Perspectives of Nutrition

1. Because learning changes everything.®
Chapter 5
Carbohydrates
WARDLAW’S
Perspectives in
NUTRITION
Twelfth Edition
Carol Byrd-Bredbenner, Jacqueline
Berning, Danita Kelley, Jaclyn M.
Abbott
© 2022 McGraw Hill, LLC. All rights reserved. Authorized only for instructor use in the classroom.
No reproduction or further distribution permitted without the prior written consent of McGraw Hill, LLC.

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Learning Objectives1
1. Identify the major types of carbohydrates and give
examples of food sources for each.
2. List alternative sweeteners that can be used to reduce
sugar intake.
3. Describe recommendations for carbohydrate intake and
health risks caused by low or excessive intakes.
4. List the functions of carbohydrates in the body.
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Learning Objectives2
5. Explain how carbohydrates are digested and absorbed.
6. Explain the cause of, effects of, and dietary treatment for
lactose intolerance.
7. Describe the regulation of blood glucose, conditions
caused by blood glucose imbalance, types of diabetes,
and dietary treatments for diabetes.
8. Describe dietary measures to reduce the risk of
developing type 2 diabetes.
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Food Sources of Carbohydrates
Source: ChooseMyPlate.gov, U.S. Department of Agriculture
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Structures of Carbohydrates 1
Includes sugar, starch, and fiber
Composed of carbon, hydrogen, and oxygen
Plants are main source
• Produce glucose during photosynthesis
• Use carbon and oxygen to form carbon dioxide, hydrogen,
and energy
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Structures of Carbohydrates 2
Monosaccharides
• 6 12 6
C H O
• Single sugars
Disaccharides
• Double sugars
• Monosaccharides and disaccharides are simple sugars
Polysaccharides
• Many glucose molecules linked together
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Monosaccharides: Glucose, Fructose, Galactose
Monosaccharides
• Most common are glucose, fructose, and galactose
• Each of these is classified as a hexose: 6 carbon structures
Glucose
• Most abundant monosaccharide
• Linked together with other sugars in our diets
• “Blood sugar”
Fructose
• Found in fruits, vegetables, honey, and high-fructose corn syrup
Galactose
• Most in our diets is combined with glucose to form lactose (milk
sugar)
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The 6-Carbon Monosaccharides: Glucose, Fructose, and
Galactose
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Monosaccharides: Sugar Alcohols, and Pentoses
Sugar alcohols
• Derivatives of monosaccharides
• Sorbitol, mannitol, and xylitol
• Sweeten sugarless gums and diabetic foods
Pentoses
• Monosaccharides with 5 carbons
• Include ribose and deoxyribose
• Not supplied by the diet
• Essential part of cell’s genetic material
• Ribose - ribonucleic acid (RNA)
• Deoxyribose - deoxyribonucleic acid (DNA)
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Disaccharides: Maltose, Sucrose, and Lactose
2 monosaccharides linked together in a condensation
reaction
Maltose
• 2 glucose molecules
• Found in seeds and alcoholic beverages
Sucrose
• 1 molecule of glucose, 1 molecule of fructose
• Table sugar
• Sugarcane, sugar beets, maple tree sap
Lactose
• 1 molecule of glucose, 1 molecule of galactose
• Milk and milk products
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Two Monosaccharides Combine to Form a Disaccharide
Source: International Union of Pure and Applied Chemistry; D. Blackman, Representing the Structure of Sucrose; Biochem Ed., 1975; 3:77.
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Oligosaccharides: Raffinose and Stachyose
Complex carbohydrates
3 to 10 sugar units
Raffinose and stachyose:
• Onions, cabbage, broccoli, whole wheat,
legumes
• Contain beta bonds
• Pass indigested into the large intestine
• Bacteria metabolize, producing intestinal gas
Beano®:
• Enzyme preparation that helps break down
indigestible oligosaccharides
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Digestible Polysaccharides: Starch
Starch – digestible
• Storage form of glucose in plants
• Amylose: Unbranched chain of glucose molecules
• Amylopectin: Highly-branched chain of glucose
molecules, consisting of mostly alpha bonds
• More branches, more sites for enzyme action
• Faster increase in blood glucose levels
• legumes, tubers, grains, such as potatoes, rice, pasta,
beans
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Digestible Polysaccharides: Glycogen
Glycogen
• Storage form of carbohydrate in humans and animals
• Linked by alpha bonds
• More highly-branched than amylopectin
• Mainly stored in liver and muscle cells
• From liver can be converted into blood glucose
• From muscles can supply muscles with glucose
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Digestible Polysaccharides
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Indigestible Polysaccharides: Dietary and Functional
Fiber1
Total fiber
• Dietary fiber, found naturally in foods, plus functional fiber,
added to foods
• Nutrition Facts labels only include dietary fiber
• Found in many of the same foods as starch
• Highly processed grains are low in fiber
Cellulose, hemicellulose, pectins, gums, and mucilages
• Lignins are only non-carbohydrate components of dietary
fibers
Linked together by beta bonds (largely undigestible)
• Pass into the large intestine where bacteria:
• Metabolize and form short-chain fatty acids and gas
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Indigestible Polysaccharides: Dietary and Functional
Fiber2
Insoluble fibers
• Do not dissolve in water
• Form structural part of the plant cell
• Cellulose, hemicellulose, lignins
• Seeds, whole grains
Soluble fibers
• Dissolve in water
• Found inside and around plant cells
• Pectins, gums, mucilages, and some hemicelluloses
• Oat bran, skins and flesh of fruits and berries; thickeners in
jams, yogurts, sauces, and fillings; seaweed and psyllium
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Types of Dietary Fiber
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Soluble and Insoluble Fibers
Dynamic Graphics/PunchStock; Stockbytes/Getty Images; Moving Moment/Shutterstock; Ingram Publishing/Alamy Stock Photo; Photodisc/Getty
Images; Mahirart/Shutterstock
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Nutritive Sweeteners1
Can be metabolized to yield energy
• Monosaccharides
• High-fructose corn syrup
• Treatment of cornstarch with acids and enzymes break starch down
into glucose
• Enzymes convert glucose to fructose
• Final syrup is about 55% fructose
• Similar in sweetness to sucrose
• Found in soft drinks, candies, jam, jelly, and desserts
• See Table 5-2 for nutritive sweeteners used in foods
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Nutritive Sweeteners2
Sugar alcohols
• Used in sugarless gums and candies
• Not easily metabolized by bacteria in the mouth; do not
promote dental caries
• Contribute energy but are absorbed and metabolized more
slowly
• Sorbitol, mannitol, xylitol
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Sweetness of Sugars and Alternative Sweeteners
Jules Frazier/Getty Images
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Non-Nutritive (Alternative) Sweeteners
Provide very-low-calorie or non-caloric sugar substitutes
Safety is determined by the FDA
Indicated by an Acceptable Daily Intake (ADI) guideline
• Amount of alternative sweetener considered safe for daily
use over one’s lifetime
• Based on animal studies
• Set at 100 times less than the level where no harmful
effects were seen
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Saccharin
Saccharin
• Oldest alternative sweetener
• 300 times sweeter than sucrose
• ADI set at 5 mg/kg body weight/day
• Used as a tabletop sweetener and in foods and beverages
• Cannot be used in cooking
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Aspartame
Aspartame
• Sweetened beverages, gelatin desserts, chewing gum,
cookies, toppings and fillings of bakery goods
• Cannot be used in cooking
• NutraSweet®, Equal®
• 160 to 220 times sweeter than sucrose
• ADI set at 50mg/kg body weight/day
• Some people may be sensitive to aspartame
• Those with phenylketonuria (PKU) should avoid; contains
phenylalanine
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Neotame and Acesulfame-K
Neotame
• Found in a wide variety of food products
• Heat stable and can be used in cooking and as a tabletop
sweetener
• 7,000-13,000 times sweeter than sucrose
• ADI set at 18mg/kg body weight/day
Acesulfame-K
• Sunette®
• 200 times sweeter than sucrose
• Can be used in cooking
• ADI set at 15mg/kg body weight/day
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Sucralose and Tagatose
Sucralose
• Splenda®
• 600 times sweeter than sucrose
• Made from sucrose
• Heat stable
• ADI set at 5mg/kg body weight/day
Tagatose
• Naturlose®
• Isomer of fructose
• Heat stable
• Prebiotic effect
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Stevia
Stevia
• Derived from a plant from Amazon rain forest
• 250 times sweeter than sucrose
• Approved to be used in beverages and to be sold as a
dietary supplement
• PureVia™, Truvia®, Sun Crystals®
• ADI set at 4 mg/kg body weight/day
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Luo han guo
Luo han guo
• Monk fruit
• Fruit from Asia
• Juice from fruit is 150 to 300 times sweeter than sugar
• Heat stable
• Tabletop sweetener: Monk Fruit in the Raw®, Nectresse™
• No ADI set; Generally Recognized as Safe (GRAS)
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Advantame
• One of the newest alternative sweeteners
• Derived from aspartame and vanillin
• 20,000 time sweeter than sugar making it the highest
intensity sweetener on the market
• Heat stable, can be used in cooking and baking
• ADI 32.8 mg/kg body weight (~ 800 cans of soda)
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Recommended Intake of Carbohydrates
RDA is 130 g/day
• Supplies adequate glucose for brain and central nervous
system
Food and Nutrition Board recommends 45-65% of total
energy intake
Carbohydrates in our diets should include mostly:
• Fiber rich fruits, vegetables, and whole grains
• Little added sugars and caloric sweeteners
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Recommended Intake of Sugars
Dietary Guidelines for Americans and World Health
Organization:
• Limit added sugars to no more than 10% of daily total
energy intake
The Institute of Medicine’s Food and Nutrition Board:
• Upper limit of 25% of energy intake from added sugars
American Heart Association:
• Upper limit of sugar intake should be half of one’s
discretionary calorie allowance
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Recommended Intake Fiber
Adequate Intake for fiber
• 14 g /1000 kcal
• Before age 50:
• 25 g for women
• 38 g for men
• After age 50:
• 21 g/day for women
• 30 g/day for men
Adequate Intake is aimed to reduce the risk of:
• Diverticular disease
• Cardiovascular disease
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Our Carbohydrate Intake
Supply 50% of energy intakes in North Americans
Types of carbohydrates consumed do not meet
recommendations
• Added sugars: 14.5%
• Sugar-sweetened beverages
• Caloric sweeteners
See Table 5-4 Suggestions for Reducing Simple-Sugar
Intake
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Sources of Added Sugars in the Diets of the U.S.
Population Ages 2 Years and Older
Source: USDHHS/USDA. Dietary Guidelines for Americans. 9th ed., 2020; diearyguidelines.gov.
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Our Carbohydrate Intake2
Many individuals lack knowledge about fiber-rich foods and
their benefits.
Fiber intake is 25-50% less than recommended
• Low intakes of fruits and vegetables
• High consumption of refined grains
Food labels can be confusing
• “Wheat flour” or “wheat bread” may be enriched white flour
• “Whole-wheat flour” must be listed first; ensures product is
truly a whole-wheat bread and contains more fiber
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Whole Grain Stamps
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Adult Fiber Intakes by Country
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The Nutrition Facts Panel on Food Labels
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Functions of Carbohydrates in the Body
Digestible carbohydrates are broken down to glucose
• Primary source of energy
• Spare protein from use as energy
• Prevent ketosis
Indigestible carbohydrates play a role in maintaining health
of the GI tract and overall health
• Prevent constipation and diverticular disease
• Enhance management of body weight, blood glucose
levels, and cholesterol levels
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Digestible Carbohydrates 1
Provide energy
• Red blood cells and the central nervous system derive
almost all their energy from glucose
Spare protein from use as an energy source
• Amino acids from dietary protein are needed to build body
tissues
• If you do not consume enough carbohydrates, amino acids
are used to form glucose (gluconeogenesis)
• When enough carbohydrates are consumed, protein is
“spared” from use as energy
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Digestible Carbohydrates 2
Prevent ketosis
• Carbohydrates are needed to complete breakdown of fats
• If consumption is low:
• Release of insulin decreases
• Fatty acids from adipose tissue are released to provide energy for
the body
• Fatty acids are not completely broken down
• Ketone bodies are formed (ketosis)
Ketosis occurs in:
• Untreated diabetes
• Low carbohydrate/high fat weight reduction diets: Atkins®,
South Beach Diet®
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Indigestible Carbohydrates 1
Promote bowel health
• Adds bulk to feces
• Prevents:
• Constipation
• Hemorrhoids
• Diverticula, causing diverticular disease
• Asymptomatic form is called diverticulosis
• Inflamed, symptomatic form is called diverticulitis
Reduce the risk of colon cancer
• May be due to nutrients commonly found in high fiber
foods
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Diverticula in the Large Intestine
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Indigestible Carbohydrates 2
Reduce obesity risk
• Absorb water and expand in the GI tract, contributing to
satiety
Enhance blood glucose control
• Soluble fiber slows glucose absorption
• Decreases insulin release from pancreas
Reduce cholesterol absorption
• Soluble fiber inhibits:
• Absorption of cholesterol
• Reabsorption of bile acids
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Carbohydrate Digestion1
Food preparation starts digestion of carbohydrates
• Cooking softens tough, fibrous tissues
• Starch granules swell as they soak up water, making them
easier to digest
Begins in the mouth with salivary amylase in saliva
• Breaks down starch into smaller polysaccharides and
disaccharides
Salivary amylase is inactivated in the stomach
Pancreatic amylase and dextrinase pick up digestion in the
small intestine
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Carbohydrate Digestion2
Disaccharides are digested by enzymes in the absorptive
cells of the small intestine.
maltase
sucrase
lactase
Maltose Glucose Glucose
Sucrose Glucose Fructose
Lactose Glucose Galactose

 

 
 
Most carbohydrate digestion and absorption take place in the
small intestine
Indigestible carbohydrates cannot be broken down
• Pass into the large intestine
• Fermented by bacteria into acids and gases or excreted
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Carbohydrate Digestion and Absorption
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Absorption1
Glucose and galactose
• Absorbed by active absorption
• Pumped into absorptive cells with sodium
Fructose
• Absorbed by facilitated diffusion
• Slower absorption than glucose or galactose
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Absorption2
Some fructose is converted to glucose in absorptive cells
• Rest is converted in the liver
Galactose is converted to glucose in the liver
Glucose is then sent to cells for use
• Liver stores extra as glycogen
If glycogen storage capacity is exceeded, glucose is
converted to fat
• Stored in adipose tissue
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Active Absorption of Glucose into the Small Intestine
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Health Concerns Related to Carbohydrate Intake
Adequate intake of carbohydrates is important for:
• Maintaining health
• Decreasing risk of chronic disease
Excessive intakes can be harmful to overall health.
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Very-High-Fiber Diets
Above 50 to 60 g/day can cause health risks.
Hard, dry stools if fluid intake is low
• Hemorrhoids, rectal bleeding, intestinal blockage
Decrease in absorption of minerals (zinc, iron)
• Increasing risk of deficiencies
Special concern for young children, elderly, malnourished
• May not be getting adequate amounts of foods and
nutrients
• May cause a sense of fullness and reduce overall intake of
foods
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High Sugar Diets
Replace with intake of more nutritious foods
• Special concern for children and adolescents
Increased risk of weight gain and obesity due to extra energy
intake
Increased risk of cardiovascular disease
• Increased levels of triglycerides and LDL-cholesterol,
decreased levels of HDL-cholesterol
Development of dental caries
• Bacteria in the mouth metabolize sugars into acids
• Acids dissolve tooth enamel
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Dental Caries
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Lactose Intolerance
Lactase production begins to decrease after early childhood.
Primary lactose intolerance
• Insufficiency of lactase production
• Symptoms include abdominal pain, bloating, gas, diarrhea
• Amount of lactose tolerance varies by individuals, but hard
cheeses, yogurt, and acidophilus milk are more easily tolerated
Secondary lactose intolerance
• Conditions of the small intestine such as Crohn’s disease
and diarrhea damage the lactase producing cells
• Causes temporary symptoms
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Glucose Intolerance
Abnormal regulation of blood glucose levels
Hyperglycemia
• More common
• High blood glucose levels
• Commonly associated with diabetes and Metabolic
Syndrome
Hypoglycemia
• Low blood glucose levels
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Regulation of Blood Glucose1
Normal fasting blood glucose levels: 70-100 mg/dl
Above 126 mg/dl is classified as diabetes
• Hunger
• Thirst
• Frequent urination
• Weight loss
Below 50 mg/dl is classified as hypoglycemia
• Hunger
• Shakiness
• Irritability
• Weakness
• Headache
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Regulation of Blood Glucose2
The liver and the pancreas are important in blood glucose
control.
Liver determines amount of glucose that is needed to enter
the bloodstream after a meal
• Stored as glycogen for later use
Pancreas secretes:
• Insulin
• Glucagon
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Regulation of Blood Glucose-Insulin
Insulin
• Released after eating, when blood glucose levels are high
• Promotes increased:
• Glucose uptake by cells
• Use of glucose as energy
• Storage of excess glucose as glycogen
• Lowers blood glucose levels
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Regulation of Blood Glucose-Glucagon
Glucagon
• Released if no dietary carbohydrates are present, blood
glucose levels have fallen
• Promotes increased:
• Breakdown of glycogen
• Gluconeogenesis
• Blood glucose levels return to normal
Epinephrine and norepinephrine also trigger
gluconeogenesis
Cortisol and growth hormone decrease amount of glucose
used by muscle cells
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Regulation of Blood Glucose
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Roles of Various Hormones in the Regulation of Blood
Glucose
Hormone Source Target Organ
or Tissue
Overall Effects on Organ or
Tissue
Effect on
Blood Glucose
Insulin Pancreas Liver, muscle,
adipose tissue
Increases glucose uptake by
muscles and adipose tissue,
increases glycogen synthesis,
suppresses gluconeogenesis
Decrease
Glucagon Pancreas Liver Increases glycogen breakdown
and release of glucose by the liver,
increases gluconeogenesis
Increase
Epinephrine,
norepinephrine
Adrenal glands Liver, muscle Increase glycogen breakdown and
release of glucose by the liver,
increase gluconeogenesis
Increase
Cortisol Adrenal glands Liver, muscle Increases gluconeogenesis by the
liver, decreases glucose use by
muscles and other organs
Increase
Growth hormone Pituitary gland Liver, muscle,
adipose tissue
Decreases glucose uptake by
muscles, increases fat mobilization
and utilization, increases glucose
output by the liver
Increase
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Metabolic Syndrome 1
Group of factors that increase risk of:
• Type 2 diabetes
• Cardiovascular disease
Factors include:
• Insulin resistance
• Abdominal obesity
• High blood triglycerides and LDL-cholesterol
• Low HDL-cholesterol
• Elevated blood pressure
• Increased inflammatory proteins
• Higher concentrations of oxidized LDL-cholesterol
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Metabolic Syndrome 2
3 or more criteria need to be present to diagnose Metabolic
Syndrome:
1. Waist circumference larger than:
• 35 inches for women
• 40 inches for men
2. Fasting triglycerides above 150 mg/dl
3. HDL-cholesterol below:
• 40 mg/dl for men
• 50 mg/dl for women
4. Elevated blood pressure above 130/85
5. Fasting blood glucose above 100 mg/dl
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Hypoglycemia
Can occur with or without diabetes
If diabetic, can be caused by:
• Injecting too much insulin
• Not eating frequently enough
• Exercising without eating carbohydrates
If nondiabetic, 2 types are possible:
• Reactive hypoglycemia: Exaggerated insulin response
after eating
• Fasting hypoglycemia: Low blood glucose levels after
fasting for 8 hours
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Clinical Perspective: Diabetes Mellitus
Fasting blood glucose level at or above 126 mg/dl
Hemoglobin A1c level at or above 6.5%
Two main forms of diabetes:
• Type 1 diabetes
• Type 2 diabetes
Gestational diabetes occurs during pregnancy
• Typically resolves after pregnancy, but leads to higher risk
of developing Type 2 diabetes
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Comparison of Type 1 and Type 2 Diabetes
Type 1 Diabetes Type 2 Diabetes
Occurrence 5% of cases of diabetes 90% of cases of diabetes
Cause Autoimmune attack on the pancreas Insulin resistance
Risk Factors Moderate genetic predisposition Strong genetic predisposition
Obesity and physical inactivity
Ethnicity
Metabolic Syndrome
Pre-diabetes
Characteristics Distinct symptoms (frequent thirst, hunger,
and urination)
Ketosis
Weight loss
Mild symptoms, especially in early phases
of the disease (fatigue and nighttime
urination)
Ketosis does not generally occur
Treatment Insulin
Diet
Exercise
Diet
Exercise
Oral medications to lower blood glucose
Insulin (in advanced cases)
Complications Cardiovascular disease
Kidney disease
Nerve disease
Blindness
Infections
Cardiovascular disease
Kidney disease
Nerve damage
Blindness
Infections
Monitoring Blood glucose
Urine ketones
Hemoglobin A1c
Blood glucose
Hemoglobin A1c
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Type 1 Diabetes1
Symptoms include increased:
• Hunger
• Thirst
• Urination
• Weight loss
• Exhaustion
• Blurred vision
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Type 1 Diabetes2
Typically:
• Occurs between 8 and 12 years of age
• Runs in families
• Caused by autoimmune disorder that destroys insulin-
producing cells
Associated with:
• Decreased release of insulin
• Increased blood glucose levels
• Glucose in urine
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Glucose Tolerance Test
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Type 1 Diabetes3
Treatment:
• Insulin therapy
• Nutrition therapy
• 3 regular meals and snacks
• Individualized plan for carbohydrate, protein, and fat intake
• Low intake of saturated fats and cholesterol
• Carbohydrate counting and diabetic exchange system are useful
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Type 1 Diabetes4
Short-term health problems include ketosis
Ketosis can develop as fat is converted to ketone bodies
• Ketones pull sodium and potassium ions with them into
the urine
• Dehydration
• Ion imbalance
• Coma
• Death
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Type 1 Diabetes5
Long-term health problems
include degenerative
conditions
• Blindness
• Cardiovascular disease
• Kidney disease
• Nerve damage
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Type 2 Diabetes1
Most common type of
diabetes
• Due to inactivity and
obesity
Insulin resistance or loss of
responsiveness by cells to
insulin
• Glucose is not readily
transferred into cells and
builds up in the
bloodstream
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Type 2 Diabetes2
Treatment includes lifestyle modification and medication use
Lifestyle modification:
• Nutritious diet
• Physical activity
• Weight loss
Medications:
• Oral
• Insulin injections
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Glycemic Index and Glycemic Load1
Indicates how blood glucose responds to various foods
Glycemic index (GI)
• Ratio of blood glucose response of a food compared with
a standard
• Influenced by a food’s characteristics:
• Starch structure
• Fiber content
• Food processing
• Physical structure
• Temperature
• Amount of protein and fat in a meal
• Shortcoming: Based on serving of food that would provide
50 grams of carbohydrate, which may not be realistic
serving size
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Glycemic Index and Glycemic Load2
Glycemic load (GL)
• Takes into account the glycemic index and the amount
typically eaten
• Better reflects a food’s effect on blood glucose
• To calculate:
Grams of carbohydrate in serving glycemic index
100

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Glycemic Index and Glycemic Load3
Foods with a high glycemic load elicit:
• Increased insulin response
• Drop in blood glucose
Chronically high insulin output can lead to:
• Increased fat synthesis in liver
• More rapid return of hunger after meal
Refer to Table 5-7 for GI and GL of common foods
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