Relation of total sugars, fructose and sucrose with incident type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies

Twenty-Four-Hour Urinary Sugars Biomarker in a Vending Machine Intake Paradigm in a Diverse Population

Accurately measuring dietary sugars intake in large-scale epidemiological studies is necessary to understand dietary sugars' true impact on health. Researchers have developed a biomarker that can be used to assess total sugars intake. Our objective is to test this biomarker in diverse populations using an ad libitum intake protocol. Healthy adult participants (n = 63; 58% Indigenous Americans/Alaska Natives; 60% male; BMI (mean ± SD) = 30.6 ± 7.6 kg.m2) were admitted for a 10-day inpatient stay. On day 2, body composition was measured by DXA, and over the last 3 days, ad libitum dietary intake was measured using a validated vending machine paradigm. Over the same days, participants collected daily 24 h urine used to measure sucrose and fructose. The 24 h urinary sucrose and fructose biomarker (24hruSF) (mg/d) represents the sum of 24 h urinary sucrose and fructose excretion levels. The association between the 3-day mean total sugars intake and log 24uSF level was assessed using the Pearson correlation. A linear mixed model regressing log-biomarker on total sugars intake was used to investigate further the association between biomarker, diet, and other covariates. Mean (S.D.) total sugars intake for the group was 197.7 g/d (78.9). Log 24uSF biomarker was moderately correlated with total sugars intake (r = 0.33, p = 0.01). In stratified analyses, the correlation was strongest in females (r = 0.45, p = 0.028), the 18-30 age group (r = 0.44, p = 0.079), Indigenous Americans (r = 0.51, p = 0.0023), and the normal BMI category (r = 0.66, p = 0.027). The model adjusted for sex, age, body fat percent, and race/ethnicity demonstrated a statistically significant association between 24uSF and total sugars intake (β = 0.0027, p < 0.0001) and explained 31% of 24uSF variance (marginal R2 = 0.31). Our results demonstrated a significant relationship between total sugars intake and the 24uSF biomarker in this diverse population. However, the results were not as strong as those of controlled feeding studies that investigated this biomarker.

Validity of the intake of sugars, amino acids, and fatty acids estimated using a self-administered food frequency questionnaire in middle-aged and elderly Japanese: the Japan Public Health Center-based Prospective Study for the Next Generation (JPHC-NEXT) Protocol Area

BACKGROUND

The Japanese database of food composition was revised in 2020, during which both the number of food items and the number of food items measured for sugars, amino acids, and fatty acids were increased. We evaluated the validity of estimated intakes of sugars, amino acids and fatty acids using a long-food frequency questionnaire (FFQ) among middle-aged and elderly Japanese.

METHODS

From 2012 to 2013, 240 men and women aged 40-74 years from five areas in the JPHC-NEXT protocol were asked to respond to the long-FFQ and provide a 12-day weighed food record (WFR) as reference. The long-FFQ, which included 172 food and beverage items and 11 seasonings, was compared with a 3-day WFR, completed during each distinct season, and validity was assessed using Spearman's correlation coefficients.

RESULTS

Percentage differences based on the long-FFQ with the 12-day WFR in men and women varied from -83.9% to 419.6%, and from -75.8% to 623.1% for sugars, -17.5% to 2.8% and -5.8% to 19.6% for amino acids, and -58.5% to 78.8% and -43.4% to 129.3% for fatty acids, respectively. Median values of correlation coefficients for the long-FFQ in men and women were 0.52 and 0.42 for sugars, 0.38 and 0.37 for amino acids, and 0.42 and 0.42 for fatty acids, respectively.

CONCLUSIONS

The long-FFQ provided reasonable validity in estimating the intakes of sugars, amino acids, and fatty acids in middle-aged and elderly Japanese. Although caution is warranted for some nutrients, these results may be used in future epidemiological studies.

GRADE GUIDANCE 38: Updated guidance for rating up certainty of evidence due to a dose-response gradient

INTRODUCTION

This updated guidance from the Grading of Recommendations Assessment, Development, and Evaluation addresses rating up certainty of evidence due to a dose-response gradient (DRG) observed in synthesis of intervention and exposure studies.

STUDY DESIGN AND SETTING

This guidance was developed using iterative discussions and consensus in multiple meetings and was presented to attendees of the Grading of Recommendations Assessment, Development, and Evaluation Working Group meeting for feedback in November 2022 and for final approval in May 2023.

RESULTS

The guidance consists of two steps. The first is to determine whether the DRG is credible. We describe five items for assessing credibility: a) is DRG identified using a proper analytical approach; b) is confounding the cause of the DRG; c) is there serious concern about ecological bias; d) is the DRG consistent across studies; and e) is there indirect evidence supporting the DRG. The first two of these items are the most critical. If the DRG was judged to be credible, then the second step is to apply the DRG domain and consider rating up, but only by one level due to the concern about residual confounding.

CONCLUSION

Systematic review authors should only rate up certainty in evidence when a DRG is deemed credible.

The mediating role of obesity on the prospective association between urinary sucrose and diabetes incidence in a sub-cohort of the EPIC-Norfolk

BACKGROUND/OBJECTIVES

Findings from epidemiological studies showed controversial findings between dietary sugar intake and the development of diabetes. Most of these studies assessed dietary sugar intake by self-reports which might be prone to bias. Urinary sucrose, an objective biomarker of sucrose intake, might provide better insights into this association. Thus, the aim of this study was to investigate the associations between sucrose intake, measured via self-reports and urinary sucrose, with incident diabetes and to detect the impact of obesity on this association.

SUBJECTS/METHODS

Data of a sub-group (n = 2996) from the prospective EPIC-Norfolk cohort were investigated. Sucrose intake was assessed by self-reports (validated food frequency questionnaire (FFQ) and 7-day diet diaries (7DD)) and as an objective urinary sucrose biomarker. Cox proportional hazard models were conducted to calculate hazard ratios (HRs) and 95% confidence intervals (CI) for the associations between urinary and dietary sucrose intake and incident diabetes. Mediation analysis was performed to investigate the mediated percentage of body mass index (BMI) and waist circumference (WC) on this association.

RESULTS

The mean age of the participants was 60.6 ± 9.5 years and 53% were women. After a mean follow-up of 11.2 ± 2.9 years, 97 participants developed diabetes. Findings suggested inverse associations regarding incident diabetes for self-reported sucrose intake per 50 g/d via 7DD [HR: 0.63 (95% CI: 0.43, 0.91)], and a tendency via FFQ [HR: 0.81 (95% CI: 0.46, 1.42)]. Urinary sucrose indicated a positive association with incident diabetes for each increase of 100 µM [HR: 1.14 (95% CI: 0.95, 1.36)]. The proportion mediated of BMI and WC for this association was 16 and 22%.

CONCLUSIONS

These findings indicate that sucrose measured as objective urinary biomarker points to a positive association with incident diabetes. BMI might partly mediate this association. However, to obtain more precise results, more studies are warranted that consider this objective biomarker.

Fructose-containing food sources and blood pressure: A systematic review and meta-analysis of controlled feeding trials

Whether food source or energy mediates the effect of fructose-containing sugars on blood pressure (BP) is unclear. We conducted a systematic review and meta-analysis of the effect of different food sources of fructose-containing sugars at different levels of energy control on BP. We searched MEDLINE, Embase and the Cochrane Library through June 2021 for controlled trials ≥7-days. We prespecified 4 trial designs: substitution (energy matched substitution of sugars); addition (excess energy from sugars added); subtraction (excess energy from sugars subtracted); and ad libitum (energy from sugars freely replaced). Outcomes were systolic and diastolic BP. Independent reviewers extracted data. GRADE assessed the certainty of evidence. We included 93 reports (147 trial comparisons, N = 5,213) assessing 12 different food sources across 4 energy control levels in adults with and without hypertension or at risk for hypertension. Total fructose-containing sugars had no effect in substitution, subtraction, or ad libitum trials but decreased systolic and diastolic BP in addition trials (P<0.05). There was evidence of interaction/influence by food source: fruit and 100% fruit juice decreased and mixed sources (with sugar-sweetened beverages [SSBs]) increased BP in addition trials and the removal of SSBs (linear dose response gradient) and mixed sources (with SSBs) decreased BP in subtraction trials. The certainty of evidence was generally moderate. Food source and energy control appear to mediate the effect of fructose-containing sugars on BP. The evidence provides a good indication that fruit and 100% fruit juice at low doses (up to or less than the public health threshold of ~10% E) lead to small, but important reductions in BP, while the addition of excess energy of mixed sources (with SSBs) at high doses (up to 23%) leads to moderate increases and their removal or the removal of SSBs alone (up to ~20% E) leads to small, but important decreases in BP in adults with and without hypertension or at risk for hypertension. Trial registration: Clinicaltrials.gov: NCT02716870.

Urinary Sucrose and Fructose From Spot Urine May Be Used as a Predictive Biomarker of Total Sugar Intake-Findings From a Controlled Feeding Study

BACKGROUND

Recently, we confirmed 24-h urinary sucrose plus fructose (24 uSF) as a predictive biomarker of total sugar intake. However, the collection of 24-h urine samples has limited feasibility in population studies.

OBJECTIVE

We investigated the utility of the urinary sucrose plus fructose (uSF) biomarker measured in spot urine as a measure of 24 uSF biomarker and total sugar intake.

METHODS

Hundred participants, 18-70 y of age, from the Phoenix Metropolitan Area completed a 15-d feeding study. For 2 of the 8 collected 24-h urine samples, each spot urine sample was collected in a separate container. We considered 4 timed voids of the day [morning (AM) void: first void 08:30-12:30; afternoon (PM) void: first void 12:31-17:30; evening (EVE) void: first void 17:31-12:00; and next-day (ND) void: first void 04:00-12:00]. We investigated the performance of uSF from 1 void, and uSF combined from 2 and 3 voids as a measure of 24 uSF and sugar intake.

RESULTS

The biomarker averaged from PM/EVE void strongly correlated with 24 uSF (partial r = 0.75). The 24 uSF predicted from the PM/EVE combination was significantly associated with observed sugar intake and was selected for building the calibrated biomarker equation (marginal R2 = 0.36). Spot urine-based calibrated biomarker, ie, biomarker-estimated sugar intake was moderately correlated with the 15-d mean-observed sugar intake (r = 0.50).

CONCLUSIONS

uSF measured from a PM and EVE void may be used to generate biomarker-based sugar intake estimate when collecting 24-h urine samples is not feasible, pending external validation.

Longitudinal Associations of Dietary Sugars and Glycaemic Index with Indices of Glucose Metabolism and Body Fatness during 3-Year Weight Loss Maintenance: A PREVIEW Sub-Study

BACKGROUND

Dietary sugars are often linked to the development of overweight and type 2 diabetes (T2D) but inconsistencies remain.

OBJECTIVE

We investigated associations of added, free, and total sugars, and glycaemic index (GI) with indices of glucose metabolism (IGM) and indices of body fatness (IBF) during a 3-year weight loss maintenance intervention.

DESIGN

The PREVIEW (PREVention of diabetes through lifestyle Intervention and population studies in Europe and around the World) study was a randomised controlled trial designed to test the effects of four diet and physical activity interventions, after an 8-week weight-loss period, on the incidence of T2D. This secondary observational analysis included pooled data assessed at baseline (8), 26, 52, 104 and 156 weeks from 514 participants with overweight/obesity (age 25-70 year; BMI ≥ 25 kg⋅m^-2) and with/without prediabetes in centres that provided data on added sugars (Sydney and Helsinki) or free sugars (Nottingham). Linear mixed models with repeated measures were applied for IBF (total body fat, BMI, waist circumference) and for IGM (fasting insulin, HbA1c, fasting glucose, C-peptide). Model A was adjusted for age and intervention centre and Model B additionally adjusted for energy, protein, fibre, and saturated fat.

RESULTS

Total sugars were inversely associated with fasting insulin and C-peptide in all centres, and free sugars were inversely associated with fasting glucose and HbA1c (Model B: all p < 0.05). Positive associations were observed between GI and IGM (Model B: fasting insulin, HbA1c, and C-peptide: (all p < 0.01), but not for added sugars. Added sugar was positively associated with body fat percentage and BMI, and GI was associated with waist circumference (Model B: all p < 0.01), while free sugars showed no associations (Model B: p > 0.05).

CONCLUSIONS

Our findings suggest that added sugars and GI were independently associated with 3-y weight regain, but only GI was associated with 3-y changes in glucose metabolism in individuals at high risk of T2D.

Dietary sugar consumption and health: umbrella review

OBJECTIVE

To evaluate the quality of evidence, potential biases, and validity of all available studies on dietary sugar consumption and health outcomes.

DESIGN

Umbrella review of existing meta-analyses.

DATA SOURCES

PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, and hand searching of reference lists.

INCLUSION CRITERIA

Systematic reviews and meta-analyses of randomised controlled trials, cohort studies, case-control studies, or cross sectional studies that evaluated the effect of dietary sugar consumption on any health outcomes in humans free from acute or chronic diseases.

RESULTS

The search identified 73 meta-analyses and 83 health outcomes from 8601 unique articles, including 74 unique outcomes in meta-analyses of observational studies and nine unique outcomes in meta-analyses of randomised controlled trials. Significant harmful associations between dietary sugar consumption and 18 endocrine/metabolic outcomes, 10 cardiovascular outcomes, seven cancer outcomes, and 10 other outcomes (neuropsychiatric, dental, hepatic, osteal, and allergic) were detected. Moderate quality evidence suggested that the highest versus lowest dietary sugar consumption was associated with increased body weight (sugar sweetened beverages) (class IV evidence) and ectopic fatty accumulation (added sugars) (class IV evidence). Low quality evidence indicated that each serving/week increment of sugar sweetened beverage consumption was associated with a 4% higher risk of gout (class III evidence) and each 250 mL/day increment of sugar sweetened beverage consumption was associated with a 17% and 4% higher risk of coronary heart disease (class II evidence) and all cause mortality (class III evidence), respectively. In addition, low quality evidence suggested that every 25 g/day increment of fructose consumption was associated with a 22% higher risk of pancreatic cancer (class III evidence).

CONCLUSIONS

High dietary sugar consumption is generally more harmful than beneficial for health, especially in cardiometabolic disease. Reducing the consumption of free sugars or added sugars to below 25 g/day (approximately 6 teaspoons/day) and limiting the consumption of sugar sweetened beverages to less than one serving/week (approximately 200-355 mL/week) are recommended to reduce the adverse effect of sugars on health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022300982.

EAT-Lancet Healthy Reference Diet score and diabetes incidence in a cohort of Mexican women

To improve the health of our planet and develop sustainable food policies, it is important to understand the health impact of a diet pattern that considers planetary and population health. We used data from the Mexican Teachers' Cohort (MTC) to estimate the association between the EAT-Lancet healthy reference diet (EAT-HRD) and type 2 diabetes (T2D) incidence. We included 74,671 women aged ≥25 years, free of T2D at baseline. A validated food frequency questionnaire (FFQ) was used to assess dietary intake. We created an EAT-HRD score based on 15 food groups recommended by the EAT-Lancet Commission (range from 0 to 15). T2D cases were identified through self-report and cross-linkage with clinical and administrative databases. We used Cox proportional hazards models to estimate the association between categories of the EAT-HRD score with T2D incidence. During a median follow-up of 2.16 y (IQR 1.8-4.3 y), we identified 3241 T2D incident cases. The median EAT-HRD score was 6 (IQR 5-7). In multivariable analyses, when comparing extreme categories, higher adherence to the EAT-HRD score was associated with lower T2D incidence (HR 0.90; 95% CI 0.75, 1.10), yet, the estimation was imprecise. Compared to those who did not meet the EAT-HRD recommendations, adhering to the red meat, legumes, and fish recommendations was associated with lower T2D incidence. Meeting the recommendation of dairy and added sugars was associated with an increased incidence of T2D. Higher adherence to a diet designed to promote environmental and human health may help prevent T2D incidence among women in a middle-income country.

The Impact of Free Sugar on Human Health-A Narrative Review

The importance of nutrition in human health has been understood for over a century. However, debate is ongoing regarding the role of added and free sugars in physiological and neurological health. In this narrative review, we have addressed several key issues around this debate and the major health conditions previously associated with sugar. We aim to determine the current evidence regarding the role of free sugars in human health, specifically obesity, diabetes, cardiovascular diseases, cognition, and mood. We also present some predominant theories on mechanisms of action. The findings suggest a negative effect of excessive added sugar consumption on human health and wellbeing. Specific class and source of carbohydrate appears to greatly influence the impact of these macronutrients on health. Further research into individual effects of carbohydrate forms in diverse populations is needed to understand the complex relationship between sugar and health.

Fructose-Induced Alteration of the Heart and Vessels Homeostasis

To date, the role of uncontrolled sugar consumption in the triggering and progression of cardiovascular events is undeniable. Modern concepts offer a new hypothesis regarding the direct myocardiotoxic effects of fructose. Experimental studies have demonstrated that cardiomyocytes have a unique ability to transport and use fructose along with the expression of all components involved in fructose metabolism. The purpose of this review article is to assess and analyze the available knowledge on fructose-induced cardiotoxicity detection since understanding the pathophysiological mechanisms and pathobiochemical aspects will become the basis for the determination of a rational myocardioprotection regimen.

Antioxidant-Enriched Diet on Oxidative Stress and Inflammation Gene Expression: A Randomized Controlled Trial

The Mediterranean Diet (MedDiet) is associated with beneficial effects against chronic non-communicable diseases (CNCDs). In particular, the content of micronutrients leads to an improvement of the oxidative and inflammatory profiles. A randomized, parallel, controlled study, on 24 subjects, was conducted to evaluate if 2-week supplementation with a mixed apple and bergamot juice (MAB juice), had a positive impact on the body composition, the biochemical profile, and oxidative and inflammatory gene expression (Superoxide dismutase (SOD1), Peroxisome Proliferator-Activated Receptor γ (PPARγ), catalase (CAT), chemokine C-C motif ligand 5 (CCL5), Nuclear Factor Kappa B Subunit 1 (NFKB1), Vitamin D Receptor (VDR), and Macrophage Migration Inhibitory Factor (MIF)), respect to a MedDiet. Body composition evaluation analysis showed a gain in lean mass (p < 0.01). Moreover, a significant reduction in total cholesterol/HDL index (p < 0.01) was pointed out between the two groups. Gene expression analysis highlighted an increase in MIF (p ≤ 0.05), PPARγ (p < 0.001), SOD1 (p ≤ 0.05), and VDR (p ≤ 0.05) expressions when comparing MedDiet and MedDiet + MAB juice groups. These data based on the nutrigenomics approach demonstrated that supplementing 2 weeks of MAB juice to the MedDiet could contribute to a reduction in the risk of CNCDs.

A modified standard American diet induces physiological parameters associated with metabolic syndrome in C57BL/6J mice

Investigations into the causative role that western dietary patterns have on obesity and disease pathogenesis have speculated that quality and quantity of dietary fats and/or carbohydrates have a predictive role in the development of these disorders. Standard reference diets such as the AIN-93 rodent diet have historically been used to promote animal health and reduce variation of results across experiments, rather than model modern human dietary habits or nutrition-related pathologies. In rodents high-fat diets (HFDs) became a classic tool to investigate diet-induced obesity (DIO). These murine diets often relied on a single fat source with the most DIO consistent HFDs containing levels of fat up to 45-60% (kcal), higher than the reported human intake of 33-35% (kcal). More recently, researchers are formulating experimental animal (pre-clinical) diets that reflect mean human macro- and micronutrient consumption levels described by the National Health and Nutrition Examination Survey (NHANES). These diets attempt to integrate relevant ingredient sources and levels of nutrients; however, they most often fail to include high-fructose corn syrup (HFCS) as a source of dietary carbohydrate. We have formulated a modified Standard American Diet (mSAD) that incorporates relevant levels and sources of nutrient classes, including dietary HFCS, to assess the basal physiologies associated with mSAD consumption. Mice proffered the mSAD for 15 weeks displayed a phenotype consistent with metabolic syndrome, exhibiting increased adiposity, fasting hyperglycemia with impaired glucose and insulin tolerance. Metabolic alterations were evidenced at the tissue level as crown-like structures (CLS) in adipose tissue and fatty acid deposition in the liver, and targeted 16S rRNA metagenomics revealed microbial compositional shifts between dietary groups. This study suggests diet quality significantly affects metabolic homeostasis, emphasizing the importance of developing relevant pre-clinical diets to investigate chronic diseases highly impacted by western dietary consumption patterns.

Effects of individualized dietary advice compared with conventional dietary advice for adults with type 2 diabetes: A randomized controlled trial

BACKGROUND AND AIMS

To investigate the superiority of individualized dietary advice based on dietary assessment for patients with type 2 diabetes.

METHODS AND RESULTS

A total of 136 Japanese adults with type 2 diabetes were randomized into either individualized or conventional dietary advice groups after dietary assessment using a self-administered brief-type diet history questionnaire. Both participants received three 30-min face-to-face dietary advice sessions by dietitians at 1, 3, and 5 months from study entry. The individualized group received dietary advice based on individual dietary intakes. The conventional group received dietary advice using generalized pamphlets. The primary outcome was the change in HbA1c over 6 months, and secondary outcomes were changes in weight, serum triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and dietary intakes. In total, 126 participants were included in the analysis. After adjustment for age, sex, and baseline measurements, HbA1c significantly decreased larger in the individualized group [-1.1%, (95% CI: -1.3 to -0.8)] than the conventional group [-0.7% (95% CI: -1.0 to -0.4)] (P = 0.0495). The individualized group significantly decreased weight, serum triglyceride, and LDL-C, and significantly increased HDL-C, without a significant difference to the conventional group. In dietary changes, the individualized group decreased intakes of energy, confectioneries, meats, oil and fats, and sugar-sweetened beverages. The conventional group decreased alcohol intake and increased total fat and saturated fatty acid intakes.

CONCLUSIONS

Individualized dietary advice among patients with type 2 diabetes was superior to conventional dietary advice in lowering HbA1c.

TRIAL REGISTRATION

UMIN000037268 (https://www.umin.ac.jp/ctr/index.htm) in July 4, 2019.

The role of dietary sugars, overweight, and obesity in type 2 diabetes mellitus: a narrative review

Nowadays, there is still a popular belief that dietary sugars, in particular sucrose, are directly linked to the development of type 2 diabetes mellitus (T2DM). Furthermore, since insulin action is impaired in T2DM, it is still believed that excluding dietary sugars from the diet can adequately treat T2DM. This might be based on the assumption that dietary sugars have a stronger impact on blood glucose levels than other carbohydrates. Therefore, the aim of this review is to discuss the effects of dietary sugars intake, including sugar-sweetened beverages (SSBs) against the background of overall energy intake and weight gain in the development of T2DM. Furthermore, the effect of dietary sugars, including SSBs on glycemic control will be discussed. Results from various systematic reviews and meta-analyses do not support the idea that the intake of sucrose and other dietary sugars is linked to T2DM. Long-chain or complex carbohydrates can have a greater impact on postprandial glycemic response than sucrose. SSBs do not affect glycemic control if substituted for other calorie sources. Current scientific evidence clearly points toward excess energy intake followed by excess body fat gain being most relevant in the development of T2DM.

Decreasing the RAG:SAG ratio of granola cereal predictably reduces postprandial glucose and insulin responses: a report of four randomised trials in healthy adults

Dietary starch contains rapidly (RAG) and slowly available glucose (SAG). To establish the relationships between the RAG:SAG ratio and postprandial glucose, insulin and hunger, we measured postprandial responses elicited by test meals varying in the RAG:SAG ratio in n 160 healthy adults, each of whom participated in one of four randomised cross-over studies (n 40 each): a pilot trial comparing six chews (RAG:SAG ratio 2·4–42·7) and three studies comparing a test granola (TG1-3, RAG:SAG ratio 4·5–5·2) with a control granola (CG1–3, RAG:SAG ratio 54·8–69·3). Within studies, test meals were matched for fat, protein and available carbohydrate. Blood glucose, serum insulin and subjective hunger were measured for 3 h. Data were subjected to repeated-measures analysis of variance (ANOVA). The relationships between the RAG:SAG ratio and postprandial end points were determined by regression analysis. In the pilot trial, 0–2 h glucose incremental areas under the curve (iAUC0–2; primary end point) varied across the six chews (P = 0·014) with each 50 % reduction in the RAG:SAG ratio reducing relative glucose response by 4·0 %. TGs1-3 elicited significantly lower glucose iAUC0–2 than CGs1–3 by 17, 18 and 17 %, respectively (similar to the 15 % reduction predicted by the pilot trial). The combined means ± sem (n 120) for TC and CG were glucose iAUC0–2, 98 ± 4 v. 118 ± 4 mmol × min/l (P < 0·001), and insulin iAUC0–2, 153 ± 9 v. 184 ± 11 nmol × h/l (P < 0·001), respectively. Neither postprandial hunger nor glucose or hunger increments 2 h after eating differed significantly between TG and CG. We concluded that TGs with RAG:SAG ratios <5·5 predictably reduced glycaemic and insulinaemic responses compared with CGs with RAG:SAG ratios >54. However, compared with CG, TG did not reduce postprandial hunger or delay the return of glucose or hunger to baseline.

Exploring diet associations with Covid-19 and other diseases: a Network Analysis-based approach

The current global pandemic, Covid-19, is a severe threat to human health and existence especially when it is mutating very frequently. Being a novel disease, Covid-19 is impacting the patients with comorbidities and is predicted to have long-term consequences, even for those who have recovered from it. To clearly recognize its impact, it is important to comprehend the complex relationship between Covid-19 and other diseases. It is also being observed that people with good immune system are less susceptible to the disease. It is perceived that if a correlation between Covid-19, other diseases, and diet is realized, then caregivers would be able to enhance their further course of medical action and recommendations. Network Analysis is one such technique that can bring forth such complex interdependencies and associations. In this paper, a Network Analysis–based approach has been proposed for analyzing the interplay of diets/foods along with Covid-19 and other diseases. Relationships between Covid-19, diabetes mellitus type 2 (T2DM), non-alcoholic fatty liver disease (NAFLD), and diets have been curated, visualized, and further analyzed in this study so as to predict unknown associations. Network algorithms including Louvain graph algorithm (LA), K nearest neighbors (KNN), and Page rank algorithms (PR) have been employed for predicting a total of 60 disease-diet associations, out of which 46 have been found to be either significant in disease risk prevention/mitigation or in its progression as validated using PubMed literature. A precision of 76.7% has been achieved which is significant considering the involvement of a novel disease like Covid-19. The generated interdependencies can be further explored by medical professionals and caregivers in order to plan healthy eating patterns for Covid-19 patients. The proposed approach can also be utilized for finding beneficial diets for different combinations of comorbidities with Covid-19 as per the underlying health conditions of a patient.

Nicotinamide riboside ameliorates high-fructose-induced lipid metabolism disorder in mice via improving FGF21 resistance in the liver and white adipose tissue

NR supplementation could ameliorate high-fructose-induced lipid metabolism disorder by improving FGF21 resistance in the liver and WAT, which may be related to the inflammation state mediated by SIRT1/NF-κB signaling pathway.

Validity of FFQ Estimates of Total Sugars, Added Sugars, Sucrose and Fructose Compared to Repeated 24-h Recalls in Adventist Health Study-2 Participants

Sugar intake is a potentially important aspect of diet which has not previously been validated in the Adventist Health Study-2 (AHS-2). We sought to validate the food frequency questionnaire (FFQ) measurement of total sugars, added sugars, sucrose, and fructose against multiple 24-h dietary recalls (recalls) in AHS-2 participants. Food consumption data from a self-administered FFQ and six recalls from 904 participants were combined with nutrient profile data to estimate daily sugar intake. Validity was evaluated among all participants and by race. FFQ and recall means were compared and correlation coefficients (Spearman’s, energy-adjusted log-transformed Pearson’s, deattenuated Pearson’s) were calculated. Mean total energy, total sugars, and fructose intake were higher in the FFQ, whereas added sugars and sucrose were higher in recalls. The energy-adjusted (log-transformed) deattenuated correlations among all participants were: total sugars (r = 0.42, 95% CI 0.32–0.52), added sugars (r = 0.50, 95% CI 0.36–0.59), sucrose (r = 0.32, 95% CI 0.23–0.42), and fructose (r = 0.50, 95% CI 0.40–0.59). We observed moderate validity for added sugars and fructose and low-moderate validity for total sugars and sucrose measured by the AHS-2 FFQ in this population. Dietary sugar estimates from this FFQ may be useful in assessing possible associations of sugars intake with health outcomes.

Single Nucleotide Polymorphisms in Close Proximity to the Fibroblast Growth Factor 21 (FGF21) Gene Found to Be Associated with Sugar Intake in a Swedish Population

Hereditary mechanisms are partially responsible for individual differences in sensitivity to and the preference for sweet taste. The primary aim of this study was to examine the associations between 10 genetic variants and the intake of total sugar, added sugar, and sugars with sweet taste (i.e., monosaccharides and sucrose) in a middle-aged Swedish population. Two single nucleotide polymorphisms (SNPs) within the Fibroblast grow factor 21 (FGF21) gene, seven top hits from a genome-wide association study (GWAS) on total sugar intake, and one SNP within the fat mass and obesity associated (FTO) gene (the only SNP reaching GWAS significance in a previous study), were explored in relation to various forms of sugar intake in 22,794 individuals from the Malmö Diet and Cancer Study, a population-based cohort for which data were collected between 1991-1996. Significant associations (p = 6.82 × 10^-7 - 1.53 × 10^-3) were observed between three SNPs (rs838145, rs838133, and rs8103840) in close relation to the FGF21 gene with high Linkage Disequilibrium, and all the studied sugar intakes. For the rs11642841 within the FTO gene, associations were found exclusively among participants with a body mass index ≥ 25 (p < 5 × 10^-3). None of the remaining SNPs studied were associated with sugar intake in our cohort. A further GWAS should be conducted to identify novel genetic variants associated with the intake of sugar.

Dietary fructose and risk of metabolic syndrome in Chinese residents aged 45 and above: results from the China National Nutrition and Health Survey

BACKGROUND

A growing number of researches supported that dietary fructose was associated with most of the key features of metabolic syndrome (MetS). However, there was no related epidemiological studies among Chinese population, despite the sharp increase in MetS cases. This study explores the relationship between dietary fructose and MetS among Chinese residents aged 45 and above.

METHODS

A total of 25,528 participants (11,574 males and 13,954 females) were included in this nationwide representative cross-sectional study of China National Nutrition and Health Survey. Dietary fructose intake was assessed by 3-day 24-h dietary records. MetS was defined by the International Diabetes Federation and Chinese Diabetes Society criteria.

RESULTS

The consumption of dietary fructose was 11.6 g/day for urban residents and 7.6 g/day for rural residents. Fruits and vegetables as well as their products were the main sources of fructose intake. There was no association between dietary fructose intake and the odds of having MetS in both urban (P = 0.315) and rural residents (P = 0.230) after adjustment for confounding factors. Moreover, for urban residents participating physical activities, the odds of having MetS in the fourth quartiles (OR: 0.67; 95%CI: 0.52-0.87) was lower than that in the first quartile. In the sensitivity analysis, a significant reduction in the odds of having MetS was also found in the fourth quartiles (OR, 95%CI: 0.68, 0.51-0.90; 0.67, 0.49-0.91; 0.74, 0.56-0.99) compared with the first quartile when excluding smokers, alcohol users, and underweight/obesity, respectively. And there was no association between dietary fructose intake and the odds of having MetS after multivariate adjustment stratified by gender, smoking and alcohol use.

CONCLUSIONS

Under the current dietary fructose intake status, there was no association between dietary fructose intake and the odds of having MetS among Chinese residents aged 45 and above. Physical activity and relatively low fructose intake may have a beneficial synergistic effect on MetS.

Evaluation of sucrose-enriched diet consumption in the development of risk factors associated to type 2 diabetes, atherosclerosis and non-alcoholic fatty liver disease in a murine model

Overconsumption of sucrose, the main contributor of the total added sugar intake in the world, has been associated with negative metabolic effects related to non-communicable diseases. However, this relationship continues to be a controversial topic and further studies are needed. The aim of this study was to evaluate the sucrose-enriched diet consumption in the development of risk factors associated with type 2 diabetes, atherosclerosis and non-alcoholic fatty liver disease in a murine model. Sucrose-enriched diet-fed rats showed a decrease in food, lipids and protein intake as well as in serum total cholesterol levels, an increase in carbohydrates intake, glucose, insulin, triglycerides, VLDL-c and HDL-c levels and a greater degree of insulin resistance, steatosis and non-alcoholic steatohepatitis. Our results show that sucrose-enriched diet consumption during 25 weeks contribute to the development of risk factors associated with type 2 diabetes, atherosclerosis and non-alcoholic fatty liver disease in male Wistar rats.

Investigating the performance of 24-h urinary sucrose and fructose as a biomarker of total sugars intake in US participants - a controlled feeding study

BACKGROUND

Developing approaches for the objective assessment of sugars intake in population research is crucial for generating reliable disease risk estimates, and evidence-based dietary guidelines. Twenty-four-hour urinary sucrose and fructose (24uSF) was developed as a predictive biomarker of total sugars intake based on 3 UK feeding studies, yet its performance as a biomarker of total sugars among US participants is unknown.

OBJECTIVES

To investigate the performance of 24uSF as a biomarker of sugars intake among US participants, and to characterize its use.

METHODS

Ninety-eight participants, aged 18-70 y, consumed their usual diet under controlled conditions of a feeding study for 15 d, and collected 8 nonconsecutive 24-h urines measured for sucrose and fructose.

RESULTS

A linear mixed model regressing log 24uSF biomarker on log total sugars intake along with other covariates explained 56% of the biomarker variance. Total sugars intake was the strongest predictor in the model (Marginal R2 = 0.52; P <0.0001), followed by sex (P = 0.0002) and log age (P = 0.002). The equation was then inverted to solve for total sugars intake, thus generating a calibrated biomarker equation. Calibration of the biomarker produced mean biomarker-based log total sugars of 4.79 (SD = 0.59), which was similar to the observed log 15-d mean total sugars intake of 4.69 (0.35). The correlation between calibrated biomarker and usual total sugars intake was 0.59 for the calibrated biomarker based on a single biomarker measurement, and 0.76 based on 4 biomarker repeats spaced far apart.

CONCLUSIONS

In this controlled feeding study, total sugars intake was the main determinant of 24uSF confirming its utility as a biomarker of total sugars in this population. Next steps will include validation of stability assumptions of the biomarker calibration equation proposed here, which will allow its use as an instrument for dietary validation and measurement error correction in diet-disease association studies.

No Effect of Added Sugars in Soft Drink Compared With Sugars in Fruit on Cardiometabolic Risk Factors: Results From a 4-Week, Randomized Controlled Trial

High intakes of added sugar from soft drinks are associated with negative health outcomes such as the increased risk of gout and type 2 diabetes, weight gain and cardiovascular disease. Fruits are naturally high in sugars but their effect on cardiometabolic risk remains unknown. We examined the effect on cardiometabolic risk factors of consuming natural sugars from fruit or added sugars from sugar-sweetened soft drinks in overweight adults. Forty-eight healthy, overweight (BMI ≥ 28 kg/m²) men (n = 21) and women (n = 20) were randomized to either a fruit (n = 19) or sugar-sweetened soft drink (n = 22) intervention for 4 weeks. The fruit group received 6 items of fresh and dried fruit per day and the sugar-sweetened soft drink group received 955 ml of sugar-sweetened soft drink per day. The interventions were matched for both energy (fruit: 1,800 kJ/d; soft drink: 1,767 kJ/d) and fructose content (fruit: 51.8 g/d; soft drink: 51.7 g/d). The soft drink intervention provided 101 g total sugars, which was all added sugar and the fruit intervention provided 97 g total sugars, which were all natural sugars. Dietary intakes were otherwise ad libitum. Despite being asked to consume additional sugar (up to 1,800 additional kJ/d), there were no changes in weight, blood pressure or other cardiometabolic risk factors, except by uric acid, in any of the intervention groups. In conclusion, our findings do not provide any evidence that short-term regular intake of added sugars is linked to higher cardiometabolic risks, with exception of uric acid in overweight men. Public health interventions to prevent obesity and related diseases should focus on the quality of the whole diet rather than only focusing on reducing sugary drinks or sugar intakes.

The metabolic effect of fructose on normal rats in a mild dose with glucose and saccharose as control

Aims

To study the metabolic effects of fructose, glucose and saccharose in a moderate dose by analyzing changes of blood indicators, pancreas inflammation, liver fat accumulation and intestinal microbiota in normal Sprague-Dawley (SD) rats.

Subjects and methods

Six-week-old rats were assigned to four groups (n = 10), which were gavaged with normalsaline (Con), glucose dissolved in normal saline (Glu), saccharose-glucose dissolved in normal saline (Sac), and fructose dissolved in normal saline (Fru) for 20 weeks.

Results

No significant differences in body weight and blood parameters including total cholesterol (TC), total triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), lipase (LPS) and free fatty acid (FFA) among the Con, Glu, Sac and the Fru group. The fructose can significantly (P < 0.05) decrease fasting and postprandial blood glucose increase compared to glucose, and the risk of pancreas inflammation and liver fat accumulation induced by fructose is lower than glucose in rats. We found there were no significant differences in intestinal microbial diversity. At the family level, rats in the Glu group had a relatively higher abundance of Peptostreptococcaceae and rats in the Fru group had a relatively higher abundance of Bacteroidaceae. Moreover, the proportions of Peptostreptococcaceae romboutsia and Staphylococcus lentus in the Glu group were significantly higher than in the Fru group, while the proportions of Lachnospira; Lachnospiraceae blautia, Bacteroides and Cellulosilyticus in the Fru group were significantly higher than in the Glu group. The concentration of isobutyric acid was relatively lower in all the sugar treated groups than in the Con. A significant decrease in isobutyric acid was found on comparing the Fru group to the Con group (P < 0.05).

Conclusion

Fructose, glucose and sucrose made no significant changes on rats in body weight, blood indicators, organ index and bacterial diversity. Moreover, fructose can potentially attenuate fasting and postprandial blood-glucose increase, pancreas inflammation and liver-fat accumulation when compared to glucose in mild doses. The relative abundance of six kinds of bacterial genera was found significantly different between rats fed on fructose and glucose.

Excessive Intake of High-Fructose Corn Syrup Drinks Induces Impaired Glucose Tolerance

The number of patients with diabetes was approximately 463 million worldwide in 2019, with almost 57.6% of this population concentrated in Asia. Asians often develop type 2 diabetes (T2D), even if they are underweight and consume a smaller amount of food. Soft drinks contain large amounts of sweeteners, such as high-fructose corn syrup (HFCS). Excessive intake of HFCS drinks is considered to be one of the causes of T2D. In the present study, we investigated the effect of excessive consumption of HFCS-water on glucose tolerance and obesity under conditions of controlled caloric intake using a mouse model. Three-week-old male ICR mice were divided into two groups and given free access to 10% HFCS-water or deionized water. The caloric intake was adjusted to be the same in both groups using a standard rodent diet. The excess HFCS-water intake did not lead to obesity, but led to impaired glucose tolerance (IGT) due to insulin-secretion defect. It affected glucose and fructose metabolism; for example, it decreased the expression of glucokinases, ketohexokinase, and glucose transporter 2 in the pancreas. These results suggest that excessive consumption of HFCS drinks, such as soft drinks, without a proper diet, induces nonobese IGT due to insulin-secretion defect.

The contribution of dietary glycemic index and glycemic load to the development of microvascular complications of diabetes

Lifestyle modification, including a healthy diet, is of paramount importance in the management of diabetes mellitus. To this end, diets have been proposed with low glycemic index (an index of carbohydrate food expressing how quickly this nutrient can increase blood glucose) and glycemic load (an index obtained by multiplying the glycemic index by the grams of carbohydrate, then dividing by 100). The aim of this review was to discuss the potential contribution of diets with low glycemic index and glycemic load in diabetic microvascular complications. Currently, their role to the prevention and delay of microvascular complications in diabetes mellitus remains unclear, and further knowledge is desirable.

Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity

Carbohydrates are increasingly being implicated in the epidemics of obesity, diabetes, and their downstream cardiometabolic diseases. The "carbohydrate-insulin model" has been proposed to explain this role of carbohydrates. It posits that a high intake of carbohydrate induces endocrine deregulation marked by hyperinsulinemia, leading to energy partitioning with increased storage of energy in adipose tissue resulting in adaptive increases in food intake and decreases in energy expenditure. Whether all carbohydrate foods under real-world feeding conditions directly contribute to weight gain and its complications or whether this model can explain these clinical phenomena requires close inspection. The aim of this review is to assess the evidence for the role of carbohydrate quantity vs quality in cardiometabolic health. Although the clinical investigations of the "carbohydrate-insulin model" have shown the requisite decreases in insulin secretion and increases in fat oxidation, there has been a failure to achieve the expected fat loss under low-carbohydrate feeding. Systematic reviews with pairwise and network meta-analyses of the best available evidence have failed to show the superiority of low-carbohydrate diets on long-term clinical weight loss outcomes or that all sources of carbohydrate behave equally. High-carbohydrate diets that emphasize foods containing important nutrients and substances, including high-quality carbohydrate such as whole grains (especially oats and barley), pulses, or fruit; low glycemic index and load; or high fiber (especially viscous fiber sources) decrease intermediate cardiometabolic risk factors in randomized trials and are associated with weight loss and decreased incidence of diabetes, cardiovascular disease, and cardiovascular mortality in prospective cohort studies. The evidence for sugars as a marker of carbohydrate quality appears to be highly dependent on energy control (comparator) and food source (matrix), with sugar-sweetened beverages providing excess energy showing evidence of harm, and with high-quality carbohydrate food sources containing sugars such as fruit, 100% fruit juice, yogurt, and breakfast cereals showing evidence of benefit in energy-matched substitutions for refined starches (low-quality carbohydrate food sources). These data reflect the current shift in dietary guidance that allows for flexibility in the proportion of macronutrients (including carbohydrates) in the diet, with a focus on quality over quantity and dietary patterns over single nutrients.

The Prospective Association of Dietary Sugar Intake in Adolescence With Risk Markers of Type 2 Diabetes in Young Adulthood

Purpose: To examine the prospective relevance of dietary sugar intake (based on dietary data as well as urinary excretion data) in adolescent years for insulin sensitivity and biomarkers of inflammation in young adulthood.

Methods: Overall 254 participants of the DONALD study who had at least two 3-day weighed dietary records for calculating intakes of fructose, glucose, sucrose, total, free, added sugars, total sugars from sugar-sweetened beverages (SSB), juice, and sweets/sugar or at least two complete 24 h urine samples (n = 221) for calculating sugar excretion (urinary fructose and urinary fructose + sucrose) in adolescence (females: 9–15 years, males: 10–16 years) and a fasting blood sample in adulthood (18–36 years), were included in multivariable linear regression analyses assessing their prospective associations with adult homeostasis model assessment insulin sensitivity (HOMA2-%S) and a pro-inflammatory score (based on CRP, IL-6, IL-18, leptin, chemerin, adiponectin).

Results: On the dietary intake level, no prospective associations were observed between adolescent fructose, sucrose, glucose, added, free, total sugar, or total sugar from SSB, juice or sweets/sugar intake and adult HOMA2-%S (p > 0.01). On the urinary level, however, higher excreted fructose levels were associated with improved adult HOMA2-%S (p = 0.008) among females only. No associations were observed between dietary or urinary sugars and the adult pro-inflammatory score (p > 0.01).

Conclusion: The present study did not provide support that dietary sugar consumed in adolescence is associated with adult insulin sensitivity. The one potential exception was the moderate dietary consumption of fructose, which showed a beneficial association with adult fasting insulin and insulin sensitivity.

Associations of carbohydrates and carbohydrate-rich foods with incidence of type 2 diabetes

Dietary carbohydrates have long been expected to be associated with risk of type 2 diabetes; however, the associations for many carbohydrates and carbohydrate-rich foods remain inconclusive. This study analysed associations between intakes of six types of carbohydrates and thirteen carbohydrate-rich foods with incident type 2 diabetes in 26 622 participants (61 % women) in the Malmö Diet and Cancer Study in southern Sweden. Dietary intake was assessed at baseline (1991-1996) by using a modified diet history method. During mean follow-up of 18 years, 4046 cases were identified. Adjusting for potential confounders (including lifestyle, BMI and dietary factors), comparing highest v. lowest quintile of intake, monosaccharides (hazard ratio (HR) 0·88; 95 % CI 0·79, 0·98; Ptrend = 0·02) and fruits (HR 0·91; 95 % CI 0·82, 1·01; Ptrend = 0·03) were inversely associated with incident type 2 diabetes, while disaccharides (HR 1·17; 95 % CI 1·04, 1·30; Ptrend = 0·002) and sweets (HR 1·09; 95 % CI 1·00, 1·19; Ptrend = 0·02) were positively associated. After stratification by sex, marmalade/honey/jam (HR 0·82; 95 % CI 0·72, 0·94; Ptrend < 0·001) and vegetables (HR 0·85; 95 % CI 0·73, 0·98; Ptrend = 0·06) were inversely associated with incident type 2 diabetes in men and chocolate (HR 1·26; 95 % CI 1·09, 1·46; Ptrend < 0·001) was positively associated in women. In conclusion, we identified inverse associations for intake of monosaccharides and fruits with type 2 diabetes risk, and positive associations for disaccharides and sweets. Additional sex-specific associations were also identified. Future studies are needed to explore these associations further.

Association of genetically predicted blood sucrose with coronary heart disease and its risk factors in Mendelian randomization

We assessed the associations of genetically instrumented blood sucrose with risk of coronary heart disease (CHD) and its risk factors (i.e., type 2 diabetes, adiposity, blood pressure, lipids, and glycaemic traits), using two-sample Mendelian randomization. We used blood fructose as a validation exposure. Dental caries was a positive control outcome. We selected genetic variants strongly (P < 5 × 10^–6) associated with blood sucrose or fructose as instrumental variables and applied them to summary statistics from the largest available genome-wide association studies of the outcomes. Inverse-variance weighting was used as main analysis. Sensitivity analyses included weighted median, MR-Egger and MR-PRESSO. Genetically higher blood sucrose was positively associated with the control outcome, dental caries (odds ratio [OR] 1.04 per log₁₀ transformed effect size [median-normalized standard deviation] increase, 95% confidence interval [CI] 1.002–1.08, P = 0.04), but this association did not withstand allowing for multiple testing. The estimate for blood fructose was in the same direction. Genetically instrumented blood sucrose was not clearly associated with CHD (OR 1.01, 95% CI 0.997–1.02, P = 0.14), nor with its risk factors. Findings were similar for blood fructose. Our study found some evidence of the expected detrimental effect of sucrose on dental caries but no effect on CHD. Given a small effect on CHD cannot be excluded, further investigation with stronger genetic predictors is required.

Development of a coded suite of models to explore relevant problems in logistics

Logistics is the aspect of the supply chain which is responsible of the efficient flow and delivery of goods or services from suppliers to customers. Because a logistic system involves specialized operations such as inventory control, facility location and distribution planning, the logistic professional requires mathematical, technological and managerial skills and tools to design, adapt and improve these operations. The main research is focused on modeling and solving logistic problems through specialized tools such as integer programing and meta-heuristics methods. In practice, the use of these tools for large and complex problems requires mathematical and computational proficiency. In this context, the present work contributes with a coded suite of models to explore relevant problems by the logistic professional, undergraduate/postgraduate student and/or academic researcher. The functions of the coded suite address the following: (1) generation of test instances for routing and facility location problems with real geographical coordinates; (2) computation of Euclidean, Manhattan and geographical arc length distance metrics for routing and facility location problems; (3) simulation of non-deterministic inventory control models; (4) importing/exporting and plotting of input data and solutions for analysis and visualization by third-party platforms; and (5) designing of a nearest-neighbor meta-heuristic to provide very suitable solutions for large vehicle routing and facility location problems. This work is completed by a discussion of a case study which integrates the functions of the coded suite.

Organismal Fructose Metabolism in Health and Non-Alcoholic Fatty Liver Disease

NAFLD has alarmingly increased, yet FDA-approved drugs are still lacking. An excessive intake of fructose, especially in liquid form, is a dietary risk factor of NAFLD. While fructose metabolism has been studied for decades, it is still controversial how fructose intake can cause NAFLD. It has long been believed that fructose metabolism solely happens in the liver and accordingly, numerous studies have investigated liver fructose metabolism using primary hepatocytes or liver cell lines in culture. While cultured cells are useful for studying detailed signaling pathways and metabolism in a cell-autonomous manner, it is equally important to understand fructose metabolism at the whole-body level in live organisms. In this regard, recent in vivo studies using genetically modified mice and stable isotope tracing have tremendously expanded our understanding of the complex interaction between fructose-catabolizing organs and gut microbiota. Here, we discuss how the aberrant distribution of fructose metabolism between organs and gut microbiota can contribute to NAFLD. We also address potential therapeutic interventions of fructose-elicited NAFLD.

Association between per capita sugar consumption and diabetes prevalence mediated by the body mass index: results of a global mediation analysis

Purpose

The aim of this study was to examine the mediation of body mass index (BMI) on the association between per capita sugar consumption and diabetes prevalence using country-related data.

Research design and methods

In this ecological study, based on 192 countries, data on per capita sugar consumption were obtained from the Food and Agriculture Organization of the United Nations (FAO), on BMI from the World Health Organization and on diabetes prevalence from the International Diabetes Federation. Data on demography and economic factors were obtained from the Central Intelligence Agency, the United Nations and the FAO. Multiple linear regression analysis was performed to investigate the association between per capita sugar consumption and diabetes prevalence, and mediation analysis to detect the mediated percentage of BMI on this association.

Results

Each increase of 100 kcal/day per capita sugar consumption was associated with a 1.62% higher diabetes prevalence [adjusted β-estimator (95% CI): 1.62 (0.71, 2.53)]. Mediation analysis using BMI as the mediator demonstrated an adjusted direct association of 0.55 (95% CI: − 0.22, 1.32) and an adjusted indirect association of 1.07 (95% CI: 0.54, 1.68). Accordingly, the BMI explained 66% (95% CI: 34%, 100%) of the association between per capita sugar consumption on diabetes prevalence.

Conclusions

These findings indicate that the association between dietary sugar intake and the occurrence of diabetes is mediated by BMI to a large proportion. However, it seems that other mechanisms may explain the association between sugar consumption and development of type 2 diabetes.

Electronic supplementary material

The online version of this article (10.1007/s00394-020-02401-2) contains supplementary material, which is available to authorized users.

The small intestine shields the liver from fructose-induced steatosis

Per capita fructose consumption has increased 100-fold over the last century¹. Epidemiological studies suggest that excessive fructose consumption, and especially consumption of sweet drinks, is associated with hyperlipidaemia, non-alcoholic fatty liver disease, obesity and diabetes^2-7. Fructose metabolism begins with its phosphorylation by the enzyme ketohexokinase (KHK), which exists in two alternatively spliced forms⁸. The more active isozyme, KHK-C, is expressed most strongly in the liver, but also substantially in the small intestine^9,10 where it drives dietary fructose absorption and conversion into other metabolites before fructose reaches the liver^11-13. It is unclear whether intestinal fructose metabolism prevents or contributes to fructose-induced lipogenesis and liver pathology. Here we show that intestinal fructose catabolism mitigates fructose-induced hepatic lipogenesis. In mice, intestine-specific KHK-C deletion increases dietary fructose transit to the liver and gut microbiota and sensitizes mice to fructose's hyperlipidaemic effects and hepatic steatosis. In contrast, intestine-specific KHK-C overexpression promotes intestinal fructose clearance and decreases fructose-induced lipogenesis. Thus, intestinal fructose clearance capacity controls the rate at which fructose can be safely ingested. Consistent with this, we show that the same amount of fructose is more strongly lipogenic when drunk than eaten, or when administered as a single gavage, as opposed to multiple doses spread over 45 min. Collectively, these data demonstrate that fructose induces lipogenesis when its dietary intake rate exceeds the intestinal clearance capacity. In the modern context of ready food availability, the resulting fructose spillover drives metabolic syndrome. Slower fructose intake, tailored to intestinal capacity, can mitigate these consequences.

Destigmatizing Carbohydrate with Food Labeling: The Use of Non-Mandatory Labelling to Highlight Quality Carbohydrate Foods

Dietary carbohydrates are components of healthy foods, but many carbohydrate foods have recently been stigmatized as primary causes of diet-related risk factors for chronic disease. There is an opportunity to enhance efforts within the food landscape to encourage the consumption of higher quality carbohydrate foods. The use of labelling is one strategy that permits consumers to identify healthy carbohydrate foods at the point-of-purchase. This review discusses the regulatory frameworks and examples of associated non-mandatory food labelling claims that are currently employed to highlight healthy carbohydrate foods to consumers. The existing labelling frameworks discussed here align with established measures of carbohydrate quality, such as 1. dietary fibre nutrient content claims and associated dietary fibre-based health claims; 2. the presence of whole carbohydrate foods and ingredients that are intact or reconstituted, such as whole grains; and 3. low glycemic index and glycemic response claims. Standards from Codex Alimentarius, and regulations from Australia and New Zealand, Canada, Europe, and the United States will be used to illustrate the means by which food labelling can be used by consumers to identify quality carbohydrate foods.

Concurrent and Delayed Behavioral and Monoamine Alterations by Excessive Sucrose Intake in Juvenile Mice

Our daily diet in the modern society has substantially changed from that in the ancient past. Consequently, new disorders associated with such dietary changes have emerged. For instance, excessive intake of compounds, such as sucrose (SUC), has recently been reported to induce pathological neuronal changes in adults, such as food addiction. It is still largely unclear whether and how excessive intake of such nutrients affects neurodevelopment. We investigated changes in behavior and monoamine signaling caused by excessive, semi-chronic intake of SUC and the non-caloric sweetener saccharin (SAC) in juvenile mice, using a battery of behavioral tests and high-performance liquid chromatography. Both SUC and SAC intake induced behavioral alterations such as altered amphetamine responses, sucrose preference, stress response, and anxiety, but did not affect social behavior and cognitive function such as attention in juvenile and adult mice. Moreover, SUC and SAC also altered dopamine and serotonin transmission in mesocorticolimbic regions. Some of these behavioral and neural alterations were triggered by SAC and SUC but others were distinct between the treatments. Moreover, alterations induced in juvenile mice were also different from those observed in adult mice. These results suggest that excessive SUC and SAC intake during the juvenile period may cause concurrent and delayed behavioral and monoamine signaling alterations in juvenile and adult mice, respectively.

Influence of total sugar intake on metabolic blood markers at 8 years of age in the Childhood Obesity Project

Purpose

We aimed to characterize the association of dietary sugar intake with blood lipids and glucose-related markers in childhood.

Methods

Data from the multicentric European Childhood Obesity Project Trial were used. Three-day weighed dietary records were obtained at 8 years of age along with serum concentrations of triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), glucose, and insulin. Total sugar intake comprised all mono- and disaccharides; different sugar sources were defined. Linear regression models were applied to investigate the cross-sectional association of total sugar intake with blood lipids and glucose-related markers with adjustment for total energy intake using the residual method.

Results

Data were available for 325 children. Children consumed on average 332 kcal (SD 110) and 21% (SD 6) of energy from total sugar. In an energy-adjusted model, an increase of 100 kcal from total sugar per day was significantly associated with a z score HDL-C decrease (− 0.14; 95% CI − 0.01, − 0.27; p value = 0.031). Concerning different food groups of total sugar intake, 100 kcal total sugar from sweetened beverages was negatively associated with z score HDL-C (− 1.67; 95% CI − 0.42, − 2.91; p value = 0.009), while total sugar from milk products was positively related to z score HDL-C (1.38, 95% CI 0.03, 2.72; p value = 0.045). None of the other blood lipids or glucose-related markers showed a significant relationship with total sugar intake.

Conclusion

Increasing dietary total sugar intake in children, especially from sweetened beverages, was associated with unfavorable effects on HDL-C, which might increase the long-term risk for dyslipidemia and cardiovascular disease.

Clinical trial registry

ClinicalTrials.gov Identifier: NCT00338689; Registered: June 19, 2006. URL: https://clinicaltrials.gov/ct2/show/NCT00338689?term=NCT00338689&rank=1.

Electronic supplementary material

The online version of this article (10.1007/s00394-020-02229-w) contains supplementary material, which is available to authorized users.

Total Sugar Intake and Macro and Micronutrients in Children Aged 6-8 Years: The ANIVA Study

The objective of this study was to study the association between total sugar intake (TSI) levels of children aged 6–8 years old, nutrient intake and anthropometry. Food and beverage intakes were collected by a prospective three-day recall questionnaire. The 2237 children were distributed into three groups according to TSI percentiles. Mean TSI was 93.77 ± 25.72 g/day, 22%–25% of total caloric intake, with boys presenting an intake of 96.24 ± 24.34 g/day and girls 91.38 ± 26.78 g/day. Greater TSI was associated with higher body fat, parental education, energy intake, nutrients/1000 kcal, and lower weight z-scores, BMI z-scores, waist circumferences, and hip circumferences. Weight, height, and waist circumference had the highest R² while body fat had the lowest. The percentage of total energy derived (%E) from protein decreased as the %E from TSI increased, while the opposite was true for carbohydrates and saccharides, while for fiber intake, the medium groups presented the highest intake/1000 kcal. For the remaining macronutrients studied, intake/1000 kcal decreased when the %E from TSI increased. Calcium, iodine, magnesium, vitamin B2, folate, and vitamin C intake increased as the %E from TSI increased, while the opposite was true for vitamin B12. Fiber, ω-6 PUFA, iodine, folate, vitamin D, and vitamin E intakes were insufficient across most of the sample. TSI levels in children were identified to exceed adult recommendations. It is not clear what the effect of up to an average of 21% of energy coming from total sugars has on childhood obesity and further research is needed in the pediatric population, however, opportunities exist to improve sugar intake patterns.

[there any association of metabolic disturbances with joint destruction and pain?]

Osteoarthritis and type 2 diabetes mellitus represent two the most common chronic diseases. They possess many shared epidemiologic traits, have common risk factors, and embody heterogeneous multifactorial pathologies, which develop due to interaction of genetic an environmental factors. In addition, these diseases are often occurring in the same patient. In spite of the differences in clinical manifestation both diseases have similar disturbances of cellular metabolism, primarily associated with ATP production and utilization. The review discusses molecular mechanisms determining pathophysiological processes associated with glucose and lipid metabolism as well as the means aiming to alleviate the disturbances of energy metabolism as a new a therapeutic approach.

Intestinal Fructose and Glucose Metabolism in Health and Disease

The worldwide epidemics of obesity and diabetes have been linked to increased sugar consumption in humans. Here, we review fructose and glucose metabolism, as well as potential molecular mechanisms by which excessive sugar consumption is associated to metabolic diseases and insulin resistance in humans. To this end, we focus on understanding molecular and cellular mechanisms of fructose and glucose transport and sensing in the intestine, the intracellular signaling effects of dietary sugar metabolism, and its impact on glucose homeostasis in health and disease. Finally, the peripheral and central effects of dietary sugars on the gut–brain axis will be reviewed.

Important Food Sources of Fructose-Containing Sugars and Incident Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Background Sugar-sweetened beverages are associated with hypertension. We assessed the relation of important food sources of fructose-containing sugars with incident hypertension using a systematic review and meta-analysis of prospective cohort studies. Methods and Results We searched MEDLINE, EMBASE, and Cochrane (through December week 2, 2018) for eligible studies. For each food source, natural log-transformed risk ratios (RRs) for incident hypertension were pooled using pair-wise meta-analysis and linear and nonlinear dose-response meta-analyses. Certainty in our evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. We identified 26 reports, including 15 prospective cohorts (930 677 participants; 363 459 cases). Sugar-sweetened beverages showed harmful (RRper-355-mL, 1.10 [95% CI, 1.08, 1.12]) whereas fruit (RRper-240-g, 0.94 [95% CI, 0.96, 0.99]) and yogurt showed protective associations (RRper-125-g, 0.95 [95% CI, 0.94, 0.97]) with incident hypertension throughout the dose range. One hundred percent fruit juice showed a protective association only at moderate doses (RRat-100-mL, 0.97 [95% CI, 0.94, 0.99]). The pair-wise protective association of dairy desserts was not supported by linear dose-response analysis. Fruit drinks or sweet snacks were not associated with hypertension. Certainty of the evidence was "low" for sugar-sweetened beverages, 100% fruit juice, fruit, and yogurt and "very low" for fruit drinks, sweet snacks, and dairy desserts. Conclusions The harmful association between sugar-sweetened beverages and hypertension does not extend to other important food sources of fructose-containing sugars. Further research is needed to improve our estimates and better understand the dose-response relationship between food sources of fructose-containing sugars and hypertension. Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02702375.