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Sweet sorrow

Many Canadians are consuming more sugar than they should, and that is contributing to a variety of health problems, including obesity, heart disease, stroke and diabetes

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Winnipeg Health Region
Wave, Summer 2013

Kyla Jensen thought she was doing everything right.

The 38-year-old mother of three knew the importance of preparing healthy, balanced meals for her family and, in spite of a hectic schedule, she and her husband, Bill, groceryshopped and cooked with that goal in mind.

Still, despite their best efforts, one of their elementary school-age daughters was chronically overweight. Concerned for the girl, the family's pediatrician suggested they meet with a dietitian.

That meeting, and the family's subsequent enrolment in the Family Lifestyles Program, offered by the Winnipeg Health Region through the YMCA, was life-changing. The program reinforced much of what Jensen already knew, but also provided her with more substantial and practical information about which foods to increase and which foods to decrease from her family's diet.

Jensen was not surprised to hear that sugar was at the top of the list of the latter group. In fact, she had learned that lesson years before. "I am a Type 2 diabetic as a result of gestational diabetes, therefore I have to watch my sugar intake," she explains. "More out of habit, I watch the sugar intake for the rest of the family, too."

This meant that whenever Jensen baked, she made a point of reducing the amount of sugar called for in the recipes. She also avoided serving her daughters fruit drinks and pop and obviously sugary snacks.

However, monitoring and adequately decreasing sugar consumption, as Jensen was reminded, requires constant and considerable diligence, as well as almost detective-calibre forensic skills. There was, she realized, much more to learn about sugar and how it is used in food products.

Sugar, in and of itself, is not harmful to the body. It is a simple carbohydrate comprised of 50 per cent fructose and 50 per cent glucose molecules. It is found in all sorts of foods, including fruits and vegetables, and is considered sweet, satisfying and tasty. Only when sugar is consumed in excess does it begin to become associated with health risks.

That usually happens whenever sugar is "added" to various food products, like soft drinks, candy, cookies and other products that have been sweetened through processing. But the thing about sugar is that it can also be found in some unlikely products. Ketchup and barbecue sauces, for example, can contain significant amounts of sugar, as can granola bars and yogurt. The pervasive use of sugar in the food product industry means that Canadians are probably consuming more sugar than they think. And therein lies the problem.

Dr. Joyce Slater is an assistant professor in the Department of Human Nutritional Sciences at the University of Manitoba's Faculty of Human Ecology. She says the main problem with sugar is that it has no nutritional value and it tends to accumulate in the body as fat when we eat too much of it.

Here's how it happens: When simple carbohydrates like sugar are consumed, they are broken down and converted into glucose. Then the glucose enters the bloodstream where it triggers the production of a hormone called insulin. Insulin is necessary to convert the glucose into energy that can be used by cells in the body. Once the energy needs of the cells are met, any excess energy from sugar is converted and stored as fat. Because we can consume more of it without feeling full, sugar is a bigger contributor to weight gain than complex carbohydrates, like starchy vegetables and whole grain breads and cereals.

According to Statistics Canada, almost 60 per cent of all Canadian adults are overweight or obese. In Manitoba, statistics suggest that 31 per cent of children and adolescents are overweight or obese. These conditions are risk factors for a host of health problems and diseases, including high blood pressure, heart disease, stroke, high triglyceride levels and metabolic syndrome.

The problem posed by excessive sugar consumption is compounded if cells become resistant to insulin. When this happens the body compensates by producing more insulin to help cells convert the glucose into energy. Eventually, the body may not be able to produce the amount of insulin required to get the job done, leaving high levels of glucose in the bloodstream. This can lead to diabetes and other health problems.

Excessive sugar has also been linked to other health issues, such as tooth decay. And researchers at UCLA have published a paper suggesting that excessive sugar consumption can also affect brain chemistry and functioning in rats. While the brain needs and uses glucose for energy, excessive consumption of quickly absorbed sugars can result in reduced memory and learning capabilities in rats, according to the study.

But while virtually everyone - medical researchers, dietitians, physicians, and even food manufacturers - agrees that excessive sugar consumption is not a good thing, there are differences of opinion as to how much is too much.

For example, the Institute of Medicine, which sets the Dietary Reference Intakes (DRI) for Canada and the United States, recommends that people derive no more than 25 per cent of their total calories from added sugar. The World Health Organization (WHO), meanwhile, sets the standard at about 10 per cent. If the average person consumes 2,000 calories a day, that would mean he or she should derive no more than 200 to 500 calories a day from added sugar, depending on whose standard is used. That works out to roughly 12.5 to 31.25 teaspoons of sugar a day.

And how much added sugar do Canadians consume? The answer is not altogether clear.

Statistics Canada published a report in 2011 estimating that the average Canadian consumes about 110 grams of sugar (27.5 teaspoons) a day. But that number includes "naturally occurring" sugar (the kind found in fruits and vegetables), as well as "added" sugar (the kind found in candy bars and soft drinks).

Although the Statistics Canada analysis does not break out the consumption of added sugars, per se, it does categorize the sources of sugar into five groups - fruits and vegetables, meat and alternatives, grains, dairy and "other." The analysis states that while Canadians on average derive as much as 30 per cent of their sugar from fruits and vegetables, they also get as much as 35 per cent from the "other" foods category, "which includes items such as soft drinks and candy that are high in added sugars." That means the average Canadian may be consuming as much as 38.5 grams (equivalent to about nine teaspoons or 144 calories) of sugar from "other" foods. That number is below the DRI and the WHO maximums for added sugar.

Statistics Canada acknowledges that the survey has limitations. For one thing, the consumption of sugar and added sugar are lumped together. For another, it is based on a 24-hour recall of respondents who completed the survey.

Slater says the shortcomings in the survey mean Canadians are probably consuming more added sugar than the survey suggests.

"People underestimate what they eat, especially 'bad' foods," she says. And just reporting the average "hides" sub-groups who have high intakes. As the survey notes, adolescent boys are actually consuming in excess of 40 teaspoons of sugar a day on average, with almost half of that amount coming from added sugar - mostly from pop and candy.

She says Canadian sugar consumption levels are probably closer to those reported by the American Heart Association in the United States. The AHA published a report in 2009 stating that the mean intake for all Americans was about 22 teaspoons of "added" sugar per day, or about 352 calories.

Slater also urges consumers to be cautious when trying to determine how much added sugar they should consume. The DRI reference to 25 per cent, she says, is not a "recommendation," but an "upper limit," and a questionable one at that.

"A quarter of your diet should be coming from added sugar? It's kind of crazy how they (the Institute of Medicine) came up with that," says Slater. "A lot of sugar is bad for you, and most of us eat way too much of it."

She said consumers would be better advised to adhere to the WHO benchmark of 10 per cent or the AHA guidelines, which suggest that the average woman should consume no more than six teaspoons of added sugar a day (96 calories), while the average male should consume no more than nine teaspoons of added sugar a day (144 calories).

Interestingly, concerns about sugar have sparked a major public policy debate in the United States. One of the leading proponents of reduced sugar consumption is Dr. Robert Lustig, a co-author of the AHA report and an expert on child obesity. Writing in the Huffington Post recently, he noted that the increase in obesity, diabetes and heart disease parallels the increase in sugar consumption over the past 30 years. "Sugar in excess is a toxin," he wrote.

On the political front, worries about the health effects of excessive sugar consumption prompted New York Mayor Michael Bloomberg to lead efforts to reduce the size of sugary drinks sold in the city. In response, the American Beverage Association has taken the city to court to have the restrictions overturned, while Coca-Cola, a major producer of sugarladen drinks has launched a campaign which suggests that problem of obesity is a complex issue and can't be blamed on sugar consumption alone.

While Canadians may or may not consume as much added sugar on average as their American counterparts, most observers agree that some Canadians do consume too much, and that it does pose health risks. That's why Eating Well With Canada's Food Guide recommends people choose products that have little or no added sugar.

And make no mistake, it is added sugar - as opposed to sugar that is found naturally in food - that poses the greatest risk.

Colleen Einarson Rand is the Regional Manager, Community Nutrition for the Winnipeg Health Region. She says the important difference between naturally occurring sugar and added sugar is how much and how quickly added sugar is consumed. One 250 ml box of fruit drink has about nine teaspoons of sugar (36 grams) while a medium sized whole fresh apple has between three teaspoons of available sugar (12 grams).

As she explains, fructose and lactose - sugars that occur naturally in foods such as fruit, vegetables and milk which are laden with essential vitamins, minerals, antioxidants and fibre - are important dietary staples. Added sugars are a different story. "When we talk about added sugars, it generally means the refined form of sugar from cane or beets that is added during processing," says Einarson Rand.

This includes the white powder sugar that is commonly mixed into coffee and the brown sugar that is commonly used in baking. It also encompasses honey, molasses and maple syrup; although the Heart and Stroke Foundation of Canada website indicates that these three are slightly better options because they contain more antioxidants than white sugar.

Other forms of sugar, often camouflaged in ingredient listings as glucose, dextrose, fructose, high fructose corn syrup and maltose, are equally troublesome when consumed in excess, as they contain as many, or in some cases, more, empty calories as plain table sugar.

While sugar in its various forms obviously shows up in treats and desserttype foods like ice cream and cake, it is often an ingredient in many foods that do not taste sweet or have any association with sweetness. These include canned soups, tomato sauces, salad dressings, ketchups, deli meats and yogurts. Sugar also is sometimes used in foods as a browning agent.

"Of the 600,000 food items in the American grocery store, 80 per cent have been spiked with added sugar," Lustig wrote in his Huffington Post article, "and the industry uses 56 other names for sugar on the label."

The best way to know if foods are loaded with or harbouring hidden sugars is to carefully read the ingredient list and check the package's Nutrition Facts table, which lists the product's total sugar content. "The higher up on the list of ingredients and the more often it appears in the list are signs that the product contains a significant amount of sugar," says Einarson Rand.

Labels, however, can be misleading. High fructose corn syrup, for example, is a synthetic product that replaced sugar in many sweet items for years until it was linked with obesity. Manufacturers recently reverted to using sucrose instead of the syrup, and mislead consumers by advertising on the package that they are now making a healthier product than they did before.

Reading labels, however, is still only half the battle. As Slater points out, the consumption of added sugar is both the cause of and the result of other factors, including physiological cravings and mood swings. "Sugar in itself causes the brain to produce endorphins that make you feel good and serotonin that makes you feel relaxed," explains Slater. "These are absorbed very quickly, causing a spike in mood. The spike in mood is followed by a dip in mood, a feeling of being tired and a need for more sugar."

Similarly, the sweet taste of sucrose causes the release of insulin, which lowers blood sugar. If carbohydrates are not consumed at the same time, this drop in blood sugar triggers hunger and cravings for more sugar.

Sugar, adds Slater, has an addictive component, and, like many addictions, it is not easy to give up. Referencing New York Times reporter Michael Moss's book Salt, Sugar, Fat: How the Food Giants Hooked Us, Slater says there seems to exist compelling evidence that food manufacturers deliberately combine sugar, fat and salt - all of which have been linked to heart disease - in certain snack items in a way that is guaranteed to trigger cravings. Sugar also remains a major concern because it is too often erroneously used as a reward or incentive for getting children to do something that they are disinclined to do. "No dessert if you don't eat your vegetables" is a common refrain in many households. As well, most foods with high sugar content are conveniently packaged, easy to open, and require no preparation.

When life is hectic, as it is in most homes with two working parents and young children, it is tempting to reach for a bag of cookies or a pudding cup for a quick and easy snack.

The way in which soft drink consumption has become normal is also a major contributor to the sugar problem. At one time, soft drinks were considered a treat, an indulgence enjoyed only on rare occasions like family celebrations and holiday meals. Now soft drinks are a staple of the North American diet.

"In the western world, soft drinks and other sugar-sweetened beverages are the number one source of added sugars," Slater says. "A 12-ounce can of soda contains about 130 calories and eight teaspoons of sugar."

In fact, approximately half of the added sugar that Canadians consume today comes from soft drinks, or pop, as well as sports energy drinks and fruit drinks, says Slater.

The problem with fruit drinks is that they are only slightly better than pop. Although they do contain some nutrients, they lack the benefits of whole fruit, especially the fibre, and contain significant amounts of sugar. A 12-ounce bottle of orange juice, for example, contains about 5.5 teaspoons of sugar. "Fruit drinks are not better than soft drinks," says Slater. "Fruit drinks are sold in huge quantities and have become normalized as a staple of childhood, but there is nothing redeeming about them. Parents have been fooled into thinking that they are doing something good by giving them to their children."

Adds Einarson Rand: "The best thing for hydration and to quench thirst is water."

That's certainly one of the lessons that Jensen took home from her initial meeting with the dietitian at the Family Lifestyles Program.

"Water is our main beverage," she says, "and juice is a very rare treat in our house. Box drinks are never included in the school lunches and are rarely purchased."

In addition to eliminating sugary drinks from her family's diet, Jensen has cut down significantly on desserts. "It is rare that we ever have dessert," she says, "but if the kids do, then they might have a fat-free yogurt, or Jello, or fruit, or small frozen yogurt or sorbet bars with reduced calories. Dessert is not a regular occurrence."

And with the exception of an occasional serving of apple sauce, a granola bar or a handful of animal crackers, her daughters do not receive treats in their school lunches either. Typically, their lunches consist of lettuce wraps or sandwiches with lean lunch meat or egg salad, cheese and crackers, and fruit and vegetables. Dinners are more likely to feature turkey, chicken or extra-lean beef. Jensen also makes her own dressings and dips to reduce sugar content and uses spices to season food rather than store-bought condiments.

The need to constantly find healthy ingredients and prepare healthy meals, especially school lunches, is an ongoing challenge, Jensen admits. At the same time, she says that in spite of the challenge and increased demands on her time, she feels good about the changes she has incorporated into her family's lifestyle and meals.

Dietitians across the board acknowledge that it would be extremely difficult and even unrealistic for families like the Jensens to completely eliminate added sugar from their diet. Instead, they encourage moderation and awareness. "Don't cut out sugar completely, you'll just be setting yourself up for failure," Slater says. "The best strategy is to manage sugar consumption."

Keeping to that strategy has helped Jensen lose 45 pounds in the last year. Her daughter's weight loss has been slower in coming, although Jensen is optimistic that will change now that summer is here and her daughter's physical activity can increase.

Einarson Rand emphasizes that health consequences related to health behaviours result from a combination of factors such as poor quality diet, lack of physical activity, smoking and an inability to manage stress.

"There is no single food or nutrient that will cause or cure illness. A lifestyle that incorporates healthy food, regular physical activity, an avoidance of tobacco, and finding ways to enjoy life is the best plan to maintain health and avoid or delay disease."

Sharon Chisvin is a Winnipeg writer.

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