Nutrition for Healthy Living 3rd

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CHAPTER 5
CARBOHYDRATES

OVERVIEW

In Chapter 5, students will learn about the different types of carbohydrates, food sources of each, and
the general pathways for their digestion, absorption, and metabolism. Lactose intolerance is discussed.
Students will be introduced to the regulation of blood glucose by the hormones insulin and glucagon
and will learn about health conditions that result from the failure of the body to properly regulate blood
glucose. Various diet patterns are discussed relative to their impact on development of chronic
diseases. In the Chapter 5 Highlight, the concepts of glycemic index and glycemic load are explored.

CHAPTER OUTLINE

I. Simple Carbohydrates: Sugars

A. Monosaccharides: simplest type of sugar; one sugar; basic chemical unit of carbohydrates
1. Glucose (a.k.a. dextrose)
 a. Dietary sources: fruits and vegetables
b. Primary fuel for body cells, especially red blood cells and nervous system cells
2. Fructose (a.k.a. fruit sugar or levulose)
a. Dietary sources: fruit, honey, and some vegetables
b. Tastes sweeter than sugar
c. High fructose corn syrup is commercially manufactured as a sweetener for foods
and beverages
d. Converted into glucose or fat in the body
3. Galactose
a. Dietary source: milk
b. Produced by breastfeeding women
B. Disaccharides: sugar comprised of two monosaccharides
1. Maltose: glucose + glucose (a.k.a. malt sugar)
2. Lactose: glucose + galactose (a.k.a. milk sugar)
3. Sucrose: glucose + fructose (a.k.a. table sugar)
a. Dietary sources
i. Naturally found in honey, maple syrup, carrots, and pineapples
ii. Most sucrose in food supply is refined from sugar cane and sugar beets
b. Sucrose and honey are very nutritionally similar
c. Table 5.2 lists various names for sugars that appear on food labels
C. Nutritive and nonnutritive sweeteners
1. Functions of sugars in foods
a. Flavor
b. Browning
c. Preservative
d. Nutritive sweetener: contributes 4 kcal/g to foods
2. Added sugars: not naturally present; added to foods during preparation or processing
3. Alternative sweeteners (a.k.a. sugar replacers, sugar substitutes, artificial sweeteners)
a. Sweeten foods while providing few or no kcal
b. Alternative nutritive sweeteners (sugar alcohols)
i. Examples: xylitol, mannitol, and sorbitol
ii. Not well absorbed; contribute only 2 kcal/g
iii. May cause diarrhea when consumed in large quantities
c. Nonnutritive sweeteners
i. Synthetic compounds that taste intensely sweet but do not contribute calories
ii. Help with control of calorie intake
iii. Do not promote tooth decay
iv. Sugar free ≠ calorie free
v. Despite controversy, current evidence does not indicate health risks from
consuming alternative sweeteners
vi. Examples
a) Saccharin
b) Aspartame
1) Contains phenylalanine, an amino acid of concern for people with
phenylketonuria, an inherited disorder that results in abnormal
phenylalanine metabolism
2) Has been under intense scrutiny for purported links to a variety of
health concerns, but no scientifically sound studies support the claims
 c) Acesulfame-K
d) Sucralose
1) Made from sugar that is chemically modified so that it cannot be
digested
2) Resists destruction by heat, so it may be used in cooking
e) Neotame
f) Stevia extracts
vii. According to the American Dietetic Association, artificial sweeteners are safe
when consumed within acceptable daily intakes, even during pregnancy
viii. Table 5.5 lists Acceptable Daily Intakes of Nonnutrive Sweeteners

II. Complex Carbohydrates

A. Introduction
1. Polysaccharides contain 10 or more monosaccharides
2. Storage of energy
3. Structure (e.g., stems and leaves)
4. Digestibility varies
B. Starch and glycogen
1. Polysaccharides that contain hundreds of glucose molecules bound together in chains
2. Starch
a. Form of glucose storage for plants
b. Dietary sources
i. Bread and cereal products
ii. Some vegetables (e.g., corn, peas)
iii. Beans
iv. Tubers (e.g., potatoes, yams)
v. Modified starches are used in some food products
3. Glycogen
a. Form of glucose storage in animal and human muscle and liver tissues
b. Glycogen breaks down after an animal dies, so meats are not a source of
carbohydrate
C. Fiber
1. Plants use complex carbohydrates to make supportive structures and protective
coatings
2. Polysaccharides that contain glucose molecules joined by bonds that humans cannot
digest
3. Two types of fiber (summarized in Table 5.6)
a. Soluble fiber
i. Examples
a) Pectin
b) Gums
ii. Dissolve and swell in water
iii. Dietary sources
a) Oat bran and oatmeal
b) Beans
c) Apples
d) Carrots
e) Oranges and other citrus fruits
 f) Psyllium seeds
iv. Physiological effects
a) Delays gastric emptying
b) Slows glucose absorption
c) Lowers blood cholesterol
b. Insoluble fiber
i. Examples
a) Cellulose
b) Lignin
ii. Do not dissolve in water
iii. Dietary sources
a) Whole grain products
1) Made from intact, ground, cracked, or flaked seeds of cereal grains
2) Contain endosperm, germ, and bran
b) Vegetables
iv. Physiological effects
a) Increases fecal bulk
b) Speeds fecal transit through GI tract
4. Food sources of fiber are listed in Table 5.7

III. What Happens to Carbohydrates In Your Body?

A. Pathway for carbohydrates
1. Mouth: some starch is broken down by salivary amylase
2. Small intestine:
a. Majority of starch is broken down by pancreatic amylase into di- and
monosaccharides
b. Disaccharides are broken down into monosaccharides by maltase, sucrase, or
lactase
c. Monosaccharides are absorbed by intestinal cells into the bloodstream
d. Very little starch escapes digestion
3. Bloodstream: monosaccharides are transported via the portal vein to the liver
4. Liver
a. Converts fructose, galactose, and some glucose to glycogen or fat, which can be
broken down later for energy
b. Some glucose remains in the bloodstream to supply energy for body cells
5. Large intestine
a. Some soluble fiber is fermented by intestinal bacteria
b. Insoluble fiber adds to fecal bulk
c. Cells of the large intestine derive some energy from bacterial fermentation products
B. Maintaining blood glucose levels
1. Insulin
a. Produced by beta cells of pancreas
b. Enables glucose to enter body cells, thereby lowering the amount of glucose in the
blood
c. Promotes production of fat, glycogen, and protein
d. Contributes to satiety after eating a meal
2. Glucagon
a. Produced by alpha cells of pancreas
 b. Promotes glycogenolysis, the breakdown to glycogen to release glucose into the
blood
c. Stimulates production of glucose from amino acids by cells in the liver and kidney
d. Stimulates lipolysis, the breakdown of fat for energy
3. Combined effects of insulin and glucagon regulate blood glucose level between 70 – 100
mg/dl in healthy humans
4. The fate of glucose depends on the body’s state
a. In a fed or resting state, glucose is likely to be stored as glycogen or fat
b. In a fasted or exercising state, glucose is likely to be metabolized for energy
C. Glucose for energy
1. Glucose is the primary fuel for body cells, especially red blood cells and nervous tissue
2. Cells break down glucose into water and carbon dioxide to release the energy stored in
its chemical bonds
3. Glucose is necessary for proper metabolism of fat
a. Ketones are chemical byproducts of incomplete fat metabolism, as occurs in the
absence of adequate glucose
b. Muscles and brain cells can use ketones for energy
c. Ketosis results from the accumulation of ketones in the blood; can be dangerous or
life-threatening
d. RDA for carbohydrates is 130 g/d to prevent ketosis
4. Cells may convert amino acids to glucose to be used for energy
a. Under normal conditions, amino acids are used for fuel only to a minor extent
b. Under conditions of starvation, amino acids are depleted from muscles and organs
to provide energy for vital processes, leading to weakness, wasting, and eventually,
death

IV. Carbohydrate Consumption Patterns

A. In developing nations, unrefined carbohydrates provide 70% or more of total calories
B. Typical American diets supply about 50% of calories from carbohydrates
C. AMDR: 45% – 65% of total calories as carbohydrates
D. Added sugars
1. Dietary Guidelines for Americans recommend maximal intake level of 25 percent or
less of total calories from added sugars
2. Typical American diets supply 30 tsp/d of added sugars
3. Regular soft drinks are the primary source of added sugars
4. Although they provide about the same amount of sugar as soft drinks, 100% fruit juices
also supply vitamins, minerals, and phytochemicals
E. Reducing your intake of refined carbohydrates
1. Refined grain products and foods with added sugars may crowd out more nutritious
foods
2. Convenience foods typically supply lots of refined carbohydrates; plan ahead to pack
nutritious foods rather than relying on convenience foods
3. Choose yogurt, fresh fruit, and low-fat dairy products instead of regular soft drinks and
other processed foods
4. Keep fruit and vegetables handy for snacks
F. Understanding nutrient labeling: carbohydrates and fiber
1. Total carbohydrate
2. Dietary fiber (some product labels may distinguish between soluble and insoluble fibers)
 3. Sugars: label does not distinguish between naturally-occurring and added sugars
4. Subtract fiber and sugars from total carbohydrate to find grams of starch
5. Look at ingredients to identify sources of sugar

V. Carbohydrates and Health

A. Are carbohydrates fattening?
1. Overall balance of energy consumed and energy expended determines weight change,
regardless of source of calories
2. Refined carbohydrates tend to be less satisfying, which may lead to overeating
3. Carbohydrate-restricted diets help to control hunger in the short term, but long-term
compliance is poor
4. High carbohydrate diets can result in weight loss if the sources of carbohydrates are rich
in fiber and unrefined starches, because fiber increases satiety
5. Starches and sugars are often combined with hidden fats, which add excess calories,
thus contributing to weight gain
6. Overconsumption of foods rich in high fructose corn syrup (e.g., regular soft drinks) is
linked to obesity
a. People consuming many calories from beverages do not adjust their calorie intake
from solid foods to compensate for the excess calories
b. Overconsumption of calories leads to weight gain, which also contributes to risk for
type 2 diabetes
7. Over the past 30 years, typical calorie intakes have increased by 523 kcal/d; excess
calories are from all food groups, with a particular increase in consumption of fats and
oils
B. What is diabetes?
1. Diabetes mellitus is a group of diseases characterized by abnormal glucose, fat, and
protein metabolism
2. Hyperglycemia (fasting blood glucose ≥ 126 mg/dl)
a. May result from insufficient production of insulin
b. May result from insensitivity of body’s cells to insulin
3. Signs and symptoms
a. Excessive thirst
b. Frequent urination
c. Blurred vision
d. Poor wound healing
4. Long-term complications
a. Nerve damage, leading to limb amputations
b. Organ damage, leading to kidney disease and heart disease
c. Blood vessel damage, leading to heart disease and blindness
d. Death
5. Prevalence of diabetes is increasing at an alarming rate among all age groups; many
cases are undiagnosed
6. Classification
a. Pre-diabetes: fasting blood glucose 100 – 125 mg/dl
b. Type 1 diabetes
i. 5% – 10% of all cases of diabetes
ii. Formerly termed “juvenile diabetes” due to typical age of diagnosis, although it
can strike at any age
 iii. Usually an autoimmune disease, with both genetic and environmental
influences (e.g., viral infections during childhood)
iv. Pancreatic beta cells are damaged and do not produce enough insulin to
regulate blood glucose
c. Type 2 diabetes
i. Majority of all cases of diabetes
ii. Formerly termed “adult onset diabetes,” but can also occur in children and
adolescents
iii. Beta cells of pancreas usually produce adequate insulin in early stages of type 2
diabetes, but body cells are insulin-resistant
iv. Over time, beta cells may lose function
v. Risk factors
a) Overweight or obese
b) Sedentary
c) Family history of type 2 diabetes
d) Hispanic, Native American, Asian, African, or Pacific Islander ancestry
e) History of gestational diabetes
7. Controlling diabetes
a. To avoid or delay complications of hyperglycemia, blood sugar must be controlled
b. Self monitoring of blood glucose and glycosylated hemoglobin (aim for <7%)
c. Diet therapy involves counting grams of carbohydrates eaten
d. Physical activity increases insulin sensitivity
e. Moderate weight loss improves insulin sensitivity
f. Oral or injectable, medications
g. What is the glycemic index?
i. Glycemic index (GI) and glycemic load (GL) are standards that indicate the
body’s glucose and insulin responses to a carbohydrate-containing food
ii. Foods with low GIs (<70) promote satiety, reduce subsequent food intake, have
smaller impact on blood glucose and insulin levels
iii. Low GI diets have been promoted for blood glucose and weight control
iv. The Academy of Nutrition and Dietetics does not support use of GI as a tool for
people with diabetes, reasoning that total carbohydrate intake is more
important
h. Can diabetes be prevented?
i. No way to prevent type 1 diabetes
ii. Risk of type 2 diabetes is reduced by therapeutic lifestyle changes (TLC):
a) Avoiding excess body fat
b) Exercising daily
c) Dietary changes
iii. Dietary habits associated with increased risk of diabetes
a) “Western diet,” which contains high amounts of red meat, processed meats,
fried foods, high-fat dairy products, refined sugars and starches
b) Intake of red meat in women
iv. Dietary habits associated with decreased risk of diabetes
a) “Prudent diet, “ which contains more poultry, fish, fiber-rich whole grains,
fruits, and vegetables than Western diet
b) High fiber intake, particularly cereal fiber
v. Currently, no cure exists, but research continues (e.g., beta cell transplants)
C. What is hypoglycemia?
1. Blood glucose levels are too low to provide sufficient energy for cells (fasting blood
glucose <70 mg/dl)
2. Symptoms (related to release of epinephrine to increase the supply of glucose and fats
in the bloodstream):
a. Irritability
b. Restlessness
c. Shakiness
d. Sweating
e. Loss of consciousness or death may result with blood glucose <30 mg/dl
3. Despite popular hype, hypoglycemia is a rare condition
4. Reactive hypoglycemia
a. May occur after ingestion of highly refined carbohydrates because the pancreas
oversecretes insulin, which causes blood sugar levels to decline rapidly after eating
b. Dietary therapy for reactive hypoglycemia:
i. Avoidance of highly refined carbohydrates
ii. Eating smaller, more frequent meals that contain a mixture of macronutrients
D. Metabolic syndrome
1. A group of signs and symptoms that increases risk of type 2 diabetes (summarized in
Table 5.10); characterized by the presence of three or more of the following signs:
a. Large waist circumference
b. Hypertension
c. High triglycerides
d. Low HDL cholesterol
e. High fasting blood glucose
2. Elevates risk for chronic diseases
a. Increases risk of developing type 2 diabetes fivefold
b. Increases risk of developing cardiovascular disease twofold
3. Risk factors for development of metabolic syndrome
a. Genetics
b. Excess abdominal fat
c. Insulin resistance
d. Poor diet
e. Inactivity
f. Cigarette smoking
4. Prevention of metabolic syndrome
a. Exercise at least 3 times/week
b. Increase intake of fruits, vegetables, and whole grains
5. Treatment of existing metabolic syndrome
a. Control elevated glucose, insulin, and triglycerides
b. Lose excess weight
c. Exercise regularly
d. Reduce intakes of saturated fat, cholesterol, and simple sugars
e. Medications
E. Tooth decay
1. Carbohydrates, especially sticky simple sugars, provide food for bacteria that live on the
teeth
2. Bacteria produce acids that break down tooth enamel
 3. Nursing bottle syndrome results when milk, formula, or other carbohydrate-rich fluids
bathe the teeth, particularly if infants are put to bed with a bottle (other than water)
F. Lactose intolerance (a.k.a. lactose maldigestion)
1. 30 – 50 million Americans suffer from lactose intolerance
2. Intolerance ≠ allergy
3. Insufficient production of lactase enzyme; undigested lactose reaches large intestine
where it is fermented by bacteria to produce gases and acids, which lead to cramping,
bloating, gas, and/or diarrhea
4. Some degree of lactose intolerance is normal after infancy, particularly among people of
African, Asian, and Eastern European ancestry
5. Dietary advice to achieve nutritional adequacy without discomfort of lactose intolerance
a. Yogurt
b. Hard cheeses (e.g., cheddar, Swiss)
c. Small amounts of milk
d. Use of lactase additives (e.g., Lactaid)
G. Does sugar cause hyperactivity?
1. Attention deficit hyperactivity disorder is characterized by impulsivity, difficulty paying
attention, difficulty controlling behavior
2. Causes of ADHD involve genetic and environmental influences
3. Scientific evidence does not relate sugar consumption to behavioral problems
4. It is more likely that the circumstances in which sugar is consumed (e.g., parties) lead to
overstimulation
H. Fiber and health
1. Fiber is not technically a nutrient because body can live without it, but fiber has
numerous health benefits
2. Fiber and the digestive tract
a. Constipation increases risk for hemorrhoids and diverticula
b. Increasing the fiber content of the diet promotes larger, softer, more frequent
bowel movements
c. Results of several recent epidemiological studies do not indicate that high-fiber
diets decrease risk of colorectal cancer
3. Fiber and heart health
a. Diets rich in fiber, particularly soluble fiber, can reduce the risk of cardiovascular
disease by reducing blood cholesterol
b. Soluble fiber (e.g., in oats) reduces the reabsorption of cholesterol components of
bile so that they are eliminated with bowel movements, thus requiring the liver to
pull cholesterol from the blood to make new bile
c. Health claims relating soluble fiber intake to reduced risk of cardiovascular disease
are permitted on food packages
4. Fiber and weight control
a. High-fiber diets promote satiety, discourage overeating
b. High-fiber foods have low energy density
5. Increasing your fiber intake
a. AIs for fiber are 25 g/d for women or 38 g/d for men
b. Typical American diets supply 15 g/d
c. Excessive fiber intake has negative consequences
i. Intestinal gas
ii. Interferes with absorption of minerals
 iii. Intestinal blockage, particularly in combination with low fluid intake
d. To avoid excess intestinal gas, increase fiber intake gradually
e. Use Beano, which contains enzymes to break down undigested carbohydrates
before they can be fermented by intestinal bacteria
f. See Food & Nutrition Tips on page148 for dietary tips to increase fiber intake

VI. Chapter 5 Highlight – Glycemic Index and Glycemic Load

A. Foods that contain large amounts of refined carbohydrates are digested rapidly and cause a
rapid rise in blood glucose followed by a sharp increase in insulin levels
B. Sources of carbohydrates with high fiber contents are digested slowly and cause less
dramatic rises in blood glucose and insulin
C. Glycemic index classifies carbohydrate-rich foods based on the rise in blood glucose
observed after consuming a portion of a food that contains 50 g of digestible carbohydrate;
this response is expressed as a percentage of the rise in blood glucose observed after
consuming a portion of a standard food (white bread or glucose) that contains 50 g of
carbohydrate
1. High ≥ 70
2. Moderate or low < 70
D. To find glycemic load, multiply the food’s GI by the grams of carbohydrate in a typical
portion of that food, then divide by 100
1. Glycemic load is a more realistic way of rating foods based on their effects on blood
glucose and insulin
2. High > 20
3. Low < 15
E. The GIs and GLs of some carbohydrate-rich foods are presented in Table 5.11
F. Criticisms of GI and GL
1. GI varies widely for a particular food based on the location it was grown, the degree of
ripeness, extent of processing, etc.
2. Measurement of GIs may vary between individuals
3. GI values reflect the blood glucose impact of a single food, whereas foods are consumed
as part of a mixed diet
G. Research on GI and GL
1. Epidemiological studies suggest an association between high GI/GL diets and serious
chronic diseases (e.g., obesity, type 2 diabetes, cardiovascular disease, and some types
of cancer)
2. Research shows an inverse relationship between GI/GL of diet and HDL cholesterol
3. Other factors besides GI/GL of diet may affect disease risk, including physical inactivity
and obesity
4. Clinical trials have shown no association between GI/GL and insulin resistance or blood
glucose levels
H. More long-term research is needed before health experts can recommend low GI/GL diets
for the general population
HELPFUL TEACHING IDEAS

1. Using the NutritionCalc Plus nutrient analysis assignment, have students determine their usual
fiber intake. Individually or in pairs, allow students time to suggest ways to increase their own
or their partner’s fiber intake.

2. As a visual demonstration, display the quantity of sugar in commonly-consumed foods, such as

those listed in Table 5.3.

3. Ask students to recall their most recent meal. Have students outline the general pathway of
digestion, absorption, and metabolism taken by the carbohydrates from that meal.

4. Invite a person with diabetes and his or her registered dietitian to class. Allow students to ask
questions of the patient and the health professional. Ask the RD to provide some counsel on
living well with diabetes.

5. Have students complete the Diabetes Risk Test available at www.diabetes.org/risk-test.jsp.

6. Divide the class into two groups. One group should be advocates for the utility of the glycemic
index and one group against. Allow students to conduct more research on GI and GL to support
their cases. During class, allow time for the two sides to debate the utility of GI and GL.

7. Demonstrate a one-day meal plan for the Atkins diet. Ask students to analyze the carbohydrate
content using NutritionCalc Plus. Explain overall carbohydrate needs and the detriments of this
type of diet.

8. Have students plan a one-day diet for themselves with adequate amounts of complex
carbohydrate servings.
STUDENT ASSIGNMENT
Lactose Intolerance

Talk with a person who has been diagnosed with lactose intolerance. Consider helping this person learn
more about the condition and how to obtain adequate calcium despite their inability to digest milk sugars
completely.

1. What are the major complaints or symptoms?

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2. Describe the physiological basis for these symptoms.

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3. Individuals with lactose intolerance may have individualized sensitivities to specific foods. Which
dairy foods cannot be tolerated? Are any dairy foods tolerated?

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4. How can this individual obtain adequate calcium in the diet despite these food limitations? What
alternative calcium-rich food choices do they have?

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5. What commercial products are available to improve digestibility of dairy foods? How do these
products work?

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