The potential of spiritual leadership in workplace spirituality
13 June 2014

Marilyn Naidoo email@example.com
Department of Philosophy

Systematic and Practical Theology
University of South Africa
South Africa

University of South Africa
PO Box 3920003South Africa

The potential of spiritual leadership in workplace spirituality
13 June 20140504673C1F1DF024331376740C12F54E10.4102/koers.v79i2.2124Received: 21 June 2013 Accepted: 03 Feb. 2014
We live in the transition period between the old definition of work as survival and the new definition of work as livelihood.A new awareness of the value of spirituality can add to the innovation and creative capacity of 'human capital', increased authenticity in communication and has the potential for increased ethical and moral behaviour.For organisations wanting greater commitment this means opening up the conversation to include dimensions of soul and spirit that have been traditionally left at the office door.Workplace spirituality has potential for leadership development as it allows employees and leaders to act from personal truth, integrity, values and ethical practice.Spiritual leadership taps into the fundamental needs of both leader and follower for spiritual survival so that they become more organisationally committed and productive.This article focuses on the potential of spiritual leadership to transform and to contribute to the success of an organisation.

Introduction

With the accelerating force of global, societal and organisational change comes the call for a more holistic leadership that integrates the four fundamental arenas that define the essence of human existence: body (physical), mind (logical or rational thought), heart (emotions, feelings) and spirit (Moxley 2000:34).Changes in our rapid modern society are causing institutions to be managed differently from the traditional, centralised, standardised and formalised bureaucratic organisational form based on fear, to a newer learning organisational paradigm that is radically different (Elmes & Smith 2001:34;Lund Dean & Safranski 2008:359).Attention is now given to the conceptual distinction between management as control and leadership as motivation (Fry 2003:697).For organisations wanting greater commitment this means opening up the conversation to include dimensions of soul and spirit that have been traditionally left at the office floor.This opens the door for workplace spirituality.

At the same time, a major proposition of this review is that spiritual leadership is necessary for the transformation and continued success of an organisation (McKee et al. 2011).There is the suggestion that an increase in spiritual development will result in enhanced leadership effectiveness (Arnold et al. 2007;Fry & Slocum 2008).However, the surge in literature on spirituality raises a red flag that this is just the next management fad as attempts to integrate spirituality into existing leadership and management practices are seen as simply the means through which people can be exploited (Elmes & Smith 2001) to improve organisational performance.

In our current context of South Africa, the workplace has been turned into a tense environment due to downsizing, restructuring, outsourcing and layoffs as well as a growing inequity in wages (Mohan & Uys 2006).Employees become dispirited, as evidenced in rising absenteeism, low morale and substandard performance, and this makes it increasingly difficult for organisations to remain competitive in the changing global marketplace.Employee creativity needs a fuller expression at work but such expression is difficult when work itself is immensely repetitive and not meaningful (Neck & Milliman 1994:10).Denton (2007) suggests that other modern developments such as an increasingly need-driven and anxious society together with the separate positions of employer and employee in the pursuit of the financial bottom line further informs the search for meaning.

Given the highly competitive nature of business, human capital often gives the competitive edge to an organisation and valuable employees must be retained.The current motivational paradigm needs to incorporate the spiritual dimension of employees, which is the missing link in understanding the problems of underperformance and ineffectiveness.The argument is advanced that spirituality, an increasingly embraced phenomenon, provides meaning and purpose in the lives of individuals and that it could be positively applied to workplace spirituality (Kinjerski & Skrypnek 2004).Workplace spirituality, viewed as sensitive and controversial, has the potential to develop leadership as it allows employees and leaders to act from personal truth, integrity, values and ethical practice (Neck & Milliman 1994;Rego & Pina e Cunha 2008).Spiritual leadership is seen to have the potential to tap into the fundamental needs of both leader and follower for spiritual survival, the antidote to meaninglessness, so they become more organisationally committed and productive.This article focuses on spiritual leadership as necessary for the transformation and continued success of an organisation.Spiritual leadership involves motivating and inspiring workers through a transcendent vision and culture based on altruist values to produce a more motivated, committed and productive workforce.

What is workplace spirituality?

As society has advanced in terms of leisure time, technology and the communication of ideas, people increasingly desire to experience spirituality not only in their personal lives but also in their work, where they spend a large amount of time (Neck & Milliman 1994).According to Ashmos and Duchon (2000:3), the spiritual dimension of human beings, namely that dimension concerned with finding meaning and purpose and living in relation to others, was not welcomed in the bureaucratic and scientific management models of the workplace (which has been the dominant organisational paradigm since the beginning of the Industrial Revolution).However, the notion that spirituality should not be brought to work is not pragmatic, as employees are holistic beings and may link their personal self-image with who they are in the world of work.

In the work environment, employees faced with conflicting value sets in their personal and professional lives are challenged by the decision to conform, leave or alter the organisation (Chatman 1991).More workers are choosing the last option, seeking self-actualisation through their work lives by acting as change agents.They are not willing to compromise their personal values for the sake of their professional careers, nor are they willing to do the reverse.In the process, they are striving to 'express and develop their complete self at work' by bringing their personal values, used here as synonymous with spiritual beliefs, into the workplace (Mitroff & Denton 1999;Lund Dean & Safranski 2008:359).These individuals derive a sense of selfactualisation (Maslow 1954) through their actions, a sense of sacredness and purpose through their work that allows them to feel more genuine and authentic in resolving conflicted value systems and shaping new ones (Ray & Anderson 2000).For these and other reasons, people search for ways to 'leave a legacy', to achieve satisfaction in knowing that their lives made the world a better place (Covey 1995).For some, this involves a religious connotation, whilst for others it does not.These values drive them to experience a higher sense of service in making a difference by contributing to society as a whole (Delbecq 1999).As a result, the nature of their work changes from a career in which they earn a living to a vocation in which they express themselves and promote positive social change (Fry 2003).It may be assumed that employees not only become personally fulfilled but the organisation reaps the benefits of high morale, a decrease in absenteeism and, ultimately, profits.

At the same time, the idea of 'work as vocation' may be idealistic for many sectors and societies.In South Africa some occupations that were traditionally viewed as noble professions or vocations such as teaching, nursing and law enforcement have lost their glory (Penceliah 2009:211).Owing to the high unemployment rate, many see work as a way to survive.It is also important to mention that some people see a lack of safety in expressing spirituality in the workplace (Lipps-Wiersma & Mills 2002:191).This is because spirituality contributes to a sense of personal vulnerability which is magnified for those who perceive themselves to be spiritually different from the majority or norm and can also be a source of marginalisation in the workplace.There is also the issue of the exercise of power and whether organisations might attempt to apply spirituality as a leadership tool without the necessary personal commitment.

To sum up, workplace spirituality has been defined as the framework of organisational values that leads to a sense of the transcendence and interconnectedness of all life, so that workers experience personal fulfilment on the job (Giacalone & Jurkiewicz 2003:99).This sense of transcendence, having a calling through one's work (vocation) and the need for membership in the corporate culture, community and social connections provides the foundation for a theory of workplace spirituality.Workplace spirituality is therefore framed within a holistic or system context of interwoven cultural, organisational and personal values.It must demonstrate its value by influencing performance, productivity and other relevant effectiveness and performance criteria.Evidence exists that suggests a link between workplace spirituality and enhanced individual creativity (Freshman 1999), increased honesty and trust within the organisation (Fry & Slocum 2008;Giacalone & Jurkiewicz 2003), an enhanced sense of personal fulfilment of employees (Burack 1999:281) and an increased commitment to organisational goals (McKee et al. 2011).

Spirituality or religion in the workplace?

Scholarly literature has tied spirituality to a religious context whereas others have not.Ali and Gibbs (1998) relate the Ten Commandments of the three major religions (Judaism, Christianity and Islam) to the work ethic and practice of believers.They argue that in a global marketplace and economy, with diversity as the norm rather than the exception, leaders and managers can benefit from understanding the basic embedded religious drives that members of these three religious may bring to their work environment.Elmes and Smith (2001) contend that workplace empowerment has a strong spiritual underpinning, with roots in Puritan and Christian ideals, emphasising hard work, right living and doing for others, which leads to individual and corporate prosperity.Pratt (2000), in his ethnographic research, found that deeply infusing religious values in an organisationputting God before one's business -can help members 'make sense' of unexpected religious and/or spiritual components.

In the Christian tradition spirituality is not just seen as human wellbeing, wholeness or meaning.It is a deeply lived experience of the person and nature of God in every aspect of life as a primary orientation.The concepts of vocation and shalom are amongst the most cherished of all doctrinal beliefs for adherents of the Christian faith.Both concepts have deep and broad implications for adherents as they pursue their daily professional lives.For Christians, human beings are created in the image of the Creator God.Thus exercising creativity in the world and extending the purpose of the Creator is a primary responsibility.Emphasising a particular Christian focus in the workplace would involve all employees subscribing to the Christian faith, which may or may not be possible.Some Christian organisations view their business as based upon 'management by the Word of God' -its structure is hierarchical and religious service is an important goal, along with profit.Organisations such as the Christian Business Network in South Africa are examples of Christian businesses that strive to support other Christian businesses and operate with standards of integrity that are in line with their faith commitment and seek to deliver customer service based on Christian values (see http:// www.christianbusinesses.co.za).It is hoped that this practice is befitting a Christian-based business and a witness to the Christian faith.

However, an overt religious agenda in business can be viewed as intolerant, exclusive and discriminatory to stakeholders.It often has the negative connotations of being parental, authoritarian and requiring unconscious obedience (King 2007).Adherence to a religious workplace orientation can lead to the belief that a particular company, faith or even race is somehow 'better' or worthier than another.The spirituality associated with such dogmatic proselytizing can take on the form of self-righteousness, and be used as a political tool against others (Nadesan 1999).It is important that workplace spirituality be separated from denomination polemics and the faith blanket in which it is frequently cloaked (Sass 2000:198) as viewing workplace spirituality through the lens of religious traditions is divisive.It excludes those who do not share in the denominational tradition and in some cases may conflict with the social, legal and ethical foundations of business and public administration (Schley 2008).What is preferred instead is not to promote a single religious (or Christian) framework but rather to create a structure and culture in which leaders and followers can respectfully negotiate religious and spiritual diversity (Hicks 2002).Being able to value human cooperation and teamwork, open dialogue and sharing of ideas will contribute to the practice of good workplace spirituality, and is equally a witness to the Christian faith.

Giving preferential treatment to one group over another, or accommodating one whilst imposing upon another, is not aligned with either the study or the application of workplace spirituality.Workplace spirituality therefore has to be inclusive of religious theory and practice.Several articles contend that spirituality should be seen as separate from any religious context (Giacalone & Jurkiewicz 2003;Mitroff & Denton 1999).Smith (1992) notes that all religions espouse the virtues of humility, charity and vision and there is much common ground between all world religions for these principles to be applied to workplace spirituality.Ashmos and Duchon (2000) argue that spirituality is neither about religion nor about getting people to accept a specific belief system.Rather it is about employees who understand themselves as spiritual beings at work whose souls need nourishment, a sense of purpose and meaning and a sense of connectedness to one another and to their workplace community.Whilst the Giacalone and Jurkiewicz (2003) definition includes transcendence and connection, it does not explicitly acknowledge religion as an integral aspect of workplace spirituality.

Concern for the separation of work and spiritual domains is further compounded by a parallel concern for the accommodation of employees' spirituality needs at work, such as the accommodation of religious dress or the need for flexible work schedules.Whilst the potential for abuse is clear, particularly in the form of religious harassment (King 2007:105), the need to accommodate spiritual issues is nonetheless important in maximising both productivity and satisfaction.At the same time, attention should be focused on developing frameworks for negotiating the everyday expressions of spirituality and religion and other potentially conflict-producing features of employee identity and diversity in the workplace (Hicks 2002:394).

It must be noted that whilst there is a distinction between religion and workplace spirituality, a leader's belief system accompanies his or her spirituality.Theory development should recognise that any form of spirituality also includes practices and beliefs (i.e. a religion) and that the accompanying beliefs are an important, if not more important element of the way in which someone's spirituality is manifest in his or leadership.Some studies (Fry 2003;Yukl 2002) describe leader belief systems in terms of values and/or attitudes and/or behaviour.Fry (2003) argues that leaders' values create their attitude, which drives their behaviours.One can imagine that there are numerous other beliefs in the religious or spiritual realms that individuals could hold that might influence their leader action and behaviours, for example, what they believe about corporate social responsibility or about a balanced work and family life.Research concludes that organisations must honour the whole person and the spiritual energy that is at the core of everything (Barrett 2003).

In South Africa, the dichotomy of work and religion is not a subject that has been vigorously debated, especially during the apartheid regime that claimed to uphold Christian values.Generally this dichotomy pervaded the work environment -the belief perhaps that if religion per se was allowed, it may promote a multitude of religious perspectives -thus threatening the neutrality of the workplace (Penceliah 2009:208).More robust discussion on religion and spirituality in the workplace is needed.Religion is valuable in that it also provides a conceptual framework for governance which may promote a leadership praxis linking the theory, practices and ethics of leadership (Duignan & Bhindi 1997).The generally optimistic view of the value and benefits of spirituality in the workplace observed in the literature is consequently eroded by the paucity of empirical research on the subject in South Africa (Van Tonder & Ramdass 2009).Research is needed to test the extent to which spiritual transformation includes the involvement of the Divine (Howard 2002:240) and whether the spiritual or religious beliefs of leaders have an impact on their actions (Smith & Louw 2007:25-27).

Spiritual leadership theory

Over the last few decades significant advances have been made in integrating the theories of leadership and human development (Yukl 2002;Wilber 2000).Whilst empirical research on leadership remained narrowly focused on leadership behaviours, power dimensions, traits and skill and situational contexts, promising new areas of research have emerged that recognise leadership as the manifestation of a leader's spiritual core (Fairholm 1998), leadership as a collective phenomenon (Ashmos & Duchon 2000) and leadership as concerned with the individual's thinking, enquiring, perceiving, valuing and acting in a community rather than an individual context (Eggerts 1998:223).These lines of research suggest the spiritual domain as an integral component of leadership and put forth spirituality as one variable of an integrated leadership development model (Sanders, Hopkins & Geroy 2003;Wilber 2000).The premise of this integrated model is that as development occurs there is a transcending of worldviews and a shift to higher levels of internal locus of control (Sanders et al. 2003), and human growth is achieved through the interplay of individual, community and environment.At the higher stages of development, leaders are deepening their intuition and inner knowing through a shared consciousness with a higher power or transcendence.

Whilst scholars clearly identified spirituality as a central thesis of a new paradigm in organisational and leadership theory, the ontology of spirituality in the workplace closely resembles the literature on leadership in that there are dynamic dimensions or contexts for describing and measuring the phenomenon (Ashmos & Duchon 2000;Cavenaugh 1999).Sometimes these dimensions confound one another; for example, spirituality is an attribute which remains relatively static over time versus the manifestation of spirituality, which can be dynamic and change depending on the situation.Some writers include ethics or team spirit within the boundaries although others do not, and some claim a nexus between spirituality and leadership practices whilst others treat workplace spirituality as an individual phenomenon (Benefiel 2003;Denton 2007;Northouse 2001).So as is evident, the field of study is marked by all of the typical characteristics of paradigm development including a lack of consensus about a definition of workplace spirituality and a lack of clarity about boundaries of the subject in context of leadership.

Most of the organisation theory that is offered in this area comes from the fields of Western religious theology and practice and leadership ethics and values (Blackaby & Blackaby 2001;McNeal 2000;Northouse 2001).Perhaps the most comprehensive theoretical models towards developing a theory of spiritual leadership to date are Fairholm (1998) and Fry (2003).Fairholm (1998) was one of the first scholars to put the terms 'spiritual' and 'leadership' together to explain spirituality in context of workplace leadership, and since then others have attempted to validate his model in order to move the field toward a theory of leadership.Fairholm's (1998) model describes leadership as a personal reality one adopts to make sense of the dynamic interactive process of leadership.He argues for five virtual environments which include: leadership as management, leadership as excellent management, values leadership, cultural leadership and spiritual leadership.On the other hand, Fry (2003:693) defines spiritual leadership as 'the values, attitudes and behaviours that are necessary to intrinsically motivate self and others so that they have a sense of spiritual survival through calling and membership'.According to Fry (2003), spiritual leadership is seen as a causal theory based on an intrinsic motivation model that explores the concepts of positive human health and psychological well-being, character ethics, positive psychology and religion.It is causal, suggesting, for example, that hope/faith lead to vision/mission, which in turn leads to calling.Other authors (Cacioppe 2000;Tischler, Biberman & McKeage 2002) have put forth spiritual leadership models that relate to constructs such as emotional intelligence, ethics, values and leadership models such as charismatic (Conger & Kanungo 1994), stewardship (Block 1993), transformational (Bass & Avolio 1994;Bass 2000) and servant leadership (Greenleaf 1977).These theories show that models are moving away from control towards influence, collaboration and partnership.

What should be required for a more comprehensive and integrated theory of leadership is an acknowledgement that leaders are complex beings who mature and develop over time in relationship to spiritual, emotional, cognitive, social and physical domains.Also, leaders have a need for desired transcendent-related work accomplishments (Sanders et al. 2003).In developing this integrated leadership theory, empirical results of the manifestations of leaders' spiritual beliefs, activities and practices should provide promising new ways to understand how leaders transcend and progress through the stages of human development.

Spiritual leadership and organisational transformation

Research suggests that when considering how to bring spirituality into the workplace, organisational culture needs to be transformed collectively (Denton 2007).This is done by transforming leadership where spiritual practices and values are incorporated into the culture of the organisation.

Spiritual leadership as a model for organisational development and transformation can guide the evolution of positive organisations in which human well-being and organisational level performance can not only co-exist but also be optimised (Dehler & Welsh 1994;Neck & Milliman 1994).Garcia-Zamor (2003:360) proposes that organisations need to establish themselves as worthy organisations, that is, organisations with a higher sense of business purpose.Howard (2002:240) suggests that organisations are exhibiting transformation characteristics when they attempt to use processes that engage people in communication through attempts at dialogue and meta-dialogue, that institute realtime strategy change, that use open space technology and lastly that encourages a culture of appreciative enquiry.These strategies show a commitment toward content (addressing spirituality explicitly) and process (working in ways that release the highest level of human potential).These changes can create a new organisational culture in which employees feel happier and perform better.This results in a culture of sharing and caring which will eventually reach all of the organisation's stakeholders and lead to good organisational performance.Since spiritual leadership taps into the leader's and the follower's fundamental need for spiritual survival and well-being through calling and membership, it has the potential to create vision and value congruence across individual, teams and organisational levels (Fry 2003;Lund Dean & Safranski 2008).It ultimately fosters high levels of organisational commitment and productivity.However, to truly transform an organisation, leaders must be committed to a long-term spiritual vision and have the ability to stick with it over time.

According to Kolodinsky, Giacalone and Jurkiewicz (2008:265-266) the implementation of spirituality in the workplace can be viewed from an organisation-centred perspective, an individual-centered perspective or as interactive workplace spirituality:

• The organisation-based approach suggests that spirituality should be implemented to the organisation as a whole since conflicting preferences and interests between different individuals would impede the process.

Organisations are classified into groups based on their principle of spirituality as religion-based, evolutionary, recovering, socially responsible and values-based (Mitroff & Denton 1999:8-9).• In the individual-centred perspective the organisation would not have a strict spiritual orientation but rather tries to accommodate and encourage spiritual requests from employees.Cash and Gray (2000), who provide a framework for dealing with spiritually related work accommodation, cite studies demonstrating that organisations are actively making reasonable accommodations for employee spirituality (recognising social and personal growth needs and accepting diverse beliefs and self-expression).Accommodations of any sort should reinforce the organisational mission of an innovative, progressive and productive culture.• The third perspective, interactive workplace spirituality, entails the interaction of the individual employee's personal spiritual values with the spiritual values of the organisation.

The Mitroff and Denton (1999) study suggests that since there are many conflicting preferences and interests between individuals, it is not possible to allow individual spirituality; rather, the organisation should be changed as a whole.Mitroff and Denton (1999:9-13) view a best-practice model as one that begins with a values-based organisation and then incorporates aspects of the other spirituality models.For example, the commitment to spirituality is borrowed from the socially responsible organisation that aims to harness the power of business to resolve social problems and allow for morality and accountability in their dealings.

Value-based leadership

Value-based leadership is predicated on shared, strongly internalised values that are advocated and acted on by the leader (Bass & Avolio 1994;House 1996;House & Shamir 1993).Value-based leaders articulate a vision of a better future to energise extraordinary follower motivation, commitment, and performance by appealing to employees' values, enhancing their self efficacy and making their selfworth contingent upon their contribution to the leaders' mission and the collective vision (House & Shamir 1993).

From an ethics and values perspective, leaders have an impact on establishing and reinforcing personal, team and organisational values (Northouse 2001).In an attempt to resolve the tension between workers' own personal and professional values, leaders promote change within their broader social settings.For example, an area in which such personal values are becoming increasingly prominent in the workplace is environmental protection.Many people hold a personal set of moral beliefs about the proper role of the organisation regarding the natural environment.These beliefs are held at the level of the individual and are formed through personal reflection, professional development, and association with other environmentally oriented individuals or cultural groups.With today's changing context of global environmental change, many religions are changing their views on the morality of behaviour towards the environment.The values underlying these beliefs inform an individualised sense of right and wrong that may be at odds with the dominant values in the workplace.With changes in such values come changes in conceptions of right and wrong in workplace behaviour that influence the environment, as well as the role of the manager in setting these conceptions.Many managers now see that role as spiritually motivated (Denton 2007:23).Further, this issue presents the tactics by which these spiritually motivated leaders act as organisational entrepreneurs, expressing their identities by fomenting change within their organisations.In so doing, they act as radicals or subversives, altering the dominant logics, metrics and values of the organisations through localised and discrete efforts at change.In this way, organisations and leaders work together to create the most committed of possible workforces by actively seeking to align professional and personal values.

Organisations are finding that a congruent fit between an individual's values and those of the organisation's culture is tied to organisational success.Value congruence models in psychology and organisational behaviour have looked at the fit between personal and organisational values (Chatman 1989).Barrett (1998Barrett ( , 2003) ) suggests that each level of Maslow's (1954) hierarchy of needs can be thought of as a level of consciousness, and that self-actualisation (the highest state) can be expanded to include four distinct stages in the development of spiritual awareness -transformation, cohesion, inclusion and unity.Barrett's model (2003) assumes that leaders who are able to operate from the full spectrum of consciousness and have a high degree of value alignment with their employees would outperform the market in customer satisfaction and shareholder value.Giacalone and Jurkiewicz (2003) posit that the greater the value congruence across levels, the more individuals will experience transcendence through their work and to the extent the organisation's culture reflects the global shift to post-materialistic altruistic values that tend to be more idealistic and spiritual, the more the individual will have a sense of connection, joy and completeness.When a greater fit exists between personal characteristics and organisational values, a variety of potentially desirable behaviours and attitudes ensues, including longer tenure, better performance and greater satisfaction (Ashforth & Pratt 2003;Chatman 1991).This phenomenon is not lost in today's management world.Companies are finding that employees who act on their personal sense of workplace spirituality are more creative, self-directed, committed and desirable employees and are therefore highly sought after (DeFoore & Renesch 1995;Hoffman n.d.).

Organisational transformation also begins with the willingness of a leader to examine their own values and behaviours.A key is to understand the shadow side of leadership: power, greed, the lure of wealth and the temptation to self-delusion, over-control and vanity.The importance of 'being' and personal integration should be prioritised over 'doing' if a leader is to avoid cynicism and burnout in the intensity of the leadership role.Four essential leader characteristics that followers admire and that give the leader credibility in motivating people to perform include being honest, forward-looking and inspiring in pursuit of a shared vision, and competence (Kouzes & Pozner 1993).

When people perceive their leaders to have high credibility, they are significantly more likely to be organisationally committed and productive.

It seems clear from both the religious and the values-based leadership approaches that leaders must get in touch with their core values and communicate them to followers through their vision and personal actions.Supporting autonomy and decision-making responsibility through self-managed, empowered teams and trusting people and letting them be who they are to use and develop their gifts are also essential.Spiritual leaders lead people through discourse and dialogue and believe that people, when they are involved and properly informed, can make intelligent decisions and can assume responsibility for decisions that affect their lives.It involves leading and managing by using values that drive fear and abuse out of the workplace and engage the hearts and minds of people (Kolodinsky et al. 2008).Hence a key contribution of spirituality to leadership is that leaders must seek to liberate others' responsibility for choices and so encourage personal growth.

Conclusion

A growing number of organisations are moving towards work arrangements that can be described as spiritual.The literature is filled with the promise of what the awareness of spirituality can do in an organisational context.However, lest the subject becomes a fad, researchers must use the utmost care in defining this concept and show how it is different from other concepts that can be used without the controversy of spirituality associated with them.For example, a South African study in the manufacturing industry found that sufficient consensus is emerging to convince institutional managers of the potential significance of workplace spirituality; however, the pragmatics of implementation are everything but uncomplicated (Van Tonder & Ramdass 2009:239).Researchers should also ask whether the foundations of values-based leadership and other concepts of inspired leadership provide a comprehensive treatment without adding new labels or a new theory of leadership to the mix.Denton (2007:27) argues that measurement, whilst desirable, should not be the sole focus of attention.

Even with an absence of measurement, he proposes that the spiritual movement is probably the most significant trend in management since the human-potential movement in the 50s.It appears to be a grassroots movement, as more and more people entertain the notion that work can be meaningful and fulfilling.This trend will endure, simply because it speaks to the deeper needs of the human heart and provides a promising remedy to declining job satisfaction.

In the developing context of the South African workplace that may not have reached the post-materialistic altruistic values of the global community, organisations mostly motivate workers through fear and extrinsic rewards.Hence, to keep the intrinsic motivation of spiritual survival alive is a challenge.However, especially because of contextual realities, spiritual leadership may not be sufficient in this highly unpredictable work world; but it does have certain potential for the transformation and success of organisations motivated by the serious re-evaluation of spiritual and moral values in our society.The workplace can no longer survive under the command and control leadership that was inspired by a mechanistic worldview, or be overwhelmed by the challenge.As Wheatley (1999) suggests:

no-one can hope to lead an organisation by standing outside or ignoring the web of relationships through which all work is accomplished.Leaders are being called to step forward as helpmates.(p.39)

AcknowledgementsCompeting interestsThe author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article.
Foundation of business ethics in contemporary religious thought: The ten commandments perspective. Ali A Gibbs, M , 10.1108/03068299810214089International Journal of Social Economics. 25101998

Transformational leadership and psychological well-being: The mediating role of meaningful work. K A Arnold, J Barling, E K Kelloway, M C Mckee, 10.1037/1076-8922.214.171.124Journal of Occupational Health Psychology. 1232007

Spirituality at work: A conceptualization and measure. D P Ashmos, D Duchon, 10.1177/105649260092008Journal of Management Inquiry. 922000

Institutionalized spirituality: An oxymoron?. B E Ashforth, M G Pratt, Handbook of workplace spirituality and organizational performance. R A Giaclone, C L Jurkiewicz, ArmonkM.E. Sharpe2003

Liberating the corporate soul. R Barrett, 1998Butterworth-HeinemannBoston

Culture and consciousness: Measuring spirituality in the workplace by mapping values. R Barrett, M.E. Sharpe, Armonk. Bass, B.M. & Avolio, B.J.2003. 1994Sage, Thousand OaksImproving organizational effectiveness through transformational leadership

The future of leadership in learning organizations. B M Bass, 10.1177/107179190000700302Journal of Leadership Studies. 32000

Irreconcilable foes? The discourse of spirituality and the discourse of organizational science. M Benefiel, 10.1177/1350508403010002012Organization. 1022003

H Blackaby, R Blackaby, Spiritual leadership, Broadman & Holman. Nashville. PMid200111358694

Stewardship: Choosing service over self-interest, Berrett-Koehler. P Block, 1993San Francisco

Spirituality in the workplace. E H Burack, Journal of Organizational Change Management. 1241999

Creating Spirit at work: Re-visioning organization development and leadership -Part 1. R Cacioppe, 10.1108/01437730010310730The Leadership and Organization Development Journal. 212000

A framework of accommodating religion and spirituality in the workplace. K C Cash, G Gray, 2000Academy of Management14

Spirituality for managers: Context and critique. G F Cavenaugh, 10.1108/09534819910273793Journal of Organizational Change Management. 121999

Improving interactional organizational research: A model of person-organization fit. J A Chatman, 10.5465/AMR.1989.4279063Academy of Management Review. 141989

Matching people and organizations: Selection and socialization in public accounting firms. J Chatman, 10.2307/2393204Administrative Science Quarterly. 361991

Home page. 18 December 2013Christian Business Network in South Africa n.d.

Charismatic leadership in organizations: Perceived behavioural attributes and their measurement. J A Conger, R N Kanungo, 10.1002/job.4030150508Journal of Organizational Behavior. 151994

Rediscovering the soul of business: A renaissance of values. S Covey, B Defoore, J Renesch, 1995. 1995New Leader PressNew York; San FranciscoFirst things first

Spirituality and organizational transformation: Implications for the new management paradigm. G E Dehler, M A Welsh, 10.1108/02683949410070179Journal of Managerial Psychology. 961994

Christian spirituality and contemporary business leadership. L A Delbecq, 10.1108/09534819910282180Journal of Organizational Change Management. 1241999

A framework for spirituality into the workplace. M Denton, World Journal of Management and Economics. 122007

Authenticity in leadership: An emerging perspective. P Duignan, N Bhindi, 10.1108/09578239710170119Journal of Educational Administration. 3531997

Contemplative leadership for entrepreneurial organizations: Paradigms, metaphors, and wicked problems, Quorum Books. N Eggerts, 1998Greenwood Publishing Group

Moved by the spirit: Contextualizing workplace empowerment in American spiritual ideals. M Elmes, C Smith, 10.1177/0021886301371003The Journal of Applied Behavioral Science. 3712001

Perspectives on leadership: From the science of management to its spiritual heart. G W Fairholm, 1998PraegerWestport

An exploratory analysis of definitions and applications of spirituality in the workplace. B Freshman, 10.1108/09534819910282153Journal of Organisational Change Management. 1241999

Towards a theory of spiritual leadership. W Fry, 10.1016/j.leaqua.2003.09.001The Leadership Quarterly. 142003

Maximizing the triple bottom line through spiritual leadership. L W Fry, J W J Slocum, 10.1016/j.orgdyn.2007.11.004Organizational Dynamics. 3712008

Workplace spirituality and organizational performance. J Garcia-Zamor, 10.1111/1540-6210.00295Public Administration Review. 6332003

Handbook of workplace spirituality and organizational performance. R A Giacalone, C L Jurkiewicz, 2003M.E. SharpeNew York

Servant Leadership: A journey into the nature of legitimate power and greatness. R K Greenleaf, 1977Paulist PressC431078New York. PMCid

Spiritual and religious diversity in the workplace: Implications for leadership. D A Hicks, 10.1016/S1048-9843(02)00124-8The Leadership Quarterly. 13022002

Reconciling professional and personal value systems: The spiritually motivated manager as organizational entrepreneur. A J N Hoffman,

Path -goal theory of leadership: Lessons, legacy, and a reformulated theory. R J House, 10.1016/S1048-9843(96)90024-7The Leadership Quarterly. 731996

Toward the integration of transformational, charismatic, and visionary theories. R J House, B Shamir, Leadership theory and research: Perspectives and directions. M Chemmers, R Ayman, OrlandoAcademic Press1993

A spiritual perspective on learning in the workplace. S Howard, 10.1108/02683940210423132Journal of Managerial Psychology. 1732002

Religion, spirituality, and the workplace: Challenges for public administration. S M King, 10.1111/j.1540-6210.2006.00700.xPublic Administration Review. 672007

Defining spirit at work: Common ground. V Kinjerski, B Skrypnek, 10.1108/09534810410511288Journal of Organizational Change Management. 1712004

Workplace values and outcomes: Exploring personal, organizational and interactive workplace spirituality. R W Kolodinsky, R A Giacalone, C L Jurkiewicz, 10.1007/s10551-007-9507-0Journal of Business Ethics. 812008

J M Kouzes, B Z Pozner, Credibility, Jossey-Bass. San Francisco. PMid199310127049

Coming out of the closet: Negotiating spiritual expression in the workplace. M Lipps-Wiersma, C Mills, 10.1108/02683940210423097Journal of Managerial Psychology. 1732002

No harm, no foul? Organizational intervention in workplace spirituality. K Lund Dean, S R Safranski, 10.1080/01900690701590751International Journal of Public Administration. 312008

Motivation and personality. A H Maslow, 1954Harper & RowNew York

Exploring linkages among transformational leadership, workplace spirituality and well-being in health care workers. M C Mckee, C Driscoll, K E Kelloway, E Kelly, 10.1080/14766086.2011.599147Journal of Management, Spirituality and Religion. 832011

A work of the heart: understanding how God shapes spiritual leaders. R Mcneal, Jossey-Bass. 2000

A spiritual audit of corporate America: A hard look at spirituality, religion, and values in the workplace. I I Mitroff, E A Denton, Jossey-Bass. 1999

Towards living with meaning and purpose: Spiritual perspectives of people at work. D L Mohan, J S Uys, 10.4102/sajip.v32i1.228SA Journal of Industrial Psychology. 3212006

R S Moxley, Leadership and spirit, Jossey-Bass. San Francisco. PMCid2000C59022

The discourses of corporate spiritualism and evangelical capitalism. M H Nadesan, 10.1177/0893318999131001Management Communication Quarterly. 131999

Thought self-leadership: Finding spiritual fulfillment in organizational life. C P Neck, J F Milliman, 10.1108/02683949410070151Journal of Managerial Psychology. 961994

P G Northouse, Leadership: Theory and practice. Thousand OaksSage Publications2001

The spiritual dimension of individuals in the context of the workplace', Alternation, Supplement. Y Penceliah, 2009

Building an ideological fortress: The role of spirituality, encapsulation and sensemaking. M Pratt, 10.1080/10245280008523537Organizations & Societies. 612000Studies in Culture

The cultural creatives. P Ray, S Anderson, 2000Harmony BooksNew York

Workplace spirituality and organizational commitment: An empirical study. A Rego, M Pina E Cunha, 10.1108/09534810810847039Journal of Organizational Change Management. 2112008

From transactional to transcendental: Toward an integrated theory of leadership. J E Sanders, W E Hopkins, G D Geroy, 10.1177/107179190300900402Journal of Leadership & Organizational Studies. 942003

Characterizing organizational spirituality: An organizational communication culture approach. J S Sass, 10.1080/10510970009388520Communications Studies. 512000

Legal aspects of spirituality in the workplace. D G Schley, 10.1080/01900690701590744International Journal of Public Administration. 312008

The world's religions. H Smith, 1992Peter SmithNew York

Conceptualization of the spiritual life dimension: A personal and professional leadership perspective. D P J Smith, M Louw, 10.4102/sajhrm.v5i1.104SA Journal of Human Resource Management. 512007

Linking emotional intelligence, spirituality and workplace performance. L Tischler, J Biberman, R Mckeage, 10.1108/02683940210423114Journal of Managerial Psychology. 1732002

A spirited workplace: Employee perspectives on the meaning of workplace spirituality. C L Van Tonder, P Ramdass, 10.4102/sajhrm.v7i1.207SA Journal of Human Resource Management. 712009

M Wheatley, Leadership and the new science: Learning of organizations from an orderly universe, Berett-Koehler. San Francisco1999

A theory of everything: Integral vision for business, politics, science, and spirituality, Shambhala. K Wilber, 2000C1885698Boston. PMCid

G A Yukl, PMid:11820775Leadership in organizations. Upper Saddle RiverPrentice Hall2002


Nutrition Journal Metabolic effects of low glycaemic index diets
2009

Gabriela Radulian
Carol Davila" University of Medicine
BucharestRomania

"N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases
BucharestRomania

Foundation for Healthy Nutrition
BucharestRomania

Emilia Rusu email@example.com
Carol Davila" University of Medicine
BucharestRomania

"N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases
BucharestRomania

Foundation for Healthy Nutrition
BucharestRomania

Andreea Dragomir
"N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases
BucharestRomania

Foundation for Healthy Nutrition
BucharestRomania

Mihaela Posea
"N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases
BucharestRomania

Nutrition Journal Metabolic effects of low glycaemic index diets

Nutrition Journal
85200910.1186/1475-2891-8-5Received: 20 November 2007 Accepted: 29 January 2009BioMed Central Page 1 of 8 (page number not for citation purposes) Review * Corresponding author This article is available from: http://www.nutritionj.com/content/8/1/5
The persistence of an epidemic of obesity and type 2 diabetes suggests that new nutritional strategies are needed if the epidemic is to be overcome. A promising nutritional approach suggested by this thematic review is metabolic effect of low glycaemic-index diet.The currently available scientific literature shows that low glycaemic-index diets acutely induce a number of favorable effects, such as a rapid weight loss, decrease of fasting glucose and insulin levels, reduction of circulating triglyceride levels and improvement of blood pressure.The long-term effect of the combination of these changes is at present not known.Based on associations between these metabolic parameters and risk of cardiovascular disease, further controlled studies on low-GI diet and metabolic disease are needed.

Reviews

Obesity is a major global health problem that has been associated with highly occurring disorders such as hypertension, type 2 diabetes, hyperinsulinemia, dyslipidemia, atherosclerosis and certain types of cancer [1,2]. More than one billion adults worldwide are overweight, with ≥ 300 million clinically obese [3]. The epidemic of overweight and obesity, which is rising worldwide, inflicts not only a reduced quality of life and large healthcare-associated costs, but also an increased risk of death [4].

Trend analysis in relation to obesity suggests that in most countries the majority of the population is less active than they should be for maintaining good health, while they are simultaneously eating more than they need [5]. Weight gain is considered as a consequence of excessive energy intake as compared with energy expenditure, while successful weigh loss depends upon achieving negative energy balance [2]. In this context, environmental influences, such as an inactive lifestyle and the consumption of energy-dense diets, appear of overriding importance on excessive weight gain in addition to genetic predisposition [6].

Weight management in the obese may take into account the energy intake and the dietary macronutrient distribution.

A number of nutritional approaches and diets with different proportions of lipids, proteins and carbohydrates are being investigated, which may be energy restricted or prescribed [7,8]. Not only the different macronutrient com-position is of interest, but also the micronutrient content and specific dietary components could also be important [9].

The prescription of nutritionally equilibrated low-energy diets is a common strategy for body-weight reduction [10]. Table 1. Influence of the different diets on weight loss [11,12] Low energetic diets can achieve short-term weight loss, but often the slimming process is not sustainable in the long term [13].

The traditional nutritionally adequate low energy diets frequently failed to promote stable weight losses, and the explanations for such limited success were mostly the "poor adherence" to specific low-energy diets.

A study about the effect of energy restriction and diet composition on weight loss and changes in plasma lipids and glucose levels concluded that all energy-restricted diets improve glucose control independently of diet composition, while only the lipoprotein profile was affected by the macronutrient composition [14].

Recently, diets low in carbohydrate (low-carbohydrate diets) have become the focus of international attention since the recent WHO recommendations to reduce the overall consumptions of sugars and some health professionals recommendations to reduce the consumption of rapidly digestible starches that lead to high glucose responses [15].

A study about the influence of low-carbohydrate or lowfat diet on weight loss and risk factors for atherosclerosis in the elderly, obese patients with type 2 diabetes mellitus, shows that the results were more obvious in patients with carbohydrate-restricted diet, with a relative improvement in insulin sensitivity and triglycerides levels [12].

High protein low-carbohydrate diets have been proposed as an alternative to conventional diets, in order to reduce or treat the risk of obesity, CVD and type 2 diabetes mellitus [16].

But this carbohydrate restriction produces a depletion of glycogen stores leading to excretion of bound water, and ketogenic effect.

It has been proposed that the glycaemic index of foods can influence body-weight control [17]. Short-term studies suggest that low-glycaemic index carbohydrates and fiber intake could delay hunger and decrease subsequent energy intake compared with high-glycaemic index foods [18].

The glycaemic index (GI) is defined as "the incremental area under the blood glucose curve following ingestion of a test food, expressed as a percentage of the corresponding area following an equivalent load of a reference carbohydrate, either glucose or white-wheat bread" [19,20].

The GI of a food will vary depending on the rate of digestion. The faster the digestion of a food, the higher is the GI value (>70).

Also, the GI is defined as Food with a low GI (≤ 70) are considered to be favorable in terms of health, particularly for the prevention of obesity, T2DM, and CVD. The GI is affected by a number of factors: 4 the physical properties of food (i.e., water content); 5 the presence of viscous soluble fibers; ripeness, cooking, or processing that renders the carbohydrate more digestible (e.g., starch) will increase the GI;

6 the presence of other factors (i.e., insoluble fiber as found in whole intact grains) that slow absorption of the carbohydrate.

TYPE OF DIET WEEKS WEIGHT LOSS WAIST LOSS

Low energy diets (800-1200 kcal/zi) 14 weeks 7-13 kg 10 cm waist Very-low energy diet (400-800 kcal/zi) 2 weeks 4-5 kg -High protein diet (30%) 12 weeks 7-9, 5 kg 8-9 cm waist Low fat diet (20%) 24 weeks 5-6, 5 kg 6-7 cm waist After consumption of high GI foods, there is a large, rapid rise in the level of blood glucose, a large insulin response, and glucagons release is strongly inhibited. Low-GI foods may also delay the return of hunger, by slowing gastric emptying. Many low-GI foods are high in fiber content, which prolongs the distension of the gastrointestinal tract, causing increased and prolonged secretion of the gut peptides cholecystokinin, ghrelin, glucagons, glucagons-likepeptid-1, and glucose-dependent insulinotropic polypeptide, all of which have been suggested as potential satiety factors [21,22].

A. Metabolic effects of low glycaemic-index diets

Observational studies indicate that the GI of the diet may be an important determinant of metabolic risk. The major sources of carbohydrate in the Western diet (highlyrefined cereal and potato products) tend to have high GI values, which has been linked to the widespread occurrence of type 2 diabetes and CVD [23].

GI has been shown to be positively associated with the prevalence of the metabolic syndrome and insulin resistance in a cross -sectional study of 2834 subjects from the Framingham Offspring cohort [24]. Odds of having metabolic syndrome were reported to be 41% higher in the highest quintile of dietary GI compared with the lowest quintile (median GI values 84 and 72 respectively), and insulin resistance was found to be increased across quintiles (p < 0.001) [23].

Associations have also been reported between GI and both unfavorable lipid profiles and raised inflammatory status. In 280 women aged 45-70 years from the Nurses Health Study fasting triacylglycerol levels were shown to be positively related to GI [25]. Serum HDL levels have been found to be negatively related to GI in 1420 subjects aged 18-64 years from the 1986-7 Survey of Britain Adults 18-64 years [26], in which GI was the only dietary factor found to be significantly associated with HDL levels in multiple linear-regression analysis. Plasma levels of high-sensitivity C-reactive protein, a sensitive marker of systemic inflammation, were found to be positively associated with both GI and GL in 244 women from the Nurses' Health Study, aged 45-82 years, with a stronger relationship in overweight women than in normal-weight women [27]. Weight loss is an additional potential mechanism by which low-GI diets may contribute to reduced risk of metabolic syndrome.

Induction of a rapid initial weight loss with low-carbohydrates diets may be partly explained by a reduction in overall caloric intake, which may be the result of a great limitation of food choices by the requirements of minimizing carbohydrates intake [28,29], to the initial increase in circulating β-hydroxybutyrate, which may suppress appetite [30] and to the satiating effect of low-carbohydrates diets containing relatively high amounts of protein [31,32]. Some of the initial weight loss may also be explained by a reduction of glycogen stores from liver (5% of liver weight) and muscle (1% of muscle weight). Each gram of glycogen is stored with approximately 3 g of water [33]. Therefore a weight loss of 1-2 kg can theoretically be achieved within the first week of the diet because of substantial glycogen reductions in liver and muscle and excretion of the liberated water in urine [15]. Depending on the rate of glycogen depletion, this process may last up to 7-14 days, after which weight loss slows [34]. It should be noticed in this respect that loss of glycogen and water is not a true measure of weight loss, as their stores will be replenished once the diet is stopped [15].

The rapid large rise in blood glucose following consumption of high-GI food triggers a large insulin response and strongly inhibits glucagons release. For most foods, a good correlation exists between glucose and insulin responses, with high-GI foods eliciting large insulin responses [35], which trigger rapid uptake of nutrients by insulin-responsive tissues and suppress nutrient mobilization. Glucose uptake and glycogen synthesis in skeletal muscle and liver, and lipogenesis in adipose tissue, are increased. Simultaneously, gluconeogenesis and glucose out put by liver and lipolysis are suppressed.

Low-GI diets give a more stable diurnal profile, reducing postprandial hyperglycaemia and hyperinsulinaemia, and attenuating late postprandial rebounds in circulating free fatty acids, all factors that exacerbate various components of the metabolic syndrome [23].

B. Insulin resistance and insulin secretion

High circulating free fatty acids levels result in lipid accumulation in skeletal muscle and liver, causing insulin resistance in these normally insulin-responsive tissues [36,37], which reduces insulin-stimulated glycogen synthesis in skeletal muscle (the primary pathway for nonoxidative glucose disposal in normal subjects [38] and decrease the ability of insulin to suppress hepatic glucose production and output.

Insulin sensitivity may be negatively affected in the long term as low-carbohydrates, high-fat diets favor an increase of plasma circulating free fatty acids [39,40], which under usual dieting conditions is typically associated with many insulin-resistant states in humans [41,42]. Altered fatty acid metabolism contributes to insulin resistance because of alterations in the partitioning of fat between the adipocytes and muscle or liver [15]. Accumulation of fatty acid and fatty acid metabolites in these insulin-responsive tissues leads to acquired insulin signaling defects and insulin resistance resulting in a reduced glucose transport [43]. The later is thought to results from fatty-acid-induced alterations in upstream insulin signaling events, resulting in decreased GLUT 4 translocation to the plasma membrane. Increased level of intracellular fatty acid metabolites, such as diacylglycerol, fatty acyl CoA's, or ceramides activates a serine/threonine kinase cascade, possibly initiated by protein kinase C. The latter leads to a non-desired phosphorylation of serine/threonine sites on insulin receptor substrates, which then fail to associate with or to activate PI 3-kinase, resulting in decreased activation of glucose transport and other downstream events [15]. It is observed an inverse relationship between adiponectin and insulinsensivity. Adiponectin is similar in structure to TNF-α (tumor necrosis factor α) which paradoxically appears to be increased in abdominal adipose tissue. Increases in proinflammatory cytokines (interleukine 6, TNF-α, resistin, C-reactiv protein -CRP) reflect overproduction by the expanded adipose tissue mass [44,45]. All of these factors contribute to the exaggerated release of free fatty acids from abdominal adipocytes into the portal system. Free fatty acids have deleterious effects on insulin uptake by the liver and contribute to the increased hepatic gluconeogenesis and hepatic glucose release observed in central obesity [46].

High glucose levels have a glucotoxic effect on β-cells, probably as a result of free radical oxidative damage [47]. Hyperinsulinaemia may reduce β-cell function by causing excess amyloid deposits [48]. High free fatty acids levels lead to triacylglycerol accumulation in β-cells, which reduces insulin secretion [49]. Accordingly, by reducing hyperglycaemia, hyperinsulinemia and free fatty acids lev-Low GI diets and metabolic syndrome Figure 1 Low GI diets and metabolic syndrome. Description: Low GI diets decrease insulin resistance and insulin levels, causing plasma glucose reduction, decrease free fatty acids levels, inflammation and endothelial dysfunction, causing an important reduction of cardiovascular risk factors.

els, low-GI foods may decrease the factors contributing to β-cell failure [23].

C. Dyslipidaemia

Hyperinsulinaemia and insulin resistance are significantly correlated to dyslipidaemia and contribute to the characteristic alteration of plasma lipid profile associated with obesity.

Low-GI diets may reduce insulin-stimulated activity of 5hydroxi-3-methylglutaryl-CoA reductase, the rate-limiting enzyme involved in cholesterol synthesis, by reducing insulin levels. Dietary fiber tends to reduce bile acid and cholesterol re-absorption from the ileum, which may inhibit hepatic cholesterol synthesis [47].

Low-carbohydrates diets as well as low-fat diets significantly decreased several biomarkers of inflammation (CRP, TNF-α, IL-6), which play a key role in all stages of the pathogenesis of atherosclerosis [15].

D. Cardiovascular risk factors

Hyperglicaemia is a continuous risk factor for CVD morbidity and mortality.

The effects of cytokines on peripheral tissues with increased intracellular lipids also lower cellular insulin sensitivity: the surge in lipids promotes proliferation of the vasa vasorum of the arterial media and apoptosis by the medial macrophages with a further release of cytokines. There is an additional complex relationship through an associated pro-inflammatory state and altera- Figure 2 Regulation of insulin secretion by glucose and lipids. Description: Insulin secretion is influenced by plasma glucose and lipids that activate on one hand glycolysis and production of pyruvate, and on the other hand β-oxidation and ATP synthesis.

Regulation of insulin secretion by glucose and lipids

tions in coagulation. A rise in blood viscosity is induced by the release of profibrinogen and plasminogen activator inhibitor 1 from adipocytes with a fall in plasminogen activator. These changes may explain the role of obesity as a promoter of intracellular inflammatory processes that result in arterial damage. Ethnic differences in CRP may explain some of the variation observed in insulin resistance across populations with comparable weight gain and associated medical complications [46].

A low-GI diet may have beneficial effects on thrombolytic function. The activity of plasminogen activator inhibitor-1, a thrombolytic factor that increases clot and plaque formation, has been found to be 53% lower after 24 days on a low -GI diet compared with a high-GI diet in twenty subjects with type 2 diabetes [50].

Long-term studies are clearly required, as recently, an increased plasma homocysteine level (+6.6%) was observed in individuals that follow strictly a low-carbohydrates diet for several months [51]. In contrast, a low-fat diet induced a decrease of plasma homocysteine by 6-8%. This may be an important observation as the relationship between total plasma homocysteine and CVD is dose dependent and independent of other risk factors. In humans, the effects of homocysteine on endothelial and vascular function and blood coagulation provide explanations for increased CVD risk [15,52,53].

The effects of increased body fatness on cardiovascular function can be predicted. Total body oxygen consumption is increased because of an expanded lean tissue mass and metabolically active adipose tissue, and this is accompanied by an absolute increase in cardiac output. The total blood volume in obesity is increased in proportion to body weight. This increase in blood volume contributes to an increase to the left ventricular pre-load and an increase in resting cardiac output. The increased demand for cardiac output is achieved by an increase in stroke volume: an increase in stroke volume results from an increase in diastolic filling of the left ventricle. This thickening of the wall with dilatation results in eccentric hypertrophy. The cardiovascular adaptation to the increased intravascular volume of obesity may not completely restore normal homodynamic function. Marked systolic dysfunction occurs when the ventricle can no longer adapt to volume overload. Dilatation of the left ventricle cavity radius leads to a decline in ventricular contractility. A combination of systolic and diastolic dysfunction progresses to heart failure [46,54]. Hyperglicaemia exacerbates oxidative stress, which is associated with inflammation, increased blood pressure, accelerated clot formation and decreased endothelium-dependent blood flow [47,55], and which may also worsen insulin resistance [56].

Conclusion

Long term compliance to a low-GI diet may induce favorable metabolic effects.

A diet high in fruits and vegetables, whole grains and low fat dairy products are important for weight loss.

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 [47,49,[55][56][57].

Based on associations between these metabolic parameters and risk of disease, further controlled studies on low-GI diet and metabolic disease are needed [58,59].

Data from long term clinical trials on the metabolic effects on different diets are needed in this area.

Fig. 1 .
1Low GI diets and metabolic syndrome.

Fig. 2Regulation
2Regulationof insulin secretion by glucose and lipids (adapted by Brand et al. (2004). Free Radic. Biol. Med.).

Table 1 :
1Influence of different diets on weight loss.
(page number not for citation purposes)
the type of carbohydrate (glucose, 138; maltose, 105; saccharose, 75; fructose, 30); 2 the fat and protein content of food (a lower GI is associated with a slowing of gastric emptying); 3 acidity affects gastric emptying and hence the GI a food, the addition of citric acid or other fruits will therefore lower the GI;
AcknowledgementsResearch was supported by "N. Paulescu" Institute of Diabetes, Nutrition and Metabolic Diseases" Bucharest, University of Medicine "Carol Davila" Bucharest and Foundation for Healthy Nutrition. A part of this study was supported by the Romanian National Authority for Scientific Research as a part of the PNCDI 2 program DIADIPOHEP 41-008/2007. Also, no other persons but the mentioned authors participated in the writing and conception of this article. The article was not published or submitted to other journals. Author Gabriela Radulian participated in collection of data and drafted the manuscript. The other authors also collected information and helped to draft the manuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Publish with Bio Med Central and every scientist can read your work free of charge http://www.nutritionj.com/content/8/1/5
Obesity: basic science and medical aspects relevant to anaesthetist. M H Cheah, P C Kam, Anaesthesia. 60Cheah MH, Kam PC: Obesity: basic science and medical aspects relevant to anaesthetist. Anaesthesia 2005, 60:1009-1021.

Different dietary strategies for weight loss in obesity: role of energy and macronutrient content. I Abete, M D Parra, M A Zulet, J A Martßnez, Nutrition Research Reviews. 19Abete I, Parra MD, Zulet MA, Martßnez JA: Different dietary strat- egies for weight loss in obesity: role of energy and macronu- trient content. Nutrition Research Reviews 2006, 19:5-17.

World Health Organization: The World Health Report 2002: Reducing Risks, Promoting Healthy Life Geneva: WHO. World Health Organization: The World Health Report 2002: Reducing Risks, Promoting Healthy Life Geneva: WHO; 2002.

The nutrition transition: worldwide obesity dynamics and their determinants. B M Popkin, P Gordon-Larsen, International Journal of Obesity and Related Metabolic Disorders. 28Popkin BM, Gordon-Larsen P: The nutrition transition: world- wide obesity dynamics and their determinants. International Journal of Obesity and Related Metabolic Disorders 2004, 28:S2-S9.

Dietary strategies for the prevention of obesity. S A Jebb, Proceedings of the Nutrition Society. 64Jebb SA: Dietary strategies for the prevention of obesity. Pro- ceedings of the Nutrition Society 2005, 64:217-227.

The prevention and treatment of overweight and obesity. Summary of the advisory report by the Health Council of the Netherlands. H C Kemper, M Stasse-Wolthuis, W Bosman, Netherlands Journal of Medicine. 62Kemper HC, Stasse-Wolthuis M, Bosman W: The prevention and treatment of overweight and obesity. Summary of the advi- sory report by the Health Council of the Netherlands. Neth- erlands Journal of Medicine 2004, 62:10-17.

Efficacy and safety of low-carbohydrate diets: a systemic review. D M Bravata, L Sanders, J Huang, H M Krumholz, I Olkin, C D Gardner, D M Bravata, Journal of the American Medical Association. 289Bravata DM, Sanders L, Huang J, Krumholz HM, Olkin I, Gardner CD, Bravata DM: Efficacy and safety of low-carbohydrate diets: a systemic review. Journal of the American Medical Association 2003, 289:1837-1850.

Medical nutrition therapy for the treatment of obesity. R A Plodkowski, S T St Jeor, Endocrinology and Metabolism Clinics of North America. 32Plodkowski RA, St Jeor ST: Medical nutrition therapy for the treatment of obesity. Endocrinology and Metabolism Clinics of North America 2003, 32:935-965.

Nutrientes y otros components de los alimentos implicados en la regulaciün del peso corporal (Nutrients and other food components implicated in the regulation of body weight). C Rodriguez, Martßnez De Morentin, B , Parra Mad, S Perez, J A Martinez, Revista Española de Obesidad. 8Rodriguez C, Martßnez de Morentin B, Parra MaD, Perez S, Martinez JA: Nutrientes y otros components de los alimentos implica- dos en la regulaciün del peso corporal (Nutrients and other food components implicated in the regulation of body weight). Revista Española de Obesidad 2005, 8:5-11.

Finer N: Low-calorie diets and sustained weigh loss. Obesity Research. 9Finer N: Low-calorie diets and sustained weigh loss. Obesity Research 2001, 9:290S-294S.

Clinical obesity in adults and children. P G Kopelman, I D Caterson, W H Dietz, Blackwell Publishing22second editionKopelman PG, Caterson ID, Dietz WH: Clinical obesity in adults and children. Volume 22. second edition. Blackwell Publishing; 2006:327-349.

The effects of low carbohydrate diet as compared with a low fat diet in elderly patients with type 2 diabetes mellitus. G Radulian, E Rusu, A Dragomir, M Stoian, M Vladica, 56448Journal of the aaamerican Diabetes Association. suppl 1Radulian G, Rusu E, Dragomir A, Stoian M, Vladica M: The effects of low carbohydrate diet as compared with a low fat diet in eld- erly patients with type 2 diabetes mellitus. Journal of the aaa- merican Diabetes Association 2007, 56(suppl 1):A448.

Advice on lowfat diets for obesity. S Pirozzo, C Summerbell, C Cameron, P Glasziou, Cochrane Database Systematic Review. 3640Pirozzo S, Summerbell C, Cameron C, Glasziou P: Advice on low- fat diets for obesity. Cochrane Database Systematic Review 2002:CD003640.

Effect of energy restriction, weight loss, and diet composition on plasma lipids and glucose in patients with type 2 diabetes. L K Heilbronn, M Noakes, P M Clifton, Diabetes Care. 22Heilbronn LK, Noakes M, Clifton PM: Effect of energy restriction, weight loss, and diet composition on plasma lipids and glu- cose in patients with type 2 diabetes. Diabetes Care 1999, 22:889-895.

Low carbohydrate diets: nutritional and physiological aspects. A Adam-Perrot, P Clifton, F Brouns, Obesity Reviews. 7Adam-Perrot A, Clifton P, Brouns F: Low carbohydrate diets: nutritional and physiological aspects. Obesity Reviews 2006, 7:49-58.

Effect of an energyrestricted, high-protein, low-fat diet relative to a conventional high-carbohydrate, low-fat diet on weight loss, body composition, nutritional status, and markers of cardiovascular health in obese women. M Noakes, J B Keogh, P R Foster, P M Clifton, American Journal of Clinical Nutrition. 81Noakes M, Keogh JB, Foster PR, Clifton PM: Effect of an energy- restricted, high-protein, low-fat diet relative to a conven- tional high-carbohydrate, low-fat diet on weight loss, body composition, nutritional status, and markers of cardiovascu- lar health in obese women. American Journal of Clinical Nutrition 2005, 81:1298-1306.

Carbohydrate and weight control: where do we stand? Current Opinion in Clinical Nutrition and Metabolic Care. K J Acheson, 7Acheson KJ: Carbohydrate and weight control: where do we stand? Current Opinion in Clinical Nutrition and Metabolic Care 2004, 7:485-492.

Glycaemic index and satiety. S B Roberts, Nutrition in Clinical Care. 6Roberts SB: Glycaemic index and satiety. Nutrition in Clinical Care 2003, 6:20-26.

Glycaemic index of foods: a physiological basis for carbohydrate exchange. D J Jenkins, T M Wolever, R H Taylor, H Barker, H Fielden, J M Baldwin, A C Bowling, H C Newman, A L Jenkins, D V Goff, American Journal of Clinical Nutrition. 34Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, Bowling AC, Newman HC, Jenkins AL, Goff DV: Glycaemic index of foods: a physiological basis for carbohydrate exchange. American Journal of Clinical Nutrition 1981, 34:362-366.

Food and Agriculture Organization/World Health Organization: Carbohydrates in Human Nutrition. FAO Food and Nutrition Paper. 66Rome: FAOFood and Agriculture Organization/World Health Organization: Car- bohydrates in Human Nutrition. Report of a Joint FAO/ WHO Expert Consultation. In FAO Food and Nutrition Paper Vol- ume 66. Rome: FAO; 1998.

Should obese patients be counselled to follow a low-glycaemic index diet? Yes. D B Pawlak, C B Ebbeling, D S Ludwig, Obesity reviews. 3Pawlak DB, Ebbeling CB, Ludwig DS: Should obese patients be counselled to follow a low-glycaemic index diet? Yes. Obesity reviews 2002, 3:235-243.

Glycemic index and metabolic risk. G Radulian, International Journal of Metabolism by fax. 17Radulian G: Glycemic index and metabolic risk. International Journal of Metabolism by fax 2007, X(17):.

Glycaemic index and metabolic disease risk. Proceedings of the Nutrition Society. L M Aston, 65Aston LM: Glycaemic index and metabolic disease risk. Pro- ceedings of the Nutrition Society 2006, 65:125-134.

Carbohydrate nutrition, insulin resistance, and the prevalence of the metabolic syndrome in the Framingham Offspring Cohort. N M Mckeown, J B Meigs, S Liu, E Saltzman, P W Wilson, P F Jacques, Diabetes Care. 27McKeown NM, Meigs JB, Liu S, Saltzman E, Wilson PW, Jacques PF: Carbohydrate nutrition, insulin resistance, and the preva- lence of the metabolic syndrome in the Framingham Off- spring Cohort. Diabetes Care 2004, 27:538-546.

Dietary glycemic load assessed by food-frequency questionnaire in relation to plasma high-density-lipoprotein cholesterol and fasting plasma triacylglycerols in postmenopausal women. S Liu, J E Manson, M J Stampfer, M D Holmes, F B Hu, S E Hankinson, W C Willett, American Journal of Clinical Nutrition. 73Liu S, Manson JE, Stampfer MJ, Holmes MD, Hu FB, Hankinson SE, Willett WC: Dietary glycemic load assessed by food-fre- quency questionnaire in relation to plasma high-density-lipo- protein cholesterol and fasting plasma triacylglycerols in postmenopausal women. American Journal of Clinical Nutrition 2001, 73:560-566.

Glycaemic index as a determinant of a serum HDL-cholesterol concentration. G Frost, A A Leeds, C J Dore, S Madeiros, S Brading, A Dornhorst, Lancet. 353Frost G, Leeds AA, Dore CJ, Madeiros S, Brading S, Dornhorst A: Glycaemic index as a determinant of a serum HDL-choles- terol concentration. Lancet 1999, 353:1045-1048.

Relation between a diet with a high glycaemic load and plasma concentrations of high-sensitivity C-reactive protein in middle-aged women. S Liu, J E Manson, J E Buring, M J Stampfer, W C Willett, P M Ridker, American Journal of Clinical Nutrition. 75Liu S, Manson JE, Buring JE, Stampfer MJ, Willett WC, Ridker PM: Relation between a diet with a high glycaemic load and plasma concentrations of high-sensitivity C-reactive protein in middle-aged women. American Journal of Clinical Nutrition 2002, 75:492-498.

A randomized trial comparing a very low carbohydrate diet and a calorierestricted low-fat diet on body weight and cardiovascular risk factors in healthy women. B J Brehm, R J Seeley, S R Daniels, D Da, J Clin Endocrinol Metab. 88Brehm BJ, Seeley RJ, Daniels SR, D'alessio DA: A randomized trial comparing a very low carbohydrate diet and a calorie- restricted low-fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab 2003, 88:1617-1623.

Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. S B Sondike, N Copperman, M S Jacobson, J Pediatr. 142Sondike SB, Copperman N, Jacobson MS: Effects of a low-carbo- hydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. J Pediatr 2003, 142:253-258.

Effects of a hypocaloric, low-carbohydrate diet on weight loss, blood lipids, blood pressure, glucose tolerance, and body composition in free-living overweight women. K A Meckling, M Gauthier, R Grubb, J Sanford, Can J Physiol Pharmacol. 80Meckling KA, Gauthier M, Grubb R, Sanford J: Effects of a hypoca- loric, low-carbohydrate diet on weight loss, blood lipids, blood pressure, glucose tolerance, and body composition in free-living overweight women. Can J Physiol Pharmacol 2002, 80:1095-1105.

High-protein, low-fat diets are effective for weight loss and favorably alter biomarkers in healthy adults. C S Johnston, S L Tjonn, P D Swan, J Nutr. 134Johnston CS, Tjonn SL, Swan PD: High-protein, low-fat diets are effective for weight loss and favorably alter biomarkers in healthy adults. J Nutr 2004, 134:586-591.

A reduced ratio of dietary carbohydrate to protein improves body composition and blood lipid profiles during weight loss in adult women. D K Layman, R A Boileau, D J Erickson, J E Painter, H Shiue, C Sather, D D Christou, J Nutr. 133Layman DK, Boileau RA, Erickson DJ, Painter JE, Shiue H, Sather C, Christou DD: A reduced ratio of dietary carbohydrate to pro- tein improves body composition and blood lipid profiles dur- ing weight loss in adult women. J Nutr 2003, 133:411-417.

Influence of injury and nutrition on muscle water electrolytes: effect of elective operation. J Bergstrom, P Furst, B U Holmstrom, E Vinnars, J Askanasi, D H Elwyn, C B Michelsen, J M Kinney, Ann Surg. 193Bergstrom J, Furst P, Holmstrom BU, Vinnars E, Askanasi J, Elwyn DH, Michelsen CB, Kinney JM: Influence of injury and nutrition on muscle water electrolytes: effect of elective operation. Ann Surg 1981, 193:810-816.

Low-carbohydrate diets and realities of weight loss. G A Bray, JAMA. 289Bray GA: Low-carbohydrate diets and realities of weight loss. JAMA 2003, 289:1853-1855.

Low glycaemic -index foods. I Björck, H Liljeberg, E Östman, British Journal of Nutrition. 831SupplBjörck I, Liljeberg H, Östman E: Low glycaemic -index foods. Brit- ish Journal of Nutrition 2000, 83(Suppl 1):S149-S155.

Adipose tissue and the insulin resistance syndrome. K N Frayn, Proceedings of the Nutrition Society. 60Frayn KN: Adipose tissue and the insulin resistance syndrome. Proceedings of the Nutrition Society 2001, 60:375-380.

Pathogenic of skeletal muscle insulin resistance in type 2 diabetes mellitus. K F Petersen, G I Shulman, American Journal of Cardiology. 90Petersen KF, Shulman GI: Pathogenic of skeletal muscle insulin resistance in type 2 diabetes mellitus. American Journal of Cardi- ology 2002, 90:11G-18G.

Muscle triglyceride and insulin resistance. D E Kelley, B H Goodpaster, L Storlien, Annual Review of Nutrition. 22Kelley DE, Goodpaster BH, Storlien L: Muscle triglyceride and insulin resistance. Annual Review of Nutrition 2002, 22:325-346.

Effects of the ketogenic diet in the glucose transporter 1 deficiency syndrome. J Klepper, S Dienfenbach, A Kohlschutter, T Voit, Prostaglandins Leukot Essent Fatty Acids. 70Klepper J, Dienfenbach S, Kohlschutter A, Voit T: Effects of the ketogenic diet in the glucose transporter 1 deficiency syn- drome. Prostaglandins Leukot Essent Fatty Acids 2004, 70:321-327.

Decreased carbo-hydrate intake is more important than increased fat intake in the glucose tolerance by a low-carbohydrate/high-fat diet. Y Wang, T Kaneko, P Y Wang, A Sato, Diabetes Res Clin Pract. 55Wang Y, Kaneko T, Wang PY, Sato A: Decreased carbo-hydrate intake is more important than increased fat intake in the glu- cose tolerance by a low-carbohydrate/high-fat diet. Diabetes Res Clin Pract 2002, 55:61-63.

Mechanism of fatty acid-induced inhibition of glucose uptake. G Boden, X Chen, J Ruiz, J V White, L Rossetti, J Clin Invest. 93Boden G, Chen X, Ruiz J, White JV, Rossetti L: Mechanism of fatty acid-induced inhibition of glucose uptake. J Clin Invest 1994, 93:2438-2446.

Measurements of plasma glucose, free fatty acid, lactate, and insuline for 24 h in patients with NIDDM. G M Reaven, C Hollenbeck, C Y Jeng, M S Wu, Y D Chen, Diabetes. 37Reaven GM, Hollenbeck C, Jeng CY, Wu MS, Chen YD: Measure- ments of plasma glucose, free fatty acid, lactate, and insuline for 24 h in patients with NIDDM. Diabetes 1988, 37:1020-1024.

Cellular mechanism of insulin resistance. G I Shulman, J Clin Invest. 106Shulman GI: Cellular mechanism of insulin resistance. J Clin Invest 2000, 106:171-176.

Association between C-reactive protein and features of the metabolic syndrome: a population -based study. M Frohlich, A Imhof, G Berg, W I Hurchinson, M B Pepys, H Breing, R Muche, H Brenner, W Koenig, Diabetes care. 23Frohlich M, Imhof A, Berg G, Hurchinson WI, Pepys MB, Breing H, Muche R, Brenner H, Koenig W: Association between C-reactive protein and features of the metabolic syndrome: a popula- tion -based study. Diabetes care 2000, 23:1835-1839.

C-reactive protein and its role in metabolic syndrome -mendelian randomization study. N J Timpson, D A Lawlor, R M Harbord, T R Gaunt, I N Day, J Palmer, A Hatterslay, S Ebrahim, G Lowe, A Rumley, Lancet. 366Timpson NJ, Lawlor DA, Harbord RM, Gaunt TR, Day IN, Palmer J, Hatterslay A, Ebrahim S, Lowe G, Rumley A: C-reactive protein and its role in metabolic syndrome -mendelian randomiza- tion study. Lancet 2005, 366:1954-1959.

Health risks associated with overweight and obesity. P Kopelman, Obesity Reviews. 81SupplKopelman P: Health risks associated with overweight and obesity. Obesity Reviews 2007, 8(Suppl 1):13-17.

Glycaemic index in chronic disease: a review. L S Augustin, S Franceschi, D J Jenkins, C W Kendall, La Vecchia, C , European Journal of Clinical Nutrition. 56Augustin LS, Franceschi S, Jenkins DJ, Kendall CW, La Vecchia C: Gly- caemic index in chronic disease: a review. European Journal of Clinical Nutrition 2002, 56:1049-1071.

Dietary carbohydrates and insulin action in humans. T M Wolever, British Journal of Nutrition. 831SupplWolever TM: Dietary carbohydrates and insulin action in humans. British Journal of Nutrition 2000, 83(Suppl 1):S97-S102.

Insulin Resistance as the core defect in type 2 diabetes mellitus. B J Goldstein, American Journal of Cardiology. 90Goldstein BJ: Insulin Resistance as the core defect in type 2 diabetes mellitus. American Journal of Cardiology 2002, 90:3G-10G.

Improved glycaemic control and lipid profile and normalized fibrinolytic activity on a low-glycaemic index diet in type 2 diabetes patients. A E Järvi, B E Karlstrom, Y E Granfeldt, I E Bjorck, N G Asp, B O Vessby, Diabetes Care. 22Järvi AE, Karlstrom BE, Granfeldt YE, Bjorck IE, Asp NG, Vessby BO: Improved glycaemic control and lipid profile and normalized fibrinolytic activity on a low-glycaemic index diet in type 2 diabetes patients. Diabetes Care 1999, 22:10-18.

Do ketogenic diets for weight loss lower cardiovascular risk?. P Clifton, M Noakes, P Foster, J Keogh, Int J Obes. 2826Clifton P, Noakes M, Foster P, Keogh J: Do ketogenic diets for weight loss lower cardiovascular risk? Int J Obes 2004, 28:S26.

Mechanisms of thrombosis in hyperhomocysteinemia. S R Lentz, Curr Opin Hematol. 5Lentz SR: Mechanisms of thrombosis in hyperhomocysteine- mia. Curr Opin Hematol 1998, 5:343-349.

Facts and recommendations about total homocysteine determinations: an expert opinion. H Refsum, A D Smith, P M Ueland, E Nexo, R Clarke, J Mcpartllin, C Johnston, F Engbaek, J Schneede, C Mcpartlin, J M Scott, Clin Chem. 50Refsum H, Smith AD, Ueland PM, Nexo E, Clarke R, McPartllin J, Johnston C, Engbaek F, Schneede J, McPartlin C, Scott JM: Facts and recommendations about total homocysteine determina- tions: an expert opinion. Clin Chem 2004, 50:3-32.

Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. S Yusuf, S Hawken, S Ounpuu, I Bautista, M G Franzosi, P Commerford, C C Lang, Z Rumboldt, C I Owen, I Lisheng, S Tanomsup, P WangaiJr, F Razak, A M Sharma, S S Anand, Lancet. 366Yusuf S, Hawken S, Ounpuu S, Bautista I, Franzosi MG, Commerford P, Lang CC, Rumboldt Z, Owen CI, Lisheng I, Tanomsup S, Wangai P Jr, Razak F, Sharma AM, Anand SS: Obesity and the risk of myo- cardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet 2005, 366:1640-1649.

The glycaemic index: physiological mechanisms relating to obesity, diabetes, and cardiovascular disease. D S Ludwig, Journal of the American Medical Association. 287Ludwig DS: The glycaemic index: physiological mechanisms relating to obesity, diabetes, and cardiovascular disease. Jour- nal of the American Medical Association 2002, 287:2414-2423.

Oxidative stress and glycaemic regulation. Metabolism 2000. 49Ceriello A: Oxidative stress and glycaemic regulation. Metab- olism 2000, 49:27-29.

The effect of fibre-rich carbohydrates on features of Syndrome X. B M Davy, C L Melby, Journal of the American Dietetic Association. 103Davy BM, Melby CL: The effect of fibre-rich carbohydrates on features of Syndrome X. Journal of the American Dietetic Association 2003, 103:86-96.

Diet managementfor obese patients with type 2 diabetes. G Radulian, E Rusu, C Constantin, Obesity reviews. 72Radulian G, Rusu E, Constantin C: Diet managementfor obese patients with type 2 diabetes. Obesity reviews 2006, 7(Suppl 2):303-304.

Role of glycemic index in a diet program for type 2 diabetes obese patients. C Constantin, G Radulian, E Rusu, Obesity reviews. 72SupplConstantin C, Radulian G, Rusu E: Role of glycemic index in a diet program for type 2 diabetes obese patients. Obesity reviews 2006, 7(Suppl 2):303-304.