Chapter 4 The Carbohydrates: Sugars, Starches, …s3.amazonaws.com/prealliance_oneclass_sample/68e4zb0G2G.pdf• LO 4.3: Explain how carbohydrates are digested and absorbed in the

Enriched Instructor’s Manual to Accompany Understanding Nutrition, First Canadian Edition 4-1

Chapter 4The Carbohydrates: Sugars, Starches, and Fibres

I F N O T H I N G E L S E , M Y S T U D E N T S S H O U L D L E A R N …

1. The difference between simple and complex carbohydrates as these dietary sources will have different effects on human physiology. The simple carbohydrates include the monosaccharides (glucose, fructose, and galactose) and the disaccharides (sucrose, lactose, and maltose). The complex carbohydrates include the polysaccharides (glycogen, starch, and fibres).

2. The process in which dietary carbohydrates are broken down (i.e., digested) and absorbed into our cardiovascular system and tissues. This forms the basis of many dietary interventions involving carbohydrates, and is characterized by a food’s glycemic index. For instance, ingesting simple carbohydrates will cause the pancreas to secrete insulin faster, which has been implicated as a cause underlying the development of various conditions.

3. That the ingestion of fibre is very important for overall health. Soluble fibre can lower the risk of heart disease, lower the risk of diabetes, and may help with weight management. Insoluble fibre is important for the gastrointestinal tract—alleviating constipation and lowering the risks of diverticulosis, hemorrhoids, and appendicitis.

4. That there are two types of diabetes mellitus: Type I and Type II. Both types are characterized by abnormally high levels of glucose in the urine and cardiovascular system and are caused by the body’s inability to regulate glucose. People with Type I diabetes cannot produce insulin and require it by injection. Type II diabetics may be able to regulate their blood sugar through lifestyle intervention (diet and exercise); however, some may need additional insulin.

L E A R N I N G O B J E C T I V E S

Students should be able to:

• LO 4.1: Describe the structural difference between simple and complex carbohydrates and identify food sources. [Understand/Apply]

• LO 4.2: Understand why carbohydrates are an essential macronutrient that is recommended to make up the majority of a person’s AMDR. [Remember/

Copyright © 2013 by Nelson Education Ltd.


Understand]

• LO 4.3: Explain how carbohydrates are digested and absorbed in the body. [Understand/Remember]

• LO 4.4: Explain the term glycemic index, how it may relate to diet planning, and identify food sources with different values. [Understand/Apply]

• LO 4.5: Outline the different metabolic pathways in which the body handles carbohydrates. [Understand/Remember]

• LO 4.6: Define diabetes mellitus, and identify the two major types (i.e., type 1 and type 2). [Understand/Remember]

• LO 4.7: Describe the health effects of consuming large quantities of sugar in one’s diet, and identify the different types of alternative sweeteners. [Understand/Apply]

• LO 4.8: Summarize the different types of dietary fibre (i.e., soluble and insoluble) and how they contribute to human health [Understand/Apply]

W H Y I S T H I S C H A P T E R I M P O R T A N T T O S C I E N T I S T S A N D H E A L T H C A R E P R A C T I T I O N E R S ?

“Of special interest to...” symbol key: = HealthCare Practitioners = Science Majors

• Scientists have recently discovered that sugars have additional roles in the body (besides that of energy provision and the role of fibre in the body). Research is now underway to understand the role and physiological effects of when sugar molecules are attached to various cells and other molecules (e.g., fat and protein).

• Individuals who consume highfibre diets generally have lower rates of colon cancer compared to those who consume lowfibre diets. Scientists are investigating the ways that fibre can protect against colon cancer.

• The glycemic index is a measure of blood glucose response to foods relative to the response to a standard food. The glycemic load is the product of the glycemic index multiplied by the carbohydrate content of a food. Nutritional scientists are becoming increasingly more concerned with the glycemic index and glycemic load of all of the new food products that are entering the

market. They also are making efforts to ensure that manufacturers adjust the carbohydrate content of familiar foods if they are reformulated.



• Scientists and healthcare practitioners are continually investigating ways to help people with diabetes mellitus improve their blood glucose control with diet and exercise interventions.

• Scientists have studied the health effects of artificial sweeteners. These include a low glycemic response and a reduction in tooth decay. Scientists are currently working toward learning more about the side effects (gas, abdominal discomfort, and diarrhea) associated with the use of artificial sweeteners and levels that define toxicity.

W H Y S H O U L D S T U D E N T S C A R E ?

• Students should know that plants combine carbon dioxide, water, and the sun’s energy to form glucose, through photosynthesis. Carbohydrates are made of carbon, hydrogen, and oxygen held together by energycontaining bonds: carbo means “carbon”; hydrate means “water.”

• It is essential for students to realize that of the monosaccharides—glucose, fructose, and galactose—glucose is the most important in the human body. The three main disaccharides are lactose, maltose, and sucrose. Long strands of thousands of glucose units are polysaccharides. Glycogen is the storage form of glucose in animals and human beings.

• Students should know that starch is the storage form of glucose in plants and is also nutritive for human beings. In plants, starch molecules are packed into granules.

• Human digestive enzymes cannot break the bonds in fibre, so most of it passes through the digestive tract unchanged. Some fibre, however, is susceptible to fermentation by bacteria in the colon. A diet that includes fibre is linked to reductions in cardiovascular disease and contributes to optimal gastrointestinal health.

• Most adults need between 21 and 38 grams of total fibre each day, but few consume this amount. Fibre needs are best met with whole foods. Purified fibre in large doses can have undesirable effects. Fluid intake should increase with fibre intake.

• It is important for students to know that lactose intolerance is a common condition in which the body fails to produce sufficient amounts of the enzyme needed to digest this milk sugar. Uncomfortable symptoms result and can lead to milk avoidance. People who are lactoseintolerant should select milk alternatives in order to provide the calcium and vitamins that milk contains.

• Students should know that without glucose the body is forced to alter its use of



protein and fat. To help supply the brain with glucose, the body breaks down protein to make glucose and converts fat into ketone bodies, which may lead to ketoacidosis.

• Students in nutrition should understand that blood glucose regulation depends mainly on the hormones insulin and glucagon. Most people have no problem regulating their blood glucose when they consume mixed meals at regular intervals.

• The liver has the ability to convert glucose into fat; under normal conditions, most excess glucose is stored as glycogen or used to meet the body’s immediate needs for fuel.

• Diabetes mellitus is an example of the body’s abnormal handling of glucose. Inadequate or ineffective insulin leaves blood glucose high and cells undersupplied with glucose energy. Weight control and exercise may be effective in preventing the predominant form of diabetes (type 2) and the illnesses that accompany it.

W H A T A R E C O M M O N S T U D E N T M I S C O N C E P T I O N S / S T U M B L I N G B L O C K S ?

1. Students have difficulty understanding the differences between glycogen and fibre. In order to overcome this, it is helpful to illustrate the molecular structure of each molecule (see Figure 48 in the textbook) and indicate that different enzymes are required to break the attachment between the different molecules.

2. Learning about the differences between soluble and insoluble fibre is often a stumbling block for students. Distributing and discussing Handout 41 can help clarify this.

3. Some students have trouble understanding the differences between type 1 and type 2 diabetes. A brief review of what causes each type is helpful. For example, type 1 can result from a virus attacking the pancreas and destroying the pancreatic cells that produce insulin. Type 2 diabetes can result from weight gain, obesity, and lack of physical activity. In type 2 diabetes, the body’s cells are not as responsive to insulin or insulin is not produced in sufficient quantities. It is important to emphasize that both conditions are characterized by hyperglycemia (i.e., high blood glucose), but are caused by different factors. In the type 1 case, the person is lacking insulin due to the destruction of the pancreatic beta cells. In the type 2 case, the pancreas is not necessarily diseased and the person may be secreting sufficient levels of insulin.

4. Students should develop an understanding that both sugars and complex carbohydrates, such as starch, provide the body with the essential



monosaccharide, glucose. However, it should be established that these two different forms of dietary carbohydrate will cause different physiological effects.

W H A T C A N I D O I N C L A S S ?

There are a variety of activities that can be done in class. Described below are classroom activities that will help introduce and describe carbohydrates (sugar, starch, glycogen, and fibre).

An excellent way to begin this chapter is with a discussion of the brain’s dependence on glucose and the body’s regulation of it. The concepts are new to the majority of beginning students, complex enough to be challenging but simple enough to grasp, and of great personal interest.

Classroom Activity 41: ChapterOpening QuizObjective: Introduction to chapter Class size: Any

Instructions: As a way of introducing any new chapter, give a quiz to the class. This is a quiz designed to be projected on an overhead projector. For details, please see Chapter 1, Classroom Activity 14.

Classroom Activity 42: Breakfast—Energy ScoresKey concepts: Protein and glucose regulation Class size: Any

Instructions: Have students close their eyes, relax, and get in touch with their feelings. Ask them to score themselves from 1 to 10 for “energy level,” and write this score on a piece of paper (no name). Then ask them to record what they ate for breakfast, and at what time. Collect the papers, eliminate those who ate more than five or fewer than two hours earlier, sort the remaining ones into highprotein, lowprotein, noprotein, and nobreakfast piles, and average the energy scores.

In over two dozen demonstrations, the results have been in the expected direction: those who ate highprotein breakfasts feel the most energetic; those with noprotein, least. (This only works for morning classes, of course.) If it doesn’t “work,” explain what you would expect to see, and why. Criticize the demonstration as unscientific (it’s not blind, there may be bias), but point out that it at least illustrates that a balanced breakfast can influence a morning’s performance, while the many deviations from the average show that a multitude of other factors are working, too.

This exercise may help students remember that dietary protein influences blood glucose regulation—a first stone in the foundation for understanding metabolism.

Classroom Activity 43: Sugar in SodaKey concept: Added sugar content of soda Class size: Any

Materials needed: Sugar (at least 50 millilitres or 10 teaspoons), measuring spoon, drinking glass of water



Instructions: Bring a measuring spoon, sugar, and a glass to class. Ask students how much sugar they put in coffee or tea. Start putting sugar in the glass and have students tell you when they would stop adding sugar to their beverages. Keep adding sugar to the glass until you have put in 40–50 millillitres (8–10 tsp). Hold the glass up, and ask if they would drink something poured into the glass with that much sugar. Explain that this is the amount of sugar in one can of soda. Discuss.

Classroom Activity 44: Sugar Content of Processed FoodsKey concept: Added sugar content of processed foods Class size: Any

Instructions: Have students read the packages of cereal boxes or other foods and record sugar contents on index cards. Be sure to instruct them to look for other terms that also denote sugar. Discuss findings in class.

Classroom Activity 45: Fibre Content of OvertheCounter Fibre SupplementsKey concept: Fibre sources Class size: Any

Instructions: Fibre supplements are marketed as providing substantial amounts of fibre. Instruct students to take index cards to the grocery or drug store and record the following regarding the fibre supplements they find: name of supplement, cost of supplement, recommended daily dose, fibre content of suggested dose, the %DV for fibre that each provides. Discuss in class and generate suggestions for more effective, enjoyable, and economical choices.

Classroom Activity 46: Scheduled Interruption: Think/Pair/ShareObjective: Reflection on content Class size: Any

Instructions: Examination of student attention levels throughout class indicate that students’ attention levels are the highest during the first five minutes of class, then levels slowly decline throughout a lecture. To enhance students’ attentiveness, teaching authorities suggest scheduled interruptions. One planned interruption is think, pair, share. The purpose of this activity is to encourage the participation of all students, especially those who are quiet. Pose a statement, problem, or situation. Instruct students to quietly write their comments including their thoughts and feelings regarding this topic. Next, pair students with a partner and instruct them to share their comments. Circulate while students are talking. After they have shared with their partner, ask for comments to be shared with the entire class.

Critical Thinking Questions1

These questions will also be posted to the book’s website so that students can complete them online and email their answers to you.

1. Discuss in some detail the three different types of carbohydrates. In your discussion, explain how each type is chemically different from the others, and how these differences relate to its activity and function.

1 Contributed by Kathleen Rourke.



2. The importance of developing strong bone mineral density is dependent on the intake of a calciumrich diet. While there appears to be an abundance of dairy products available to individuals in Canada and the United States, there still appears to be an increasing prevalence of bone diseases such as osteoporosis (thin or brittle bones). From your readings, discuss why you think this may be a problem. What are your suggestions to help a patient to avoid bone issues, and why would these suggestions work with someone that has problems digesting lactosecontaining products?

3. Obesity has developed as a significant problem for Canadians, as are its comorbidities: heart disease, diabetes, and some cancers. Describe how carbohydrates can play a role in the cause and in the prevention of obesity and its subsequent comorbidities. What types of assessment should be utilized as a diagnostic tool in the prevention and treatment of obesity and its comorbidities?

4. Discuss the differences between type 1 diabetes and type 2 diabetes mellitus.

5. In this chapter, you have learned about the importance of carbohydrates in a number of facets. Carbohydrates can serve as energy for the brain, storage energy for the muscles, and digestive aids. However, unlike proteins, carbohydrates continue to be perceived as a “bad food” in the diet. Individuals may go to great length to “avoid” carbohydrates but eat a “healthy diet.” While some consumers may take a more moderate approach and use replacement or substitute sweeteners (alternative sweeteners) to replace sucrose, use of a variety of foods should be the preferred route to a healthy diet. Discuss the fallacies in thinking that alternative sweeteners can replace sugar and discuss the role of alternative sweeteners in a dietary plan for a healthy adult.

6. In Highlight 4 you learned a bit about the issues surrounding carbohydrates, calories, and weight gain. In the following scenario, what advice would you recommend to the individuals and why?

You are visiting overnight with family relatives that you have not seen for some time. They have learned that you are studying to become an registered dietitian. The mother of the family (your aunt) is quite overweight and the two children, 12 and 16 years old, are “heavy,” but you would not classify them as obese. The father of the family recently had a heart attack and while in the hospital was put on a lowfat diet. He is not overweight by observation.

Your aunt is trying to follow the diet “faithfully” for her husband and believes that having everyone in the household follow the diet would be best (children included). The diet includes lean meats and lowfat dairy products. Your aunt decided that the family should also cut out carbohydrates as well, given that “they can cause you to become fat” and is making sure that everyone is consuming plenty of liquids to wash away the plaque in the arteries.

What do you think of this diet and what recommendations would you give to your aunt and her family?



W H A T O T H E R R E S O U R C E S A R E A V A I L A B L E ?

You can look up information about government policy as well as any health condition that you are interested in learning more about. Consult the following websites to get reliable information on the following:

• Find out more about the nutritional needs of individuals living with diabetes at the Canadian Diabetes Association: http://www.diabetes.ca

• Find out more about the role of fibre and regulation of fat intake in the prevention of cardiovascular disease at the Heart and Stroke Foundation of Canada: http://www.heartandstroke.ca

• Fibre content of foods can be found at the nutrition website: http://www.nutritioncc.nelson.com. Follow the nutrient links under student resources to the Canadian Nutrient file 2010 to check the fibre content of any food.

• To learn more about whole grains go to Health Canada – Food and Nutrition: http://www.hcsc.gc.ca/fnan/nutrition/wholegrainentierseng.php.

A N S W E R K E Y F O R A L L I N S T R U C T O R ’ S M A N U A L A C T I V I T I E S

Critical Thinking Questions2

These questions will also be posted to the book’s website so that students can complete them online and email their answers to you.

1. Answer: Monosaccharides: These are simple sugars that are made up of 6 carbon and 6 oxygen units with 12 hydrogen units. The three monosaccharides are:

• Glucose• Fructose• Galactose

Each monosaccharide retains a differing level of sweetness as a consequence of its chemical structural arrangement. While glucose is most abundant, fructose is actually the most sweet, and galactose is least sweet. Glucose is the primary “sugar” used in the body and by the brain, and in its absence, the body will break down protein to make glucose. This process is known as gluconeogenesis.

Disaccharides: These simple sugars all contain glucose and one other monosaccharide. The process by which they are linked together is known as condensation. A molecule of water is created in the process. The three disaccharides are:

2 Contributed by Kathleen Rourke.


http://www.hc-sc.gc.ca/fn-an/nutrition/whole-grain-entiers-eng.php

http://www.nutritioncc.nelson.com/

http://heartandstroke.ca/

http://www.diabetes.ca/


• Maltose: glucose + glucose• Sucrose: glucose + fructose• Lactose: glucose + galactose

Sucrose is what is known as simple table sugar, while lactose is the carbohydrate found in milk products.

Polysaccharides: These molecules are better known as complex carbohydrates and are often referred to as the preferred carbohydrate for consumption. Complex carbohydrates or polysaccharides are made up of many units of monosaccharides and disaccharides. They contain many glucose and other units and include the following:

• Glycogen: Storage form of energy in animals• Starches: Plant storage for glucose• Fibres: Structural part of plant

Polysaccharides are very important for the body for several reasons. First, the body is able to store a limited amount of energy in the form of glycogen. Glycogen is generally stored in the liver and muscle tissue and can be released very quickly when needed. Athletes frequently work to increase their ability to store glycogen in an effort to improve their performance abilities in endurance events.

Starches can be used for energy and for cooking purposes and are found in the grains and root vegetables such as potatoes, yams, and parsnips, while fibres can be found in fruits, vegetables, and wholegrain foods. Fibres serve as an important digestive aid to our bodies. Dietary fibres help to facilitate passage of food through the intestines, thus reducing the time that digested food may sit in the intestinal tract, causing constipation and/or inappropriate bacterial growth. There are two types of important fibres patients should be aware of: soluble (which are found in oats, barley, and legumes) and insoluble (found in whole grains and vegetables).

Phytic acid is discussed in the textbook under the fibre section. While not generally considered a fibre, phytic acid is found in many foods that contain fibrous content. Phytic acid does readily bind to minerals such as calcium. The consequences can be quite problematic for individuals who are at higher risk for bone mineral problems and who consume diets high in phytic acid or other binding agents. The registered dietitian should be particularly cautious in these cases.

It is important to point out that while carbohydrates do often receive a bad reputation for “causing obesity,” carbohydrates are necessary in the diet as a source of reliable energy. Carbohydrates are rather easily digested and absorbed by the body and available for use by the cells. Glucose is the primary source of energy for the brain and in its absence, body proteins must be broken down to provide ketone bodies as a substitute for glucose. This process is called gluconeogensis. Therefore, carbohydrates in a variety of forms (fruits, vegetables, and whole grains as well as simple sugars) are necessary for the body. The preferred source of carbohydrates should be the complex carbohydrates or the polysaccharides.

Glycogen storage is limited and while it can be increased to some extent through muscle development and dietary manipulation, it does not represent an endless



storage capacity. Athletes that manipulate their diet excessively may risk depleting their bodies of other important nutrients for the important race. Therefore, it is very important to keep careful documentation on an athlete’s dietary patterns.

2. Answer: This question is asking students put together several disparate facts. For instance, the enzyme lactase is most efficient at birth and in childhood. As a person ages, the enzyme’s efficiency declines. As outlined in the textbook, lactose intolerance is also genetically linked. Given the ever increasing ethnic diversity of our country, the likelihood that students will serve a patient with lactose deficiency is great. Also, as an adolescent becomes a teenager, the influence of dietary fads increases and milk or dairy product consumption is less likely to be adequate. Finally, overall dietary patterns of the North American society tend to be poor with regard to dairy products, further propagating issues with bone density. Student may have other suggestions.

While an individual may have lactose intolerance issues, it is still important for the individual to consume products that provide calcium in the diet and for the body. Depending on the severity of the intolerance and the age of the patient, the practitioner can start the patient out with a very small amount of dairy product to consume and allow the body to “work up” to the ability to tolerate a reasonable serving of a dairy product. This process may start with a taste on the finger and move to an 80 mL (1/3 cup) to 125 mL (1/2 cup) serving. Many individuals who complain of lactose intolerance can consume dairy products if they do so by slowly retraining their bodies to digest the lactose again. These individuals may still have some active enzyme that is able to work on the lactose present. However, it is important for these individuals to start slow if they have avoided dairy products for some time because their lactase levels have been low.

Some people can tolerate “fermented products” such as yogurt, as well as some of the hard cheeses such as parmesan, better than regular milk products. Digestive aids such as Lactaid are also helpful for those that can’t tolerate any of the other above suggestions. As above, some individuals are able to tolerate dairy products to some degree and still retain some lactase enzyme to enable them to process the lactose in their diets. However, the types of dairy products they consume must be consumed in small amounts and the fermented products or those that have some of the lactose removed are better tolerated by these individuals.

Calcium is also available in broccoli and spinach as well as foods such as sardines if the bones are eaten. Calcium supplementation is recommended for severely lactose intolerant individuals. Some individuals will never be able to consume dairy products in any appreciable amounts to allow them to provide for a significant source of dietary calcium. Therefore, supplementation and digestive aids are recommended.

The important takeaway point is that lactose intolerance is not as unusual as one might think, and it is important to work through the problem with each individual, as what may work for one person may not work for another. Calcium is quite important to the health of the body and its bones; therefore, a solution to lactose intolerance must be found for each patient as he or she presents. Given the global society in



which we live, this will provide us options for calcium replacement, such as tofu, as well as an increased prevalence for the problem of lactose intolerance. Learn and grow from the lessons culture and society provide us!

3. Answer: Overingestion of simple sugars, which is often accompanied with ingestion of fats, is a major contributor to obesity in Canada and the United States. For example, the ingestion of sugar candies is often associated with chocolate. Snack products that are simple sugars are often fried, making the product high in fat. While the ingestion of these products alone does not result in obesity, it is the overingestion of such products in combination with lack of exercise that contributes to the significant problem of obesity.

As noted in the textbook, simple sugars are rather easily digested and rapidly absorbed by the body, resulting in a rapid spike in the body’s blood sugar level. Following this rapid rise is a rapid drop in the blood sugar level. This accompanying rapid drop in blood sugar makes the individual feel hungry, often resulting in the individual returning to similar food choices and/or overeating because of the rapid drop in blood sugar.

The body first utilizes the calories from the diet it requires for metabolic functions and activity, and then stores excessive calories from any source as fat. Calories from simple sugars can easily add up unnoticed because they are metabolized so quickly and so frequently accompanied with fat. Another example of the addition of calories to a carbohydrate food product is baked potatoes, to which most individuals will add butter and sour cream. All of the extra sauces that are added to starches and vegetables, many high in fat content, add many unnecessary calories.

Another frequently noted contributor to obesity in our country is our “biggie size” society. Most North Americans do not have any knowledge of portion sizing for any food product and product labels often provide misinformation on portion control. Therefore, there are many areas within the production and distribution of simple sugars that accentuate the issue of obesity.

Overconsumption of simple sugars is stored as fat and can lead to heart disease, stroke, diabetes, and some cancers. Many diseases are a result of overaccumulation of excess fat, plaque accumulation on the artery walls, lack of exercise, and the body’s inability to continue to function in an environment that is wearing out all of its control mechanisms. For example, in type 2 diabetes, an individual who is obese continues to call upon the pancreas and all its hormones to work in a continually overloaded situation. Eventually, this system becomes inefficient or stops operating.

The consumption of polysaccharides is beneficial as polysaccharides provide both an energy source and a source of nutrientdense kcalories. For example, many products that retain polysaccharides are good sources of vitamins, fibre, and starch. Therefore, use of polysaccharides in the diet is a useful way to help in the prevention of obesity and its comorbidities. One word of caution: polysaccharides do contain a good deal of fibre and individuals who have been on a lowfibre diet may want to slowly work up to a higherfibre diet, as the digestive system can have a difficult time with this



transition.

While polysaccharides are an important part of one’s diet, portion control is still important. Therefore, nutrition education on portion size is very important for every patient. Patients are often surprised with the amount of pasta that is considered a normal portion. The RD should always spend time with each patient, making sure that the patient understands how much of each of the carbohydrate groups is considered to be a “normal portion size.”

It is also important to stress the importance of complex carbohydrates (polysaccharides) to patients who believe that carbohydrates are “bad.” Carbohydrates are essential for energy, in particular brain energy and muscle energy, something that many individuals do not understand. In addition, carbohydrates provide an important source of B vitamins, fibre, and more. Deleting them from the diet does not improve health status.

The use of carbohydrateplanning tools such as the glycemic index does assist some individuals who find themselves very sensitive to consumption of carbohydrates. The glycemic index is a measure of the rise in blood sugar caused by various carbohydratecontaining foods. For some individuals, particularly brittle diabetics and hypoglycemics, use of the glycemic index can be very helpful. However, keep in mind that product information is not always kept up to date nor does it account for the variety of foods in one product. There are times that one individual may react slightly different than another. Finally, some foods rate differently than would be expected: e.g., lowglycemic index foods are the complex carbohydrates while highglycemic foods are the simple sugars. With combined foods, some foods will react as a highglycemic food when they are expected to be a lowglycemic food.

Many practitioners use a combination of tips and therapies to assist their patients as there is no one tip or therapy that can fully support all individuals. The glycemic index may be a useful tool in combination with other tools when guiding a patient toward the most healthful diet, but not to the exclusion of other tools.

Practitioners should use a multiplicity of assessment tools to work with obese patients to optimize their health and success. Certainly the use of careful dietary information is important and this information should be gathered from a number of different tools, such as a food frequency, 3 or 7day diet recall, and a 7day diet record. Careful information should be gathered from the history and physical, including laboratory values. If there is no fasting glucose level or 3hour glucose test, the dietitian may want to speak with the healthcare provider about requesting one. The importance of this test in planning a nutrition education plan cannot be stressed enough. All other laboratory tests should be checked as well (e.g., for cholesterol, HDL, LDL, etc). These will be important in planning the patient’s course of treatment.

4. Answer: The key difference between type 1 and type 2 diabetes is the etiology, or root cause. Type 1 results from autoimmune destruction of the pancreatic beta cells that produce insulin. This leads to a decline in insulin release to the point that severe hyperglycemia develops and many body cells are starved for the glucose that they cannot effectively take up from the blood. Type 2, on the other hand, results from an



impaired response of body cells to insulin, known as insulin resistance. The pancreas releases sufficient insulin (at least at the onset of the disease) when blood sugar rises, but the cells do not respond to the insulin by taking up glucose from the blood—they “resist” insulin.

Type 1 diabetes is also known as juvenile diabetes; its cause is not fully understood at this time. Onset is usually in children between the ages of less than four years old to the teen years. Regulation of blood sugar does take some time to achieve but is achievable. Many children wear an insulin pump to deliver the insulin automatically so that they do not have to be injected constantly. The issue with juvenile diabetes is the ability to regulate the blood sugar and the sequelae of the disease such as blindness, vascular disease, etc. Medical advances have helped considerably in the recent years; however, children with juvenile diabetes must always be vigilant of their diets and blood sugar.

Type 2 diabetes is often associated with obesity. Excessive body fat stores are associated with insulin resistance, which forces the pancreas to produce more and more insulin in an effort to compensate. After continual overstressing of the pancreas, the cells of the pancreas do not appear to be as reactive to glucose in the system and require either oral hypoglycemic or injectable insulin. While obesity is not the only reason for type 2 diabetes, it is often the cause, and reduction of obesity in Canada would vastly decrease the incidence of type 2 diabetes. Other causes include pancreatic disease, autoimmune diseases, and genetics. As the prevalence of obesity continues to rise in this country, the prevalence of type 2 diabetes also rises.

Changes in diet can sometimes improve the condition of a type 2 diabetic with the inclusion of weight loss. Many times, oral hypoglycemics must be added to the regime. Those individuals with severe problems must be put on an injectable insulin regime, but dietary compliance is very important to the overall improvement of a diabetic patient.

5. Answer: Carbohydrates are very important in the diet as a source of energy for the body, brains, red blood cells, and muscle. Carbohydrates are absorbed and quickly transported to the cells where they are metabolized to provide energy to the body. Unlike proteins and fat, which require more extensive energy to metabolize and absorb, carbohydrates are quickly ready for our bodies to utilize. Therefore, it is unfortunate that individuals believe that they are “bad foods.” Carbohydrates only become bad if they are overconsumed as simple sugars, which provide little nutritional value and are most often accompanied by fat sources. This combination drastically increases the caloric value of the food. These food stuffs are readily absorbed into the body, causing a spike in the blood sugar. Unfortunately, this rise in blood sugar level is shortlived and drops rapidly, resulting in the individual feeling tired and hungry fairly shortly after eating. To avoid this problem, complex carbohydrates are recommended. These carbohydrates help sustain the blood sugar level for a longer time and retain more nutrients per serving.

Carbohydrate sources are abundant and in foods that people often do not think of as carbohydrates, such as milk and dairy products, fruits, and vegetables. Vegetables and



grains are significant sources of complex carbohydrates that include fibre and starch. They also provide many good sources of vitamins and minerals. Therefore, individuals may often be eating carbohydrates that they are unaware that they are eating. Unfortunately, avoiding wholegrain breads, pastas, and rice deprives the body of many rich sources of B vitamins and minerals that are often found in the soils that the grains are grown in. These complex carbohydrates not only provide a rich source of vitamins and minerals (especially B vitamins, which are important for the nervous system), but are important sources of fibre for GI maintenance. Patients should be encouraged to consume complex carbohydrates because of their role in energy and the nutrients and fibre they provide. The registered dietitian must help patients to understand their very important role in the overall diet.

It is important to point out, however, that even complex carbohydrates can become too much of a good thing if they are over eaten and/or there are sauces, butters, and heavy creams added to flavour them. As with simple sugars, these are the foods or condiments that add hidden calories and can turn a “good thing” not so great! Consumers should be cautioned regarding the hidden calories from added fat, which has double the calories and often hides the fresh flavours of vegetables and wholegrain pastas and rice.

Alternative sweeteners are a popular market item that have a place in the diet of the North American public. Their use has long been recognized for diabetics who cannot add simple sugars to their diet; however, with a dietcrazed public, alternative sweetener sales are a multimilliondollar industry. Recognizing that “all foods fit” in the diet of any individual, working with the consumer to moderate the use of alternative sweeteners is the preferred approach.

If patients are consuming a great deal of highfructose soda, the registered dietitian is encouraged to work with them so that they replace half of their regular soda consumption with onefourth water consumption and onefourth diet soda consumption. Over time, the registered dietitian can try to reduce the soda consumption with greater amounts of water and far less of either diet or regular soda, as neither retains any nutritional value.

Consumption of fruit juice can also be deceiving, given that more and more products including fruit drinks are being made with highfructose corn syrup. Therefore, it is important to encourage consumers to read food labels carefully and practise moderation. However, excessive use of simple sugars such as highfructose corn syrup should be avoided for many reasons as outlined in the textbook. Whole fruits or 100% fruit juices should be selected over their alternatives as they provide more nutrients per serving.

Any focus on one food product does not allow an individual to explore a variety of food products with the variety of nutrients that this type of diet will offer. Therefore, the registered dietitian should focus on trying to achieve variety in the patient’s diet to allow the diet to provide for a variety of offerings of different nutrients. Any focus on any one nutrient, food, or product will result in a possible deficiency of a nutrient that can aid in nutrient digestion, absorption, and metabolism. The greater the variety, the greater the chances of providing everything the body and mind need for health and



happiness.

6. Answer: Students might start by asking with a few questions: First, who educated the aunt, and what does the aunt understand to be lean meats and lowfat dairy products? Next, why does she think that carbohydrates “make you fat”? Finally, what types of liquids are being consumed, and why does she think it will wash plaque away? With these types of information, students can then help the aunt out a bit more.

In this answer, each student will make some assumptions, and the instructor will have to grade each response dependent on the students’ assumptions. Overall, students would assume that the aunt was given the appropriate information on lean meats and lowfat dairy products and that the aunt is discussing liquids such as water or lowcalorie products. Students should go back over each category to make sure that the aunt understands all the different types of protein categories, dairy categories, and different types of beverages one can purchase and the differences in calories. This is to expand the nutrition counselling the aunt received previously as well as reinforce what she had learned.

Next, it would be important to introduce the concept of lean, moderate, and highfat meats as well as dairy products. One might assume that the dietitian in the hospital only had enough time to introduce the basics. This helps the aunt to provide variety for the family, which will be important over a long period of time. It is also important to help everyone understand the importance of all the food groups, and therefore the registered dietitian student may want to meet with each family member separately and then as a group.

While fluids, particularly water, are important to the body, if many other types of fluids are consumed that add calories and no other nutrition, this can be a problem. The registered dietitian student would want to assess this and discuss with the family. Fluids are important for hydration but cannot remove plaque. Therefore, the aunt must be advised about what fluids provide to the diet and what types of fluids are best for each individual.

Finally, each individual in this family should have a different goal, weightwise. While the uncle had the heart attack, there can be many reasons other than weight for this. As indicated, his weight is within normal standards for his height, but upon assessment (not provided in the case) of his lipid profile, his LDL is extremely high and his HDL is very low. He has a family history of cardiac disease. Therefore, the uncle remains at high risk for cardiovascular disease and will benefit from the lowfat, highfibre diet.

The aunt is obese, but if students looked further, they may not find the same type of lipid profile (not provided). The aunt nonetheless can benefit from this dietary plan, with a loss of weight. Exercise is also recommended for the aunt, after first being cleared by her physician. As noted, the children are heavy but not obese. It is certainly time for the whole family to work together, and with a nutritious diet the children can grow into their height, to some extent, given their age. Adding exercise to the plan will help to balance calories in with overall energy needed for each of the teen’s body frames. Given their age group, it will be important for each of them to



consume at least four servings of milk or its equivalent daily, six servings of lean meat or the equivalent, and plenty of fruits and vegetables.

The mother’s goal should be to optimize the cardiac profile of her children and her husband and to reduce her weight. Part of this would be to reduce their weight to an appropriate BMIforage or check their body fat and make sure that they are within normal range, and to make sure that they get lots of exercise. Given her husband’s history, it will be important for her and her husband to follow their medical histories and for all of them to follow a lowfat, highfibre diet.

The mother is in need of a weightloss plan, which can be achieved by following the rest of the family’s program of lowfat, moderateprotein, highfibre foods and lots of exercise. Plenty of fresh water and sunshine are also helpful in her success. If she becomes anxious, she is recommended to go to massage therapy or yoga, etc. All of these approaches will help all of the family improve their health and overall wellbeing.

Worksheet Answer KeyWorksheet 41: Hidden Sugars—What Is Your Sugar IQ? Answers will vary depending on source of nutrition data used. Here are some example answers from APPENDIX H:

500 mL (16 oz) cola = 56 g CHO, 220 kcal250 mL (8 oz) brewed unsweetened tea = 1 g CHO, 3 kcal250 mL (8 oz) fruit cocktail in syrup = 60 g CHO, 234 kcal1 small bag potato chips = 21 g CHO, 230 kcal8 Ritz crackers = 14 g CHO, 120 kcal

Fruitfilled cereal bar = 26 g CHO, 135 kcal250 mL (1 c) Raisin Bran cereal = 47 g CHO, 187 kcal20 pieces gumdrops = 72 g CHO, 286 kcal10 pieces jellybeans = 26 g CHO, 105 kcal

Worksheet 42: Glycemic Index and Glycemic Load

Food GI Net Carbs GL GI Level

Apple (1 med.) 38 16 6 (6.08) low

Watermelon (250 mL/1 c)

72 11 8 (7.92) low

White rice (250 mL/1 c)

64 52 33 (33.28) high

Sugar (15 mL/1 Tbsp)

68 12 8 (8.16) low

Worksheet 43: Check Your Carbohydrate ChoicesAnswers will vary.



Worksheet 44: Chapter 4 Crossword Puzzle1. fructose2. dextrose3. glucose

4. sucrose5. lactose6. maltose

7. hexoses8. glycogen9. monosaccharide

10. levulose

Worksheet 45: Carbohydrate Basics (Internet Exercise)1. False2. False3. a) Starch; b) Naturally occurring sugars

found in foods; c) Highfructose corn syrup

4. a5. False6. True



W O R K S H E E T A C T I V I T I E S

Worksheet 41: Hidden Sugars—What Is Your Sugar IQ?

For each of the following food items, indicate the relative sugar (carbohydrate) content, amount of kcalories that are provided, and whether or not you consider the item to be a significant source of sugar in your diet (circle “Yes” or “No”). Use the Food Composition Table in APPENDIX H of your textbook.

Food Item Relative Sugar Content

Amount of kcal Significant Source of Sugar in your Diet?

500 mL (16 oz) cola Yes No

250 mL (8 oz) brewed unsweetened tea

Yes No

250 mL (8 oz) fruit cocktail canned, not drained, in heavy syrup

Yes No

1 small bag potato chips Yes No

8 Ritz crackers Yes No

Cereal bar, fruit filling Yes No

250 mL (1 c)Raisin Bran (Kellogg’s) cereal

Yes No

20 pieces gumdrops Yes No

10 pieces jellybeans Yes No



Worksheet 42: Glycemic Index and Glycemic Load

Glycemic Index Factors Glycemic Load

A method of classifying foods according to their potential for raising blood glucose as determined by the rate of their absorption.

Definition A method of using the glycemic index as the basis for understanding the interrelated effects of glucose and insulin.

Calculated value in response to the ingestion of a specific food product that indicates the relative increase in blood glucose levels that is expressed as a %.

Calculation Calculated value using the glycemic index multiplied by the amount of carbohydrates ingested per serving to arrive at a numerical indicator.

• 70 and above = high • 56–59 = medium • 55 or less = low

Values1 • 20 and above = high • 11–19 = medium • 10 or less = low

• Foods that have a higher glycemic index will cause an elevation in blood sugar based on fast absorption.

• Foods that have a lower glycemic index will cause a modest rise in blood sugar levels based on slow absorption.

Implications • Usually foods with a low glycemic load also have a low glycemic index.

• Since there is variation in the amount of carbohydrate found in a serving of food, a food with a high glycemic load may correlate with a range of glycemic index values (low to high).

1Additional Reference Information can be found at:http://www.mendosa.com/gilists.htm http://lpi.oregonstate.edu/infocenter/foods/grains/giglrefs.html

For the following foods, please calculate the glycemic load (GL) and indicate whether it is low or high.

Glycemic Load (GL) = Glycemic Index (GI) of food/100 × Net carbs (# of grams of CHO per serving)

Food GI Net Carbs GL GI Level

Apple (1 med.) 38 16

Watermelon (250 mL/1 c)

72 11

White rice (250 mL/1 c)

64 52

Sugar (15 mL/1 Tbsp)

68 12


http://lpi.oregonstate.edu/infocenter/foods/grains/giglrefs.html

http://www.mendosa.com/gilists.htm


Worksheet 43: Check Your Carbohydrate Choices

Most of the energy we receive from foods comes from carbohydrates. Healthy choices provide complex carbohydrates or naturally occurring simple carbohydrates, rich in watersoluble vitamins and dietary fibre. A diet that is consistently low in dietary fibre and high in added sugar can lead to health problems. Look at these examples of related foods and identify which are most similar to your food choices.

High in Fibre/Low in Added Sugar

Intermediate Low in Fibre/High in Added Sugar

Apple with peel Applesauce, sweetened Fruit drink, 10% apple juice

Brown rice Cream of rice cereal Rice crispy treat

Pumpernickel bread Bagel, plain Danish pastry

Baked sweet potato Candied sweet potato casserole

Sweet potato pie

Corn on the cob Creamed corn Frosted corn flakes

Oatmeal Granola Granola breakfast bar

1. Do you select wholegrain products and fresh fruits and vegetables regularly?

2. Do you choose foods that increase your intake of fibre and limit your intake of sugars?

Contributed by Sharon Rady Rolfes.



Worksheet 44: Chapter 4 Crossword Puzzle

Across Down

2. An older name for glucose7. The monosaccharides important in

nutrition; they have the formula C6H12O6

8. An animal polysaccharide composed of glucose; it is made and stored in the liver and muscles as a storage form of glucose

9. A carbohydrate of the general formula CnH2nOn that consists of a single ring

10. An older name for fructose

1. A monosaccharide; sometimes known as fruit sugar or levulose

3. A disaccharide composed of glucose and fructose; commonly known as table sugar, beet sugar, or cane sugar

4. A monosaccharide; sometimes known as blood sugar or dextrose

5. A disaccharide composed of glucose and galactose; commonly known as milk sugar

6. A disaccharide composed of two glucose units


1

2

3

4

5

6 7

8

9

10


Worksheet 45: Carbohydrate Basics (Internet Exercise)

Go to the following website to answers questions 1–3: http://www.cdc.gov/nutrition/everyone/basics/index.html. Do not close the window until you have answered all of the questions.

On the website, click on Carbohydrates to answer questions 1 through 3.

1. “Bad carbs” and “good carbs” are terms that are used in the Dietary Guidelines for Americans 2005.a. Trueb. False

2. An example of insoluble fibre is oatmeal.a. Trueb. False

3. Match the term with the best explanation.a. Complex carbohydrateb. Simple carbohydratec. Added sugar

_____ Naturally occurring sugars found in foods_____ Highfructose corn syrup_____ Starch

Go to this website to answer questions 4–6: http://www.hsph.harvard.edu/nutritionsource/whatshouldyoueat/carbohydratesfullstory/index.html. Do not close the window until you are done answering the questions.

4. Which of the following are considered to be basic building block elements of carbohydrates?a. Carbon, hydrogen, and oxygenb. Glucose, dextrose, and sucrosec. Carbon, hydrogen, and nitrogend. Carbon and oxygen

5. Fructose has a strong effect on blood sugar.a. Trueb. False

6. Inclusion of whole grains in one’s dietary pattern will lead to improved health.a. Trueb. False


http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/carbohydrates-full-story/index.html

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/carbohydrates-full-story/index.html

http://www.cdc.gov/nutrition/everyone/basics/index.html


Handout 41: Characteristics of Fibre

Dietary fibres are classified according to a number of characteristics, including their solubility in water and whether they are a polysaccharide. These differences influence their physiological effect on the body.

Water Soluble Water Insoluble

Polysaccharides • Gums• Hemicellulosea

• Mucilages• Pectins

• Cellulose• Hemicellulosea

Nonpolysaccharides • Lignins

Food Sources • Fruits• Oats• Barley• Legumes

• Vegetables• Wheat• Grains

Health Effects • Lower blood cholesterol• Lower rate of glucose

absorption

• Softened stools• Acceleration of intestinal

transit time

aSome hemicelluloses are water soluble and others are water insoluble.



Handout 42: Where Is the Sugar?

• Do you know how much sugar is in your favorite snack food?

• Do you know where to look on the food label to find out?

• If the term sugar is not listed, could there still be sugar in your snack food?

Check It Out:1. Select three of your favorite snack foods; or your instructor can provide you with a

list of snack foods.

a. Your foods could be three similar types of a snack food that you would like to compare.

2. Read the ingredients list on the food label. This is found below the Daily Values table on the label.

a. Do you see the word “sugar” listed anywhere?

Sugar’s other names: brown sugar, corn sweetener, corn syrup, dextrose, fructose, fruit juice concentrates, glucose, highfructose corn syrup, honey, invert sugar, lactose, maltose, molasses, raw sugar, and syrup.

b. Do you see any of these names listed?

3. The ingredients are listed in order from the ingredient with the highest percentage of the total weight of the product (listed first) to the ingredient with the lowest percentage of the product’s weight.

a. Does your product have one of sugar’s “other names” listed near the beginning of the ingredient list? If so, this product has a lot of sugar in it.

4. You can also check the number of grams of sugar in the product. This is found right below the serving size information on the food label.

a. It is recommended that you keep the total number of calories from sugar to less than 10% of your total calories.

b. You can multiply the number of grams of sugar by 4 to get the number of calories from sugar.

5. You can compare your snack food to another brand or a similar snack food that may claim to be healthier or contain less added sugar. You now know where to look.

a. You can compare any type of food for sugar content. This can help you to reduce the amount of added sugar in your diet.

Reference: Tuft's University Health & Nutrition Letter. Volume 22 (4) June 2004, p. 3.

Contributed by Mary Ellen Clark.



Handout 43: Where Sugar Can Hide Out!

You’ve made a point to swear off added fat or salt in your diet, so you try lowsalt or lowfat alternatives to your traditional favourites. You hope to also be able to reduce the number of calories that you take in. Have you ever compared the calorie totals between a lowfat food and that of its fullfat counterpart and not noticed much of a difference in the number of calories? Why is that? You may want to check the amount of sugar in the product. Sometimes, extra sugar may be added to give the product flavour or a different texture.

Have you ever noticed that lowsalt soups can taste sweet? Food manufacturers often add sugar to help flavour the soup so that it is not blandtasting without the salt. You should check out the amount of sugar in the lowsalt soup as compared with that of its salted counterpart.

What types of products should you check out?

• Lowfat cookies• Lowfat sweet snacks• Lowsalt juices• Lowsalt soups• All of the fullfat or salt versions of these foods

One way to appreciate the contribution of the sugar calories (amount) to the total calories of a product is to calculate the percentage of calories from a given macronutrient. You can use these percents of total calories from sugar to directly compare the products.

Example: Cookie A: 120 calories per serving

15 grams of sugar per serving

Cookie B: 150 calories per serving

14 grams of sugar per serving

Cookie A: 15 grams sugar × 4 calories/gram = 60 calories (sugar)

60 calories (sugar) ÷ 120 calories × 100 = 50% of total calories come from sugar.

Cookie B: 14 grams of sugar × 4 calories/gram = 56 calories (sugar)

56 calories (sugar) ÷ 150 calories = 37% of total calories come from sugar

If you wish to find a lowsalt or lowfat product with less sugar, you may need to look around for other similar products that may have less sugar. You could also consider reducing the serving size of the lowfat or lowsalt food. You could also try reducing your portion size for the traditional favourite if you want to watch your sugar intake as well.

Contributed by Mary Ellen Clark.


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Chapter 4 The Carbohydrates: Sugars, Starches, …s3.amazonaws.com/prealliance_oneclass_sample/68e4zb0G2G.pdf• LO 4.3: Explain how carbohydrates are digested and absorbed in the