How to Prevent Hyperglycemia with the Vegetables-Meat-Carbs Sequence

This article presents a study that shows how to prevent the rapid rise of blood sugar after a meal or Post-Prandial Glycemia (PPG)

After-Meal Blood Sugar and atherosclerosis

High blood sugar after meals is a risk factor for developing diabetes and atherosclerosis. It injures the inner lining of the arteries and starts or continues atherosclerosis.[1]

PPG is more strongly associated with atherosclerosis than fasting blood sugar or HbA1c. [2]

Glycosylated hemoglobin or HbA1c is a blood test that measures the average blood sugar from the preceding three months.

Depending on the amount of food, the post-prandial period can last four to five hours.[2]

In 24 hours, depending on the size of the meal, if someone has three meals a day, the total post-prandial period could be 15 to 16 hours.[2] If there are snacks in between, the duration could be longer!

The body stores nutrients during the post-prandial state. However, if blood sugars are too high, oxidation can increase, changing LDL to a more damaging oxidative form and worsening atherosclerosis.

High blood sugars also induce inflammation and clot formation and disrupt the normal function of the endothelium, which is the inner lining of the blood vessels. Read about the complex function of the endothelium at  – The Magical Endothelium.

Meanwhile, the high insulin, which increases with elevated blood sugar levels, stores the eaten carbs, fat, and proteins into fat.

In short, after-meal glucose spikes damage arteries and make you fat. With that intro, let’s go to the study.

The PATTERN Study

The journal Clinical Nutrition published the study Postprandial glucose, insulin, and incretin responses differ by test meal macronutrient ingestion sequence (PATTERN study). [3]

The research was conducted at the Clinical Nutrition Research Centre in Singapore.

The subjects were sixteen healthy adults, 13 males, and three females. The average age was 25.8 (range: 21-38), and all had body mass indexes within the normal range.

They all came once a week to eat a meal. After a washout period of one week, they came to have another variation of the meal for a total of five sessions.

The sex discrepancy was because many female volunteers dropped out of the study because they could not tolerate the repeated attempts to insert an intravenous cannula.

Meal Patterns

The meal consisted of 50 gm of cooked rice, 100 g of chicken breast without skin steamed for ten minutes, and 180 gm of bok choy boiled for three minutes in water.

The 5 test meal food intake sequences 127 were as follows:

1. Vegetables first before Meat and Rice (V-MR)
2. Meat first before vegetables and rice (M-VR)
3. Vegetables first, meat second before the rice (V-M-R)
4. Vegetables, meat, and rice together (VMR)
5. Rice before vegetables and meat (R-VM)

Blood tests

The participants were instructed to fast for 10 to 12 hours the night before each study session.

Blood tests were made before a meal (fasting) and collected at 15, 30, 45, 60, 90, 120, 150, and 180 minute intervals following the meal’s start.

To prevent the subjects from becoming human pincushions,  an indwelling cannula was inserted at the first blood draw and used to obtain blood for the succeeding test.

The blood tests included the following:

1. Glucose or sugar. It is the breakdown product of carbohydrates after digestion. Dietary sugar requires minimal digestion and is absorbed rapidly in the intestines and stomach.

2. Insulin is a hormone that rises in the blood after we eat. It stores glucose in the liver, skeletal muscles, and fat, lowering blood glucose. It also removes amino acids from protein from the muscles and fatty acids from the liver and fat tissues.

We don’t want insulin to be too high because persistent insulin (hyperinsulinemia) can also damage the arteries and other body organs. 

I wrote about that in Hyperinsulinemia.

3. GLP-1 (Glucagon-like peptide-1) increases the insulin level and lowers the blood sugar level, just like insulin.

4. GIP stands for Gastric inhibitory polypeptide or Gastric Inhibitory Peptide. It also increases insulin secretion and lowers blood sugar.

GIP slows down food transit from the stomach, resulting in slower absorption of nutrients and a blunting of glucose and insulin elevation.

Because they both increase insulin secretion and lower blood sugar, GLP-1 and GIP are called incretins.

An increased GLP-1 and GIP after eating is good because they result in lower blood sugar and insulin.

Ghrelin is called the hunger hormone. It goes up when we are hungry and lowers after feeling full. 

Results

Blood sugar/glucose levels

Compared to the other meal patterns, when rice is the first food consumed, followed by vegetables and meat (R-VM), it causes the highest glucose increase after a meal.

The lowest blood sugar increase was seen in vegetables, followed by meat and rice (V-MR), and vegetables first, followed by meat and rice (V-M-R). Both meal patterns prevented a sudden increase in blood sugar and insulin.

Eating vegetables first makes the rice stick to them instead of the stomach and intestinal wall. The result is slower absorption until they are in the small intestines.

Higher GIP and GLP-1 secretions with V-MR and V-M-R contributed to lower blood sugars due to higher insulin levels. And as mentioned earlier, GIP slows the emptying of food from the stomach to the small intestines.

The small intestines can absorb more glucose, amino acids, and fats than the stomach.

The image below shows the increase and decrease of glucose levels after meals. Note that rice, followed by vegetables and meat (R-MV), is the highest, while vegetables, meat, and rice (V-M-R) are the lowest.

Vegetables, meat, and rice V-M-R had the lowest blood sugar in the post-prandial period. (AUC- Area under the curve)

Insulin levels

Regarding insulin, R-VM spiked the highest but is the lowest at 180 minutes. (see image below) The sudden increase in insulin with R-VM leads to a faster drop in blood sugar, as seen in the image above.

Real-life meaning: The resulting low blood sugar that happens earlier with a rice-first diet makes a person feel hungry much earlier and prompts them to advance their next meal. In total, more carbs and calories are consumed.

In contrast, a vegetable then, meat then rice meal (V-M-R) pattern has the lowest initial insulin level and prevents low blood sugar at 180 minutes. A person who eats using the (V-M-R) pattern will not be hungry after 180 minutes.

As shown below, the total amount of insulin in the post-prandial period is with the V-M-R and the VMR.

In the body, proactive is better than reactive. With the V-M-R and V-MR pattern, the insulin is already up before the carbs come. I hear insulin say, “Don’t worry, we got this! That is why the glucose spike does not happen.

In contrast, in rice-first, the glucose absorption is suddenly high, and now the insulin has to play “catch-up,” which tends to overshoot the desired level.

The insulin level will always stay high if a high-carb diet is always eaten.

Like any other hormones like adrenaline and cortisol, insulin secretion should be intermittent or pulsed and not persist.  If not, disease states happen. Read about them in Hyperinsulinemia.

Hunger Hormone Ghrelin

Rice, followed by vegetables and meat (R-VM), had the highest ghrelin after 180 minutes, consistent with the low blood sugar seen in the graph above. This is another reason why people who eat rice or more carbs get hungry before other meal patterns.

In contrast, meat first, then vegetables and rice (M-VR), have the lowest amount of ghrelin and will make you hungry much later. This is an argument used by those who propose a carnivore diet.

The results of this study are consistent with another study from Japan that showed that eating fish or meat before rice increased incretin release (GLP-1), delayed gastric emptying time, and prevented glucose spikes after a meal.[4]

Summary

In this study, rice is used to represent other carbohydrate-rich foods like bread, pasta, or noodles. The study also shows why eating snacks and drinking pop, soft drinks, and fruit juices, whether with meals or between meals, is bad.

I saw a commercial earlier saying orange juice is the original wellness drink. That is not true. It is laden with sugar that increases blood glucose and insulin.

Intermittent fasting is another way of decreasing the episodes of post-prandial glycemia.

Postprandial glycemia or repeated high blood sugar after meals explains why people who do not have high cholesterol levels, those who are not diabetic, and those with controlled diabetes still have heart attacks.

Diabetes medications are prescribed to lower after-meal sugar spikes, but based on a recently released study two days ago, they are no more effective than lifestyle changes.

Rearranging our food intake is an elegant, inexpensive, and effective way to lower the risk of heart attacks and strokes, which are the top causes of death globally.

Walking after meals can also help post-prandial high blood sugars. – Walk After Meals to Prevent Sky High Blood Sugars

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References: 

1. O’Keefe JH, Bell DS. Postprandial hyperglycemia/hyperlipidemia (postprandial dysmetabolism) is a cardiovascular risk factor. Am J Cardiol. 2007 Sep 1;100(5):899-904. doi: 10.1016/j.amjcard.2007.03.107. Epub 2007 Jun 26. PMID: 17719342.
2. Soeters MR. Food intake sequence modulates postprandial glycemia. Clin Nutr. 2020 Aug;39(8):2335-2336. doi: 10.1016/j.clnu.2020.06.009. Epub 2020 Jun 19. PMID: 32600856.
3. Sun L, Goh HJ, Govindharajulu P, Leow MK, Henry CJ. Postprandial glucose, insulin and incretin responses differ by test meal macronutrient ingestion sequence (PATTERN study). Clin Nutr. 2020 Mar;39(3):950-957. doi: 10.1016/j.clnu.2019.04.001. Epub 2019 Apr 27. PMID: 3105351
4. Kuwata H, Iwasaki M, Shimizu S, Minami K, Maeda H, Seino S, Nakada K, Nosaka C, Murotani K, Kurose T, Seino Y, Yabe D. Meal sequence and glucose excursion, gastric emptying and incretin secretion in type 2 diabetes: a randomised, controlled crossover, exploratory trial. Diabetologia. 2016 Mar;59(3):453-61. doi: 10.1007/s00125-015-3841-z. Epub 2015 Dec 24. PMID: 26704625; PMCID: PMC4742500.

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