Credit Andrew Scrivani for The New York Times
Obese children who cut sugar from their diets saw improvements in markers of heart disease after just nine days, a study in Atherosclerosis found.
For the study, researchers evaluated 37 children ages 9 to 18 who were obese and at high risk for heart disease and Type 2 diabetes. The children were given food and drinks totaling the same number of calories, fat, protein and carbohydrates as their typical diets.
The only change was their sugar intake: The researchers swapped foods high in added sugars, like pastries and sweetened yogurts, for options like bagels and pizza. This lowered dietary sugar from 28 percent to 10 percent, and fructose from 12 percent to 4 percent of total calories.
After nine days, the researchers found a 33 percent drop in triglycerides, a type of fat tied to heart disease; a 49 percent reduction in a protein called apoC-III that is tied to high triglyceride levels; and dramatic reductions in small, dense LDL cholesterol, a risk factor for heart disease.
Though this study is small and short-term, it builds on this group’s previous research implicating added sugars as a contributor to metabolic disorders and heart disease.
“Sugar calories are not like other carbohydrate calories,” said Dr. Robert Lustig, a co-author of the study and professor of pediatrics at Benioff Children’s Hospital at the University of California, San Francisco. “Without changing total carbohydrate, or fat, or protein, we were able to accomplish this enormous improvement in their cardiovascular risk factors,” unrelated to weight loss, he said.
The federal government’s decision to update food labels last month marked a sea change for consumers: For the first time, beginning in 2018, nutrition labels will be required to list a breakdown of both the total sugars and the added sugars in packaged foods. But is sugar really that bad for you? And is the sugar added to foods really more harmful than the sugars found naturally in foods?
We spoke with some top scientists who study sugar and its effects on metabolic health to help answer some common questions about sugar. Here’s what they had to say.
Why are food labels being revised?
The shift came after years of urging by many nutrition experts, who say that excess sugar is a primary cause of obesity and heart disease, the leading killer of Americans. Many in the food industry opposed the emphasis on added sugars, arguing that the focus should be on calories rather than sugar. They say that highlighting added sugar on labels is unscientific, and that the sugar that occurs naturally in foods like fruits and vegetables is essentially no different than the sugar commonly added to packaged foods. But scientists say it is not that simple.
So, is added sugar different from the naturally occurring sugar in food?
It depends. Most sugars are essentially combinations of two molecules, glucose and fructose, in different ratios. The sugar in a fresh apple, for instance, is generally the same as the table sugar that might be added to homemade apple pie. Both are known technically as sucrose, and they are broken down in the intestine into glucose and fructose. Glucose can be metabolized by any cell in the body. But fructose is handled almost exclusively by the liver.
“Once you get to that point, the liver doesn’t know whether it came from fruit or not,” said Kimber Stanhope, a researcher at the University of California, Davis, who studies the effects of sugar on health.
The type of sugar that is often added to processed foods is high-fructose corn syrup, which is the food industry’s favored sweetener for everything from soft drinks to breads, sauces, snacks and salad dressings. Made commercially from cornstarch, high-fructose corn syrup is generally much cheaper than regular sugar. It contains the same components as table sugar – glucose and fructose – but in slightly different proportions.
What about “natural” sweeteners?
Food companies like to market agave nectar, beet sugar, evaporated cane juice and many other “natural” sweeteners as healthier alternatives to high-fructose corn syrup. But whatever their source, they are all very similar. To suggest one is healthier than another is a stretch, experts say. In fact, last month, the F.D.A. urged food companies to stop using the term evaporated cane juice because it is “false or misleading” and “does not reveal that the ingredient’s basic nature and characterizing properties are those of a sugar.”
Is high-fructose corn syrup worse than regular sugar? How is it different?
High-fructose corn syrup and regular sugar are so similar that most experts say their effects on the body are essentially the same.
The main difference is that the variety of high-fructose corn syrup used in soft drinks tends to have more fructose. In one 2014 study, researchers analyzed more than a dozen popular soft drinks and found that many sweetened with high-fructose corn syrup – including Pepsi, Sprite, Mountain Dew, Coca-Cola and Arizona Iced Tea – contained roughly 40 percent glucose and 60 percent fructose. Regular sugar contains equal parts glucose and fructose.
Why doesn’t the F.D.A. require that added sugars be listed in teaspoons rather than grams?
When the new food labels go into effect, the daily recommended limit for added sugars will be 50 grams, or roughly 12 teaspoons, daily. (One teaspoon of sugar is 4.2 grams.) But the new food labels will list the amount of added sugars solely in grams.
Many nutrition advocates have urged the F.D.A. to require that food labels list added sugars in both teaspoons and grams on food labels, arguing that Americans often underestimate the actual amount of sugar in a product when it’s expressed in grams alone.
But the F.D.A. ultimately sided with the food industry, which opposed the teaspoon proposal.
“It would be difficult, if not impossible, for a manufacturer to determine the volume contribution that each ingredient provides toward the added sugars declaration,” the agency said. “For example, a cookie made with white chocolate chips and dried fruit would have added sugars in the form of sugar in the batter as well as in the white chocolate chips and the dried fruit.” The F.D.A. also said that requiring both grams and teaspoons would “cause clutter and make the labels more difficult to read.”
But Michael Jacobson, the president of the Center for Science in the Public Interest, an advocacy group that had petitioned the F.D.A. to require the teaspoon measurement, said the agency was under enormous pressure from the food industry, “which knows that consumers would be far more concerned about a product labeled 10 teaspoons than 42 grams.”
So what’s the issue with added sugars?
It mainly comes down to the way they’re packaged.
Naturally occurring sugar is almost always found in foods that contain fiber, which slows the rate at which the sugar is digested and absorbed. (One exception to that rule is honey, which has no fiber.) Fiber also limits the amount of sugar you can consume in one sitting.
A medium apple contains about 19 grams of sugar and four grams of fiber, or roughly 20 percent of a day’s worth of fiber. Not many people would eat three apples at one time. But plenty of children and adults can drink a 16-ounce bottle of Pepsi, which has 55 grams of added sugar – roughly the amount in three medium apples – and no fiber. Fiber not only limits how much you can eat, but how quickly sugar leaves the intestine and reaches the liver, Dr. Stanhope said.
“You can’t easily eat that much sugar from fruit,” she said. “But nobody has any problem consuming a very high level of sugar from a beverage or from brownies and cookies.”
Why is it a problem to have too much sugar?
Many nutrition experts say that sugar in moderation is fine for most people. But in excess it can lead to metabolic problems beyond its effects on weight gain. The reason, studies suggest, is fructose. Any fructose you eat is sent straight to your liver, which specializes in turning it into droplets of fat called triglycerides.
“When you ingest fructose, almost all of it is metabolized by the liver, and the liver is very good at taking that fructose and converting it to fat,” said Dr. Mark Herman, an assistant professor of medicine at Harvard. Studies show a predictable response when people are asked to drink a sugary beverage: A rapid spike in the amount of triglycerides circulating in their bloodstreams. This also leads to a reduction in HDL cholesterol, the so-called good kind.
Over time, this combination – higher triglycerides and lower HDL – is one major reason sugar promotes heart disease, said Dr. Aseem Malhotra, a cardiologist and adviser to the United Kingdom’s national obesity forum. This sequence of events may even overshadow the effects of LDL cholesterol, the so-called bad kind.
“What many people don’t realize is that it’s triglycerides and HDL that are more predictive of cardiovascular disease than LDL cholesterol,” Dr. Malhotra said. “I’m not saying LDL isn’t important. But if there is a hierarchy, triglycerides and HDL are more important than LDL.”
Dr. Malhotra said that when people reduce their sugar intake, “their overall cholesterol profile improves.”
“I see this in so many of my patients,” he added. “The effects are rapid.”
How much sugar is too much?
One of the largest studies of added sugar consumption, which was led by the Centers for Disease Control and Prevention, found that adults who got more than 15 percent of their daily calories from added sugar had a higher risk of cardiovascular disease. For the average adult, that translates to about 300 calories, or 18 teaspoons of added sugar, daily. That may not sound like a lot. But considering that a single 12-ounce can of Coca-Cola has almost 10 teaspoons of sugar, it can add up quickly
The study found that most adults got more than 10 percent of their daily calories from added sugar, and that for 10 percent of people, more than 25 percent of their calories came from added sugar. The biggest sources for adults were soft drinks, fruit juices, desserts and candy.
While those might seem like obvious junk foods, Dr. Malhotra said, about half of the sugar Americans consume is “hidden” in less obvious places like salad dressings, bread, low-fat yogurt and ketchup. In fact, of the 600,000 food items for sale in America, about 80 percent contain added sugar.
Everyone’s tolerance for sugar is different. Studies show, for example, that people who are already obese may be more susceptible to metabolic harm from sugar than others. But Dr. Malhotra said that he generally advises people to follow the World Health Organization’s guidelines, which recommend that adults and children consume no more than about six teaspoons daily of added sugar.
“Could I tell you the exact limit where sugar starts to definitely impact cardiovascular health?” he said. “That’s difficult. But I think if people stick within the W.H.O. limits, then their risk is reduced.”
Credit Dan Deitch
A century ago, most local health departments concentrated their efforts on fighting infectious diseases like cholera, polio and tuberculosis. But today, many health departments have a very different focus: cancer, heart disease and Type 2 diabetes, some of America’s leading killers. Fighting these diseases often means promoting changes in lifestyle and behavior, and no health department has done that more aggressively than New York City’s.
Under former Mayor Michael R. Bloomberg, New York’s health commissioners — first Dr. Thomas R. Frieden, and then Dr. Thomas A. Farley — took on smoking, sugary drinks, sodium, trans fats and binge drinking. Those battles weren’t always successful. A state court struck down the city’s controversial soda tax initiative, and critics complained that New York City was becoming a “nanny” state.
But Dr. Farley, who served as New York’s health commissioner from 2009 to 2014, says the city’s efforts helped demonstrate that the key to eradicating lifestyle-related diseases is by changing environments — making bad choices harder and good ones easier. He makes a case for this approach in his latest book, “Saving Gotham: Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives,” which shares the behind-the-scenes story of the Bloomberg administration’s radical approach to fighting chronic disease.
Dr. Farley, who later served as the Joan H. Tisch Distinguished Fellow in Public Health at Hunter College and chief executive of the Public Good Projects, is now the health commissioner of Philadelphia, where earlier this month the mayor proposed a soda tax as a way to fund schools, libraries, and parks and recreation centers. Recently we caught up with Dr. Farley to talk about his book, his battles with the beverage industry and how his approach to public health may have influenced other health departments around the world. Here are edited excerpts from our conversation.
Why did you write your latest book, “Saving Gotham”?
I wanted to show that there’s a way to fight disease other than through expensive medical care. In the United States, we spend roughly twice as much per capita for medical care as other high-income countries, and our health statistics are close to last. People naturally assume we’re going to solve this problem through medical care. But it doesn’t fit with those statistics. There’s a different approach — a public health approach — that costs very little. The book tells the story of how with using that public health approach we were able to prevent the leading causes of death and save many lives.
As New York City’s health commissioner you led many public health campaigns. Which had the most impact?
I would say it was our efforts to reduce smoking. During the time of the Bloomberg administration, smoking rates fell by about 25 percent in New York. Since then they’ve fallen by about a third. That’s about 400,000 fewer smokers. And that alone should save thousands if not tens of thousands of lives. At the same time, sugary drink consumption fell by about a third, and heart disease mortality fell by about 40 percent.
Did these efforts ultimately translate into an increase in life expectancy?
Absolutely. During the Bloomberg years, life expectancy at birth in New York City increased by about 3.2 years. During the same period, life expectancy in the U.S. as a whole increased by 1.8 years. So we were fast outpacing the rest of the country, and that increase in life expectancy was bigger than it was in any other big city in America.
Some of your health initiatives created a lot of controversy. Where did you find the most resistance?
There was controversy, but most of the resistance came from industry. In the book, I show how some of the biggest risks today are coming from companies that make, sell and market products that over a lifetime make us sick, like cigarettes and sugary drinks.
When New York City passed the smoke-free air rule that made bars and restaurants smoke free, it was a radical idea. And that idea has now spread across most of the U.S. and almost all of Europe — so much so that it’s almost hard to imagine what it would be like to have smoking in a bar or restaurant. The book shows how those good ideas can quickly spread from one city to others, despite resistance from industry.
The beverage industry says that sugary drink taxes disproportionately hurt the poor economically. How do you respond?
I would say that the poor are disproportionately suffering from obesity and Type 2 diabetes as a consequence of sugary drinks. They drink more sugary drinks now than people who have more money. Because people with lower incomes are more price-sensitive, they will disproportionately benefit from efforts to reduce sugary drink consumption.
The new soda tax proposal in Philadelphia was presented as a way to generate more revenue for the city, rather than as a “sin tax.” Do you think that will make it more appealing to the public?
This is something that is central to the mayor’s agenda, and I think his way of approaching it is terrific. The revenue from the sugary drink tax will go for pre-K, for what they call community schools — which is providing services for children so they can stay in school and learn — and for rebuilding the city’s parks and recreation centers. All of those preferentially benefit people of lower income in Philadelphia. All of those are very popular and will benefit health over the long term. It’s a great way to match up the benefits of the tax revenue with a source of revenue that is also good for health.
You have spent a lot of time fighting the beverage industry. Have you seen any change in their response over the years?
The beverage companies understand that they’re going to have to change the way that they do business. And they are making changes — but they’re not making changes fast enough. They still market very heavily these products that are major contributors to our health problems. In the end, they will move only as fast as we push them.
How did New York’s health initiatives impact the greater public health landscape?
That was another theme I tried to bring out in the book. This is the story of a local health department reinventing itself to take on the biggest health problems of our time. Before the Bloomberg period, most local health departments were seen as organizations that did restaurant inspections and rat control. We showed that local health departments could take on smoking and make a meaningful difference in life expectancy. That model is now being copied by local health departments around the country. And that’s why I think local health departments are where you’re seeing public health innovation right now.
Are there any common misconceptions about the role of public health agencies that you have tried to dispel?
A thing that people often don’t understand and that I hoped to show in the book is that health is political, but not in the way that most people think. If you ask most reporters about the politics of health, they’re going to talk about Obamacare. But as you saw in the book, the fights we faced over health were with the tobacco industry and with the food industry. I hope people read the book just for the story, because it’s a great story, but that in the end they will have learned the great value of public health.
Credit Tony Cenicola/The New York Times
- Ask Well: The Sugar in Fruit
- Ask Well: Is Day-Old Kale Salad Less Nutritious Than Fresher Kale?
- Ask Well: Should You Filter Your Water?
Credit Andrew Scrivani for The New York Times
Sophie Egan is the director of programs and culinary nutrition for strategic initiatives at the Culinary Institute of America. She is the author of the forthcoming book “Devoured: From Chicken Wings to Kale Smoothies — How What We Eat Defines Who We Are” (William Morrow, May 2016).
- “Making the Case for Eating Fruit”
- Ask Well: Is Day-Old Kale Salad Less Nutritious Than Fresher Kale?
- Ask Well: Should You Filter Your Water?