Carbohydrates, sugars and chronic disease: a global health focus Prof Dr Fred Brouns Faculty of Health Medicine and Life Sciences School of Nutrition and Translational Research in Metabolism Maastricht University, Maastricht, Netherlands
Obesity and Type 2 diabetes: global health threats Will in 2050 one out of three have diabetes?
Although Diabetes and Insulin resistance affects CHO metabolism, they are not a disease of CHO consumption Sievenpiper et al. Can J Diet Prac Res 2002, 63; 20-32 Strong focus on reduction of sugars. But, cutting down only sugars will not solve the problem
Today s health guidelines: strong focus on sugars reduction Recently many dietary guidelines have had their periodical renewal: WHO, SACN, USDA, Netherlands, Nordic countries, etc. In general: reduce the consumption of added sugars (free sugars) to <10% of daily energy intake, favorably to < 5% for reasons of dental health Buyken, Brouns et al. 2018 : Dietary carbohydrates: a review of international recommendations and the methods used to derive them. European Journal of Clinical Nutrition. Open access
Reducing per capita consumption is only part of a good solution The recent nutrition guidelines of WHO to reduce the amount of free/added sugars have lead to the reformulation of sweet products, to contain less added sugars. As an overall result, per capita sugar consumption is in decline over the last decade in several regions. However, overweight and obesity prevalence are still on the rise, indicating that other lifestyle factors do play a significant role.
Carden and Carr Nutrition Journal 2013, 12:130 http://www.nutritionj.com/content/12/1/130
Obesity Is a multi-factorial Life Style Issue! Why are 40% of US pets overweight with similar co-morbidities as humans? Not because of consuming lots of SSB s.
Do sugars drive diabetes development? Healthy subject: Hyper-glycemia insulin secretion normal glucose Overweight subject, reduced insulin insensitivity: Hyper-glycemia insulin hyper-secretion normal glucose Obese subject, insulin resistant: Persistent elevated blood FFA and glucose progression to diabetes.
Insulin signaling pathways regulating Glucose upatke in muscle cells and adipocytes
Insulin signaling and the externalization of GLUT-4 transporters to regulate blood glucose T3L1 adipocytes were transfected with a fusion construct of GLUT4 and enhanced green fluorescent protein.the image is a confocal micrograph of single cells. Saltiel & C. Kahn, NATURE VOL 414 13 DECEMBER 2001
Does the food matrix/type of carbohydrate play a role?? Do naturally present or added sugars differ in digestion, absorption and metabolism What makes a carbohydrate rapidly digestible high blood glucose response/ high glycemic index Do solid or liquid food matrices change carbohydrate digestion do the sugars from an orange differ from those in its juice?
Consuming Fructose-sweetened Beverages Increases Body Adiposity in Mice. Jurgens et al 2005 Ad libitum access to: fructose sucrose artificial sweetener (0% calories, popular diet soft drink) Study effects on adipogenesis and energy metabolism Hella Jurgens et al.obesity RESEARCH Vol. 13 No. 7 July 2005
Hella Jurgens et al.obesity RESEARCH Vol. 13 No. 7 July 2005 Fructose induces weight gain But not when given along with glucose
Jürgens et al conclude that Increasing per capita consumption of dietary fructose from drinks. Fructose is converted to fat! Fructose likely is a causal factor for obesity The author ignores that humans do not consume fructose in isolation and that only little fructose is converted to fat.* Hella Jurgens et al.obesity RESEARCH Vol. 13 No. 7 July 2005 * Buul, Brouns and Tappy, Nutr. Res. Rev., 2013
Our gut cells never see' the food source.. They are exposed to molecules Starch Fruit Honey Sugar Syrup Glucose Fructose metabolism Accordingly, the metabolism of GLUC and FRUC, obtained from the digestion of starch, fruits, table sugar, glucose- fructose syrups (GFS) or fructose-glucose syrups (FGS), is exactly similar. Consumption related effects on health are also similar but can be influenced by matrix: solid slower/more satiating than liquid.
Honey, Sucrose and HFCS 55 produce similar blood glucose/ insulin responses Normal Glucose tolerance Impaired Glucose tolerance Raatz et al J Nutr 2015;145:2265 72.
Fruit Syrups are Concentrated Sugar Sources fruc gluc gluc fruc gluc fruc gluc fruc gluc fruc gluc fruc fruc World of Food Ingredients March 2016 Relative carbohydrate compositions of several types of syrups and sucrose. Water content is substracted from the total mass and this value is set as 100%.
Often suggested.. Composition, digestion, absorption and metabolism of sugars in fruits differs from sugars in juice Fact: the molecular composition of sugars in fruit and juice is 100% equal thus also digestion, absorption and metabolism gut Sucrose Glucose Fructose blood Glucose Fructose
The blood glucose response of orange and orange juice is virtually similar-1 Blood Glucose (mmol/l) 9 Glucose Group 1 Glucose Group 2 8 Orange Juice Group 1 7 Oranges Group 2 6 5 4 3 0 30 60 90 120 Minutes Jenkins et al. Am J Clin Nutr 1981;34:362.
Obesity Genes Inactivity Insulin Sensitivity High glycemic load Low Fiber CHO food Counterregulatory hormones (years) Insulin demand Postprandial glucose Late postprandial free fatty acids -cell exhaustion reduced insulin prod. Insulin resistance Inflammation Diabetes Elevated cholesterol Metabolic syndrome
Only SSBs, not total sugars, are associated with diabetes: Results from 5 systematic reviews and meta-analyses of 13 cohorts Source Cohort comparisons Participants Cases Median Follow-up Risk ratios (95% CI) I 2 Foods SSBs 1 9 310,819 15,043 10y 1.26 (1.12, 1.41) 66%* SSBs (fruit drinks) 2 4 191,686 12,375 19y 1.28 (1.04, 1.59) 43% 100% Fruit juice 2 4 137,663 4,906 10y 1.03 (0.91, 1.18) 6% Yogurt 3 8 187,170 15,893 10y 0.86 (0.75,0.98) 59%* Sherbet 3 2 78,437 2,846 11y 0.90 (0.79,1.03) 0% Ice Cream 3 2 78,437 2,846 11y 0.83 (0.73,0.95) 0% Cakes, cookies 4 8 16,154 778 16y 0.96 (0.86, 1.07) 35% Cereal (whole grain) 5 3 128,314 4,202 10y 0.72 (0.55,0.93) 78% Fruits 6 11 424,677 22,995 11y 0.93 (0.88,0.99) 0% Sugars Total sugars 7 13 109,651 13,906 12y 0.90 0.73, 1.12) 90%* Total sucrose 7 7 175,360 3,829 6y 1.0 (0.90, 1.1) 50%* Total fructose 7 7 129,480 3,613 9y 1.0 (0.90, 1.1) 50%* 0 0.5 1 1.5 2 1 Malik VS et al. Diabetes Care. 2010;33:2477-83 2 Xi et al. PLoS One. 2014;9:e93471 3 Aune et al. Am J Clin Nutr. 2013 Oct;98(4):1066-83. 4 Buijsse et al. Eur J Clin Nutr. 2015 Apr;69(4):455-61. 5 Aune et al. Eur J Epidemiol. 2013 Nov;28(11):845-58. 6 Li et al. BMJ Open. 2014;4:e005497 7 Tsilas, et al., unpulished Benefit Harm Sievenpiper et al. Mayo Clin Proc. 2015 Jul;90(7):984-8
Low carbohydrate diets are unsafe and should be avoided Banach et al Eur Soc Cardiol, Munich 2018, August 26 Banach et al Low carbohydrate diets might be useful in the short term to lose weight, lower blood pressure, and improve blood glucose control, but our study suggests that in the long-term they are linked with an increased risk of death from any cause, and deaths due to cardiovascular disease, cerebrovascular disease, and cancer. https://www.escardio.org/the-esc/press-office/press-releases/low-carbohydrate-diets-are-unsafe-and-should-be-avoided
Low and very high carb increase mortality depending on diet quality. Low carb = high fat more risk: No risk More risk: refined, low fiber-high GI foods Less risk- plant based foods Seidelman et al. Lancet Public Health 2018; 3: e419 28
Seidelman et al. Lancet Public Health 2018; 3: e419 28 Food source modifies association between carbohydrate intake and mortality. Both low and a high energy % of carbohydrate in the diet are associated with increased mortality. Minimal risk are seen with 50-55% carbohydrate Low CARB living with preference for animal proteins and fats lead to increased mortality Preference for plant proteins and lipids from legumes, vegetables, nuts, peanut butter and whole grain are associated with lower risks
25 > The known and the Unexpected! 1. Diabetes is not caused by carbohydrate or sugars but is associated with disturbed carbohydrate metabolism 2. SSB consumption in very high amounts, super-exposed on the daily diet, elevates energy intake, overweight, abdominal and liver fat, uric acid and diabetes risks. 3. SSB consumers have many other signs of unhealthy lifestyle overweight, diabetes, CVD. 4. Consuming a plants based high CARB diet with abundant fiber strongly reduces risks of chronic disease
26 > The known and The Unexpected! 1. Sugar types do not differ in impact on weight gain and obesity. 2. Consumption of confectionary is not associated with overweight but does impact on dental health. 3. Sugar consumption is falling since a decade. Yet, obesity and diabetes are further on the rise call for total make-over lifestyle! 4. HIS sweetened drinks behave physiologically and metabolically as water. 5. Exchange of sugars for high intensity sweeteners (HIS) in beverages reduces risks of chronic disease and of dental caries.
Any Questions? Ask me! fred.brouns@maastrichtuniversity.nl https://www.linkedin.com/today/author/fredbrouns.