Tag Archives: Axel Sigurdsson

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.



Happy Thanksgiving: UpToDate Says Don’t Worry About Saturated Fat Consumption

UpToDate now says high fat dairy OK!

Despite mounting evidence to the contrary, mainstream nutritional guidelines have, for the last 30 years, instructed Americans to reduce fat and, more specifically, saturated fat in their diets.

As I have written here and here, that advice is not supported by the bulk of evidence and is being challenged. Despite this, the USDA guidelines and the American Heart Association guidelines continue to recommend reducing fat intake.

On October 26, 2014 a highly respected online resource called UpToDate changed its recommendations in this area. I became aware of this when I found an outstanding blog post by Dr. Axel Sigurdsson. Dr. Sigurdsson is a cardiologist and the former president of the Icelandic Cardiac Society who writes a blog called Doc’s Opinion; his recent post is titled: “About Heart Disease, Nutrition, Healthy Lifestyle and Prevention of Disease.”

His post, entitled “We no longer recommend avoiding saturated fats per se” provides an outstanding summary of the importance of the change and I highly recommend reading it.

UpToDate is by far the most commonly utilized online clinical decision resource in the world. A recent paper surveyed physicians and found that

the 4 most frequently used resources were online journals (46%), PubMed/MEDLINE (42%), UpToDate(40%), and online books (30%). The overall rating for UpToDate was high due to the large proportion of residents who reported using this resource (77%).

My hospital pays for a subscription to UpToDate and the medical staff and residents (doctors in training) use it very frequently to access the latest information on preventing, diagnosing and treating diseases.  Hopefully, since the residents represent the future of medicine, these changed dietary recommendations will become more widespread and become the dominant nutritional message to the public.

The UpToDate authors wrote:

“Although it is known that there is a continuous graded relationship between serum cholesterol concentration and coronary heart disease (CHD), and that dietary intake of saturated fats raises total serum cholesterol, a 2014 meta-analysis of prospective observational studies found no association between intake of saturated fat and risk for CHD.

The meta-analysis also found no relationship between monounsaturated fat intake and CHD, but suggested a reduction in CHD with higher intake of omega-3 polyunsaturated fats; a benefit with omega-6 polyunsaturated fats remains uncertain.

Given these results, we no longer suggest avoiding saturated fats per se, although many foods high in saturated fats are less healthy than foods containing lower levels.

In particular, we no longer feel there is substantial evidence for choosing dairy products based on low-fat content (such as choosing skim milk in preference to higher fat milk). We continue to advise reducing intake of trans fatty acids.”

I’m particularly happy to see this change with respect to dairy products because I think the switch to non or low fat diary has been deleterious to Americans’ health and is not supported by data.

As Dr. Sigurdsson observes:

Today, blaming the rising incidence of coronary heart disease 40-50 years ago on the intake of red meat, whole-fat milk, cheese, cream, butter and eggs appears naive at best.

To condemn one macronutrient and suggest it be replaced with another, without having any scientific evidence that such and intervention is helpful, would today be considered careless and irresponsible.

Sticking with the same conclusion for 40 years, despite abundant contradictory evidence is shocking and hard to understand. Hopefully, UpToDate’s recent reconsideration of the issue is a sign that the tide is turning.

Of course, there’s no reason to promote high consumption of saturated fats and surely there will often be healthier options. However, it’s time we stop telling people that avoiding saturated fats may protect them from heart disease. Why should we say such a thing if it’s not supported by evidence?

It will be interesting to see how public authorities such as the American Heart Association will react to recent scientific evidence on the proposed link between saturated fats and coronary artery disease. Will we see a change in the forthcoming 2015 version of The Dietary Guidelines for Americans?

Will their approach be evidence-based or not? Will they accept that red meat, whole-fat milk, cheese, cream, butter and eggs can be a part of a healthy diet? Will they reconsider their recommendations as UpToDate has now officially done? Only time will tell.