Setting Carbohydrate Goals for the Diet

Refined grain diet like white bread, white rice, and white flour comprises approximately, 30% of the calories in the American diet and contains substantially lower amounts of vitamins, minerals, and fiber than unrefined grains [8]. In addition, refined grains are absorbed rapidly and may lead to blood glucose control issues.


Nearly 20% of the calories in the typical American diet are derived from added sugars (not including the sugars that occur naturally in fruit, milk, and other unprocessed foods) [8]. This translates into around 40 teaspoons of added sugar per person per day [9] and many bariatric surgery patients consume much more than that. Since refined sugar contains no vitamins, minerals, or micronutrients, added sugar consumption needs to be significantly reduced.

Sweets were once considered a treat but now the average American adult consumes one-third of their calories in sugar and white flour according to Jacob Teitelbaum, MD, in Complete Guide to Beating Sugar Addiction [10]. Dr. Teitelbaum outlines four types of sugar addicts, which may be helpful for health-care professionals to keep in mind when designing weight loss management messages pre- and postbariatric surgery.

The type 1 sugar addict is always exhausted and hooked on caffeine and sugar for energy, usually presenting with immune dysfunction. Type 2 is the perpetual crisis person with too much to do and stressed out trying to do everything while juggling blood pressure, blood glucose, and fatigue issues. Type 3 craves sugar to feed the intestinal yeast overgrowth, which causes sinusitis, spastic colon, and food intolerances. Type 4 is depressed with low hormone levels that drive the need for sugar.

Damon Gameau, graphically illustrates what 40 teaspoons of sugar from foods considered beneficial can do to your health in “That Sugar Film [11]. Grace Shearrer et al., at the University of Texas, Austin, studied sugar-sweetened beverage intake and found greater visceral fat in the high-intake group, which was associated with higher cortisol response [12].

Among the world’s largest sugar producers in the United States where sugar cane accounts for approximately 45% of the total sugar produced and sugar beets for around 55%, with the United States Department of Agriculture (USDA) production data showing increases over the past three decades [13]. Sugar also plays an important part in food processing and the more processed foods Americans consume, the more sugar they eat.

The best way to reduce sugar intake is to limit consumption of processed foods and drinks, since sugar is an ingredient in three-fourths of all packaged foods and sweetened beverages. Eat, don’t drink, your fruits and vegetables and skip bakery products like the bagel (55 g carbohydrate), cinnamon roll (94 g carbohydrate), or cookie (30 g carbohydrate).

Bariatric surgery can curb the sweet tooth by altering the brain’s reward system according to a study in Cell Metabolism [14]. This study was done in mice and the how and why still need to be worked out in humans. Patients need to start changing food habits before surgery for success by reducing high-calorie, high-sugar foods. Madjd et al. found that the replacement of diet beverages with water led to greater weight reduction and less insulin resistance [15].

Personalizing the carbohydrates in the diet requires assistance in understanding the glycemic index, sugar substitute preferences, and/ or dietary fiber recommendations and tolerances. Support groups could focus on these topics to illustrate the importance of these issues.

The concepts of glycemic index and glycemic load are described as a means of classifying carbohydrate foods based on the food’s impact on glucose response in the body. A high-glycemic index food is more rapidly converted to glucose [16]. Most breads, breakfast cereals, and grain products have a high glycemic index, whereas most fruits, nonstarchy vegetables, and legumes are low glycemic index.

Sugar substitutes (also known as artificial sweeteners or nonnutritive sweeteners or noncaloric sweeteners) are sweeteners that contain virtually no calories and no carbohydrates. They are plant-based or chemical substances that are hundreds of times sweeter than sugar and have no effect on blood glucose levels. Some sugar substitutes can be used in baking to reduce carbohydrate content but flour also contributes to the carbohydrate level in cookies, cakes, and desserts.

Stevia rebaudiana is a plant native to South America and is grown throughout China. Stevia was previously sold as a dietary supplement until two companies—Cargill and Merissant—developed an extract that received the Food and Drug Administration generally recognized as safe (FDA GRAS) status in 2008. It is 200-400 times sweeter than sugar [17].

Sucralose is made from sugar by replacing three hydroxyl groups on a sucrose molecule with three chlorine atoms. This process was discovered in 1976, approved for use in food in 1999 and is found in over 5,000 foods and beverages today. Sucralose is 600 times sweeter than sugar [17].

Saccharin, discovered by researchers at Johns Hopkins University in 1878, is the oldest sugar substitute. It was used during sugar shortages in World War I and II and is 300-500 times sweeter than sugar [17]. Monk fruit or swingle fruit (Luo Han Guo) is a native of southern China and is a gourd the size of a lemon. Its extracts, called mogrosides, are 300 times sweeter than sugar and possess antioxidant properties [17].

Acesulfame K (Ace-K) is often combined with other sweeteners and is around 200 times sweeter than sugar. Aspartame sold under the name Equal® or NutraSweet® is around 200 times sweeter than sugar but should not be used by people with phenylketonuria (PKU) disease.

Sugar alcohols are used as sugar replacers in foods—candy, gum, ice cream products. Their sweetness varies because they are not true sugars. Chemically, they are hydrogenated sugars—with an extra hydroxyl group. Erythritol, mannitol, sorbitol, and xylitol are identified on the food label. Sugar alcohols are absorbed more slowly than glucose and are more resistant to digestion but have similar calorie content as sugar. The sugar alcohols that are not digested are fermented in the large intestine that can cause a laxative response [18].

Fiber is a nondigestible carbohydrate that is fermented in the colon and/or excreted in the feces. The fiber that occurs naturally and is intact in foods is called dietary fiber. Nondigestible carbohydrates that are added to foods after being extracted from a natural source or synthesized are called functional fiber [19]. Food manufacturers use fibers as bulking, stabilizing, and thickening agents. Inulin and fructo-oligosaccharide may be used as a fat or sugar replacer or prebiotic [20]. Tolerance to dietary fiber and functional fiber will vary significantly pre- and postsurgery.

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