Added Sugar: Not All that Sweet?

The following article is a guest post written by one of EBNC's collaborators, Gina Battaglia, PhD.

In an effort to reduce the obesity epidemic in the United States and other westernized countries, the World Health Organization (WHO) has recently recommended added sugar intake to be less than 5 percent of total calorie intake—half of its previous recommendation.  According to the WHO, added sugar “may result in both reduced intake of foods containing more nutritionally adequate calories and an increase in total caloric intake, leading to an unhealthy diet, weight gain and increased risk of noncommunicable diseases.” (1)

As you probably know, added sugar—such as that in soda, baked goods, and even condiments like ketchup and barbeque sauce—is not really the healthiest thing you can eat.  However, lowering the WHO recommendations for sugar may not directly address the energy balance issue that is the central principle of weight loss and maintenance.  Simply put, you must burn more calories than you eat to lose weight.  Theoretically, you could eat nothing but cookies all day and lose weight if your total calorie intake is less than your energy expenditure (your nutrient intake would be woefully inadequate, but that’s a topic for another day).

Because calorie requirements to maintain or lose weight vary drastically between individuals and depend upon factors such as gender, activity level, and current body size; the amount of sugar “allowable” by these recent guidelines will vary accordingly.  Consider these four hypothetical individuals and their respective calorie requirements:

1) male construction worker trying to maintain weight (3700 kcal)

2) female office worker trying to lose weight (1800 kcal)

3) male nurse trying to lose weight (2400 kcal)

4) stay at home mom trying to maintain weight (2600 kcal)

And the amount of sugar each can eat based on these current guidelines:

1) male construction worker trying to maintain weight (3700 kcal*0.05 = 185 kcal sugar)

2) female office worker trying to lose weight (1800 kcal*0.05 = 90 kcal sugar)

3) male nurse trying to lose weight (2400 kcal*0.05 = 120 kcal sugar)

4) stay at home mom trying to maintain weight (2600 kcal*0.05 = 130 kcal sugar)

One 12-ounce can of Coca Cola contains 39 grams of sugar, which is equivalent to 10 sugar cubes or 4 Double Stuf Oreo cookies.

As illustrated in my hypothetical examples, for most individuals the amount of sugar allowed by WHO standards is less than one can of regular soda per day (a 12-oz can of Coca Cola contains 140 calories of sugar).  Considering that added sugar is also present in unlikely places such as pasta sauce and sweetened yogurt, you may find yourself surpassing the guidelines by lunchtime even if you don’t drink soda.  According to National Health and Nutrition Examination Survey (NHANES) data, sugar consumption in the U.S. makes up ~22.7% of the calories in our diets (2).  This added sugar is heavily blamed by many researchers as the culprit for the epidemic proportions of obesity in the U.S.  Some, such as pediatric endocrinologist Dr. Robert Lustig, from University of California, San Francisco, even compare the toxic and addictive nature of sugar to drugs like cocaine and heroin.  Others are quick to criticize the nearly century-old tradition of selling Girl Scout cookies, suggesting that it is capitalizing on Americans’ love for high-sugar treats.

But high-sugar foods and drinks have been around much longer than this recent rise in obesity rates, which have skyrocketed to include about one-third of the U.S. population.  The portion size increase of these sugary foods may be to blame, as the rise in obesity has increased in parallel with the increase in portion sizes (3).  For example, a commercially sold blueberry muffin contains about 500 calories—nearly 300 more than the average blueberry muffin sold just 20 years ago (4).  And if you’ve ever seen the Big Gulp soda cups at 7-Eleven, you probably know that soft drink portion sizes have gotten a little out of control. 

As the WHO panel of experts indicates, added sugar may make it harder to maintain that calorie deficit, especially if your calorie needs are low.  Many foods high in added sugar are calorie-dense and not satiating, so they can be easy to overdo.  One Oreo Double Stuf cookie has 70 calories, approximately the amount of calories in a medium-sized apple.  If we ignore the nutritional profile of the cookie vs. apple, eating one cookie, in theory, will have the same impact as an apple on your calorie budget.  However, many people will reach for a second (or third or fourth) cookie immediately after eating the first one, whereas they typically don’t reach for a second or third apple.  This tendency to overeat sugar contributes to the obesity epidemic, not sugar in and of itself.

One Double Stuf Oreo cookie contains the same number of calories as an entire apple (note: these items are not sized to scale).

The concept of eating sugar also introduces the psychological element.  Eating sugar releases the feel-good brain chemicals serotonin and dopamine (5) that increases the likelihood that you’ll eat four (or ten) cookies in one sitting because they taste good, not because you need calories for energy.  Sugar releases the brain chemicals and activates areas of the brain (including the orbitofrontal cortex, caudate nucleus, hippocampus, and insula) where drug cravings are activated, (6) thereby supporting the opinion of experts such as Lustig.  You probably identify with this “addiction” if you are the type of person who can’t stop at just one or two cookies, or you cut yourself several slivers of cake until one-quarter of the entire cake is gone.  These habits can pack on the calories quickly and make it more difficult to maintain a calorie deficit, especially if your calorie needs are similar to the female office worker (1800 kcal) trying to lose weight.  Some individuals find that eliminating sugar completely reduces cravings and makes it easier to maintain a calorie intake suitable for their physical activity level and weight goals. 

However, completely banning sugar from your diet can exert negative psychological effects in other people.  If you’re the person who falls victim to sugar binges three days after complete sugar deprivation, a reasonably-sized portion of added sugar—whether it be a couple of small cookies after dinner or a doughnut at breakfast on Sundays—may help you stick to a healthy eating regimen the majority of the time.  Furthermore, cutting out sugar alone won’t magically result in weight loss if you overcompensate with healthy foods.  A 2012 study found that people who were instructed to eat the amount of fruits and vegetables recommended by the Dietary Guidelines for Americans actually gained weight, presumably because they neglected to compensate for this additional calorie load by reducing intake elsewhere (7). This finding further emphasizes that eating the recommended amount of fruits and vegetables is not a magic bullet to weight loss unless it helps you maintain an overall calorie deficit.

The key to successful weight loss/maintenance is to be aware of your overall calorie needs and to strategize how sugar will fit into your diet.  If you’re the male construction worker, your relatively high energy requirements (3700 kcal) allow you to get away with eating a few extra cookies whereas the female office worker (1800 kcal) will have a tough time fitting these cookies into her diet.  On its own, the WHO guidelines on added sugar intake (reducing sugar intake to < 5% of total calories) will not stop the obesity epidemic.  What these guidelines can do is highlight the role that empty calories (sugar intake) plays in promoting a positive overall energy balance and weight gain.  It is highly unlikely that Americans will reduce their current sugar intake of 22% down to the recommended 5%.  Five percent is a little ambitious, 22% is clearly too high, can we please meet somewhere in the middle?  Let’s try to focus on increasing our healthy behaviors by decreasing sugar consumption.  If we don’t hit the magical 5% and only get to 14% at least we are taking a step in the right direction!

Gina Battaglia, PhD

References:

1. Draft Guideline: Sugars intake for adults and children http://www.who.int/nutrition/sugars_public_consultation/en/
2. Austin GL, Ogden LG, Hill JO. Trends in carbohydrate, fat, and protein intakes and association with energy intake in normal-weight, overweight, and obese individuals: 1971-2006. Am J Clin Nutr. Apr 2011;93(4):836-843.
3. Young LR, Nestle M. The contribution of expanding portion sizes to the US obesity epidemic. American journal of public health. Feb 2002;92(2):246-249.
4. National Heart, Lung, and Blood Institute: Serving Sizes and Portions http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/eat-right/distortion.htm
5. Fortuna JL. Sweet preference, sugar addiction and the familial history of alcohol dependence: shared neural pathways and genes. Journal of psychoactive drugs. Jun 2010;42(2):147-151.
6. Benton D. The plausibility of sugar addiction and its role in obesity and eating disorders. Clinical nutrition. Jun 2010;29(3):288-303.
7. Houchins JA, Burgess JR, Campbell WW, et al. Beverage vs. solid fruits and vegetables: effects on energy intake and body weight. Obesity. Sep 2012;20(9):1844-1850.

The Human Brain & the Senses

If the human brain was unable to “filter out” nonessential incoming sensory information, we would become paralyzed by indecision, our sensory systems overwhelmed, and our brain unable to translate this information into action.  In the world of yesteryear this indecision would have caused us to be eaten by a lion or starve to death.  Our brain has a tremendous ability to filter incoming signals and determine which information is important and which is not.  If you stop what you are doing right now and focus on all the noises and sensations around you, you may notice that your furnace is running, the birds are chirping, the sound of a passing car, or a conversation on the street.  From an evolutionary standpoint, our auditory system was initially designed to alert us to danger.  Because none of these background sounds represent any real danger our brains allow us to easily ignore them.  But what if we couldn’t help but pay attention to every passing sound?  Would that not be paralyzing?

In today’s day and age our nutrition senses are overwhelmed with information.  We are bombarded with so much information on a daily basis that we are unable to decipher which information is important and which is not.  Even the experts do not have a grasp (or offer a consensus) on what we ‘should’ and ‘should not’ be eating.  This week a new large-scale research study was published stating that there is no association between saturated fat intake and heart disease!  This new analysis is HUGE because it flies in the face of the dietary advice medical professionals have been prescribing for the past 25 years and really causes us to reevaluate what we should and should not be eating.  Eventually we will all figure out that a diet based on obtaining the correct macro and micro nutrient requirements is of very little value, that this type of diet is nothing more than auditory noise alerting us to a danger that is no longer present in today’s nutrient rich society.  In fact all of this noise is leading us to ignore the very real danger of consuming too many calories, expending too few calories, and upsetting our metabolic balance.

We have created a medical nutrition therapy to treat and prevent every single diagnosed and/or conceived disease that we may or may not have.  What if we have multiple conditions?  Then what?  How are we supposed to eat?  What rule cancels out what rule?  What food exacerbates our condition(s)?  What food helps it?  Are the foods additive or detrimental to our health?  Although dietary interventions for the management of some diseases have been well studied and it is clear that certain changes are necessary for successful management of the disease (e.g., type 2 diabetes), this is not the case across the board.  Don’t you wish that instead of trying to micromanage your diet for the prevention of every single possible disease there was a simple means of eating that could cover all of your bases without having to follow strict guidelines and rules?  Well, call me a genie because I just granted you your wish.  It’s called energy balance.  Why not follow one rule, calories in = calories out.  This rule applies to the prevention of heart disease, diabetes, and some types of cancer.  By living according to the energy balance principles, you will prevent weight gain and the development of obesity – one of the major risk factors for the development of many of the preventable diseases we see today.  Instead of micromanaging your diet and being paralyzed by multiple dietary rules and indecision, why not follow one simple relatively easy rule, energy balance, and have the freedom to eat what you want, when you want?  Enough is enough.  I’m fed up with micromanaging miniscule dietary manipulations.  Filter out the noise and make the change today!

Todd M. Weber, PhD, MS, RD

America, We have a (eating) Problem

The human race has been around for thousands and thousands of years.  During this time we have proven to be an ingenious species.  We form complex, fulfilling, and lasting relationships with one another, have created many deep and rich literary works, have eradicated many horrendous diseases, have put a man on the moon, and have done and will continue to do countless other truly amazing things.  Despite our ingenuity we epically fail when it comes to a single, biologically driven, simple task that we have been practicing for thousands of years: EATING!! 

One would think that with thousands of years of practice and experience we would actually be pretty good at this; however, approximately 70% of United States adults are overweight or obese (1).  Obesity is a symptom of many things including emotional distress, busy lives, and a lack of time.  From a purely physiological standpoint, obesity is a symptom of caloric consumption being greater than caloric expenditure, period.  Instead of focusing on this basic nutritional tenet, excess caloric consumption, our attention has been diverted elsewhere by food marketers, wannabe endocrinologists, naturalistic medicine, and yes, even physicians.  Instead of focusing on reducing energy intake or increasing energy expenditure we are too often focused on remedies and causes outside of our own control. 

On the New York Times bestseller list of the top 20 books on “Advice, How-To, and Miscellaneous” it is striking that 8 of the top 12 are some type of diet related books.  This tells me two things, that people 1) do not know how to eat and 2) are looking for help in figuring out how to eat.  The United States government tries very hard to help Americans eat better by putting out the Dietary Guidelines for Americans and the MyPlate guidelines.  The problem is that < 10% of Americans are actually meeting these dietary guidelines (2).  This leaves an exorbitant amount of room for self-help books to try and tell people how they should eat (and they don’t work either). 

In addition, the health benefits of vitamins and minerals has largely been exaggerated and/or manipulated by the food industry.  A recently published editorial in the Annals of Internal Medicine (3) reviewed several large scale scientific studies on the ability of vitamin and mineral supplementation to prevent chronic disease and concluded that vitamin and mineral supplementation studies “...consistently found null results or possible harms” of supplementation (4, 5) and in some cases actually increase the risk of death (5).  I would never say that vitamins and minerals are not important to your health.  Clearly they are necessary to remain alive (6).  However, if vitamins and minerals were personified, there is no way they would live up to our ideals as they would surely crack under the weight of our expectations.  In addition, recent research suggests that public health campaigns (such as MyPlate) aimed at promoting increased vitamin and mineral consumption may have little to no effect on reducing the risk of obesity as individuals continue to remain in a positive caloric balance despite these types of interventions (7).

Lastly, by primarily focusing on organic ingredients and sustainable agriculture (both of which are great causes and could/should be discussed at length on their own) in some cases we are sacrificing our own health.  Case in point: Chipotle.  While Chipotle can trumpet their cause of promoting healthful food, there is no denying that many of the items on their menu, when eaten together as in a typical visit to their restaurant, contain well over 1,000 calories or > 50% of many individual’s daily calorie requirements.  The Chipotle scenario is a classic case of a self-righteous cause that may actually be detrimental to your health.  I’m not saying you should never eat at Chipotle.  It is possible to eat healthy there, I am raising the argument that it is just as easy to eat unhealthily at a place that touts only the best natural ingredients as it is at someplace that does not (see pictures above).  Furthermore, just because the quality of the ingredients may be superior at one chain over the other, Subway versus McDonald’s for instance, there may be no difference in the total number of calories consumed at each restaurant (8).

The bottom line is, Houston, we have an eating problem and we will continue have a problem until we can refocus the eating conversation back to what matters, caloric intake and energy expenditure!

Todd M. Weber, PhD, MS, RD

References:

1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. Feb 1 2012;307(5):491-497.
2. Krebs-Smith SM, Guenther PM, Subar AF, et al. Americans do not meet federal dietary recommendations. Oct 2010 J Nutr. 2010;140(10):1832-1838.
3. Guallar E, Stranges S, Mulrow C, Appel LJ, Miller ER, 3rd. Enough is enough: Stop wasting money on vitamin and mineral supplements. Ann. Intern. Med. Dec 17 2013;159(12):850-851.
4. Huang HY, Caballero B, Chang S, et al. The efficacy and safety of multivitamin and mineral supplement use to prevent cancer and chronic disease in adults: a systematic review for a National Institutes of Health state-of-the-science conference. Ann. Intern. Med. Sep 5 2006;145(5):372-385.
5. Bjelakovic G, Nikolova D, Gluud LL, et al. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. March 14 2012.
6. Hopkins, FG. Feeding experiments illustrating the importance of accessory factors in normal dietaries. J Physiol. July 15, 1912;44:425-460.
7. Srinivasan CS. Can adherence to dietary guidelines address excess caloric intake? An empirical assessment for the UK. Econ Human Biol. 2013;11:574-591.
8. Lesser LI, Kayekjian KC, Velasquez P, et al. Adolescent purchasing behavior at McDonald's and Subway. J Adolesc Health. 2013;53:441-445.

References for Pictures:

Dunkin Donuts Chicken Salad Sandwich: https://www.dunkindonuts.com/content/dunkindonuts/en/menu/food/sandwiches/Bakery_Sandwiches/chickensaladsandwich.html

Chipotle Burrito: http://endurancesportsflorida.com/2011/02/04/chipotle-so-good-so-salty/

Panera Napa Almond Chicken Sandwich: https://www.panerabread.com/en-us/menu-categories/sandwiches.html#napa-almond-chicken-salad-sandwich

What to Expect from this Blog?

I am going to be posting nutrition, exercise, and various health related content on this blog at least monthly and maybe more often.  Most of the content will likely be my own but if I come across someone else who has great content I will post that as well.  In addition to these formats you can also expect to see some material that I feel misses the point and a brief editorial on why I think we as health and fitness professionals can (and must) do better.