The U.S. Centers for Disease Control's September 2000 report on the sharp increase in diabetes between 1990 and 1998 got major media attention, including the front page of The New York Times, the cover of Newsweek, and an editorial in The Boston Globe.
It was a big mistake about sugar.
The Newsweek article twice referred to diabetes as "poisoning by sugar."
Although it might not have been Newsweek's intention to imply that dietary sugar is what makes people with diabetes sick (it is excess blood sugar that does it), their use of the phrase "poisoning by sugar" reinforces a misconception that refuses to die.
Elizabeth Rhodes, a registered dietitian in Fort Lauderdale, Fla., was particularly concerned.
"I often have to dispel myths about sugar," she said. "With all the current information about a healthy diabetes diet, it appalls me to see a popular nationwide news magazine stating that diabetes is due to 'poisoning by sugar.' It's no wonder my clients are confused and have difficulty with compliance."
Food industry is living in the past
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.
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 foods. 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 replied.
What's wrong with sugar? "Diabetics can't digest it properly," she said. "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Not to fault these vendors too much—they might just be out of date. The biggest change came in 1994.
In May of that year, 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 said. 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."
Glycemic index reveals foods worse than sugar
The association based its change of heart on a review of glycemic index studies that have been under way since 1981. For example, using white bread as a base line 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."
Jennie Brand-Miller, associate professor in human nutrition at Australia's University of Sydney, is considered by many to be the world's leading glycemic index researcher. She is author of The G.I. Factor: the Glycemic Index Solution, published in three Australian and U.K. editions. The North American edition of the book, titled The Glucose Revolution: The Authoritative Guide to the Glycemic Index, has been published in New York by Marlowe & Co.
"I'm sick of seeing foods with no sugar in them being advertised for people with diabetes," Brand-Miller said. "If they applied the same reasoning to all high-GI foods, you'd have to do away with much of the starch people eat."
She said 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," Brand-Miller said. "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 Brand-Miller does. Herself a Type 1 diabetic for more than 30 years, 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," Biermann said. They opened the first SugarFree Center in Van Nuys, Calif., 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," Biermann said. "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."
Some experts are more lenient
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," said 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 United Kingdom, 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 carbohydrates, fat and protein that your physician and dietitian work out for you, she said.
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, said Anne Dubner, a registered dietitian in private practice in Houston and 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 on NutriNews.com on November 10, 2000.
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