Dr Rupy: When you do one of these challenges, like go seven days without added sugar, you start to realise, oh wait, this is where all the sugar is in the house and in my diet. And you know, and then even within seven days, sometimes parents realise, wait a second, my my child isn't always moody like, you know, I thought it was just a temperament, a permanent temperament, but it's actually diet related.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life.
Dr Rupy: Sugar. It is everywhere and in everything in various guises. Fake sugar, artificial, refined, raw, natural, low calorie sweeteners, a ton of names for it exist. And if you Google sugar and health, you could be told it's as innocuous as water or it is as dangerous and as addictive as cocaine and worse for you than alcohol for your liver. So to get to the crux of what's really going on and how dangerous sugar is in our food system and its artificial counterparts, I'm speaking with Professor Michael Goran, professor of paediatrics at Children's Hospital of Los Angeles, and Dr Emily Ventura, a nutrition educator, public health advocate, writer and cook with a master's in public health and a doctorate of philosophy in preventative medicine. They are the co-authors of the fantastic book, Sugarproof, in which they explain the hidden danger that sugar poses specifically to a child's development and what options there are for parents and carers who want to mitigate sugar consumption. This is the podcast I've been asked to do many times and so finally we can lift the lid on sugar and its impact. And I would listen right to the end for my top tips and do check out the book Sugarproof on the podcast show notes at thedoctorskitchen.com. On the show, we speak about the different types of sugar and their various forms, why artificial sweeteners could also be just as problematic, why children are uniquely vulnerable to sugar and how problems with sugar can also be independent of weight. And I think we have a quite a pragmatic discussion about that as well. We do talk about the clinical definition of addiction and whether sugar fits into that, fatigue and sugar, the potential link with attention deficit, as well as inflammation on the brain as well. This isn't a podcast that is geared towards making you super afraid of putting any sugar into your diet at all, but I think we definitely need to be pragmatic about how much we have in our food system and how we can mitigate the effects. And that's why we've decided to do this podcast as part of the obesity series because actually it is beyond obesity, but it is certainly one of the many issues that we have in our food system that needs to be challenged. I really hope you enjoy this podcast. Do check out the show notes and here is my conversation with Professor Michael Goran and Dr Emily Ventura.
Dr Rupy: That's definitely something I thought came across in the book because every chapter is sort of presented through the lens of a typical child, whether that be an infant, a toddler or even teenagers. And I think the stories that you tell really bring the research to life. Emily, was that your experience in terms of the writing element of it?
Dr Emily Ventura: A lot of it was, yes, just from, you know, experience working with kids in the community and also some of the kids that Michael has seen in his research and, um, and then we had families that we worked with as we were working on the book that helped test some of the challenges that we suggest and our recipes and we received a lot of good feedback from them and some good stories as well that we were able to share.
Dr Rupy: Yeah, brilliant. Yeah, I love the seven day challenges that you've got in the back of the book and the 28 day challenge and and how effective just that short period of time can be when you remove sugar in its forms. But um, the the first element of of the the the research and the introduction to the book, you mentioned right at the start was was pretty alarming and it was that that 2014 study I believe that showed the fructose and glucose in sugar sweetened beverages. Why was that such a revelation for you guys and what impact did that have on the way you thought about sugar companies and the research?
Professor Michael Goran: Yeah, it made a big impact. We started off, and Emily was a graduate student in the lab at the time, so this was part of her thesis work. But we had a very simple question. We were just, we were trying to make estimates of how much fructose versus glucose children were consuming. And given that the majority of sugars were being consumed as sweetened beverages with the ingredient high fructose corn syrup, we didn't really know what that meant in terms of the amount of fructose and glucose. We were taking it at face value. The industry says it's 55% fructose, but we wanted to know for sure. Um, so we sent, we sent Emily out shopping and gathering samples and then we we sent them off, we aliquoted them and sent them off blinded to labs for analysis. And when the results came back, we were very surprised because in some cases we saw 65% of the sugars as fructose. Um, so we kind of came to the conclusion that kids were consuming more fructose, we were shifting the balance. If you start off with milk, which is zero fructose, sugary beverages, which is supposed to be 55% fructose, and then high fructose corn syrup, which is now 65% fructose, we're just shifting this balance to more uh, more fructose. So I came to the realization that kids weren't just consuming more sugars, but they were consuming different types of sugars and in particular fructose, which at the same time, we were showing fructose to be the sugar that was causing major um, metabolic and health problems and particularly during the developmental period. So it was kind of a coming together of a lot of different facts, but that opened up the story because we got to the point of, oh, kids are actually consuming quite a lot more fructose than we thought they were and that it's shifted generationally.
Dr Rupy: Yeah, yeah. So that that was a big, big revelation for you guys. And I I suppose before we dive into a further discussion about sugar and its forms and its impact on health, we should perhaps define exactly what we mean by sugar itself, the various forms of sugar, how that relates to sugar sweetened beverages and and perhaps even the the low calorie sweetener alternatives as well.
Professor Michael Goran: Yeah, we we so so sugar now has more than 200 different names, which we tried in one chapter to describe and organize systematically so that we can give readers a better understanding of the different types of sugars and their different differences. Um, they're all based on predominantly glucose, the glucose based sugars like rice syrup and corn syrup, sucrose and its different derivatives, brown sugar, white sugar, baking sugar and all the different types of sucrose, which is a glucose fructose disaccharide. And then the fructose based sugars which are high in fructose, like fruit based sugars which are proliferating in the food supply, not just high fructose corn syrup. So there's different chemical components of these different sugars that make a difference in how they act in the body that we can get into in a bit more detail. And and then the alternative sugars, which is a whole other conversation, um, which is fascinating and we got a lot of detail in the book on this, really beginning to take over the the food supply. Um, there's now dozens and dozens of different types of low calorie sweeteners that elicit sweetness hundreds, thousands or tens of thousands of times sweeter than ordinary sugar. Um, but have different makeups chemically and can act in the body in different ways and have their own effects on the body that um are problematic. So they may eliminate calories. We know that that is correct, they do eliminate calories, but they have a lot of other side effects that we can get into. And just to say, you know, chemically the most popular sweetener right now is sucralose, which is basically chlorinated sugar. So food scientists basically converted the the sugar molecule, added a few chlorine residues and lo and behold, it's 200 times sweeter and not absorbed. Brilliant. But um, it turns out that we don't have a lot of information on how this compound affects the body, growing bodies, developing bodies and what the unintended consequences might be.
Dr Rupy: Yeah, I I think we definitely need to go into the uh sweetener alternatives because there is a prevailing opinion out there, uh I believe still in the nutrition world that if it lowers calories then ergo it is much better for you than sugar itself. But as you go into in the book, there are a whole bunch of unknowns as well as probably unknown unknowns about sweeteners that we need to be pragmatic about. Um, Emily, I wonder if I could bring you in here talking about the actual impact of um sugars itself. So we've got different types of sugars that exist both naturally and unnaturally. Why are children so uniquely vulnerable to the impact of of sugars in general?
Dr Emily Ventura: Well, following on with what Michael was talking about fructose, what's often times really confusing is that some of these sugars sound really healthy. So, you know, parents might think that if they see a product that says fruit juice sweetened or they scan the back of an ingredient label and you know, it says fruit juice concentrates, but they don't see any sugar. Um, and often times these things are in um, baby foods, you know, and the pouches and the rice cakes that are sprayed with things. And what is especially harmful for children is that fructose is not naturally a part of, wouldn't naturally be a part of their diet in especially in such big concentrations. So, you know, fructose is not present in breast milk. Michael's research has shown that it can actually be transmitted into breast milk, um, based on the maternal diet. Um, but naturally children wouldn't be receiving that type of fructose and they certainly wouldn't be receiving it in, you know, a concentrated form. But now there's all these baby food, you know, and toddler foods on the market that are really high in fructose and it's just, it's a sugar that the, you know, the body isn't able to process well. Um, and I think Michael could go into more detail on that, you know, based on some of his research. Um, but you know, those are some of the effects that we're seeing that that we're concerned about.
Professor Michael Goran: Yeah, well, here's, here's, here's the, here's the other deal. Like, so, so kids, infants, babies are actually born with a built-in preference for sweetness. So they crave sweetness naturally. And this was supposed to be evolutionary protective, supposed to like get them to like breast milk and get them to like good food. But now, you know, 70% of foods in the supermarket have added sugar, 80% of kids foods have added sugar. So now kids are grabbing for these things and the food supply is is is not suited for that built-in mechanism. So and and the more you feed that sweetness, the more it gets amped up. And on top of that, there's physiological vulnerabilities. Take a very simple example like tooth decay. Why do kids get tooth decay from sugar? Okay? It's because sugar feeds bacteria in the mouth, those bacteria produce acid and as kids' teeth erupt, they're not fully developed. So they don't have the full amount of enamel to protect those teeth from the acid produced by the bacteria that feed on the sugar. So there's a very clear cut example of how the kids' developing bodies aren't fully equipped to protect themselves from these adverse effects of sugar. So they have a built-in drive to consume it and then their bodies aren't physiologically built to be protected from it. And tooth decay is just one very tangible example. We can talk about other examples too.
Dr Rupy: Absolutely. I I'm glad you brought up tooth decay. It reminds me of a a talk I gave at a a dental association was a charity event and I learned on that day actually about the number of hospital operations for tooth removals in children in the UK between 2017, 2018, something like 45,000 a year. And you actually used that statistic in your book as well and it reminded me of that. And I just thought that is when I first came across it and again when it reminded me of that in the book, I just remember feeling so angry about that because that translates into literally hundreds of millions of pounds of spent money on something that is very preventable with removing those excess added sugars from infant drinks as well as drinks that are marketed towards teenagers.
Professor Michael Goran: Yeah. Yeah, well and we used that statistic um, because it's well cited. There's actually not great numbers for the US, but I would imagine they're they're they're they're just as bad. I mean the other the other thing about it is that why kids are more vulnerable is because they have they have more frequent bouts of feeding throughout the day. So, um, if you think about an infant who's um feeding on a bottle multiple times per day, so there's more opportunity for the for the bacteria to thrive on that sugar.
Dr Rupy: Yeah, yeah. And and another thing I learned from the along with the many other things I learned from the book, um, fructose is able to reprogram developing cells specifically. Talk a bit more about that.
Professor Michael Goran: Yeah, I mean this this this was a major um, kind of aha moment when I kind of came to this realization because like Emily mentioned, we found that fructose can transfer from the mother's diet into breast milk and therefore into the baby, but it was in very small concentrations. So then I asked, well, would small concentrations of fructose be problematic for a baby and for its developing cells? So we have to look at this through the lens not just even of a baby but of a developing fat cell or a developing brain cell. And studies have been done that show even minute amounts of fructose, not glucose, you know, hundreds if not thousands of times lower in concentration that you might find in let's say a soda. So even that level of small concentration can change the fate of a developing cell. So if you incubate developing cells that have not yet determined their destiny with small amounts of fructose, you can um change the fate of how those cells develop and they're more likely to develop into fat cells with low amounts of fructose.
Dr Rupy: Wow. I mean that that for me was was really astounding, the fact that you can change developing cells and make them more likely to become fat cells. That that for me was a real like I had to stop and and think about that for a second. And and is this the same with with the sweeteners as well?
Professor Michael Goran: Yes, yeah, there's also similar studies, very similar studies that show uh different sweeteners uh have the same effect on uh developing cells. So, so you know, I started to look at this problem through the lens of development, through what's happening in babies and kids organs and cells, how they're being built and how during that building process they might be disrupted by uh sugars and sweeteners.
Dr Rupy: Wow, wow. And and Emily, I I want to bring you in here because I think most um parents listening to this might think, well, you know, my kid eats a bit of sugar every now and then, maybe, you know, a bit more than they should, but they they look pretty healthy. They're not overweight. They're not one of these kids that, you know, you think of when you think of the obese problem. Is this an issue where you have to be obese to have a sugar problem or or can it be independent of weight?
Dr Emily Ventura: It can be completely independent and that's what's so surprising is that some of these things are occurring and either parents might be seeing the symptoms and not really linking them to sugar and a high sugar diet or they're just not seeing them at all. You know, so fructose malabsorption for example is a common problem and so kids that maybe having frequent stomach aches, um parents might not know that that might be because of the juice that they're consuming or other um sweeteners that are high in fructose, even things like agave or fruit juice concentrates. Um, or you know, there's the silent development of non-alcoholic fatty liver disease, which is now an epidemic and you wouldn't know that your child's having um that type of development because it's, you know, it's not something that's regularly screened for and it's really doesn't usually get noticed until the symptoms are so severe. Um, but then, you know, there's all the behavioral aspects, you know, kids that are drowsy a couple hours after breakfast, they're having a hard time staying awake in school. Often times parents aren't seeing that, you know, they're not with their children mid-morning. I think with COVID, you know, a lot of us have seen more of the, you know, what our kids are like two hours after breakfast, but some parents are really not tuned into the fact that, you know, the the sweet porridge oats or the sweet cereal that their kids have had in the morning is actually creating a problem with their concentration and their ability to to learn in school.
Dr Rupy: You know, often as as a general practitioner working in the NHS, um, and I also work in pediatric emergency, a common complaint alongside a few other things that they parents might mention is fatigue. Um, and and obviously whilst excluding other more serious issues surrounding fatigue, one thing I tend to ask obviously about is food. And I sometimes struggle to get the idea of perhaps the amount of sugar in a typical child's diet across to the parent as to why they might be suffering from fatigue. Um, because it's not one of those things that's well understood unless the child clearly appears to have an obesity issue. What what kind of things do you have or tactics that you have to to get parents thinking about this as a problem that is actually independent of weight?
Dr Emily Ventura: Well, I think sometimes it's not until parents feel somehow motivated to make some changes that they start to see the effects. Um, so just, you know, I think the awareness of some, you know, taking a look at some of the staple foods that are in the house, some of the cereals and yogurts and biscuits and granola bars and things like that. That starts to sort of raise awareness and parents start to realize, oh wait a second, actually, you know, I didn't think my kids were eating a lot of sugar, but you know, all these things start to add up, you know, even a slice of bread can have as much as one teaspoon of sugar in it. Um, so, you know, with one simple sandwich, you're at two teaspoons, which is quite a bit given, you know, the the references that we suggest for daily maximum sugar intake, which would be between three and seven teaspoons a day depending on age and gender. So, you know, that adds up really quickly. And, you know, when when families start to make changes, they start to see changes. Um, and that's why we suggest these challenges because it's a fun way to do it and you know, we're certainly not suggesting that that kids and families take out sugar entirely for the long the long haul, that's just not realistic. Um, and sugar does have a role, you know, in in celebrating and treats are are fun to have on occasion. Um, but when you do one of these challenges, like go seven days without added sugar, you start to realize, oh wait, this is where all the sugar is in the house and in my diet. And, you know, and then even within seven days, sometimes parents realize, wait a second, my my child isn't always moody like, you know, I thought it was just a temperament, a permanent temperament, but it's actually diet related. Um, and then comes the question of what's worth adding back in. So, you know, once you've taken it out and your palette is sort of reset, then it's easier to make choices of saying, you know, maybe we won't buy this sweet yogurt, but maybe as a family we'll have dessert once a week, something we bake together, you know.
Dr Rupy: Absolutely. I I think that whole family motivation element is really key when trying to make changes that are that big, especially when those habits are so ingrained. And Michael, um, Emily mentioned NAFLD there that I want to double click on this um non-alcoholic liver fatty liver disease. Could we go into a bit about the biology behind how this occurs in in children and and why this is so worrying?
Professor Michael Goran: Yeah, well non-alcoholic fatty liver disease is now the major um, the major source of liver disease in the US, probably rising, I assume also in the UK. Multiple factors at play, but fructose, sugar metabolism plays a key role here. And a fundamental difference between fructose and glucose. Fructose and glucose are the two sugars joined together in sucrose. When you consume that or if you consume a sweetener with more fructose, those two sugars act completely differently in the body. They're chemically identical, but glucose is used all the way through the body for energy where it's combusted to carbon dioxide and water. And fructose is taken up by the liver. So everything that the gut absorbs first passes through the liver, right? Um, glucose passes through because the liver says, okay, I'm not, you know, the body needs glucose for energy. The body doesn't see a use for fructose. So, um, there's no way for the body to store excess sugars. So the liver takes it out of the circulation. There's very small amounts of fructose that get through the liver. And what what does the liver do with it? It converts the fructose into fat. And that fat can either get stuck in the liver and contributes slowly over time to fatty liver disease, which you know, eventually will become problematic and require a liver replacement, which unfortunately is growing in frequency, including in children, unfortunately. Or that fat can be repackaged and put back into the circulation as lipids. And here's where we get the connection between sugars and dyslipidemia in the blood and cardiovascular risk. So basically the liver is doing the job of kind of making use of that fructose by converting it into fat, which gets stuck in the liver or goes back into the circulation. That's basic biochemistry. That's but what's interesting is what's crucial is that pathway is very carefully regulated and depends on the amount and concentration of fructose that hits the liver, which is why drinking sugar and drinking consuming large amounts of sugar with fructose is problematic. And here's where people say, well, does that mean I shouldn't eat an apple which also has fructose? And the answer is, of course you should eat an apple. And the reason why it's different is because there's less fructose to begin with. If you drink a glass of apple juice, that has the juice of three apples and those sugars are highly concentrated and hit the liver very quickly. It's an immediate swamping, it overwhelms the capacity of of those pathways. But when you eat an apple, it's smaller fructose and it's wrapped up inside the fiber, it slows down the release. This slow release of fructose, there's a pathway in the gut for small amounts of fructose to be converted to glucose. So they can be used for energy throughout the body. So under conditions of eating an apple, slow release, small fructose, some of it's converted to glucose, you bypass all those adverse effects. You drink a glass of apple juice or a soda, fructose is already liberated, free in solution, it immediately swamps, overwhelms the capacity of that conversion and it's taken up by the liver.
Dr Rupy: So this again adds weight as to why you were so uh concerned about the the study that we mentioned right at the start of this podcast with regards to the amounts of fructose and the different types of sugars that were contained within sugar sweetened beverages being widely variable across different um drinks.
Professor Michael Goran: Yeah, I mean the the more fructose that's being consumed and the more of it that's free in solution, like in juices and beverages and so on, the more you're going to tip the balance towards those adverse effects of fatty liver disease, conversion to fat, dyslipidemia, that whole process by the way also produces uric acid and other proinflammatory um effects downstream. That whole pathway becomes much more of a factor in in in the body and during development. Not to mention the fact that those small amounts of fructose that do get through the liver do have effects. So for and and they're not registered as calories by the brain. So the brain doesn't register fructose as calories. It does register glucose as calories, so it's regulated in that way.
Dr Rupy: So that will have a knock on effect on on feeding patterns that we'll get onto a bit later. But what was interesting there and I think for the listeners just to clarify what you're saying, fruit juices are out in as much of a way as sugar sweetened beverages like, you know, your your favorite types of uh cola and and and other fizzy drinks. But there are fruit in its whole form, even though it contains fructose is good and in some cases I I read in the book can actually improve your blood sugars as well. Is that is that right? Some berries and pears?
Professor Michael Goran: There are there are some studies that show that uh some fruit, some fruits have protective effects for example on diabetes development. Berries are particularly good because they're low in fructose and high in fiber and may have other phytonutrients. So fruits vary in their in their sugar content and their fructose to glucose ratios. Um so there are some definitely some there is evidence for some protective effects. So, you know, whenever you have the opportunity to eat fruit versus drink it, uh we should definitely be eating it. And yeah, juices are out. I mean, they can be diluted as well, um if you want to kind of gradually uh reduce the sugar, but we we we we include juice from we include sugar, we include juice as added sugar. And it can be even higher in fructose. So if you compare a glass of apple juice with a glass of soda, the apple juice will have more fructose because apples are 70% fructose.
Dr Rupy: Oh wow.
Professor Michael Goran: So those are the highest culprits for fructose.
Dr Rupy: Yeah, yeah. And that's why I think there's been this general fear around fruit in their whole form being just as harmful as sugar sweetened beverages. But I think that's a really good clarification about the added phytonutrients, the fiber and how it's wrapped up and how it blunts the uh intake of the the sugar into the bloodstream. Um, I wanted to talk about um refined carbohydrates as well as sugar. Are the distinct biological effects that you've just talked about there through the processing of the liver, are they distinct to sugar only in its various forms or can that be applied to refined carbohydrates? So breads and pastas when they're using refined flowers?
Professor Michael Goran: We we kind of include those in the same category because ultimately, especially for refined flowers and grains, very rapidly broken down to glucose, obviously. So those can be problematic uh for in terms of glucose, insulin regulation and so on. So we tend to try to promote more unrefined uh flowers and grains that also have protein and fiber at all times trying to um increase the protein and fiber content of of grains that that we suggest in sugar.
Dr Rupy: You know, often as as a general practitioner working in the NHS, um, and I also work in pediatric emergency, a common complaint alongside a few other things that they parents might mention is fatigue. Um, and and obviously whilst excluding other more serious issues surrounding fatigue, one thing I tend to ask obviously about is food. And I sometimes struggle to get the idea of perhaps the amount of sugar in a typical child's diet across to the parent as to why they might be suffering from fatigue. Um, because it's not one of those things that's well understood unless the child clearly appears to have an obesity issue. What what kind of things do you have or tactics that you have to to get parents thinking about this as a problem that is actually independent of weight?
Dr Emily Ventura: Well, when you have, you know, a high sugar breakfast, you do get a quick burst of energy. And, you know, that might prompt a bout of activity initially, but then quickly, you know, you experience more of a crash and the lethargy sets in and um energy levels, you know, aren't able to be sustained as well. However, when you eat something that has fiber, um the absorption of of the sugar is slower and so that provides more steady energy and also leads to um healthier eating at the next meal, which is a big thing as well. So in the book we talk about the sugar roller coaster and how to avoid that. So if you have a a sweet breakfast that's not high in fiber and doesn't include protein, you quickly board what we call the sugar roller coaster and your um blood sugar spikes and then crashes and then what happens is the body instinctively craves more sweets to quickly restore those blood sugar levels and that can just set off a cycle that can continue all day and be very hard to get off of that roller coaster once you're on it. Um, so we suggest, you know, trying to skip that um all together by selecting a breakfast that is higher in fiber and lower in sugar.
Dr Rupy: I think um, one thing I I'm constantly asked by parents and and also people uh on on social media alike is sugar's impact on attention and specifically if sugar has an impact on ADHD. Now I know you covered that in the book, but I I thought I'd ask you point blank definitively if we can say anything about sugar's relationship to ADHD and the risk of it.
Dr Emily Ventura: Yeah, I don't think we have evidence to say that, you know, there's a causal link like that. Um there are some large scale studies that show that dietary quality in general um is related, it has a protective effect. You know, so studies that have looked in, you know, comparing diets that are um more western, quote unquote, you know, have higher amounts of sugar and refined carbohydrates and lower quality fats tend to be connected to higher rates of ADHD in the population. And diets that are more, you know, beneficial, have beneficial elements like the Mediterranean diet with higher, you know, better quality fats and omega 3s and more fruits and vegetables tend to have a protective effect. So, you know, we can't say that a high sugar diet's going to necessarily cause ADHD. Um, there, you know, is probably some evidence to say that, you know, if your child does have ADHD, then it might be worth trying to look at sugar and see if a lower sugar diet might be beneficial.
Dr Rupy: Is there a definitive effect of uh of sugar on um behavior in terms of their mood and and sleep? Is there is there a mechanism that we've we've discovered, Michael?
Professor Michael Goran: Well, not a specific mechanism. I mean the whole the whole question, we spent a lot a lot of time looking into this. Um, the whole question of whether sugar causes irritability and energy highs and lows is actually um not not not well um not not not well concluded. There there's one there was one definitive paper, when was that paper published? 10, 15 years ago in a very high quality journal that actually said there was no effect of sugar on energy levels in kids. Um, so but we debunk that idea and um, ask any parent with kids if sugar causes energy highs and lows and they'll say absolutely, right? I mean, so, so most parents will tell you there there is an effect. And the problem with those studies that were reported um 10, 15 years ago is almost all of those studies compared, did studies to compare the effects of giving sugar to a kid versus giving something like aspartame or sucralose, a non-caloric sweetener. So they didn't control for sweetness. They just took the calories out and showed that the effect on energy levels or mood levels was the same between sugar and a non-caloric sweetener. Um, there are a few studies including some done by my colleagues that we talk about in the book that carefully studied um high sugar diets versus higher fiber diets for example. And did show clear effects on on on as Emily just mentioned, you give sugar, you get an energy rush and then a crash. That has been scientifically shown in several studies, but there is this major idea in the literature due to this meta-analysis that there's no such effect, but it doesn't equate at all with what parents report. So we, you know, and kids may respond differently on different days, that's part of the problem. And if you have different kids, you're going to see different patterns of responses and that's that's okay. We know that people respond differently to different diets on different days. There's all lots of other factors involved as well. But in general, I think most parents would agree there is a direct relationship between a sugar binge and uh energy high and low.
Dr Rupy: Yeah, absolutely. Ask any parent. And and this brings me on to another sort of controversial uh area, I guess, about whether sugar is addictive. Does sugar meet the clinical criteria for it being labeled as a substance that has addictive properties?
Professor Michael Goran: Yes. So, you know, it's debatable, is it, you know, whether you call it addiction or not, but it meets the it meets the clinical definition criteria uh such as uh difficult to to give up, uh withdrawal effects if you stop eating sugar, you're going to crave it more. If you are successful in stopping eating it the first few days, you're going to get um negative effects such as headaches, withdrawal symptoms and so on. So it does meet the clinical criteria and when we when we worked with families to go and no to go without added sugars for a week, you know, we see that happening and the first few days are difficult. But um, so I think it does meet the criteria for for being addictive.
Dr Rupy: Emily, do you think there's a reluctance to accept sugar being this bad for us because we're all sort of like users of sugar and we we enjoy, you know, sticky buns and we enjoy cake and all that kind of stuff. And we have a a baking program dedicated to sugar here in the UK. You know, there's so many pulls towards this substance that knowing that it's addictive, it has these effects on our mood, you know, it's it's not great news, is it?
Dr Emily Ventura: No, it's not. But you know, that's the great thing about our approach is we definitely aren't suggesting anything overly restrictive. We're we're really also all about what we're bringing into our family's diets and what we're suggesting that families start to use to displace some of these sweet things. And then that makes it a much more positive approach. So it's not just about taking sugar out, it's about what are you adding in, you know, you know, healthier meals and maybe just new ideas for baking and new ideas for staples. And then I think what's what's great for me and what I've seen starts to happen, it's happened um in my family and in in families that I've worked with is that once you get used to a lower level of overall sweetness in your daily foods, when you do try something like one of those sticky buns or whatever it is, it's a treat, you might enjoy a couple bites of it, but you sort of immediately realize, whoa, this is really sweet, you know. And I think that, you know, that kind of awareness is so positive because, you know, then, you know, it's not like you can't have those things, but maybe you just don't need to eat it quite as often or you, you know, you might want to just have a bite or two and share it and not eat the entire thing yourself.
Dr Rupy: Yeah, yeah. I I always talk about retraining your taste buds and getting a a more sort of natural appreciation for the natural sweetness in in fruits and vegetables and and and other sources that are much better for us.
Professor Michael Goran: And that can happen. That that that's one of the main um reasons why we do the seven-day challenge because you can reset quite quickly and and and and get a better appreciation for those other tastes. So we don't have any problem enjoying those those sweet treats. The problem is we're overwhelmed with sugar that, you know, our sweet taste preferences have been so amped up that we can't appreciate some of those other flavors. So it's it's an attempt to kind of reset that and reset their appreciation and identify all the hidden sources of sugar that are kind of taking over our diet so that we can enjoy those sweet treats. So if we can if we can eliminate all the hidden sugars that don't really even need to be there, then we can enjoy with without overwhelming our sugar intake budget, we can enjoy those those sweet treats.
Dr Rupy: Yeah, absolutely. And and just to go back to the addictive properties one last time uh before we move on. But I I read in the book about the potential for um sugar addiction to be passed to baby in utero. Is that tolerance effect of sugar and that that sort of almost dependency to to to use the the clinical word, is that is that true? Is that is that what can potentially happen?
Professor Michael Goran: Yeah, I mean, studies certainly in animal models have shown that and hinted at that from human studies. And and it gets back to this idea that I mentioned earlier that babies are born with an innate preference for sweetness. Um, but you can you you can amp that up not just in you know, post-natal but also in utero as well by exposure to too much uh sugar in during development. So that built-in preference can definitely be reprogrammed upwards.
Dr Rupy: I I I couldn't end and I couldn't miss out on this opportunity to talk about the epidemic of our time, which is dementia and neurodegenerative disease. There's a a clear sort of um element of of the book and the research that points towards sugar having an impact on our brain, whether that be through inflammatory mechanisms, but one thing that really stood out to me is smaller brains with sugar. Can we talk a bit more about that? Because that for me was the super, super worrying.
Professor Michael Goran: Yeah, so I mean there are there is one study we talk about that did measure brain volume and brain structure um in adults who were habitual consumers and showed a smaller brain. It was very it's a subtle effect, but it was still significant. Um, and that was due to habitual consumption of of sugars across across the life course. And some of these things also we have to remember are we're talking about, you know, perhaps the upper end of consumption. So if you're at the level of two, three, four uh servings per day of a sugary beverage, you might see a significant effect. So we're not again, we're not saying you have to completely eliminate, but you certainly if you reduce, you'll you'll get benefits. And then also, you know, on along the same lines, studies show an an epidemiological association, again, hard to show actual causative mechanism. We're not saying absolute certainty that it's a causation because it's hard to do the human studies, but there are certainly epidemiological associations between habitual consumption of non-caloric sweeteners and uh prevalence of cognitive decline in aging and Alzheimer's disease. So there's clearly an effect of sugars and sweeteners on the brain, on brain development in early life and on brain health and and cognitive health at the other end of the age spectrum.
Dr Rupy: Emily, why do you think we're wedded to this idea given the weight of evidence against the paradigm of sugar being an issue because of its calorie content and its counterparts in terms of low calorie sweetness? Why do you think we're wedded to that idea when clearly there's a lot there's loads of other things going on which are the reasons as to why sugar is so potentially bad for us?
Dr Emily Ventura: Yeah, well it seems like quite the easy substitution, doesn't it? Right? Just take out the sugar and put in the low calorie sweetener. And you know, you see this time and time again, also, you know, even in schools, like, oh, we'll take out the squash, but we'll start, you know, offering the no added sugar squash. Um, and I think it's just we just don't know enough about the full range of long-term effects that these these sweeteners may have, but what we do know is not good. So I think, you know, it's enough evidence at least, you know, for me as an educator and a mom to say it's just not worth the the risk. Um, it certainly those products, they're considerably sweeter than sugar and so they don't do anything to address that sweet taste preference. Um, also they can potentially lead to more hunger because they can trigger an insulin response, the same way that regular sugar could and does. Um, so, you know, if you have, say you have diet squash or diet no added sugar, um, products, you may think, oh, I'm saving some calories here, but actually that's just going to rev up your hunger and cause you potentially to eat more. And we think that's why we've seen some of these results in these large scale studies that associate um low calorie sweeteners to obesity. And then some of the more frightening, you know, research that shows that the breakdown products of some of these sweeteners um actually do end up negatively impacting the brain and you know, other parts of the body. Um, it's, you know, it's just not worth it, I guess. And you know, for me it's it's kind of a no-brainer in a way. It just it brings me back to the whole idea that, you know, natural whole foods are always best. You can't really get around it, right? But I think it's just about learning, you know, how to cook them so that it's easy and this is all about your work, you know, with your one pot, you know, 321 meals is just a beautiful concept, you know, just learning how to make something in one pot that's not that hard, has a lot of flavor, you know, you add the dried spices and the fresh herbs and you know, all the different elements to it and those those things end up becoming very flavorful and easy as well. So, I think it's, you know, it's just kind of a return to the basics, um, and appreciation of of how to do that and how how great they can be.
Dr Rupy: Yeah, definitely. I'm definitely going to get you to be a spokesperson for my book in the future.
Dr Emily Ventura: Sign me up.
Dr Rupy: Yeah, I'm all about the less dishes and more flavor, so.
Dr Rupy: Yeah, totally. Less dishes, more flavors. That's I'm going to use that. That's brilliant. I'm going to use that. Yeah, no, it's it's it's fantastic the work that you've done and I think you've created like a really accessible book which actually has the action plan, you know, the seven-day challenge and the the 28 days as well and and some examples of recipes and stuff. Um, I guess I I wanted to round up this uh conversation by talking about the inequalities in response to sugar. Uh it's something you mentioned uh in the later chapters about how people respond to sugar in different ways. I I wonder if we can touch on the potential ethnic inequalities there are.
Professor Michael Goran: Yeah, I mean there are there are there are some physiological differences. I mean, a lot of it has to do with social inequalities and socioeconomic factors and um availability of health, you know, healthy foods and the fact that you can use snap dollars, which is basically low-income food supplements to purchase things like soda and junk food. So there's there's there's definitely socioeconomic um issues and inequalities, but also physiologically as well. So I mean, for example, um, Hispanics tend to have a much higher uh prevalence of fatty liver disease. So for some reason and part of it is genetic, there is one gene that promotes the uptake of fructose and the conversion to fat in the liver. So Hispanics have a higher prevalence of fatty liver disease, whereas blacks for whatever reason tend not to accumulate fat in the liver or even around the organs in the belly. So there's there's different differences physiologically in where uh different ethnic groups um store body fat and how that body fat affects the body. Asian Americans also have higher or Asians in general anywhere have higher prevalence of fatty liver and visceral fat which can affect diabetes risk. So there's there's not a universal relationship between somebody's weight and somebody's risk for diabetes or cardiovascular disease, for example. So, uh, different segments of the population can have a higher risk of those chronic diseases without having a high BMI or high body weight. And so again, it gets away from this whole idea that a calorie is a calorie, which it's not because it can be metabolized very differently and that body fat is universally bad. In some cases it's not and in some cases, in some ethnic groups, there's high risk uh at low BMI or low body weight.
Dr Rupy: Brilliant. Well, I'm I'm glad we've we've made that very clear that a calorie is not a calorie because it's still something I I'm asked about uh even today and I think there's this prevailing sort of myth out there that that it's all about, you know, fuel in, fuel out.
Professor Michael Goran: It's a it's a convenient story for the food industry to uh, you know, to kind of cover up issues with with that story that well, it's just about calories and kids are active, therefore they should be drinking energy drinks and soda to replace those calories.
Dr Rupy: Do you think the nutrition science world is catching up to this idea as well? Because I mean, even during my masters and I had lectures from some pretty esteemed colleagues and they were still wedded to this idea of the issue around obesity being because we have too much fat in our diet and too many sources of of high high energy calories, which we do, but it's still being explained through that lens rather than the other aspects of what we've just discussed today that are irrespective of the calorie content. Do you think it's getting through to the wider nutrition science circles?
Professor Michael Goran: Slowly, uh, slowly, yeah. Um, slowly and gradually we've had we've had some major developments and now with the whole revolution of personalized nutrition and the realization that people respond differently anyway to different foods. I mean, I think that's helped because we've realized that not everybody uh is the same and the response to calories can be different. But clearly, you know, the whole story of sugars and fructose versus glucose, which is calorically and chemically identical, yet have different effects on the body for me is a clear cut example of why a calorie is not a calorie. So, I think it's happening but it's very it's it's slow.
Dr Rupy: Yeah, yeah. It's like we're we're moving this Titanic ship in a different direction. So it's always going to take a bit more time than we thought. Um, you talk a lot about the history of how we get here. Now, rather than getting you to regale the entire story, which would probably take hours, I wonder about what we can learn going forward about how we say introduce foods into the supply chain or or what it would take for us to protect ourselves today so we prevent this from occurring again in terms of the food industry being allowed to just populate our supermarket shelves with these products that are potentially very dangerous for us.
Professor Michael Goran: Yeah, well there's I think there's some good examples of of policies that are working. We we we need more data. The UK has been, you know, quite progressive, Mexico, Chile, some other countries in um food taxing mechanisms or um better better regulation on food marketing towards children.
Dr Emily Ventura: Yeah, I think another really important piece too is the type of education that we provide for our children and um particularly a fan of sensory education. So education like, you know, edible education where kids are learning how to grow fruits and vegetables or to taste things or how to cook. And I think those are ways that we will ensure that the next generation is really um receptive to eating well, um and veering more toward fresh foods and homemade foods than processed foods because if you're eating a diet that's high in processed foods, you're naturally going to have a diet that's high in added sugar and high in, you know, sodium and other things that aren't great for you. So, you know, in excess. So I think um, you know, the more that we can support those type of initiatives, the better.
Professor Michael Goran: Yeah, I mean I don't have I don't have a whole ton of faith over the um success to the actual implementation of the types of policies that we need to happen. I think it's happening very slowly, it's going to continue to happen very slowly. There's big big problems in the world today and um, I'm not I'm not so sure it's going to happen fast enough. So I think what Emily is saying is that we can make rapid progress within families, get kids involved. Emily's background is in uh working with kids in growing fruits and vegetables and then getting them involved in the kitchen. And I think what we try to propose in in the book was, you know, family-based approaches to tackle this issue in your family, get kids inspired, get kids motivated. They they're going to be motivated by very different factors than you are as a parent. So find out what those motivating factors might be and work together uh as a family to to address this.
Dr Rupy: Yeah, absolutely. I think I share your sort of worry in relying on policies alone and I think it's going to take a a grassroots approach uh where we get families involved, uh and institutions involved at a at a level where people can actually join and and and learn about these kind of stuff yourself. And that's why I congratulate you for your book. It's awesome. And uh I can't wait for it to to have an impact here in the UK as well.
Professor Michael Goran: Well, yeah, thank you for for for helping us get the message out to to the to the population in the UK. We're very excited about that.
Dr Rupy: Oh, well, thank you for all the research that you guys are both doing. Honestly, it makes my job a lot easier because I can refer to a lot of the studies that you published and obviously the book now. So it's um, it's been a pleasure chatting to you guys and I'm sure this won't be the first the the last time.
Professor Michael Goran: Sure, well, we'd love to do it again anytime.
Dr Rupy: Thank you and congratulations to you as well on your new book.
Dr Rupy: Oh, thanks. Yeah, thank you for all for all your work uh as well. Thank you so much for everything you're doing.
Dr Rupy: Thank you so much for listening to today's podcast. I really hope you enjoyed listening to the issues around sugar and what we can do to mitigate it. You learned today about the specific issues with fructose and where you find fructose, why children are driven towards sweet items and how that's an evolutionary thing and also why the effect of sugar is independent of weight. So it doesn't matter whether you feel that your child is of normal weight, there is a lot of sugar in their diet that could be a whole bunch of other things going on, not just their teeth but a whole bunch of other issues um from a neurological point of view. You've also learned why eating an apple is fine versus apple juice and why refined flowers can be as problematic as sugar. Like I said, there is a whole bunch more we could be talking about on this subject. The book Sugarproof is fantastic. I highly recommend you read it, particularly if you are a parent. Um and you can find all the information at more at thedoctorskitchen.com/podcast for all the show notes. Thanks so much and I will see you here next week.
