If you open the pages of advertiser-supported magazines for people with diabetes, you're likely to see ads for sugar-free cookies, no sugar added ice cream, at least two brands of sugar-free syrup, a no sugar added frozen desert, sugar-free gelatin, and even sugar-free iced tea mix.
‘It was all a big mistake about sugar.’
If you go on the Web looking for companies catering to people with diabetes, you can find many distributors of these and other sugar-free products. For example, everything at one online shop is "safe for a diabetic to eat. We offer the largest selection of sugar-free or no added sugar foods around."
The online Twin Peaks Gourmet Trading Post explicitly makes the connection between diabetes and sugar free. It "offers gourmet food that is sugar free for people with diabetes."
We asked owner Sheryl Heller why she writes on her Web site that these are diabetic foods. "Because they are not made with real sugar," she replies.
What's wrong with sugar? "Diabetics can't digest it properly," she maintains. "Sugar is not good for diabetics. It's not good for their blood sugar."
That's her opinion. But the American Diabetes Association, the American Dietetic Association, the British Diabetic Association, the Joslin Diabetes Center, and the U.S. Government all disagree.
Not to fault these vendors too much, they may be just out of date. The biggest change came nine years ago.
In May 1994 the American Diabetes Association stopped recommending that people with diabetes avoid sugar. Published originally in the association's professional journal Diabetes Care and subsequently in its position statement, "Nutrition Recommendations and Principles for People with Diabetes Mellitus," the new guidelines focus instead on the total amount of carbohydrates in the diet.
It was all a big mistake about sugar, the association says. It's worth reviewing the exact words of its position statement.
"For most of this century, the most widely held belief about the nutritional treatment of diabetes has been that simple sugars should be avoided and replaced with starches," the statement says. "This belief appears to be based on the assumption that sugars are more rapidly digested and absorbed than are starches and thereby aggravate hyperglycemia to a greater degree. There is, however, very little scientific evidence that supports this assumption…. Sucrose produces a glycemic response similar to that of bread, rice, and potatoes…. The use of sucrose as part of the total carbohydrate content of the diet does not impair blood glucose control in individuals with type 1 or type 2 diabetes. Sucrose and sucrose-containing foods must be substituted for other carbohydrates gram for gram and not simply added to the meal plan."
The association based its change of heart on a review of glycemic index studies that have been underway since 1981. For example, using white bread as a baseline set at 100, sucrose (table sugar) has a glycemic index of 92. That means it doesn't raise blood glucose quite as fast as the same number of grams of carbohydrate in bread.
The glycemic index of another food mentioned in the statement, rice, depends greatly on the type and how it's prepared. Baked potatoes, on the other hand, have a glycemic index of 121, much worse than sugar.
Since the association changed its position after reviewing glycemic index studies, we asked the world's leading glycemic index researcher her opinion of so-called "diabetic foods." Dr. Jennie Brand-Miller, professor of human nutrition at Australia's University of Sydney, is the author of The New Glucose Revolution: The Glycemic Index Solution for Optimum Health.
She says that like other nutritionists she used to think that people with diabetes didn't need a special group of foods—that their diet could be "just any old healthy diet." Indeed, many nutritionists and dietitians now recommend that the best diet for people with diabetes is balanced, varied, and keeps track of total carbohydrates consumed.
"But I've changed my attitude in recent years," Dr. Brand-Miller continues. "I think it's not ethical anymore to recommend high GI starchy foods. They may be doing more harm than good for diabetes and lipid control. I think any carbohydrate in a diabetic diet needs to be low to medium GI."
Author June Biermann goes even further than Dr. Brand-Miller does. Herself a type 1 diabetic for more than 30 years, Ms. Biermann has written nine books about diabetes together with Barbara Toohey. Writing one of them, The Diabetic Woman with Dr. Lois Jovanovic-Peterson, helped convert her to a low-carbohydrate diet.
But back in the 1980s "like everybody else we were well into diabetic foods," Ms. Biermann recalls. They opened the first SugarFree Center in Van Nuys, California, in 1981, sold it in 1986, and managed it until 1993.
"Dr. Jovanovic recommended that a pregnant diabetic woman could control her blood sugar almost perfectly with a low-carb diet," Mr. Biermann says. "I started it and it worked beautifully. Sugar is just another carb. I just don't eat foods that are high on the glycemic index."
But many experts don't even apply that restriction. "With proper education and within the context of healthy eating a person with diabetes can eat anything a non-diabetic eats," maintains Karen Chalmers, director of nutrition services at Joslin in Boston and a registered dietitian.
The government's National Institute of Diabetes and Digestive and Kidney Diseases takes a similar position. "People with diabetes do not need special foods. The foods on your diabetes eating plan are the same foods that are good for everyone in your family."
In the UK the major producer of "diabetic foods," Boots, in June stopped marketing them after working out an agreement with the British Diabetic Association. Recommending instead balance and variety, the association says these foods cost more, set up a false sense of security, and have no special advantages.
Gail Frank, a registered dietitian, professor of nutrition at California State University, Long Beach, and a spokesperson for the American Dietetic Association, calls diabetic foods a misnomer, because all foods can fit in the diet of people with diabetes. Just watch the overall calories and the percentage of calories from carbohydrate, fat, and protein that your physician and dietitian work out for you, she says.
The problem with foods labeled as being diabetic because they are sugar free is that they give the impression that you can eat as much of them as you want, says Anne Dubner, a registered dietitian in private practice in Houston and also a spokesperson for the American Dietetic Association. "I have a bone to pick with those companies that promote diabetic or dietetic foods, because they have lots of calories and fat in them."
This article originally appeared in Diabetes Wellness Letter, September 1999, pp. 6-7.
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