The dietary advice on added sugar needs emergency surgery
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3199 (Published 21 May 2013) Cite this as: BMJ 2013;346:f3199
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I welcome the response from Barbara Young, chief executive of Diabetes UK to my article entitled “the dietary advice for added sugar is need of emergency surgery.” I do believe that the majority of those within her organisation are well intentioned but my question was over their relationship with their sponsors and how that may influence specific policy statements. Diabetes UK’s website states “partnerships (with corporates) are tailored to meet their corporate objectives,”and that “this approach guarantees mutually beneficial outcomes.”(1) Abbott,which is listed on their corporate acknowledgements page(2) and is the parent company of Abbott nutrition has declared financial support to Diabetes UK for conference exhibition fees and sponsorship totalling £44,302 in 2012. (3) This is at best a branding opportunity (and association with a respected Diabetes charity) for a company that produces formula milk whose excessive sugar content is implicated in infant obesity.(4) It is also worthy to note that a 240ml serving of Abbott PediaSure fortified milk (which is marketed for 1-3 year olds) contains a staggering 32.4g added sugar(5) which is just over 8 tea spoons and is significantly higher than the upper limit from all added sugar calories recommended for a 12 month old baby based on current UK dietary reference values. A 330ml can of cola contains 9 tea spoons of added sugar.
Barbara Young mentions only one recent study implicating sugary drinks with obesity and type 2 diabetes failing to acknowledge several other robust observational studies and RCTs linking the aforementioned.(6)(7)(8)(9 ) It also begs the question, given this wealth of scientific evidence why their website continues to state “eating sweets and sugar does not cause diabetes, but eating a lot of sugary and fatty foods can lead to being overweight”.(10) A longitudinal cohort study by Basu et al, involving 175 countries that looked at sugar availability revealed for every additional 150 calories of sugar consumption there was an eleven fold increase in the prevalence of type 2 diabetes independent of body weight and physical activity.(11) There is a clear scientific consensus that added sugar has no nutritional value and contributes to excess calories, obesity and type 2 diabetes. I therefore urge Diabetes UK to update their policy statements and website to reflect this evidence and maintain their reputation as a credible organisation that has independent interest for those who have, and are at risk of developing type 2 diabetes; a condition which is rapidly increasing in prevalence and represents a serious threat to public health.(12)
(1)http://www.diabetes.org.uk/Get_involved/Corporate/
(2)http://www.diabetes.org.uk/Get_involved/Corporate/Acknowledgements/
(3)http://www.abbott.co.uk/media/114443/transparency_2012-support_for_pt_or...
(4)Sugar: the bitter truth. University of California Television. www.youtube.com/watch?v=dBnniua6-oM.
(5)http://www.firststepsnutrition.org/pdfs/Fortified%20milks%20-%20FINAL.pdf
(6)de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med2012;367:1397-1406
(7)Malik VS, Popkin BM, Bray GA, Després J-P, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation2010;121:1356-64.
(8)Malik VS, Hu FB. Sugar-sweetened beverages and health: where does the evidence stand? Am J Clin Nutr2011;94:1161-2.
(9)Singh G, Micha R, Khatibzadeh S, Katibzadeh S, Lim S, Ezzati M, et al. Mortality due to sugar sweetened beverage consumption: a global, regional, and national comparative risk assessment. EPIN-PAM 2013; New Orleans, 19-22 Mar 2013. Abstract MP22.
(10)http://www.diabetes.org.uk/Guide-to-diabetes/Introduction-to-diabetes/Ca...
(11)Basu S, Yoffe P, Hills N, Lustig RH. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PLoS One2013;8:e57873
(12)http://www.nhs.uk/news/2012/04april/Pages/nhs-diabetes-costs-cases-risin...
Competing interests: No competing interests
In a recent issue of the BMJ, Dr Aseem Malhotra implied that Diabetes UK’s view on the link between sugar and Type 2 diabetes has been influenced by a corporate partnership.
We defend absolutely Dr Malhotra’s right to criticise our position on sugar. That is his view. We were, however, upset and disappointed that Dr Malhotra called our integrity into question just because he disagrees with us. He had no evidence to support that implication. He hadn’t raised this with us directly first and allowed us to demonstrate our absolute commitment to an evidence based approach.
We would never allow our view of the science to be swayed by a corporate partnership. We have a long history as an evidence-based organisation that gives independent advice and we are committed to continuing this. Indeed our very survival as a trusted charity, which supports people with diabetes, policy makers and others with robust independent advice and campaigns vigorously for people with diabetes, depends on this.
Of course, some people do not think charities should have corporate partnerships at all. But this would significantly diminish our ability to make a difference for people with diabetes and most people realise that, just as the BMJ‘s editorial stance is not influenced by its advertisers, a charity can accept money from a company without being in its pocket.
At Diabetes UK, we achieve this by having systems for ensuring we only enter into corporate partnerships with appropriate organisations and by fostering a culture where the kind of separation that exists between the BMJ’s advertising and editorial departments exists between our fundraising directorate and those working in research and policy. This means that any judgments we make on research are entirely evidence based and do not permit any input at all from colleagues in fundraising. Our corporate partners are clear from the outset that we reserve the right to be ruggedly independent, and that we may be critical of their position or actions from time to time.
In terms of our comments on the relationship between sugar and Type 2 diabetes risk, we clearly acknowledged the key findings of the InterAct study in our media comment. We stand by our view that this study does not provide definitive evidence that sugar increases risk of Type 2 diabetes independent of its effect on body fat. Dr Malhotra may think this is too cautious, but this is a single study, showing a statistically significant but small association between sugar and diabetes risk after correcting for BMI, and a larger body of evidence is needed to demonstrate whether this finding is medically relevant. We are pleased that the Scientific Advisory Committee on Nutrition is currently considering all the available evidence. Once that official assessment is available, we will all be better placed to reach an evidence based view.
But we already know that sugar is an energy dense food source that we are consuming far too much of and which contributes considerably to the obesity epidemic that is fuelling the record rate of Type 2 diabetes that we see today. This is why we are putting pressure on food companies and government and giving healthy lifestyle advice to those at high risk to try to reduce their consumption of sugar, as part of a balanced and healthy diet. But sugar is not the only cause of obesity and while debating the science openly we have a collective duty not to send confusing messages to the public. Healthcare advice must continue to reflect the body of evidence that maintaining a healthy weight through a balanced diet is the most effective way to prevent Type 2 diabetes.
Competing interests: Chief Executive of Diabetes UK
The cardiologist Aseem Malhotra (1) describes with great insight the problems associated with sugar consumption and the obesity and type 2 diabetes (T2DM) epidemics and requests urgent action. Dr Malhotra highlights some of the conflicts of interest involved in the sugar industry. Conflicts of interest were also highlighted by Dr Des Spence in his recent article ‘Bad medicine: the way we manage diabetes’ (2) http://www.bmj.com/content/346/bmj.f2695
Sugar, however, is not the only confounding issue concerning healthy living. Hidden Sugars seem to have provided a replacement ‘filler’ for the low fat fad which has wreaked havoc on human health. Unlike sugar, the correct proportions of fats within the diet are irrefutably essential. Cardiovascular health, renal function, eyesight, healthy brain function and healthy reproduction (Male and female) fundamentally rely on good quality fats in the diet for normal function. Fats are also important for satiety of appetite. Yet the majority of those with T2DM are put on slimming diets as a priority. This may be due to the lack of knowledge on what constitutes a diabetic diet.
The Look AHEAD (Action for Health in Diabetes) study tested whether a lifestyle intervention resulting in weight loss would reduce rates of heart disease, stroke, and cardiovascular-related deaths in overweight and obese people with type 2 diabetes, a group at increased risk for these events.
In 2012, after eight to eleven years of participant follow-up, the Look AHEAD intervention arm was stopped by the study sponsor when it was determined that intensive lifestyle interventions did not decrease the occurrence of cardiovascular events, the primary trial outcome.(3) It therefore might be concluded that diet and lifestyle approaches are ineffective in type 2 diabetes management. However looking at the sponsorship received in the LOOK-AHEAD trial it is not surprising to see why. (4) http://www.lookaheadtrial.org/public/la%20donor%20list%20website%2007.pdf
Medical research is too reliant on financial support from those with commercially vested interest. What a disappointing result for all the undeniably hard work by the researchers and participants in this extensive study. If only they had used real food instead of slimming aids such as meal replacement shakes and Orlistat! Hardly a sustainable option for T2DM which affects many countries with very limited health and financial resources.
A healthy balanced diet appropriate to the individual, not a slimming diet, is fundamentally a key factor in disease .prevention. Commercial interests have played a key part in pushing the high carbohydrate/low fat diet which has undoubtedly contributed to the T2DM epidemic. The food and drug industry are inextricably linked. They are therefore in a win-win situation. The diet currently recommended for T2DM is not a balanced one. When blood glucose results are consistently too high (which you would expect when consuming a high refined carbohydrate diet) Combined with consuming fats which are in an unhealthy balance contributing to the disease process. The person, having failed to control their condition by lifestyle measures, is then a target for polypharmacy.
Type 2 diabetes is fundamentally a self-managed condition. As a priority it is essential for people to be given meaningful and appropriate advice on managing their life with diabetes. Prevention at the grass roots level of this problem has to be a priority. Children are being diagnosed with T2DM are we really to believe this disorder cannot be reversed? Dr Malhotra is absolutely right to be concerned about the adverse effects of sugar in children’s diets. Sugary foods used to be an occasional treat, but is now an everyday diet staple for many children. This is a ticking health time bomb which needs diffusing. Unfortunately there are still members of the public and health professionals who believe diabetes (both types 1 and 2) is caused by the consumption of too much sugar, this myth should be dispelled.
The food and drug industries are commercial organisations and are therefore driven by profits. They enjoy close relationships with various world health organisations, whether through sponsorship of clinical trials, patient information leafleting, or providing refreshments at the local diabetes association meetings. How can any headway be made in improving outcomes for those with diabetes. Whilst overcoming such conflicts of interest and potential research bias? Certainly the BMJ Open Data Campaign would be of great benefit within diabetes research.
Dr Malhotra states that ‘It’s time for the UK’s Scientific Advisory Committee on Nutrition and the Department of Health to act swiftly as the dietary advice on added sugar is in desperate need of emergency surgery’ Unfortunately, one of the biggest problems would be to convince the public to listen to and follow such advice.
In 1990 the eminent diabetologist Professor Robert Tattersall (now retired). Wrote in an article about perceived benefits of high fibre diet and diabetes:
‘Since medicine began doctors have been liberal dispensers of conflicting nutritional advice and this phenomenon is currently at a peak. Many of the proffered recommendations are scientifically dubious or premature, confusing patients and reducing the credibility of the adviser’. (5)
Over twenty years on this statement is still pertinent, although the dispensers of advice seem to belong to commercial industry. There is an urgent need to clarify the diet and lifestyle measures as a guide for healthy living. The aim should be to prevent obesity and allied diseases in the first place. There is also an urgent need to provide unbiased common sense advice on living a normal life with diabetes.
(1) The dietary advice on added sugar needs emergency surgery
Aseem Malhotra BMJ 2013;346:f3199
(2) Bad medicine: the way we manage diabetes. Des Spence BMJ 2013;346:f2695 http://www.bmj.com/content/346/bmj.f2695
(3) Association of an Intensive Lifestyle Intervention With Remission of Type 2 Diabetes Edward W. Gregg, PhD; Haiying Chen, PhD; Lynne E. Wagenknecht, DrPH; Jeanne M. Clark, MD, MPH; Linda M. Delahanty, MS, RD; John Bantle, MD; Henry J. Pownall, PhD; Karen C. Johnson, MD, MPH; Monika M. Safford, MD; Abbas E. Kitabchi, MD, PhD; F. Xavier Pi-Sunyer, MD; Rena R. Wing, PhD; Alain G. Bertoni, MD, MPH; for the Look AHEAD Research Group JAMA. 2012;308(23):2489-2496. doi:10.1001/jama.2012.67929.
(4) Lookaheadtrial.org public donors.
http://www.lookaheadtrial.org/public/la%20donor%20list%20website%2007.pdf
(Accessed 31 May 2013)
(5) Benefits of fibre itself are uncertain Robert Tattersall, Peter Mansell 'BMJ VOLUME 300 19 MAY 1990
Competing interests: No competing interests
The beliefs expressed in this “Observations” piece are based on exaggeration, selection and substantial errors of fact. The persistent repetition of these beliefs does not contribute to rational and evidence-based advice to the public. The gross errors in reporting earlier studies surely illustrate the dangers of not subjecting such publications to peer review.
The 2003 report of an expert panel convened by WHO is misquoted, and other, more recent, expert committee reviews from the Institute of Medicine (2005) and the European Food Safety Authority (2010) are ignored. The controversial suggestion of the WHO panel to limit “free sugars” to 10% of food energy intake was not, as he claims, related to obesity prevention but was an arbitrary guideline intended to reduce the incidence of dental caries. This report was not accepted by the World Health Assembly as a basis for the Global Strategy on Diet, Physical Activity and Health, and the WHO has not adopted this limit. The WHO is currently reconsidering its guidance on sugar consumption.
The American Heart Association opinion on sugars is largely related to the supposed avoidance of obesity but provides no evidence to substantiate the quantitative guidelines given. Equally, the recent WHO-funded review of sugar and body weight (Te Morenga et al. 2013) provides no evidence with which to guide advice on any quantitative limit on intake. Indeed, this review specifically includes evidence showing that sugar has no unique effect on body weight other than as one, relatively minor, source of food energy.
The most serious error of fact is the wild exaggeration of the data in an ecological paper by Basu et al. (2013). Malhotra claims that this paper reports an “11 fold increase in the risk of developing type 2 diabetes” “for every additional 150 sugar based kilocalories consumed daily”. In fact, this Basu etal. paper reports an increase of 1.1% in estimated diabetes prevalence associated with a calculated increase in 150 kcal/person/day in sugar availability (which is not the same as actual consumption).
Ecological studies, such as that of Basu et al. are the most unreliable form of evidence currently available on relationships between diet and disease, and serious epidemiologists distrust small relative risk differences as likely due to residual confounding or bias (Grimes & Schultz, 2012; Young & Carr, 2011; Ioannidis 2005).
It is important to discriminate between evidence of reasonable reliability, such as randomized controlled intervention trails, and evidence that is intrinsically unreliable in determining causality, such as observational epidemiology. No serious scientific review should give equal weight to these different forms of evidence.
This opinion piece fails to provide evidence from randomised controlled trials, despite asserting that they exist. The most current evidence-based recommendations for prevention of Type 2 diabetes mellitus in high-risk groups from Diabetes UK and the American Diabetes Association comprise lifestyle interventions of energy restriction, a low fat diet and increased physical activity (Bantle et al., 2008, Dyson et al., 2011). Advice on sugar is notably absent. These guidelines, and those from the British Dietetic Association, are not based on opinion, but on the prevailing scientific evidence.
It is regrettable that this article seems to include an attempt to avoid debating the science by smearing those who hold views contrary to those expressed, including reputable bodies such as the British Dietetic Association and Diabetes UK.
What is needed is a reasoned debate correctly citing all relevant evidence.
References
Basu S, Yoffe P, Hills N, Lustig RH (2013) The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross sectional data. PLOS ONE 8(2):e57873.doi:10.1371/journal.pone.005783.
Bantle, J.P., Wylie-Rosett, J., Albright, A.L., Apovian, C.M., Clark, N.G., Franz, M.J., Hoogwerf, B.J., Lichtenstein, A.H., Mayer-Davis, E., Mooradian, A.D. & Wheeler, M.L. 2008, "Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association", Diabetes care, vol. 31 Suppl 1, pp. S61-78.
Dyson, P.A., Kelly, T., Deakin, T., Duncan, A., Frost, G., Harrison, Z., Khatri, D., Kunka, D., McArdle, P., Mellor, D., Oliver, L. & Worth, J. 2011, "Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes", Diabet Med, vol. 28, pp. 1282-1288.
European Food Safety Authority (2010) Scientific opinion on dietary reference values for carbohydrates and dietary fibre. EFSA Panel on Dietetic Products, Nutrition and Allergies. EFSA Journal 2010; 8(3):1462.
False Alarms and Pseudo-Epidemics: The Limitations of Observational Epidemiology. Grimes D, Schulz K F (2012) Obstetrics & Gynecology 120: 920-927.
Food and Nutrition Board, Institute of Medicine of the National Academies (2005) Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, amino acids (macronutrients). The National Academies Press. Washington, DC.
Ioannidis JPA (2005) Why Most Published Research Findings Are False. PLoS Med 2(8): e124. DOI:10.1371/journal.pmed.0020124. Available at: http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124 (accessed 25 March 2013).
Te Morenga (2013) Te Morenga L, Mallard S, Mann JM (2012) Dietary sugars and body weight: systematic review and met-analyses of randomised controlled trials and cohort studies. British Medical Journal BMJ 2012:345:e7492 doi: 10.1136/bmj.e7492
WHO/FAO (2003) “Diet, nutrition and the prevention of chronic diseases” Report of a Joint FAO/WHO Expert Consultation. WHO Technical Report Series 916. WHO Geneva, Switzerland.
Young SS and Carr A (2011) Deeming, data and observational studies. A process out of control and needing fixing. Significance. September 2011:116-120.
Competing interests: R C Cottrell is an employee of the World Sugar Reserch Organisation, a non-profit scientific research organisation funded by the sugar industry.
I concur with Malhotra's comment about both added-sugar's toxicity and Food industry's escape strategies. However, I disagree with Malhotra's assertion that the role of physical activity in the obesity epidemic is overemphasized. Beside a lack of physical activity, sedentary behaviors dramatically increase (1) and can explain a great part of the increasing prevalence of obesity and related diseases (2). Even if we can deplore that toxic food producers are allowed to use sporting events as marketing tools, the critical role of sedentary life style in the obesity epidemic will never be overemphasized.
(1)Kohl 3rd HW, Craig CL,Lambert EV,Inoue S, Alkandari JR,Leetongin G, Kahlmeier S. The pandemic of physical inactivity: global action for public health.Lancet 2012;380:294–305
(2)Charansonney O, Despres JP. Disease prevention-should we target obesity or sedentary lifestyle? Nat. Rev. Cardiol. 2010;7:468–472
Competing interests: No competing interests
Re: The dietary advice on added sugar needs emergency surgery
What do we have to do to get Dr Malhotra to understand that he is just downright wrong in his account of our "relationship" with Abbott Nutrition? Two Abbott companies were present at our Diabetes Professional Conference(DPC) to promote their products to healthcare professionals: Abbott Healthcare Products Ltd and Abbott Diabetes Care. They shared an exhibition space which they had paid for. This was a straight commercial transaction, not charity sponsorship, and was not with Abbott Nutrition. So to say our sugar position has been influenced by that transaction is frankly bonkers. But if Dr Malhotra would like to visit the exhibition hall of the Diabetes Professional Conference (it's in Liverpool in March 2014 www.diabetes.org.uk/Diabetes-UK-Professional-Conference) to verify for himself, we'd be happy to give him a free day pass (if he'd feel he could accept it......! He might think we are trying to pervert his views.)
Competing interests: Chief Executive of Diabetes UK