Fructose in diabetes: Friend or Foe Kim Chong Hwa MD,PhD Sejong general hospital, Division of Endocrinology & Metabolism
Contents What is Fructose? Why is Fructose of Concern? Effects of Fructose on glycemic control in DM Fructose replacement of glucose or sucrose in food or beverages- glycemia & lipid Summary
What is fructose? Fructose or levulose or fruit sugar is a simple sugar, which belongs to simple carbohydrates. Name origin: from Latin fructus = fruit; -ose denotes sugar. Fructose Functions Fructose is a source of energy; it can provide 3.6 Calories per gram, which is about the same as sucrose. Fructose Sources Main fructose sources include fruits, fruit juices, honey, soft drinks sweetened by high-fructose corn syrup (HFCS), and products sweetened by agave syrup or invert sugar.
Classification of carbohydrate
Metabolic fate of fructose Nutrients 2017, 9(2), 181
Fructose and glucose metabolism in liver cells Nutrition & Metabolism20107:82
What is Fructose? Why is Fructose of Concern? Effects of Fructose on glycemic control in DM Fructose replacement of glucose or sucrose in food or beverages- glycemia & lipid Summary
Adjusted consumption of refined sugar per capita in the U.S. "Food sources of added sweeteners in the diets of Americans". Journals of American Dietetic Association 100: 43 51
Parallel epidemic of diabetes and sugar consumption Am J Clin Nutr 86:899 906, 2007 (27 )
Effect of fructose on various organ systems
Mechanism for high fructose diet induced dyslipidaemia and ectopic lipid accumulation.
Sources of sugars and incident type 2 diabetes Mayo Clin Proc 90(7):984 988.
Effect of isocaloric exchange of fructose for carbohydrate on TGs and total cholesterol (TC) in subjects with type 2 diabetes Diabetes Care 32:1930 1937, 2009
Why is Fructose of Concern? First, in the 1980's, sucrose was replaced to a large extent, particularly in North America, by high fructose corn syrup (HFCS) in carbonated beverages. The intake of soft drinks containing HFCS has risen in parallel with the epidemic of obesity. Second, dietary fructose has been implicated in risk factors for cardiovascular disease (CVD): Plasma triglycerides (TG) and VLDL-TG increased following the ingestion of large quantities of fructose Fructose intake has been found to predict LDL particle size in overweight schoolchildren A positive relationship has been demonstrated between fructose intake and uric acid levels. Third, the use of fructose as a sweetener has increased. The third National Health Examination Survey (NHANES) demonstrated that over 10% of Americans' daily calories were from fructose.
What is Fructose? Why is Fructose of Concern? Effects of Fructose on glycemic control in DM Fructose replacement of glucose or sucrose in food or beverages- glycemia & lipid Summary
Effect of Fructose on Glycemic Control in Diabetes- Glycated blood proteins (HbA1c and glycated albumin) Diabetes Care 35:1611 1620, 2012
Effect of Fructose on Glycemic Control in Diabetes- Fasting glucose Diabetes Care 35:1611 1620, 2012
Effect of Fructose on Glycemic Control in Diabetes- Fasting insulin Diabetes Care 35:1611 1620, 2012
Summary Isocaloric exchange of fructose for carbohydrate reduced glycated blood proteins (SMD 20.25 [95% CI 20.46 to 20.04]; P = 0.02) with significant intertrial heterogeneity (I 2 = 63%; P = 0.001). This reduction is equivalent to a ;0.53% reduction in HbA1c. Fructose consumption did not significantly affect fasting glucose or insulin.
What is Fructose? Why is Fructose of Concern? Effects of Fructose on glycemic control in DM Fructose replacement of glucose or sucrose in food or beverages- glycemia & lipid Summary
Fructose replacement of glucose or sucrose in food or beverages lowers postprandial glucose Am J Clin Nutr 2017;106:506 18.
Peak postprandial blood insulin concentrations after replacement of glucose by fructose in food or beverages by diabetes status Am J Clin Nutr 2017;106:506 18.
Peak postprandial blood TG concentrations after replacement of glucose by fructose in food or beverages by substituted sugar Am J Clin Nutr 2017;106:506 18.
Peak postprandial blood glucose concentrations after replacement of glucose by fructose in food or beverages in healthy weight, normoglycemic populations by sugar presentation Am J Clin Nutr 2017;106:506 18.
Relation between intake of fructose and incident type 2 diabetes CMAJ 2017 May 23;189:E711-20
Summary Substituting fructose for glucose or sucrose in food or beverages lowers peak postprandial blood glucose and insulin concentrations. Isoenergetic replacement does not result in a substantial increase in blood triglyceride concentrations.
Chronic fructose substitution for glucose or sucrose in food or beverages has little effect on fasting blood glucose, insulin, or triglycerides
Fasting blood glucose after the substitution of glucose or sucrose by fructose in food or beverages by substituted sugar or diabetes status Am J Clin Nutr 2017;106:519 29.
Fasting blood insulin after the substitution of glucose or sucrose by fructose in food or beverages by substituted sugar or diabetes status Am J Clin Nutr 2017;106:519 29.
Fasting blood glycated HbA1c, HOMA-IR and body weight after the substitution of glucose or sucrose by fructose in food or beverages by substituted sugar or diabetes status Am J Clin Nutr 2017;106:519 29.
Fasting blood TG after the substitution of glucose or sucrose by fructose in food or beverages by substituted sugar or diabetes status Am J Clin Nutr 2017;106:519 29.
Fasting blood lipids after the substitution of glucose or sucrose by fructose in food or beverages by substituted sugar or diabetes status fasting total cholesterol (A), fasting LDL cholesterol (B), fasting HDL cholesterol (C), fasting VLDL cholesterol (D), and fasting apoplipoprotein B (E). Am J Clin Nutr 2017;106:519 29.
Summary The studies varied in length from 2 to 10 wk (mean: 28 d) and included doses of fructose between 40 and 150 g/d (mean: 68 g/d). Fructose substitution in some subgroups resulted in significantly but only slightly lowered fasting blood glucose (20.14 mmol/l; 95% CI: 20.24, 20.036 mmol/l), HbA1c [210 g/l (95% CI: 212.90, 27.10 g/l; impaired glucose tolerance) and 26 g/l (95% CI: 28.47, 23.53 g/l; normoglycemia)], triglycerides (20.08 mmol/l; 95% CI: 20.14, 20.02 mmol/l), and body weight (21.40 kg; 95% CI: 22.07, 20.74 kg). There was no effect on fasting blood insulin or HOMA-IR or blood lipids
Association between sugar-sweetened beverage intake and incident hypertension Am J Clin Nutr,2015
Substitution trials- Fructose was exchanged for other carbohydrate sources Eur J Nutr (2016) 55 (Suppl 2):S25 S43
Addition trials-the meta-analyses of hypercaloric addition trials Eur J Nutr (2016) 55 (Suppl 2):S25 S43
Fructose-containing sugars and weight change in controlled dietary trials Eur J Nutr (2016) 55 (Suppl 2):S25 S43
Summary Fructose-containing sugars can lead to weight gain, increase in cardiometabolic risk factors and disease only if it provides the excess calories. In fact, the harmful effect of SSBs is likely driven by a collinearity with an unhealthy lifestyle as SSB drinkers consume more calories, exercise less, smoke more and have a poor dietary pattern. Rather than just focusing on one energy source, we should consider the whole diet for health benefits.
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