Sievenpiper: Fructose should not "worry" in diabetes

As the fructose debate rages on, one serious concern has been what the message should be for people who have diabetes. There’s no question that the alarming media headlines, articles, and YouTube videos have confused many with prediabetes and both type 1 and type 2 diabetes.

Even health professionals and organizations like the American Diabetes Association have taken a cautious approach by recommending avoidance of fructose as a sweetening agent. That is, for fear it may raise plasma lipids. They stop short of recommending people avoid fructose from fruit.

There is also the extreme arguments of Internet marketers like Joe Mercola blasting out articles about the supposed danger of fructose including that of which comes from fruit. (I’ve had more questions than I can count about Mercola’s unreasonably scary headlines and viral copy. He makes baseless recommendations that those with diabetes should cut fructose from all sources to amounts of less than 15g per day.)

In my prior interview with John Sievenpiper, M.D., of St. Michael’s Hospital, University of Toronto,  we talked of the controversies surrounding fructose, as well as rhetoric used by scientists like Dr. Robert Lustig and others, which he said could lead people to reduce intake of fruits. “That’s the danger,” Dr. Sievenpiper said, “that people will say that fruit is a source of fructose and won’t consume fruit because it may induce obesity, metabolic syndrome, and so on. It’s not just the lay public that may take this message to heart, but health professionals.”

As the lead author of three systematic reviews and meta-analyses evaluating fructose’s effects in randomized controlled feeding trials, Dr. Sievenpiper offered some perspective to the metabolic fate of this simple sugar in humans (versus animals). In short, these analyses found fructose had no significant effect on body weight or blood pressure in humans (as it does in rats, for example). In fact, fructose in amounts similar to that found in fruit improved glycemic control in humans.

Now, Dr. Sievenpiper and his colleagues — including Dr. David Jenkins (who first introduced the concept of a low-glycemic index) — has released yet another meta-analysis and systematic review to evaluate the effect on fructose on long-term glycemic control in diabetes.

The new study, published in Diabetes Care, included 18 controlled feeding trials that included 209 individuals with type 1 and type 2 diabetes. The study’s results: The isocaloric exchange of fructose improves long-term glycemic control as determined by significantly reduced glycated proteins, namely hemoglobin (HbA1c) and glycated albumin.

Moreover, the isocaloric exchange of fructose reduced HbA1c by an average of 0.53 percent, which is the equivalent to taking a hypoglycemic or anti-hyperglycemic agent like glucophage (Metformin). The fructose also didn’t significantly affect fasting glucose or insulin.

When I asked Dr. Sievenpiper what people with diabetes should take away from the results of the study, what they should make of fructose’s contribution to total carbohydrates, and its use as a substitute for other carbohydrates in the diet, he wrote:

In the context of a healthy, nutritionally balanced, weight-maintaining diet, people with type 2 diabetes do not need to worry about avoiding sources of fructose.  

Provided weight management goals are being met, no one dietary pattern has shown itself to be best for the nutritional management of diabetes. A number of dietary patterns have shown benefit in people with diabetes. These include a low-glycemic index, Mediterranean, or vegetarian dietary patterns, as well as those which emphasize specific foods such as dietary pulses or nuts or allow for a range of macronutrient distributions. The range of possibilities allows for the individualization of diets based on treatment goals and the values and preferences of the individual. 

Within this context, using small to moderate amounts of fructose in place of other sugars and starch may offer added benefit. This would be expected to be especially true where the sources are low-glycemic index fruits and cereal grain products, both of which have shown metabolic benefit.  

That being said, we need larger, longer, and higher quality trials to clarify the benefit of fructose in people with diabetes. We are currently planning such trials. 

Fructose, far from being “toxic,” may be a uniquely beneficial carbohydrate in diabetes when given in amounts equivalent to what’s found in fruits, according to the evidence. Once again, the study drives home the point further that dose matters, as it does with most nutrients and bioactive compounds, and that fructose can be healthy when eating as part of a well-balanced diet.

With the virtues of a low-glycemic diet extolled recently in the media for healthy weight loss (mainly after Dr. David Ludwig and colleagues published an impressive three-way crossover study in the Journal of American Medical Association evaluating low-fat, low-glycemic index, and very low-carb diets) it’s odd that more attention hasn’t been given to the value of fructose as a source of low-glycemic carbohydrate.

The most likely reason, perhaps, as addressed in my previous posts, is the continuing fears people have about high-fructose corn syrup. Despite the fact that it’s chemical makeup being almost identical to plain sucrose, the ingredient is still often singled out as somehow uniquely problematic. Greater intake of all foods, especially all carbohydrate sources, is what is most likely what has led us down the road of the obesity epidemic.

Bottom line? Fruit is still healthy. Fructose is most likely good for folks in amounts equivalent to what’s found in fruit. Moderation in the diet needs to be the key message as it comes to any nutrient. Plus, more focus could be put on the intake of low-glycemic carbohydrates along with balanced amounts of proteins and good fats as part of a reduced-calorie diet for weight management.

Reference

Cozma AI et al. Effect of Fructose on Glycemic Control in Diabetes: A Systematic Review and Meta-analysis of Controlled Feeding Trials. Diabetes Care 2012;35:1-10.doi: 10.2337/dc12-0073
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10 Comments on “Sievenpiper: Fructose should not "worry" in diabetes

  1. Thanks for this David. Did you attend the ASN’s Advances and Controversies in Clinical Nutrition conference sponsored with the Northwestern University Feinberg School of Medicine, on June 22-24, 2012 in Chicago.Especially these few sessions?Battle of the Weight Loss Plans: Is Anyone Winning at Losing?Speaker: Christopher Gardner, PhD, Stanford UniversityLearning Objectives:• Summarize the evidence accumulated over the past decade for the comparative success of Low-Fat vs. Low Carbohydrate weight loss diets.• Define newly developed approaches of determining which weight loss diet a patient might be relatively more successful with.• Describe why oversimplifying the communication of “Low-Fat” and “Low-Carb” messages to patients can undermine their success with these diets.How Do We Stem the Obesity Epidemic? Speaker: Boyd Swinburn, Deakin University and World Health Organization Lifestyle Modification for Diabetes Prevention: Does it Work?Speakers: Richard Khan, PhD, Consultant, and Ron Ackermann, MD, MPH, Northwestern UniversityLearning Objectives:• Describe the results of major clinical trials that focused on diabetes prevention.• Describe the results of major weight loss clinical trials.• Understand the importance of type 2 diabetes prevalence on trends in future health, healthcare costs, and quality of care.• Consider the costs, benefits, opportunities, and challenges inherent in the scaling of evidence-based, intensive lifestyle interventions for the prevention of type 2 diabetes in American adults.Glycemic Load and Glycemic Index: Are They Important? Speakers: Xavier Pi-Suyer, MD, MPH, Columbia University College of Physicians and Surgeons and Cara B. Ebbeling, PhD, Harvard School of MedicineKeynote lecture by Dr. Dean Ornish: Evidence for a Comprehensive Lifestyle Approach to the Prevention and Treatment of Chronic Disease.If you do know pl let me know if there exists a transcript/video upload that I can access online as a Non-US ASN member.Thanks,Sangeetha

  2. soooo… lustig is the chicken little of hfcs? so we can just ignore all of the other studies i suppose… also i find it interesting that the US is the only industrialized nation that allows hcfs to be added to food. i personally buy my cokes from mexico to avoid it since i started reading on the subject. and from what i read, no, it is not the same as sugar or other types of natural fructose.studies and researchers who you did not name that disagree with your (and the food industry) hypothesis are listed below.hfcs hypertension study: Diana Jalal, MD Richard Johnson, MD, Gerard Smits, PhD, and Michel Chonchol, MD (University of Colorado Denver Health Sciences Center), Gerald Shulman of Yale University School of MedicineTumor cells thrive on sugar but they used the fructose to proliferate. "Importantly, fructose and glucose metabolism are quite different," Heaney's team wrote."These findings show that cancer cells can readily metabolize fructose to increase proliferation," Dr. Anthony Heaney

  3. Sangeetha (MomPHDstudent), I didn't attend the ASN Advances and Controversies conference. You should check out some of the posts on the ASN blog: http://www.nutrition.org/asn-blog/. You might also contact the organizers for possible transcripts or videos. Kat, Please read some of my earlier posts. The evidence is pretty clear that HFCS is metabolized in the same way that cane sugar is. HFCS is made up of about 55% fructose, 45% glucose. Cane sugar is 50% fructose, 50% glucose. Fructose is naturally occurring in almost every fruit and vegetable. Eating more fruits and vegetables is associated with reduced risk of cancer. It's important to put these things in perspective, and to not make diet decisions based on in vitro experimental data. David

  4. In response to Kat's comment, I agree with David's opinion regarding hfcs metabolism. Fructose is metabolized past the point of metabolic regulation, and this only poses a problem when in excess (hfcs). Also, tumor cells exhibit the Warburg Effect wherein they have increased glycolytic activity across the board- from glucose and fructose as well as amino acids. They would grow at a faster rate than normal tissue regardless of the substrate.

  5. "In the context of a healthy, nutritionally balanced, weight-maintaining diet, people with type 2 diabetes do not need to worry about avoiding sources of fructose." I suggested in my post http://wp.me/p16vK0-dg that if you refer to a diet as "healthy," that is not science, it is an infomercial. Almost all sources of fructose have an equal amount of glucose. The average fruit is about 1;1;1 F:G:sucrose, that is overall 50:50 F:G. Bottom line on what is "healthy": a low-glycemic index, Mediterranean, vegetarian,nuts, range of macronutrients. In other words, at all costs avoid a low-carb diet shown to benefit people with type 2 diabetes.

  6. The thing I find difficult about the recommendation to eat a “low-glycemic index” diet is that these diets tend to differ in many ways from typical diets. For example, Dr. Ludwig’s LGI diet is focused on beans, nuts and such, and is higher in fiber, micronutrients, and phytonutrients than the low-fat diet. Differences are often attributed to the glycemic index, but there’s no evidence that the effect is specifically attributable to this factor. Longer-term trials have generally shown no advantage for LGI vs normal GI diets when the food patterns are not totally different.

  7. The proponents of fructose are arguing that because fruit contains fructose, and fruit is good for you, then a can of Coke is therefore just as good for you because it contains fructose. So your healthy dietary choice is 3.5 apples or one 12 oz can of Coke. Another half can of Coke and you’ve satisfied your five a day requirement for fruits and vegetables.

    Fructose may or may not be the same as glucose – but fructose sweetened drinks, pastries and all other food like products are not the same as fruits, vegetables, roots, tubers, nuts, meat, fish and fowl.

    Cheers

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