CARBOHYDRATE

For Mph Postgraduate Students

Melese.S(B.Pharm,Msc ,Ass.Professor, PhD fellow )

Jimma University
Institute of Health
Faculty of Public Health, Nutrition & Dietetics Department
February 2, 2023

Melese .S
 Objecties
• Describe the function of macronutrients ?
• Describe the function dietary fiber
consumption ?
• Describe disease associated with abnormal
metabolisms of carbohydrate , proteins and
fats ?
• Mention the good source of foods for
macronutrients ?

Melese .S
 The 6 Essential Nutrients
What You Need to Know!

WATER

Fats &
Carbs Protein Vitamins Minerals
Oils
 “Essential” Nutrients
Nutrients are categories of substances we need
for our nutrition.

Essential Nutrients are nutrient substances that

we can only get from food, because our bodies
cannot produce them on our own.
**For example, your body can’t just decide “hey,
I need some calcium so I’m going to make it!”
You have to consume something that contains
calcium in order for it to get into your body
Melese .S
NUTRIENTS

Melese .S
 The Nutrients
• Nutrients in Foods and in the Body
– Composition of foods includes the six nutrient classes of
water, carbohydrates, lipids, proteins, vitamins and
minerals. Foods can also contain nonnutrients and other
compounds, such as fibers, phytochemicals, pigments,
additives, alcohols and others.
– Composition of the human body is made of chemicals similar
to food.
– Chemical composition of nutrients includes both organic (those
that contain carbon) and inorganic (those that do not contain
carbon) compounds.
– Essential nutrients are those the body cannot make or cannot
make in sufficient quantities to meet needs. These are also
called indispensable nutrients.
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 The Nutrients
• Energy-Yielding Nutrients: Carbohydrate, Fat and Protein
– Macro- vs. micronutrients
• Carbohydrate, fat, and protein are macronutrients
because the body needs them in large quantities.
• Water, vitamins, and minerals do not provide energy
and are known as micronutrients because the body
needs them in smaller quantities.
– Energy is measured in Calories (calories, kilocalories,
kcalories, kcal).
• Internationally, food energy is measured in joules.

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 Energy-Yielding Nutrients

Calories and kilocalories

• Calories are units by which energy is
measured.
• Food energy is measured in
kilocalories (kcal)
– Carbohydrate = 4 kcal/gram
– Protein = 4 kcal/gram
– Fat = 9 kcal/gram

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Melese .S
Food is eaten and digested in the
body to allow the absorption of
energy and nutrients.
There are two different types of
nutrients:
• macronutrients;
• micronutrients.
There are three macronutrients
that are essential for health.
These are:
• carbohydrate;
• protein;
• fat.
Macronutrients are measured in
grams (g).
Macronutrient Best for
Protein Building muscles

Carbohydrates (carbs) Primary source of energy

Hormones, nerves, tissues,

Fats vitamin absorption
Secondary source of energy

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MACRONUTRIENTS

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• Macronutrients: - are nutrients that are
required by our body in larger quantities on
a daily basis and need to be broken down to
smaller units for use by the body.
• They include carbohydrates, lipid and proteins.
• All of them contribute to the energy pool of the
body
• Alcohol also gives energy, but it is not a
macronutrient for we do not need it for survival.

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 Macronutrients contribute to the energy pool
of the body

Energy Pool
Carbohydrates of the body Fats
(45-65%) (100%) 20% - 35%

 45-65% Carbohydrates (sugar, sweets,

bread, cakes)
 20-35% Fats (dairy products, oil) Proteins
 10-35% Protein (eggs, milk, meat,
poultry, fish) (10% - 35%)

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 Cont…

• While each of these macronutrients provides calories, the

amount of calories that each one provides varies.
– Carbohydrate provides 4 calories per gram.
– Protein provides 4 calories per gram (5.2 kcal/gram is removed as
metabolizable energy).
– Fat provides 9 calories per gram.
• Besides carbohydrate, protein, and fat the only other
substance that provides calories is alcohol. Alcohol
provides 7 calories per gram.
• Alcohol, however, is not a macronutrient because we do
not need it for survival.

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Melese .S
120 grams of glucose / day = 480 calories
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 Functions of Carbohydrates
1) Energy
• glucose fuels the work of most of the body’s cells
– preferred fuel of NERVOUS TISSUE (the brain, nerves) and
RED BLOOD CELLS (RBC)
• excess glucose is stored as GLYCOGEN in liver and
muscle tissue

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 Functions of Carbohydrates
2) Sparing Body Protein
• if diet does not provide enough glucose, then other
sources of glucose must be found
• if carbohydrate intake < 50 - 100 g, body protein will
be used to make glucose
• an adequate supply of carbohydrate spares body
proteins from being broken down to synthesize
glucose

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 Functions of Carbohydrates
3) Preventing Ketosis (Anti-ketogenic)
• carbohydrates required for the complete
metabolism of fat
• incomplete fat metabolism produces KETONES
• an adequate supply of carbohydrate (> 50 –
100 g per day) prevents KETOSIS

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 WHY DO WE NEED CARBOHYDRATES TO SURVIVE?

We need this amount of carbohydrate because:

– 45% - 65% of calories should come from carbohydrate
– Carbohydrates are the body’s main source of fuel.
–  All of the tissues and cells in our body can use glucose for
energy.
– Carbohydrates are needed for the central nervous system, the
kidneys, the brain, the muscles (including the heart) to function
properly.
– Carbohydrates can be stored in the muscles and liver and later
used for energy(glycogen).
– Carbohydrates are important in intestinal health and waste
elimination (e.g.. Dietary fiber).

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 “GOOD” CARBS V. “BAD” CARBS
• “Good” Carbohydrates have more fiber
• “Bad” Carbohydrates are referring to
and complex carbohydrates.
foods with refined carbohydrates.
• Guidelines recommend choosing fiber-
• Refined Carbohydrates are items that are
rich carbohydrate choices.
made from white flour or added sugar.
• Fiber-rich foods include:
• Examples: white bread, cakes, &
fruits, vegetables, & whole grain breads cookies
& pastas.

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Complex carbs (good Fibrous and Highly processed
starchy carbs carbs (bad simple
carbs)
(good carbs) carbs)

Veggies Refined grains

Whole grains Fruits Sugars
Brown rice Honey
Oatmeal Lentils Syrups
Quinoa Beans, peas Soft drinks
Sweet potato Candy etc

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 Types of Carbohydrates
Simple Carbohydrates
– monosaccharides
– disaccharides
Complex Carbohydrates
– oligosaccharides
– polysaccharides
• glycogen
• starches
• fibers
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Carbohydrates may be
A. Refined
B. Unrefined
Refined means that the food is highly
processed.
The fiber and bran, as well as many of the
vitamins and minerals they contain,
have been stripped away.
Thus, the body processes these
carbohydrates quickly, and they
provide little nutrition although they
contain about the same number of
calories.
Refined products are often enriched,
meaning vitamins and minerals have
been added back to increase their
nutritional value.
A diet high in simple or refined
carbohydrates tends to increase the risk
of obesity and diabetes.
 Carbohydrates can be…
Simple Carbs Complex Carbs
- Fruits -Grains (bread & pasta)
- Honey -Vegetables (potatoes &
- Milk beans)
- Sugars added to cookies, -Rice
candies, soft drinks -Cereals
-Wheat
-Tortillas
-Whole-wheat rolls

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Dietary Carbohydrates

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Dietary Carbohydrates

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Monosaccharides: Single Sugars

Glucose
– carbohydrate form used by the
body, referred to as “blood sugar”
– basic sub-unit of other larger
carbohydrate molecules
– found in fruits, vegetables, honey

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 Monosaccharides: Single Sugars

Fructose
– sweetest of the sugars
– occurs naturally in fruits & honey,
“fruit sugar”
– combines with glucose to form
sucrose

Galactose
– combines with glucose to form
lactose, “milk sugar”

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 Monosaccharides (Hexoses)
Sugar Source Importance Clinical significance

D-Glucose • Fruit juices,  The sugar of the body. Present in the urine
(Dextrose) • Hydrolysis of  The sugar carried by
the blood, and the
(glycosuria) in
Grape sugar starch diabetes mellitus
Blood sugar cane sugar, principal one used by owing to raised
maltose & the tissues, RBCs,
brain cells
blood glucose
(Aldose) lactose (hyperglycemia)
• Stored as
 Acts as immediate
energy source for
glycogen cellular functions like
muscle contraction,
nerve transmission and
tissue repair
 Can be converted into
other sugars or
derivatives required for
GAGs & Glycolipids

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Monosaccharides (Hexoses)
Sugar Source Importance Clinical significance

D-Fructose • Fruit juices, Can be Herediatary

• Fruit Sugar Honey changed to Fructose intolerance
• Levulose • Hydrolysis of glucose in the leads to fructose
• Keto sugar cane sugar & inulin
• Seminal fluid is
liver and so accumulation and
• Sweeter used in the hypoglycemia
than Glu rich in Fructose
body

D-Mannose Hydrolysis of • A constituent of many  

• Aldo- Sugar plant mannans Glycoproteins
and gums • When oxidized
• Epimer of gives IdUA-a
glucose component of Heparin

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Monosaccharides (Hexoses)

Sugar Source Importance Clinical

significance
D-Galactose • Can be changed Failure to
Hydrolysis of to glucose in the
• Aldo- Sugar metabolize
 Milk sugar liver and then leads to
• Epimer of metabolized. galactosemia
Glucose  Galactolipids
• Synthesized in
and cataract
• Less sweet
 Glycoproteins the mammary (Galactitol)
than Glu gland to make
the lactose of milk.

• A constituent
of glycolipids and
Glycoproteins

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 Hexoses of Physiologic Importance.

Sugar Source Biochemical Importance Clinical Significance

D-Glucose Fruit juices, hydrolysis The main metabolic fuel for Excreted in the urine
of starch, cane or beet tissues; "blood sugar" (glucosuria) in poorly
sugar, maltose and controlled diabetes
lactose mellitus as a result of
hyperglycemia
D-Fructose  Fruit juices, honey, Readily metabolized either Hereditary fructose
hydrolysis of cane or via glucoseor directly intolerance leads to
beet sugar and inulin, fructose accumulation
enzymic isomerization and hypoglycemia
of glucosesyrups for food
manufacture
D- Hydrolysis of lactose Readily metabolized Hereditary
Galactose  to glucose; synthesized in the galactosemia as a result
mammary gland for synthesis of failure to metabolize
of lactose in milk. A galactose leads to
constituent of glycolipids and cataracts
glycoproteins
D-Mannose  Hydrolysis of plant Constituent of glycoproteins  
mannan gums

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 Disaccharides

Sucrose (“table sugar”)

– glucose + fructose

Lactose (“milk sugar”)

– glucose + galactose

Maltose (“malt sugar”)

– glucose + glucose
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SUCROSE: Table sugar/cane sugar

 It’s the main transport form of CHOs in plants.

 Obtained from cane and beet commercially.
 Made of 2 monosaccharides glucose and fructose which are linked by a glycosidic
linkage; α for glucose and β for fructose.
 It can be cleaved to its 2 components by enzyme sucrase.
 Provides 20-30% of the total calories.

Sucrose----------------------> Glucose + Fructose

Sucrase/invertase

Glycosidic linkage is α 1-2 bond.

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LACTOSE: (milk sugar)

Major dietary CHO for infants.

10% of total CHOs consumed. Lactose is the only natural source of
galactose.
Lactose is hydrolysed to its monosaccharides by lactase in humans
and by β-galactosidase in bacteria.
Synthesized also during lactation.

Galactose is joined to glucose by

a β-1,4-glycosidic linkage.

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MALTOSE: Malt sugar

 Produced by the hydrolysis of starch and is in turn hydrolysed to glucose by

maltase.

 Present in germinating cereals and not naturally found in diet.

 Maltose in beer is produced by partial digestion of starch.

Glycosidic linkage is α 1-4 bond

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 Disaccharides

• Lactulose (Gal + Frc)

– Used in the treatment of some chronic liver diseases
associated with hyper-ammonemia

• Lactitol (galactosido-sorbitol)
– Also used in the treatment of some chronic liver
diseases

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 Complex Carbohydrates
Oligosaccharides
– short carbohydrate chains of 3 - 10
monosaccharides
– found in legumes and human milk
– Examples:
cannot be broken down by human enzymes,
• raffinose though can be digested by colonic bacteria
• stachyose

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 Complex Carbohydrates
Polysaccharides
• long carbohydrate chains of
monosaccharides linked by glycosidic bonds
– alpha (a) bonds (starch)
– beta (b) bonds (found in fiber)

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 amylose
Complex Carbohydrates

Starch amylopectin

– plant storage form of

carbohydrate
– long branched or
unbranched chains of
glucose
• amylose
• amylopectin

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 Complex Carbohydrates
Glycogen
– highly branched chains of
glucose units
– animal storage form of
carbohydrate
• found in LIVER and MUSCLE
• Humans store ~ 100g in liver; ~
400g in muscle
– negligible source of
carbohydrate in the diet (meat)

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 Complex Carbohydrates
Dietary Fiber
– non-digestible carbohydrates (chains of monosaccharides)
and lignin that are intact and intrinsic in plants (includes
oligosaccharides)
Functional Fiber
– isolated, non-digestible carbohydrates that have beneficial
physiological effects in humans

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 Complex Carbohydrates

• dietary fiber found in all types of plant

foods
• refining removes fiber from whole grains
and other foods

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 Complex Carbohydrates

• types of non-starch
polysaccharides include:
 cellulose
 hemicelluloses
 pectins
 gums & mucilages
 b-glucans
 chitin & chitosan
 lignans

Melese .S
 Dietary fiber
• Fiber refers to certain types of carbohydrates that our
body cannot digest (oligosaccharides and non-starch
polysaccharides).

• These carbohydrates pass through the intestinal tract

intact and help to move waste out of the body.

• Diets that are low in fiber have been shown to cause

problems such as constipation and hemorrhoids and to
increase the risk for certain types of cancers such as colon
cancer.
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 Dietary Fiber
• Chronic constipation can
lead to diverticulosis and
diverticulitis
• Prevention of constipation
and diverticulosis
– Insoluble fiber helps reduce
transit time of foods in the
colon
– Soluble fiber helps make
stool easier to pass by
increasing bulk and softening
texture Melese .S
Figure 4.12
 Benefits of Fiber

i) Prevent constipation
Insoluble fiber binds water, making stools softer and
bulkier.
Therefore, fiber especially that found in whole grain
products is helpful in the treatment and prevention of
constipation, hemorrhoids and diverticulosis.
Diverticula are pouches of the intestinal wall that can
become inflamed and painful.
In the past, a low-fiber diet was prescribed for this
condition.
A high-fiber diet gives better results once the
inflammation has subsided.
 Cont …
• beneficial for weight control by contributing to satiety
& delay gastric emptying
• soluble fibers lower blood cholesterol to help reduce
risk of cardiovascular disease
• minimizes risk of and helps control Type II Diabetes

• insoluble fibers help promote intestinal health by

enlarging stool size and easing passage of stool

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 ii) Lower cholesterol levels

• Low blood cholesterol levels (below 200 mg/dl.) have been

associated with a reduced risk of coronary heart disease.

• The body eliminates cholesterol through the excretion of bile

acids. Water-soluble fiber binds bile acids, and hence a high-
fiber diet may result in an increased excretion of cholesterol.

• Some types of fiber appear to have a greater effect than others.

• The fiber found in rolled oats is more effective in lowering blood

cholesterol levels than the fiber found in wheat.

• Pectin has a similar effect in that it, too, can lower the amount
of cholesterol in the blood.
 Dietary Fiber
• Prevention of heart disease and diabetes
– Viscous, soluble fiber helps lower elevated blood
cholesterol levels
• Interferes with reabsorbtion of bile acid

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Figure 4.13
 Cont…
• Diets high in fiber; however, have been shown to
decrease risks for heart disease, obesity, and
they help lower cholesterol.

• Foods high in fiber include fruits, vegetables, and

whole grain products.

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 iii) Reduce the risk of some cancers

Dietary fiber may help reduce the risk of some cancers,

especially colon cancer.

This idea is based on information that insoluble fiber

increases the rate at which wastes are removed from the
body.

This means the body may have less exposure to toxic

substances produced during digestion.

A diet high in animal fat and protein also may play a role
in the development of colon cancer.
 How does fiber prevent different health
problems?

Cancer (Colonic, breast..)

• Prevents secondary bile acid circulation
• Decrease intestinal transit time
• Decrease contact of carcinogens with intestinal
cells
• Fermentation product butyrate has apoptotic
effect
• Decreases absorption fats and sugars
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 Cont…

• Dietary Fiber prevents Constipation,

Hemorrhoids & Diversticulosis by:

• Increasing perystalsis making stool bulk

• Decreasing straining to pass stool

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 iv) Useful for losing weight

High-fiber diets may be useful for people who wish to lose

weight.

Fiber itself has no calories, yet provides a "full" feeling

because of its water-absorbing ability.

For example, an apple is more filling than a half cup of apple

juice that contains about the same calories.

Foods high in fiber often require more chewing, so a person is

unable to eat a large number of calories in a short amount of
time.
 Soluble Fiber
• examples include gums, pectins, mucilages,
some hemicelluloses
• functions:
– delay gastric emptying
– slow transit through the digestive system
– delay glucose absorption
– bind to bile, help decrease cholesterol
• food sources: fruits

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 Insoluble Fiber
• examples include cellulose, hemicellulose
• functions:
– speed transit through the digestive tract
– delay glucose absorption
– increase fecal weight and soften stool to ease passage
– reduces risk of hemorrhoids, diverticulitis and appendicitis
• food sources: cereal grains, legumes, vegetables,
nuts

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Effect of dietary fiber on breast Cancer
Systematic review

Sourec: Annals of Oncology, Jnaury, 2012

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Insoluble fibre has more effect on weight

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Fiber and Colorectal Cancer: review of evidence

Source
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 Adverse effect
• Although fiber is important, it is just one part of a
properly balanced diet.

• Too much fiber may reduce the amount of calcium, iron,

zinc, copper and magnesium that is absorbed from
foods.

• Deficiencies of these nutrients could result if the amount

of fiber in the diet is excessive, especially in young
children.

• Fiber supplements are sold in a variety of forms from

bran tablets to purified cellulose.
• Many laxatives sold as stool softeners actually are fiber
supplements.

• Fiber's role in the diet is still being investigated.

• Various types of fiber have different roles in the body.

• For these reasons fiber supplements should be avoided.

• Eating a variety of fiber-rich foods is the best way to

receive the maximum benefits from each type of fiber
present in foods, and obtain necessary nutrients.
 Fiber: Too much of a good thing?
Excessive amounts of fiber may lead to:
– displacement of other foods in the diet
– intestinal discomfort
– interference with the absorption of other
nutrients

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 Butyrate and colon cancer.
• Butyrate has been shown to act as both preventive and inhibitory
in carcinogenesis of the colon. The chemopreventive effect is
mediated by upregulation of detoxifying enzymes for xenobiotics
and oxidants
 helps prevent and inhibit colonic carcinogenesis. Extra-intestinal
beneficial effects of butyrate include
1) increasing fetal hemoglobin production;
2) lowering serum cholesterol levels;
3) stimulating neurogenesis in brain after ischemic injury; and
4) providing positive effects in the treatment of obesity, insulin resistance,
cystic fibrosis, urea cycle enzyme deficiency, and sickle cell disease
 The role of butyrate in the inhibition and prevention of colon
cancer is likely one of its most important beneficial effects.
Source: Am J Physiol Cell Physiol 301: C977–C979, 2011;
doi:10.1152/ajpcell.00290.2011.
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 Food sources of Carbohydrates

• Free sugars are found from: fruits, juices, confectionery, Soft

drinks, , milk, sugar, sugar cane, honey and yogurt, Cereal grains,
Legumes & dried fruits, vegetables, processed foods (pasta), jams,
pastries, breads, candies fruits like banana, dates, and sweet potato
• Starch is found from: starchy foods (like cereals and legumes
and potatoes), Other foods like fruits, vegetables, beans, nuts,
seeds
• OligoSacharides are found from : Garlic, onion, Whole grain
cereals and legumes (beans and peas)
• Non starch polysaccharides are found from: Fruits,
vegetables, Whole grain cereals and legumes

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 Carbohydrate digestion
a. Digestion of starch and disaccharides
-Che m ical Starch, Lacto se
salivary Am ylase D e xtrin, Lactase Sucro se
Mo uth and
(Ptyalin) &
sm all
Pancre atic
inte stine Sucrase
am ylase Gluco se
 -Me chanical;- + Gluco se
biting actio n o f +
Galacto se
the te e th Fructo se
From the sm all
Maltose inte stine
Maltase

Gluco se + Gluco se
Absorbed by simple
diffusion

Absorbed by active transport

mechanism coupled with sodium

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 Digestion & Absorption

1. Mouth
• chewing
• salivary amylase
2. Stomach
• fibers remain in the
stomach longer, delays
gastric emptying
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 Digestion & Absorption
Small Intestine
• pancreas secretes enzyme pancreatic amylase
• enzymes located on the cell membranes of the intestinal
epithelial cells complete digestion

maltase
maltose glucose + glucose

sucrase
sucrose glucose + fructose

lactase
lactose glucose + galactose
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b. Digestion of oligosaccharides, resistant starch and non-
starch polysaccharides
O ligosaccharide s (e g. Raffinose , Stachyo se)
and non-starch po lysaccharide s re sistant
starch

Escape digestion in the

upper gut (small intestine

They get fermented in the

colon by anaerobic bacteria

Production of
gases likes co2, Production of
methane and short chain fatty Increased faecal Biomass
hydrogen acids (SCFA) resulting in increased
sulphide  Acetate peristalsis
 Propionate
 Butyrate Melese .S
 Digestion & Absorption
Small Intestine cont.
• only monosaccharides can be absorbed
– glucose & galactose absorbed by ACTIVE TRANSPORT
– fructose absorbed by FACILITATED DIFFUSION
• all three monosaccharides travel in the portal vein
to the liver
• three fates of glucose at the liver
– Energy, storage as glycogen, released to blood

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 Digestion & Absorption
Large Intestine
• resistant starches and fibers may be digested
by bacteria
– produces short chain fatty acids
• absorbed by the intestine and used for energy
(dietary fiber yields about 2 kcal/g)
• other health benefits

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Digestion of
carbohydrates.

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 Metabolism of Carbohydrates
Glucose –6-Phosphate

Fructose-6-phosphate
Glycolysis

Fructose1, 6-diphosphate

3-Dihydroxy Acetone phosphate

Glyceraldehyde-3 phosphate
bGlyceraldehyde 3-phosphatephosphate
Acetyl CoA

Crebs Cycle
CO2+ Energy+H2O

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Melese .S
 Overview of Metabolism
protein polysaccharides lipids
ADP + Pi ADP + Pi ADP + Pi
ATP ATP ATP
amino acids hexoses
fatty acids
ADP + Pi pentoses
ADP + Pi ADP + Pi
ATP ADP + Pi
ATP
ATP
pyruvate ATP
urea
acetyl-CoA ADP + Pi
urea O2
ATP
cycle
electron transport
e- chain
citric acid oxidative
cycle phosphorylation
CO2
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ATP
Overview of Catabolic Processes
Proteins Carbohydrates Fats
Stage 1
Amino acids Simple Sugars Fatty acids

Glycolysis
Stage 2
Pyruvate ATP

Acetyl CoA

Citric acid cycle Stage 3

Oxidative phosphorylation

ATP
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 GLUCOSE TRANSPORTERS
family of proteins called the solute carriers (SLC)

GLUT1: RBC’s
GLUT2 :intestine, pancreatic β-cells, kidney and liver(glucose sensor)
GLUT3: binds glucose with high affinity
GLUT4: insulin-sensitive tissues, such as skeletal muscle and adipose tissue
GLUT5: fructose transporter

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Melese .S
 Effect of food processing on Carbohydrates

• Polishing – loss of vitamines (eg. Thiamin)

• Fermenting
– increase mineral bioavailability (Fe, Zn, Mg, Ca)
– Functional foods (prebiotic VS probiotic)

• Germination
– Decreases viscosity due to gelatinization
– Increases nutrient density

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 Probiotic vs Prebiotic
• Probiotics are live bacteria in yogurt, other dairy products
and pills. And while probiotics have been shown effective
in managing certain gastrointestinal conditions, they do
not have the same power that prebiotics do.
• The Prebiotic is a specialized plant fiber that beneficially
nourishes the good bacteria already in the large bowel or
colon. The body itself does not digest these plant fibers;
instead, the fibers act as a fertilizer to promote the growth
of many of the good bacteria in the gut.

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 PREBIOTIC VS PROBIOTIC
PREBIOTICS PROBIOTICS
PREBIOTICS are a special form of PROBIOTICS are live bacteria in yogurt,
dietary fiber dairy products and pills. There are hundreds of
probiotic species available. Which of the hundreds of
available probiotics is best for the average healthy
person is still unknown.

PREBIOTIC powders are not affected by heat, cold, PROBIOTIC bacteria must be kept alive. They may be
acid or time. killed by heat, stomach acid or simply die with time.

PREBIOTICS provide a wide range of health benefits to PROBIOTICS are still not clearly known to provide
the otherwise healthy person. Most of these have been health benefits to the otherwise healthy. Some are
medically proven. suspected but still not proven.
PREBIOTICS nourish the good bacteria that everyone PROBIOTICS must compete with the over 1000
already has in their gut. bacteria species already in the gut.

PREBIOTICS may be helpful for Certain PROBIOTIC species have been shown to be
helpful for childhood diarrhea, irritable bowel disease
several chronic digestive disorders or and for recurrence of certain bowel infections such as C.
inflammatory bowel disease. difficile.

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Melese .S
Diseases associated with abnormal carbohydrate
metabolism include

Diabetes mellitus

Galactosemia
Lactose intolerance
Glycogen storage diseases

Hypoglycemia.

Melese .S
 There are 3 types of lactase deficiency:
1. Inherited lactase deficiency:
• In this syndrome, which is relatively rare, symptoms
of intolerance develop very soon after birth
• The feeding of a lactose-free diet results in
disappearance of the symptoms
• The occurrence of lactose in the urine is a prominent
feature of this syndrome, which appears to be
attributable to an effect of lactose on the intestine
2. Secondary low-lactase activity:
• Because digestion of lactose is limited even in
normal humans, intolerance to milk is not
uncommon as a consequence of intestinal disease
• Examples are tropical and non tropical (celiac)
spure,Crohn’s disease, kwashiorkor, colitis, and
gastroenteritis.
• The disorder may be noted also after surgery for
peptic ulcer
3. Primary low-lactase activity:
• This is a relatively common syndrome, particularly
among non white populations
• Since intolerance to lactose was not a feature of
the early life of adults with this disorder, it is
presumed to represent a gradual decline in activity
of lactase in susceptible individual
 Cont …
• Lactose Intolerance - Dietary Changes
– Increase consumption of milk products
gradually.
– Mix dairy with other foods.
– Spread dairy intake throughout the day.
– Use of acidophilus milk, yogurt, and kefir
(fermented products)
– Use of enzymes
– Individualization of diets
– Must be careful that vitamin and mineral
deficiencies do not develop
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 Consequences of chronic elevation in concentration
of hexoses in blood

 2 possible consequences are

• Enzymatic formation of sugar alcohols
• Nonenzymatic glycosylation (“glycation”) of proteins
 Both of these associated with long term pathologies of
nerves, blood vessels, kidneys, and lens as found in
diabetes and galactosemia

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 Galactose Metabolism
• By far major source of galactose in human diet is in
form of lactose
• Major source of lactose is milk and milk products
• Major organ involved in galactose metabolism is liver
• There are several inborn errors involving
metabolism of galactose

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 2 types of galactosemia are caused by
deficiency or absence of:
D-galactose 1-P uridyltransferase andgalactokinase
• The first more common (prevalence = 1 in 70,000) than
second (prevalence = 1 in 1 x 105) and has far greater
clinical importance in terms of associated pathologies,
especially in homozygotes

• In Illinois the incidence of the first defect is ~1 in 30,000

live births

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The pathologies associated with defective D-galactose
1-P uridyl transferase include:
• severe mental retardation, hepatomegaly, cataracts, and
non-specific morphological changes in the CNS

• In Illinois, all newborns are screened for galactosemia

• Affected infants MUST be placed on a galactose-free (i.

e., milk-free) diet immediately to prevent irreversible
damage

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 Fructose Metabolism
• Major sources of fructose in diet are fruits, honey,
sucrose and, now, in form of high fructose corn syrup or
solids as an added sweetener in soft drinks, candy, etc.
• Fructose -in one form or another- may account for 30 -
60% of total dietary carbohydrates for some
• Major organ involved in fructose metabolism is the liver

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 Regulation of Blood Glucose
Optimal functioning of the body is dependant on
keeping levels of glucose within certain parameters.
 Elevated blood glucose = Hyperglycemia
 Low blood glucose = Hypoglycemia
The ENDOCRINE SYSTEM is primarily responsible for
regulating blood glucose. The two main hormones are
INSULIN and GLUCAGON.

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 Diabetes Mellitus
• a disorder of energy metabolism due to failure of
insulin to regulate blood glucose
• results in hyperglycemia
• acute symptoms include thirst, increased urine
production, hunger
• long term consequences include increased risk of
heart disease, kidney disease, blindness, neural
damage
• two forms: Type I and Type II

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 Diabetes Mellitus
Type I
• accounts for about 10% of cases
• occurs when b cells of the pancreas are destroyed
– insulin cannot be synthesized
• without insulin, blood glucose levels rise because the
tissues are unable to access the glucose
• death occurs shortly after onset unless given
injections of insulin

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 Forms of Diabetes
• Type 1
– Usually begins in childhood or early adulthood
– 5–10% of diabetics
– Immune system destroys beta cells of the
pancreas
• No insulin produced
– Common symptoms of elevated blood sugar
• Polydipsia
• Polyuria
• Polyphagia
– Require insulin and frequent blood glucose
monitoring
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 Diabetes Mellitus
Type II
• occurs when cells of body are unable to respond to
insulin
• called “insulin insensitivity” or “insulin resistance”
• blood glucose levels rise
• insulin secretion increases in an attempt to
compensate
– leads to hyperinsulinemia

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 Forms of Diabetes
• Type 2
– Overweight individuals develop this form
frequently
– 90–95% of diabetics
– Can go undiagnosed
• Damages vital organs without individual being aware of
it
• Polycystic ovary syndrome
– Hormonal imbalance in women
– Have higher incidence of insulin resistance and
hyperinsulinemia
• Increased risk of developing type 2 diabetes
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 Hypoglycemia
• dramatic drop in blood glucose
• symptoms similar to an anxiety attack: rapid weak
heart beat, sweating, anxiety, hunger, trembling,
weakness
• RARE in healthy people
• may occur as a result of poorly managed Diabetes or
other causes:
– reactive hypoglycemia
– fasting hypoglycemia

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Complications Of Diabetes

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Copyright 2005 Wadsworth Group, a division of Thomson Learning
 Forms of Diabetes
• Prediabetes
– Impaired glucose tolerance
– Fasting blood sugar between 100 mg/dl and 126
mg/dl
– High risk of developing diabetes and heart disease

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 Diabetes
• Long-term damage from diabetes
– Nerve damage • Tooth loss
• Gum problems
– Leg and foot amputations
• Kidney disease
– Eye diseases • Heart disease
– Blindness
• Slowing of onset of complications
– Control level of blood glucose through
• Diet
• Insulin or oral medication
• Monitoring blood glucose
• Regular healthcare visits
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 Management of DM
• The major components of the treatment of
diabetes are:

A • Diet and Exercise

• Oral hypoglycaemic
B therapy

C • Insulin Therapy

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 Some dietary recommendations for diabetes
- Saturated fatty acids, <10% of total energy
- w -6 polyunsaturated fatty acids, <10% of total
energy
Components of dietary energy
- Protein, 10-20% of total energy
- Carbohydrate and cis-monounsaturated fatty acids,
for the remainder
- Low glycemic index foods and those rich in soluble
fibre recommended
- Vegetables, fruits, pulses and cereal-derived foods
preferred
Carbohydrate issues
- Sucrose, <10% total energy acceptable in certain
circumstances
- Timing of intake essential for those on insulin

- Non-alcoholic beverages sweetened with non-

nutritive sweeteners are useful
Special 'diabetic' and 'dietetic' foods - Other special foods not encouraged
- No particular need of fructose and other 'special'
nutritive sweeteners over sucrose
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 Whole Grains and Type 2 Diabetes
• Finnish study: 1.00
– 4,300+ men/women 1.00

Type 2 Diabetes (RR)

– 10 year study 0.75
• Those eating the most
0.65
whole-grains had 35% 0.50
less type 2 diabetes.
0.25 0.39
• Those with highest
cereal fiber intake had
0.00
61% less diabetes. Low High 29+ g
Cereal
Fiber
Whole Grain Intake

Amer Jour Clin Nutr 77: 527-529 Melese .S

 Whole Grains & Risk of Mortality
• ARIC study, 15,792 1.00
people 45-64, 11 yrs 1.00

Mortality, any cause (RR)

• Those eating the most 0.75 0.84

whole-grains had a 48%

0.66
decrease in mortality. 0.50
0.63
0.52
• After adjusting for BMI,
exercise, cholesterol, 0.25
etc. they still had a 23%
lower risk of dying from
0.00
any cause. 0.1 0.5 1 1.5 3

Whole Grains, Servings/Day

(Quintiles)

Amer Jour Clin Nutr 78: 383-390 Melese .S

 Blood Glucose and Insulin Curves
High energy
storage
zone

After eating:
• White bread (solid line) Hunger Zone

and then
• Spaghetti (dotted line) High insulin response
leads to obesity,
(each food was eaten on insulin resistance and
exhaustion
different days)

JAMA, May 8, 287:2415 Melese .S

 The Glycemic Index
• a measure of the extent to which a food raises
blood glucose concentration & elicits an insulin
response compared to pure glucose

Low Moderate High

pasta banana white bread
baked beans orange juice cornflakes
bran cereals ice cream potatoes
apples jelly beans
milk watermelon
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The Glycemic Index

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The Glycemic Index cont.
Glucose 100
Baked potato 85
Jelly bean 78
Honey 73
Bagel 72
Sucrose 65
Boiled new potato 62
Brown rice 55
Chocolate 49
Boiled carrots 47
Orange 44
Spaghetti 42
Apple 38
Skim milk 32
Lentils 29
Fructose 23

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 Glycemic Index (contd)
• Use of Glycemic Index
– Lower GI foods digest & Fastest Glucose
Dextrose
convert to glucose more slowly
Starch (branched-chain)
– High-fiber slower than low
Sucrose/Corn Syrup
– High-fat slower than low Fructose
– Solids slower than liquids Starch (straight-chain)
– Cold foods slower than hot Lactose
– Type of sugar/starch affects GI Galactose
Slowest Sugar Alcohols

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Glycemic Index
 Glycemic Index (GI)

The GI reflects the rate of digestion and absorption of

CHO

Blood glucose area after test food

GI = X 100
Blood glucose area after reference food

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 What Does the Glycemic Index Value Mean?
• The glycemic index (GI) is expressed as a ratio comparing the blood glucose increase caused
by a test food to that of a reference food (usually glucose [G], historically white bread [WB])
for 2 hours following ingestion:

Area Under the Curve for Test Food

× 100 = GI
Area Under the Curve for Reference Food
• Conversion for different reference foods: GIG × 1.4 = GIWB
– The GIG for carrots (mean of 4 studies) = 47
– The GIWB for carrots (mean of 4 studies) = 68
• How about a ½ cup of carrots? GI of 47% and it contains about 6 g carbohydrate

GL + 47 x 6/100= 3g
• Let’s take a medium apple. It has a GI of 40% and it contains 15 grams of carbohydrate
GL = 40 x 15/100 = 6 g
• What about a small baked potato? Its GI is 80% and it contains 15 g of carbohydrate

GL = 80 x 15/100 = 12 g
Atkinson FS, et al. Diabetes Care. 2008;31(12):2281-2283. Melese .S
 GI rating for some common carbohydrates

• A Glycaemic Index of
 less than 55 is considered Low,
 56 to 69 Medium and
 Greater than 70 is High.
• Values will vary depending on brand, variety,
ripeness, preparation etc.

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Factors Influencing GI Ranking

Type of starch Cooking

Physical entrapment Food processing

Viscosity of fiber Acid content

Sugar content Protein content

Fat content

How does all this affect our glycemic levels?

How does all this make us feel after eating

carbohydrate-containing foods?
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 Glycemic Load
• Glycemic index relative to the serving size
• Some CHO have high GI but are consumed in
small quantities per serving
• GL = (GI x CHO/serving)/100
• Ratings of glycemic loads
– High GL = >20
– Medium GL = 11-19
– Low GL = <11

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 High Glycemic Load Meals
• Eating high glycemic load meals, compared to
lower glycemic load meals, results in:
– Higher 24-hour blood sugar levels
– Higher insulin levels
– Higher glycosylated hemoglobin levels (HbA1c)
– Increased hunger following reactive low blood sugar
• It also results in increased risk for diabetes, obesity,
and coronary heart disease.

JAMA, May 8, 287:2415 Melese .S

GI vs. GL

Glycemic Index: ranks carbohydrates based on

their immediate blood glucose
response.
GI = glycemic quality

Glycemic Load: helps predict blood glucose

response to specific amount of
specific carbohydrate food.
quality
GL = glycemic
quantity
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Benefits of Low GI Diet

Are there any documented benefits to

lowering the GI of one’s diet?

YES!
BG levels type 2 DM risk

cholesterol levels heart disease risk

weight

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 Glycemic Load and Risk of Heart Disease

2.00 N = 75,521
Risk of Heart Disease (RR)

10 year study 1.98

1.50
1.51
1.25
1.00
1.00 1.01

0.50

0.00
117 145 161 177 206
Low glycemic load High glycemic load
Glycemic Load Quintiles

AJCN, 71:1455-61 Melese .S

 Glycemic Index and Dietary Fiber and Risk of Diabetes

Women’s Health study 2.5

Risk of Getting Diabetes (RR)

• Women who ate the least fiber 2.50
were twice as likely to get 2.0
diabetes as those who ate the
most fiber. 1.80
1.5
• Women with the highest
glycemic index were 51% more
likely to get diabetes then 1.0
1.00
women who ate the lowest GI
diet. 0.5
• Overall risk was 2.5 times higher
on the low fiber, high GI diet. 0.0
Decreasing fiber
Increasing Glycemic Index

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Journal of the American Medical Association 277 (6): 474-477
 Glycemic Index - Oats
52 Glycemic Index
Steel cut oats Low GI is less than 55
Medium GI = 55-59
High GI = 60+
Oatmeal 55

Quick oats 65

White bread 70

Cheerios 74

Table sugar 65
Glycemic Index (GI) based on glucose
0 10 20 30 40 50 60 70 80 90 100 110

University of Sydney, Nutrition Department

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Legumes Lower Glucose Levels and CHD Risk
• Legumes are high in fiber
and have a very low
glycemic index.
• Adding 1 cup of legumes to
the diets of 121 diabetics
for 3 months significantly
lowered:
– Blood A1C levels
– Body weight and blood
pressure
– Risk of coronary heart
disease

Archives of Internal Medicine 2012;172(21):1653-1660

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 The Low Glycemic Index Diet:
Epidemiologic Studies
• In some but not all studies, low GI diets are
associated with:
– Increased insulin sensitivity
– Reduced adiposity
– Reduced risk of metabolic syndrome
– Reduced risk of type 2 diabetes
 The Low Glycemic Index Diet:
Clinical Trials
• Low GI diets:
– Reduce postprandial glucose levels in normal
individuals and people with diabetes (Ludwig, JAMA,
2002)
– Produce modest improvements in HbA1c in
patients with diabetes (Brand-Miller, Diabetes Care, 2003)
– May or may not affect insulin sensitivity
(improvements noted in 2 of 7 studies)
 The Low Glycemic Index Diet:
Clinical Trials
• Low GI diets:
– May be beneficial for weight management,
particularly in individuals with features of the
metabolic syndrome (Pittas, Diabetes Care, 2005)
– May reduce LDL cholesterol and TG and increase
HDL (Luscombe, EJCN, 1999 and Pereira, JAMA, 2004)
– May reduce inflammatory markers such as C-
reactive protein (Pereira, JAMA, 2004) and IL-6 (Kallio, AJCN,
2008)
– May increase antioxidant capacity (Botero, Obesity,
2009)
 Questions
• Does the DASH diet or the low GI improve insulin
sensitivity, in the absence of weight loss?
• Does the DASH diet or the low GI diet improve other
features of the metabolic syndrome (such as
dyslipidemia and inflammation), in the absence of
weight loss?
• Do these dietary patterns and weight loss have
synergistic effects?
 Glycemic Load of Common Foods

Food Glycemic Load Food Glycemic Load

Instant rice, ½ C Banana, 1
25 13
Baked potato, sm. Spaghetti, ½ cup
16
20
Apple, 1 fresh 8
Corn flakes, 2/3 C
Lentils, ½ C
21 6
White bread, 2 s. Carrot, 1 5
21 Peanuts, 1 oz. 3
Rye bread, 2 slices
Journal of the American Medical AssociationBroccoli,
Melese .S 287:2415 ½C
 Glycemic Index of Selected Foods
Foods Glycemic Index Foods Glycemic Index
White Bread 100 Oatmeal 82
Table sugar 84 Orange juice 75
Baked potato 104 Bran flakes 74
Cheerios 106 All bran 72
Pancake 119 Pasta 71
Cornflakes 120 Baked beans 60
White rice 102 Apple, raw 51
Instant rice 129 Skim milk 46
Fruit punch/soda pop 95 Soy beans (soy milk 43) 35
Banana 88 Peanuts 20
Pizza 86 Broccoli 15
Based on a “White Bread Standard”. To convert to the “Glucose Standard”, multiply by 0.7 .

Harvard Nutrition Department, (white Melese

bread .S standard)
 Calculating the Energy in Foods
• Each energy-yielding nutrient provides a set
number of kilocalories per gram
– 4 kilocalories per gram of carbohydrates
– 4 kilocalories per gram of protein
– 9 kilocalories per gram of fat (lipid)
– 7 kilocalories per gram of alcohol (non-nutrient)
• Number of kilocalories in one serving of a given
food can be determined based on
– Grams of carbohydrates, protein, and fat in the food

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Melese .S
Melese .S
 5 min

Exercise 1
A group of 905 children are measured over
the course of a survey. None of the children
suffered from edema. Fifteen children had
z-scores <-3, and 45 between <-2 and >= -3.

What is the prevalence of severe,

moderate and global acute malnutrition ?
 Exercise 1 - Answer
Prevalence of severe acute malnutrition (SAM) = number of
children severely malnourished / total number of children x
100: SAM =(15)/905  100 = 1.7%
Prevalence of moderate acute malnutrition (MAM) = number
of children severely malnourished / total number of children
x 100: MAM = (45)/905  100 = 5.0%
Prevalence of global acute malnutrition (GAM) = Prevalence
of severe acute malnutrition + prevalence of moderate
acute malnutrition. GAM = (45+15)/905  100 = 6.6%
 5 min

Exercise 2
A group of 910 children are measured over the
course of a survey. Six children are edematous.
Of these six, only one has a W/H z-score of <-
3,0, two are between -3,0 et -2,0; and three are
>- 2,0. Globally, 17 children have z-scores <- 3,
and 55 had a z-score between <- 2 and > - 3.
What is the prevalence of severe, moderate
and global acute malnutrition ?
 Exercise 2 - Answer
Prevalence of severe acute malnutrition (SAM) = number of
children severely malnourished / total number of children x
100: SAM =(17+6-1)/910  100 = 2.4%
Prevalence of moderate acute malnutrition (MAM) = number
of children moderately malnourished / total number of
children x 100: MAM = (55-2)/910  100 = 5.8%
Prevalence of global acute malnutrition (GAM) = Prevalence
of severe acute malnutrition + prevalence of moderate acute
malnutrition. GAM = (17+55+6-1-2)/910 x 100 = 8.2%
Thank You!
Melese .S