1. Sugar, addiction and obesity
Simon Thornley
Public Health Physician/ PTF/ PhD student
University of Auckland

2. Summary What is science? Is there an obesity epidemic?
A brief history of nutrition
I get involved…
Food addiction
What next?

3. Dairy photo
This is a sugar palace, no sorry, it’s a dairy. Hard not to find anything not containing sugar. Even the cigarettes behind the counter are over 10% sugar.

4. Museum photo…
This is what a grocery shop looked like at the turn of the century – hard to see any food at all, let alone sugar.

5. What is science? “In God we trust, all others must bring data”
William Edwards Deming
“First establish the facts, then seek to explain them” Aristotle
Anarchistic
Consensus not useful
Hypothesis and argument
Disproving useful, not proof.
Probabilities over absolutes

6. The obesity epidemic Where has it occurred? Over what time period?
Explanations?
What have we been told to eat?
Is it working?

7. Is there an obesity epidemic?
Explain source of data. Definition of obesity. Prevalence on Y axis, years on x- axis. Ask audience for patterns. What do you notice about English speaking countries? Are there any Asian countries? What has happened to the prevalence of obesity in these countries?

8. What happened in the 1960s? Diet-Heart Hypothesis
Heart disease caused by saturated fat
Response: reduce fat (↑sugar or carb.)
Cheap sugar (HFCS)
American Heart Assoc.– spread to other English speaking countries
Taubes G. The Diet Delusion. New York: Vermilion; 2007.

9. Laws of thermodynamics
A – B = C
A = Energy in (food)
B = Energy out (burned, exercise/basal metabolic rate)
C = Energy stored (as fat)
δA - environmental change (Coke ads/vending machines)

10. My story

11. My thoughts on obesity 1994 2005 2007 2011 Medical training
Traditional Nutritional theory
- Energy density
Public Health
Understanding addiction
Research
Similarities between obesity and smoking
Research
Critique of energy density
Focus on sugar
1994
2005
2007
2011

12. Tobacco withdrawal

13. Symptoms in detail Signs and symptoms Duration (weeks) Proportion (%)
Irritability
< 4 50
Depression 60
Restlessness
Poor concentration
<2
Increased appetite
>10 70
Sleep disturbance
<1 25
Urges to smoke
>2
Mouth ulcers
<4 40
Constipation
>4 17

14. Addiction? Automatic behaviour
Rational behaviour
e.g. Planning,
Picking up children after work
Addiction – Automatic, withdrawal, can’t stop, causes harm
e.g. heroine
Automatic behaviour?
e.g. breathing
Mid brain/brain stem
Cortex

15. Negative re-inforcement
Withdrawal
discomfort
Puff
cigarette
Nicotine metabolised
Withdrawal
relief
More
puffs

16. How to profit from tobacco...?

17. Food Addiction?

18. Carbohydrate?
Important, because in a prominent publication summarising findings, not one mention of the health effects of fructose was mentioned.

19. Eating and addiction?
“Atkins Diet”
An executive who had tried obesity surgery, laxatives, diets, everything…
“Often I would shake until I could put some sugar in my mouth”
Smoker’s are addicted because they need nicotine to relieve unpleasant withdrawal symptoms. The cigarette provides rapid relief but also keeps them hooked. Sugar is not so commonly associated with physiological withdrawal or addiction but these quotes provide some insight.

20. “I had an hour’s drive from my office to my home, and I knew every restaurant, every candy machine and every soft drink dispenser along the whole route.”

21. What about glucose? Glycemic index very similar for glucose
Is carbohydrate the same as nicotine?
Is low GI a way out like nicotine patch or gum?

22. Bread - White vs Vogel’s

23. Glucose: glycemic index?
High GI food such as white bread causes a rapid spike in blood sugar whereas low GI food such as Vogel’s 12 grain, gives a much slower release of glucose. This may predict the addictive potential of food just as the nicotine curve predicts the addictive potential of tobacco delivery devices.

24. What about sugar?
Sugar is actually moderate GI

25. What do we know about sugar?

26. My ideas about food addiction started with observations of myself and my son. Sugary foods never seem to be a problem for him.

27. Brian Mckenna
Big Sugar

29. What does the good book say?
“It is not yet clear whether any single attribute of the Western way of life is particularly important in increasing the risk of diabetes. Excess sucrose has largely been exonerated as an important dietary factor in the aetiology of type 2 diabetes...”
J. I. Mann and A. S. Truswell
Diseases of overnourished societies and the need for dietary change: in the Oxford Textbook of Medicine, 4th Edition.

30. Sugar – traditional views
30% increase over last 30 years
Popkin BM, Nielsen SJ. The sweetening of the world's diet. Obesity Research 2003;11(11):
“empty calorie”
Nestle M. Soft drink "pouring rights": marketing empty calories to children. Public Health Reports 2000;115(4):
Sucrose and other free sugars restricted to up to <15% of total caloric intake, due to excess energy and dental caries.
Food and nutrition guidelines (Ministry of Health) 2003.
Fructose not mentioned
How much sugar do you think Nzers eat on average?

31. Average NZ consumption:
UN statistics (‘07)– 153g/day
= 38 teaspoons/ day
17% of total energy
Compare – 1961 – 33 teaspoons/day

32. Average daily dose

33. Absorption

34. Recent guidelines American Heart Association 2002
Circulation 2002;106;
“No definitive evidence... Rely on professional judgement”
“Consuming fructose either free or in the form of sucrose has neither beneficial or adverse effects”
Sitting on the fence

35. Brian Mckenna
Big Sugar

37. Update...
“Originally proposed as the ideal sweetener for people with diabetes... Fructose... has been indirectly implicated in the epidemics of obesity and type 2 diabetes”
Circulation 2009;120;
Why the about face????

38. Update
Upper limit set to reduce heart disease risk and maintain healthy weight
“6 teaspoons per day” for women
“9 teaspoons per day” for men

39. Health effects? 1990s ADA encouraged diabetics to eat sugar/HFCS
2000s about face due to ↑triglycerides
Small RCTs:
Rots teeth; raises triglycerides, ↓HDL, ↑BP, ↑urate.
Johnson, R.J., et al., Hypothesis: Could Excessive Fructose Intake and Uric Acid Cause Type 2 Diabetes? Endocr Rev, (1): p
Segal, M.S., E. Gollub, and R.J. Johnson, Is the fructose index more relevant with regards to cardiovascular disease than the glycemic index? European Journal of Nutrition, (7): p

40. Sugar - What has changed?
GI ignores fructose –Sugar half fructose (half glucose)
4x as sweet as glucose
Links to gout, diabetes
Human studies limited,
Does not trigger satiety hormones→↑hunger
E.g. Insulin, CCK
Johnson, R.J., et al., Hypothesis: Could Excessive Fructose Intake and Uric Acid Cause Type 2 Diabetes? Endocr Rev, (1): p
Segal, M.S., E. Gollub, and R.J. Johnson, Is the fructose index more relevant with regards to cardiovascular disease than the glycemic index? European Journal of Nutrition, (7): p

41. Refined carbohydrate (high GI)
Reduced risk of chronic disease
Heart disease, cancer, gallstones.
Barclay A, Petocz P, McMillan-Price J, Flood V, Prvan T, Mitchell P, et al. Glycemic index, glycemic load, and chronic disease risk—a metaanalysis of observational studies. Am J Clin Nutr 2008;87:627-37
Modest weight loss
Thomas D, Elliott E, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database of Systematic Reviews 2007;Art. No.: CD DOI: / CD pub2(3).

42. What about saturated fat?
Meta-analyses now show no link between eating saturated fat and heart disease.
Skeaff CM, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence from Prospective Cohort and Randomised Controlled Trials. Ann Nutr Metab 2009;55:173–201
Mente A, de Koning L, Shannon HS, Anand SS (April 2009). A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch. Intern. Med. 169 (7): 659–69.

43. Coronary Heart Disease
Sugar and CHD?
Sugar consumption
Dental caries
Coronary Heart Disease

44. Sugar addiction?
Yes in rats
Anecdote in humans

45. Food addiction-evidence
Neural pathways (dopamine)
Correlation between obesity & receptor density like other addictions
Automaticity – serving size, availability
Rise in sugar consumption worldwide over last 40 years.
Rodents – sugar induces withdrawal; fat does not.
What evidence do we have? I speculate first about the biological plausibility. Volkow has noticed correlations of receptor density to obesity in patients similar to that observed in other disorders. Ample evidence shows that eating behaviour is automatic. Environmental stimuli such as serving size and ease of access are strong predictors of eating behaviour.

46. Dairy photo
This is a sugar palace, no sorry, it’s a dairy. Hard not to find anything not containing sugar. Even the cigarettes behind the counter are over 10% sugar.

47. Food addiction in the headlines…

48. After the publicity... my inbox...
“For the first three weeks I cut all processed sugar and flour from my diet and suffered mood swings with extreme tension and depression, even a sense of hopelessness at times, I had horrible stomach pains, all my joints and muscles throbbed, and I had the shakes constantly.”

49. “I don't even know how to describe the horrible headaches that went along with all this. People who knew me started thinking I was hiding a drug problem.”

50. “The worst physical symptoms have been gone for about two weeks now, and the cravings are finally starting to subside… I look at birthday cake today and all I see is myself curled up in the foetal position crying in bed. “

51. Overeater’s Anonymous
“When you are addicted to drugs you put the tiger in the cage to recover; when you are addicted to food, you put the tiger in the cage, but take it out three times for a walk”
Kerri-Lynn Murphy Kriz

52. Critique: Academia
“Any addictive type of hypothesis can't explain the rise that we've seen over the last 20 to 30 years of obesity.
Prof. Boyd Swinburn, Professor of Population Health, Deakin University (now U of A) 13 Jan 2009

53. Citique: Academia and Industry
“The data quoted on sugar consumption in New Zealand are presented misleadingly and are not correctly referenced to primary sources.”
Parnell and colleagues NZMJ 2010

54. “Sugar Research Advisory Service”

55. Brian McKenna
Big Sugar

57. So What?

58. Conclusions Nutrition ignores hunger, instead focuses on energy
Low energy or low fat idea unhelpful for populations
Sugar intake continues to rise
Likely subtle addiction to refined carb and sugar
We need more research, but if this idea proves true, a change of focus may be necessary, shifting away from fat to sugar

59. Conclusions ↓ sugar likely to ↓ No downsides except $$$ Heart disease
Obesity
Diabetes
Dental caries
Other diseases?
No downsides except $$$

60. What about children?
Marketing sugary foods common

62. My advice… Zero sugar (alternatives)
Whole grains over white flour (low GI)
No low fat food – tends to be high in sugar or refined carbohydrate

63. Other lessons Ink is a powerful weapon
The ideals of science are only that
Science integrates
Don’t be scared of the big guys...
History over latest and greatest

64. The book

65. Other reading
Freedman “Wrong: Why experts keep failing us and how to know when not to trust them”. Little, Brown and Company, (journalist)
Taubes G. The Diet Delusion. New York: Vermilion; (physicist/writer)
Gillespie D. Sweet poison. Sydney: Penguin; 2008 (lawyer)

66. Thank you!