CHAPTER 5

CARBOHYDRATES

RECOMMENDED INTAKE OF CARBOHYDRATES

• RDA: 130 grams to avoid ketosis• AMDR: 45%-65% of total energy needs• Limit added sugars • Fiber (AI: 14 g/1000 kcal)• 25 grams woman under 50• 21 grams woman over 50• 38 grams men under 50• 30 grams men over 50

2

OUR CARBOHYDRATE INTAKE

• 50% of total energy needs• Added sugars 16%• Recommended 6%

•Dietary fiber• 25-50% less than recommended• Average intake-1 fruit and 1 whole grain

serving

3

FUNCTIONS OF DIGESTIBLE CARBOHYDRATES

• Provide energy• 4 kcal/gm

• Protein sparing• Body does engage gluconeogenesis

• Prevent ketosis• Incomplete breakdown of fatty acids

Ketosis- increased urination so dehydration, loss of lean mass, and electrolyte imbalance

4

FUNCTIONS OF INDIGESTIBLE CARBOHYDRATES

• Promoting bowel health• Diverticula and Diverticulosis (active

disease: low fiber)

• Reducing obesity risk• Enhancing blood glucose control• Water soluble fibers

• Reducing cholesterol absorption• Water soluble fibers

5

NEGATIVE HEALTH CONSEQUENCE OF INADEQUATE FIBER INTAKE

• Diverticulosis results when muscles of the colon wall become weaken and lose their elasticity. This is often d/t lack of fiber• If they become

inflamed=diverticulitis.

6

CARBOHYDRATE DIGESTION

7

CARBOHYDRATE ABSORPTION

• Active absorption-Glucose and Galactose • Facilitated absorption-Fructose• Liver converts fructose and galactose to

glucose

8

Blood glucose used by cells

Storage-muscle and

liver glycogen

Extra-adipose tissue

HEALTH CONCERNS

• Very High Fiber Diets (above 50-60 grams)• High fiber + low fluid = constipation,

hemorrhoids, blockage• Decrease absorption of certain minerals

•High Sugar Diets• Increase risk of weight gain and obesity• Increase risk of dental caries

9

HEALTH CONCERNS

• Lactose Intolerance• Primary• Decreased lactase production

• Secondary• Associated with disease that damage the

lactase producing cells

•Glucose Intolerance• Hypoglycemia• Hyperglycemia

10

REGULATION OF BLOOD GLUCOSE

If your blood sugar is high your body will decrease it

Insulin• Hormone that increases glucose uptake by

muscles and adipose tissue• Increase glycogen synthesis, suppress

gluconeogenesis

11

REGULATION OF BLOOD GLUCOSE

If your blood sugar is low your body will increase it

• Glucagon• Increase glycogen breakdown, increase

gluconeogenesis

• Epinephrine, norepinephrine• Increase glycogen breakdown, increase

gluconeogenesis

• Cortisol• Increase glucose use by muscle and other organs,

increase gluconeogenesis

12

BLOOD GLUCOSE REGUALTION

13

TYPE 1 DIABETES MELLITUS

• Insulin producing cells in pancreas are destroyed• Insulin shots required• Diet must be coordinated with insulin• Exchange system, carbohydrate counting

• Increased risk for cardiovascular disease, blindness and kidney disease

14

TYPE 2 DIABETES MELLITUS

• 1 out of 10 Americans has type 2 diabetes now

• By 2050 1 out of 3 Americans is projected to have type 2 diabetes

• WHY the increase?

15

TYPE 2 DIABETES MELLITUS

• Caused by insulin resistance• Most common type of diabetes• Risk factors include ethnicity, obesity, genetics,

inactivity, age, hypertension• Treatment:• Diet• Exercise• Medications

Type 2 diabetes is reversible!

16

DEVELOPMENT OF TYPE 2 DIABETES

Insulin Resistance•High fasting insulin•When people are insulin resistant, their muscle, fat, and liver cells do not respond properly to insulin. As a result, their bodies need more insulin to help glucose enter cells. The pancreas tries to keep up with this increased demand for insulin by producing more. Eventually, the pancreas fails to keep up with the body's need for insulin. Excess glucose builds up in the bloodstream, setting the stage for diabetes. Many people with insulin resistance have high levels of both glucose and insulin circulating in their blood at the same time.•Insulin levels are usually not tested routinely

17

DEVELOPMENT OF TYPE 2 DIABETES

18

Diabetes and prediabetes can be detected with one of the following tests:

Fasting glucose test. -8 hour fast (best done in am)-Fasting glucose levels of 100 to 125 mg/dL are above normal but not high enough to be called diabetes. This condition is called prediabetes or IFG. People with IFG often have had insulin resistance for some time. They are much more likely to develop diabetes than people with normal blood glucose levels.

Glucose tolerance test. -8 hour fast- Drink sugary drink and have BG test after 2 hours. A blood glucose level between 140 and 199 mg/dL means glucose tolerance is not normal but is not high enough for a diagnosis of diabetes. This form of prediabetes is called IGT and, like IFG, it points toward a history of insulin resistance and a risk for developing diabetes.

DEVELOPMENT OF TYPE 2 DIABETES

Complications•Renal•Eye•Skin CVD

Management: Meal planning, Physical activity, and, Medication

19

OTHER BLOOD SUGAR DISORDERS

•Hypoglycemia• Reactive Hypoglycemia• Exaggerated insulin response after

eating

• Fasting Hypoglycemia• Low blood sugar after fasting

20

OTHER BLOOD SUGAR DISORDERS

• Metabolic Syndrome• Group of factors that increase risk for Type 2

diabetes and cardiovascular disease

• Criteria for diagnosis is at least 3 of the following:• High blood pressure• High fasting blood sugar (glucose) • Large waist circumference (length around the

waist): • Low HDL cholesterol: • Triglycerides equal to or higher than 150 mg/dL

21

GLYCEMIC INDEX

GI

• Glycemic Index• Ratio of a blood

glucose response compared with a standard (white bread)• Based on a 50 gm

carbohydrate serving

Evaluate the GI

22

GLYCEMIC LOAD

• Amount of carbohydrate in a food multiplied by glycemic index and divided by 100• Takes into accounts GI and carbohydrate consumed•More accurately reflects blood glucose impact

23

Food Serving Size

GI CHO (g) GL

Brown rice 1 cup 55 46 25

White rice 1 cup 72 53 38

Lentils 1 cup 30 40 12

Sucrose 1 tsp 65 5 3

Apple 1 38 22 8

Coke 1 cup 63 26 16

Skim milk 1 cup 32 12 4

Ice cream 1 cup 61 31 19

24

GLYCEMIC INDEX AND GLYCEMIC LOAD

Brown Rice (46*55)/100= 25.3

LOW CARB DIETS

• Atkins, Sugar Busters, Carb Addicts, South Beach (early phase)• Generally less than 100 g of CHO/day• Pros?• Cons?

25

• Atkins• Breakfast:

Southwestern omelet with tomato, avocado and ham

• Lunch:Caesar salad with grilled chicken

• Dinner:Steak au PoivreRoasted AsparagusMixed green salad with lemon vinaigretteGelatin dessert made with sucralose

• Snack:Celery stuffed with herb cream cheese

• South Beach• Breakfast: 2 eggs scrambled and

grilled lean bacon. Small glass of tomato juice, decaf coffee or tea.

• Morning Snack: 1 small chunk reduced-fat Cheddar cheese.

• Lunch: Chicken Caesar salad (no croutons) with 2tbsp Caesar dressing.

• Afternoon Snack: 3tbsp low-fat cottage cheese w/ 1 tomato and cucumber.

• Dinner: Grilled salmon with steamed asparagus and a salad (mixed leaves, cucumber, green pepper, cherry tomatoes and 2tbsp low-sugar dressing.

• Dessert: Mixing 4oz reduced-fat ricotta cheese with a little sweetener and lemon zest and vanilla extract.

26

LOW CARB DIETS- WHAT’S MISSING?

• 65 yo F• Background: High school education, now

retired, lives with 72 yo sister• PMH: HTN, high cholesterol, overweight• Family Hx: brother heart disease, sister type 2

DM• Complaint: Cut on foot not healing, not seeing

well• Step 1?

27

DX

• Normal Results

• Glucose 70-110 325• Cholesterol 120-199 300• Triglycerides 35-135 400• HbA1c 3.9-5.2 8.5

28

LABS

• BF: One egg fried in butter, 2 strips bacon, 1 cup coffee w/cream and sugar, 1 cup orange juice• Lunch: Ham and cheese sandwich on 2 slices enriched

white bread, mustard, 1 glass unsweetened iced tea• Dinner: 1 cup turnip greens made with butter, salt, and

pepper (simmered on stove for 3 hours), 1 baked potato w/butter and sour cream, 1 cup beans w/ham• Snack: 2 vanilla wafers

29

WHAT SUGGESTIONS CAN WE MAKE ABOUT HER DIET