How science is going sour on sugar
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f307 (Published 16 January 2013) Cite this as: BMJ 2013;346:f307
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It constantly amazes me that in the discussion on sugar being a major cause of ‘diabesity’1, in this issue of the BMJ, and over the years elsewhere, that basic physiology moves out of the picture. Starches are polysaccharides which are easily broken down or hydrolysed to constituent simple sugars; a common starch is amylose which becomes glucose, releasing a small amount of energy, when acted on by the enzyme amylase. Interestingly, amylase is even present in human saliva, and in high amounts in some human groups2, in addition to pancreatic secretions. One can taste the increasing sweetness of glucose on chewing tasteless white bread, which is unlikely to be good for teeth3. Breads, rice and white potatoes, our so-called staple foods, provide starch with a high glycaemic index and load, which may be greater than sucrose4. The sugars (monosaccharides) are absorbed extremely quickly, raising blood glucose to high levels, and releasing large amounts of energy for use or storage. Willet and Ludwig(1136/bmj.e8077)5 acknowledge this fact about starch in their commentary in this issue.
Pre-agriculture, 10,000 years ago, starchy food was scarce; tough, stringy roots and tiny grains. Subsequently, these tubers and grains have been bred to produce greatly increased volumes and proportions of starch6, and sugars, which preserve, pack and travel well. Baked breads and crackers, even of the ‘whole grain’ type, contain much refined flour. Whilst many clinicians advise whole grain based foods as part of a ‘prudent diet’ which confers health benefits, when studied, cardiovascular risk markers did not improve on a whole grain augmented diet7 8. Non fruit sources of mono- and di- saccharides (fructose, sucrose) such as from maise, sugar cane and beet, have also been highly bred for their rich energy yield. This whole group of refined starches and sugars is highly implicated in energy dense food addiction9.
On the other hand, humans evolved from a ripe fruit-eating primate, approximately 20 million years ago, and generally apes (except gorillas) have continued to eat a high energy plant diet of seeds and fruit, probably helping to supply the enlarging, energy-demanding brain10. It appears that when fruit sugars are ingested with fibres and other complex plant chemicals, it is absorbed at a slower rate. Whilst fruits may have been cultivated to be fleshier and contain more sugar they can still be eaten whole, often with skins and seeds, which appears to contribute to their low glycaemic index. Even preserved (dried, frozen), they retain fibre and unknown types of plant nutrients. Notably, it is important that these food constituents are eaten as food. As the meta-analysis of Myung et al (1136/bmj.f10)11, also in this issue, shows, vitamins and supplements are not effective at preventing cardiovascular disease (CVD).
Yudkin’s book ‘Pure White and Deadly’ mentioned by Jackson (1136/bmj.f307)12 and Watts (1136/bmj.e7800)13 could refer to both sucrose and starch. We may have to face the fact that refined starches should be treated as refined sugars and that to decrease diabesity rates, consumption of ‘high (refined) carb’ diets needs to be severely curtailed, probably aided with addiction management in the already centrally overweight.
However, adequate dietary energy for modestly active, older or overweight and/or diabetic individuals can be replaced with plenty of low-processed fruit, vegetables, oil seeds/nuts14 and free range animal products, which are also known to confer health15 16. Rapidly, such a diet rights the wrongs of severely unbalanced micronutrient to macronutrient ratios. Micronutrient insufficiency seen in diabesity17, or rather malnubesity18, decreases. Such diets reduce the central obesity related metabolic syndrome continuum of CVD, diabetes and cancer risk.
So, appetising sugar and starch laden foods indirectly cause obesity by energy overload, as well as effectively displacing food micronutrients needed for healthy metabolism.
1. Anonymous. From the NIH: Successful diet and exercise therapy is conducted in Vermont for "diabesity". JAMA 1980;243(6):519-20.
2. Luca F, Perry GH, Di Rienzo A. Evolutionary adaptations to dietary changess. Annu. Rev. Nutr. 2010;30:291-314.
3. Garcia-Closas R, Garcia-Closas M, Serra-Majem L. A cross-sectional study of dental caries, intake of confectionery and foods rich in starch and sugars, and salivary counts of Streptococcus mutans in children in Spain. Am. J. Clin. Nutr. 1997;66(5):1257-63.
4. Atkinson FS, Foster-Powell K, Brand-Miller JC. International Tables of Glycemic Index and Glycemic Load Values: 2008. Diabetes Care 2008;31(12):2281-83.
5. Willett WC, Ludwig DS. Science souring on sugar. BMJ 2013;346.
6. Jacobs DR, Pereira MA, Meyer KA, Kushi LH. Fiber from whole grains, but not refined grains, is inversely associated with all-cause mortality in older women: the Iowa women's health study. J. Am. Coll. Nutr. 2000;19(3 Suppl):326S-30S.
7. Brownlee IA, Moore C, Chatfield M, Richardson DP, Ashby P, Kuznesof SA, et al. Markers of cardiovascular risk are not changed by increased whole-grain intake: the WHOLEheart study, a randomised, controlled dietary intervention. Br. J. Nutr. 2010;104(1):125-34.
8. Jacobs DR, Jr., Tapsell LC. Food, not nutrients, is the fundamental unit in nutrition. Nutr. Rev. 2007;65(10):439-50.
9. Avena NM, Gold JA, Kroll C, Gold MS. Further developments in the neurobiology of food and addiction: update on the state of the science. Nutrition 2012;28(4):341-3.
10. Leonard WR, Snodgrass JJ, Robertson ML. Effects of Brain Evolution on Human Nutrition and Metabolism. Annu. Rev. Nutr. 2007;27(1):311-27.
11. Myung S, Ju W, Cho B, Oh S, SM P, Koo B. Efficacy of vitamin and antioxidant supplements in prevention of cardiovascular disease: systematic review and meta-analysis of randomised controlled trials. BMJ 2013;346:f10.
12. Jackson T. How science is going sour on sugar. BMJ 2013;346.
13. Watts G. Sugar and the heart: old ideas revisited. BMJ 2013;346.
14. Jenkins DJA, Kendall CWC, Banach MS, Srichaikul K, Vidgen E, Mitchell S, et al. Nuts as a Replacement for Carbohydrates in the Diabetic Diet. Diabetes Care 2011;34(8):1706-11.
15. Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F. Beneficial effects of a Dietary Approaches to Stop Hypertension eating plan on features of the metabolic syndrome. Diabetes Care 2005;28(12):2823-31.
16. Mente A, Koning Ld, Shannon H, Anand S. A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease. Arch. Intern. Med. 2009;169(7):659-69.
17. Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J. Gastrointest. Surg. 2006;10(7):1033-7.
18. McGill A-T. Malnutritive obesity ('Malnubesity'): Is it driven by human brain evolution? Metab. Syndr. Relat. Disord. 2008;6(4):241-46. .
Competing interests: No competing interests
In the latest BMJ I saw an advert for a "Course on Safety in Chest Drain Insertions" to be held at Maidstone Hospital.
I found this astonishing and rather depressing. It is to cost a junior doctor £200 - and a day of study leave - both presumably covered by their employing Trusts.
What seems extraordinary is that chest drain insertion was, until recently, a skill one would expect to be taught to medical students. This course is designed for FY2 to ST3/SpR. This assumes that junior doctors 6 and 7 years into their training lack this basic emergency skill. I fear this is yet another example where the rigid application of EWTD has allowed for dangerous depletion of hands-on training.
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High levels of Insulin which is a highly anabolic hormone are responsible for the significant weight gain associated with diets that are high in sugar and associated high GI Carbs. Most people would accept that the burning of body fat as a source of energy with which to lose weight is key to any diet. However it is almost impossible to burn fat when insulin is the dominant metabolic hormone as is seen when the diet contains standard volumes of carbohydrate and sugars in particular. To burn fat the body needs to switch off the drive to insulin production and this is only possible in a much lower sugar and carb diet than is promoted by the low fat diet regimes - unless sever calorie restriction like the counterpoint study is used. Continued stimulation of insulin production in turn leads to fat production, obesity and probably insulin resistance which further fuels the problem. One answer is to restrict the drive to insulin production through lower sugar and high GI foods in the diet and give the B cells of the pancreas a rest. I have postulated before that continued overstimulation of this system leads in time to fatigue of the B cells and resistance in the target tissues with associated impairment in glucose tolerance and Type 2 DIabetes ensues in susceptible individuals. A serious discussion is needed now on the biochemical and physical benefits of a low carb diet which in turn lowers the drive to insulin production and it's associated negative health outcomes.
Competing interests: No competing interests
Again, as every year on January, the bmj starts 2013 with an issue devoted to a very important global problem, related with the increasing of the world population of sugar babies. Congratulations to you for this wonderful 7891st issue. We like most the super red pasteboard with that sugar image of a body, located on the front journal cover. For us that image represents a child who has chemical characteristics similar to that of a expressed juice of fruits before the beginning of a fermentation process.
“People who have lived more than eighty years always have the reason and think correctly” is a typical Colombian expression. We can perfectly apply that expression to the author of “Pure, White, and Deadly”- Mr. John Yudkin.
In low and middle income countries, like ours, it is very common to find children who have signs and symptoms of radical biological changes. Children show overweight and obesity. That is a logical consequence of excessive consumption of carbohydrates in the typical form of the three daily compulsory meals; of immoderate ingestion of the high sold and distributed in Colombia street products; of children sedentary living style, caused by their stay for several hours, from a very early age, searching for Internet virtual sites, or playing against the computer, or in the stations of console’s games, or watching cartoons and children's pleasant programs in face of the TV screen. Although children sometimes take their correct daily quantity of food ration; meals taken are characterized by their high carbohydrates composition and their very low nutritional content. Furthermore, in the intervals, between meals, children eat street sugar foods of low biological value: low cost syrup, honey or sugar confections, candies, snacks, sugar pies, sweet tarts and cakes, soft drinks, mainly pony malt, ice creams, gums ... That kind of diet and children daily sedentary life create at a very short time, an individual with similar chemical characteristics to those, which has a popular mixture produced, at the first step, in the alcohol fermentation industry, technically called MUST.
Must is characterized by having a high concentration of carbohydrates. In order to prevent its damage during the anaerobic fermentation until the end of alcohol production, that initial mixture, all the time, should be assessed and monitored. If the chemist doesn’t control well the process in must will proliferate various microorganisms’ classes: fungi, bacteria and even big animals, as mice, rats, cockroaches and other insects.
As we briefly, have explained in a past bmj response (1), as a logical consequence of a bad life style, by the age of five or six, children can present the so called by us, at the Surcolombiana University, The MUST HUMAN SYNDROME. At that age in oversaturated with sugar children we can easily appreciate several typical signs or symptoms. On the children scalp can be found dandruff, and/or louses. There may be dirty (grime) in the armpits, at the neck skin, the ears back, in the arm binding site with the forearm, or the homologous one between the leg and thigh, and at the toes bottom. Usually these children have smelly feet, bad odored head, halitosis, armpits, laziness, and have flatulence. Most are ill-mannered annoying sniveled children with breathing difficulty. In a most advanced state, in those children may appear several often infectious and contagious diseases, at the skin level, at the airways, and gastro-intestinal system. In some cases, it may be characteristic the presence of certain chronic diseases, such as sinusitis, asthma, migraine, cardiovascular problems and degenerative diseases. Sometimes, in these children, on the anus, it is easy to observe the presence of oxyuriasis and other small worms. With some frequency, they expel, with feces, nematodes and other dangerous helminthes. It´s most likely to met these children with a low immunological activity. In them decreases the immunoglobulin’s production and the number of white line blood cells. These children, like animals, can be easily attacked by flies, hematophagous, mosquitoes and other insects. They often get measles, mumps, fever, whooping-cough, indigestion, earache, toothache, stomachache, heart troubles, sore throat, and pneumonia.
Long before the appearing of classic children metabolic disorders, they show the typical signs and symptoms of the MUST HUMAN SYNDROME. Its early detection may be used as criterion for primary prevention of several expensive and catastrophic diseases.
1. Polo Ledezma E., Polo Rivera C.E. Quixotic Enterprise, but a Good, Conforming to Nature, Project. Electronic Response. BMJ 2011; 342:d716. http://www.bmj.com/rapid-response/2011/11/03/
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There are many popular diets, but none of them seem to work. They all leave us hungry and weak, not satisfied or strong. Is there a healthy diet that actually works? If so, how do we find and follow it?
A healthy diet is balanced nutrition without toxins or addictions, both of which are common, covert causes of sickness. Toxins, like pesticides, herbicides, and fungicides, don't belong in our diet. The same is true for addictions, like honey, sweets, chocolate, vanilla, cola, coffee, tea, alcohol, tobacco, and drugs. So how do we avoid toxins and addictions?
We should eat organic food and follow a lacto-ovo-vegetarian diet. Organic food (which excludes chemicals) minimizes toxins by purifying our diet, and a lacto-ovo-vegetarian diet (which excludes meat and fish) minimizes addictions by balancing our diet. (1)
(1) What is a balanced diet? Mann, H.
http://www.bmj.com/content/346/bmj.f74/rr/624546
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The inescapable conclusion of the papers on obesity risk factors is that no-one is wrong. Overingestion of sugar is harmful; over-ingestion of fat is harmful; but then over-ingestion of anything is harmful.
We will get nowhere by trying to persuade people to alter their diets when the advice is conflicting. We may get further by empahsising the importance of not overeating anything and everything. And from a scientific viewpoint we may achieve more by investigating the relative effects of various foodstuffs on satiety; the suggestion that fructose has less inhibitory effect on appetite than other sugars is interesting in that context.
Having spent many a lunchtime watching the indiscriminate scoffing of too much of everything in hospital canteens (the worst I can remember was a double plate of chips followed by a huge dollop of sponge pudding and custard - nothing else) by folk who are already enormous it is clear that many modern men and women have lost the ability to feel full. If we could restore that then perhaps the burden of heart disease and diabetes would finally reduce. This may owe more to general education than to dietary strictures: grazing may be very bad; eating large meals and sitting doing little may be bad also (hence eat at lunch and not in the evening - no chips!- so calories might be burnt off if only by walking to the car).
Competing interests: No competing interests
Re: How science is going sour on sugar
In response to your article I wanted to mention that finally there is noticeable change in way the United States is approaching the sugar epidemic. Every 5 years, following an expert panel's systematic review of the literature on diet, the US Department of Agriculture and the Department of Health and Human Services issue dietary guidelines. The 2015 Dietary Guidelines Advisory Committee (DGAC) report has two startling changes: The 30% upper limit on fat consumption has been eliminated and dietary cholesterol is no longer listed as a nutrient of concern.1 It appears that we are in the midst of a paradigm shift, and we need more information and education on this matter to pass on to our patients. With research such as this, we can better inform our patients and break the cycle of incorrect patient education which contributes to the nation’s obesity crisis.
I believe that most of us can agree, that the majority of the physicians have very busy schedules and sometimes are undereducated on matters of nutrition. The bottom line is that the PCP have inadequate time to convey their knowledge to their patients. This is where the role of physician assistants becomes crucial. Physician assistants along with other midlevel providers seem to be best suited for the role of educating patients along with ensuring proper follow up.
Where the real problem exists, however, is the lack of better and more direct education while the during physician assistant school and subsequent training. Greater emphasis should be placed on addressing the biochemistry, pathophysiology and nutritional science as it relates to excess fructose ingestion and atherosclerosis.
I believe that countries should empower professional organizations or to establish new taskforce focusing on improving the training and education of physician assistants so that they may serve as nutritional advisors to their patients.
Not only should American Association of Physician Assistants make this a priority, but the healthcare community, including supervising physicians and other mid-levels, should participate in making sure they have sufficient tools to efficiently convey their understanding of correct diet to their patients.
References:
1. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. 2015. www.health.gov/dietaryguidelines/2015-scientific-report/. Accessed March 25, 2016.
Competing interests: No competing interests