American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, March 16, 2012

Sugar, on a slippery slope

A commentary published last week in Nature argues for the regulation of sugar as a toxic substance. The authors and I agree about ends--reducing sugar intake--but have some potential differences about means.

sugar, sugar by gringer via Flickr and a Creative Commons licenseThe notion that sugar is a "poison" was established when a lecture by Dr. Robert Lustig espousing that view went viral. Dr. Lustig has made the same case in peer-reviewed articles, and he and his co-authors do so again in last week's commentary.

While the construction of alarming tables and figures demonstrating the calamitous effects of sugar (and specifically, fructose--Dr. Lustig's particular nemesis) can be defended with legitimate science, it is nonetheless something of a distortion. Even more calamitous pathways could be mapped out for oxygen, which in excess is not just highly toxic, but lethal in rather short order. Oxygen, per se, is not poison of course. The dose makes the poison.

So, too, for sugar, including fructose. Our excessive consumption of it is the poison.

There is no question that excess sugar is one of the great liabilities of the modern diet, and consequently, one of the great liabilities of public health. Excess sugar intake is implicated in everything from obesity to diabetes to coronary artery disease. Because excess consumption of sugar induces hormonal imbalances, notably high levels of insulin, which in turn foster inflammation, excess sugar intake is linked to cancer risk as well. Finding effective ways to reduce ambient sugar intake is not only warranted, but rather urgent, as we confront epidemics of obesity, diabetes and associated chronic diseases.

Dr. Lustig and colleagues argue for a modest tax on soda and for restricting sales of "fizzy" drinks and candies during school hours. I support these proposals. There is no reason why schools should be propagating the consumption of solid or liquid candy by students.

As for the tax, arguments that it is an unfair burden are fatuous. People who really want soda can by and large afford the extra penny, and people who can't afford the extra penny should perhaps consider that they can't afford to squander such limited food funds on the empty calories of soda. Certainly if they can't afford an extra penny for soda, they can't afford to get and treat diabetes! If the tax nudged them to drink less soda and more water, it would be as intended. There is no inalienable right to afford soda in the Constitution.

The authors also propose subsidies in federal programs, such as WIC and SNAP, for healthful foods. Here, too, we agree entirely.

But they also suggest an age limit for purchasing soda. They propose regulation or a ban on television commercials for "products with added sugar." As stated, this would encompass virtually all breakfast cereals, many breads, all desserts, many salad dressings, ketchup, jam, pancakes, deli meats and much more. That may be what the authors intend.

Whether it is or isn't, it hints at the challenges in determining just where nutrient-based regulations should begin and end. It also shows why the tempting comparison to tobacco (made by the authors) is of limited utility. Tobacco can be banned outright. Food and most ingredients in food cannot. And even the most healthful diets on the planet generally contain some foods with added sugar. The dose makes the poison.

Regulating nutrients, per se, is a slippery slope. If we regulate sugar, we should certainly regulate trans fat, which is far less important to palatability, and more toxic in smaller quantities.

But what about sodium, which the Center for Science in the Public Interest has argued kills 150,000 Americans a year? The Nature authors argue that fructose should not have GRAS (generally recognized as safe) status from the FDA; the same argument has been made about sodium. Do we regulate both?

And if so, what about the real culprit in much of what most ails modern public health: calories? The root cause of most diabetes and much other chronic disease is obesity, and the most indelible link between weight and food is not composition, but quantity. If sugar is poison because of the harms of excess, so too--and then some!--for calories. Shall we regulate the quantity of food people eat?

Even if we were to isolate sugar as public health enemy number one, its regulation would draw us into challenging subtleties. There is, of course, sugar (and fructose) in fruit, which Dr. Lustig and colleagues clearly do not mean to indict. But what about canned fruit packaged in fruit juice? Where, exactly, would the regulation start, and end? If we did succeed in making sugar in all forms the enemy, what is to prevent the food industry from making far more use of artificial sweeteners, and what do we know about the health effects of that?

I have concerns that the bounds of sugar regulation are not clearly defined -- and would prove challenging, at best. I have greater concerns that excessive focus on any given nutrient, good or bad, invites the proverbial failure to see the forest for the trees. We have cut fat, and eaten poorly. We have cut carbs, and eaten poorly. We could now cut sugar, and still eat poorly. We have decades of dietary debacles to show we are unlikely to get to health one nutrient at a time. It is past time to start thinking about the overall nutritional quality of foods, and diet, which are what truly matter to health outcomes. Sugar is an important component of this, to be sure, but only a component.

Just as a preferential focus on any given nutrient may divert attention from the overall nutritional quality of foods, a preferential focus on the food supply can divert attention from the potential power of the food demand. Ultimately, food manufacturers committed to their bottom lines care about one thing above all: keeping the customer satisfied. If we empower people with readily interpretable information about nutrition, they can act on it.

We do not need randomized trials to prove that the food demand trumps the food supply; we have seen natural experiments prove it. When the Atkins diet was wildly popular, every supermarket in the country filled up with low-carb foods, no regulation required. The challenge is to convert this latent power into a force for genuine good, by directing it at the overall quality of nutrition rather than the next nutrient preoccupation du jour.

Empowering the public to demand better nutrition and less sugar involves finding effective ways of telling people some things they never knew they never knew.

For instance, you likely know that the first item on an ingredient list is the most abundant. So, if you are concerned about your sugar intake and want some apricot jam, which is better: the one with sugar as the first ingredient, or the one with apricot as the first ingredient?

It's a trick question: they may be identical. What manufacturers do sometimes is "divide" the sugar added to a food into multiple aliases: sucrose, corn syrup, and so on. If no one of these is more abundant than apricot, they can list apricot as the first ingredient. But what really matters is that added up, sugar by all these different names is, in fact, the most abundant ingredient, just as it is in the competing jam that lists sugar first. Such practices undermine a consumer's ability to demand better, and that needs to be addressed.

We eat too much sugar; doing so conspires against our health, and needs to change. The ends are clear, the best means are less so. I worry that some good intentions could bog us down in conflict that forestalls all progress, distort the relative importance of just one nutrient relative to overall nutrition, and land us on a slippery slope headed toward unintended consequences. The sweet spot will be defined by what works in the real world to improve the quality of prevailing diets, and health.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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The Blog of Paul Sufka
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Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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