ArticleLiterature Review

Effects of Sucrose on Carbohydrate and Lipid Metabolism in NIDDM Patients

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Abstract

Recently, there has been increasing interest toward the liberalization of sucrose in the diets of individuals with non-insulin-dependent diabetes mellitus (NIDDM). However, there is evidence from several well-controlled prospective studies demonstrating that the consumption of moderate amounts of sucrose may result in hyperglycemia, hyperinsulinemia, hypertriglyceridemia, hypercholesterolemia, and reduced high-density lipoprotein cholesterol concentrations. The fact that not all studies demonstrate these deleterious effects does not negate the positive data. The magnitude of the deleterious effects will probably vary with individual patients, baseline status, and amount of sucrose. Because these metabolic abnormalities are most disturbed in diabetes and are associated with increased risk of coronary artery disease, it would seem reasonable to continue to advise patients with NIDDM to limit sucrose consumption, at least until available data would allow us to predict in which individuals and at what level of sucrose consumption these adverse metabolic effects would not be present.

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... The rates of severe hypoglycemia and hyperglycemia were alarmingly high in the Epidemiology of Diabetes and Ramadan study, a population-based large epidemiological study that spanned 13 countries with sizeable Muslim populations (3). Such a high rate of fasting-related morbidity was reported earlier in a small study by Uysal et al. (4). Education of patients is the cornerstone of safe fasting, which is needed on both an individual and large-scale level, and this is the responsibility of diabetes care team members. ...
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Al-Arouj et al. (1) have made recommendations for fasting during the holy month of Ramadan for Muslim diabetic patients. The recommendations were drafted by an expert panel of diabetologists from around the globe, and it represents a landmark for practicing clinicians who look after diabetic Muslims. The recommendations were based on expert opinion rather than evidence-based scientific research, which, as the panel pointed out, is lacking in this area. These provisional recommendations await well-designed research aimed specifically at seeing whether fasting is beneficial or harmful to patients with type 1 diabetes. Type 1 diabetic patients are often advised not to fast by physicians. The nature of …
... Diets with high carbohydrates (e.g. sucrose) have been shown to accentuate metabolic abnormalities, including hypertriglyceridemia [74,164]. There is a well-established carbohydrate-induced stimulation of plasma TG (both in VLDL and CM) in the fasting state as well as an effect of carbohydrate feeding on postprandial lipemia, even after a single meal [reviewed in [142]]. ...
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... In general, individuals with type II diabetes are overweight and need overall calorie restriction rather than permission to eat desserts that would probably increase their daily calorie intake. Two excellent reviews have recently been published that discuss the controversies in this area (12,22). On the other hand, children and young adults with type I diabetes do not usually require calorie restriction. ...
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... The rates of severe hypoglycemia and hyperglycemia were alarmingly high in the Epidemiology of Diabetes and Ramadan study, a population-based large epidemiological study that spanned 13 countries with sizeable Muslim populations (3). Such a high rate of fasting-related morbidity was reported earlier in a small study by Uysal et al. (4). Education of patients is the cornerstone of safe fasting, which is needed on both an individual and large-scale level, and this is the responsibility of diabetes care team members. ...
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A critical review composed of two parts: estimates of present levels of sugars intake and of recent trends in nutritive carbohydrate sweetener content of the food supply and a review of recent scientific literature addressing potentially adverse health effects associated with sugars consumption. The review contains an executive summary, an appendix with 75 tables summarizing the estimation of sugars intake of U.S. population groups, and over one thousand citations.
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The effects of variations in dietary carbohydrate and fat intake on various aspects of carbohydrate and lipid metabolism were studied in patients with non-insulin-dependent diabetes mellitus (NIDDM). Two test diets were utilized, and they were consumed in random order over two 15-day periods. One diet was low in fat and high in carbohydrate, and corresponded closely to recent recommendations made by the American Diabetes Association (ADA), containing (as percent of total calories) 20 percent protein, 20 percent fat, and 60 percent carbohydrate, with 10 percent of total calories as sucrose. The other diet contained 20 percent protein, 40 percent fat, and 40 percent carbohydrate, with sucrose accounting for 3 percent of total calories. Although plasma fasting glucose and insulin concentrations were similar with both diets, incremental glucose and insulin responses from 8 a.m. to 4 p.m. were higher (p less than 0.01), and mean (+/- SEM) 24-hour urine glucose excretion was significantly greater (55 +/- 16 versus 26 +/- 4 g/24 hours p less than 0.02) in response to the low-fat, high-carbohydrate diet. In addition, fasting and postprandial triglyceride levels were increased (p less than 0.001 and p less than 0.05, respectively) and high-density lipoprotein (HDL) cholesterol concentrations were reduced (p less than 0.02) when patients with NIDDM ate the low-fat, high-carbohydrate diet. Finally, since low-density lipoprotein (LDL) concentrations did not change with diet, the HDL/LDL cholesterol ratio fell in response to the low-fat, high-carbohydrate diet. These results document that low-fat, high-carbohydrate diets, containing moderate amounts of sucrose, similar in composition to the recommendations of the ADA, have deleterious metabolic effects when consumed by patients with NIDDM for 15 days. Until it can be shown that these untoward effects are evanescent, and that long-term ingestion of similar diets will result in beneficial metabolic changes, it seems prudent to avoid the use of low-fat, high-carbohydrate diets containing moderate amounts of sucrose in patients with NIDDM.
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To learn more about the metabolic effects of dietary fructose and sucrose, 12 type I and 12 type II diabetic subjects were fed three isocaloric (or isoenergic) diets for eight days each according to a randomized, crossover design. The three diets provided, respectively, 21% of the energy as fructose, 23% of the energy as sucrose, and almost all carbohydrate energy as starch. The fructose diet resulted in significantly lower one- and two-hour postprandial plasma glucose levels, overall mean plasma glucose levels, and urinary glucose excretion in both type I and type II subjects than did the starch diet. There were no significant differences between the sucrose and starch diets in any of the measures of glycemic control in either subject group. The fructose and sucrose diets did not significantly increase serum triglyceride values when compared with the starch diet, but both increased postprandial serum lactate levels. We conclude that short-term replacement of other carbohydrate sources in the diabetic diet with fructose will improve glycemic control, whereas replacement with sucrose will not aggravate glycemic control.
Article
This study addresses the metabolic effects of sucrose in the diets of 11 individuals with noninsulin-dependent diabetes mellitus (NIDDM). Each of two dietary periods were 15 days in length, and contained 50% of the calories as carbohydrate, 30% as fat, and 20% as protein. The only variable between the two periods was the percentage of total calories as sucrose, 16% v 1%. Fasting blood samples were analyzed for plasma glucose and insulin as well as total plasma VLDL-, LDL- and HDL-cholesterol and triglyceride concentrations. In addition, postprandial blood samples were obtained for the measurement of plasma glucose, insulin and triglyceride concentrations. Fasting plasma glucose, insulin, and day-long insulin concentrations were similar between the two diets. However, the addition of sucrose in amounts comparable to those typically consumed by the general population resulted in significantly elevated day-long glucose (P less than 0.05) and triglyceride (P less than 0.05) responses, as well as elevated fasting total plasma cholesterol (P less than 0.001), triglyceride (P less than 0.05), VLDL-cholesterol (P less than 0.01), and VLDL-triglyceride (P less than 0.05) concentrations. LDL-cholesterol and HDL-cholesterol concentrations were unchanged during the added sucrose diet. It is clear that the consumption of diets containing moderate amounts of sucrose resulted in changes to plasma lipid and postprandial glucose concentrations that have been identified as risk factors for coronary artery disease. Therefore, it seems prudent at this time to advise patients with NIDDM to avoid added dietary sucrose.
Article
Eighteen healthy young men on an Antarctic base were observed for 10 months. For a baseline period of 4 weeks they received a normal diet, then they were put on an isocaloric, virtually sucrose-free diet for a period of 14 weeks, and this was followed by a further period of 24 weeks on the normal diet. They took all their meals together, and the diet was found generally acceptable. Estimations were made, on fasting serum samples, of triglyceride, total cholesterol, and phospholipid levels. In those men with higher triglyceride levels on the normal diet (>120 mg. per 100 ml.) there was a significant fall in triglyceride levels during the sucrose-free period, whilst there was no significant change in triglyceride levels in the men with lower triglyceride levels (<120 mg. per 100 ml.). Smaller changes occurred in total cholesterol and phospholipid levels. Such weight changes as occurred were not significant and did not correlate with changes in lipid levels.
Article
1. Fasting serum cholesterol and triglyceride, and post prandial insulin secretion and lipaemia were measured in human subjects in a metabolic ward, who were given an ordinary diet (diet 1) in which the sucrose was isocalorically replaced by starch (diet 2) or vice versa. The subjects were nine healthy normolipaemic adult males. In eight of these subjects the effect of sucrose calorie reduction (diet 3) on fasting serum lipids was also studied. 2. When starch replaced sucrose, there were no singnificant differences in fasting serum lipid concentrations or immunoreactive insulin or in the insulin response and alimentary lipaemia after a standard mixed breakfast. 3. Serum triglyceride concentration fell and cholesterol concentration rose during the period of sucrose (and calorie) restriction. 4. After lunch and supper on the first two diets (when different carbohydrates were given) the lipaemic response was larger and the insulin response smaller after meals containing sucrose. 5. Thus, there was no difference between concentrations of fasting serum lipids when starch replaced sucrose at 23% total calories, but the concentrations of serum triglycerides were higher after individual mixed meals containing sucrose. 6. There were no significant differences in the fatty acid patterns of serum lipids on the different diets.
Article
A group of 101 diabetic patients containing equal numbers of patients with and without clinical atherosclerosis and 104 control subjects of similar age and sex were studied. The diabetic patients with atherosclerosis were found to have higher triglyceride and cholesterol levels, higher insulin-glucose ratios, and a higher frequency of pre-β band staining on lipoprotein electrophoresis than diabetic patients without atherosclerosis or control subjects. Diabetic patients with atherosclerosis could be discriminated better from those without atherosclerosis by the use of triglyceride levels than by the use of cholesterol levels. Segregated arbitrarily into three categories of body weight, diabetic patients with atherosclerosis had higher triglyceride levels than similarly classified diabetic patients without atherosclerosis. Basal insulin levels, triglyceride levels, and indices of body weight were highly intercorrelated in the diabetic patients with atherosclerosis. However, fasting levels of serum insulin were similar in the two groups of diabetic patients. There was no clear relationship
Article
1. The effects of isocalorically exchanging dietary starch and sucrose on glucose tolerance, plasma insulin and serum lipids were examined in nine middle-aged subjects. A ‘sucrose’ period in which 70% of dietary carbohydrate was supplied as sucrose was alternated with a ‘sucrose free’ period in which dietary carbohydrate was supplied mainly as starch. Each period lasted 4 weeks; eleven balances were completed. 2. Changes in body weight during the balances were small and statistically insignificant. 3. Fasting blood sugar levels were significantly elevated during the ‘sucrose’ period. During 50 g glucose tolerance tests, blood sugar levels were slightly higher during the ‘sucrose’ period but this difference was not statistically significant. 4. Plasma insulin levels were similar during the dietary periods, both in the fasting state and after 50 g of glucose. 5. Mean levels of serum cholesterol, serum triglyceride and plasma NEFA showed no significant differences between the two dietary periods. 6. It is concluded that glucose tolerance, plasma insulin and serum lipids are not significantly altered by the substitution of sucrose for starch at levels of sucrose intake comparable to those in the Western diet.
Article
In the Whitehall Study of 18,403 male civil servants aged 40--64 years, 7 1/2 year coronary-heart-disease (CHD) mortality has been examined in relation to blood-sugar concentration 2 h after a 50 g oral glucose load. CHD mortality was approximately doubled for subjects with inpaired glucose tolerance (IGT), defined as a blood-sugar above the 95th centile (greater than or equal to 96 mg/dl). There was no trend of CHD mortality with blood-sugar below the 95th centile. Within the IGT group, age, systolic blood-pressure, and ECG abnormality (Whitehall criteria) were significantly predictive of subsequent CHD mortality. These findings are relevant to discussions on the criteria for diabetes which include the definition of an IGT category with increased risk of large-vessel disease, but without the high risk of small-vessel disease as occurs in diabetes mellitus.
Article
The hyperglycaemic effect of 20 g sucrose taken at the end of a regular mixed meal by diabetic patients was measured in six adult type 1 diabetics, C-peptide negative, controlled by the artificial pancreas, and twelve adult type 2 diabetics, with fasting plasma glucose levels below 7.2 mmol/l (130 mg/100 ml) and post-prandial plasma glucose levels below 10.0 mmol/l (180 mg/100 ml), treated by diet alone or with glibenclamide and/or metformin. All the patients were given on consecutive days, in random order, two mixed meals of grilled meat, green beans, and cheese, as well as a cake made either of rice, skimmed milk, and saccharine (meal A) or rice, skimmed milk, and 20 g sucrose (meal B). The meals contained equal amounts of calories and of carbohydrate. There was no difference between the meals in plasma glucose curves and plasma insulin or insulin infusion rate variations whether in peak values, peaking times, or areas under the curves, in either group of patients. Sparing use of sucrose taken during mixed meals might help well-controlled diabetic patients to comply with their daily dietary prescription while maintaining good blood glucose control.
Article
The determine the effect of different foods on the blood glucose, 62 commonly eaten foods and sugars were fed individually to groups of 5 to 10 healthy fasting volunteers. Blood glucose levels were measured over 2 h, and expressed as a percentage of the area under the glucose response curve when the same amount of carbohydrate was taken as glucose. The largest rises were seen with vegetables (70 +/- 5%), followed by breakfast cereals (65 +/- 5%), cereals and biscuits (60 +/- 3%), fruit (50 +/- 5%), dairy products (35 +/- 1%), and dried legumes (31 +/- 3%). A significant negative relationship was seen between fat (p less than 0.01) and protein (p less than 0.001) and postprandial glucose rise but not with fiber or sugar content.
Article
To examine whether the form of dietary carbohydrate influences glucose and insulin responses, we studied the glucose and insulin responses to five meals--each containing a different form of carbohydrate but all with nearly identical amounts of total carbohydrate, protein, and fat--in 10 healthy subjects, 12 patients with Type I diabetes, and 10 patients with Type II diabetes. The test carbohydrates were glucose, fructose, sucrose, potato starch, and wheat starch. In all three groups, the meal containing sucrose as the test carbohydrate did not produce significantly greater peak increments in the plasma concentration of glucose or greater increments in the area under the plasma glucose-response curves than did meals containing potato, wheat, or glucose as test carbohydrates. Urinary excretion of glucose in patients with diabetes was not significantly greater after the sucrose meal. The meal containing fructose as the test carbohydrate produced the smallest increments in plasma glucose levels, but the differences were not always statistically significant. In healthy subjects and patients with Type II diabetes, peak serum concentrations of insulin were not significantly different in response to the five test carbohydrates. Our data do not support the view that dietary sucrose, when consumed as part of a meal, aggravates postprandial hyperglycemia.
Article
We investigated the effect of ice cream ingestion on blood glucose control in conventionally treated and intensively treated insulin-dependent (type I) diabetic patients. After the ingestion of 100 g of ice cream, plasma glucose excursions as measured by the peak increment (90 +/- 30 mg/dL) and area under the curve (166 +/- 59 mg/dL X hour) were modest and not significantly different between the subgroups of intensively treated and conventionally treated diabetics. A small dose (3 to 5 units) of rapid-acting insulin given 30 minutes before ingestion of ice cream reduced the modest plasma glucose excursion. A modest amount of ice cream may be included in weight-maintaining diets of insulin-dependent diabetics. Small doses of rapid-acting insulin prevent any adverse effect of the ice cream on blood glucose control.
Article
To further understand the effect of high carbohydrate (CHO)-low fat diets and the role of variations in dietary sucrose on CHO and lipid metabolism, 10 patients with hypertriglyceridemia were fed 2 isocaloric, typical American diets, containing 40% and 60% CHO, for 15 days in random sequence. Each patient was their own control, and they were divided into 2 groups of 5 patients each. In one group, sucrose was held constant at 13% of total calories (40-13% and 60-13%), whereas the sucrose content was 9% of the total calories on a 40% CHO diet (40-9%), and 15% of total calories on a 60% CHO diet (60-15%) in the other group. Fasting and postprandial blood samples were analyzed for plasma glucose, insulin, cholesterol (Chol), and triglycerides (TG), as well as for Chol and TG in chylomicrons, very low density, low density, and high density lipoproteins (HDL). Fasting plasma TG levels were significantly increased in both groups on the 60% CHO diet, primarily due to increases in very low density-TG concentration. The magnitude of the elevation was attenuated when sucrose content was kept constant. Postprandial TG responses were qualitatively similar. There were no significant changes in plasma Chol concentrations, except for a modest fall in plasma HDL-Chol level after the 60-13% diet period (P less than 0.05). No significant differences were found in fasting plasma glucose or insulin concentration. However, postprandial glucose and insulin responses were increased on both high CHO diets. The results of these studies demonstrate that high CHO-low fat diets, in general, tend to elevate plasma glucose, insulin, and TG concentrations and reduce HDL-Chol concentration in patients with endogenous hypertriglyceridemia. In addition, these data illustrate the important role that small variations in dietary sucrose can play in modulation of CHO and lipid metabolism.
Article
Overtly hypertriglyceridemic patients with non-insulin-dependent diabetes mellitus were given a control diet containing 120 g of sucrose and 50 percent carbohydrate, and later randomly assigned to receive isocaloric high- (220 g), intermediate- (120 g), or low- (less than 3 g) sucrose/carbohydrate diets for four weeks. The low-sucrose diet group demonstrated a modest but significant decrease in mean fasting serum glucose level in the first week only, although this change was no different from the other two dietary groups and was not sustained. All groups had little change in late postprandial serum glucose levels from control values, and no significant alterations in 24-hour glycosuria. The high-sucrose diet group demonstrated a significant increase in fasting serum triglyceride levels by the second week of the study, whereas the intermediate- and low-sucrose diet groups showed a decrease in mean fasting triglyceride levels. In contrast, the low-sucrose diet group's late postprandial serum triglyceride levels increased by the fourth week, whereas levels fell in the high-sucrose diet group. Mean fasting serum cholesterol concentrations decreased from control values in the high-sucrose diet group. Thus, although very high sucrose and carbohydrate consumption is clearly deleterious to fasting tryglyceride levels in non-insulin-dependent diabetes mellitus with preexisting hypertriglyceridemia, it appears that low dietary sucrose and carbohydrate proportions do not further improve preprandial glycemia and glycosuria and may adversely affect late postprandial serum triglyceride concentration. This study suggests that isocaloric sucrose and carbohydrate restriction below usual daily levels (120 g per day) offers no consistent benefit in glycemia or lipid control in overt type II diabetes.
Article
In 9 of the 14 national samples of diabetic patients assembled for the WHO Multinational Study of Vascular Disease in Diabetes additional laboratory data made it possible to relate manifestations of macrovascular disease to blood glucose concentrations as well as to diabetes duration and to other potential determinants. In five of the samples, serum triglyceride concentrations were also measured and were included in simple and multivariate analyses. Ischemic heart disease defined from Minnesota-coded EKGs and standardized WHO questionnaires was more strongly associated with serum triglyceride concentrations than with serum cholesterol concentrations, an association less notable in non-insulin-dependent diabetic patients. Ischemic heart disease was not related to the single fasting plasma glucose estimated for this study. Stroke and amputation were much more strongly related to the known duration of diabetes than was ischemic heart disease, and they were both related to blood glucose concentration measured at the time of study. Despite major variation in arterial disease prevalence rates between collaborating centers, risk for diabetic women appeared to equal that for diabetic men. The major variation in arterial disease prevalence between national groups could be accounted for only in part by the risk factors studied. Other factors, genetic or more likely environmental, are likely to contribute to the variation in arterial disease susceptibility and, if definable, may be potentially preventable.
Article
The effects of dietary sucrose on blood lipids and their distribution in lipoprotein fractions were determined in 12 males and 12 females diagnosed as carbohydrate-sensitive on the basis of an exaggerated insulin response to a sucrose load. The subjects were fed diets containing 5%, 18% or 33% of the total calories as sucrose for 6 weeks each in a crossover design. Initial body weights were essentially maintained. Total fasting triglycerides of males, but not females, increased significantly as the level of sucrose in the diet increased. Triglycerides in males averaged 132% more than in females and were significantly greater at all three levels of sucrose. Significant increases in total cholesterol, VLDL cholesterol, LDL cholesterol, and HDL cholesterol were observed as the sucrose content of the diet increased. HDL cholesterol ratios decreased significantly in males as sucrose increased and for 5%, 18% and 33% were 0.34, 0.32 and 0.27, respectively. Abnormal lipoprotein phenotypes were most common when the subjects consumed 33% sucrose and least common when they consumed 5% sucrose. These results indicate that sucrose intake at levels now common in the American diet by carbohydrate-sensitive males could lead to a blood lipid profile associated with coronary risk.
Article
We studied the acute effects of oral ingestion of 50-g loads of dextrose, sucrose, and fructose on post-prandial serum glucose, insulin, and plasma glucagon responses in 9 normal subjects, 10 subjects with impaired glucose tolerance, and 17 non-insulin-dependent diabetic subjects. The response to each carbohydrate was quantified when the respective carbohydrate was given alone in a drink or when given in combination with protein and fat in a test meal. The data demonstrate that (1) fructose ingestion resulted in significantly lower serum glucose and insulin responses than did sucrose or dextrose ingestion in all study groups, either when given alone or in the test meal; (2) although fructose ingestion always led to the least glycemic response compared with the other hexoses, the serum glucose response to fructose was increased the more glucose intolerant the subject; (3) urinary glucose excretion during the 3 h after carbohydrate ingestion was greatest after dextrose and least after fructose in all groups. In conclusion, fructose ingestion results in markedly lower serum glucose and insulin responses and less glycosuria than either dextrose or sucrose, both when given alone or as a constituent in a test meal. However, as glucose tolerance worsens, an increasingly greater glycemic response to fructose is seen.
Article
Twenty-four adult men and women, classified as carbohydrate-sensitive on the basis of an exaggerated insulin response to a sucrose load, consumed diets containing 5, 18, and 33% of calories as sucrose for 6 wk each in a cross-over design. The diets contained identical natural and processed foods except for a patty containing 2, 15, or 30% of the calories as sucrose at the expense of wheat starch. Carbohydrate, fat, and protein provided 44, 42, and 14% of the calories, respectively. Of total calories, 25% were consumed at breakfast and 75% at dinner. Initial body weights of the subjects were essentially maintained. Fasting serum insulin levels increased with the sucrose content of the diet and were significantly higher in men than in women. Mean fasting glucose was significantly higher on either 18 or 33% sucrose than on 5% sucrose. The sucrose content of the diet did not affect fasting serum glucagon. When compared to the insulin response to a sucrose load (2 g/kg body weight) after consuming the 5% sucrose diet, serum insulin was significantly higher at 1 h after the 18% sucrose diet and at 0.5, 1, 2, and 3 h after the 33% sucrose diet. Except after 2 h, the glucose response was significantly greater after the 18 and 33% sucrose diets than after the 5% sucrose diet. These results indicate that sucrose intake by carbohydrate-sensitive individuals, even at levels approximating the average United States intake, can produce undesirable changes in several parameters associated with glucose tolerance.
Influences of dietary fructose and sucrose on serum triglycerides in hypertriglyceridemia and diabe-tetes
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