Elsevier

Clinical Nutrition

Volume 36, Issue 2, April 2017, Pages 355-363
Clinical Nutrition

Review
Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group

https://doi.org/10.1016/j.clnu.2016.09.010Get rights and content

Summary

Growing evidence underscores the important role of glycemic control in health and recovery from illness. Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to help lessen glycemic variability and its negative health consequences when nutritional support is administered. Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, Italy, 8–9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional recommendations for carbohydrate utilization and management in nutritional support. The main conclusions were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing glucose control relative to nutritional support.

Section snippets

Introduction: carbohydrates, insulin resistance, and clinical nutrition

Carbohydrates in the diet provide an essential metabolic fuel, commonly in the form of glucose. While necessary for life, excess or rapidly changing levels of glucose in the blood can lead to several health problems and contribute to the development of obesity, insulin resistance, and type 2 diabetes mellitus (T2D). Furthermore, poorly controlled glucose levels in critically ill patients or in those recovering from surgery can lead to glucose variability with hyper- and hypoglycemia, conditions

Glucose metabolism in the organs

Advances in research have shed light on the ways in which glucose interacts with a number of organ systems. Excess exposure of these organs to glucose as a result of hyperglycemia, as well as uncontrolled spiking of glucose levels after meals, can contribute to the deterioration of an individual's condition by causing metabolic derangements such as oxidative stress, tissue and systemic inflammation, and insulin resistance. This section summarizes the impact of glucose on major organs involved

Diet and lifestyle

Obesity and excess adiposity can lead to the development of glucose insensitivity, impaired insulin action, and inability to properly regulate glycemic variations. Although dietary recommendations aimed at weight loss have recently emphasized the importance of inducing energy deficits, at least in part independently of diet composition, high GI and GL foods are associated with metabolic disease risk and health complications [3], [4], [5]. Lowering dietary GI and GL may conversely improve these

Summary and conclusions

While carbohydrates, which provide glucose to the body to support metabolism, are crucial to the diet, inappropriate intake can lead to hyperglycemia, hypoglycemia, and glycemic fluctuations that are harmful to health outcomes (Fig. 2).

Excess glucose ingestion interacts with the gut and its microbiome and ultimately affects a number of organs including skeletal muscle, adipose tissue, and the liver. Excess glucose availability may induce expansion of adipose tissue and may favor ectopic fat

Conflict of interest

None.

Acknowledgment

The authors thank Dr. Cecilia Hofmann (C. Hofmann & Associates, Western Springs, IL, USA) for her capable assistance with writing, reference management, and editing the manuscript.

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