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PUBLIC HEALTH Sugar and the heart: old ideas revisited
Abstract
Forty years after he first put them forward, John Yudkin’s warnings on sugar are finally being recognised. Geoff Watts reports
“Diets high in added sugar raise heart disease risk”; “One soft drink a day raises heart attack danger”; “Added sugars increase heart disease risk.” Few things are more prey to fad and fashion than alleged dietary influences on health. So the word “sugar” in headlines where, for 30 years, we’ve been accustomed to expect the word “fat” may be little more than a caprice. Alternatively it may indicate a more substantial change. Which is perhaps why Penguin Books is reissuing Pure, White and Deadly , John Yudkin’s valiant, 40 year old attempt to warn us against our lust for sucrose.1
Born in 1910, Yudkin studied physiology and biochemistry at Cambridge University, embarked on a career in microbiology, but then switched to medicine and nutrition. In 1945 he was appointed professor of physiology at Queen Elizabeth College, London, and set about creating a department with an international reputation in nutrition. He died in July 1995.
His book Pure, White and Deadly is about the uses of sugar, who consumes it, in what amounts, and how it’s handled by the body. But most of all it’s about what he saw as sugar’s deleterious effects on health. As he points out, carbohydrates have always been part of our diet and, until 50 years ago, the general view was that the form in which you consumed them was neither here nor there. But the more he thought and read, the more doubtful he became—about this, and also about the role of fat in heart disease.
Back in 1957, commenting that much had been said on the role of diet in coronary thrombosis, he wrote: “In particular, many believe that the disease is related …
... Excessive free-sugar intake is linked to higher risk of dental caries (5), weight gain (5), and increased risk of various chronic diseases (6) such as cardiovascular disease (7,8) and metabolic syndrome (9). According to the WHO guidelines on sugar intake, free-sugar intake should contribute <10% of the total energy intake of the diet mainly based on the prevention of dental caries (4), with very limited evidence related to micronutrient dilution, defined as a concurrent decrease in micronutrient intake when the intake of a negative nutrient such as free sugar increases. ...
... 7 Smoker was defined as individuals who had ever smoked, including current smokers and ex-smokers. 8 Remoteness of areas was determined according to the Accessibility/Remoteness Index of Australia, major cities included Sydney, Canberra, Melbourne, Brisbane, Adelaide, Wollongong, and Perth. Table 2 shows the mean usual intake of micronutrients across the modified cut-offs. ...
Background
The negative health effect of excessive intake of free sugars has been gaining increasing public awareness.
Objective
This secondary analysis aimed to evaluate the impact of free-sugar intake on micronutrient dilution, and estimate a threshold level of free-sugar intake at which a decrease in micronutrient intake becomes evident, based on data from the Australian Health Survey 2011–2012.
Design
Dietary data from adult respondents (weighted n = 6150) who had completed two 24-h recalls were analyzed. A published 10-step methodology was adopted and used to estimate the free-sugar intake of the respondents. Six modified cut-offs for percentage of energy of free sugars (%EFS) were created based on recommendations from the WHO and the Institute of Medicine to examine the association between %EFS on micronutrient intakes. Estimated marginal means and SEs were calculated using ANCOVA. Logistic regression was used to calculate the ORs of not meeting the nutrient reference values for Australia and New Zealand for each micronutrient with an increase in free-sugar intake. Analyses were adjusted for age, sex, socioeconomic status, country of birth, whether dieting, smoking status, and remoteness of living area.
Results
Peak intake for most micronutrients was observed at %EFS between 5% and <15%. A significant reduction in most micronutrient intakes was observed at >25%EFS. At <5%EFS, some micronutrient intakes were reduced. Only small variations in micronutrient consumptions were observed when %EFS was between 5% and 25%. Core food intake decreased and discretionary food increased with an increase in free-sugar intake.
Conclusion
A high free-sugar intake, particularly >25%EFS, was found to have a significant diluting effect on most nutrients. However, a free-sugar intake <5%EFS may increase the risk of undesirably low micronutrient consumption related to inadequate total energy intake. This secondary analysis was registered at anzctr.org.au as ACTRN12617000917336.
... Ma i suoi studi erano stati fatti su confronto tra assunzione di zucchero e tassi di malattia in popolazioni diverse e pertanto le sue analisi avevano poca forza. In passato le preoccupazioni ruotavano intorno all'obesità e alla carie dentale e genericamente alle malattie cardiovascolari (CVD) (15) , comunque l'eccesso di assunzione di zucchero veniva considerato un esempio di cattiva alimentazione. Oggi il consumo eccessivo di zucchero viene considerato un rischio indipendente di CVD e di molte altre malattie croniche, tra cui diabete mellito, cirrosi epatica e demenza, tutte collegate ad alterazioni metaboliche che inducono dislipidemia, ipertensione e insulino-resistenza (16) . ...
Sugars are essential for life because they represent the main source of energy for living beings. From the second post-war period their consumption has had a continuous and progressive increase for many reasons. This trend especially with regard to the increasingly significant use of “free” sugars in beverages can pose a serious health risk, in particular for the development of cardiovascular disease, obesity, liver cirrhosis, dementia and diabetes mellitus both of type 1 and 2. The WHO strongly recommends reducing the intake of free sugars, hoping for a reduction to <5% of daily calorie intake, and health policy interventions can help to achieve this goal by changing its free and uncontrolled use. KEY WORDS sugar; health; diabetes; sugar sweetened beverages; cardiovascular risk.
... The potential negative effects of excessive added sugar intake on health outcomes have been a hot topic of research in recent years. Studies have linked high added sugar consumption to overweight and obesity (2), as well as various chronic diseases such as metabolic syndrome (3) and cardiovascular diseases (4,5). Individuals who consume a high proportion of energy from added sugars were also reported to have poorer diet quality (6)(7)(8)(9)(10)(11)(12). ...
Misreporting of added sugar intake has been the major criticism of studies linking high added sugar consumption to adverse health outcomes. Despite the advancement in dietary assessment methodologies, the bias introduced by self-reporting can never be completely eliminated. The search for an objective biomarker for total added sugar intake has therefore been a topic of interest. In this article, the reasons this search may be a wild goose chase will be outlined and discussed. The limitations and inability of the 2 candidate biomarkers, namely urinary sucrose and fructose and δ¹³C isotope, which are based on the 2 only possible ways (i.e., difference in metabolism and plant sources) to identify added sugar based on current knowledge in human physiology and food and nutritional sciences, are discussed in detail. Validation studies have shown that these 2 candidate biomarkers are unlikely to be suitable for use as a predictive or calibration biomarker for total added sugar intake. Unless advancement in our understanding in human physiology and food and nutritional sciences leads to new potential ways to distinguish between naturally occurring and added sugars, it is extremely unlikely that any accurate objective added sugar biomarker could be found. It may be time to stop the futile effort in searching for such a biomarker, and resources may be better spent on further improving and innovating dietary assessment methods to minimize the bias introduced by self-reporting.
... In the 1970, the American biochemist Ancel Keys, using his seven countries ecological study, argued for a role of saturated fat in heart disease [9], while in 1972 John Yudkin, a British nutritionist, warned in his book, 'Pure, White and Deadly' that dietary sugars were responsible for the rise in heart disease and diabetes [10]. At that time, the fat hypothesis gained general acceptance, and for the next four decades, low-fat dietary advice became part of many national nutritional guidelines with the aim of reducing the risk of chronic diseases like cardiovascular disease [11]. ...
Fructose-containing sugars are a focus of attention as a public health target for their putative role in obesity and cardiometabolic disease including diabetes. The fructose moiety is singled out to be the primary driver for the harms of sugars due to its unique endocrine signal and pathophysiological role. However, this is only supported by ecological studies, animal models of overfeeding and select human intervention studies with supraphysiological doses or lack of control for energy. The highest level of evidence from systematic reviews and meta-analyses of controlled trials has not shown that fructose-containing sugars behave any differently from other forms of digestible carbohydrates. Fructose-containing sugars can only lead to weight gain and other unintended harms on cardiometabolic risk factors insofar as the excess calories they provide. Prospective cohort studies, which provide the strongest observational evidence, have shown an association between fructose-containing sugars and cardiometabolic risk including weight gain, cardiovascular disease outcomes and diabetes only when restricted to sugar-sweetened beverages and not for sugars from other sources. In fact, sugar-sweetened beverages are a marker of an unhealthy lifestyle and their drinkers consume more calories, exercise less, smoke more and have a poor dietary pattern. The potential for overconsumption of sugars in the form of sugary foods and drinks makes targeting sugars, as a source of excess calories, a prudent strategy. However, sugar content should not be the sole determinant of a healthy diet. There are many other factors in the diet—some providing excess calories while others provide beneficial nutrients. Rather than just focusing on one energy source, we should consider the whole diet for health benefits.
Diyet farklı türde şekerler içerir. Bazıları üretim veya pişirme sırasında besinlere eklenmekte, bazıları da meyve, sebzeler, bal ve süt gibi besinlerde doğal olarak bulunmaktadır. Son yıllarda aşırı eklenmiş şeker tüketiminin diş çürükleri, fazla kilo ve obezite, metabolik sendrom ve kardiyovasküler hastalıklar gibi bulaşıcı olmayan kronik hastalıkların sağlık üzerine olası olumsuz etkileri araştırmaların önemli konusudur. Ayrıca enerji alımı eklenmiş şek erden gelen bireylerin diyet kalitelerinin düşük olduğu da rapor edilmiştir. Sağlık profesyonelleri uzun yıllardır eklenmiş şeker alımını sınırlandırmayı önermektedir. Dünya Sağlık Örgütü (WHO) artan bilime dayalı kanıtlar sonucunda 2015 yılında şeker alım rehberini güncellemiş ve eklenmiş şeker artı bal, meyve sularında bulunan doğal şekerler olarak tanımlanan “serbest şeker” üzerine odaklanmıştır. Yeni rehberlerde serbest şekerin diyette toplam enerjinin <%10’u olması, ek sağlık yararları için de toplam enerjinin <%5’e azaltılması önerilmiştir. Avrupa Gıda Güvenliği Otoritesi (EFSA) toplum görüşüne sunduğu ve 2021 yılı sonunda tüm kaynaklardan sağlanan diyet şekeri için bilime dayalı olarak Tolere Edilebilir Üst Alım Miktarı (UL) yayınlayacaktır. Ulusal otoritelerin diyetle eklenmiş/serbest şeker alımını azaltma için sağlıklı besin çevresi oluşturulmasını desteklemesi ve ulusal besin ve beslenme politikalarını oluşturması, uygulaması ve izlemesi gerekmektedir.
This analysis aimed to examine the association between intake of sugars (total or added) and nutrient intake with data from a recent Australian national nutrition survey, the 2007 Australian National Children’s Nutrition and Physical Activity Survey (2007ANCNPAS). Data from participants (
n
4140; 51 % male) who provided 2×plausible 24-h recalls were included in the analysis. The values on added sugars for foods were estimated using a previously published ten-step systematic methodology. Reported intakes of nutrients and foods defined in the 2007ANCNPAS were analysed by age- and sex-specific quintiles of %energy from added sugars (%EAS) or %energy from total sugars (%ETS) using ANCOVA. Linear trends across the quintiles were examined using multiple linear regression. Logistic regression analysis was used to calculate the OR of not meeting a specified nutrient reference values for Australia and New Zealand per unit in %EAS or %ETS. Analyses were adjusted for age, sex, BMI
z
-score and total energy intake. Small but significant negative associations were seen between %EAS and the intakes of most nutrient intakes (all
P
<0·001). For %ETS the associations with nutrient intakes were inconsistent; even then they were smaller than that for %EAS. In general, higher intakes of added sugars were associated with lower intakes of most nutrient-rich, ‘core’ food groups and higher intakes of energy-dense, nutrient-poor ‘extra’ foods. In conclusion, assessing intakes of added sugars may be a better approach for addressing issues of diet quality compared with intakes of total sugars.
We are in the midst of a paradigm shift in research on the health effects of sugar, one fueled by extremely high rates of added sugar overconsumption in the American public. By “added sugar overconsumption,” we refer to a total daily consumption of sugars added to products during manufacturing (ie, not naturally occurring sugars, as in fresh fruit) in excess of dietary limits recommended by expert panels. Past concerns revolved around obesity and dental caries as the main health hazards. Overconsumption of added sugars has long been associated with an increased risk of cardiovascular disease (CVD).1 However, under the old paradigm, it was assumed to be a marker for unhealthy diet or obesity.2 The new paradigm views sugar overconsumption as an independent risk factor in CVD as well as many other chronic diseases, including diabetes mellitus, liver cirrhosis, and dementia—all linked to metabolic perturbations involving dyslipidemia, hypertension, and insulin resistance.3 The new paradigm hypothesizes that sugar has adverse health effects above any purported role as “empty calories” promoting obesity. Too much sugar does not just make us fat; it can also make us sick.
Although “sugar causes heart disease” might become a little more fashionable after Pure, White and Deadly is reissued, the scientific data and constructs will not change. Evidence for the fat hypothesis is massive and has increased since Yudkin’s book went out of print.
I think Watts conveys two wrong impressions about Yudkin’s disappointment that the sugar hypothesis was not confirmed.1 I was …
Accumulating evidence points towards a role for sugar and other refined carbohydrates in the development of overweight
Sugar—most importantly sucrose (table sugar) and high fructose corn syrup—has long been thought to have adverse health effects, such as contributing to dental caries, overweight, diabetes, and heart disease. A linked feature (doi;10.1136/bmj.e7800) comments on the 40th anniversary of the publication of the popular book— Pure, White and Deadly— written by the British physiologist John Yudkin, which claimed that high sugar consumption was associated with heart disease.1 2
The association between sugar and poor health has remained contentious over the past few decades. This is partly because of weaknesses in the data (Yudkin’s conclusions were largely based on comparisons of sugar intake and disease rates among different populations, which is generally considered a weak form of evidence) and because powerful economic interests are invested in the production and sale of sugar based products. The tension between industry and scientists can be illustrated by a 2003 recommendation from the World Health Organization that sugar intake be limited to 10% of energy intake,3 which was heavily attacked by the sugar industry and many governments, but was ultimately sustained. Because WHO plans to update its recommendations, a systematic review of the literature on the association between sugar consumption and body weight was commissioned, the findings of which are presented in …
Dietary carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk. Added sugars (caloric sweeteners used as ingredients in processed or prepared foods) are an increasing and potentially modifiable component in the US diet. No known studies have examined the association between the consumption of added sugars and lipid measures.
To assess the association between consumption of added sugars and blood lipid levels in US adults.
Cross-sectional study among US adults (n = 6113) from the National Health and Nutrition Examination Survey (NHANES) 1999-2006. Respondents were grouped by intake of added sugars using limits specified in dietary recommendations (< 5% [reference group], 5%-<10%, 10%-<17.5%, 17.5%-<25%, and > or = 25% of total calories). Linear regression was used to estimate adjusted mean lipid levels. Logistic regression was used to determine adjusted odds ratios of dyslipidemia. Interactions between added sugars and sex were evaluated.
Adjusted mean high-density lipoprotein cholesterol (HDL-C), geometric mean triglycerides, and mean low-density lipoprotein cholesterol (LDL-C) levels and adjusted odds ratios of dyslipidemia, including low HDL-C levels (< 40 mg/dL for men; < 50 mg/dL for women), high triglyceride levels (> or = 150 mg/dL), high LDL-C levels (> or = 130 mg/dL), or high ratio of triglycerides to HDL-C (> 3.8). Results were weighted to be representative of the US population.
A mean of 15.8% of consumed calories was from added sugars. Among participants consuming less than 5%, 5% to less than 17.5%, 17.5% to less than 25%, and 25% or greater of total energy as added sugars, adjusted mean HDL-C levels were, respectively, 58.7, 57.5, 53.7, 51.0, and 47.7 mg/dL (P < .001 for linear trend), geometric mean triglyceride levels were 105, 102, 111, 113, and 114 mg/dL (P < .001 for linear trend), and LDL-C levels modified by sex were 116, 115, 118, 121, and 123 mg/dL among women (P = .047 for linear trend). There were no significant trends in LDL-C levels among men. Among higher consumers (> or = 10% added sugars) the odds of low HDL-C levels were 50% to more than 300% greater compared with the reference group (< 5% added sugars).
In this study, there was a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.
Obesity has emerged as one of the greatest global health challenges of the 21st century.1 Its increase among children and adolescents is particularly frightening, given the associated metabolic and cardiovascular complications.2,3 Studies from developing countries with populations that are undergoing rapid changes in nutrition are showing increases in the prevalence of childhood obesity.4 The increase in consumption of sugar-sweetened beverages among both adults and children in the United States and other countries is considered a potential contributor to the obesity pandemic.5,6 Sugar intake from sugar-sweetened beverages alone, which are the largest single caloric food source in the United . . .
Sugar-sweetened beverage consumption is associated with weight gain and risk of type 2 diabetes mellitus. Few studies have tested for a relationship with coronary heart disease (CHD) or intermediate biomarkers. The role of artificially sweetened beverages is also unclear.
We performed an analysis of the Health Professionals Follow-Up Study, a prospective cohort study including 42 883 men. Associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (myocardial infarction) were examined with proportional hazard models. There were 3683 CHD cases over 22 years of follow-up. Participants in the top quartile of sugar-sweetened beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (relative risk=1.20; 95% confidence interval, 1.09-1.33; P for trend <0.01) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body mass index, pre-enrollment weight change, and dieting. Artificially sweetened beverage consumption was not significantly associated with CHD (multivariate relative risk=1.02; 95% confidence interval, 0.93-1.12; P for trend=0.28). Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes mellitus slightly attenuated these associations. Intake of sugar-sweetened but not artificially sweetened beverages was significantly associated with increased plasma triglycerides, C-reactive protein, interleukin-6, and tumor necrosis factor receptors 1 and 2 and decreased high-density lipoprotein, lipoprotein(a), and leptin (P<0.02).
Consumption of sugar-sweetened beverages was associated with increased risk of CHD and some adverse changes in lipids, inflammatory factors, and leptin. Artificially sweetened beverage intake was not associated with CHD risk or biomarkers.
High intakes of dietary sugars in the setting of a worldwide pandemic of obesity and cardiovascular disease have heightened concerns about the adverse effects of excessive consumption of sugars. In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day (355 calories per day). Between 1970 and 2005, average annual availability of sugars/added sugars increased by 19%, which added 76 calories to Americans' average daily energy intake. Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans' diets. Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients. Although trial data are limited, evidence from observational studies indicates that a higher intake of soft drinks is associated with greater energy intake, higher body weight, and lower intake of essential nutrients. National survey data also indicate that excessive consumption of added sugars is contributing to overconsumption of discretionary calories by Americans. On the basis of the 2005 US Dietary Guidelines, intake of added sugars greatly exceeds discretionary calorie allowances, regardless of energy needs. In view of these considerations, the American Heart Association recommends reductions in the intake of added sugars. A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars.
The role of diet in the origin of metabolic syndrome (MetSyn) is not well understood; thus, we sought to evaluate the relationship between incident MetSyn and dietary intake using prospective data from 9514 participants (age, 45 to 64 years) enrolled in the Atherosclerosis Risk in Communities (ARIC) study.
Dietary intake was assessed at baseline via a 66-item food frequency questionnaire. We used principal-components analysis to derive "Western" and "prudent" dietary patterns from 32 food groups and evaluated 10 food groups used in previous studies of the ARIC cohort. MetSyn was defined by American Heart Association guidelines. Proportional-hazards regression was used. Over 9 years of follow-up, 3782 incident cases of MetSyn were identified. After adjustment for demographic factors, smoking, physical activity, and energy intake, consumption of a Western dietary pattern (P(trend)=0.03) was adversely associated with incident MetSyn. After further adjustment for intake of meat, dairy, fruits and vegetables, refined grains, and whole grains, analysis of individual food groups revealed that meat (P(trend)<0.001), fried foods (P(trend)=0.02), and diet soda (P(trend)=< 0.001) also were adversely associated with incident MetSyn, whereas dairy consumption (P(trend)=0.006) was beneficial. No associations were observed between incident MetSyn and a prudent dietary pattern or intakes of whole grains, refined grains, fruits and vegetables, nuts, coffee, or sweetened beverages.
These prospective findings suggest that consumption of a Western dietary pattern, meat, and fried foods promotes the incidence of MetSyn, whereas dairy consumption provides some protection. The diet soda association was not hypothesized and deserves further study.
Pure, white and deadly
- J Yudkin
Yudkin J. Pure, white and deadly. Penguin Books, 2012.
Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men/clinical perspective
- De Koning
- L Malik
- V S Kellogg
- M D Rimm
- E B Willett
- W C Hu
De Koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage
consumption, incident coronary heart disease, and biomarkers of risk in men/clinical
perspective. Circulation 2012;125:1735-41.