysis for both men and women. P values in circles are based on generic inverse variance (IV) methods in random-effects models and represent the significance for association of high-GL diets with CHD. The P value in a rectangle depicts the significance of differences between the subgroups. Interstudy heterogeneity was tested by Cochrane's Q (χ2) at a significance level of P<0.10 and quantified by I2.38 CHD indicates coronary heart disease; GI, glycemic index.CC BY · PubMed Central
Figure 4. Test for publication bias in the overall pooled analysis of CHD risk estimates associated with the highest GI quantiles; Grau et al43 report on men was identified outside the 95% pseudo–confidence limits. Neither Begg's test (P>0.837) nor Egger's test (P=0.621) revealed evidence of publication bias.39,40 CHD indicates coronary heart disease; GI, glycemic index.
Figure 4. Test for publication bias in the overall pooled analysis of CHD risk estimates associated with the highest GI quantiles; Grau et al43 report on men was identified outside the 95% pseudo–confidence limits. Neither Begg's test (P>0.837) nor Egger's test (P=0.621) revealed evidence of publication bias.39,40 CHD indicates coronary heart disease; GI, glycemic index.CC BY · PubMed Central
Figure 5. Test for publication bias in the overall pooled analysis of CHD risk estimates associated with highest GL quantiles; Grau et al43 report on women was identified outside the 95% pseudo–confidence limits. Begg's (P>0.115) and Egger's (P=0.134) tests approached significance for evidence of publication bias.39,40 CHD indicates coronary heart disease; GL, glycemic load.
Figure 5. Test for publication bias in the overall pooled analysis of CHD risk estimates associated with highest GL quantiles; Grau et al43 report on women was identified outside the 95% pseudo–confidence limits. Begg's (P>0.115) and Egger's (P=0.134) tests approached significance for evidence of publication bias.39,40 CHD indicates coronary heart disease; GL, glycemic load.CC BY · PubMed Central

Verification

Claims the paper makes

38 Not checked yet · 32 Own result · 8 Own method · 5 Own interpretation · 2 No basis given

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  • It may state two separate claims as one. 27
  • The quote only partly states this claim. 1
  • Probably not a substantial claim. 22
40 of 40
  • The paper relies on this without support.

    Carbohydrates with differing physical form, particle size, chemical structure, and fiber content alter the rate of starch digestion and their physiological response.

    “Carbohydrates with differing physical form, particle size, chemical structure, and fiber content alter the rate of starch digestion and their physiological response.”
  • The paper relies on this without support.

    The observed associations between GI/GL and CHD in women reflect causal effects that would be modified by reducing GI/GL.

    “We conclude that a reduction in the glycemic index and glycemic load may favorably affect CHD outcomes in women.”
2 of 2

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Metadata

Authors
Mirrahimi, A., de Souza, R. J., Chiavaroli, L., Sievenpiper, J. L., Beyene, J., Hanley, A. J., Augustin, L. S. A., Kendall, C. W. C., & Jenkins, D. J. A.
Affiliations
  • St. Michael's Hospital (CA)
  • Clinical Nutrition and Risk Factor Modification Center, St. Michael's Hospital, Toronto, Ontario, Canada
  • University of Toronto (CA)
Venue
Journal of the American Heart Association
Published
2012-09-26
Volume
1
Issue
5
Pages
e000752-e000752
ISSN
2047-9980 (ISSN-L)
OpenAlex
W2170277419
Cited by
161
References
67
Citations by year
2026: 3 · 2025: 4 · 2024: 10 · 2023: 8 · 2022: 13 · 2021: 10 · 2020: 13 · 2019: 11 · 2018: 12 · 2017: 16 · 2016: 17 · 2015: 11 · 2014: 25 · 2013: 7
FWCI
2.14
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • Journal of the American Heart Association (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
  • Health Sciences › Nursing › Nutrition and Dietetics › Food composition and properties
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diet, Metabolism, and Disease
Keywords
glycemic index, glycemic load, coronary artery disease, cardiovascular risk, sex differences, prospective cohort
MeSH terms
Coronary Disease, Humans, Risk Factors, Incidence, Glycemic Index

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