Clinical Question

1. Clinical Question Morgan Garlock May 16, 2014

2. Sugar is toxic, I haven’t eaten it for 20 years. Why do dietitians let people eat sugar?

3. What the Media Says FED UP

4. Types of Sugar • Added: sugars and syrups that are added to foods or beverages when they are processed or prepared. • Naturally Occurring: sugars such as those in milk and fruits. • Fructose, lactose

5. Added Sugars • Anhydrous dextrose, brown sugar, confectioner's powdered sugar, corn syrup, corn syrup solids, dextrose, fructose, high-fructose corn syrup (HFCS), honey,invert sugar, lactose, malt syrup, maltose, maple syrup, molasses. nectars (e.g., peach nectar, pear nectar), pancake syrup, raw sugar, sucrose, sugar, white granulated sugar

6. What is high fructose corn syrup? • Manufactured from corn syrup (glucose) processed to yield equal glucose and fructose • Lead to liver toxicity some claim • Sucrose: equal parts glucose and fructose • Naturally occurring

7. Do I Need To Eat Sugar? • Brain uses about 120 grams of glucose/day • Energy Production • Glucose converted to Adenosine triphosphate ATP

8. Guidelines USDA • Sugar is included on the Generally Regarded as Safe (GRAS) list • Vitamin A, D, etc are also on this list AHA • Recommends limiting added sugars to half of daily discretionary calorie amount

9. Is Naturally Occurring Sugar Toxic? • Foods with naturally occurring sugar provide: • Vitamins and Minerals • Antioxidants • Fiber • Consume fruit “to help reduce risk of chronic diseases, as part of an overall healthy diet. A diet rich in potassium may help to maintain healthy blood pressure.” choosemyplate.gov

10. Benefits of sugar • Sugar used for wound healing • Mesopotamians washed wounds with water or milk and then dressed them with honey or resin • Latin America, Europe, and Asia still use some of these techniques

11. Research Findings • Cancer • Diabetes • 7% of US adult population has Type II Diabetes • Weight • 30% more people are obese than malnourished

12. Sugar Containing Soda • Risk of lymphoma and leukemia in men and women? • Nurses’ Health Study and Health Professionals Follow-Up Study • 22 years: 1324 non-Hodgkin lymphomas, 285 multiple myelomas, 339 leukemias • Contradictory results based on if separated or combined men and women • Concluded that there could be a detrimental effect, but that chance is the likely explanation

13. Sugar and Cancer • 435,674 aged 50–71 years from the NIH-AARP Diet and Health Study were followed for 7.2 years • 29,099 cancer cases in men • 13,355 cancer cases in women • 124 item FFQ • Sugar in diet and risk of cancer

14. Sugar and Cancer continued • In gender-combined analyses, added sugars were positively associated with risk of esophageal adenocarcinoma (95% CI, HRQ5 vs. Q1: 1.62, 95% CI: 1.07–2.45; P= 0.01) • Added fructose was associated with risk of small intestine cancer (HRQ5 vs. Q1: 2.20, 95% CI: 1.16–4.16; P= 0.009) • All investigated sugars were associated with increased risk of pleural cancer • No association between dietary sugars and risk of colorectal or other major cancer

15. Diabetes • Repeated cross-sectional data on diabetes and nutritional components of food from 175 countries • 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p <0.001) • Tested for biases and controlled for factors

16. Meta-analysis • 11 studies with 310,819 participants and 15,043 cases of type 2 DM • Sugar sweetened beverages • 1-2 servings/day of SSB had 26% greater risk of developing type 2 DM (RR 1.26 [95% CI 1.12-1.41]) compared to those in the lowest quantile (<1 serving/month)

17. The Toxic Truth About Sugar • Sugar consumption is linked to a rise in chronic diseases such as heart disease, cancer, and diabetes. • Sugar’s effects on the body can be similar to those of alcohol

18. Toxic? • Leads to hypertension: Fructose increases uric acid, which raises blood pressure • High triglycerides and insulin resistance through synthesis of fat in the liver • Diabetes from increased liver glucose production and insulin resistance • The aging process—damage to lipids, proteins, and DNA by non-enzymatic binding of fructose to these molecules

19. Other Effects of Sugar • Dampens suppression of ghrelin • Ghrelin signals hunger • Interferes with the normal transport and signaling of leptin • Leptin: satiety hormone • Reduces dopamine • Dopamine: reward hormone

20. Recommendations • Focus on following food group guidelines • Avoid excess of low nutrient-dense foods • Encourage clients to enjoy foods

21. References Basu S, Yoffe P, Lustig RH. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data.Public Library of Science. 2013;8(2):e57873. Berg JM, Tymoczko JL, Stryer L. Biochemistry. 5th ed. New York: Freeman; 2002. Biswas A, Bharara M, Hurst C, Gruessner R, Armstrong D, Rilo H. Use of Sugar on the Healing of Diabetic Ulcers. J Diabetes Sci Technology. 2010; 4 (5): 1139-1145. LustigRH, Schmidt LA.,Brindis CD. The toxictruth about sugar. Nature. 2012; 482(7383):27-29. Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, Hu FB. Sugar Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes. Diabetes Care. 2010:33(11):2477-2483. Tasevska N, Jiao L, Potischman N. Sugars in diet and risk of cancer in the NIH-AARP Diet and Health Study. 2012;130(1):159-169. International journal of cancer. Schernhammer ES, Bertrand KA, Feskanich D. . Consumption of artificial sweetener– and sugar-containing soda and risk of lymphoma and leukemia in men and women. The American Journal of Clinical Nutrition American Society for Nutrition. 2012: 98(6):1419-1428.