Sugar consumption does not cause diabetes

•Dr Joko Adeleye

In Nigeria, the incidence of diabetes is rising at an exponential rate. In this report by SADE OGUNTOLA, an endocrinologist, Dr Joko Adeleye, explains why this is the case, the common myths on the disease and how Nigerians can prevent the disease.

It is said that diet, level of activity, family history, all play a role in developing diabetes. But, can a can of soda per day increase the risk of Type 2 diabetes by as much as 22 per cent?

Indeed studies have reported that persons who drank one or more sugar-sweetened drinks every day had a higher risk of diabetes when compared with those who did not. One of the explanations given is that drinking too many sweetened drinks can lead to the body storing excess energy as fat, playing a role in people becoming overweight or obese which increases the risk for type 2 diabetes.

Diabetes mellitus is the most common metabolic disease worldwide. There are three main types of diabetes, including type 1 diabetes; type 2 diabetes and gestational diabetes.

Type 2 diabetes accounts for about 80 to 90 per cent of the persons with diabetes, so the pandemic that we talk about is largely attributed to cases of type 2 diabetes. Gestational diabetes, which is diabetes diagnosed for the first time during pregnancy, has also become increasingly important.

We know that genetics plays a role in type 1 diabetes and type 2 diabetes. That is why a family history is associated with an increased risk of developing these diseases.

We do know that environmental and lifestyle-related factors like obesity and overweight are very crucial in the development of type 2 diabetes.

Risk factors for type 2 diabetes include a family history of diabetes, ethnicity and increasing age. As we get older, the body becomes less sensitive to insulin or more insulin-resistant.

What I eat, do I have an excessive intake of calories? Do I take a diet that is rich in vegetables and fruits,? Do I take a lot of fats in my diet, and do I exercise regularly? Do I take a lot of alcohol or do I smoke? All of these matters.

The World Health Organisation (WHO) recommends that every adult should have at least 30 minutes of moderate physical activity at least five days in a week. So, our lifestyle does matter, and these are areas we have in mind in terms of prevention and management of diabetes.

The average person with type 2 diabetes doesn’t just have diabetes. He/she has a greater risk of having hypertension. For instance, among patient attending our diabetes clinic, up to 70 per cent also have hypertension. Overweight, obesity and cholesterol abnormalities are also very common.

Although genes play a role in the development of type 2 diabetes, lifestyle choices are also important and thought to be responsible for the epidemic of type 2 diabetes.

Majority of patients with type 2 diabetes initially would have had pre-diabetes, a condition where the blood glucose level is higher than normal but not high enough to merit a diagnosis of diabetes. Why is it important that people should know their blood sugar levels and monitor it?

Studies have shown that the time a person is first diagnosed to have type 2 diabetes mellitus is not the same time when the process that leads to it starts. There are already certain metabolic abnormalities present for even up to 15 -20 years before the time of diagnosis.

By the time many persons are diagnosed to have type 2 diabetes, up to 50 per cent of their beta cell function (the function of the insulin-producing cells in the pancreas) could have been lost. In persons with type 2 diabetes, the earliest recognisable sign is what we call insulin resistance. This is a subnormal biologic response to a given concentration of insulin. This can predate the diagnosis of diabetes by many years.

Over time, the pancreatic beta islet cells try to compensate for the insulin resistance by producing more insulin. Eventually, that compensatory mechanism fails because the pancreas can’t keep up. So the blood glucose becomes persistently elevated and diabetes results.

In between the continuum, from the time of normal blood glucose to when a diagnosis of diabetes is made, there is an intermediate category which is often called pre-diabetes or intermediate hyperglycaemia.

Why is the awareness of diabetes not translating into actions to ameliorate that pandemic?

There is no doubt that compared to many years ago, people know more about the entity called diabetes and its related problems, but the question is what do people know?

Interestingly, even among health care providers in Nigeria, awareness about diabetes and its proper management is not as good as it should be.

What are those common habits that predispose to type 2 diabetes?

These include excessive calorie (energy) consumption from meals, eating too much fat, inadequate intake of fruits and vegetables, physical inactivity/sedentary lifestyle, excessive alcohol consumption and cigarette smoking.

How long people sit down (sitting time) has been linked to the risk of diabetes, hypertension and cardiovascular diseases.

WHO recommends that every adult should have at least 30 minutes of moderate physical activity daily at least five days a week. This could be brisk walking, bicycling, low impact aerobics class, swimming and so on.

Alcohol in excess can damage the liver, the heart and nerves. Excessive alcohol intake is also a risk factor for type 2 diabetes. Cigarette smoking is a bad habit that should be expunged totally. Stress is a risk factor for many of these diseases, diabetes inclusive. It can aggravate or be a contributive factor.

How true is it that Ketogenic or low carbohydrates diets can help people with diabetes reverse their conditions?

Studies have shown that low carbohydrate diets are associated with significant weight loss in the short term and improved glycemic control, but there have been concerns about its long-term effects and safety in the long term.

Of course, a ketogenic diet will not reverse a damaged pancreas. But the weight loss can make the body less insulin-resistant. It means the pancreas doesn’t have to work as hard and that might mean that whatever insulin the person is able to produce will be more adequate.

What is the epidemiology of diabetes in Nigeria; what are its determinants in Nigeria?

In the 60s, diabetes was thought to be nonexistent but over the last four decades there has been a progressive increase. The first national prevalence of diabetes in 1992 was put at about 2.2 per cent amongst the adult population.

But of recent, a systemic review and meta-analysis of studies on the prevalence of diabetes by Uloko et al reported an overall prevalence of 5.77 per cent. However, the prevalence varies from one region to the other and from rural and urban areas.

It is believed that increasing age, being overweight or obese, physical inactivity, excessive calorie consumption or diets that are not rich in vegetables and fruits, eating a lot of refined snacks, excessive alcohol consumption and cigarette smoking and the presence of high blood pressure put an individual at a greater risk of type 2 diabetes.

Is it advisable to swap sugar for low-calorie sweeteners to control blood glucose level and help maintain a good blood glucose level?

First, sugar intake does not cause diabetes. That is a myth. However, we do know that food that is rich in sugar tend to have a lot of calories and a lot of such foods are also rich in fat. And so if you take a lot of such things you increase the risk for weight gain and obesity and this increases the risk of developing type 2 diabetes.

Generally, reducing sugar intake is beneficial in anyone. There is a certain amount of sugar beyond which is considered unhealthy. So that is why some people have said rather than take table sugar in large amounts, maybe one could use sweeteners to reduce calorie intake.

The challenge is that some people may think because they have taken low-calorie sweeteners with their tea rather than sugar, it means they can eat much more. That is one of the reasons why some studies have shown that people who take sweeteners may not even lose any weight or even be at a greater risk for weight gain and metabolic abnormalities.

It might have to do with the attendant behaviours that go with intake of low-calorie drink or sweeteners. However, for people who do have diabetes, lowering their carbohydrates intake may help to control their blood glucose, as they are deficient in insulin which is required for the uptake of glucose by the cells of the body. So generally, we would say cut down on these things if you have diabetes, but starchy carbohydrates should still be part of a healthy balanced diet in persons with diabetes.

Everything we eat as carbohydrates eventually end up as glucose, but simple or refined carbohydrates such as white bread and soft drinks are broken down more quickly placing more demand on the pancreas, while more complex carbohydrates such as whole grains, beans, oatmeal, corn etc produce a slower glucose right. However, both simple and complex carbohydrates are broken down by the body into glucose so, moderation in portion size is crucial

So sugar does not cause diabetes. Rather the diets rich in sugar promote weight gain which put a lot more stress on the body metabolism.