Tag Archives: added sugar

Does Eating Saturated Fat Lower Your Risk of Stroke and Dying?: Humility and Conscience in Nutritional Guidelines

A study presented at the European Society of Cardiology  meetings in Barcelona and simultaneously published in The Lancet earlier this month caught the attention of many of my readers. Media headlines trumpeted  “Huge New Study Casts Doubt On Conventional Wisdom About Fat And Carbs” and “Pure Shakes Up Nutritional Field: Finds High Fat Intake Beneficial.”

Since I’ve been casting as much doubt as possible on the  conventional nutritional wisdom  to cut saturated fat, they reasoned, I should be overjoyed to see such results.

What Did the PURE Study Find?

The Prospective Urban Rural Epidemiology (PURE) study, involved more than 200 investigators who collected data on more than 135000 individuals from 18 countries across five continents for over 7 years.

There were three high-income (Canada, Sweden, and United Arab Emirates), 11 middle-income (Argentina, Brazil, Chile, China, Colombia, Iran, Malaysia, occupied Palestinian territory, Poland, South Africa, and Turkey) and four low-income countries (Bangladesh, India, Pakistan, and Zimbabwe)

This was the largest prospective observational study to assess the association of nutrients (estimated by food frequency questionnaires) with cardiovascular disease and mortality in low-income and middle-income populations,

The PURE team reported that:

Higher carbohydrate intake was associated with an increased risk of total mortality but not with CV disease or CV disease mortality.

This finding meshes well with one of my oft-repeated themes here, that added sugar is the major toxin in our diet (see here and here.)

Higher fat intake was associated with lower risk of total mortality.

Each type of fat (saturated, unsaturated, mono unsaturated ) was associated with about the same lower risk of total mortality. 


These findings are consistent with my observations that it is becoming increasingly clear that cutting back on  fat and saturated fat as the AHA and the Dietary Guidelines for Americans have been telling you to do for 30 years is not universally helpful (see here and  here ).

When you process the fat out of dairy and eliminate meat from your diet although your LDL (“bad”) cholesterol drops a little your overall cholesterol (atherogenic lipid) profile doesn’t improve (see here).

Another paper from the PURE study shows this nicely and concluded:

Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk.

Further findings from PURE:

-Higher saturated fat intake was associated with a lower risk of stroke

-There was no association between total fat or saturated fat or unsaturated fat with risk of heart attack or dying from heart disease.

Given that most people still believe that saturated fat causes heart disease and are instructed by most national dietary guidelines to cut out animal and dairy fat this does indeed suggest that

Global dietary guidelines should be reconsidered …”


Because the focus of dietary guidelines on reducing total and saturated fatty acid intake “is largely based on selective emphasis on some observation and clinical data despite the existence of several randomizesed trials and observational studies that do not support these conclusions.”

Pesky Confounding Factors

We cannot infer causality from PURE because like all obervational studies, the investigators do not have control over all the factors influencing outcomes. These confounding factors are legion in a study that is casting such a broad net across different countries with markedly different lifestyles and socioeconomic status.

The investigators did the best job they could taking into account household wealth and income, education, urban versus rural location and the effects of study centre on the outcomes.

In an accompanying editorial, Christopher E Ramsden and Anthony F Domenichiello, prominent NIH researchers,  ask:

“Is PURE less confounded by conscientiousness than observational studies done in Europe and North American countries?


“Conscientiousness is among the best predictors of longevity. For example, in a Japanese population, highly and moderately conscientious individuals had 54% and 50% lower mortality, respectively, compared with the least conscientious tertile.”

“Conscientious individuals exhibit numerous health-related behaviours ranging from adherence to physicians’ recommendations and medication regimens, to better sleep habits, to less alcohol and substance misuse. Importantly, conscientious individuals tend to eat more recommended foods and fewer restricted foods.Since individuals in European and North American populations have, for many decades, received in influential diet recommendations, protective associations attributed to nutrients in studies of these populations are likely confounded by numerous other healthy behaviours. Because many of the populations included in PURE are less exposed to in influential diet recommendations, the present findings are perhaps less likely to be confounded by conscientiousness.”

It is this pesky conscientiousness factor (and other unmeasured confounding variables) which limit the confidence in any conclusions we can make from observational studies.

I agree wholeheartedly with the editorial’s conclusions:

Initial PURE findings challenge conventional diet–disease tenets that are largely based on observational associations in European and North American populations, adding to the uncertainty about what constitutes a healthy diet. This uncertainty is likely to prevail until well designed randomised controlled trials are done. Until then, the best medicine for the nutrition field is a healthy dose of humility.


Ah, if only the field of nutrition had been injected with a healthy dose of humility and a nagging conscience thirty years ago when its experts declared confidently that high dietary fat and cholesterol consumption was the cause of heart disease.!

Current nutritional experts and the guidelines they write will  benefit from a keen awareness of the unintended consequences of recommendations which they make based on weak and insufficient evidence  because such recommendations influence the food choices  (and thereby the quality of life and the mechanisms of death) of hundreds of millions of people.

PUREly Yours,


Dear Kaldi’s, Please Stop Serving Candied Bacon: It Is A Health And Gastronomic Abomination

The skeptical cardiologist enjoys bacon (in moderation), often with quiche, despite the fact that The Who (World Health Organization, not the band that John Entwhistle played for) classifies it as a carcinogen.

Enjoying bacon has become more difficult these days due to the development of a most disturbing fad: the adulteration of bacon  with sugar in some way, shape, or form.

The Eternal Fiancee’ recently ordered a bacon, egg and cheddar on croissant sandwich at my favorite St. Louis coffee spot, Kaldi’s when to our horror, candied bacon was served.

An inquiry at the serving counter  revealed that Kaldi’s only serves candied bacon; you can’t get any that hasn’t been turned into a monstrosity!

I find candied bacon to be an abomination.  All I can taste is sugar and any subtleties of the bacon or its preparation are eclipsed by the saccharine bulk of the sugar.

If this graphic (from my fitness pal.org) is to be believed, the three slices in her sandwich added 40 grams of sugar. This is the equivalent of 10 teaspoons of sugar and the amount of sugar in a bottle of Coke.





Readers of this blog know that I consider sugar, not fat, as the major toxin in our diet, contributing to obesity, diabetes and ultimately heart attack and stroke. I’ve also pointed out that huge amounts of added sugar are hidden in smoothiescoffee drinks, and non fat yogurt.

The massive amount of sugar in this candied bacon is not exactly stealth: you can tell it from the first bite. However, there is nothing in the description of the croissant sandwich that alerts you to the fact that your bacon will be transmogrified into candy.

Serving only candied bacon in my opinion is the equivalent of only serving coffee that has had sugar added to it and Kaldi’s should know better.

Kaldi’s is proud of their community commitment which includes support for the Juvenile Diabetes Research Foundation. What about supporting healthier food choices (with no added sugar)  for kids so they are less likely to get diabetes and if they have diabetes will be  less likely to be poorly controlled?

I implore Kaldi’s to stop this madness.

Antisucroporcinely Yours,


N.B. The Eternal Fiancee’ just tried to order a smoothie at the Clayton Kaldi’s and discovered to her horror that their peanut butter contains hydrogenated oils and added sugar. Yikes!

Added Sugar | Why and How to Avoid Added Sugar

The Holiday Season is upon us so it may seem cruel for the skeptical cardiologist to resume harping on the toxicity  and ubiquity of added sugar as is he is wont to do.

Instead, I’m reposting an excellent summary of the topic by Axel Sigurdsson, a cardiologist/blogger from Iceland. Axel writes an excellent blog called Doc’s Opinion which touches on many of the themes I have covered here.

Added Sugar – Why and How to Avoid It

(reposted  from Axel F. Sigurdsson, MD at Doc’s Opinion)

3506628_m-150x150When it comes to the science of nutrition, everyone seems to have an opinion. Consequently, there is huge disagreement, even among the experts. If we ask for advice, there are likely to be dozen different answers. So, in the era of information overflow, the general population has become severely confused.

Apart from having to choose between various food products, we are urged to choose between different paths, almost like finding a favorite football team or choosing a political party. Your cardiologist will likely recommend the DASH diet or a Mediterranean-type diet. Low carb and Paleo have become very popular but are often condemned by the traditional university academic. Then there is low-fat, vegan, gluten free, raw foodism and much more.

In their search for better health, people spend billions every year on books, DVD’s, meal plans, diet products, and food supplements. Simple plans that promise big results are most popular, but usually don’t work. Nonetheless, we are continuously hoaxed by marketing and empty promises.

However, in the midst of all the confusion and disagreement there is a simple measure that if taken seriously may improve our health and lessen the risk of disease more than we might ever realize. And, in fact, the academics, the vegans and the low carb, low fat and Paleo enthusiasts might all agree on this one.

Yes, I am talking about avoiding added sugar.

What Is Added Sugar?

The sugar in our diet is either naturally occurring or added. For example, fruit and milk contain naturally occurring sugars (fructose in fruit and lactose in milk).

Added sugar is the sugar that is added to food or drink during preparation or processing. Added sugar may be natural (such as fructose ) or processed (such as high-fructose corn syrup).

Added sugar provides no nutritional value. However, it boosts flavor, texture and color, and extends the shelf-life of foods like bread, breakfast cereals, tinned fruit, and vegetables. No wonder food manufacturers love sugar.

Why We Should Avoid Added Sugar

Because of the lack of nutritional value, foods that are rich in sugar are often described as empty calories. If sugary foods and beverages are a large part of our diet we are likely to miss out on important nutrients, vitamins and minerals.

Added sugar is believed to contribute to obesity.

Sugar promotes tooth decay by optimizing growth conditions for bacteria.

Recent evidence from epidemiological studies suggests that high intake of sugar-sweetened beverages increases the risk for metabolic syndrome, type 2 diabetes, coronary heart disease, and stroke (1).

Studies show that sugar-sweetened beverages increase accumulation of fat in the liver, muscle, and the visceral fat depot. Most of the studies support the fact that fructose is the main driver of these metabolic aberrations because it drives fat production and fat release from the liver (2).

A large survey published 2014 showed a significant relationship between added sugar consumption and risk of death from cardiovascular disease (3). Individuals who reported more of their total calorie intake as added sugar had a significantly increased risk of dying from cardiovascular disease.

A recently published paper addressed the link between sugar intake and risk factors for heart disease (4). The study tested the effects of consuming beverages sweetened with different doses of high fructose corn syrup on blood lipids (fats). The results showed that blood levels of LDL-cholesterolnon-HDL cholesterol, and apolipoprotein B, and triglycerides increased in a dose-dependent manner within two weeks following consumption of different doses of high-fructose corn syrup. The authors believe their findings provide a possible link to the increased risk of death from heart disease associated with increased intake of added sugar.

Sugar intake may have negative effects on blood pressure. A meta-analysis of randomized controlled trials showed high intake of sugar to be associated with elevated blood pressure (5).

What Are The Main Sources of Added Sugar?

To avoid added sugar, we have to know where to find it.

The figure below is based on data from NHANES showing the sources of added sugars in the diet of the US population 2005-2006.

Added Sugar - Why and How to Avoid It

Sources of added sugars in the diets of the U.S. population ages 2 years and older. National Health and Nutrition Examination Survey, 2005-2006

The figure shows that soda drinks, energy drinks, and sports drinks provide more than a third of added sugars consumed by Americans. If we add fruit drinks to this number, it becomes evident that more than 46.1 percent of added sugar consumed comes from sugar-sweetened beverages.

Other important sources of added sugar are grain-based desserts, dairy desserts, candy, ready-to-eat cereals, sugars and honey, tea and yeast bread.

Why It’s So Hard to Avoid Sugar

Because sugar is such a popular food additive, we can expect to find it where we least expect it. Food we think of as healthy may contain high amounts of added sugar, such as low-fat yogurt, fruit juice and sauces (e.g. tomato ketchup and sweet and sour sauce).

Added Sugar - Why and How to Avoid it

The Nutrition Facts label contains information about the amount of sugar per serving. The size of the serving (53 g in this case) has to be taken into account. Here the amount of total sugar is 24.5g per 100g (100/53 x 13g) which is very high.

Finding out how much added sugar is in our food may be confusing. The Nutrition Facts label may be misleading because it contains information about the amount of sugar per serving. So, to interpret this information, the size of the serving has to be taken into account.

The only reliable way is to look at the ingredient list. However, food manufacturers are not required to separate added sugars from naturally occurring sugars. Nonetheless, if you find sugar is listed among the first few ingredients, the product is likely to contain a high amount of added sugar.

A rule of thumb is that more than 15g of total sugars per 100g means that sugar content is high, and 5g of total sugars means that sugar content is low.

Another problem is that sugar goes by many different names. The chemical name for sugar has the ending “ose” like fructose, sucrose, glucose, and maltose. So, watch out for the “ose” ending.

The biggest obstacle, however, is that humans seem to love sugar and for most of us the love affair lasts a lifetime. Love is not easily conquered by practical reasoning and level-headed common sense.

Furthermore, there is evidence that sugar consumption can induce behavior and neurochemical changes that resemble the effects of a substance of abuse. In other words, similar to drugs such as opiates, sugar may be addictive (6).

The Bottom-Line

A worldwide study published earlier this year suggests that sugary soft drinks kill 184,000 adults every year (7). The study shows that 133,000 deaths from diabetes, 45,000 deaths from cardiovascular disease and 6,450 deaths from cancer were caused by fizzy drinks, fruit drinks, energy drinks, and sweetened iced teas in the year 2010.

Furthermore, the same study suggests that sugar-sweetened beverages significantly increase disability from diabetes, heart disease, and cancers.

The authors of the paper pin-point sugar-sweetened beverages as a single, modifiable component of diet that can impact preventable death and disability in adults in high-, middle-, and low-income countries, indicating an urgent need for strong global prevention programs.

Thus, taking actions to reduce the intake of added sugar is one of the major challenges facing public health authorities worldwide. Due to their potential commercial significance, effective measures will undoubtedly be followed by severe repercussion from parts of the food industry. But, if better health is our aim, confrontations are inevitable.

However, for us, individuals and mortal human beings the message is simple; few lifestyle measures are likely to be more effective than avoiding added sugar whenever possible.

So, what are you waiting for?


Doc’s Opinion is written and edited by Axel F. Sigurdsson MD, PhD, FACC.

Dr. Sigurdsson is a cardiologist at the Department of Cardiology at The Landspitali University Hospital in Reykjavik Iceland. He also practices cardiology at Hjartamidstodin (The Heart Center) which is a private heart clinic in the Reykjavik area. He is a Fellow of the American College of Cardiology (ACC), The Icelandic Society of Cardiology and the Swedish Society of Cardiology.

Dr. Sigurdsson is a specialist in internal medicine and cardiology. He did his cardiology training at the Sahlgrenska/Östra University Hospital in Gothenburg, Sweden and at the Royal Jubilee Hospital in Victoria BC, Canada between 1988 – 1996. He is past president of the Icelandic Cardiac Society.

Dr. Sigurdsson main interest has been in the field of coronary heart disease and heart failure. He has published more than 100 scientific abstracts, articles and book chapters in international journals and text books.



Fructose and the Ubiquity of Added Sugar

Since realizing that sugar, and not fat, was the major problem in the modern Western diet, The Skeptical Cardiologist has been ratcheting down how much sugar he consumes to the smallest possible amount.

This has lowered what I like to call my “sugarstat,” and has made me exquisitely sensitive to the presence of added sugar in foods.

With this sensitivity comes the heightened realization that added sugar is everywhere.

The obvious sources are soft drinks and other sweetened beverages, candy, cakes, pies, cookies, donuts and fruit juices. Once you mostly eliminate such things from your diet you become aware of the “background” levels of added sugar in other foods.

For example, when I consume what many Americans probably perceive as a “healthy” granola bar (from even the most natural or organic of manufacturers), all I can taste is a sickly sugar taste overwhelming all the other ingredients.

Low-fat yogurt (which I have compared unfavorably to a Snickers Bar here) tastes like pure sugar mixed with odd chemicals and a vague dairy flavor.

Seemingly healthy sushi tastes too sweet to me as it turns out to have lots of sugar mixed in  the rice and the popular eel sauce is mostly made up of sugar.

Most annoying  is the current trend for restaurants to put a “balsamic glaze” loaded with sugar on perfectly good vegetables like brussel sprouts, ruining them for me.

Fructose and Processed Foods

A review article in the Mayo Clinic Proceedings (1) this month presents the case for fructose (from glucose and high-fructose corn syrup) being the major cause of our obesity and diabetes epidemics and thus, the major contributor to cardiovascular disease in the US.

Fructose is a monosaccharide that combines with the monosaccharide glucose to form sucrose, which is what most people recognize as sugar.

Processed foods commonly contain a lot of added fructose-containing sugar but also, increasingly they contain high fructose corn syrup (HFCS) which contains up to 65% fructose.

Large intake of fructose goes hand in hand with consumption of processed foods. Approximately 75% of all foods and beverages in the US contain added sugars. Consumption of added sugar by Americans increased from 4 lbs per person per year to 120 lbs per person per year between 1776 and 1994.

Thanks to a dramatic increase in sugar-sweetened beverages, American teenagers consume about 72 grams of fructose daily.

There are a substantial amount of observational, short-term basic science, and clinical trial data suggesting that all this added sugar, especially fructose, are posing a serious public health problem.

The article presents these data in detail and I’ll summarize the major points as follows:

  1. Fructose is the likely component of sucrose and HFCS that promotes insulin resistance.
  2. In animals and humans, replacement of starch (chains of glucose) with sucrose or fructose causes increase glucose and insulin levels and reduced insulin sensitivity.
  3. Fructose stimulates epigenetic changes and metabolic alterations that shunt calories into storage depots in abdominal fat cells.

In simpler language, fructose promotes abdominal fat build-up and makes you more likely to develop type 2 diabetes.

Fruits and Fructose

I’m sure many of you are thinking, “but fructose is the major sugar in fruit, should I stop eating fruit?”

The answer is NO! The fructose in fruit is not highly concentrated. Fructose makes up 1% of the weight of a pear for example. It is combined with all of the good things, including fiber and phytonutrients and vitamins, that make fruit good for you.

Eliminating added fructose (sugar and HFCS) is by far the simplest thing you can do diet wise to improve your health. If you avoid added fructose, you will be cutting out a lot of the processed foods and sugar-sweetened beverages which have no nutritional value but contribute to obesity and diabetes.

Fructose as Toxin

Real fruit (right) and “Just Fruit Spread” (left). Note the attempts to make the spread appear healthy by announcing that it is “non-GMO”, glutan-free, “organic” and “perfectly sweetened with fair trade cane sugar”. Cane juice is added sugar .

Robert Lustig, a pediatric endocrinologist has talked and written extensively about fructose as a “toxin.” You can watch him here. He’s also published a lot of books on the topic including one which identifies the 56 names under which sugar masquerades.

It’s probably not worth buying that book, but keep in mind that agave and evaporated cane juice are just different forms of sugar. Makers of organic and “natural” foods are   as guilty as food industry giants at adding sugar, but they try to pretend that “natural” sources of sugar are somehow better for you.

I don’t think the science on fructose is totally settled, however, and another recent review (from scientists not funded by the food industry) concluded:

“current evidence on the metabolic effects of fructose, as consumed by the majority of populations, is insufficient to demonstrate such a role in metabolic diseases and the global obesity epidemic”

Skeptically Yours,

Anthony C. Pearson, MD, FACC

1. Added Fructose: A Principal Driver of Type 2 Diabetes Mellitus and Its Consequences. Mayo Clin Proc. 2015:90(3);372-381. DiNicolantonio, JJ, O’Keefe, JH and Lucan SC