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Endocrine Society 12/2/11
Nutrition and Diabetes:
Current Controversies
James L. Rosenzweig, MD
Director of Diabetes Services
Boston University
Endocrine Society 12/2/11
Major Diabetes Nutrition Issues
• Does it affect blood glucose
• Does it increase or decrease
the risk for atherosclerosis?
• Does it affect weight?
Endocrine Society 12/2/11
Diabetes Nutrition Controversies
• High Fructose Corn Syrup
• Diet Drinks
• Caffeine
• Omega-3 fats and diabetes
• Vitamin D
Endocrine Society 12/2/11
High Fructose Corn Syrup;
What’s the big deal?
• Fructose is a monosaccharide
• It doesn’t raise blood glucose directly, but
indirectly from conversion in the liver
• Fructose is also converted to glycogen
(starch) and fats in the liver
• It is found in fruits, sucrose (table sugar)
honey, agave syrup, maple syrup, brown
rice syrup, vegetables.
• Found in HFCS, a commercially prepared
sweetener, developed from corn
Endocrine Society 12/2/11
High Fructose Corn Syrup;
What’s the big deal?
• There are two types of HFCS– HFCS 55 (55% fructose and 42%glucose)
– HFCS 42 (42% fructose and 52%glucose)
• Used in baked goods, prepared foods,
breakfast cereals, frozen desserts, yogurt,
sweetened beverages, etc.
• The use of HFCS has steadily increased in
the past 30 years, while consumption of
sucrose has decreased.
Endocrine Society 12/2/11
Comparison of Sweetener
HFCS 55 HFCS 42 Sucrose
Endocrine Society 12/2/11
Possible Areas of Harm with
• Link with high consumption to obesity
• Associated with increase in serum triglycerides,
when compared with glucose
• Women who drank fructose-sweetened
beverages had lower levels of leptin and higher
levels of ghrelin, two hormones associated with
appetite control (controversial, not backed up by
other studies.)
• May be associated with higher levels of uric acid
in men—a risk factor for gout, kidney stones,
Endocrine Society 12/2/11
Possible Areas of Harm with
• Possible link with hypertension: Data from
National Health and Nutrition Examination Study
showed association of 74g/day intake with 77%
higher risk of substantial blood pressure
• Recent study at U. of California showed higher
levels of lipids, abdominal adipose tissue, and
fasting glucose when fructose containing
beverages were consumed instead of glucose
• Studies associate fructose consumption with
non-alcoholic fatty liver disease (NAFLD)
Endocrine Society 12/2/11
Conflicting Results
• In a number of large studies of diet and disease
risk, fructose not associated with hypertension,
and no difference in risk factors when HFCS or
sucrose compared with milk, artificially
sweetened drinks (Netherlands)
• No difference between sucrose and HFCS on
appetite hormones (U. of RI)
Endocrine Society 12/2/11
Take-Home Messages
• No evidence for increased risk of use of HFCS
when compared to table sugar. There is nothing
unique about HFCS with respect to risk of obesity
and diabetes
• Fructose itself may have specific metabolic risks
when compared with glucose as a sweetener,
including worsening lipid profile, increasing
obesity risk, hypertension and uric acid, but it is
found everywhere, often in “healthy” foods
• Fructose use has advantages in diabetes with
respect to glucose control
Endocrine Society 12/2/11
Further Messages
• The ADA does not recommend fructose as an
added sweetener in diabetes because of its
adverse effects on plasma lipids but encourages
fruit intake
• The ADA, however, recommends that sucrose
does not need to be restricted, and can be
substituted for other carbohydrates
• 20% of adults average more than 120 g/day added
sugar (33 tsp/day, 480 calories) Half is fructose
• 25% of children average more than 150 g/day
added sugar (48 tsp, 600 calories) Half is fructose
Endocrine Society 12/2/11
Diet Soft Drinks and Diabetes
• No Calories
• Have long been a staple of dietary
treatment of patients with diabetes
• Recent Studies have suggested that
they may have other, less beneficial
Endocrine Society 12/2/11
Current Sweeteners
Aspartame, since 1981 (200x)
Acesulfame K (Sunnet and Sweet One) (180x)
Sucralose (Splenda) 600x
Stevia, a natural product extracted from an herb
Neotame, recently approved (6000-13000x)
Alitame (not yet approved, stable in baking and
• Cyclamate (banned in 1969 because of small
association with bladder cancer in rats. Available in
55 countries
Endocrine Society 12/2/11
Sweetener Controversies
• FDA acceptable daily intakes are huge (18 cans of
diet soda containing aspartame, 32 cans containing
acesulfameK, 6 cans of sucralose, 12 packets of
• Blamed for a variety of health concerns—headaches,
allergies, digestive problems, neurological disorders,
cancer---association largely unproven
• Up until recently, NO clear association of use with
weight loss
• One large study showed that drinking one or more
servings of diet soda was associated with 67%
increased risk of developing type 2 diabetes.
Endocrine Society 12/2/11
Sweetener Controversies
• Women’s Health Study showed increased renal
kidney function decline with consumption of at least
two diet sodas daily
• Two studies show association of 1 or more servings
with 35% increased risk of developing metabolic
syndrome (combination of increased risk for CVD
and diabetes)
• High use of aspartame associated with worse
glucose control in one study
• Several sweeteners may work in the brain to
stimulate appetite, but may increase production of GI
hormones (GLP-1) which can affect satiety.
Endocrine Society 12/2/11
Take-Home Messages
• Artificial sweeteners are extremely helpful in
patients with diabetes as aids for glucose control
• Their use in weight loss, and effects on
cardiovascular risk, are more controversial
• It is not clear whether widespread use in the
general population is of benefit or harm, from the
perspective of public health
• The sweeteners should not be “lumped” together.
Different agents may have different effects.
Endocrine Society 12/2/11
Caffeine Controversies
• 17 studies have shown that caffeine can
decrease the body’s sensitivity to insulin
(increase insulin resistance) in people
without diabetes
• Two cups of instant coffee can increase the
rise in blood glucose after an iv glucose test
• Caffeine raised the average blood glucose in
patients with diabetes using CGM
Endocrine Society 12/2/11
Epidemiological Studies
• A large study of 17,111 men and women without
diabetes indicated that those who drank 7 or more
cups of coffee per day were half as likely to develop
type 2 DM
– The study was adjusted for confounding variables, like
weight, physical activity, alcohol, smoking
• A meta-analysis of 18 studies involving 450,000
people found that each daily cup of coffee is
associated with a 7% lower risk of diabetes
• Is it something other than caffeine that is beneficial?
Endocrine Society 12/2/11
Omega 3 Fats and Diabetes
• Omega -3 PUFA is found principally in fish, flax seed oils, and
• Known to have anti-inflammatory and anti-coagulant properties
• Early studies appeared to show Omega-3 increased insulin
resistance, potentially worsening blood glucose control
• A more recent large meta-analysis shows no effect on insulin
• Recent studies show major benefits on cardiovascular risk
prevention in diabetes
• Recent presentation at Renal Meetings showed marked
prolongation of graft patency with Omega-3 treatment
Endocrine Society 12/2/11
Vitamin D and Diabetes
• 25% of American population is vitamin D deficient
• Vitamin D deficiency is associated with an increased
risk of type 1 diabetes
• In one study with patients with LADA (latent
autoimmune diabetes of adults) vitamin D in
combination with insulin protected the beta cells
(which make insulin) from further damage
• Vitamin D reduces insulin resistance in a number of
studies, and treatment reduces markers of insulin
• There is an increased association of vitamin D
deficiency with type 2 diabetes
Endocrine Society 12/2/11
Vitamin D and Diabetes
• There is an increased association of diabetes and
• A study of vitamin D with yogurt improved markers of
vascular disease in patients with type 2 diabetes
• Major study, VITAL, will evaluate effects of Omega 3
fats and vitamin D on prevention of CVD and cancer,
as well as diabetes
• There is no question that vitamin D deficiency is
especially harmful in both type 1 and type 2 diabetes:
The question is, are the appropriate levels of vitamin
D the same for patients with diabetes and other
individuals, and is the necessary replacement dose
Endocrine Society 12/2/11
Special Thanks to:
Karen Chalmers, RD, CDE
Diabetes Education Program Manager
Boston University School of Medicine