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Monday, November 21, 2016

Sugar: my position

Sugar seems to be everywhere these days, and I don't just mean in the copiously over-sweetened standard American diet (“SAD”). I mean in the news about diet, too.

Partly, this is as it should be, as one of the principal liabilities of a dreadfully junk-laden and hypocrisy-laden diet, literally engineered to subjugate the health of the many to the profit of the few, gets the attention it deserves. Partly, though, it is the result of a well orchestrated, well funded effort by those with ties to the beef industry, and/or interest in sticking butter in your coffee, to divert your attention from the harms to people and planet alike of all those bacon-cheeseburgers, through the time-dishonored expediency of a scapegoat.

In conjunction with all this attention to sugar, there has been a fair amount of attention in media and social media to my positions on sugar, because I say things like I just said about bacon, beef, and butter, and the peddlers of those don't like it. I've got trolls, in other words.

Fortunately for me, though my trolls misrepresent my position on sugar egregiously, the truth is a matter of public record, running through columns I've written, educational programs I've helped develop and test, and algorithms I've engineered. But finding all of that scattered information is a challenge, particularly for those disinterested in the truth. So here it all is in one place, with selective links to some of those vintage materials.

1) Sickly sweet.

I don't know how to put it much more bluntly than I already did above: excess added sugar is one of the principal liabilities of the prevailing American (and, increasingly, “modern global”) diet, noteworthy for its many liabilities. From my perspective, there are three salient harms of excess added sugar in the diet: (1) excess sugar itself is metabolically harmful, via its effects on insulin release and fat deposition; (2) sugar contributes to the excess calories propagating obesity, and without any redeeming nutrient value; and (3) sugar is used expressly to make foods, even foods not overtly sweet, hyperpalatable, and thus contributes disproportionately to overeating in general.

None of these positions is remotely new. They figure prominently in a book I wrote more than 15 years ago, and a nutrition textbook I wrote before that, and have recurred in my writing ever since.

2) Sum of parts.

It's the total dose of added sugar in our diets that matters much more than which kind of sugar it is. The many aliases of sugar in the food supply are confusing, and problematic. We have taught children, and their parents, how to defend themselves against this deception for nearly 15 years in our well-studied, freely available food label literacy program, Nutrition Detectives®.

An interesting anecdote on this matter, courtesy of my work on a nutrient profiling algorithm (the Overall Nutritional Quality Index, or ONQI™; more on that below). Many years ago, a shopper in a supermarket featuring this system, known as NuVal®, expressed concern that several different jars of apricot jam all scored a lowly “1” (lowest nutritional value) on the scale from 1 to 100. Why the concern? All but one of the jars had sugar as the first ingredient, but one of them had apricots as the first ingredient, but that one scored a 1 as well. We were asked to look into it, and did.

What we found was a precautionary tale about food labels almost as dubious as the products they adorn. Ingredients are listed in order of abundance, and in the apricot-first jam, apricot was indeed more abundant than any other single ingredient for one reason only: the product used 4 or 5 different “kinds” of added sugar, and listed them separately. So, while apricot was more abundant than any one of the added sugars, it was less abundant than total added sugar, just like all the other jams that listed sugar first. The shopper was deceived by this, just as the manufacturer intended, but the algorithm was not. It prompted us to take this issue to the FDA and USDA, with the request that labels consistently use “total added sugar” to establish the order of entries in an ingredient list, even if they go on to enumerate the varieties of sugar.

3) What's in a name?

Per the above, I think the many aliases used to indicate added sugar in processed foods are confusing, and thus harmful. There are dozens of alternatives, all of which are really just “added sugar.” I am not sure anyone knows the exact number, as the food industry is ever adept at adding more, but Prevention Magazine came up with 57!

My view, now as ever, is that the right approach is to list “total added sugar” and situate that in the ingredient list wherever that cumulative dose belongs, and then, in parentheses, spell out the kinds of sugar in order of abundance.

Here, too, history adds some interest. Given how vilified high-fructose corn syrup (HFCS) has become (more on that below), I think many have forgotten that one of the advantages of its use in the early days was that even sugar-conscious shoppers didn't reliably recognize it for what it was, and thus tended to overlook it. (The other, salient advantage was that it was a cheaper alternative to sugar derived from cane or beets.) We called it, accordingly, a “wolf in sheep's clothing” in Nutrition Detectives®, and by distributing that program around the world in some 50,000 free DVDs, were in the vanguard of those raising awareness, and opposition, to this pernicious ingredient.

4) Hyperbole about harms, and the harms of hyperbole.

Some have claimed, famously, that sugar is “poison” and fructose is “toxic.” These contentions are, simply, untrue. Sugar includes the lactose in breast milk, and the glucose that floats constantly, and essentially, in our bloodstreams; it is absurd to declare the composition of mother's milk and our own blood intrinsically “poisoned.” Rather, the dose makes the poison.

As for fructose, it occurs naturally in all fruits and many vegetables. If it is “toxic,” by extension, apples and berries are toxin delivery systems.

I have consistently warned those colleagues involved, some of whose efforts on behalf of public health I very much appreciate, that hyperbole about harms would result in three harms of hyperbole. My warnings mostly fell on deaf ears, and only convinced these colleagues that they disliked me. Oh, well. Alas, my warnings about the three harms have all been borne out over time.

(1) Exaggerated focus on fructose invites the “sideways to sucrose” phenomenon.

There are really two issues here. The first is that if “fructose” is vilified, the public in general will not necessarily know that fructose is nearly as abundant in table sugar (sucrose) as it is in HFCS. The food industry is thus invited to put big banner ads on the front of products that say something like, “now without high-FRUCTOSE corn syrup” with the emphasis on fructose, and thus derive a halo effect, under which a host of ills can be concealed. This has certainly happened. We can file this one under: “Tell them what they've won, Johnny!Log Cabin original syrup, now FREE of HFCS, has just plain “corn syrup” as the first ingredient, sugar as the third, and maple … nowhere on the list!

The second is that if fructose is “the” villain, it implies that everything else is exonerated. Again, since the public tends not to know that table sugar is half fructose, it allows for replacing HFCS with sugar, and pretending that's anything other than a lateral move. It is not. But Pepsico, among others, has tried to get credit for just such an exercise in going nowhere.

(2) If fructose is evil, can apples be far behind?

Another of my anxieties about excessively vilifying fructose is that it would invite people to extend the indictment to the premier delivery vehicle for this nutrient, fruit. There is no justification for this, as fruit intake is not only good for health in general, but specifically associated with protection against the very harms of excess sugar intake, notably diabetes. But, sadly, this prediction has also come true. I have received innumerable emails over the years since fructose first became “toxic” asking me if it's OK to eat whole fruits; and this matter has caused such widespread confusion that the New York Times felt obligated to address it. What a sad waste of time we can't spare, though, to need to convince people that whole fruits are … still good for them!

(3) The “sugar did it” proviso.

The third liability of hyperbolizing the harms of sugar, or fructose, is that it lets all of the other bad actors off the hook. Yes, excess sugar is bad, but that does nothing to exonerate trans fat, processed meats, food chemicals, salt, refined starches, or for that matter, butter. But that's exactly the case currently being made, or feigned, by the agents of meat, butter, and cheese. They are exploiting the hyperbole about the toxicity of sugar to imply that sugar is solely responsible for the sorry state of our diet, which is, in a word, baloney. Baloney also contributes to the sorry state of our diets, both when it does (yes, it sometimes does), and when it doesn't contain added sugar.

5) Industrial light and magic: of conflicts, confluence, and contracts.

My lab has run studies funded by industry over the years, which my various detractors have cited to imply I have conflicted interests. I do not; I have no interest in the sales of anything we've studied. Rather, their contentions are conflicted, since most of them want you to buy meat and butter, their book about them, or both. The noise is just so much CGI smoke.

My lab, of course, has had IRB approved contracts for every study we've ever run. That process probes for conflicts of interest, and prohibits them.

But we have set the bar much higher than that. Our contracts have always guaranteed the lab full autonomy and guaranteed our rights to publish, no matter the outcome. The result is that we have published both positive and negative outcomes of industry-funded studies.

Our studies of food have been agnostic with regard to food type, and have rather followed our hypotheses, ranging from the effects of egg intake on diet quality and cardiovascular health, to the effects of soy on vascular status at menopause, to the effects of walnuts on body composition, to the effects of snacking on appetite and weight.

Only once have we focused specifically on sugar, and when we did, we indicted it. We studied the effects of cocoa and dark chocolate on vascular health, finding benefits, as have the many others who have studied this. However, we found that sugar-free cocoa was decisively better than sugar-sweetened cocoa, or stated alternatively, we found that sugar significantly attenuated the vascular benefits conferred by cocoa.

The whole topic of industry-funded research is obviously fraught. I know of some thoughtful colleagues devoting dedicated attention to the matter now, and look forward to the results of their efforts. My view is that there is certainly the risk of conflict in this realm, but also the possibility of confluence, and that we are best served by scrupulous efforts to distinguish between the two.

6) Of trials, and tribulations.

I serve occasionally as an expert legal witness. I hate it. It's tedious, inconvenient, and when it involves deposition and cross-examination by hostile attorneys, extravagantly unpleasant. I do it when I care passionately about the case, or absent that, when two criteria are met: first, that I believe the side seeking to engage me is right; and second, that I am compensated suitably for my pains. Frankly, that sum is set absurdly high, which works as intended to drive away the uncommitted. But some say, “OK,” and I engage accordingly.

The result is lots of attention in social media to two lawsuits pertaining to sugar in which I served as an expert witness.

In one, the yogurt maker, Chobani, was being sued for deceiving the public by using “evaporated cane juice” as the name for added sugar in its products. I've noted my position about the many aliases used for sugar above, and that has never changed. But, frankly, since almost everyone knows what “sugar cane” is, I think “evaporated cane juice” is one of the least deceptive in the mix. More importantly, until or unless the FDA changes the rules, the simple fact is that many names are in use for sugar throughout the food supply. I have examined the issue carefully, and “evaporated cane juice” is used preferentially by many of the most virtuous, corporately responsible food companies out there, and appears on the very select products that make it into my own home.

The bottom line in this case, and this is the position I took all along, was that suing Chobani for being deceptive about sugar was like suing the maker of Prius for carbon emissions and climate change. Yes, it might be true in both cases that they contribute to the prevailing problem, but in both cases, they are well above the standard, not pulling it down. Singling out Chobani was absurd, and almost certainly involved ulterior motives.

The other suit was, in essence, one sugar producer versus another. I said in deposition and in open court that as far as I was concerned it was the case of the “pot versus the kettle,” and that the principal public health problem was too much of both of their products. But the case was about a very specific question: can the human body ‘tell’ the difference between HFCS and sucrose. As a simple matter of fact, the human body can, even if the body politic doesn't have much cause to care. That was my position then, as it is now.

7) Are artificial sweeteners better?

I really don't know, because nobody knows for sure. The literature on this topic is mixed with some studies showing benefit from cutting out sugar and calories through the medium of no-calorie, “artificial” sweeteners. Other studies, however, suggest that the currently prevailing sugar substitutes may do significant damage of their own. Whether or how this pertains to the newer entries such as stevia, or monk fruit extract, is still a work in progress.

What I can say is that I avoid artificial sweeteners personally for three reasons. First, the precautionary principle, which argues that it's safer to assume harms until they are disproven than it is to assume harmlessness until it is confirmed. Second, when sugar is “put in its place“ and one's diet is made up overwhelmingly of unprocessed foods, there is neither need, nor place, for artificial sweeteners. And third, I think there is a better way to reduce sugar intake, which I call “taste bud rehab.” By trading up choices and eliminating stealth sugar first, and more overt sugar after, you can cut your intake of sugar and calories; avoid any actual or potential harms of chemical additives; and rehabilitate/sensitize your palate into the bargain, so you actually come to prefer more wholesome, less copiously sweetened food.

8) Of attitudes and algorithms.

I suppose simply because facts can be inconvenient and innuendo is easier, on-line comments have suggested that the ONQI®, in nearly 2000 supermarkets nationwide under its consumer-facing name, NuVal®, somehow favors sugar. This is mathematically confirmed nonsense. The two most severely penalized nutrient entries in the formula are trans fat, and added sugar. The ONQI (the world's most robustly validated nutrient profiling system, to the best of my knowledge) differentiated between total sugar (which includes the lactose in dairy, and the fructose in whole fruit) and added sugar long before the FDA concluded they should do the same. Both are penalized, as is glycemic load, but added sugar is penalized preferentially. The result is that copiously sugary products, such as sodas, are the lowest scoring items in the entire food supply.

The bottom line is that I have been among the prominent critics of excess sugar in our diets for nearly three decades, and but for minor refinements to keep pace with research findings, my position has never wavered. It is consistent across columns and books, research studies and review articles, programs and algorithms. I hasten to add that I have been in excellent company all along. Despite the long line of claimants that has queued up under the “I discovered the harms of excess sugar last Thursday, so buy my book” sign, the reality is that advice to limit sugar has been not just present, but prominent, in the Dietary Guidelines for Americans since the first, in 1980.

Through clinical trials, and the tribulations of lawsuits, my position on the considerable harms of excess added sugar in our diets is pretty much the same as it ever was.

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:

Albert Fuchs, MD
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.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

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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.

DrDialogue
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.

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

FutureDocs
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.

Glass Hospital
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.

Gut Check
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.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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.

Just Oncology
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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

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David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
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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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

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
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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