YPCAD-00904; No of Pages 2
Progress in Cardiovascular Diseases xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Progress in Cardiovascular Diseases
journal homepage: www.onlinepcd.com
In Critique of “In Defense of Sugar”: The Nuance
of Whole Foods
To the Editor:
We appreciate the article written by Archer in the current issue of
Progress in Cardiovascular Diseases entitled, “In Defense of Sugar: A
Critique of Diet-Centrism”.1 Importantly, it presents an opportunity for
us to clear up some common misconceptions. Our letter will succinctly
address most of the points Archer uses as “Evidence Contrary to the
‘Diet-Centric’ Disease-Mongering of Dietary Sugars.”
Counters to Archer's “Evidence Contrary to the ‘Diet-Centric’
Disease-Mongering of Dietary Sugars.”
“Without Sugar, we die: biological life depends on sugar in its many forms.”
An important nuance about this statement is that dietary sugar
(either glucose, sucrose, or high-fructose corn syrup) is not necessary
for life. While endogenous glucose molecules are important for vital
functions, glucose can be made from glycerol and amino acids in a
process called gluconeogenesis. This can come from dietary fat and
protein or from the catabolism of body proteins and adipose tissue. In
other words, there is no dietary requirement for “sugar”.2,3
“Dietary sugars and sugar-polymers were the predominant source of
nutrient-energy for most human populations since the invention of
agriculture.”
While we cannot be certain what the predominant source of energy
was for humans over the past several million years (although one can
speculate) there was virtually zero consumption of refined sugar,
e.g., sucrose, and absolutely zero consumption of high-fructose corn
syrup. Consuming raw honey, which is a whole food, cannot be
extrapolated as having the same biological effects in the body as
consuming refined sucrose or high-fructose corn syrup as sugar is only
one molecule out of dozens that make up honey. Thus, it is without
question that humans did not consume refined sucrose or high-
fructose corn syrup throughout most of their evolution.
“Sugar (glucose) is so vital to human health and well-being that it is
one of the World Health Organization's (WHO) Essential medicines.”
The new WHO guideline recommends that adults and children
reduce their daily intake of free sugars to b10% of their total energy in-
take. Indeed, “We have solid evidence that keeping intake of free sugars
to less than 10% of total energy intake reduces the risk of overweight,
obesity and tooth decay,” stated Dr. Francesco Branca, Director of
WHO's Department of Nutrition for Health and Development. The
WHO goes on to state that a further reduction in the intake of free sugars
to below 5% (6 teaspoons) of total energy per day would provide addi-
tional health benefits “in the form of reduced dental caries.”4 Moreover,
to our knowledge there is zero definitive proof that glucose is needed in
the treatment of dehydration compared to using salt and water alone.
☆ Conflicts: Dr. DiNicolantonio is the author of The Salt Fix. Dr. O'Keefe has no conflicts.
https://doi.org/10.1016/j.pcad.2018.07.006
0033-0620/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: DiNicolantonio JJ, O'Keefe JH. In Critique of “In Defense of Sugar”: The Nuance of Whole Foods. Prog Cardiovasc Dis
(2018), https://doi.org/10.1016/j.pcad.2018.07.006
Lastly, to state that “sugar sweetened beverages saves lives” is in di-
rect contrast to the estimated 184,000 people that die each year from
the consumption of sugar sweetened beverages from diabetes, cardio-
vascular disease, and cancers.5
“Diet-centrism is based on physiological illiteracy: one size does not
and cannot fit all.”
In regards to, “Consequently, detailed, prescriptive, population-level
dietary recommendations are futile because one size does not and cannot
fit all.” While this may be true for dietary substances that are essential,
such as salt, free sugars are not essential for life. Thus, a limit on the
intake of added sugars would cause zero harm to the public. Addition-
ally, added sugars provide zero nutrition yet require vitamins and
minerals to be metabolized in the body and in order to liberate their
calories.3 Thus, the more free sugars one consumes, such as sugar-
sweetened beverages for example, the more nutrient depleted one
becomes. In other words, limiting the intake of added sugars would
have no harm to the public yet clear health benefits, which is why the
WHO recommends their restriction.
“Physical activity, not diet, is the Major Modifiable Determinant of
Metabolic Health.”
As the saying goes, you can't outrun a bad diet. Indeed, there are 9
essential amino acids, essential fatty acids such as parent omega-3 and
omega-6, and around two dozen essential vitamins and minerals. If a
person is lacking any of these essential nutrients health will suffer and
increasing physical activity will not treat the lack of one or more of
these essential nutrients. According to Global Burden of Disease Study,
which was “prepared by the Institute for Health Metrics and Evaluation
(IHME) based on seven papers for the Global Burden of Diseases, Inju-
ries, and Risk Factors Study 2010,” dietary risks cause the most health
loss in the United States; physical inactivity and low physical activity
was only ranked 6th.6
“The consumption of dietary sugars up to 80% of total energy intake
is entirely innocuous in active populations.”
Archer argues that hunter-gatherers that consume 20–80% of their
total energy intake as ‘added sugar’ (honey) have some of the lowest
non-communicable disease risks ever recorded. However, consuming
raw honey, again which is a whole food, cannot be extrapolated to
being the same as consuming added sugars such as glucose, sucrose or
fructose. Indeed, fructose and glucose only make up 69% of honey.7 Fur-
thermore, honey has a lower glycemic index compared to glucose or
sucrose.8,9 In animal studies, feeding honey leads to less weight gain
than sucrose or mixed sugars despite similar food intake.10 In humans,
consuming natural honey causes reductions in body weight, body fat,
total cholesterol, LDL-cholesterol, triglycerides, fasting blood glucose,
inflammation (C-reactive protein) and raises HDL, whereas no benefits
are found with sucrose.11 And while refined sugars cause dental caries,
the antibacterial properties of honey may actually prevent them.12,13 To
summarize, honey is a whole food consisting of around 200 substances
including vitamins, minerals, amino acids, antioxidants, carotenoids,
enzymes, and antibacterial compounds,7 which is not the same thing
as “added sugars”, such as sucrose or high-fructose corn syrup, which
lack all of them.
2 In Critique of “In Defense of Sugar”: The Nuance of Whole Foods
“There is strong, positive association between sugar availability/con-
sumption and health.”
In fact, to our knowledge there is not a single population that
we are aware of that consumes a high amount of added sugars
(sucrose or high-fructose corn syrup) that is in good health. Moreover,
an econometric model of repeated cross-sectional data on diabetes
and nutritional components of food from 175 countries found that
for every 150 kcal/person/day increase in sugar availability (about
one can of soda/day) there was an increased diabetes prevalence
by 1.1% (p b 0.001) even after controlling for other foods types
(fiber, meats, fruits, oils, cereals), total calories, and overweight
and obesity.14
“Obesity and Type 2 Diabetes Mellitus: Blood Sugar, not Dietary
Sugars Matter.”
In regards to Archer's statement that “[…] obesity and type 2 diabe-
tes mellitus are not diet-related diseases but are metabolic conditions
caused by the positive energy balance (i.e., over-nutrition) driven by
the confluence of physical inactivity […]”.
Clinical studies in humans show that consuming a diet low in
sucrose (5%) vs. a diet high in sucrose (18% and 33%) reduces the
prevalence of diabetes or borderline diabetes by N50%.15 In other
words, diabetes can be caused by a diet high in sugar. In fact, sucrose,
even when compared to wheat starch, produces greater increases in
fasting insulin, insulin to glucose ratio, and insulin response when
given a sucrose load.16 Other studies show that replacing starch with
sucrose increases fasting glucose17 and glucose and insulin responses
to a sucrose load.16,18 In other words, dietary sugar drives
increased blood sugar, which is just one way to measure and diagnose
diabetes.
The intake of added sugars has increased in the human diet by 30-
fold over the past few hundred years going from just 4 lbs. per person
per year to approximately 120 lbs. per person per year.19 Considering
that most of this sugar is “added” and hidden in nearly 75% of all pack-
aged foods in the United States calls for greater attention to this dietary
demon.
There is no biological need for the consumption of added sugars.
While our ancestors may have consumed glucose and fructose in nature
it was always packaged in whole foods (fruits and honey for example)
providing fiber, vitamins, minerals, and polyphenols/antioxidants,
which help to counteract the harmful metabolic effects of glucose and
fructose. We no longer live in hunter-gatherer societies and even if
humans did go back to living this way or attempted to increase their
physical activity to those previous levels consuming 80% of energy
intake in the form of raw honey is not the same as consuming it from
pure white crystals (e.g. sugar) or syrups (e.g. corn syrup or high-
fructose corn syrup).
Please cite this article as: DiNicolantonio JJ, O'Keefe JH. In Critique of “In Defense of Sugar”: The Nuance of Whole Foods. Prog Cardiovasc Dis
(2018), https://doi.org/10.1016/j.pcad.2018.07.006
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James J. DiNicolantonio*
James H. O’Keefe
Department of Preventive Cardiology, Saint Luke's Mid America Heart
Institute, Kansas City, Missouri, United States
⁎Address reprint requests to James J. DiNicolantonio.
E-mail address: jjdinicol@gmail.com (J.J. DiNicolantonio).