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Fructose & Cardiovascular Disease: A not so sweet connection. Cindy Brinn MPH, RD, CDE, BC-ADM PeaceHealth St. Joseph Medical Center Nutrition & Diabetes Clinic CBrinn@PeaceHealth.org. Presented by:.

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  1. Fructose & Cardiovascular Disease:A not so sweet connection Cindy Brinn MPH, RD, CDE, BC-ADM PeaceHealth St. Joseph Medical Center Nutrition & Diabetes Clinic CBrinn@PeaceHealth.org Presented by:

  2. SUGAREmpty calories . . . associated with dental carries. Obesity is really just an excess calorie problem . . source of calories doesn’t really matter.

  3. FDA, ADA, ADA . . . .Sugar is fine in “moderation”

  4. Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association Circulation 2009;120;1011-1020; originally published online Aug 24, 2009;

  5. Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association Women: 100 calories a day of added sugar = 6tsp/day Men: 150 calories a day of added sugar = 9tsp/day Circulation 2009;120;1011-1020; originally published online Aug 24, 2009;

  6. Sugar associated with: • Hypertension • Altered lipids • Inflammation • Obesity Circulation 2009;120;1011-1020; originally published online Aug 24, 2009;

  7. Sucrose, High Fructose Corn Syrup & Cardiovascular Disease • What’s the evidence that sugar and high fructose corn syrup is associated with CVD? • What exactly is high fructose corn syrup and what happens when we eat it? • How much sugar are we really eating? • What should I tell my patients?

  8. Who will win the Sweetener Race? • Artificial Sweeteners • Saccharine • Nutrasweet • Acesulfame K • Splenda

  9. Who will win the Sweetener Race? • Natural Sweeteners • Sucrose • High fructose corn syrup • Agave syrup • Honey & Maple syrup • Sugar alcohols • Stevia

  10. How Much Sugar do we really eat?

  11. Sugar Intake UK & USA kg/person years 1700-2000 80 60 40 20 0 Johnson R. AJCN 2007;86:899-906 1700 1750 1800 1850 1900 1950 2000

  12. Measurement of Sweetener Consumption: Added Sugar Added Sugar Availability –Disappearance data Over estimates Up 19% between 1970-2005 148g/day to 176 g/day = 37t./day to 44t./day Added Sugar intake ((NHANES) self reported consumption) Under estimates Up 25% between 1977-1999 64 g/day to 82 g/day = 16 t./day to 20 t./day 256 calories/day to 328 calories/day

  13. Average added sugar: Increased about 4 tsp/day/past 25 years

  14. Sugar Intake UK & USA kg/person years 1700-2000 80 60 40 20 0 Johnson R. AJCN 2007;86:899-906 1700 1750 1800 1850 1900 1950 2000

  15. Sugar Intake UK & USA kg/person years 1700-2000 80 60 40 20 0 Johnson R. AJCN 2007;86:899-906 Problem: Chronic 50 year exposure to high and increasing intakes of sugar . . . 1700 1750 1800 1850 1900 1950 2000

  16. How Much Sugar is OK to eat? **

  17. WHO/FAO Expert Consultation:Diet, Nutrition and the Prevention of Chronic Diseases “Free sugars” (added sugars) <10% of total caloric intake 1600 calorie diet = 10 tsp sugar World Health Organization

  18. USDA Food Guide or DASH 1600 calorie diet 3 tsp. added sugar per day 2000 calorie diet 8 tsp added sugar per day

  19. Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association “100 calories a day of added sugar = 6tsp/day” Circulation 2009;120;1011-1020; originally published online Aug 24, 2009;

  20. Institute of Medicine (IOM)U.S. Dietary Reference Intakes (DRIs) <25% of energy from added sugar Lack of clear and consistent relationship between total or added sugar intake and obesity Insufficient evidence to recommend upper limit for dietary sugars http://books.nap.edu/openbook.php?isbn=0309085373

  21. 25%/day of calories from added SUGAR 25% calories for 2000 calorie diet = 500 sugar calories = 33tsp sugar = 2/3cup sugar per day

  22. How many people eat more than 25% of calories from added sugars?

  23. >25% of calories from SUGAR Males 13% 4-8 yrs 20% 9-18yrs 15% 19-50yrs Females 13% 4-8yrs 21% 9-13yrs 31% 14-18yrs 21% 19-50yrs National Academy of Sciences, IOM, Dietary Reference Intakes 2002

  24. US Sources of Added Sugar Intake

  25. Are some eating < 10% of calories from added sugars?

  26. <10% of calories from SUGAR 25% 4-8 yrs 21% 9-18yrs 30% 19-50yrs 45% 50+yrs National Academy of Sciences, IOM, Dietary Reference Intakes 2002

  27. >50% of your patients eat more than 10tsp/sugar/day • >70% of your patients <50 years eat more than 10tsp/added sugar/day • Likely most of your patients consume more than 6tsp/added sugar/day

  28. Sugar Chemistry:Sucrose: The “Gold” Standard

  29. Natural Sugar Sources Glucose* Fructose* Galactose* Sucrose** (glucose-fructose) (Table Sugar) Lactose** (glucose-galactose) (Milk Sugar) *Mono-saccharide **Di-saccharide

  30. Sugar Sources Glucose*-- Sucrose (50%), High Fructose Corn Syrup (50%), Maple Syrup & Starches (100%) & Fruits, Juices & Milk (50%) Fructose*-- Sucrose (50%), High-Fructose Corn Syrup (50%), Honey (40%), Maple Syrup, Fruits (5-20%) & Juices Galactose*-- Milk/Dairy

  31. Sugar Sources Absorption/Metabolism Glucose* Fructose* Galactose* Sucrose** (glucose fructose) Lactose** (glucose galactose) Intestinal enzymes

  32. Glucose & Fructose Metabolism Galactose → Liver quickly converts majority to glucose Glucose → Used as an immediate energy source by all cells OR stored as glycogen by all cells OR converted into TG by the liver and stored in cells Fructose → NO cells use fructose as an energy source! Goes immediately to the liver where it is rapidly converted to fatty acids and transported as free fatty acids or triglycerides and ultimately stored

  33. Excellent article on Carbohydrate Chemistry & Metabolism http://www.medbio.info/Horn/PDF%20files/carbohydrate_metabolism_March_2007b.pdf

  34. What’s the problem with added sugars?

  35. USDA Food Guide:Why “Moderate” intake of sugar? Excess Energy & fewer nutrients Adverse health effects of sugar Dental carries Murphy S. AJCN 2003; 78(suppl):827s-33s

  36. American Diabetes Association & FDA “No adverse health effects w/ increased sucrose consumption in individuals with diabetes or with normal glucose.” Based mostly on acute blood glucose effects

  37. American Heart Association • Excess sugar linked to metabolic abnormalities & adverse health conditions • Reduces essential nutrient intake • Limited trial data . . Observational studies indicates soft drinks is associated with excess energy intake, higher body weight & lower intake of essential nutrients.

  38. Chronic Diseases & Sugar Heart Disease  TG, LDL, HDL,  insulin sensitivity No conclusive studies Cancer  lung cancer risk --Case-control study in Uruguay-- risk with  sugar intake Breast—inconsistent  colorectal cancer & polyps Mardes A. Fam Econ Nutr Rev 2001;13(1):87-91 Burly EurJCancerPrev 1997;6:422-34

  39. Limitations of Nutrition Science Research • Nutrition Research isn’t easy to do! • Most study one nutrient at a time—(“deeply flawed”) Marion Nestle New York University Nutritionist

  40. Nutrition Research Challenges • Theory: Sugar causes heart disease • Study: Low Sugar diet • Diet is now higher in foods not containing sugar—what are these foods . . What is their impact on health? • Second variable introduced • Maybe it is not the reduced sugar that is working, but the increased mono fat or non-sugar containing food . . . . . . how do we know??

  41. “Gold Standard” Clinical Investigation • Costly • Many variables to control—smoking, medications, stress, exercise and food

  42. 49,000 women followed for 8 years, 2 groups . . . “dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits and grains did not significantly reduce the risk of CHD, stroke or CVD . . . JAMA Feb. 8, 2006

  43. Women’s Health Initiative Trial • 160,000 women • 45 clinics • $625 million

  44. Low Sugar Diet

  45. Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association “100 calories a day of added sugar = 6tsp/day” Circulation 2009;120;1011-1020; originally published online Aug 24, 2009;

  46. FRUCTOSE

  47. Controversy & Confusion around high fructose corn syrup (HFCS) Unique digestion, absorption & metabolism of fructose Association with elevated lipids & insulin resistance Fructose

  48. Trends in obesity and Fructose Intake Bray G. AJCN 2004;79:537-43 Total Fructose HFCS Free Fructose Obesity Overweight HFCS

  49. June 30, 2008 Seattle-area food cooperative PCC Natural Markets has removed all products containing high-fructose corn syrup from its shelves, and has announced that it will no longer carry any product sweetened with the controversial ingredient.

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