The role of carbohydrates in a healthy diet

Nursing Standard
The role of carbohydrates in a healthy diet
ISSN: 0029-6570
Accession: 00002311-200609270-00062
Full Text (PDF) 1588 K
Author(s):

Govindji, Azmina
Issue:
Volume 21(3), 27 September 2006, pp 56-64
Publication Type:
[Learning Zone: Continuing Professional Development: Nutrition Focus]
Publisher:
© Copyright 2006 RCN Publishing Company Ltd.
Institution(s):
Azmina Govindji is nutritionist and registered dietician, Govindji Nutrition, Greater London. Email: azmina@govindjinutrition.com
Date of acceptance: June 2 2006.
These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.
Keywords: Diabetes management, Diet, Eating disorders, Health promotion, Healthy eating, Obesity
Summary

Nurses have an important role to play in improving patients' diets. This article examines the role of carbohydrates in the prevention and management of disease. It discusses the glycaemic response and index, the importance of fibre, insulin sensitivity, weight management and the role of resistant starch in healthy eating.

Aims and intended learning outcomes

The aim of this article is to summarise the latest clinical research evidence about carbohydrate nutrition, to demonstrate how the physical structure of carbohydrates can have physiological effects, and emphasise how nurses can play a valuable role in advising patients on dietary strategies to improve health status.

After reading this article you should be able to:

[black right pointing small triangle] Demonstrate an understanding of the effect that the physical structure of carbohydrate has on its digestion and the subsequent promotion of health. This will include an awareness of current carbohydrate-related terminology, such as rapidly digestible starch, slowly digestible starch, fibre, resistant starch, available carbohydrate, glycaemic index (GI) and glycaemic load (GL).

[black right pointing small triangle] Outline the research behind different types of carbohydrate and their role in the prevention and management of conditions such as metabolic syndrome, type 2 diabetes, obesity and cardiovascular disease.

[black right pointing small triangle] Describe at least two manufactured foods that offer health benefits as a result of improvement of the carbohydrate quality.

[black right pointing small triangle] Advise patients on the types of carbohydrate foods that are most appropriate for good health and wellbeing.
Time out 1

Cut out articles from newspapers and magazines about the 'healthiest' approach to eating. Comment on each of these approaches under the following terms:

[black right pointing small triangle] Who is the diet aimed at?

[black right pointing small triangle] What specific recommendations are made about the carbohydrate foods in the diet?

[black right pointing small triangle] Does the diet address the glycaemic response of the carbohydrate foods? Provide examples of this. If not, detail why you have come to this conclusion.
Introduction

The role of carbohydrates in a balanced diet is at the forefront of current discussions on health, both in consumer and healthcare professional press. Carbohydrate terminology, such as GI and GL, has become part of professional debate, especially in relation to weight management and prevention of type 2 diabetes.
Carbohydrates

Carbohydrates from the diet perform vital functions in our body - they provide energy and dietary fibre, help to satisfy hunger and regulate blood glucose levels. The World Health Organization (WHO) acknowledges that carbohydrates are critical to a balanced diet and recommends that they amount to at least 55 per cent of the total energy value of our daily food intake (Food and Agriculture Organization FAO/WHO 1998, WHO/FAO 2003).
Time out 2

List high-fibre versions of the carbohydrate-rich foods shown in Box 1. Examine some examples of food packaging to provide examples of products that are high in fibre.

Graphic
BOX 1 Examples of foods rich in carbohydrates

Carbohydrates can be categorised according to how they are digested. First, there are those that are rapidly digested and cause a fast and high peak in blood sugar. These are generally found in refined or processed foods, such as white bread, most white rice, cooked potatoes and many extruded breakfast cereals (often called high-glycaemic carbohydrates) (Box 2).

Graphic
BOX 2 Useful definitions

These foods can vary in their fibre content, that is, the roughage or indigestible component of the carbohydrate (Box 2). Wholegrain, wholemeal breads and cereals provide more fibre than products made with refined white flours. The 'brown' or unrefined versions of pasta, rice and grains are higher in fibre, as are pulses, such as lentils and beans. The skins of vegetables, such as potatoes, or fruits also contain fibre.

Low-glycaemic carbohydrates (often found in unrefined foods containing intact wholegrains), break down more slowly in the digestive system and result in more balanced (that is, steady or sustained) blood sugar levels.

Figure 1 shows that we should base meals on starchy foods. The number of recommended servings is between five to 11 portions per day, dependent on energy requirements. However, it is important to consider which starchy foods and carbohydrates are best for health.

Graphic
FIGURE 1 The Balance of Good Health
Time out 3

Information is presented below on the terms used to discuss the different blood glucose responses to the digestion of varying carbohydrates and foods: glycaemic response, glycaemic index, glycaemic load and insulin index. Summarise these different definitions using bullet points. Include a maximum of five points for each definition.
Glycaemic response

When digestible carbohydrates are digested, blood glucose levels rise. The speed and level of this rise (per consumption of a serving of food) is described as the glycaemic response (GR). Carbohydrates that are digested quickly are said to have a high GR - they enter the bloodstream and cause blood glucose levels to rise sharply. These carbohydrates are found in foods such as white rice, sweet biscuits and white bread, and provide a short, quick burst of energy, quickly replenishing energy stores.

Slowly digested carbohydrates are found in foods such as apples, kidney beans, intact wholegrains and many foods containing fibre or resistant starch. These carbohydrates are said to have a low GR. They enter the bloodstream gradually and provoke a lower maximum blood glucose level. This can result in a steady, more sustained release of energy, which may help to maintain a longer period of satiety (feeling of satisfaction).
Glycaemic index

This is the relative area under the GR curve (Figure 2) when 50g of available carbohydrate are consumed relative to a standard food such as white bread or glucose. In other words, the GI of foods is a ranking system that compares the immediate impact of carbohydrate in foods on blood glucose levels. To make a standard comparison, all foods are compared with a reference food of glucose, or occasionally white bread.

Graphic
FIGURE 2 Glycaemic response chart

'Available carbohydrate' means carbohydrate digested in the small intestine. So, if a food is 50 per cent available carbohydrate and 50 per cent fibre (unavailable carbohydrate), then 100g would be consumed and compared to 50g of glucose. GI is a useful 'ranking' system for similar carbohydrate-rich foods.

The first categorisation of GI was published in 1981 where ranges for low, medium and high GI values were proposed (Jenkins et al 1981):
[black right pointing small triangle] Low GI - less than 55.
[black right pointing small triangle] Medium GI - between 56 and 69.
[black right pointing small triangle] High GI - greater than 70.

GI is only appropriate in relation to foods containing carbohydrate. Foods that are devoid of carbohydrate, often high fat and high protein foods (meat, eggs, nuts and cheese), contain too little carbohydrate to be valid for measurement of GI. Similarly, many fruits and vegetables (except potatoes) contain small amounts of carbohydrate per portion, and hence have very low GI values.
Time out 4

There are several factors that make it impractical to use GI in isolation as a health-promotion strategy. List at least five limitations of using GI on its own. Include reference to available carbohydrate and consider how foods are consumed on a practical basis. You will find the following references useful: Leeds et al (2003), Govindji and Puddefoot (2004), Brouns (2005), Brouns et al (2005), Govindji (2005).

The GI also depends on a number of other factors:

[black right pointing small triangle] The type of starch in the food. There are two types of starch in food - amylose and amylopectin - and the ratio of these components has an effect on the GI of a food. Amylopectin is a large molecule, more open in structure and easier to digest, so foods like white rice that contain more amylopectin have higher GI values. Amylose forms tight compact clumps, making them harder to digest and therefore foods like basmati rice have lower GI values.

[black right pointing small triangle] The physical structure of the food itself. For example, if potatoes are mashed, the GI increases.

[black right pointing small triangle] The fat and protein content of the food. If a food contains fat and protein, this will mean that it contains less carbohydrate and GI is a measure of the GR to the carbohydrate in the food. Fat also slows down the rate of stomach emptying, therefore slowing the digestion of the starch, for example, potato crisps have a lower GI than boiled potatoes.

Foster-Powell et al (2002) published comprehensive international tables of GI values (Table 1). Although the measurement of GI is relatively robust, variation of results between different laboratories may occur because of differences in methods used.

Graphic
TABLE 1 Examples of glycaemic index values of common foods

More recently, commercially available products that are common in the UK diet have been reliably tested (Henry et al 2005a), as well as the major commercial brands of potatoes (Henry et al 2005b).

Fibre and glycaemic index As humans do not produce the enzymes required to digest fibre (it is fermented by the bacteria living in the large intestine), it does not affect blood sugar levels and is thus excluded from the calculations of GI. Many foods that have high fibre content, such as wholegrains, beans and lentils, also have a low GR and are termed 'healthy'. However, some high-fibre foods may not appeal to all consumers. There has therefore been much interest in the application of resistant starch in processed foods from food manufacturers and nutritionists.

Resistant starch is a starch that completely resists digestion in the small intestine, and reaches the colon where it acts like dietary fibre. The potential health benefits of resistant starch in promoting colon health and the unique functional properties it gives to food processing can promote the development of high quality, nutritious products with a lower glycaemic impact. In other words, processed foods that are often popular with the public can contain the beneficial effects of added fibre. There are many ongoing studies investigating the effect of resistant starch on health and possible health claims for a diet high in resistant starch. Examples of foods that contain resistant starch include bread, cereal flakes, pasta, biscuits, snack bars and gluten-free products.
Glycaemic load

This provides a measure of postprandial blood glucose response and insulin demand produced on eating an average portion of a carbohydraterich food. This is calculated mathematically by multiplying the GI value of the food by the carbohydrate content of the serving size of the test food:

Graphic
Equation (Uncited)

GL will be highest in foods that provide the most carbohydrate, regardless of the quality of carbohydrate. A scale of foods according to their GL value would be likely to rate low carbohydrate foods at the lower end of this scale. Consequently, low GL diets are often low in carbohydrate.
Insulin index

This is a measure that compares the postprandial insulin response of 1,000kJ (240kcalorie) portions of foods to a standard reference food, for example, the equivalent amount of white bread (Holt et al 1997). The test is conducted on healthy participants and finger prick blood samples are analysed every 15 minutes over a period of two hours. An insulin score is then calculated from the area under the insulin response curve for each food using white bread as the reference food, which has a score of 100 per cent.
Time out 5

Explore why insulin response and sensitivity is a key health indicator? Consider the role of insulin in glucose metabolism and the effect of insulin resistance on health.

GI values are a useful guide to help people choose carbohydrates that offer glycaemic benefits when compared to other carbohydrate-rich foods, but the GI concept does not consider concurrent insulin responses. However, the insulin response after eating is crucially important, as this has relevance in terms of blood lipids, body fat and insulin sensitivity. Insulin has two important actions in the body - to facilitate glucose uptake into the cells from the bloodstream so that glucose can be used as a source of energy, and to inhibit the release of fat from fat stores. This means that the higher the insulin levels, the more carbohydrate is burned at the expense of fat (British Dietetic Association 2001).

Insulin secretion can be stimulated by a high concentration of blood glucose, but eating carbohydrate is not the only factor in provoking an insulin demand. Holt et al (1997) showed that dairy foods, for example, milk and yoghurt, as well as foods containing no carbohydrate, such as meat, fish and eggs, also stimulate significant rises in blood insulin. Research into the 'insulinaemic' (the effect a food has on the secretion of insulin) response of food is ongoing.
Time out 6

Recent research suggests that there are potential health benefits in selecting foods that deliver a lower GR. Identify if any of your patients might benefit from choosing carbohydrates with a lower GR and detail why.
Effects on health

It has been shown that a high GI diet may be associated with an increased risk of type 2 diabetes in both men and women (Salmeron et al 1997a, 1997b, Meyer et al 2000, Aston 2006). There is no reason to believe that this association does not exist in children and it may be partly responsible for the increased incidence of type 2 diabetes in children. The low, or less dramatic, elevations of blood glucose levels from foods with a low GI mean that less insulin needs to be secreted from the pancreas. This reduces the potential risk of developing type 2 diabetes.

Reduced insulin secretion is also associated with more heart-healthy blood lipid levels, in particular lower triglycerides and higher density lipoprotein (HDL) ('good') cholesterol, thus reducing the risk of cardiovascular disease (Liu et al 2001).

In a follow up to the Harvard Nurses' Health Study, researchers used GL measures to assess the impact of carbohydrate consumption on 280 post-menopausal women (Liu et al 2001). They found that a high GL diet (which in practice generally means high GI foods and greater total carbohydrate intake) correlated with lower HDL concentrations and higher triglyceride levels. The strongest association was in overweight women with a body mass index (BMI) of more than 25. This study suggests that the quality and quantity of carbohydrate may directly relate to blood lipid profiles.

Maintenance of healthy blood glucose levels has been linked to a reduced risk of diabetes, heart disease and obesity (FAO/WHO 1998). This is supported by the WHO/FAO (2003) report Diet, Nutrition and the Prevention of Chronic Diseases, which states there is a possible decreased risk of the development of type 2 diabetes and obesity through the consumption of low GI foods. For foods high in non-starch polysaccharides (NSP) - that is, foods high in fibre - the WHO report concludes that there is convincing evidence of decreased risk of obesity and probable decreased risk of type 2 diabetes and the development of cardiovascular disease when they are consumed (WHO/FAO 2003).

Diabetes UK (2006), the Canadian Diabetes Association (2006) and the Dietitians Association of Australia (2005), all recommend high fibre, low GI/GR foods as a means of improving blood glucose and weight control in people with diabetes.
Time out 7

With your colleagues, consider the issue of weight management and the help that is available locally for patients. Make a list of any facilities and support that is available and consider the advantages and disadvantages of using each service. Consider any barriers to their use and discuss the issue with your colleagues and a dietician if possible.
Insulin sensitivity and weight management

A diet based on low glycaemic carbohydrates that provokes less insulin demand may assist with satiety and appetite control, and reduce the urge to snack between meals.

In a recent study, lunch intake was significantly lower in a group of children fed a low GI breakfast (muesli, porridge, a bran-based cereal or linseed bread) than after a high GI breakfast (white bread, cereal such as cornflakes or chocolate-flavoured cereal) (Warren et al 2003).

Previous to this, at least 16 studies have examined the effects of glycaemia on appetite and all but one have demonstrated an increase in satiety, delayed hunger return and reduced food intake following low GI foods than following high GI foods (Ludwig 2000).

Maintaining energy balance throughout the day by choosing a healthy diet based on low GI/GR carbohydrates may help individuals feel fuller for longer, consume fewer calories and achieve portion control more easily (Ebbeling et al 2003, Foster et al 2003, Samaha et al 2003).

By lowering carbohydrate consumption in the diet and replacing the carbohydrate with protein or fat, it is possible to lower the overall GL of the diet. This resonates with popular low carbohydrate diets. Restricting carbohydrates to very low levels does not make sound nutritional sense. It could mean that only low intakes of fibre or fruit and vegetables are eaten and there is an increased likelihood of consuming a higher intake of saturated fats. Therefore, it is appropriate to consider other methods of lowering insulin resistance.
Reducing glycaemic index and response of diet

Choosing carbohydrates that have a low GI over those with higher levels is one way to reduce the GI/GL of a diet. However, it should be remembered that other non-carbohydrate foods also need to be chosen wisely to achieve a balanced diet. For example, this includes choosing small portions of lean meats and fish, using fat-reduced dairy products such as semi-skimmed milk or lower fat cheeses, limiting the amount of sugary and fatty snacks and including at least five portions of fruit and vegetables daily. Another way is to replace some of the carbohydrate in high GI/GR carbohydrates with low GI/GR carbohydrates, for example, replacing mashed potato with boiled new potatoes or sticky rice with basmati or brown rice.

By adding fibre to a food product, this can lower the quantity of available carbohydrate for digestion and thus the impact on GR. Traditional sources of fibre, such as wheat bran, can have a significant impact on the taste and texture of foods. Food manufacturers have found that the incorporation of high amylose resistant starch in their products delivers the reduced glycaemic benefits of fibre without sacrificing the quality of foods. Combining a low or medium GI food with a high GI food can also lower the overall GI content of a meal. Examples of this are adding baked beans to toast or using oats as a fruit crumble topping instead of flour.

Resistant starch Most starches are digested and absorbed into the body through the small intestine, but some can resist digestion and pass through to the large intestine, where they act like dietary fibre. This type of starch is called resistant starch. When bacteria that make up the gut microflora feed on resistant starch, they produce more butyrate - a fatty acid and an indicator of gut health.

Foods with naturally present or added resistant starch generally have a lower GR than other carbohydrate-rich processed foods, that is, they slow the rate at which glucose is released into the bloodstream.

A study by Robertson et al (2005) examined the effect of resistant starch on insulin sensitivity in ten healthy participants. A supplement of 30g of resistant starch per day over a period of four weeks was consumed and this was compared to a placebo. The results suggested that dietary supplementation with resistant starch has the potential to improve insulin sensitivity in healthy volunteers and further trials are to be carried out with people who have insulin resistance.

Insulin resistance Excess fat around the waist can cause a resistance to the action of insulin in the body, resulting in the need to secrete increasing amounts of insulin. This is also true of those who are overweight and those with type 2 diabetes (or a family history of it). High circulating levels of insulin can cause problems by making the development of type 2 diabetes or cardiovascular disease more likely. It also makes it more difficult to lose excess fat as carbohydrates in the body are burned at the expense of fat.

Box 3 illustrates the blood glucose concentrations of ten healthy people after consumption of different types of breads. When resistant starch is added, the GR is decreased in a dose-related fashion.

Graphic
BOX 3 Relative glycaemic response of bread

Defined physiologically as starch that resists digestion in the small intestine, resistant starch is a form of dietary fibre that exhibits the health benefits of other fibre sources, such as improved colonic health, increased faecal bulk and controlled energy release. In addition, as a source of prebiotic fibre, it promotes the growth of bacteria in the colon and encourages positive effects (Phillips et al 1995, Noakes et al 1996).
Time out 8

A prebiotic is a non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or the activity of one or a limited number of bacteria in the colon and thus improves host health. You should be aware that this is different from a probiotic that 'contains live microbial supplements that beneficially affect the host by improving its gut microbial balance' (Gibson and Roberfroid 1995).

Draw a chart of other food products that contain prebiotics and probiotics. Then consider whether more people are using these types of products than they were ten years ago and list the reasons for this.

Resistant starch is naturally present in some foods, including raw fruits, vegetables and intact wholegrain cereal products. However, as many foods become more processed, the naturally occurring resistant starch level can often decrease. As a result, the amount of naturally occurring resistant starch in our diet has significantly decreased over the last century. In the UK figures indicate that only 4g of resistant starch per person per day is consumed (Dyssler and Hoffman 1994). This compares with approximately 30-40g per day in developing countries where high amounts of carbohydrate are consumed (Baghurst et al 2001).

In response, a range of resistant starches has been developed commercially. Natural and functional, high amylose-based resistant starches have been incorporated into processed and convenience foods, for example, bread and cereals, to increase the fibre content and lower the GI/GR (Achour et al 1997).

A wide variety of products can be reformulated to include low GI/GR carbohydrates. As an insoluble ingredient, natural resistant starch is appropriate for grain-based, low and moderate moisture foods, such as bread, cakes, muffins and cereals and it is found in UK supermarkets in products such as breakfast cereals and bread. Table 2 shows a nutritional comparison of breads, one containing resistant starch.

Graphic
TABLE 2 Nutritional comparisons of breads

Resistant starch appears to have no adverse effects on the gastrointestinal function of well-nourished people and it appears to be more readily acceptable to people than other forms of dietary fibre (Nugent 2005). No cases of allergic reactions have been reported following supplementation with more traditional forms of resistant starch, such as those made from high-amylose maize (Goldring 2004).
Time out 9

Define 'resistant starch' and explain any benefits or adverse effects on health that it may have. List the foods where it is found naturally and added to manufactured products. What are the nutritional differences between the four types of bread listed in Table 2?

Food labelling Not all food products will provide nutritional information on a label. This is only a requirement where a manufacturer is making a claim, such as 'rich in vitamin C', although in the UK many manufacturers give this information on a voluntary basis. Table 3 shows an example of the nutrition information box on a food label. You will notice that the carbohydrate value in this case indicates the amount derived from sugar. However, as the labelling regulations currently stand, there is no way of telling whether this is fruit sugar, milk sugar or white table sugar. Further, there is no differentiation in terms of glycaemia, so the presence for example of resistant starch is not indicated.

Graphic
TABLE 3 Typical nutrition panel listing the main nutrients - lentil soup
Time out 10

Compare the labels on different foods and discuss with colleagues how you would improve the carbohydrate labelling to make it a more accurate reflection of the health benefits of a food product. Create your own healthy food product using food ingredients that improve carbohydrate quality to enhance insulin sensitivity. Indicate the type of food, the active ingredients and any claims you would hope to make on the label.
The nurses' role

It is clear that not all carbohydrates are of equal nutritional and physiological value. Modern lifestyles have seen an increase in consumption of 'fast carbs' and there are advantages to encouraging the consumption of fibre, intact wholegrains and slowly digestible material. FSA guidelines (2001) suggest that starchy foods should make up about one third of the food we eat. However, it is important to consider the quality as well as the quantity of the carbohydrates. Advice to patients should include:

[black right pointing small triangle] Choose high-fibre versions of breads and cereals wherever possible.

[black right pointing small triangle] Base your meals around starchy foods and vegetables with small portions of lean meat, fish, eggs, meat substitutes (such as Quorn™ or soya) or lower fat cheese.

[black right pointing small triangle] Include more beans and pulses in the diet. They are a great source of fibre as well as being low GI.

[black right pointing small triangle] Choose wholegrain or seeded breads or those with added resistant starch.

[black right pointing small triangle] Eat at least five portions of fruit and vegetables a day. These are a good source of vitamins and minerals as well as the majority being low GI and providing fibre.

[black right pointing small triangle] Limit fatty and sugary snacks and foods as these provide quick rushes, although sugary snacks do have their place, for example, for those at risk of hypoglycaemia and those who play a lot of sport.

[black right pointing small triangle] Choose more natural or whole foods rather than ready meals and take a ways.

[black right pointing small triangle] Semi-skimmed or skimmed milk is ideal, along with natural low-fat yoghurt as a calcium provider for strong bones and teeth. Soya versions (with added calcium) are useful alternatives.
Time out 11

Make a list of practical recommendations that you could use with a patient to help him or her transfer from a diet of processed foods towards an eating pattern that contains more wholegrain foods and more slowly digestible carbohydrates. Remember to consider issues such as preparation time, the local availability of foods and the cost.
Conclusion

It is sensible to base healthy eating recommendations on the consumption of high fibre, low saturated fat foods, lots of fruits and vegetables and accompany this with recommendations on healthy lifestyle habits such as regular physical activity. This has been shown to reduce the overall GL of the diet as well as diabetes risk factors by more than 40 per cent (Tuomilehto et al 2001, Anderson et al 2004). It may also significantly reduce the chances of becoming overweight (Westerterp 2001).

As diets become increasingly 'processed' - with fewer raw fruit and vegetables and wholegrain cereals - the consumption of naturally occurring resistant starch decreases. Therefore, processed foods with added resistant starch are particularly valuable sources of this form of dietary fibre and can increase resistant starch consumption. Adding wholegrains and pulses to convenience foods is another way of lowering the GR to foods and subsequent insulin demands. If the population were attracted to foods which offered glycaemic benefits, we may well promote healthier eating habits and influence long-term disease risk.

Carbohydrate-rich foods are important in our diet. Current UK dietary recommendations do not differentiate clearly between the different types and classifications of carbohydrate and studies are under way by the FSA to examine the fat and carbohydrate quantity and quality in relation to cardiovascular disease risk factors. Once the evidence is established, we may see a change in recommendations regarding the quality of carbohydrate consumption. The hope is that the end result from the food industry is quality, nutritious food, with clear, accurate labelling
Time out 12

Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 68.
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Keywords: Diabetes management; Diet; Eating disorders; Health promotion; Healthy eating; Obesity

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