Wardlaws Perspectives in Nutrition A Functional

Approach 1st Edition Byrd-Bredbenner Solutions

Manual
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Chapter 5
Carbohydrates

Overview

In Chapter 5, the authors present the first of the energy-yielding nutrients, carbohydrates. The
chapter begins with the chemistry of carbohydrates and an introduction to basic carbohydrate structures,
including monosaccharides, disaccharides, oligosaccharides, and polysaccharides. The differences
between digestible and indigestible carbohydrates are discussed with a particular emphasis on the health
benefits of indigestible carbohydrates (e.g., dietary fiber). Food sources and uses of the various types of
carbohydrates are given along with a discussion of uses and safety of nutritive and alternative sweeteners.
Students will learn about the recommendations of various health agencies for carbohydrate intake - from
total carbohydrates to dietary fiber to added sugars - and how typical North American food intake patterns
compare to these recommendations. The processes of digestion and absorption are reviewed as they
specifically relate to carbohydrates. The chapter wraps up with a discussion of health concerns associated
with carbohydrate intake, including type 1 and type 2 diabetes, lactose intolerance, and dental caries.

Key Terms

Acceptable Daily Intake Dextrinase Glucagon

(ADI) Diabetes mellitus Gluconeogenesis
Acesulfame-K Dietary fiber Glucose
Alpha bond Disaccharide Glycemic index
Amylase Diverticula Glycemic load
Amylopectin Diverticulitis Glycogen
Amylose Diverticulosis Growth hormone
Aspartame Epinephrine Gum
Beta bond Fasting blood glucose Hemicelluloses
Carbohydrate counting Fasting hypoglycemia Hemoglobin A1c
Cellulose Fiber Hexose
Condensation reaction Fructose High-fructose corn syrup
Cortisol Functional fiber Hyperglycemia
Cyclamate Galactose Hypoglycemia
Insoluble fiber Neotame Sorbitol
Insulin Norepinephrine Stachyose
Ketosis Oligosaccharide Starch
Lactose Pectin Stevia
Lignin Pentose Sucralose
Maltase Photosynthesis Sucrose
Maltose Polysaccharide Sugar alcohol
Mannitol Raffinose Tagatose
Metabolic syndrome Reactive hypoglycemia Total fiber
Modified food starch Ribose Type 1 diabetes
Monosaccharide Saccharin Type 2 diabetes
Mucilage Soluble fiber Xylitol

Student Learning Outcomes

After studying this chapter, you will be able to:

5.1 Identify the major types of carbohydrates and give examples of food sources for each.

5.2 List alternative sweeteners that can be used to reduce sugar intake.

5.3 Describe recommendations for carbohydrate intake and health risks caused by low or excessive
intakes.

5.4 List the functions of carbohydrates in the body.

5.5 Explain how carbohydrates are digested and absorbed.

5.6 Explain the cause of, effects of, and dietary treatment for lactose intolerance.

5.7 Describe the regulation of blood glucose, conditions caused by blood glucose imbalance, types of
diabetes, and dietary treatments for diabetes.

5.8 Describe dietary measures to reduce the risk of developing type 2 diabetes.

Lecture Outline

5.1 Structures of Carbohydrates

A. General
1. Composed of carbon, hydrogen, and oxygen
2. Plants produce glucose by photosynthesis from carbon (air), oxygen (air),
hydrogen (water), and energy (sun)
3. General chemical formula is (CH2O)n
B. Monosaccharides: Glucose, Fructose, Galactose, Sugar Alcohols, and Pentoses
1. Each monosaccharide contains 6 carbon, 12 hydrogen, and 6 oxygen molecules,
but in slightly different configurations (see Figure 5-3)
2. Having 6 carbon molecules classifies these monosaccharides as hexoses
3. Glucose
 a. Most abundant monosaccharide
b. Usually linked with other monosaccharides
c. Also called dextrose
4. Fructose
a. Found in fruits, vegetables, honey, and high-fructose corn syrup
b. HFCS is sweeter and less expensive than sucrose, used in many food
products
c. Also called levulose
5. Galactose in the diet is usually linked with glucose to form lactose
6. Sugar alcohols are derivatives of monosaccharides; used as sweeteners in gum
and dietetic foods
a. Sorbitol
b. Mannitol
c. Xylitol
7. Pentoses: 5 carbon sugars
a. Ribose (part of RNA)
b. Deoxyribose (part of DNA)
C. Disaccharides: Maltose, Sucrose, and Lactose
1. Contain 2 monosaccharides linked together in a condensation reaction, which
forms 1 molecule of water (see Figure 5-4)
a. Alpha bonds: found in maltose and sucrose; easily broken down by
intestinal enzymes
b. Beta bonds: found in lactose and dietary fiber; not easily broken down by
intestinal enzymes
2. Maltose
a. Glucose + glucose
b. Found in malted alcoholic beverages: seeds allowed to sprout
c. Formed in small intestine upon digestion of longer-chain polysaccharides
3. Sucrose
a. Glucose + fructose
b. Found in plants such as sugar cane, sugar beets, maple tree sap
c. Brown, white, and powdered sugars are produced from plant sources
4. Lactose
a. Glucose + galactose
b. Found in milk and milk products
c. Lactose intolerance results from insufficient lactase production, leads to
intestinal gas, bloating, cramping, discomfort when undigested lactose is
metabolized into acids and gases by colonic bacteria
5. Simple sugars include monosaccharides and disaccharides
D. Oligosaccharides: Raffinose and Stachyose
1. Oligosaccharides
a. Contain 3 - 10 simple sugar units
b. Cannot be digested by human enzymes, metabolized by colonic bacteria,
produce intestinal gas
 c. Enzyme preparation (e.g., Beano) breaks down oligosaccharides before
they reach the large intestine
2. Raffinose: indigestible oligosaccharide made of 3 monosaccharides (galactose +
glucose + fructose)
3. Stachyose: indigestible oligosaccharide made of 4 monosaccharides (galactose +
galactose + glucose + fructose)
E. Polysaccharides: Starch, Glycogen, and Fiber
1. General
a. Polysaccharides are complex carbohydrates with many glucose
molecules
b. Digestibility is determined by type of bonds (alpha or beta)
2. Digestible Polysaccharides: Starch and Glycogen
a. Starch
i. Major digestible dietary polysaccharide
ii. Storage form of glucose in plants
iii. Amylose: straight chain of many glucose molecules linked by
alpha 1-4 bonds which are broken by amylase produced in mouth
and pancreas
iv. Amylopectin: branched chain of many glucose molecules linked
by alpha 1-6 bonds which are broken by an intestinal enzyme
called alpha-dextrinase; causes more rapid rise in blood glucose
than amylose because there are more sites for enzyme action
v. Cooking increases digestibility of starches by making them
soluble in water
vi. Modified food starch is made by amylose molecules bound
together; used as thickening agent in foods
b. Glycogen
i. Storage form of carbohydrate in humans and animals
ii. Glucose units linked by alpha bonds
iii. More highly branched than amylopectin; broken down quickly
iv. Stored in liver and muscle cells, amount is influenced by dietary
intake
3. Indigestible Polysaccharides: Dietary and Functional Fiber
a. Total fiber: dietary fiber + functional fiber
b. Dietary fiber: occurs naturally in foods
c. Functional fiber: added to foods, provides health benefits
d. Nutrition Facts panel only includes dietary fiber
e. Non-starch polysaccharides with beta bonds
i. Cellulose
ii. Hemicelluloses
iii. Pectins
iv. Gums
v. Mucilages
f. Non-carbohydrate component
 i. Lignins
g. Fermented by colonic bacteria to produce short-chain fatty acids and
gases (pectins, gums, and mucilages yield ~1.5 - 2.5 kcal/g)
h. Body adapts to higher fiber intake - decreased bloating, gas, discomfort
i. Insoluble fibers
i. Not easily dissolved in water
ii. Not easily metabolized by colonic bacteria
iii. Decrease intestinal transit time
iv. Reduce constipation, diverticular disease, and colon cancer
v. Examples: cellulose (skin of fruits and vegetables, legumes,
celery, whole grains), hemicelluloses (whole grains, some
vegetables), lignins (seeds of fruits, bran layer)
j. Soluble fibers (a.k.a. viscous fiber)
i. Dissolve in water
ii. Metabolized by colonic bacteria
iii. Lower blood cholesterol
iv. Delays gastric emptying
v. Lower blood glucose
vi. Reduce risk of CVD and diabetes
vii. Examples: pectin (fruits), some hemicelluloses (oat bran), gums
and mucilages (legumes, seaweed, psyllium)

5.2 Carbohydrates in Foods

A. Starch
1. Legumes
2. Tubers
3. Grains (wheat, rye, corn, oats, barley, rice) used to make breads, cereals, and
pasta
B. Fiber
1. Whole grains
2. Legumes
3. Tubers
4. Psyllium
5. Seaweed
6. Functional fiber is available as supplement
C. Nutritive Sweeteners
1. Can be metabolized to yield energy
2. Monosaccharides (glucose, fructose, galactose)
3. Disaccharides (sucrose, lactose, maltose)
4. Most dietary sucrose has been added during processing; not naturally-occurring
5. High-fructose corn syrup
a. Made by treating cornstarch with acid and enzymes to break down starch
to glucose; some glucose converted to fructose by enzymes
b. Final product is 40 - 90% fructose
 c. Similar to sucrose in sweetness, but less expensive
6. Sugar Alcohols
a. Examples
i. Sorbitol
ii. Mannitol
iii. Xylitol
b. Do not promote dental caries because they are not metabolized by
bacteria in the mouth
c. Do contribute energy (1.5 - 3 kcal/g), but are absorbed and metabolized
more slowly than sugars
d. May induce diarrhea in large quantities
D. Alternative Sweeteners (see Table 5-1)
1. General
a. Non-caloric or very-low-calorie sugar substitutes for diabetes or weight
loss
b. Safety determined by FDA, indicated by Acceptable Daily Intake
guideline: amount of a sweetener that an individual can safely consume
daily over a lifetime (mg/kg body weight/d)
c. ADIs are based on animal studies and set 100 times less than level at
which no harmful effects were noted in animal studies
d. Considered safe for use by adults and children and during pregnancy
2. Saccharin (Sweet n’ Low)
a. 300x sweeter than sucrose
b. Early research linking saccharin to bladder cancer has been proven weak
and inconclusive
c. ADI: 5 mg/kg/d (3 cans of diet soft drinks or 9 packets of Sweet ‘n Low)
d. Not useful in cooking because heating causes bitter taste
e. Uses: tabletop sweetener, variety of foods and beverages
3. Aspartame (NutraSweet, Equal)
a. Not useful in cooking because it loses its sweetness when heated
b. Yields 4 kcal/g
c. 180 - 200 x sweeter than sucrose
d. ADI: 50 mg/kg/d (18 cans of diet soft drink or 80 packets of Equal)
e. Some reports of adverse reactions (e.g., headaches, dizziness, seizures,
nausea)
f. Should be avoided by those with phenylketonuria (PKU) a disease that
interferes with phenylalanine metabolism
g. Uses: beverages, gelatin desserts, chewing gum, cookies, toppings and
fillings of baked goods
4. Neotame
a. Heat stable, can be used in cooking and as tabletop sweetener
b. 7000 - 13,000 x sweeter than sucrose
c. Contains phenylalanine, but is not a problem for individuals with PKU
d. ADI: 2 mg/kg/d
 e. Uses: baked foods, non-alcoholic beverages, chewing gum, confections,
frostings, frozen desserts, gelatin, pudding, jams, jellies, processed fruits
and fruit juices, toppings, syrups
5. Acesulfame-K (Sunette)
a. 200 x sweeter than sucrose
b. Not digested, provides no calories
c. Heat stable, can be used in baking
d. ADI: 15 mg/kg/d
e. Uses: chewing gum, powdered drink mixes, gelatins, puddings, baked
goods, tabletop sweeteners, candy, throat lozenges, yogurt, non-dairy
creamers
6. Sucralose (Splenda)
a. 600 x sweeter than sucrose
b. Substitutes 3 chlorines for 3 hydroxyl groups on sucrose
c. Not digested, yields no calories
d. Heat stable, used in cooking and baking
e. ADI: 5 mg/kg/d
f. Uses: tabletop sweetener, soft drinks, chewing gum, baked cookies,
syrups, gelatins, frozen dairy desserts, jams, processed fruits and fruit
juices
7. Tagatose (Naturlose)
a. Isomer of fructose
b. Almost as sweet as sucrose
c. Can be used in cooking and baking
d. Poorly absorbed, yields 1.5 kcal/g
e. Prebiotic effect
f. Should be avoided by those with disorders of fructose metabolism
g. Uses: cereals, diet soft drinks, health bars, frozen yogurt, fat-free ice
cream, soft and hard confectionary products, frosting, chewing gum
8. Stevia (PureVia and Truvia)
a. 100 - 300 x sweeter than sucrose
b. Provides no calories
c. ADI: 4mg/kg/d
d. FDA has recently approved its use in beverages, but it can be purchased
as a dietary supplement
e. Blended with cane sugar and sold as Sun Crystals

5.3 Recommended Intake of Carbohydrates

A. Recommendations for total carbohydrate intake
1. RDA for adults: 130 g/d of digestible carbohydrate to supply adequate glucose
for the brain and central nervous system without having to rely on ketosis
2. Food and Nutrition Board recommends that carbohydrates comprise 45 - 65% of
total energy intake
3. Various weight-loss approaches vary considerably from FNB recommendations
 4. Carbohydrates should come mainly from fiber-rich fruits, vegetables, and whole
grains with little added sugars and caloric sweeteners
5. Ample carbohydrate intake may be achieved by consuming 6 oz grains, 2.5 c
vegetables, 2 c fruit, and 3 c milk
B. Recommendations for added sugars
1. Dietary Guidelines recommend limiting added sugars to 6% of total energy
intake
2. World Health Organization recommends limiting added sugars to 10% to total
energy intake
3. American Heart Association recommends limiting sugar intake to half of one’s
discretionary calorie allowance: less than 100 kcal/d for women and 150 kcal/d
for men
C. Recommendations for dietary fiber
1. 14 g/1000 kcal
2. Women: 25 g/d
3. Men: 38 g/d
D. Our Carbohydrate Intake
1. Typical North Americans consume 50% of total energy intake as carbohydrates,
mostly from white bread, soft drinks, cookies, cakes, doughnuts, sugars, syrups,
jams, potatoes
2. Worldwide carbohydrate intake averages 70- 80% of total energy, mostly from
whole grains, fruits, vegetables, and legumes
3. Added sugars supply 16% of total energy intake (mainly due to sweetened
beverages)
4. Insufficient fiber intake (25 - 50% lower than recommendations)
a. Lack of knowledge about fiber-rich food sources and benefits
b. Confusing food labeling (e.g., “wheat” bread is not necessarily made
from whole grains

5.4 Functions of Carbohydrates in the Body

A. Digestible Carbohydrates
1. Providing Energy
a. Most digestible carbohydrates are broken down to glucose, source of
energy for all body cells
b. Red blood cells and CNS cells use glucose almost exclusively
c. Glucose provides 4 kcal/g
2. Sparing Protein from Use as an Energy Source
a. Adequate carbohydrates are required to allow amino acids to be used to
build body tissues and perform vital functions
b. Gluconeogenesis: synthesis of glucose from amino acids
c. Typical American protein intake is high, sparing protein is not a primary
concern except for carbohydrate- and energy-reduced diets and in
starvation
3. Preventing Ketosis
 a. When carbohydrate intake falls below 50 - 100 g/d, fatty acids are
incompletely metabolized for energy, generating ketone bodies
b. Brain and CNS can adapt to using ketones for energy when
carbohydrates are inadequate
c. Excessive ketone production (ketoacidosis) may result from poorly
controlled diabetes due to inadequate insulin (or insulin resistance) for
cells to use glucose
d. Ketosis is promoted by some weight-loss programs because it suppresses
appetite and increases water losses, but over time, can lead to
dehydration, loss of lean body mass, and electrolyte imbalances
B. Indigestible Carbohydrates
1. Promoting Bowel Health
a. Fiber adds bulk to feces to ease bowel movements, preventing
constipation
b. Straining during defecation can lead to
i. Hemorrhoids
ii. Formation of diverticula (diverticulosis), which may become
inflamed (diverticulitis)
iii. Fiber intake must be limited during episodes of diverticulitis, but
high-fiber, high-fluid diet with physical activity is recommended
for prevention of future attacks of diverticulitis
c. High-fiber diets may reduce risk of colon cancer, likely due to nutrients
present in high-fiber foods (e.g., vitamins, minerals, phytochemicals)
2. Reducing Obesity Risk
a. Bulk of high-fiber diet limits energy intake, contributes to satiety
3. Enhancing Blood Glucose Control
a. Soluble fibers slow glucose absorption from the small intestine and
decrease insulin release from the pancreas
b. High-fiber diet decreases risk of developing diabetes
4. Reducing Cholesterol Absorption
a. High soluble fiber intake inhibits absorption of cholesterol and
reabsorption of bile acids from small intestine
b. Reduced risk of cardiovascular disease
c. Reduced risk of gallstones
d. Short-chain fatty acids from bacterial fermentation of soluble fiber in the
large intestine reduce cholesterol synthesis in the liver

5.5 Carbohydrate Digestion and Absorption

A. Digestion
1. Starts with food preparation - softens tough, fibrous tissues of vegetables, fruits,
and whole grains; swelling with water aids digestion
2. Mouth: salivary amylase breaks down starch into smaller polysaccharides and
disaccharides
3. Stomach: salivary amylase inactivated by acidity of stomach
 4. Small intestine
a. Pancreatic amylase and dextrinase further digests polysaccharides
b. Disaccharides are digested to monosaccharides by specific enzymes
i. Maltase
ii. Sucrase
iii. Lactase
5. Large intestine: indigestible carbohydrates (dietary fibers and resistant starch) are
fermented to acids and gases by bacteria or excreted in fecal waste
6. Intestinal diseases may interfere with carbohydrate digestion (e.g., lactose),
leading to bloating, flatulence, and diarrhea
B. Absorption
1. Glucose and galactose are actively absorbed with sodium
2. Fructose is absorbed by facilitated diffusion; slower process than active transport
3. Once absorbed, monosaccharides are transported via portal vein to liver
4. In liver, fructose and galactose are converted to glucose
5. Glucose circulates from liver to body cells where it is used for energy or stored
as glycogen (stored in liver and muscle) or fat (stored in adipose tissue)

5.6 Health Concerns Related to Carbohydrate Intake

A. Very High Fiber Diets
1. Fiber intakes about 50 - 60 g/d, especially combined with low fluid intake, can
result in hard, dry stools, leading to painful elimination, hemorrhoids, rectal
bleeding, or intestinal blockages
2. May decrease absorption of some minerals (e.g., zinc and iron)
3. May lead to inadequate calorie consumption in children, elderly, and
malnourished individuals
B. High Sugar Diets
1. Average American sugar intake is 22 tsp/d (335 kcals/d)
2. Provide empty calories, contribute to obesity
3. Excess consumption of sugar-sweetened drinks decreases milk consumption,
leading to lower calcium and vitamin D intakes, thus diminishing bone health
4. Low-fat and fat-free snacks are usually made with lots of sugar
5. High intake of sugar (especially fructose) is associated with increased risk for
CVD (decreased HDL and increased LDL)
6. Purported link between high sugar diets and hyperactivity in children is not
supported by scientific evidence
7. Dental caries develop when oral bacteria metabolize sugars into acids, which
dissolve tooth enamel and cause decay
C. Lactose Intolerance
1. Primary lactose intolerance: insufficiency of lactase that develops after childhood
in ~75% of the world’s population
a. In North America, ~25% of adults have decreased lactose digestion
b. Asian, African, or Latino/Hispanic individuals are more likely to have
primary lactose intolerance than Caucasians
 c. Not all people with primary lactose intolerance experience symptoms
d. Nearly all people with lactase deficiency can tolerate ½ to 1 c of milk
with meals
e. Hard cheese, yogurt, and acidophilus milk are well tolerated because
lactose has been converted to lactic acid
2. Secondary lactose intolerance
a. Conditions of the small intestine (e.g., Crohn’s diease or severe diarrhea)
damage lactase-producing cells
b. Symptoms are often temporary
3. Symptoms with ingestion of lactose
a. Abdominal pain
b. Bloating
c. Gas
d. Diarrhea
D. Glucose Intolerance
1. Regulation of Blood Glucose
a. Fasting blood glucose typically varies from 70 to 100 mg/dl
b. Hyperglycemia: high blood glucose, above 126 mg/dl while fasting
c. Hypoglycemia: low blood glucose, below 50 mg/dl
i. Hunger
ii. Shakiness
iii. Irritability
iv. Weakness
v. Headache
d. Liver regulates how much glucose from a meal is released into the blood
and how much is stored as glycogen
e. Pancreas releases hormones to regulate blood glucose
i. Insulin promotes uptake of glucose by cells, storage of glucose
and glycogen, thus lowering blood glucose when it is high
ii. Glucagon prompts breakdown of glycogen to glucose when
blood sugar is too low
f. Adrenal glands secrete hormones to regulate blood glucose (fight or
flight response)
i. Epinephrine (adrenaline) triggers breakdown of glycogen to
increase blood glucose
ii. Norepinephrine triggers breakdown of glycogen to increase
blood glucose
iii. Cortisol decreases glucose use by muscle
g. Pituitary gland
i. Growth hormone decreases glucose use by muscle
2. Metabolic Syndrome
a. Group of factors that increase risk of type 2 diabetes and CVD
i. Insulin resistance or glucose intolerance (e.g., FBG >110 mg/dl)
 ii. Abdominal obesity (e.g., waist circumference >35” for women
or 40” for men)
iii. High blood triglycerides (e.g., >150 mg/dl), high LDL, low HDL
(e.g., <40 mg/dl for men or <50 mg/dl for women)
iv. Elevated blood pressure (e.g., >130/85 mmHg)
v. Increased inflammatory proteins (e.g., C-reactive protein)
b. Diagnostic criteria are not standardized; American Heart Association and
National Heart, Lung, and Blood Institute suggest diagnosis based on
presence of 3 or more of the above criteria
c. Treatments include lifestyle modification focused on weight loss,
decreased dietary fat intake, and increased physical activity
3. Hypoglycemia
a. Can occur with or without diabetes
b. Among people with diabetes, hypoglycemia may occur with use of too
much insulin, low food intake, or exercising without increasing
carbohydrate intake
c. Reactive hypoglycemia
i. Exaggerated insulin response after eating
ii. Symptoms include irritability, sweating, anxiety, weakness,
headache, and confusion occurring 2 - 5 hours after a meal
d. Fasting hypoglycemia
i. Low blood glucose after fasting for 8 hours or more
ii. Usually caused by underlying medical condition (e.g., cancer,
liver disease, renal disease)
e. Diagnosis requires classic symptoms of hypoglycemia and BG <50 mg/d
f. Treatment
i. Regular meals with balance of protein, fat, and low glycemic
load carbohydrates
ii. Ample fiber
iii. Substitute high-protein snacks for high-carbohydrate snacks
iv. Spread carbohydrate intake throughout day
v. Limit caffeine and alcohol
E. Glycemic Index and Glycemic Load
1. Glycemic index (GI): ratio of blood glucose response of a given food compared
with a standard (e.g., glucose or white bread)
a. Influenced by
i. Starch structure (amylose or amylopectin)
ii. Fiber content
iii. Food processing
iv. Physical structure
v. Temperature
vi. Protein and fat content
b. High GI foods
i. Potatoes
 ii. Breads
iii. Gatorade
iv. Short-grain white rice
v. Honey
vi. Jelly beans
c. Based on serving of food that supplies 50 g carbohydrate, which may or
may not reflect typical serving size
2. Glycemic load: accounts for GI and amount of carbohydrate consumed: (g
carbohydrate X GI)/100
3. Table 5-7 shows the GI and GL of common foods
4. Why GI and GL?
a. High GL foods elicit increased insulin response followed by rapid drop
in blood glucose
b. Chronically high insulin increases blood triglycerides, fat deposition in
adipose tissue, fat synthesis in liver, and rapid return of hunger after a
meal
c. Low GL foods typically contribute needed fiber
5. Limitations of GI and GL
a. Neither tool indicates blood glucose responses to mixed meals

5.7 Expert Perspective: Taxing Sugar-Sweetened Beverages

A. Intake of sweetened beverages in the U.S. has doubled between 1977 and 2002, adding
an extra 175 calories to our daily diets
B. Sugar-sweetened beverages are associated with an increased risk of obesity, diabetes and
heart disease
C. It is estimated that a tax of 1 cent per ounce could generate about $15 million in revenue
each year
1. May also lead to a decrease in calorie intake
D. Beverage industry argues that the increase in obesity rate is not related to sugar-
sweetened beverages but a lack of regular physical activity and poor dietary habits
E. However, sweetened beverages are the single largest source of added sugar in the
American diet

5.8 Medical Perspective: Diabetes Mellitus

A. General
1. Diagnosis of diabetes is based on fasting blood glucose >126 mg/dl
2. Affects 6% of North Americans, leads to 200,000 deaths/year
3. 15% of North Americans show evidence of pre-diabetes (FBG 100 - 126 mg/dl)
B. Type 1 Diabetes (insulin-dependent, juvenile-onset)
1. Classic symptoms of hyperglycemia
a. Increased hunger
b. Excessive thirst
c. Excessive urination
d. Weight loss
 2. Caused by autoimmune attack on pancreas, leading to insufficient insulin
production to allow glucose uptake by cells
3. Moderate genetic predisposition
4. Excess glucose excreted in urine
5. Experience ketosis as fats are broken down for energy; also causes electrolyte
imbalances, dehydration, coma, or even death
6. Historical treatment included low-calorie, high-fat diet, which led to poor growth
among children and poor compliance
7. In 1921, Banting and Best isolated insulin and used it as a treatment
8. Complications of type 1 diabetes
a. CVD
b. Kidney disease
c. Nerve disease (neuropathy)
i. Constipation or diarrhea
ii. Amputations of limbs
d. Blindness
e. Infections
9. Treatment
a. Insulin
i. Injections
ii. Pump
b. Diet
i. Regular meals and snacks
ii. Regulated ratio of carbohydrate:protein:fat to maximize insulin
action and moderate glucose excursions
iii. Ample fiber
iv. Balance calorie intake with expenditure
v. Meets overall nutritional needs
vi. Carbohydrate counting and diabetic exchange system are tools to
regulate dietary intake
c. Exercise enhances glucose uptake by muscles independent of insulin
action
d. Diabetes Control and Complications Trial demonstrated that
development of CVD and nerve damage can be delayed with aggressive
blood glucose control
C. Type 2 Diabetes (non-insulin-dependent, adult-onset)
1. 90% of all cases of diabetes
2. 30 - 50% of cases of type 2 diabetes are asymptomatic
3. Characterized by insulin resistance, wherein cells become resistant to the action
of insulin, thereby decreasing uptake of glucose by cells
4. Risk factors
a. Strong genetic predisposition
b. Obesity
c. Physical inactivity
 d. Ethnicity (e.g., Latino/Hispanic, African, Asian, Native American,
Pacific Islander)
e. Metabolic syndrome
f. Pre-diabetes
5. Treatment
a. Diet
i. Energy-controlled
ii. Meets nutrient needs
iii. Regular mealtimes
iv. Limit total and saturated fat
v. Moderate alcohol (1 drink/d) may increase HDL to reduce CVD
risk, but must be consumed in conjunction with meals to avoid
hypoglycemia
b. Exercise
c. Oral medications
i. Reduce glucose production by liver
ii. Increase insulin synthesis by pancreas
iii. Slow intestinal absorption of glucose
iv. Decrease insulin resistance
d. Insulin (in advanced cases)
D. Gestational diabetes
1. Occurs in 7% of all pregnancies
2. Treated with dietary therapy and insulin
3. Resolves after delivery
4. Increases maternal risk for developing type 2 diabetes later in life
E. Decreasing the Risk of Diabetes and Protecting Health if Diabetes is Diagnosed
1. Maintain healthy body weight
2. Stay physically active
3. Follow Dietary Guidelines
4. Regular testing of FBG for those with genetic predisposition