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HEALTH PROFESSIONALS

Sugars and Health

Diabetes

In recent years, new research has led to key changes in the nutrition advice clinicians provide to people with diabetes. Despite recent advances, there are still numerous misconceptions about the role of sugars in the diet for people with diabetes.

General Nutrition Goals

According to the Canadian Diabetes Association’s (CDA) 2008 Clinical Practice Guidelines, a multifaceted approach by a wide array of health care providers (e.g., dietitians, nurses) is required to improve diabetes management. Balancing nutrition therapy and physical activity with insulin and/or oral medications is critical to improvements in blood glucose control.

The CDA states that “Nutrition therapy is an integral part of the treatment and self management of diabetes. The goals of nutrition therapy are to maintain or improve quality of life and nutritional and physiological health, and to prevent and treat the acute and long-term complications of diabetes, associated comorbid conditions and concomitant disorders”.

Carbohydrates

Carbohydrate recommendations for Canadians with diabetes parallel recommendations for the general public. The Canadian Diabetes Association (CDA) suggests that dietary carbohydrate from a variety of sources should provide approximately 50 - 55 % of an individual’s daily energy intake.

The total amount of carbohydrate, preparation and cooking methods, as well as carbohydrate characteristics like particle size and starch structure can influence the body’s response to carbohydrate in food. According to the CDA, choosing low-glycemic index foods within the same category of food more often may help optimize glycemic (blood glucose) control. It is for this reason that the glycemic index may be a useful tool for managing blood glucose in people with diabetes.

Individuals using insulin therapy should adjust their insulin based on the carbohydrate (starch and sugar) content of their meals and snacks. Nutrition counseling by a registered dietitian, along with education on meal planning and matching insulin to carbohydrate content is essential.

Sugars

It was previously believed that sucrose (table sugar) and other sugars contributed to the development of diabetes and that people with diabetes should avoid sugars. This belief was based on the assumption that sugars were more rapidly digested and absorbed than other carbohydrates and would therefore aggravate hyperglycemia. In fact, numerous studies show that sucrose and fructose actually produce a lower blood glucose response than equal amounts of many starches.

Recent Canadian, American and International recommendations have concluded that sugars do not contribute to the development of diabetes and can be included as part of healthy meal plans for people with type 1 and type 2 diabetes.

The Canadian Diabetes Association (CDA) does not recommend the avoidance of sugars. The CDA recommends that in addition to naturally occurring sugars in fruits, vegetables and dairy products, sugars added to foods can contribute up to 10% of total daily energy requirements without deleterious effects on blood glucose or lipid control.

Fibre

Dietary fibre has been associated with improved health in people with diabetes. Evidence suggests that the inclusion of soluble fibre (e.g., psyllium, barley) in the diet can reduce serum cholesterol and improve blood glucose control. Cereal fibre may reduce the risk for coronary heart disease. All Canadians are advised to increase their dietary fibre intake from a variety of foods by following Canada’s Food Guide. The Canadian Diabetes Association recommends an intake of 25-50 grams of fibre per day for people with diabetes, due to the recognized beneficial effect of fibre intake on glycemic control and blood lipids.

Glycemic Index

The glycemic index (GI) was developed by Canadian researchers as a tool to measure the body’s blood glucose response to the ingestion of carbohydrate-containing foods. GI is a scale that ranks carbohydrate foods based on how much they increase blood glucose levels about 2-3 hours after eating. The GI uses a numbering system to label foods as low GI (less than 55), medium GI (55-70) or high GI (more than 70). Foods with a high GI result in a larger increase in blood glucose than foods with a low GI. Table sugar (sucrose) has a medium GI.

The GI was originally created to help people with diabetes control their blood glucose levels. The Canadian Diabetes Association recommends that people with diabetes choose low and medium GI foods more often than high GI foods. However, it is important to note that the GI system does have some limits including:

The GI of a single food may change when it is eaten with other foods as part of a meal or snack
High GI foods can also be part of a healthy diet. For example, parsnips, winter squash and rutabaga have a high GI but are also rich in fibre, vitamins, and minerals.
The GI of a food may vary depending on how it is cooked or where it was grown.

The concept of the glycemic index challenges the traditional view that people with diabetes should avoid sugars. In the past, clinicians believed that sugars were detrimental to people with diabetes because they were thought to cause a rapid and larger increase in blood glucose than starchy foods such as potatoes and bread. However, it was discovered that some sugars actually have a lower GI value than many starchy foods. It was also found that sucrose, or table sugar, in moderate amounts does not compromise blood glucose control.

Glycemic Index of Various Foods*
	Low GI (<55)	Medium GI (55-70)	High GI (>70)
Grains and Starches	Canada’s Food Guide recommends making at least half of your grain products whole grain each day. All cereals provide energy, vitamins and minerals. Whole grain and bran cereals also provide fibre.
Cereals	All Bran™, Steel Cut Oats, Oat Bran	Shredded Wheat™, Quick Oats	Rice Krispies™, Corn Flakes™, Bran Flakes™, Cheerios™, Instant Oats
Breads	Stone ground Whole Wheat Bread, 12-Grain / Mixed Grain Bread, Pumpernickel Bread	Whole Wheat Bread, Rye Bread, Sourdough Bread	White Bread, White Bagel, Kaiser Roll
Rice/ Pasta	Pasta (cooked until firm), Converted or Parboiled Rice	Basmati Rice, Brown Rice, Couscous	Instant Rice
Fruits and Vegetables	High GI vegetables, such as parsnip, rutabaga and winter squash, are also rich sources of vitamins, minerals and fibre. Canada's Food Guide recommends eating at least one dark green and one orange vegetable each day.
Starchy Vegetables	Sweet Potato, Green Peas, Yam	Raw Carrots, Baked Potato with Skin, New Potato, Corn	Baked Potato without Skin, Mashed Potato, Parsnip, Rutabaga, Winter Squash
Fruit and Fruit Juices	Apple, Orange, Strawberries, Peach, Cherries, Grapes, Apple Juice, Orange Juice, Grapefruit Juice	Banana, Raisins, Apricots, Grape Juice, Cranberry Cocktail	Watermelon, Dried Dates
Milk Products	Milk products provide important minerals for bone health including calcium, phosphorus and magnesium. Canada's Food Guide recommends choosing lower fat milk such as 2%, 1% or skim.
	Milk, Plain Yogurt, Sweetened Yogurt, Chocolate Milk	Sweetened Condensed Milk
Legumes	Legumes, including beans and lentils, are an excellent source of protein and fibre. They can be used as an alternative to meat in many dishes.
	Lentils, Kidney Beans, Chick Peas, Baked Beans
Sweeteners	It is a myth that brown sugar and honey are "healthier" than white sugar (sucrose). They are all mainly carbohydrate and provide the same number of calories.
		Table Sugar (Sucrose), Brown Sugar, Honey
Source: International table of glycemic index and glycemic load values: Am J Clin Nutr 2002;76:5-56.

For more on the glycemic index, please see The Glycemic Index: Clinical and Public Health Significance and Understanding the Glycemic Index .

Weight Management

An estimated 80% to 90% of people with type 2 diabetes are overweight or obese. However, most cases of type 2 diabetes can be prevented or delayed with better weight management. In fact, weight management improves all aspects of diabetes control including blood glucose, blood lipids and hypertension.

According to the Canadian Diabetes Association (CDA) a small weight reduction of 5 -10% of initial body weight is all that is needed to fuel these improvements. Thus, achieving a ‘goal weight’ is not essential. Further, the CDA recommends that weight loss be slow and gradual – and that the focus for people with diabetes be on adopting a healthy lifestyle by balancing food intake and daily physical activity.

For more on weight management, click here.

Physical Activity and Exercise

It is well established that exercise is an important part of healthy living, providing numerous health benefits and contributing to improved confidence and vitality. In people with type 2 diabetes, physical activity can also boost insulin sensitivity and blood glucose control, improve lipid profiles, as well as lessen or eliminate the need for medication.

Physical activity can also assist people with diabetes in losing weight. This in itself can improve blood glucose control. However, with weight loss associated with physical activity, an adjustment of carbohydrate intake, insulin and oral medications may be required before and after activity. The Canadian Diabetes Association recommends a gradual increase in the intensity, duration and frequency of physical activity over a period of weeks or months on an individual basis.

Hypoglycemia

It is essential that people with diabetes taking insulin and/or oral medications carry with them a source of fast-acting carbohydrate. The Canadian Diabetes Association recommends that 15 g of carbohydrate be administered for the treatment of mild or moderate hypoglycemia.

Examples of 15 g of carbohydrate for the treatment of mild to moderate hypoglycemia

15 mL (3 teaspoons) or 3 packets of table sugar dissolved in water
175 mL (3/4 cup) of juice or regular soft drink
6 Life Savers (1=2.5 g of carbohydrate)
15 mL (1 tablespoon) of honey
15 g of glucose in the form of glucose tablets

The recommendations indicate that glucose tablets or sucrose in solution is preferred because other sources of carbohydrate such as orange juice and glucose gels are slower to raise blood glucose levels.

For additional information on the management of hypoglycemia please see The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.

References

Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Diabetes Association, 2008

Eating Well with Canada’s Food Guide, Health Canada, 2007

Nutrition Recommendations and Interventions for Diabetes - A position statement of the American Diabetes Association, 2008. Diabetes Care 31:S61-S78

The Glycemic Index: Clinical and Public Health Significance, Canadian Sugar Institute, 2008

Understanding the Glycemic Index, Canadian Sugar Institute, 2008

Critical Review of International Guidelines: What is Agreed upon – What is Not? Katsilambros N et al. In Bantle JP, Slama G (eds): Nutritional Management of Diabetes Mellitus and Dysmetabolic Syndrome. Nestlé Nutr Workshop Ser Clin Perform Program, 2006, vol 11, pp 207-218

Carbohydrates in Human Nutrition, FAO/WHO, 1998