Sugar & Sugar Free Diets

 

By Charlotte Foster BSc (Hons), MSc, RD.

 

Talk on following a “sugar free” diet has become so prevalent that I’m pretty sure that even tribal communities in far flung regions of our planet have had conversations about this latest dietary craze.

 

We feel it is important to examine the evidence around by looking at some key points.

 

What is sugar and can we actually eat a diet which is sugar free?

 

Many of you reading this may be tempted to click away, thinking that this is a simplistic article opening with an obvious question. I plead with you to continue to read on! The problem today is that there is a liberal use of the term sugar which has instilled fear into food lovers.

 

Fact – most foods will contain sugar. The term “sugar-freer” seems to have been used as a marketing tool and attached onto a plethora of food products/ recipes and diets. The problem is, it has left us more confused than ever before about what is in our food and what implication that does or doesn’t have on our health.

 

So let’s unpick the different definitions to discover the sweet truth!

 

The definitions of sugar…

 

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  • Carbohydrates – organic compounds made from molecules of carbon, hydrogen and oxygen. “Carbohydrate” refers to sugars, starches and cellulose (fibre) and contributes as a source of energy in the diet for many animals. They are categorised by their chemical structure into monosaccharides, disaccharides, oligosaccharides and polysaccharides.

 

  • Starch- Many dietary sources of starches (e.g. rice, potatoes and cereal grains) will provide B vitamins, iron, and folate. In the UK, potatoes provide a large dietary source of vitamin C (usually containing ~11-16mg of vitamin C per 100g of potatoes) because we eat so many of them!

 

  • Fibre – structurally they are classified as polysaccharides (3 or more monomers) and are found in plant sources. They are neither digested nor absorbed in the small intestine. There are soluble and insoluble forms of fibre, both of which are needed in the diet for a healthy digestive system (to help with stool formation).

 

  • Naturally present sugars – e.g. found in fruits as fructose or in dairy products (such as milk and yoghurt) as lactose.

 

  • Refined sugars (processed sugars added to foods) – These come from sugar cane or sugar beets, which are processed to extract the sugar. It is typically found as sucrose, which is the combination of glucose and fructose.

 

  • Intrinsic sugars – integrated into the cellular matrix of foods e.g. sugar found in fruit and vegetables

 

  • Extrinsic sugars – sugars that are not integrated into a cellular matrix e.g. lactose in milk.

 

  • Non-milk extrinsic sugars (NMES) –sugars that are not integrated into a cellular matrix and not from a milk/ dairy source e.g. honey, fruit juices, table sugar. This term has now been replaced by “free sugars”.

 

  • Free sugars – alternative name for NMES (see above).

 

 

Where did concerns over the health effects of sugar arise from?

 

As explained in an article featured on the British Nutrition Foundation website (well worth a read) the headlines that made the newspapers were in retaliation to an article ‘The toxic truth about sugar’ published in a commentary by a Professor of Clinical Paediatrics at the University of California  (1). This commentary expressed the author’s opinions on the role they believe sugar has to play in the development of diet-health related disease and was not a robust scientific review or a presentation of novel research (2). However, they do mention a couple of published research papers to support their case, one of which is written by Lustig (introducing possible bias) (2).  Also, there was no critical appraisal (carefully critiquing the results to decipher their impact) of the evidence regarding the relationship between sugar and diet-related disease development. It would seem that these headlines may be portraying a slightly false picture.

 

A report published in 2015 by Scientific Advisory Committee on Nutrition (SACN) looked at randomised controlled trials and found that sugar-sweetened drinks (compared to low calorie drinks) resulted in increases in weight gain and body mass index in children and adolescents. It is being overweight which increases a risk of diet-health related diseases.  SACN’s report emphasised that no association between developing type 2 diabetes and total or individual sugars intake. However, prospective cohort studies associate greater consumption of sugar sweetened drinks with an increased risk of developing type 2 diabetes (3).

 

 

Should we try and reduce our sugar consumption?

 

We are all individual and therefore this is not an easy question to answer.

 

Sugar is a highly dense source of energy (calories) and so can be useful for those trying/needing to gain weight. Dietitians may recommend having high energy containing foods/ fortifying your diet with sugar based foods as strategies for adding extra energy in a concentrated food source. This is often the same with fat sources.

 

However, for many, the sugar content of the diet is something to watch out for. Excess sugar in the diet could mean excess energy (calories) intake. This may lead to weight gain. It is the weight gain (being overweight/obese) that puts us at risk of diet reacted diseases such as type 2 diabetes and heart disease.  People with diagnosis of diabetes may be advised to limit the amount of sugar in the diet or advised to “carbohydrate count” in order to adjust medications and insulin regimens.

 

 

How much sugar should we have according to healthy eating guidelines?

 

Recent guidelines published in July 2015 by SACN advise that the average intake of “free sugars” (previously known as non-milk extrinsic sugars ) should be no more than 5% total energy intake.  This is half of the previous recommendations for 10% total energy intake (3).

 

5% of total energy intake (as calculated by Public Health England) means:

 

  • no more than 19g/day of free sugars for children aged 4-6 year olds (3)

This equates to ~ 5 sugar cubes!

 

  • no more than 24g/day for 7-10 year olds (3)

This equates to ~ 6 sugar cubes!

 

  • no more than 30g/day 11+ year olds (including adults) (3)

This equates to ~ 7 sugar cubes!

 

 

The report highlighted that only 13% (1 in 8) of adults already achieve this 5% recommendation!

 

Make sure you check out DINE’s video reviewing Change 4 Life’s Sugar Smart App – a useful tool to help keep track of your sugar intake.

 

 

How to interpret sugar – label reading…

 

Sugar can be given a variety of names so the skill of label reading becomes important when analysing a food’s nutritional composition.

 

Labels on food packaging will state “Carbohydrates” and “Carbohydrates (of which sugars)”. “Carbohydrates” refer to the starchy carbohydrate content as well as the sugars and so should not be used as a sole interpretation of a food’s sugar content. The “Carbohydrates (of which sugars)” figure refers to the sugar content in the food – including naturally occurring sources found in milk or fruit as well as added sugar.

 

  • High– over 22.5g of total sugars per 100g

 

  • Low – 5g of total sugars or less per 100g

 

Be aware!  Sugar is not only present in “obvious” sweet tasting processed foods e.g. cakes/biscuits/ chocolates or sweets, but can be added sneakily to savoury snacks, salad dressings and pasta sauces etc.

 

Therefore, in order to work out whether a food contains lots of added sugar, you need to check the ingredients list.

 

 

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Hopefully the list above has highlighted something important… just because “table”/ “caster”/ “granulated” SUGAR may not be listed, it doesn’t mean it’s sugar-free!  These are all sources of sugar (some are natural and found in less processed foods).

 

This is often where the confusion arises. Many glamorous recipes for batches of sumptuous “sugar-free” brownies will in fact contain plenty of sugar in the forms of honey/ maple syrup/ agarve syrup/ dates or some other dried fruit!

 

Perhaps these recipes should be renamed “wholefood” or “less processed” rather than “sugar-free”. There is no denying that these recipes contain superior nutritional profiles compared with refined, processed or manufactured versions, but that is often not what is being promoted.

 

Our hope is, that with a better understanding of the term “sugar”, you will be able to see past this marketing ploy and make an informed decision on how regularly this appears in your diet.

 

 

Key take home messages:

 

 

  • Sugar has many definitions – watch out for the context of this term i.e. carbohydrates are different to refined sugars

 

  • Many foods contain high sugar contents; just because it isn’t called “sugar” doesn’t mean it isn’t a source of it.

 

  • We must consider the food’s overall nutrient profile – what other nutritional benefits does it provide?

 

For example orange juice vs a full sugar cola drink.

 

Orange juice though also high in sugar, if “not from concentrate” will contain vitamin C and 150mls will count as one of your 5 a day. Whereas a full sugar cola drink merely contains a sugar hit, caffeine and empty calories.

 

  • Sugar can still form part of a healthy and balanced diet – it is the amount that we have in our diet which we need to consider.

 

 

References

 

 

(1): British Nutrition Foundation (2012) Is sugar really toxic? Available at https://www.nutrition.org.uk/nutritioninthenews/previous-facts-behind-the-headlines/sugar.html [last accessed 24/03/16]

 

(2): Lustig, R.H., Schmidt, L.A., Brindis, C.D. (2012) Public health: The toxic truth about sugar. Nature 482; 27-29.

 

(3): SACN (2015) The Scientific Advisory Committee on Nutrition’s recommendations on sugars. Available at https://www.nutrition.org.uk/attachments/article/872/sugars%20factsheet.pdf [last accessed 24/03/16]

 

 

Useful Links:

For further information make sure you check out some of these links!

 

 

 

 

 

Josephine Townsend (MNutr, RD).

 

 

We look at 5 common myths about Diabetes to help you know the truth about the disease.

 

 

Myth: Diabetes is reversible

 

 

I often see worrying headlines bandied about, such as this classic from a well-known sensationalistic tabloid newspaper “I reversed my diabetes in just 11 days – by going on a starvation diet” ! This statement is concerning for several reasons:

 

 

  • It may give false hope.

 

  • People may decide to put themselves on very restrictive diets without support from their healthcare team. This could result in nutrient deficiencies and further health-related complications, in addition to potential harm if medication is not appropriately adjusted.

 

  • Not everyone will be appropriate or fit for extreme changes to diet, exercise or other. Certain co morbidities and possible risks should be assessed beforehand to establish safety.

 

  • Some people may develop unhealthy eating behaviours, such as eating disorders.

 

  •  The ability to reverse diabetes may be confused between the different types, and we know that certain forms of diabetes cannot be reversed (e.g. type 1 diabetes).

 

However, it’s not all doom and gloom!

 

 

The positive news is that evidence does exist to show that Type 2 diabetes may be at least temporarily ‘reversed’ in some circumstances.. Normalisation of blood glucose levels has been observed in many people following bariatric surgery (1) , and success has also been seen with the use of “Very Low Calorie Diets’”(VLCD) to promote quick and significant weight loss. A VLCD tends to consist of meal replacement drinks, an extra allowance of non-starchy vegetables and plenty of sugar/calorie-free fluids to avoid dehydration.

 

 

However, the success of this diminishes with the duration of diabetes, and possibly with age and greater requirements for treatment too.

 

 

One study demonstrated that in a group of 29 people following an 800 calorie per day diet for 8 weeks and with an average weight loss of around 14 kg, 87% of those with a diagnosis of diabetes for less than 4 years were able to achieve ‘non-diabetic’ fasting blood glucose levels compared to 50% of those who had had diabetes for more than 8 years (2).

 

 

When breaking it down according to those who achieved a ‘non-diabetic’ HbA1c (see section on diabetes), an indication of longer term blood glucose control, 40% of those with diabetes for the shorter period managed this versus 14% of those who had had diabetes for longer. However, it is important to note there were limitations to this study, such as the small number of participants. This study was also controlled, whereas in real-life adherence to VLCD’s can be poor due to possible side effects including hunger, fatigue, dizziness, nausea , headaches, diarrhoea/constipation etc. It’s not the most sociable diet either!

 

 

There is a lack of evidence for the long-term effectiveness of VLCDs, and as we know it is also difficult for many to maintain weight loss once returning to normal eating, it is possible that diabetes will return with any weight regain or if pancreatic function deteriorates with age. It is not a miracle cure!

 

 

VLCD’s can be very helpful for some to aid weight loss and improve diabetes control, if not reverse it, but it is important that these diets are followed with the appropriate support, and are only short-term due to the risk of nutrient deficiencies. The positive effects are therefore only sustainable with the continuation of a healthy lifestyle – balanced diet, avoiding excessive food consumption and maximising physical activity.

 

 

Myth: Eating too much sugar causes diabetes

 

 

Please don’t punish yourself with the idea that you have given yourself diabetes due to eating lots of sugary things, as this simply isn’t the case!

 

 

It’s not the total amount of sugar we eat that causes diabetes (as confirmed by scientific studies).  However, if we do eat lots of sugary things which leads to excess energy (calorie) intake and weight gain, then we are more likely to develop type 2 diabetes (whereas weight is not linked to type 1 diabetes). This is because it’s the excess weight we carry that affects the body’s ability to regulate glucose levels in the blood.

 

 

However, a recent report by the Scientific Advisory Committee on Nutrition (3) did conclude that there is evidence to show an association between greater consumption of sugar-sweetened beverages and the incidence of type 2 diabetes.  So choosing diet sugar-free drinks is preferable.

 

 

Myth: Everyone with diabetes should eat a low carbohydrate diet

 

 

Media attention around this topic can certainly be overwhelming and confusing, but also very appealing when you hear all the promises of disappearing muffin tops or achieving a body not too dissimilar from a Victoria’s Secret model!

 

 

To keep it simple, there is insufficient evidence to suggest that a diet specifically low in the food group known as carbohydrate is beneficial for people with diabetes of any type (or for the general public without diabetes for that matter). It is for this reason that organisations including the British Dietetic Association and Diabetes UK do not actively advocate it.

 

 

Cutting down on carbohydrate intake can certainly aid weight loss in the short-term, which isn’t surprising when you think about how much carbohydrate foods contribute to our typical daily diets and therefore, how many fewer calories we are likely to consume! This would also mean a reduction in the extra butter we add to bread, cream added to pasta or cheese we top a jacket potato with, which again would significantly cut down on energy intake thus promoting weight loss. Of course this isn’t necessarily a bad thing if we are able to reduce our fat intake too.

 

 

But is this sustainable? And what about side effects, including fatigue, bad breath, constipation, headaches, etc? What about all the nutrients we’d be missing out on by removing certain carbohydrates from the diet  such as the fibre, vitamins and minerals found in whole grains, fruit, veg, pulses and some cereals?

 

 

There isn’t any evidence to show greater success from low carbohydrate diets than other dietary approaches in the long-term. Maybe portion sizes of carbohydrates have increased over the years and do need reducing, but this doesn’t need to be to the extent that would be classed as a low-carbohydrate or carbohydrate-free diet!

 

 

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The SACN report highlighted evidence for the benefits of certain carbohydrate (3). This included an association between a greater intake of whole grains and/or dietary fibre and a reduced risk of high blood pressure, stroke and cardiovascular disease, and of course not forgetting the added benefits for bowel health including a reduced risk of bowel cancer. In fact, some research suggests that higher consumption of cereal fibre may actually reduce the incidence of type 2 diabetes mellitus!

 

 

An additional concern regarding a low carbohydrate/no carbohydrate diet would be a tendency to compensate with a greater intake of high fat/protein foods. This is likely to lead to an increase in saturated fat intake, which is linked to higher cholesterol – not good for heart health.

 

 

So whilst it may be beneficial for many to cut down on the quantity of carbohydrate piled on their plates, this does not have to mean a very low carbohydrate or carbohydrate-free diet. General guidelines are:

 

 

  • ~ 50% of our total daily energy intake should come from carbohydrates- including a minimum of 3 servings of whole grains and 5 portions of fruit and vegetables per day.

 

  • Aim to keep “free sugar” (sugar added to food products e.g. fizzy drinks, sweets, cakes, chocolate or the sugar/honey/syrup we add ourselves to drinks and cereal) to less than 5% of energy intake – ~ 7 tsp sugar per day (NB: a can of cola = 9 tsp of sugar!). 

 

However, if you do decide to pursue a low-carbohydrate diet, your healthcare team should work with you to ensure the safest possible outcome.

 

 

Myth: Foods marketed at people for diabetes are better for you

 

 

Anything labelled as diabetic, sugar-free or no added sugar is certainly tempting but it may not be all it’s cracked up to be.  Sugar-free can be better when it comes to versions of certain products, such as fizzy drinks, fruit squash or the odd mint. This is because they often are genuinely sugar-free and calorie-free (but it is always best to check the label to make sure).

 

 

However, if you decide to compare the labels of regular and diabetic marketed versions of chocolate, ice cream or biscuits it’s not unusual to discover that the latter contains the same amount, or if not more fat (and saturated fat) and therefore calories. This is because fat improves the flavour and other sensory qualities when sugar content is reduced (a key reason why we tend to gravitate towards fatty foods and we’ve seen the subsequent expansion of our waistlines over the years). These foods will also still be likely to contain a certain amount of sugar as they won’t have replaced it all, so please don’t assume they are sugar-free.

 

 

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Thinking something is suitable for diabetics may also lead us into a false sense of security so that we think it’s ok to eat more of it, even though it’s still high in fat and calories. We are all human after all!

 

 

If everything so far isn’t enough to put you off then another particularly unpleasant downside is the particular type of sweeteners commonly used in these products to add flavour; polyols (erythritol, xylitol, sorbitol, etc). When consumed in larger amounts these may trigger a laxative effect, which I’m sure for most people is an unwelcome side effect. In fact if you check the back of a packet of sugar-free chewing gum you may see the phrase “excessive consumption may produce laxative effects”, as it often contains the same sweeteners.

 

 

Of course the usual hefty price tag that accompanies these products is another off-putting factor and I rarely come across someone who has said they’ve tried and liked Diabetic products. The most sensible option is therefore to have a small of the good old tasty regular treats, as long as we know how to moderate ourselves and avoid overdoing it.

 

 

Myth: I can’t eat out as the food isn’t suitable for people who have diabetes

 

 

Please be reassured by the fact that there is NO such thing as a special diabetic diet! Life does not need to be miserable by cutting out all yummy foods or being the awkward friend at a party requiring a different menu.

 

 

In theory, the same healthy balanced diet is recommended for everyone, regardless of a diagnosis of diabetes. However, people with diabetes may need to be more careful around portion sizes of carbohydrate foods and/or adapting their treatment regimens according to what they’re eating and which medications they’re taking. And of course, if overweight it’s advisable to reduce energy intake. Despite this you can eat out at restaurants or have a piece of birthday cake on occasion! You can even scan the menu for healthier options or reduce a hefty portion size by taking half your meal home in a doggy bag if you want to be really virtuous. The only things that really ought to be cut out from the diet are sugar-sweetened drinks (e.g. fizzy drinks) and sweets, which cause quick spikes in blood glucose and are of no nutritional value.

 

 

However, there is nothing wrong with the odd treat here and there as long as the phrase ‘in moderation’ is understood and aims are being met, from good blood glucose control to managing weight and optimising cholesterol levels. But maybe a diagnosis of diabetes is a good reason to change up the regular routine when it comes to unhelpful eating habits and preparing meals – try new foods or get experimenting in the kitchen to create healthy but tasty meals for all the family and help prevent diabetes rearing its ugly head in each generation!

 

 

References

(1): Ardestani, A., Rhoads, D. and Tavakkoli, A. (2015) Insulin cessation and diabetes remission after bariatric surgery in adults with insulin-treated type 2 diabetes. Diabetes Care 38(4):659-664.

 

 

(2): Stephen, S. and Taylor, R. (2015) Restoring normoglycaemia by use of a very low calorie diet in long- and short-duration Type 2 diabetes. Diabetic medicine: a journal of the British Diabetic Association 32(9):1149-1155.

 

 

(3): SACN (2015) Carbohydrates and health. Norwich: TSO. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf [ last accessed 21 March 2016].

 

Registered Dietitian, Charlotte Foster  reviews a new app developed by Change4Life which is a fantastic free resource which you can download to track the sugar contents of food items.

 

Download it, give it a go and let us know what you think!

 

Click here for more information on sugar and sugar free diets and an overview of the newly updated healthy eating guidelines.