Currently browsing posts about: Diabetes

Sugar has long been thought to increase risks for type 2 diabetes, but whether it really does has not been easy to prove and is still a matter of debate.

A new study suggests one reason why.  It distinguishes between the effects of sugar in beverages (increased risk) and foods (no increased risk).

The study: Dietary Sugar Intake and Incident Type 2 Diabetes Risk: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies.

Method: The study analyed prospective cohort studies reporting relative measures of incident T2D [type 2 diabetes] risk by categories of dietary sugar (total, free, added, fructose, sucrose) or 2 beverage sources (non-diet sugar-sweetened beverages [SSBs], fruit juice) in healthy adults.

Results: 

• Each additional serving of SSB and fruit juice was associated with a higher risk of T2D.
• In contrast, 20 g/d intakes of total sugar and sucrose were inversely associated with T2D.
• No associations were found for added sugar…or fructose.

The figure shows the effect of 20 g/d sugar intake on T2D risk, in comparison to typical doses of SSB and fruit juice.

A) shows the bar plot illustrating the summary effect of a 20 g/d intake for different sugar types on risk of T2D.

B) compares these doses to typical servings sizes per day of SSBs (39 g/d) and fruit juice (23.3 g/d).

Conclusion: These findings suggest that dietary sugar consumed as a beverage (SSB and fruit juice) is associated with incident T2D risk. The results do not support the common assumption that dietary sugar (i.e., total sugar and sucrose), irrespective of type and amount, is consistently associated with increased T2D risk.

Comment: Sugar is still nutritionally empty, causes tooth decay(especially if water is unfluoridated), and is best consumed in small amounts.  But if this finding holds up, the moral is clear:  Don’t drink your calories.

FDA has announced a joint research initiative with NIH

Under the new Nutrition Regulatory Science Program, the FDA and NIH will implement and accelerate a comprehensive nutrition research agenda that will provide critical information to inform effective food and nutrition policy actions to help make Americans’ food and diets healthier. The initiative will aim to answer questions such as:

• How and why can ultra-processed foods harm people’s health?
• How might certain food additives affect metabolic health and possibly contribute to chronic disease?
• What is the role of maternal and infant dietary exposures on health outcomes across the lifespan, including autoimmune diseases?

This sounds terrific —and I’m all for all of this.

An article about it in JAMA, of all places, raises some concerns.  It quotes Jerry Mande,

The bad news, he noted, is that the announcement may follow a recent pattern within the federal government of unveiling an initiative but providing few details on how it will be executed. The April press conference held by the HHS and the FDA on eliminating synthetic food dyes is one such example, in his view.

It also quotes me as noting that the announcement is short on detail and even shorter on timeline.

The food industry is in a difficult position…Ultraprocessed foods are among their most profitable, and food companies consider the ability to market to children to be essential to their business models. They could voluntarily start making and marketing healthier products and reducing unhealthy ingredients, but experience tells us that they won’t do this unless forced.

MAHA has now issued requests for proposals on two initiatives.

I.  A Research Study of Contaminants in School Meals

This pilot study supports a comprehensive, FDA-led initiative aimed at evaluating the toxicological safety and nutritional quality of meals served in all schools that actively participate in the National School Lunch Program (NSLP), including both public and nonprofit private schools…Schools must be equipped to engage in structure intervention activities and collaborate with a partner to support the transition to minimize the use of foods commonly considered ultra-processed.

The goals of this funding opportunity

1. Identify contaminants (e.g., heavy metals) present in school meals.
2. Promote whole food offerings and minimize the use of foods commonly considered ultra-processed,
3. Measure potential changes in contaminant levels and nutritional content pre- and post-intervention.

Yes, let’s give kids real foods in school, preferably and whenever possible cooked from scratch.  But,

• Are heavy metals a problem in school meals?  What other contaminants are of concern?  Why?
• How are schools to increase whole food offerings when the administration has cancelled the farm-to-school program?
• Will schools be given the additional funds needed to pay for whole foods and the staff to cook them?

The offer is for grants of about $2 million each.  The timeline for submission is short (check the links for how to submit and by when).

The FDA sent further information to applicants.

It also sent an FAQ.

Comment: I have a nagging suspicion that what this is really about is a push to substitute “cleaner” products for current products used in schools.  This is a concern because so many of the people now associated with HHS sell “clean” products and, no doubt, would love to sell them in schools.  Substituting one product for another will not solve the single major problem faced by school meal programs: lack of adequate funding for personnel, equipment, and fresh food.

II.  Take Back Your Health Campaign

Purpose:  The purpose of this requirement is to alert Americans to the role of processed foods in fueling the diabetes epidemic and other chronic diseases, inspire people to take personal responsibility for their diets, and drive measurable improvements in diabetes prevention and national health outcomes.

Scope: The U.S. Department of Health and Human Services (HHS) will launch a series of bold, edgy national campaigns with innovative messaging to inspire and empower Americans to reclaim control over their health. This initiative will challenge individuals to adopt disciplined, lifelong habits—centered on eating real food, physical fitness, and spiritual growth—to build a healthier, stronger nation.

As Stat News puts it, HHS plans ‘bold, edgy’ campaign on ultra-processed foods and diabetes. 

The campaign, estimated to cost between $10-20 million, will urge Americans to shift their behaviors and see health wearables as ‘cool’.  The call for pitches was posted on the evening of June 12, with a swift deadline of June 26. It asks not only for “daring, viral messaging to motivate behavior change” but for campaigns that specifically “popularize technology like wearables as cool, modern tools for measuring diet impact and taking control of your health.” Surgeon general nominee Casey Means’ health tech company, Levels, uses continuous glucose monitors and lab testing to help people track their health.

Comment: Oh dear.  Personal responsibility.  Never mind that the MAHA Commission report clearly identified environmental factors as responsible for epidemic chronic disease.  Neither of these initiatives gets at changing the “toxic” food environment.  To really do that, MAHA would need to stop food industry marketing of ultra-processed foods, especially to children.  And to get at other environmental causes of poor health, especially for children, it would need to take on the cigarette industry, the gun lobby (guns are a leading cause of kids’ deaths), and the industries that dump chemicals into the water and food supplies.

I’m totally for educating people about healthy diets, eating real food, and physical fitness.  But education is not enough to change behavior.  Education has to be backed up by policy.

Where’s the policy?  For that, we must wait for the next MAHA Commission report, due out in August.  Stay tuned.

Thanks to everyone who flooded my mailbox with this piece from The Guardian: She was fired after not endorsing Splenda-filled salads to people with diabetes. Why?

According to a lawsuit {Elizabeth] Hanna recently filed against the ADA, the organization – which endorses recipes and food plans on its websiteand on the websites of “partner” food brands – tried to get her to greenlight recipes that she believedflew in the face of the ADA’s mission. These included recipes like a “cucumber and onion salad” made with a third of a cup of Splenda granulated artificial sweetener, “autumnal sheet-pan veggies” with a quarter cup of Splenda monk fruit sweetener and a “cranberry almond spinach salad” with a quarter cup of Splenda monkfruit sweetener.

Guess which company gave more than $1m to the ADA in 2022? Splenda.

I also was sent an email from Georgia Warren, the  Guardian’s Interim membership editor: The link between investigative reporting, some nightmarish recipes and the diabetes epidemic.

Why would a public health charity promote a product that its own science shows contributes to the disease it is fighting? Well, as Neil Barsky reported for us this week, the ADA took more than $1m from Splenda in 2022 – and then fired their chief nutritionist when, according to a lawsuit she recently filed, she refused to sign-off on the Splenda-based recipes that her bosses wanted the ADA to publicly endorse.

Neil – creator of our new series ‘Death by diabetes: America’s preventable epidemic’ – told me…“The ADA has bought into a system that requires them to raise money from corporations to fund their research. I don’t for a second doubt that every single person who works there cares about people with diabetes and wants to do the right thing, but being beholden to these groups distorts your judgment.”

..And what else is pharma funding? The ADA. The organization – whose guidance doctors rely on when treating their diabetes patients – boasts a $100m annual budget. Between 2017 and 2024, pharmaceutical and device manufacturers contributed over $134m to the organization – or roughly 20% of its total funding.

Comment: The ADA has long appeared to be in thrall the the drug industry.  I well remember the talk I gave at one of its annual conventions years ago.  I was one of two speakers about diet and diabetes (the other was a session on the role of sugar in diabetes sponsored by Coca-Cola—truly you can’t make this stuff up).  The other talks, hundreds of them, were about drugs.  At that time, the ADA said virtually nothing about diet on its website.

It’s gotten much better.  Here’s what it says about carbohydrates:

• Try to eat less of these: refined, highly processed carbohydrate foods and those with added sugar. These include sugary drinks like soda, sweet tea and juice, refined grains like white bread, white rice and sugary cereal, and sweets and snack foods like cake, cookies, candy and chips.

And here’s what the ADA says about artificial sweeteners:

It’s also important to know that at this time, there is no clear evidence to suggest that using sugar substitutes will help with managing blood sugar or weight or improving cardiometabolic health in the long run. So here’s the bottom line:

• Sugar substitutes are effective alternatives to sugar for some people, but not a perfect fit for all—it’s a personal choice.
• If you’re looking to reduce your intake of sugar or sugar substitutes, start slowly. For example, start by replacing one soda or juice with water or a no-calorie drink at a time.
• Water will always be a great choice! If you start feeling yourself get bored with just water, you can always spruce it up with fruits or herbs like this sparkling strawberry mint infused water.

And, finally for now, here are the ADA’s corporate sponsors, and its national sponsors.

Conflicted?  Sure looks like it.

I received an e-mailed press release from the Senate Committee on Health, Education, Labor, and Pensions (HELP), chaired by Sen. Bernie Sanders (I-VT):  NEWS: Sanders and Booker Take on Food and Beverage Industry with New Legislation to Address Childhood Diabetes and Obesity Epidemics.

Sen. Sanders, along with Sens. Cory Booker (D-NJ) and Peter Welch (D-VT), have introduced legislation to

Take on the greed of the food and beverage industry and address the growing diabetes and obesity epidemics negatively impacting millions of American children and families across the country. The Childhood Diabetes Reduction Act establishes a first-of-its-kind federal ban on junk food advertising targeted to children in the United States, requires the Food and Drug Administration (FDA) to implement strong health and nutrient warning labeling, directs the National Institutes of Health (NIH) to investigate the dangers posed by ultra-processed foods, and develops a national education campaign for children and caregivers through the Centers for Disease Control and Prevention (CDC).

The press release quotes Sen. Sanders:

“Let’s be clear: The twin crises of type 2 diabetes and obesity in America are being fueled by the food and beverage industry that, for decades, has been making massive profits by enticing children to consume unhealthy products purposely designed to be overeaten…We cannot continue to allow large corporations in the food and beverage industry to put their profits over the health and well-being of our children.

Nearly 30 years ago, Congress had the courage to take on the tobacco industry, whose products killed more than 400,000 Americans every year. Now is the time for Congress to act with the same sense of urgency to combat these diabetes and obesity epidemics. That means banning junk food ads targeted to kids and putting strong warning labels on food and beverages with unacceptably high levels of sugar, salt, and saturated fat.”

Resources:

• Senate hearing:  What is Fueling the Diabetes Epidemic?
• Sanders’ letter  to the FDA to require warning labels on unhealthful food products
• The bill, section-by-section, is here.
• The bill text is here.

At long last, congressional representatives are trying to do something to prevent childhood obesity.  Let’s urge our representatives to sign on to this bill.

Arleen Tuchman.  Diabetes: A History of Race and Disease.  Yale University Press, 2020.I did a blurb for this book:

This is a superb, deeply researched history of the role of racism and class bias in perceptions of type 2 diabetes.  Its root causes?  Poverty and discrimination—a new vision for a prevention agenda.

Tuchman does for type 2 diabetes what historians of other diseases have done: explore the central role of race and racism.  Racism, she explains, can

Generate ill health by producing pathological responses to the stress of living in a society in which skin color is endowed with privileges denied to others.  Racism, in other words, can make people sick.  In this way, racism—not race—becomes a fundamental cause of differential disease rates, making it impossible to draw a sharp line between what is biological and what is social.

As she documents, health professionals first viewed diabetes as a disease of the Jews—perhaps because they went to doctors more often.   It took decades for scientists to distinguish type 1 from type 2 diabetes, and more decades to recognize that its higher prevalence among non-white minority groups might be due to the obesity-promoting diets and lifestyles of poverty.

For documentation of the social determinants of health, this book is an instant classic.

Knowing that this review was sponsored by the dairy industry, can you predict its conclusions?

Association between dairy intake and the risk of contracting type 2 diabetes and cardiovascular diseases: a systematic review and meta-analysis with subgroup analysis of men versus women. Moshe Mishali, Shiri Prizant-Passal, Tova Avrech, and Yehuda Shoenfeld . Nutrition Reviews 2019;77(6):417–429.

Conclusions: “In conclusion, these results, indicating that dairy product consumption decreases the risk of T2D and CVD, are in line with the recommendations for the public to consume dairy products. The findings about sex differences and the positive effect of milk on women need further establishment. Future studies should focus on isolating the effect of dairy products for men and women throughout their life span

Funding. This work was financed by the Israel Dairy Board.

Declaration of interests. M.M. is a consultant for the Israel Dairy Board. S.P. was paid for her work by the Israel Dairy Board. T.A. is Chief Health Officer at the Israel Dairy Board. Y.S. is a consultant for the Israel Dairy Board.

Comment: This is a study paid for by the Israeli dairy industry.  As such, it can well be considered an advertisement.  Like other such industry-funded studies (as I discuss in Unsavory Truth), it puts a positive spin on equivocal results (“need further establishment”).

Dr. Robert Lustig notes that the American Diabetes Association (ADA) has just released its newest guidelines for management of type 2 diabetes in children.

He has plenty to say about this organization, its ties to the pharmaceutical industry, and its lack of focus on effective dietary approaches to prevention and treatment—at a time when “insulin prices have soared into the stratosphere.”

The ADA, he says,

is a “bought” organization. Bought by Big Pharma. It’s only about the money. It’s not about lives or health or society. This is extortion. Big Food is Al Capone. And the ADA is Frank Nitti, his henchman.

The ADA recommendations do talk about physical activity and diet, but judge the evidence for them as not particularly strong (grades B and C).

These are standard recommendations, but difficult to follow consistently, not least because they are not nearly forceful or specific enough.

Dr. Lustig would like much greater emphasis on restricting sugars.  That’s a good place to begin.

I visited the AC supermarket in Utqiagvik, the town formerly known as Barrow.

It could be anywhere USA, with anything you could possibly want, including fresh blueberries from Argentina.  How’s that for food miles?

Remember: all of this, no exceptions, comes in by cargo plane.

The produce section was lovely, with remarkably fresh foods at equally remarkable prices.

Would you believe the green leaf lettuce is $3.50, the baby carrots $7.29, and the romaine $4.69?  New York prices on steroids.

How about white potatoes at $3.29, red ones at $2.79, and baking potatoes at $18.99 for 10 pounds.

Or the reason I was so concerned about the tossed out school lunch milk cartons: $7.11 on sale.

How about bread on sale for $5.98 a loaf?

Just to make me feel at home, here are the sugary drinks down one entire aisle.  The 12-packs were on sale for $10.98, which must not be enough to discourage sales.

Are soft drinks a problem in Utqiagvik/Barrow?

Yes, they are.

The prevalence of obesity and diabetes is low, but rising steadily, and the Indian Health Service dentists told me that they see plenty of little kids with rotted teeth from drinking sodas and sweet juices in baby bottles.

The nutrition transition is taking place in America too, and for the same reasons that obesity and diabetes are becoming problems in the developing world.