- Study suggests artificial sweeteners may raise the risk of Type 2 diabetes
- Does Sugar Cause Diabetes? Fact vs Fiction
- What About Fruit Juice?
- What About Natural Sweeteners?
- Sugar and Type 2 diabetes
- Basic sciences
- Human experimental trials
- Type 2 diabetes: How do fructose-sweetened drinks affect risk?
- Sugar in Sweetened Drinks, Not Fruit, Raises Diabetes Risk: Study
- The Findings Support That Eating Fruit May Play a Role in Diabetes Prevention
- The Importance of Drinking Fruit Juice Only in Moderation
- What We Don’t Yet Know About the Relationship Between Diabetes and Fructose
- Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African American Women
- Could Artificial Sweeteners Raise Diabetes Risk?
Study suggests artificial sweeteners may raise the risk of Type 2 diabetes
- Consuming artificial sweeteners could increase the risk of developing Type 2 diabetes, according to research from the University of Adelaide. The researchers investigated whether large amounts of no-calorie artificial sweeteners altered the ability of the body to control the levels of glucose in the blood.
- Some of the 27 healthy volunteers for the study were given capsules of sweeteners sucralose and acesulfame K that were the equivalent of 1.5 liters (about six cups) of diet beverage per day. Some volunteers took the capsules before meals three times a day for two weeks, while others were given a placebo.
- After two weeks, tests showed an impaired bodily response to glucose in those given the sweetener. “This study supports the concept that artificial sweeteners could reduce the body’s control of blood sugar levels and highlights the potential for exaggerated post-meal glucose levels in high habitual NAS [non-caloric artificial sweeteners] users, which could predispose them to develop type 2 diabetes,” the researchers said.
Because the study group was relatively small and details of the research results have yet to be published, the conclusions of this Australian study have attracted some skepticism.
Emma Elvin, a clinical advisor at Diabetes UK, told The Guardian that “this is a small study with interesting results, but it doesn't provide strong evidence that artificial sweeteners increase the risk of Type 2 diabetes.” She added that larger testing trials in more real life settings need to take place before more can be concluded.
Victor Zammit, professor of metabolic biochemistry at the University of Warwick, said the available data made it impossible to conclude that the body’s changed response to glucose would necessarily result in diabetes, and that proper clinical trials were needed. “Increased sweetener intake may be associated with other lifestyle elements that may be more direct causes of type 2 diabetes,” he told The Guardian.
Other studies, usually on mice, have suggested that different artificial sweeteners, particularly saccharin, altered gut bacteria which help to digest nutrients. Such changes may limit the body's ability to handle sugar, and if that leads to glucose intolerance, it can be an early warning sign of Type 2 diabetes.
Artificial sweeteners have been losing their appeal in the U.S. marketplace for some time as increasing information comes to light about their less-desirable aspects such as weight gain.
Consumers also have cut back on sugar and high-fructose corn syrup for health reasons.
Meanwhile, natural sweeteners derived from stevia, agave and monk fruit, among other sources, have been emerging to take their place.
By July 2018, manufacturers will have to include “added sugars” on the Nutrition Facts panel, providing additional motivation to cut sweeteners sugar, honey, fructose and fruit juice concentrates.
Solutions Tate & Lyle’s blend of allulose, sucralose and fructose may come into their own, allowing food companies to find a compromise with a smaller amount of added sugars and added sweetness from low- and zero-calorie sweeteners.
If nothing else, the Australian study seems to suggest it might be wise for manufacturers to continue experimenting with natural sugar alternatives and/or cutting down or replacing artificial sweeteners in their products — at least until further studies come to light providing a clearer picture of their connection to the risk of Type 2 diabetes.
Does Sugar Cause Diabetes? Fact vs Fiction
Written by Erica Julson, MS, RDN, CLT on September 18, 2018
Since diabetes is a disease characterized by high blood sugar levels, many people wonder whether eating sugar can cause it.
While it’s true that eating large amounts of added sugar may increase your risk of diabetes, sugar intake is just one piece of the puzzle.
Many other factors — including overall diet, lifestyle and genetics — also impact your risk.
This article reviews sugar’s role in developing diabetes and provides tips for preventing the disease.
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Diabetes occurs when your body is no longer able to effectively regulate blood sugar levels.
This can happen when your pancreas stops producing enough insulin, when your cells become resistant to the insulin that is produced or both (1).
Insulin is the hormone required to move sugar your bloodstream and into your cells — so both scenarios result in chronically elevated blood sugar levels.
High blood sugar levels over a long period can lead to complications an increased risk of heart disease, as well as nerve and kidney damage, so it is important to keep them in check (2).
There are two main types of diabetes, each with different causes:
- Type 1: Occurs when your immune system attacks your pancreas, destroying its ability to produce insulin.
- Type 2: Occurs when your pancreas stops producing enough insulin, when your body’s cells no longer respond to the insulin it produces or both.
Type 1 diabetes is relatively rare, largely genetic, and only accounts for 5–10% of all diabetes cases (3).
Type 2 diabetes — which will be the focus of this article — accounts for more than 90% of diabetes cases and is mainly triggered by diet and lifestyle factors (4).
Summary Type 2 diabetes is the most common form of diabetes. It occurs when your body stops producing enough insulin or when cells become resistant to the insulin produced, leading to chronically elevated blood sugar levels.
When most people talk about sugar, they’re referring to sucrose, or table sugar, which is made from sugar beets or sugarcane.
Sucrose is made up of one molecule of glucose and one molecule of fructose bonded together.
When you eat sucrose, the glucose and fructose molecules are separated by enzymes in your small intestine before being absorbed into your bloodstream (5).
This raises blood sugar levels and signals your pancreas to release insulin. Insulin shuttles glucose the bloodstream and into your cells where it can be metabolized for energy.
While a small amount of fructose can also be taken up by cells and used for energy, the majority is carried to your liver where it is converted to either glucose for energy or fat for storage (6).
If you eat more sugar than your body can use for energy, the excess will be converted into fatty acids and stored as body fat.
Since fructose can be converted to fat, high intakes tend to increase triglyceride levels, which may increase your risk of heart disease and fatty liver (7, 8).
High intake of fructose is also associated with higher uric acid levels in blood. If these uric acid crystals settle in your joints, a painful condition known as gout can develop (9).
Summary Glucose from sugar is mostly used by your body for energy, while fructose is taken to your liver for conversion into glucose or fat. High fructose intake has been linked to elevated triglycerides, fatty liver and gout.
A large number of studies have found that people who regularly drink sugar-sweetened beverages have a roughly 25% greater risk of type 2 diabetes (10).
In fact, drinking just one sugar-sweetened beverage per day increases your risk by 13%, independent of any weight gain it may cause (11).
Additionally, countries where sugar consumption is highest also have the highest rates of type 2 diabetes, while those with the lowest consumption have the lowest rates (12).
The link between sugar intake and diabetes still holds even after controlling for total calorie intake, body weight, alcohol consumption and exercise (13).
While these studies do not prove that sugar causes diabetes, the association is strong.
Many researchers believe that sugar increases diabetes risk both directly and indirectly.
It may directly increase risk because of the impact fructose has on your liver, including promoting fatty liver, inflammation and localized insulin resistance (9, 14, 15).
These effects may trigger abnormal insulin production in your pancreas and increase your risk of type 2 diabetes (14, 16).
Eating large amounts of sugar can also indirectly raise diabetes risk by contributing to weight gain and increased body fat — which are separate risk factors for developing diabetes (17).
What’s more, animal studies suggest that eating a lot of sugar may disrupt the signaling of leptin, a hormone that promotes feelings of fullness, leading to overeating and weight gain (18, 19).
To reduce the negative effects of high sugar consumption, the WHO recommends getting no more than 10% of your daily calories from added sugars that are not naturally found in foods (20).
Summary Added sugars, especially from sugar-sweetened beverages, are strongly linked to the development of type 2 diabetes. This is ly due to sugar’s direct effect on your liver, as well as its indirect effect of increasing body weight.
While eating large amounts of added sugars has been linked to diabetes, the same is not true for natural sugars (21).
Natural sugars are sugars that exist in fruits and vegetables and have not been added during manufacturing or processing.
Since these types of sugar exist in a matrix of fiber, water, antioxidants and other nutrients, they’re digested and absorbed more slowly and less ly to cause blood sugar spikes.
Fruits and vegetables also tend to contain far less sugar by weight than many processed foods, so it is easier to keep your consumption in check.
For example, a peach has approximately 8% sugar by weight, while a Snickers bar contains 50% sugar by weight (22, 23).
While research is mixed, some studies have found that eating at least one serving of fruit per day reduces diabetes risk by 7–13% compared to eating no fruit (24, 25).
What About Fruit Juice?
Research is mixed on whether drinking 100% fruit juice increases diabetes risk.
Several studies have found a link between drinking fruit juice and developing diabetes, perhaps due to juice’s high sugar and low fiber contents (26, 27).
However, not all studies have replicated these results, so more research is needed (28).
What About Natural Sweeteners?
Though some natural sweeteners, honey and maple syrup, are generally not as heavily processed as table sugar or corn syrup, they are still relatively pure sources of sugar and contain almost no fiber.
These products contain large amounts of sucrose and fructose and are considered sources of added sugar when used in cooking.
Many other sweeteners, marketed as being “natural”, should also be considered added sugar. These include agave syrup, coconut sugar and cane sugar, to name a few.
Therefore, they should be consumed in moderation all added sugars, ideally making up less than 10% of your daily calories (29).
Summary While added sugars are strongly linked to the development of diabetes, natural sugars found in whole fruits and vegetables don’t have the same effect.
Artificial sweeteners are man-made, sweet-tasting substances that cannot be metabolized by humans for energy. As such, they provide sweetness without any calories.
Though artificial sweeteners don’t spike blood sugar levels, they have still been linked to the development of insulin resistance and type 2 diabetes (30).
Drinking just one can of diet soda per day has been associated with a 25–67% increased risk of type 2 diabetes, compared to drinking no diet soda at all (11, 30).
It’s unclear why artificial sweeteners increase diabetes risk, but there are a variety of theories.
One thought is that artificially sweetened products increase cravings for sweet-tasting foods, leading to higher sugar consumption and weight gain, which increases diabetes risk (31).
Another idea is that artificial sweeteners disrupt your body’s ability to properly compensate for calories consumed from sugar since your brain associates the sweet taste with zero calories (32).
Some research has found that artificial sweeteners can change the type and number of bacteria that live in your colon, which may contribute to glucose intolerance, weight gain and diabetes (33).
While there does appear to be a link between artificial sweeteners and diabetes, more research is needed to understand exactly how they’re related.
Summary While artificially sweetened foods and beverages contain no sugar and fewer calories than sugar-sweetened alternatives, they’re still linked to the development of diabetes. More research is needed to understand why.
While consuming large amounts of added sugar is linked to an increased risk of diabetes, many other factors are at play, such as:
- Body weight: Research shows that obesity is one of the main risk factors for type 2 diabetes but that losing just 5–10% body weight can reduce the risk (34).
- Exercise: People who live sedentary lifestyles have nearly twice the risk of developing type 2 diabetes compared to those who are active. Just 150 minutes per week of moderate activity can reduce the risk (35, 36).
- Smoking: Smoking 20 or more cigarettes per day more than doubles your risk of diabetes, but quitting brings the risk nearly back to normal (37).
- Sleep apnea: Sleep apnea, a condition in which breathing is obstructed during the night, is a unique risk factor for diabetes (38, 39).
- Genetics: The risk of developing type 2 diabetes is 40% if one of your parents has it and nearly 70% if both parents have it — suggesting a genetic link (40).
Summary While sugar intake can influence diabetes risk, it’s far from the only contributing factor. Other diet, lifestyle and genetic factors also play a role.
In addition to cutting back on added sugars, there are many other dietary changes you can make to reduce your diabetes risk:
- Follow a whole-foods diet: Diets rich in nuts, fruits, vegetables and whole grains have been linked to a reduced risk of diabetes (36, 41, 42).
- Drink coffee: Drinking coffee may reduce your risk of type 2 diabetes. Each daily cup is associated with a 7% lower risk of diabetes (43).
- Eat green leafy vegetables: Eating a diet rich in green leafy vegetables has been linked to a 14% lower risk of diabetes (44).
- Drink alcohol in moderation: Moderate alcohol consumption — defined as about 0.5–3.5 drinks per day — has been linked to a roughly 30% lower risk of diabetes, compared to completely abstaining or drinking heavily (45).
If reducing your intake of added sugars feels overwhelming, you can start by simply reducing your intake of sugar-sweetened beverages, which are the primary source of added sugars in the standard American diet (46).
This one small change could make a big impact.
Carefully reading nutrition labels is another must, since there are over 50 different names for sugar used in food products. Learning to notice them is the first step in reducing your consumption.
Thankfully, there are many ways to cut back on sugar while still enjoying a flavorful and nutrient-dense diet, so you don’t have to feel deprived.
Summary Eating fewer added sugars can reduce your risk of diabetes, as can a diet rich in fruits, vegetables and coffee with moderate alcohol consumption.
Excessive amounts of added sugars have been associated with an increased risk of type 2 diabetes, ly due to negative effects on the liver and a higher risk of obesity.
Natural sugars those found in fruits and vegetables are not linked to diabetes risk — whereas artificial sweeteners are.
In addition to sugar consumption, overall diet quality, body weight, sleep quality, exercise and genetics all play a role in the development of this disease.
Eating a diet rich in fruits, vegetables, nuts and coffee, consuming alcohol in moderation, maintaining a healthy body weight and exercising regularly can help reduce your risk of type 2 diabetes.
Sugar and Type 2 diabetes
Consumption of sugar, specifically sugar-sweetened beverages, has been widely held responsible by the media for the global rise in Type 2 diabetes (T2DM).
Systematic reviews and dietary guidelines relating dietary sugars to T2DM.
Weight gain and T2DM incidence are associated with diet and lifestyle patterns characterized by high consumptions of any sweetened beverages. High sugar intakes impair risk factors for macrovascular complications of T2DM.
Much of the association between sugars and T2DM is eliminated by adjusting data for body mass index (BMI). However, BMI adjustment does not fully account for adiposity (r2=0.65–0.75). Excess sugar can promote weight gain, thus T2DM, through extra calories, but has no unique diabetogenic effect at physiological levels.
Ethical concerns about caffeine added to sweetened beverages, undetectable by consumers, to increase consumption.
Areas timely for developing research
Evidence needed for limiting dietary sugar below 10% energy intake.
diet, soda, body mass index, diabetes, evidence, beliefs
Diabetes was first identified as sweet-tasting urine.
Historically, its treatment paradigms have lurched dramatically from the homeopathic (replace the lost sweetness by consuming more sugar, led by the 19th century French physician Piorry) to the allopathic (avoid sweetness and sugar to deplete the body of sugar, as per Bouchardat, Rollo and Allen).
1 With better characterization of Type 2 diabetes (T2DM), it became appreciated that sweet, sugar-laden urine marks high blood glucose concentration, which is just one of the many complex metabolic derangements. Elevated blood glucose may cause symptoms (thirst, polyuria) but not in every case.
Other clinical manifestations (fatigue, accelerated macrovascular diseases, microvascular complications) are not entirely consequences of the raised blood glucose. Hyperglycaemia is a marker of the disease process, but not the main pathological feature.
T2DM arises as a function of age and of fatness, in individuals predisposed by genetic and epigenetic factors that promote ‘ectopic’ fat storage within the abdomen and in muscle, liver and pancreas.
It is thus part of the metabolic syndrome spectrum, marked by a large waist circumference, and most patients share other metabolic syndrome features including high blood pressure, dyslipidaemia and fatty liver.
The current global T2DM epidemic closely follows the epidemic of overweight and obesity, but it does not require ‘obesity’ qua BMI > 30 kg/m2. It is rare with BMI >22 kg/m2, but prevalence rises rapidly with weight gain to a higher BMI,2 particularly among Asians.
Most people with T2DM have BMI 25–30, not >30, and the metabolic abnormalities can all be reversed, including remission of T2DM, by early substantial weight loss of the order 15 kg (enough to convert BMI 25–22 kg/m2).3 Systematic reviews of interventions to prevent and manage T2DM have found the evidence very consistent that body weight control is the dominant factor.4–6
In principle, dietary sugar could influence T2DM either directly or indirectly through the accompanying food matrix, meal structure or pattern of consumption. Language problems bedevil this field. Biochemically, ‘sugars’ are hexose monosaccharides or disaccharides.
Sweet-tasting sugars occur naturally in foods; the most common are lactose in milk (not discussed further here) and sucrose in fruits and vegetables.
Commercial ‘sugar’ (sucrose, extracted from sugar cane or from beet) is a disaccharide of glucose and fructose, but modern technology has made it possible to convert glucose into the much sweeter fructose.
Sugar in the body and blood is almost exclusively glucose (the fuel for most metabolism and stored as glycogen in liver and muscle). It is mostly derived from hydrolysis of starch in cereals and other foods during digestion, a little from the metabolism of proteins.
Dietary sugar (sucrose) contributes a variable, usually small, proportion of blood glucose, from glucose directly and from fructose after metabolism in the liver. A widespread misunderstanding is that blood glucose is derived directly from the diet, and that sugars are particularly potent at elevating blood glucose.
In fact, while pure glucose does cause a rapid rise in blood glucose (high glycaemic index), other sugars do not. Sucrose and fructose have medium–low glycaemic indices.7
It is not possible to construct a diet containing no sugars, which are natural components of every living cell. Indeed, all life on earth depends on photosynthesis, capturing energy from the sun to build glucose, fructose and sucrose from atmospheric CO2 and water.
Thus, the dietary debate is about amounts and thresholds of consumption.
Recognizing that many natural sugar-containing foods such as fruits, vegetables and milk are beneficial for health and help prevent T2DM, the debate focuses on ‘added sugar’ or ‘free sugars’ (glucose, fructose and sucrose, commonly as refined sugar, corn syrup or honey), added to foods and meals at home or in food manufacturing.
There is an intriguing history that colours the public debates about added sugar. Until the 16th century, sweetness could only be provided by honey (a combination of glucose/fructose in almost equal proportions).
Honey supply, thus sweetness, was largely controlled by aristocracy and the monasteries.
When shipping allowed transatlantic trade, sugar arrived in vast quantities, providing sweetness (and capacity to ferment alcohol) to ordinary people, in rapidly growing seaports with inadequate social cohesion and infrastructure, disrupting control by the old order.
In some settings, sugar provided most of the calories for new urban populations, where normal food supply systems were lacking, so malnutrition emerged, particularly affecting the very young and old people with new patterns of diseases.
any new food, sugar invoked neophobia and still falls under suspicion for a wide range of diseases, even for corrupting morals (Table 1). It is a non-essential nutrient for which there is no specific dietary need but adds palatability and ‘empty’ calories to foods.
Several theoretical rationales have linked it to diabetes (Table 2).
The proposal that dietary sugar might cause or contribute to the disease process behind T2DM would require either that sugar has a specific effect, in causing the weight gain necessary for its onset, or that sugar has some unique weight-independent effect to precipitate T2DM at an earlier stage for a given weight.
Once T2DM has developed, sugar might in principle have some specifically hazardous effect to accelerate its main complication, macrovascular disease. To explore the unknowns, different research designs are necessary, generating different type and quality of evidence.8Table 1
The error of the ways of the Vatican*
|‘There is corruption not just in politics, but in every institution, even in the Vatican. Corruption is something that gets inside of us, it's sugar: it's sweet, we it, and it goes down easily. But then we get sick! We come to a nasty end! When we have too much sugar, we end up with diabetes, and our country ends up being diabetic!’|
|(Pope Francis, quoted by Ojeifo, 2016)|
There are several theoretical rationales for why, in principle, dietary sugar might be of concern with respect to T2DM
|1. Sugar causes, or contributes to causing, T2DM?|
|2. Sugar consumption aggravates glycaemia with T2DM?|
|3. Sugar consumption promotes macrovascular complications of T2DM?|
|4. Sugar consumption promotes microvascular complications of T2DM?|
Laboratory studies can explore hypothetical mechanisms in the aetiology of T2DM, for example, the effect of sugars on insulin synthesis, release or function, and on regulation of the enzymes involved in glucose production, transport and metabolism.
Such studies cannot themselves decide whether sugar is a cause of diabetes but might inform clinical trial designs to establish mechanisms of the disease, once a causal factor has been established.
In vitro laboratory studies of isolated factors seldom truly reflect physiological conditions or complex real-life situations, so may generate misleading results, but they do raise hypotheses.
Early rat studies showed that diets high in sucrose led to rapid weight gain and impaired blood pressure, glycaemia, insulin sensitivity and lipid and uric acid concentrations. These effects subsequently proved primarily due to the fructose component of sucrose and not glucose.
Fructose administration to rats has since been shown to produce a wide range of metabolic abnormalities, including increased oxidative stress, inflammation, intra-abdominal fat accumulation, kidney dysfunction and fatty liver, further exacerbated by combining fructose with a high-fat diet.
High fructose consumption has been proposed as causally linked to diabetes through two pathways.
The first is via obesity-mediated mechanisms whereby fructose increases hepatic triglyceride synthesis and free fatty acid concentrations, increasing peripheral lipid uptake that may impair insulin-mediated glucose uptake in peripheral tissues.
9 The second pathway relates to increased uric acid synthesis as a result of unregulated fructose metabolism. Cell culture and animal studies have shown that uric acid influences endothelial function, and high levels may reduce blood flow and delivery of insulin to peripheral tissues. Several plausible biological mechanisms through which high-sucrose intakes could contribute to T2DM development were reviewed by Johnson et al.10
Human experimental trials
Proven interventions from experimental studies in animal models can be taken forward to see if they apply in humans.
Causal relationships and safety or lack of hazard can only be proved (or disproved) by an experimental study using a randomised controlled design.
Given the inherent uncertainty in any statistically significant effect, more than one such study is necessary to confirm effects.
It would never be ethical to conduct a human experiment to test whether a certain dietary intervention causes diabetes. Alternative designs with interventions aimed at preventing or delaying diabetes are possible. Weight loss, achieved by a variety of measures, has been proved to be very effective in preventing T2DM development in high-risk individuals.
4,11,12 Such studies need to include large numbers over long time periods. Suggestive evidence is however obtainable from shorter term studies with biomarkers of T2DM risk as the outcome measures.
Experimental trials can also be conducted to examine dietary effects on macrovascular risk factors in people with T2DM and on microalbuminuria as an early risk marker for microvascular complications.
Human intervention studies comparing diets with low versus higher content of added sugars demonstrate that sugars increase body weight and body fat, when energy intakes (EIs) are not strictly controlled. Weight gain is typically accompanied by impaired glycaemic control, lipids and blood pressure.
13 However, when EIs are carefully matched, sugar content does not influence body weight, body fat or markers of glycaemic control. Experimental studies of fructose and fructose-containing sweeteners on insulin sensitivity, triglycerides, cholesterol,14 blood pressure15 or hyperuricaemia,16 however, have only shown effects when the sugars have contributed well above normal consumption (i.e.
>100 g fructose per day).17 Replacing dietary starch or glucose with fructose with lower intakes (
Type 2 diabetes: How do fructose-sweetened drinks affect risk?
A new review of existing studies published in The BMJ finds that sugary drinks that contain fructose raise the risk of type 2 diabetes more than other fructose-containing foods.
Share on PinterestNew research finds that ‘nutrient-poor’ sweetened drinks have a harmful effect on metabolic health when they add excess energy.
A range of recent studies has pointed out the potential health risks of sugary drinks. Studies have confirmed that there is a link between sugary drinks and obesity, as well as cautioning that as few as two sugary drinks per week may raise the risk of type 2 diabetes considerably.
Now, a comprehensive review of existing research confirms that fructose-containing drinks can increase the risk of type 2 diabetes more than other foods that contain fructose.
Dr. John Sievenpiper, a researcher in the Clinical Nutrition and Risk Factor Modification Centre of St. Michael’s Hospital in Toronto, Canada, is the lead author of the study.
In their paper, Dr. Sievenpiper and colleagues quote other studies which have focused on fructose in particular as a threat to cardiometabolic health.
Although some research has suggested that fructose might be a good alternative to sugar, especially for people who are already living with diabetes, more recent studies have pointed out that “fructose could be particularly detrimental to metabolic health, and even more so than other sugars.”
As the researchers explain, fructose is a natural ingredient in several foods, such as fruits, natural fruit juice, honey, and even some vegetables. However, some food manufacturers artificially add the compound to soft drinks, desserts, cereals, and other baked foods.
In the new study, Dr. Sievenpiper and team wanted to see how different “food sources of fructose-containing sugars” affected the glycemic control of both people with diabetes and people who do not have the condition.
To find out, the researchers analyzed the conclusions of 155 studies that looked at how different food sources affected peoples’ blood sugar levels. The researchers followed the participants, some of whom had diabetes, for up to 3 months.
During this time, the researchers also assessed the participants’ glycated hemoglobin — that is the amount of sugar that is attached to red blood cells — as well as their glucose and insulin levels after a period of fasting.
Dr. Sievenpiper and team divided the 155 controlled intervention studies into four groups their design.
- Substitution studies compared the energy derived from sugars with that from other carbohydrates.
- Subtraction studies removed sugar-derived energy from the participants’ diet and compared it with a regular diet.
- Addition studies added glucose-derived energy to the diet and compared it with a non-sugar-enhanced diet.
- Ad libitum studies replaced the energy from sugars with other nutrients that the participants were free to consume at will.
The reviewers assessed the bias and the level of certainty of these studies.
Overall, the review found that most of the fructose-containing sugary foods do not harm blood sugar levels when they do not add excess calories. Some of the studies, however, found a harmful effect on fasting insulin levels.
In fact, fruit and fruit juice, which are high in fructose, may even benefit the blood sugar and insulin levels of those with diabetes, when these foods do not add excess calories, the review suggests.
However, some “nutrient-poor” foods that add excessive energy to the diet, such as sweetened drinks and fruit juice, have a harmful metabolic effect.
The researchers hypothesize that the higher content of fiber in fruit, for example, may partly explain this difference, because they slow down the release of glucose. Also, fructose has a lower glycemic index than other carbohydrates.
“These findings might help guide recommendations on important food sources of fructose in the prevention and management of diabetes,” says the study’s lead author.
“But the level of evidence is low,” he cautions, “and more high-quality studies are needed.” Therefore, Dr. Sievenpiper and his colleagues conclude:
“Until more information is available, public health professionals should be aware that harmful effects of fructose sugars on blood glucose seem to be mediated by energy and food source.”
Sugar in Sweetened Drinks, Not Fruit, Raises Diabetes Risk: Study
When it comes to how what you eat affects your diabetes risk, not all sugar sources may be created equal. A review published in November 2018 in the journal BMJ has found that fructose from fruit, fruit juices, and other natural sources are less ly to increase risk factors related to type 2 diabetes compared with fructose found in sugar-sweetened beverages.
Fructose is a type of simple sugar found naturally in fruits and vegetables, But it's also used in high-fructose corn syrup to sweeten beverages such as colas.
“In general, sugars, when they provide excess calories, may lead to adverse outcomes or adverse metabolic effects that can increase the risk for diabetes,” says lead study author, John Sievenpiper, MD, PhD, a staff physician in the division of endocrinology and metabolism at St. Michael's Hospital and an associate professor in the department of nutritional sciences at the University of Toronto in Canada. “We saw this especially with sugar-sweetened beverages. These drinks don’t provide any nutritional value.”
RELATED: Can Eating Too Much Sugar Cause Type 2 Diabetes?
Dr. Sievenpiper says that sweetened drinks increased both glucose and insulin while providing excess calories. “No studies measured HbA1C (a two- to three-month average of a person’s blood sugar level), so we cannot say what the effect was on HbA1C, but we would expect that the adverse effects on glucose and insulin would translate into an adverse effect on HbA1C.”
The Findings Support That Eating Fruit May Play a Role in Diabetes Prevention
He notes that even when fruits provided excess calories, they still did not show any negative effects on glucose or insulin.
“You don’t have to worry about adding more fruit to your diet,” says Sievenpiper. “In fact, fruits showed benefit for blood sugar control.
We have a certain amount of discretionary calories, but our study results show you don’t have to worry about sugar in fruit.”
Osama Hamdy, MD, PhD, medical director of the obesity clinical program and director of the inpatient diabetes program at the Joslin Diabetes Center at Harvard Medical School in Boston, emphasizes that fruit also improves the intestine’s microbiota (the microorganisms that live in the gut).
“When you take fructose from a natural source fruits, you are not just taking fructose is a separate format,” says Dr. Hamdy, who was not involved in the study. “You are taking the fructose as soluble fiber. Soluble fiber in general slows the absorption of fructose but at the same time may have other benefits, such as reducing bad (LDL) cholesterol.”
RELATED: The 8 Best Fruits for People With Type 2 Diabetes
Sievenpiper and his colleagues evaluated data from 155 nutritional studies involving 5,086 individuals, including those with and without diabetes. The investigations measured how blood glucose levels responded from various food sources of fructose. The average follow-up ranged from 1 to 76 weeks.
The American Diabetes Association discourages drinking sugar-sweetened beverages, such as soda, fruit punch, sweet tea, and energy drinks. Sugary drinks raise blood sugar and can add hundreds of empty calories to a diet.
These calories can contribute to weight gain, and being overweight is a risk factor for developing diabetes.
In fact, a review published in the journal Public Health Nutrition estimated that sweetened beverages were responsible for one-fifth of Americans’ weight gain between 1977 and 2007.
The Importance of Drinking Fruit Juice Only in Moderation
While the analysis suggests fruit has a beneficial effect on diabetes risk, Sievenpiper says the results show fruit juice isn’t as innocent.
“Fruit juice showed a protective effect in terms of insulin, but when fruit juice provided excess calories then you saw an adverse effect on glucose,” he says.
That said, he suggested that ½ cup of juice daily may be okay if you’re using it to complement a diet rich in whole fruits and veggies.
Sharon Zarabi, RD, the director of the bariatric program at Lenox Hill Hospital in New York City, echoes Hamdy, saying it all comes to the fiber. “Fructose in fruits is usually bound to fiber, so the fiber content acts to slow down the absorption into the bloodstream; the same effect is not in fruit juice alone.”
RELATED: 10 Fiber-Rich Foods for Your Diabetes Diet
What We Don’t Yet Know About the Relationship Between Diabetes and Fructose
Hamdy says that the nature of the study as a meta-analysis of several other studies may help strengthen the findings but that this model is not a replacement for a well-designed long-term clinical trial. “Each study has different patients and different variables — you cannot adjust for everything in a meta-analysis” he says.
Study authors also reported that the quality of evidence was considered low and “more high-quality randomized controlled trials are needed.”
RELATED: 5 Bad Habits That May Increase Your Risk of Prediabetes
Jan Rystrom, MD, a registered dietitian and diabetes educator at Swedish Medical Center in Seattle, who was not involved in the study, says the topic deserves deeper analysis. She says that the effect of fructose on the eyes warrants attention.
“As a food additive, fructose has a cumulative effect in tissue, particularly in the lens of the eye,” she says.
“There have been many studies done showing this accumulation of fructose in lens tissue contributes to cataracts,” which is a known health complication of diabetes.
For now, opt for whole fruit over fruit juice, and certainly over sources of refined sugar, such as cake, cookies, and candy, to help lower your risk of developing diabetes.
“The bottom line is if people have to choose between natural sources and sweetened beverages, they should always select the natural sources,” Hamdy says.
“They should select the whole fruit over juice, and don’t overconsume.”
Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African American Women
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Could Artificial Sweeteners Raise Diabetes Risk?
From the WebMD Archives
By Robert Preidt
THURSDAY, Sept. 14, 2017 (HealthDay News) — A small Australian study suggests that consuming high amounts of artificial sweeteners might affect how the body responds to sugar — and might raise a person's risk of diabetes.
“This study supports the concept that artificial sweeteners could reduce the body's control of blood sugar levels,” said lead author Richard Young, an associate professor at the University of Adelaide's medical school.
High sweetener intake might lead to “exaggerated” spikes in people's blood sugar levels after a meal, he explained, which over time “could predispose them to developing type 2 diabetes.” He spoke in a news release from the annual meeting of the European Association for the Study of Diabetes in Lisbon, Portugal, where the findings were to be presented on Wednesday.
The study was small — just 27 people — and lasted just two weeks, so more research would be needed.
However, the findings bring up interesting questions, said one U.S. diabetes specialist.
Dr. Roubert Courgi is an endocrinologist at Southside Hospital in Bay Shore, N.Y. Reading over the Australian research, he noted that it “proved glucose [blood sugar] response is hampered” in heavy users of artificial sweeteners.
“This study reaffirms that artificial sweeteners can still affect your body's response to glucose,” he said.
In the study, 27 healthy people were randomly picked to consume capsules containing either artificial sweeteners — either sucralose or acesulfame-K — or a “dummy” placebo.
The capsules were taken three times a day before meals for two weeks. The total dose included in a day's worth of sweetener capsules was equal to drinking a little more than 1.5 quarts of an artificially sweetened diet beverage daily, the researchers noted.
At the end of the two weeks, tests showed that people who had taken the artificial sweeteners had changes in their body's response to sugar, while those who had taken the placebo pills did not.
Young noted that prior research has shown that regular consumption of large amounts of artificial sweeteners is associated with increased risk of type 2 diabetes.
A U.S. nutritionist agreed that while artificial sweeteners may seem a healthy alternative to sugar, these products aren't without their downsides.
“Artificial sugars are lower in calories but can still be an unhealthy addition to the diet,” explained Dana Angelo White, a registered dietitian who teaches at Quinnipiac University in Hamden, Conn.
“Just eating too much sugar, too much fake sugar can also lead to health problems,” she said. “The bigger concern seems to be the long-term, large-quantity consumption, so, just nutrition experts are always saying, moderation is key.”
For his part, Courgi said that sometimes the use of “low-cal” sweeteners simply encourages other unhealthy eating behaviors.
“These artificial sweeteners may offer less sugar than other products, but they are not a free pass to mass consumption,” he said. “Consumers should use discretion with these products because of the risk of diabetes.”
Experts note that findings presented at medical meetings are typically considered preliminary until published in a peer-reviewed journal.
The Calorie Control Council, which represents the makers of artificial sweeteners, did not reply to a HealthDay request for comment.
SOURCES: Robert Courgi, M.D., endocrinologist, Southside Hospital, Bay Shore, N.Y.; Dana Angelo White, MS RD, registered dietitian and clinical assistant professor of athletic training and sports medicine, Quinnipiac University, Hamden, Conn; European Association for the Study of Diabetes, news release, Sept. 13, 2017 Copyright © 2013-2018 HealthDay. All rights reserved.