Sugar and Health —The Sweet, the Sour, and the Sticky!

Sugar and Health —The Sweet, the Sour, and the Sticky!

Thank you, everybody,
for being here tonight. I know it’s late on
a Thursday night, but I appreciate
that you’re here. And I really want to
say thank you to Holly for inviting me to come and
talk tonight and remind you of all the wonderful things
the Cancer Supportive Care Program at Stanford
offers to patients. So if you haven’t picked
up one of the brochures– the more laminated
ones, please grab one of those, because
there’s a lot of benefits beyond the lectures
tonight that we can offer. Can everyone hear me OK? So when Holly asked me to give
this talk on sugar and health, I was like, oh, man, this is
a really complicated topic. So my disclaimer in the
beginning is to say one hour, you know is not enough time
to fully cover this topic, probably not even a whole day
seminar or even a whole college course. This is a multifaceted,
controversial fascinating topic. So we’ll just scratch
the surface tonight. If at any point
you feel like you have a brief comment that
you want to interject, I would encourage you. Let’s keep this
interactive, so it’s not just me talking to you guys. I’ll probably repeat
your question, that way the people
listening on the web can also hear the question. Or if you talk really loud,
maybe we won’t have to, but I’ll still repeat
it, just in case. So again, please ask questions. Keep them kind of concise, so we
can keep good flow to the talk tonight, but I would
encourage you to interact. So thank you, Holly. Here we go– a quick
objective review. So we’re going to talk a little
bit about the history of sugar in the human food
system and how it came to be around us so much. We’re going to talk about
its effect on the human body and what actually happens
when we consume sugar and how that affects our health
and different disease states. We’re going to talk about some
of the many recommendations that there are
about sugar intake. Although, these are
constantly evolving. And then the more important
and more practically, how do we apply this
information and how do we incorporated it into our life? So and again, I’m not
a historian on sugar, but it was interesting
to do a little research and find out how this has grown
over time in our food supply. Honey was one of our very
first sweeteners available. And that makes sense because
where does honey come from? Honeybees, some brave soul
looked inside a beehive one day and found a sweet
syrup in there. And so that’s a readily
available and easy to obtain. So then we started
looking– we’re humans, and we explored
different other plants and what have different tastes. And sugar cane was one
of the first plants that really took off as far
as a sugar source in the diet. So has anyone eaten raw sugar
cane or seen raw sugar cane? Yeah, there’s a few people. Well, there’s a picture
of it coming up. But it’s this– it almost looks
like a really big, like bamboo, almost. And on the inside, if you
chew on it, it’s sweet. But there sure is a lot
of fiber and texture you got to get through to
get to that sweet taste. But nonetheless,
from ancient times, we’ve been using sugar cane. But it wasn’t until the
fifth century AD, still a long time ago, that
sugar became crystallized. So before it was
these long canes and they would extract a
little syrup out of it. But syrup isn’t really
easily transportable. So then they dried it
out, they figure out some way to dry it
out, and it became like a form of granulated
sugar or like raw sugar. And then they were able
to take it on the move because sugar cane
grows near the equator. So how would people
in Europe get it, in northern Europe
especially, or different parts of the world? So when they
crystallized it, they were able to send
it out and about. And it became part of
commodities and in circulation amongst humans across the globe. So then that was so–
fifth century, now we’re going to skip all the way
to the 18th and 19th century. And that’s when Europe– or
when sugar became almost readily available in Europe. It was mostly for the halves
of society, not the have nots. But it was a luxury food
because it was still something that came a long way
in the 18th and 19th century. But people were aware of it
and it was used in cooking. This was also
around the same time that the sugar beet became
another source of sugar. And so– and sugar beets are
commonly another sugar source in our diet today. Anyone driven
through Tracy lately? And you can smell the sugar
beet, the Holly Sugar Sugar Beet Factory. I grow up near there, so I
know that sugar beet smell. So here’s a picture of these. And again, not
necessarily something you’d be like, mm,
sweet and candy, right? But once you do a significant
amount of processing on these, you get these– what
we know as table sugar. And essentially, caned
sugar versus beet sugar, you probably wouldn’t be
able to detect the difference by the time it gets into
our diet or the time it’s processed to the
point where we use it. That was it’s
transition through time. Now how about our
transition in eating sugar? For a little perspective, in the
1700s, whoever kept this data or was able to find
this data, they said that the
average Englishman– so we’re talking British
times because that’s where it was one of the
first places it became a commodity of sorts– an
average Englishman consumed around four pounds of
added sugar per year. And we’re going to
talk more in detail about this term added sugar, but
please keep that in mind here. By 1800, the
average man consumed 18 pounds of added sugar per
year– still the Englishman. Then we’re going to transition
to Americans nowadays. And there’s different
numbers on what they estimate but in a few different
places, they’ve said 22 teaspoons of
added sugar each day which equates to about 77
pounds of added sugar per year. So pretty big jump from
four pounds per year to 77 pounds per year. Anything that changes that
significantly in our diet is likely to have an effect
on our health, right? Positive or negative, right? We also have increased access to
a lot of other different things and malnutrition over
time is decreased as we had access to adequate
amounts of healthy foods. So there’s the good and the
bad of food industry and food production growth. So please keep that in mind. It’s not just all bad news. We’ve eradicated a lot of
nutritional deficiencies over time. So what happens to
sugar in the body. So here’s some boring
biochemistry stuff. Sugars are these
simple carbohydrates. Carbohydrates are
these things called monosaccharides, disaccharides,
and oligosaccharides. Generally, the sugars
are these monosaccharides and disaccharides. Glucose, or also known
as dextrose, fructose, and galactose are
monosaccharides. When you have two–
and mono means one, some of you maybe more or less
familiar with these terms– disaccharide means two. So it’s two of these sugar
chains that are connected. So sucrose or table sugar is
glucose connected to a fructose and they’re a little compound. And then those
oligosaccharides, those are many, many
compounds bound together to form one big
carbohydrate chain. So again there’s lactose. Many of you have
probably heard this term if you’re lactose
intolerant, especially. That’s glucose with galactose
or glucose and glucose. There’s a few different forms of
this depending on the chemical shape. And that’s maltose. And then galactose and
fructose is this other sugar called lactulose. So again, generally these
mono, disaccharides– simple carbohydrate
chains are sugars. And sugars provide us with
four calories per gram. Again here’s just some
background, basic information. Complex carbohydrates– so,
a grain, one gram of sugar has four calories. One gram of carbohydrate from
quinoa also has four calories. But there’s a difference
there between a gram of sugar and a gram of quinoa and we’re
going to talk a little bit more about that. But calories– the same. Calories per gram of
protein is also four grams. Calories per gram of
fat is nine grams. And alcohol has seven
calories per gram. So when you see
something like fat provides more than twice as many
calories than a gram of sugar, this was one of the reasons
why maybe 20 to 30 years ago, the trend was low
fat everything. You look at it, it makes sense. Fat provides nine
calories per gram. We’re all gaining
too much weight. Cut out the fat. When we keep this
data on what people are eating over the
years, fat intake has gone down in the
last 50, 100 years. Nonetheless, we’ve still
continued to gain weight. So the simple thought
about– and this is as a population, not
necessarily as an individual, but when we look at society. It has public health
professionals and scientists and the public saying
what do we do now. We cut back on fat and
we’re getting fatter anyway, so what can we do? So then we’re looking at,
well, maybe it’s not fat. Maybe it’s something
else in our diet. And certainly sugar intake
has been on the rise, so we’re looking at that. But now sugar, innately
we love sugar, right? Humans love sugar. It tastes good. And the first thing
you taste when you’re an infant
is milk and milk has that natural sugar
in it– lactose– and that’s sweet to the taste. So it’s an innate thing. It stimulates the pleasure
centers in our brain and we get positive
feedback to eat more of it. Sugar is used to make
food more palatable and it is a significant
source of calories. Good or bad, it gives us a
lot of our energy or calories that we need to function
and have our body function on a daily basis. It’s approximately 13
percent of the energy or calories in our diet is from
added sugars based on the data from the Centers for Disease
Control and Prevention in the US. I’ll stipulate that. Each country is different. Most of the data we’re going
to talk about is United States. So let’s consider this picture. Who– when you see this, do
you get a positive thought or do you get a
negative thought? Positive, I mean, so
everyone’s different, right? Some people are like, oh,
cavities or some people are like, wow, that’s
a lot of fake coloring and fake sugar and
stuff like that. But overall, for most people, if
you– especially if you’re not one that reads all the stuff
about sugar and health, you might think, oh, that’s
fun and it’s delicious and it’s a treat. How do we think about
something like this? Like Martha– I know it’s
harder to see because it’s all white, but Martha
Stewart, fancy cakes, and those delicious
macarons, and all that stuff. Also, probably a
positive thought, right? I mean, these things
taste delicious. And this is super
fancy, so you feel like it’s an extra special
treat more than just some candy bar, like some candies, Runts,
and Skittles, and stuff. And I’ll say brand
names in here tonight, but I’m not picking on
anything in particular, it’s just whatever
comes to my mind. Or like Coca Cola, for example. Now what do we think
when we see this? Do we think positive
or negative? Same like Martha
Stewart cake feeling, you think, oh, my gosh,
look at that Double Gulp. And if it– has anyone seen
that [AUDIO OUT] –doctor that called sugar poison,
so he’s real famous now. He– according to a talk I
was watching in preparation for this that he
gave in Texas, they have a Texas Big Gulp–
or whatever Double Gulp that’s even bigger
than the– they’re always trying to outdo the next thing. So I mean, that’s all–
this a lot of soda. And this is not something
we think, oh, healthy, and special, and fancy. We think, wow, that’s
a lot of sugar. And this picture showing
the transition from maybe the ’30s or ’40s size Coca
Cola bottle up to modern day, and who’s to say we’re not
going to get a bigger one? I think they’ve even
made cup holders in cars bigger to accommodate
things like this. So now we’ve
identified sugar, we’ve talked a little bit
about the biochemistry. What actually happens when
we eat sugar in our diet? So we take it in by our mouth,
we do some mechanical digestion by chewing. There are enzymes
in our mouth that help start the breakdown of
sugars amongst other things, but it’s called
salivary amylase. Then we get food into our
stomach, where there’s more mechanical digestion. Your stomach churns food
around, and then there’s also some chemical
digestion, which are again enzymes and
different things that help break down sugars. It gets in these
small– we can’t take like a piece of quinoa and
get that in our bloodstream. So we break it down into these
small components, those mono and disaccharides again. And that’s where, in
our small intestine, they enter the bloodstream. They’re able to pass
the intestinal borders in the smallest forms and
get into our bloodstream where they’re out throughout
our body, sends it out to the muscles, and
the heart, and all the places we need to
use it for energy. So it goes out to
every cell in our body. Now what seems to matter
is how quickly this happens and to what extent it happens. So just like I was saying
earlier, four grams of sugar– or one gram of sugar
has four calories, one gram of carbohydrate
from like a whole grain also has four calories. But how quickly we
digest those things is different because of the
structure of the carbohydrate. So who’s heard of this
thing glycemic index? Yeah, so a few people
have, but I’ll torture you with explaining it again. Glycemic index is one way,
it’s pretty popular right now. And it’s not the
be all and end all, but it’s a good
way to understand why there’s a difference
between sugar and the quinoa. So again, I’m not pushing
quinoa, it’s just our example. So if you eat an equivalent
amount of grams of sugar and an equivalent amount
of grams of quinoa, when something is considered
high glycemic index– so sugar is high glycemic index,
just pure table sugar– that’s the red line. And what that’s showing
you on this vertical– on this column here, whichever
way– yeah, vertical, that’s right. That’s showing blood
sugar rising quickly because this line here is time. So the red line is showing
a quick rise in blood sugar in a pretty short
amount of time. What the line shows the
low glycemic index, that’s what GI stands for here, that
shows a much smaller rise in blood sugar and over
a longer period of time. So glycemic index is this
thing that’s how much of food raises our blood sugar
and in what time compared to the reference
standard, which I think is like a piece of
white bread or something like that which they consider
like a high glycemic food. So this helps us
to know which foods are going to raise our blood
sugar the most and the most quickly. And why we care about
that in terms of health, and especially– we’re here for
part of the Cancer Supportive Care Program, so
we’re going to try to highlight some of the
cancer aspects of this– is when we stimulate our body
to have a quick rise in blood sugar levels, that is also
telling our body to have a quick rise in insulin levels. Do you all know– are you
familiar with insulin? So insulin is a hormone
made by our pancreas that allows us to take
sugar out of our blood and get it into our cells,
where we need it for energy. Because the little
mitochondria and these little components in our
cells need a fuel source to keep going and keep doing
their normal functions. Insulin, while it’s
important to get that job and get it in there,
if we have high circulating levels
of insulin, insulin is also a growth hormone. So because of insulin– and
all these are simplified. This is a very
complicated thing, but I’m giving you
the simple version. Insulin will promote
more cell growth. Like as kids, we have more–
we need more insulin levels or more insulin in our
body to help us grow. It’s a growth hormone. Or if we get too much insulin
when we don’t need it, we grow more fat cells
or we gain weight. So high blood sugar rise
stimulates more insulin rise, which is a growth hormone. It’s a growth hormone
for making us bigger, it is also one of the ways
that cancer cells can grow. And if anyone here
has certain– or knows anyone who is treated
with treatments that target insulin-like
growth factor, if that’s familiar
to anyone, that’s one pathway that we’re trying
to design drugs to target certain types of cancers. But cancer is not quite
that straightforward. If you target that
one pathway, it can get clever and
find another one. And then, maybe it doesn’t
even use that pathway at all, it uses a totally
different once. So you can’t even
target it that way. So that’s just something–
it’s one reason why we think insulin and blood
sugar and sugar, thus, play a role in cancer,
but not the only rule. So I don’t ascribe to
the sugar feeds cancer– just like that
straightforward of a sentence. It’s just too complicated to say
that one phrase, in my opinion. So we have an explanation
of glycemic index. So now what about–
this was popular, but this got some
flack from dietitians because what do you think are
high glycemic index foods, just straight glycemic index? Can anyone say
anything out loud? We said sugar and
white bread already. Any other thoughts? Ketchup? Ketchup? Yeah, we’ll have to check. I mean, there’s big charts. It’s probably somewhere
in there, yes. Candy. Candy. Carbs. Pardon? Carbs. Carbs, yeah, depends–
I mean, all carbs have the potential
to raise blood sugar. Some do it quicker than others. What’s tricky– carrots
are high glycemic index, technically high glycemic index. But carrots, anyone
here ever have diabetes? Carrots don’t actually
raise your blood sugar. And so that’s why just glycemic
index is not super helpful. We need to know
about glycemic load. That takes into account
how much of a carbohydrate you’re likely to eat at a meal. Who’s going to
eat seven carrots? Like yeah, that may be able
to make your blood sugar rise quickly, but that’s
a lot of carrots to eat. So it’s all– this takes
into account perspective, basically, the glycemic load. So I’m more of a
glycemic load proponent because it gives
you perspective. So a carrot is a low
glycemic load food. So this– again,
like Atkins craze, they were like
don’t eat carrots, like this was part of the reason
why they say don’t eat carrots. But it’s not– people say
they’re high in sugar, they’re not. So glycemic load
takes into account how much of the carbohydrate
you’re likely to eat. It also takes into
account some other factors like how you’re going to
cook the carbohydrate, like something like al dente
pasta, where it’s really firm, has a lower glycemic
index them really soggy noodles that
have been cooked till the point of limpness. It doesn’t change
it from low to high, but it changes it within
a significant range. Or what do you think ice cream,
high or low glycemic index? High. You would say high, right? High in sugar. But because there’s so
much fat in ice cream, it helps lower
the glycemic load. So I know– she says yippee. So it’s complicated. Glycemic load really has
to do with like pure sugar and the quick kind. So I like to pick on
Pixie Sticks for this one. Imagine it’s like,
powdered puff sugar that you like take in a blast. That’s going to hit your
blood sugar super fast. But again, something like boiled
wheat berries, and the farrow, and like quinoa,
and that, you got to chew that for
a long time, then you know that’s going to sit in
your stomach for a little while and churn. And then eventually, it’s
going to make your blood sugar rise a little bit, but
nothing like that Pixie Stick. Hope you know what that is. If you don’t what a–
it’s this powdered sugar that comes in this tube. And you like rip the top off and
you just like– throw it back and it’s powdered sugar
that’s like a fruity flavor. It’s– anyway, it’s
awesome and terrible. So glycemic load, so if
at the end of this talk, there’s a bunch of
sites, some recommended websites for learning more, I
know they’re not on the handout there, but this site
will or this presentation will be up on the website,
the Stanford YouTube channel, and so you’ll be able to look. Or you can use some
of the search terms. Like if you say glycemic
load, Harvard School of Public Health, or something like that,
if you can kind of see it, even if you don’t type in the
exact right address at the end, you’ll get the right page. So there’s really good
resources for learning more about this stuff. So here’s more examples
of high glycemic load or low glycemic load. I’ve pointed out the
load ones because I think that’s more important. So white rice, apple juice,
instant oatmeal, baked potato, raisins, those are
high glycemic load. This is not a complete
list, obviously. These are a few examples. Low glycemic load– tomato
juice, beans, carrots, and peas. Right, here, again, you
think carrots and peas. Oh, if anyone has
diabetes, again, you have to count those for
carbs, but it’s still not the same as Pixie Stick,
when you have a carrot or pea. Rye or pumpernickel or
whole grain bread, milk, and ice cream are these
lower glycemic index. Dr. Lustig, that I was
talking about earlier, and a few other
scientists are also– and there’s a lot of the
anti high fructose corn syrup too, because high fructose corn
syrup is a lot more fructose. So if we think back to
those monosaccharides, fructose is one of them. So that is metabolized a little
bit different in our body. And so some people
and scientists are really promoting anti
fructose in particular. Fructose is also what’s
in fruit, mostly. It’s the main fruit sugar. They’re not really talking as
much concern about whole fruit, it’s more about these
isolated fructose sugars that are added to foods. But some people
say, well, there’s more than just
sugar as a problem because so much of the
sugar now is coming from this fructose sugar,
that maybe there’s something unique about fructose. So we’ll just mention it
because it’s kind of interesting and it’s out there and it might
be worth looking into more. When we eat a lot
of fructose, this doesn’t go through
the exact same pathway as if you eat glucose
or something– or some of the other mono
and disaccharides. It goes directly to the liver. And if we don’t
use it right away, it basically becomes
stored pretty quickly. And there’s a condition called
nonalcoholic steatohepatitis or nonalcoholic
fatty liver disease, that we are finding
more and more. People are having liver failure
from overweight and obesity and it’s this liver
failure, which you would have thought before
was cirrhosis, or alcohol, or different
inherited conditions. But now it appears to have
this big link with overweight and obesity. And one of the
reasons they think there’s all this fat
deposition in the liver is from high fructose. So it’s some– it’s just
an interesting thing to maybe look into
or that you might be hearing more about on the
horizon if we can [AUDIO OUT]. So we know that sugar
intake on the rise– this– so these things
are hard to study. If you can imagine, how do
you say cause and effect for different things
people are doing in their diet and something
that happens over a lifetime? Kids, nowadays, they’re
becoming more and more obese. So there’s a shorter
amount of time frame we can study these
things versus 50 years. Maybe you can look at the first
20 years of someone’s life and see what are their
behaviors and what are the things they’re doing
that make one child more obese than the other, or one
child obese and one child not. But worldwide obesity
has doubled since 1980, according to the World
Health Organization, so that’s worldwide. In 2014, more than 1.9 billion
adults were overweight. And of those, 600 million obese. These are huge numbers. This is a lot of people that
are overweight or obese. And this was a powerful
statement, I thought. Obesity is preventable. We could be preventing this. It’s just– that is
a fact and point. So what– why is this
still happening though and why is it on the rise? It’s not even
plateauing or declining. So diets that are high in
sugar and probably high in fat are likely a contributing
factor to obesity. We have to obviously
point that out. Now it’s not just food,
too, it’s physical activity, it’s stress, it’s all of our–
there’s many, many factors. All of those many,
many factors make studying this super difficult. So if anyone here’s PubMed savvy
and tries to do a PubMed search and look for sugar and obesity
with a few limiting criteria on it, there are thousands and
thousands of studies out there. And they do these meta analyses
in these review articles to try to find are
several studies finding the same conclusion. Because you can
go crazy if you do try to scroll through and
look for all these studies. So some fun scientists
have done that for us. So you will still
not find many studies that will overtly be
like sugar causes– sugar contributes to obesity. They really just don’t even
say that, to be honest. They’ll say, oh,
it appears to have trends and that kind
of stuff, there is not like a clear linear
connection that they can point out scientifically. But we all kind of
think it and know it. But we– scientists
have to prove this to be the case with research. So it’s really complicated,
and I say this in detail to set the tone for sugar
and every other condition we’re going to talk about. There’s significant
scientific agreement, but hard and fast data
is really difficult to find out there about the
direct connection between sugar intake and obesity. Sugary drinks get
particular attention. Sugar-sweetened beverages,
whatever you want to call them, they have a bunch of different
names that they’re referred to. They are unique because
sugar-sweetened beverages, like that Coca Cola
picture we saw– none of us were like– you can hardly find
a redeeming quality in there other than refreshing and kind
of tasted good that one day. Sugary drinks contain
a lot of calories. They’re pure added sugar
with caffeine, and colorings, and flavors, but nothing else,
no vitamins, no minerals, no fiber, none of that. Not even particularly
hydrating because of all the sugar and the
caffeine that’s in them. So they give us a lot of
calories and guess what? Whoever is like I’m so
full after that Coke, I just can’t eat anything else. No one says that. Coke is the thing that
goes along with your meal and that other thing
is filling you up. So they’re not satisfying
or satiating is the term we like to use. Sugar-sweetened beverages
comprise 6% to 7% of overall calorie
intake in the US. That’s a lot, when you
think about how many people live in the United States. Certain organizations will make
firmer standpoints, but even still, the
organizations all– they try to be
scientifically accurate, and then there’s some
conspiracy theorists that say too many
industry people involved. But the obesity– society
says there is enough data to link sugar-sweetened
beverages and obesity,
especially in children. But even then, even to
say, oh, we’ll link them. It’s still not like yes,
a really strong statement, even though probably everyone
in here may be biased and think, yes, there’s plenty of data. So that was a little
bit about obesity. Kind of crazy to think
they’re not saying sugar’s related– for sure
related, but this is what we are with, with our science. So sugar and diabetes– also
another one where the American Diabetes Association
won’t necessarily say eating too many sugars or
too many carbs causes diabetes, but they do agree
that sugary drinks are linked to type 2 diabetes. They think there’s enough
scientific evidence to say sugar-sweetened beverages
are linked to type 2 diabetes. But they also have
the general claim– and this is what most
organizations would say, but what we as individuals
and just the public get bored of hearing
is a diet high in calories from any source
contributes to weight gain. Well, it’s like,
OK, we know that, but that doesn’t– the thing is
we all– most people know that. Most people that are
health conscious know that. And yet, why isn’t it working? Why are we all
still gaining more weight than we should
over the years? So– or as a society? And so because a diet high
in calories for many source contributes to weight
gain, and overweight is one of the biggest
factors for diabetes, that’s where they say the link is
between sugar and diabetes, is because of the
overweight factor. And that’s what most
of the science– we can feel strongly enough saying. So then sugar and
cancer– similarly, the American Cancer Society
says by promoting obesity, a high sugar intake
may indirectly increase cancer risk. But even here, they
say indirectly. This is a controversial
point because I would say half my patients that
come to see me are like, oh, and I’m avoiding sugar because
I know it feeds cancer or causes cancer or whatever. I, again, I’m not I don’t say
it so black and white like that, but I do think
that we should be– and the American Institute
for Cancer Research, we’re going to talk
about what they say– there is some kind of connection
there that we should be taking seriously and that we should
change our life and diet about. Yes, sir? Shouldn’t it be very simple
to take a large population of, say middle-aged people, say men
or women, doesn’t matter, who are underweight, and check the
livers and the fats and all these things that you
have done and then take a whole large population
of obese people and check the same items? And then see if liver fat is
related to sugar, and obesity, and all that. And if you could take
a large enough sample, you should get a
very reliable result. So his question is
could we not take a group of people that
are thin or underweight and check their liver and
take a group of people that are overweight or obese
and check their liver and some of their health parameters,
and make a conclusion from that about, well, so– you
have to say, well, what did people actually eat? Because what are the factors
that led to that person being underweight or not? So we say, well, what have
you been eating last week? What did you eat last year? What did you eat 10 years ago? We have to obtain all this
information because life is not just one snapshot in time. It’s accumulation of
exposure over time. So the tricky thing
about the science is cause and effect is
really hard to prove. Links and connections and
correlation is much easier. But for people to say
cause and effects, there has to be very
clear scientific data for– so that’s why you
get all these like more moderate recommendations,
because the hard to connect cause and effect. Or is it because [INAUDIBLE]– No, I think
scientists really want to be able to prove– I think
passionate scientists believe that there is a link or that
there’s cause and effect. But to do that study is
super challenging to do. And you can’t take
someone normal weight, feed them a high calorie
diet to induce diabetes, to induce these things
because that’s not ethical. So then we just rely on
obtaining information about what people do and making
correlations between that. So there’s stuff
done in test tube, and stuff done in
animals, and then we try to do it as ethically
as possible in humans. But sometimes, what
pans out in a test tube or an animal isn’t true for a
human being when we study it. So it’s complicated,
but we’re still trying. They’re still looking
and they’re still trying to adjust the
way they do studies and find clear cause and effect. Because ultimately,
we want to be able to give good
recommendations that will work to people to
change their health. So we’ll get to the
recommendations. You see even if we have not
a lot of great, great data, the recommendations still
say the right thing. So we’ll get there. So the American
Heart Association, they were a little bit
more– first to say things a little strongly. So good job, American
Heart Association. Getting to– this
was just actually a recent study in the Journal
of the American Medical Association, getting too
much added sugar in your diet could significantly
increase your risk of dying from cardiovascular disease. That’s a pretty
strong statement. We don’t have one
of those for cancer. I wish we did. And so– and what they
found in this study, people that consumed 17
to 21% of total calories from added sugar had
a 38% higher risk of dying from
cardiovascular disease compared to those who
consumed 8% of their calories from added sugar. So that’s pretty significant. Now not very many people consume
only 8% of their calories from added sugar. So those patients– here’s
the other tricky thing. Those patients that ate such
a low sugar diet probably did a lot of other things
healthier than the people that ate a higher sugar diet. And then, of course, we think
maybe this isn’t a big deal, but tooth decay
is a huge problem. 92% of US adults have
some kind of dental caries or dental cavities or some
kind of oral health disease that could have been prevented
with different behaviors or with diet. So the American
Dental Association also has some recommendations
because sugar they say is a major contributor
to this as well. And our teeth and
our mouth, that is the portal to
our digestive tract. So it’s hugely important. We used to just
think, oh, cosmetic or just being able to chew
or something like that. But if you’ve ever had to go
and get major dental work done, now they give you
some antibiotics because you can get a
serious heart infection or there’s a lot of
links between oral health and other conditions. So it’s not just up here. Our whole body is these
interconnected systems. And similarly, I
really like thinking about that when we think about,
oh, sugar and cancer or sugar and dia– everyone thinks
sugar and diabetes. But all of our health systems
in our body are connected. So just trying to
focus on one thing, you’re missing out
on the big picture. We look at these
microscopic things ask one simple
research question, but we got to expand the
scope and look bigger at how does this affect
the human, not just this one metabolic pathway. So what are the recommendations? So we’ve reviewed the science
that’s not like super duper strong, but the
recommendations, thankfully, even without the
best rock solid data, they still are pretty good. The American Institute
for Cancer Research– if you haven’t been
to that website, it’s an excellent
one for anyone that’s interested in cancer
and health information. They say avoid sugary drinks. I love it when I see avoid,
because for organizations to make avoid statements,
they feel strongly about it and they feel that
there’s enough data to say something strong. Because most the time,
it’ll be like limit, cutback– these
kind of more loose– so avoid sugary drinks,
limit consumption of energy dense foods. The American Cancer Society
says “Limit your intake of sugar-sweetened beverages,
such as soft drink, sports drinks, fruit-flavored drinks.” Going back to the
AICR one, what do you think energy dense foods are? The only problem
with this phrases is like who the heck knows what
that is, other than dietitians. What do you think that means? Energy dense,
anyone have an idea? PowerBars? Someone said red
meat, someone said– PowerBar. Any other guesses? High calorie? So energy dense, if
you just think of it like a physics
equation or whatever, it’s a lot of calories
in a small space or in a small amount of food. So those things tend to be
things with a lot of fat and a lot of sugar. So that’s kind of– I wish
they would just say it, but instead they say
energy dense foods. The problem is energy dense also
says– it’s things like nuts. Nuts are technically
energy dense, but nuts are nutrient
dense, which means lots of nutrition in a small place. And most– what they
mean here by energy dense is lots of calories, but not
necessarily a lot of nutrients. Because, again, creme brulee
is very energy dense, but not nutrient dense. Delicious though, right? So the American
Heart Association, they came out with more
specific recommendations. Now you see this, less
than nine teaspoons per day or 150 calories per day
of added sugar for men, six teaspoons per day or 100
calories per day for women. I like that they have specific
recommendation like that, but I also don’t
like my patients to be obsessing about food where
they’re measuring and weighing and that– food should be, in
my opinion, a little bit more normal and innate. But that’s like
a personal thing. But if you’re one
that likes– if you’re an engineer in the room and
you like to tabulate and know exactly how much and all that,
these are the guidelines. It would be an
interesting challenge– and I would encourage
any of you to do it, I’ve not been able
to succeed at it yet. Try to actually count up how
many added grams of sugar you have for one or two
days and see how you compare to the recommendations. And we can talk about how
we can try to do that. [INAUDIBLE] define added sugars? Great question. So what is an added sugar? Anyone want to– you want
to just hear my spiel or does anyone want
to take a guess? Added sugars are something that
is not the naturally occurring sugar and that is
added to a food to make it taste differently. So because people ask me
a lot like, oh, well it’s a 100% juice. And that’s not
technically added sugar, but that’s basically
sugar-sweetened beverage because you’ve taken
all the fiber away. And who– how many–
who’s made fresh squeezed orange juice here? How many oranges do you need
to make like one cup of juice? I’d say like six. Like six, right? Who sits down and eats
six oranges at one time? Some people do, but
it’s very unusual. But it’s really easy to down
that orange juice really quick. So you got all the sugar
from those six oranges, none of the fiber– and by
the way, you probably could chug it pretty
quick, especially if it’s really delicious orange juice. So that’s one of the
sticky things about juice. Even if it’s 100%
juice, I consider it added sugar or
sugar-sweetened beverage. So added sugar, though, like a
lot of people say, well, honey, but that’s the natural sugar,
the first one we ate, right? But what do you do with honey? You’re adding it to another
food to make that food sweeter. So that’s how I say
the added sugars. Yes, there– it
has some minerals and it have some
phytochemicals that make it a little bit
better than table sugar, but ti’s still added sugar. So if you can pick
one or the other, I’d say, yeah, OK, go for
honey, go for maple syrup, but still try to use less of it. Try to train your mouth out
of wanting that food to taste sweeter than it already is. So a naturally occurring
sugar, a not added sugar, would be apple, banana,
mango, the little bit of sugar that’s in sweet
corn, or carrots, or something like that. Those are naturally
occurring sugars and we don’t limit those. We don’t recommend
limiting those. And the American
Heart Association doesn’t recommend
limiting those. Weight Watchers doesn’t
recommend limiting those. If anyone’s done that,
you can eat as many fruits and vegetables
you want, that you don’t have to count
those anymore for points. The American Institute for
Cancer Research, no one’s recommending not eating
fruits and those naturally occurring sugars. But we are recommending
limiting added sugars. So thank you for asking. The World Health Organization,
currently their recommendations are for less than
10% of calorie intake to come from added sugars. So then based on the average
diet, average calorie needs of the average
reference person, that’s 12 teaspoons per day. That’s a lot more than the
American Heart Association. There are current
proposed guidelines that were open for public
comment, but it’s closed now. So sorry, it’s too late for us. But you could have
made a comment about the proposed World
Health Organization change that will now
say 5% of calorie intake from added sugar or less. So now here’s where we
get to talk a little bit about the industry influence
like you were alluding to over there. When people– when the
big organizations like this come out with
recommendations like this, guess who goes crazy? Pepsi, Coke, I mean, again,
we’ll be brand specific. Anyone that makes food
with a lot of added sugar, and the lobbyists, and things,
they don’t like to see that. That means cutting
into their profits. You would hope that
they would care about keeping
people alive longer to eat their food longer,
but in the mean– anyway, so they get upset when
these things come out. Thankfully, the World
Health Organization has stood their ground and
been like we’re saying it because it’s the right
thing, it doesn’t matter what the industry says. So they’re proposed guidelines,
we’ll see what– actually, get– make it to publish
and are the things we see. 5% of calories or less
are about six teaspoons per day, which is again
similar to the American Heart Association. What I like about the
more extreme guidelines is it’s– to me, it’s OK to
say these hard to do goals because if we get a little
closer to it, that’s success. If you put a goal that’s
looser and then you don’t feel like you have to
make it, do as hard of work to get to it, you’re not
likely to try as hard. So even if it’s an
extreme goal, if we get people to move even a
few percentages closer to it, it’s beneficial on
a population basis. American Dental Association–
keep added sugar in your diet to a minimum by making wise
food and beverage choices. So another thing
about added sugars, or healthy food versus more
junkie food, is displacement. This is my approach
with my patients. I really don’t– there are
certain foods that are bad foods, they really are. Again, the PC and
dietitians like to say, oh, there’s no bad foods. Every food can fit, and
all that kind of stuff. I think there are some things
we should not be eating, period. Or it should be like
very, very, very rarely. So what’s the problem is when we
fill up on this category here, what were you not eating that
you should have been eating that gave you
vitamins, that gave you minerals, that gave
you phytonutrients, that gave you fiber, that
didn’t cause dental cavities, that didn’t cause obesity, that
didn’t cause heart disease, that didn’t clean out your
colon really well for you? If you fill up on
the junk food, you’re less likely to eat the foods
that your body actually needs. Again, here’s energy density,
but not nutrient density. The veggies and the
fruits over there, those are nutrient dense
and not energy dense. So I like the
whole– I don’t like to tell my patients a lot
of like don’t eat this. A lot of people say
what shouldn’t I eat. And I tell them a few
things, but they’re surprised when it’s like is
that all I shouldn’t eat. I’d rather you think
about what should I eat, what should I be filling up on. And if you focus on what
should you be eating, there’s not as much room for the
things you shouldn’t be eating and they’ll be in
balance that way. You can’t have a
cancer nutrition talk without showing the New
American Plate, which recently got a new graphic. This was new to me. I learned something
preparing for this talk. It used to be like a sketch
and now it’s a picture. So it actually looks more
like food, thankfully. So the New American
Plate, and this is from the American
Institute for Cancer Research, and their website, like
I said, is excellent and you should check it out. 2/3 or more of your diet
should come from plant food, and then within plant
foods– again, Cheetos is mostly a plant
food, but that’s not what they’re talking about here. They’re talking about fruits,
vegetables, whole grains, beans, nuts, seeds,
herbs, spices, all those wonderful things. One third or less of your
plate from animal protein, what’s animal protein? It’s the obvious stuff–
chicken, fish, beef, pork, lamb, but also milk,
yogurt, cheese, eggs. Those are all animal foods, and
animal protein, specifically. So most of your plate should
be vegetables, fruits, whole grains. This is broccoli, this is some
zucchini with red bell peppers or something, brown
rice, and some chicken. How does this compare, do you
think most American plates? What do you think? This plates got half of
it with vegetables, right? Probably half of most
plates are taken up with the meat and the baked
potato or something like that. Or there’s a lot of people that
are carbatarians, I call them. Just the quantity on that plate
seems minimal compare to what you’re– That’s right, yes. So there’s proportion
of our diet, she’s saying the quantity
on this plate seems not like restaurant portions. This plate– you can
have a bigger plate or you can have a
smaller plate, depending on your size and your
nutritional needs. If we want to lose weight, we
got to make this plate smaller, but the proportion should
stay the same, roughly, where half of our diet is from
veggies and fruits and things like that, and just a
bit– enough of carbs and enough protein to give us
some energy and the vitamins we need from them and
enough protein. But you’re right. These are normal–
these are actually good portion sizes versus
what normally are served. I know that meat is small. I know Holly’s
husband would be– he be like where’s the meat. So now we know what we– why
and what we should be doing, now how do we– I like– I really–
I hope you guys can appreciate a slide coming up here. How do we apply this knowledge? So here’s the good
question, added sugar versus naturally
occurring sugar. Naturally occurring sugars
are in the whole fruits. Again, yes, there’s naturally
occurring sugar in juice, but I don’t– I try to get my
patients to not drink fruit juice. Vegetable juice is different,
much, much, much less sugar in vegetable juice, but there’s
a lot of sugar and fruit juice. Milk, lactose, that naturally
occurring sugar there, plain yogurt, also
contains lactose, fruit yogurt contains lactose
plus whatever they sweeten it with. It’s not like it’s just milk
culture and strawberries. There’s a whole bunch of other
things they put in there too. So why do we use added sugars? Historically, there
was good reason. If you needed– or if anyone
does canning or jarring, if you want to make
fruit preserves and have them last
all winter or whenever till you need them next, sugar
is a really good preservative and so is salt. That’s why canned stuff
is either sugary or salty. Sugars also make
food taste better. I remember growing up, my
grandma sprinkling sugar on my sliced strawberries. Like they needed it, but
hey, I ate the strawberries because she put sugar on them. And then fruit is
also– some people, again, back to
the conspiracy, do they add extra sugars to
make us crave food more and to make us
addicted, potentially. And I think of it more of
like training your mouth to want these things. We are creatures of habit. And so if you always get
that 3:00 PM little sweet treat or whatever at work,
you condition your body to look for that. You condition– like same
thing you can do with salt too. People that are restricting
salt in their diet for health reasons– at first, food
tastes bland, tasteless. You’re like, oh, the horror. Then you get used
to it after a while, the more you just
accept and move on. And when you taste something
that has salt in it, you’re like, whoa,
this is so salty. So our body can acclimate to
whatever we challenge with. So similarly, with
sugar, the more we cut back on it–
even like Stevia, super popular right now, Stevia. It’s a natural artificial–
or not artificial, it’s a natural
nonnutritive sweetener, so it doesn’t have sugar in
it, but it sweetens food. And my patients are like,
well, what about Stevia. Can I use Stevia? I was like, yeah,
you can use Stevia, but I treat those
type of things– Stevia equals Splenda, whatever,
treat them like regular sugar and you should be trying to use
as little as you can get away with to train your mouth out
of wanting that sweet flavor and just appreciating
the natural sugar and the natural taste and
sweetness of the food, the way it is from the
ground or from the earth or with just minimal
human processing. So Stevia, sugar,
all that stuff, try to use less and
train your mouth out of craving for those things. So here’s the picture
I hope you like. Does anyone know who this is? Benedict Cumberbatch. Benedict Cumberbatch,
thank you very much. He’s the newest Sherlock
Holmes in like the BBC series or whatever, some
British series. So this is when we all
need to become detectives. How the heck do we find the
added sugars in our food? So I like– we’ll whip
out our magnifying glass and we’ll try to find
these added sugars. And so because when you
look at a food label, who has tried to figure out how much
added sugar is in– yogurt’s the easiest example,
I would say. How much added
sugar is in yogurt? Anyone have an idea? I would think a lot. We think a lot. If you look at that– you
turn that label– in fact, let’s skip ahead
to this picture. Dannon Fruit or
whatever– this thing– six ounces of Dannon Fruit
on the Bottom yogurt, again, I’m not
picking on brands. It was just to give
exact information, you have to use brands
because if you generalize, they vary so much. Six ounces of Dannon
Fruit on the Bottom yogurt has about three
teaspoons of added sugar, but there are about three
teaspoons of natural sugar in there from the lactose. But when you turn that label and
you look total carbohydrates, sugar, and it says 24 grams,
you don’t know what was natural and what was added. So drumroll– in
2016 or 2017, maybe, depending on the
government, there are going to be new food labels. So in those proposed
new food labels, they’re going to
have to distinguish added sugar versus
naturally occurring sugar to make our lives easier,
thank you very much. Yes– I mean, unless– hopefully
no lobbyist gets in there and it makes it not happen. But I’m pretty sure–
it’s been so supported, it’s going to happen
to help us as consumers make better decisions
about what we’re eating. Because again, you look at
24 grams of sugar on a yogurt and you’re like,
wow, that’s a lot. Some of my patients
get confused. They look at milk and
they’re like there’s 12 grams of sugar in this
milk, so I didn’t drink it. But it’s just the
naturally occurring sugar and we don’t have a
problem with that. If, again, if you have
diabetes, you have to count it, but it’s not something
we say you can’t eat. So for perspective on– we’re
pointing out the added sugars in these foods. A soda has eight
teaspoons of added sugar. Can you imagine, eight? This is a 12 ounce
soda, eight teaspoons. Who puts sugar in their
coffee in the morning? Confessions, right? Brave soul. How many teaspoons do you put? Like one or two, right? Can you imagine putting
eight teaspoons of sugar in a 12 ounce coffee? That’s a lot of sugar. When we are doing it ourselves,
it’s a lot more awareness. But how many teaspoons
of sugar are in there in a Grande Caramel
Frappuccino from Starbucks? 15 teaspoons of added sugar. Again, if you are doing that
yourself, you’d be like, oh, and you might cut back. But you drink it at Starbucks
and ignorance is bliss. I used to work at
Starbucks too, so I can pick on them a little bit. 15, that’s huge,
in just a Grande. Whipped cream, that barely
made a difference because that was just fat. The Frappuccino itself
had a bunch of sugar. Two Reese’s peanut butter
cups have about five teaspoons of added sugar. True confessions, the
foods that are on here are some of my favorites. So I put them on here
for self awareness. Half a cup of Ben and Jerry’s
Chubby Hubby ice cream, half cup, how much is that? Six and half teaspoons
of added sugar. Man, so plain ice cream– just
FYI, plain vanilla ice cream, you’re like– it’s
like the best choice. All the caramel swirls,
and the chocolate chunks, and the buh, buh, buh. Only if there’s like nuts
added is it probably OK. All the other stuff
adds tons more sugar. So again, we already
looked at the Dannon Fruit on the Bottom yogurt. Nature Valley Granola Bar
has about three teaspoons of added sugar. It’s not like they just put some
oats and something like that, they had to bind it
all together and make it taste sweet and delicious. So again, just imagine
sprinkling three teaspoons of sugar on your
oatmeal or something, maybe– I guess that’s
kind of possible. But when we do it
ourselves, we are much more aware of how much is
actually going on there then when we just ignorantly
eat these delicious things. A cup of blueberries? Zero teaspoons of added sugar. So one thing I just
read and I guess I think about it
indirectly, but I really like seeing it
explicitly stated. With you our allowance
of added sugars, what should we be
doing with those? So yes, there’s always room
for splurge, and for the Ben and Jerry’s, and whatever,
and stuff like that. You may want to use your
special allowance on that. But what– one way, how do
we control added sugars, but in the healthiest way? Try to use them to make
nutritious foods more palatable so that way you
get the nourishment from that nutritious food. And so maybe there was a little
bit of added sugar with it, but at least you still
ate the nourishing food. So like you take
your own yogurt, your plain yogurt, and you
might add one teaspoon of honey yourself. And you’re like you see
that again and you’re like, OK, well, that’s one
teaspoon of added sugar, but that’s not the
three teaspoons that Dannon added to it. Or if you need a little bit of
sugar in your plain oatmeal, again, it’s not those– maybe
not those three teaspoons that Nature Valley put
in that tiny granola bar. Or if you are trying
to drink green tea, but you just don’t love it? Maybe you could just do like
a little pinch of sugar just to take a little sweetness
to it, or again, the berries or something. Not that you want to go
out of your way to do this, but if it’s making a really
healthy food more likely that you’re going
to eat it, it’s probably the best
use of an added sugar than just a Pixie Stick. I say this again too with things
like kids, or even adults, if you’re trying
to eat broccoli, but you don’t love broccoli–
the little bit a ranch dip that you might need
to get yourself to eat or someone else to
eat that broccoli, it’s still better that you eat
that broccoli than the trade off for a little bit of
some kind of flavoring. So look at it that way
a little bit, there’s a little bit of that
give and take there. So what do we do– and oh,
by the way, that handout, the one added sugars, if
you didn’t get that one– I didn’t want to put a daunting
list of added sugars up on here, but this is
for your detective lens. Yeah, these are the– this
is not a complete list, but it is a big list
of added sugars that can be added to food. So until those
these labels change, what can we do to try to
determine how much added sugar is in our food? You have to look at the
ingredient list on a food item. Ingredients lists
in the US must be labeled by how much
of a food is in there. So the first ingredient, there’s
the most of it by weight. So and as the list gets
smaller, there’s less of it. So when you’re looking at a
food label, if one of those added sugars that’s
on that list there is towards the top of
that ingredient list, it’s probably got a lot
of added sugar in it. So while we don’t know how
many grams of added sugar in something, you can’t
really count it up now, you can get a clue that
something’s going to have a lot of added sugar if it’s– those
list of sugars are pretty high up in the ingredient list
or if it’s on there at all. Like ketchup, someone
said that earlier. They add sugar to ketchup, they
add sugar to salad dressing, they add sugar to things
that are salty and savory, and you wouldn’t think have
sugar, there is sugar added. So it’s not like it’s just
the obvious– soda, and candy, and that kind of stuff,
the ones we know are sweet. Sugar is lurking all around. And some of it is this whole
addictiveness, or maybe some of it’s shelf stable
stuff, but probably a lot of it is to make us want to drink it
and eat it and take it more. So manufacture– food
manufacturers and food scientists are smart about
making food palatable. A pinch of sugar here, a
couple pinches of sugar there, helps it tastes better to us. We’re going to eat more
of it, but adds sugar. Could you discuss bread? Is there a lot of
sugar in bread? So is there a lot
of sugar in bread? So it depends. Thankfully, we live in
2015, thankfully and not, we have so much more sugar in
the food supply, but at least, we have so many health
conscious people that care. And there are many, many,
many brands to choose from. Some breads have a
lot of added sugar. If anyone’s homemade
bread– you know that you need a little
sugar in the beginning to feed the yeast to kind
of start the fermentation. But you just– that’s
like a very small amount for an entire loaf of bread. It’s negligible, plus the yeast
itself is like digesting it for you basically. So but many brands
have added sugar to make them more palatable
and to taste good. Similarly, with salt, you’d
be surprised at how much salt is in bread too. Some of that is for,
again, the leavening and helping the bread to rise,
but a lot of it’s for taste. So if you look at a bread label
and if it’s whole wheat bread, even, if you see
sugar grams in there, that is likely to
all be added sugar. Because if you just took
wheat, grounded up in to flour, added some yeast, and
whatever, and salt, and water, that’s not sugar there, so
they’re adding the sugar to the bread label. So you can look
on the food label and look at grams of sugar,
not total carbs, but grams of sugar, and that’ll
give you a clue of how much added sugar’s in there. So there’s a big variability. Some are low sugar, no
sugar, some have a lot. Sorry for that long
answer for that. How about coconut– healthy
sugar that the call– the coconut sugar– Yeah. Yeah, I know what you mean. Agave, that’s another one. Oh, well, xylitol’s different. Coconut sugar, she’s
asking about, or agave is real popular too. Those are all still
added sugars in the end. Because what are you
doing with coconut sugar? You’re adding it to something
else to make it taste good. Yes, there are differences
in like the fructose. Like agave’s super
high in fructose. Or there’s some differences
in mineral composition or– but again,
hopefully, you’re not eating so much
sugar that you’re relying on that coconut sugar
for some calcium or something. That’d be a lot of
coconut sugar you’d need to eat to get a
significant amount of minerals or something. So I think there are
certainly small differences. And if you look down the sugar
aisle at a natural food store, there’s a huge selection. In the end, it’s all still
added sugar and they all fall under the try to do
less with those things. Again, it’s training your mouth. So now what happens when
we over consume sugar? Hopefully, if you’re working
on it and you’re getting– no one’s perfect overnight. So we make these small steps
and try to get better over time. And I’m guilty too, we’re
all guilty here, I’m sure. Some of my patients are so good,
and at least what they tell me, they’re so good. So what do we do? Over indulgence will happen. How do we cope? Now if over indulgence
happens every day, I hope you guys get a
good pair of running shoes because you really want
to try to work it off. You really can help prevent
that crazy rise in blood sugar if you go and use that sugar. Now again, I don’t know
if that’s a good strategy if you’re like I’m going
to eat this whatever but I’ll go for a run. If you’re an athlete,
that’s a different thing. They have to replenish. But if you’re just trying to do
this interesting getting away with added sugars because you
will exercise– but even still, that’s kind of like the ranch
dressing on the broccoli. If it gets you to work out,
maybe it’s a good thing. If you can justify a
little bit of indulgence, but you’ll go and
do some exercise, it’s still good that you
did exercise in the end. So if you overdo it, try to
move your body significantly, for like 15 or 20 minutes. And I’m not talking about
just like strolling around the Stanford shopping
center leisurely, but really get a little sweat
on your brow or something. Get your heart rate
up a little bit, so that you can
burn off that sugar. And then also, don’t
get down on yourself. This happens. The dietitian admits
it, I eat sugar. I try to cut back,
but I’m human too. I don’t let it get to me, I move
on to the next day and I say, OK, well, I’m going to do
better at the next meal or I’m going to do
better tomorrow. What happens for some people,
they get so down on themselves, they feel like they backtracked. And then instead of getting
right back on track, they just are like,
well, I already blew it, so then I’m going to go
do this, this, and this. But that’s the opposite of
what we should try to do. You should just try to
accept it, and move on, and move forward, and do the
right thing the next time, and think about why
did that happen, and what could I do differently
to set myself up for success. Hanging out by the buffet
table or hanging out– walking by the person
with the candy jar, id that’s a temptation
for you, you’re setting yourself up for failure. So to try to change up
your routine a little bit or ask people not
to offer you things that you don’t
want to be eating, but are hard to turn down. So pick yourself up and move on
is my recommendation for that. So here, I’ll just
briefly point out some of the good
website– I know that it’s like daunting
to see these references, but I’ll tell you what was
good about each of these sites. So this one, the American
Heart Association, had one about added sugars. So they’ve got a really
nice section on their site. If you just do American
Heart Association, sugar, you Google that, you’ll come
up with their whole section on their site is
really excellent. Similarly, the Harvard
School of Public Health– I mean, Stanford’s awesome–
Harvard School of Public Health has this excellent
resource, so we should cross reference each other. They come up with– they
send emails periodically and they have really
good summaries. So they have one about
added sugar in the diet. They also have a really good
one on the glycemic index and glycemic load. Some of where I got
some of this information was from Wikipedia and then
some of their references, so I double-checked everything
that they put on there. National Geographic has
an interesting article a little bit more on
history, so that’s where I got some of
that historical data. The Linus Pauling Institute
at Oregon State University has a pretty good– they have good
info on herbs, and spices, and antioxidants ,
and things like that. And they also have some
good stuff on added sugars. If you haven’t been to, it’s a website that’s all
created by oncology dietitians. They have a really long
and good sugar and cancer article on their, specific
just to sugar and cancer. So I think that one’s
worth looking at. And again, the Harvard
School of Public Health has another one about
carbohydrates and blood sugar. And sugary drinks fact
sheet, so the Harvard one’s excellent too. How much time do we
have for questions? Do we know? Who’s got the time? Oh, nice. OK I’ll start with you,
since you’re standing up. Two questions–
can the human body turn sugar into cholesterol? And is the cholesterol
in eggs– is that high-density lipoprotein
or low-density lipoproteins? So can the human body turn
sugar into cholesterol? That is a good question. I do not know for sure,
but what we usually say is that saturated
fat in the diet is what usually tells your
body to make more cholesterol. Your liver makes cholesterol. Usually, what we
say is saturated fat stimulates your body
or tells your body to make more cholesterol. Now that is separate
from that thing saying that the American Heart
Association saying high sugar intake is linked with increased
risk of cardiovascular death. Not everything about
cardiovascular risk factors is cholesterol levels. So does sugar
promote inflammation? Does sugar promote like
a pressure differential in blood flow in like
hypertension and things like that? So I don’t think– I’m not
aware of the direct link between sugar and
making cholesterol, but I would think it would have
to do more with saturated fat, and then the other
reasons that sugar increased cardiovascular risk. For the second question
you asked about, does egg– what– it
was do eggs contain high-density or
low-density lipoprotein? So there, again,
cholesterol in an egg, in the yoke of an
egg, when we eat it, doesn’t equal exact
cholesterol in our body. So what does our body do when it
eats the cholesterol of an egg? It breaks it down into
a whole bunch of things and then it gets
into our bloodstream. And how does our
body respond to it? I guess I don’t know exactly
how to answer that question, but what I’ll say
is eggs are not as bad as the rap they
used to get from years ago. Because dietary cholesterol
that’s in that egg does not equal cholesterol
made by your liver. It’s the saturated fat again. Where’s saturated fat? Chicken skin. Meat, the fat on
meat, chicken skin– Animal proteins. Animal fats, but also
it’s in a few plant fats, but mostly it’s animal fats. So what we usually
say, if you’re worried about
cholesterol levels, I’m not as worried about eggs. But I’m also biased where
I like pasture raised or if your neighbor– if your
neighbor has some chickens and feeding them–
letting them eat bugs, and letting them eat
some greens and flaxseed, I think those egg yolks
are better than just the average grocery store egg. So I think those are the best. I don’t– I’m not worried about
especially those kind of eggs and body cholesterol. American Heart Association
used to say three eggs a week. They got away from
that statement because there’s not
enough data, and also it’s not the dietary cholesterol,
it’s the saturated fat. Some people now say one
egg a day is about right, or seven a week, if you want
to think about it that way. So they’re less demonized
than they used to be. Long– I know, I’m sorry. I give long answers because
it’s all complicated questions. Doesn’t the brain
need sugar to operate? Doesn’t the brain
need sugar to operate? I’m so glad you
asked that question. I’m not a plant. Not a plant, OK. Yes, I didn’t pay
him to say that. So this is where
sugar is extra-tricky. Do we need sugar to function? Our brain, yes, it wants sugar. Our liver? The preferred fuel–
the preferred substrate, if you want to hear it in how
we talk about it– is sugar. But guess what? We can make all
the sugar we need from carbohydrates in the diet. We do not have a
physiologic, biologic need to eat sugar because we can
make it from carbohydrate. We can make from the quinoa. We can make from
the wheat berry. We can make it from
whatever, lactose. We don’t need it. So this is what adds
to the whole thing. We need certain vitamins. We need protein. We need some carbs. We don’t need sugar and we
can make whatever we need. Even people that go on a
really strict low carb diet, even if you don’t
eat very many carbs, your body– because you need a
certain amount of blood sugar for your brain to function
and for your organs and all your cells to
work– it’s clever enough, it can make sugar from
protein and from fat. It’s called gluconeogenesis. It’s not the most
efficient pathway and it has some positive and
negative effects on the body. But it’s a protection mechanism
so you don’t get low blood sugar, which you can die from. If anyone has overdosed
on insulin or anything, low blood sugar
is very dangerous. So we have this
protective mechanism. We do not need to eat
sugar in the diet. We can make it when we need it. So it’s purely for
fun that we eat sugar. Yes? Yes, you mentioned xylitol. Oh, yes, I’m sorry. So xylitol. Xylitol– and
there’s a few other, anytime you hear it ending in
that “ol,” maltitol, xylitol, there’s a few others, these are
what we call sugar alcohols. They do not appear raise
blood sugar levels very much. And according to the
American Dental Association, not only are they
not cariogenic, or don’t cause
cavities, but they appear to have protective
benefits for our teeth. So a lot of the sugar-free
gums that are in a natural food store will be
sweetened with xylitol because technically, it’s
not an artificial sweetener. It’s just a sugar alcohol. And it may even be particularly
protective for your teeth. The only tricky thing
with the sugar alcohols, so they won’t raise your blood
sugar levels like other carbs will, but if you over
eat sugar alcohols– you’d have to have like 8
or 10 grams of the sugar alcohol a day– they can
have a laxative effect. So you must be
careful with those. Or like that other
one, lactulose, that sugar that was in one
of those disaccharides, that is a laxative that you can
give people to help them have bowel movements. It’s very effective. Mhm? I was wondering if
you could actually touch on endurance sport,
where people who are involved in training for
an endurance sport actually intake a lot of sugar. And do they have any
results of– even though they’re
burning the sugar, is there any results
that you know of that it’s still harmful? That’s a great question. So she’s asking
endurance athletes– we know that when
you are working out at a very high level for
more than 60 minutes, you need to replenish the
carbohydrate in the body. And you have to do it quickly. So as good as quinoa is,
if you eat some quinoa and that’s not going
to raise your blood sugar for an hour from now, and
you’re an endurance athlete, maybe she’s going
to run out of steam and she’s not going
to be able to keep doing at the same intensity. So a lot of athletes
have to have glucose or different simple
carbohydrate replenishment to help fuel their sport. Again, most kids,
most people do not need to be drinking
Gatorade unless you are doing more than 60 minutes
of rigorous physical activity. That is when you need replacing
the sugar, the electrolytes, and things like that. Water is what most people
need when they’re working out. Unless, again, you’re
these endurance athletes. So you do need to
replace that because it’s a matter of not just
performance, but your health. You need to be able
to protect your body and keep your blood sugar
levels at the right range. I’m not aware, but I could, if
you want, I can get your email. One of the other
dietitians I work with is a sports dietitian. She may be aware of– and
there are a group of dietitians that specialize in this. They have this website called–
if you Googled “Scan DPG” and it stands for
Dietetic Practice Group, they have some fact
sheets on their site. I’m not aware of studies
showing detrimental effects of the sugar replacement
in the athletes. I would think it would be not
very– not a huge deal because of all the exercise
you’re doing. Is it burning off the sugar and
is that way it’s not a big deal or is it just that
you exercise so much and there’s so many huge
benefits from exercise? I don’t know. But people that do
really super-duper-duper endurance athletes for
a lot of their lives, it does have some
negatives to it. It’s not all positive. But I’m not aware of it
in a cancer relationship. But that’s an
interesting question. Mhm? [INAUDIBLE] anecdote
to one story I know of and it’s not related to cancer. OK. But a young man, Finn, who
is an entrepreneur here, is a super-duper triathlete–
was– triathlon, did the Iron Man multiple times,
finished second in his class for a 30 to 35 year
old or something, and ate a lot of
goop because he’s exercising all these hours. And he actually was
like a David statue. He was this perfection
of an athlete and he was diagnosed
pre-diabetic because of all the goo that he was consuming. And so he and his wife rode from
California to Hawaii recently, last summer, actually, to
bring awareness to the fact that these high sugar
consumption and our habits are actually detrimental to even
the most outstanding athletes. Even fit athletes? Yeah, I mean and there
are products out there that are lower sugar and or more
complex carbs that are becoming more and more popular. Just for the people
watching online, she was talking about how she
knows someone that ended up getting diabetes,
they think, probably related to the amount of goo
or replacement energy things he had been taking even though
he was a super triathlete. Even for the fittest
people, should we be taking in these very large
amounts of these things? I don’t know if we know
the answer to that, but it’s a good question. A change in subject, [INAUDIBLE]
fruits because I think people are [INAUDIBLE] scared
of eating fruits because it has a lot of sugar. Eating the fruit
itself with fiber is the best way, not juicing. My question is is fruit
metabolized a little bit different than any other
foods because it does have a higher fructose level? Well, yeah. Is it in the liver or is it OK
for diabetics to eat fruits? Yes. A lot of the information–
we’ve been studying diabetes for a long time, so it actually
helps us to understand it for other conditions too. We do still allow and recommend
that people with diabetes do eat fruits. The thing is with fruits
is we want to make sure that you’re eating
not too much of it and that even within fruit,
there is some variation. Something like berries, you
could eat a cup of berries and get the same
amount of carbohydrate that’s in half of a banana. But not very many people
eat just half of a banana. Some people do. But you think it’s
a single serving, so you finish the whole thing. She asked also about does our
body metabolize it differently. Like she was saying,
the fiber slows the digestion, so that
glycemic index thing again, slows how quickly the
blood sugar will rise and to what extent
because it’s more complex and takes more time. The fructose in it having
a detrimental effect– some people in the extremer
categories of diet and cancer do recommend limiting
certain fruits. I do not believe– well, they’ll
limit all fruits actually, some of the like extreme people. I think there is much more data
showing that there are benefits to eating the fruits than any
particular harms to eating them. But again, there are
the people out there that are cancer survivors
or cancer– trying to prevent the risk of
recurrence or something like that– that
they say cutting out almost all carbohydrates,
doesn’t matter if it’s healthy or not. So I don’t think that
there’s enough data to do that for everyone or
even anyone, potentially. There is going to be some
interesting studies coming out on what they call
a ketogenic diet, or fasting around the
time of treatment. These are some new things
that are being studying. I know it’s not exactly
answering your question, but I do not tell
people to limit fruits. What I’d tell them is we need
two to three servings of fruit per day, and a serving of
fruit is roughly half a cup. Yes, there’s variation between,
again, banana and berries or there’s other examples, or
like grapes and something else, watermelon. But people with diabetes,
people with cancer survivors, the general population
should be trying to eat two to three servings
of whole fruit per day to get the benefit, but not
excessive amounts of sugar. Mhm? Does it help if I have
a protein while I’m eating my fruit with it? Yes, it does help if you
have a protein while you’re eating the fruit. There, again, if you look
for stuff on the internet, you find all kinds of
interesting things. Some people say you can’t
eat fruit with anything else, you have to eat it
alone because it’ll ferment in your
digestive tract and that causes a bunch of problem. I mean, yeah, there’s all
kinds of interesting stuff you can search for out there. I think there is benefit
to having what we call– or to not having naked carbs. This is another thing. Like if you just
have fruit alone, the fruit is going to
raise the blood sugar, not as fast as the Pixie
Stick, but it’ll still raise the blood sugar. But when we’re talking
about glycemic load and you add some fat or
something like that to it, or if you add protein
to it, again, we know this for people
with diabetes, if you have carbs combined with
protein or with fat or both, it slows that digestion
of that carbohydrate and that rise in the
blood sugar as well. So I do recommend that people,
when you have some fruit, have some almonds with it,
have some plain yogurt, put the fruit in
your plain yogurt to help give it the fruit
sweetness without adding sugar. Or have a piece of– have some
other avocado with your mango or something like that. The fat will help slow the
carbohydrate digestion. So yes, I do recommend
combining a little bit to help slow carbohydrate digestion. I’m going to check
her really quick. Me? Mhm. Well, I have radiation
to my head and neck for mucosal melanoma. And the radiation
affected my taste buds. And food did not
taste like anything, it was very difficult to eat. So I was basically subsisting
on something like Ensure. But that’s basically
a ton of sugar. So just for future
reference, what would have been a
better choice to be able to get calories in me? Sure. And I take care of
people– so she’s saying when she was treated
for head and neck cancer, and had a lot of taste issues
and probably painful difficulty chewing and swallowing,
she drank a lot of the oral nutrition beverages
like Ensure, or Boost, or something equivalent, that
are pretty high in sugar. If anyone’s looked at
them– I mean, again, if you tried to make
that in your own kitchen, like do you have all those
ingredients on hand to make that? Probably not, hopefully not. But it’s something that’s a
really useful tool that people use during treatment. I don’t tell my
patients they can’t have those type of things. I think it is helpful
and it’s super easy get and they can use it
during treatment. There are currently some other
and better options, maybe, according to who you ask. Some of our
doctors– our doctors don’t care, to be honest. They’re like just don’t lose
weight, however you do it. Yeah. Yes, so and– there’s
truth to that. But I think for the more
sophisticated patient, there also is choice
within those drinks. So there are– some
of them– one of them, nowadays, if we’re going
to do brand names here, Orgain is super easily
available and it’s like an organic, more
natural, lower sugar, Ensure type of drink. But it’s only 250
calories per container. And when you’re going through
head and neck cancer treatment, you need a lot more than that. There’s one called
Enu, E-N-U, that has about 480 calories per bottle. It has a lot of
carbohydrate, but again, it’s like more complex carbs
and not the sugars. The calories have to come
from somewhere in a drink. So the calories are coming from
carbs, they’re coming from fat, and they’re coming from protein. And just to keep like
a normal balance, it’s got to have carbs. So it doesn’t have
a lot of sugar, but it does have carbohydrate. So those are two
commercially available ones. I had more creative
patients go– there’s this stuff called Liquid
Hope, which was made for tube feeding, like to go here. But it’s basically like
a high calorie soup. And so one of my patients
wanted to drink that. And like if you can’t
taste anything anyway and it feels OK in
your throat, they would do that Liquid Hope tube
feeding but take it by mouth. And they would add extra oil
and stuff like that to it too. So there are– if you have
a savvy enough dietitian or health care provider,
there are options out there to know about. But to be honest, we don’t
push it on the patients. You have to ask and
then we tell you about the variety of
options, because these things are harder to get too. They’re not just like on
every Walgreens shelf. You got to go out
of your way to find some of these special things. They are out there,
they are better options, but it takes some
effort to get them. Thank you. You had a question here, yeah? Is there a difference when you
have fresh or cooked vegetables or fruits? So is there difference
between raw or cooked fruits and vegetables and
their health properties? So here, again, where
there’s the extremes. All raw diet, you have
to eat everything raw and if you cook it,
it becomes useless. I don’t think that’s true. I think we should get a
combination in our diet. We should get variety. I like to include almost
everyone and everything in every form. So try to get some things
cooked, some things raw. Certain nutrients
are more easily absorbed when they’re cooked. So like a tomato has more
lycopene available to our body when we cook it. Or some– I even heard
recently, apparently blueberries have
a little bit more of one of their
phytonutrients available to us if they’re cooked. Not– maybe not like just
blueberry pie filling, I’m not talking about
that kind of thing, but if you’ve cooked the
blueberries a little bit in your oatmeal or
something like that. So I think it’s important
to have variety. The stuff– more
important though, eat it whichever way
you like the taste of it more because then you’re more
likely to eat more of it. And there’s benefit
to eating more of it than if you force down that
one piece of raw whatever. But if you eat a whole
bunch of it cooked, eat that because
then you’ll eat more. So we can eat the whole
bunch of it raw too, no? You can do that too. I think that– yeah,
I mean, the more raw is usually a little bit better
because certain vitamins can be destroyed with heat. So if you want to err in one
way, err on the side of raw, I suppose. But don’t feel like you won’t
get any benefit if something’s cooked. I’ve read and heard from
people that fresh fruits and vegetables often
have pesticides on them and it’s tough to get
the pesticides off, I mean more than just rinsing. How do you reconcile
the nutritional value versus the [INAUDIBLE] value? So he’s asking
about, basically, do we need to get all
organic food or how do we reduce the pesticide
that’s on our produce or how do we approach fresh
produce, get all the benefit, but not with unnecessary
amounts of pesticides. So there is a thing
called the Dirty Dozen, and you can Google the
Dirty Dozen, food, maybe put that word on it too. Careful what you
Google nowadays. Or if you go to, that’s
the Environmental Working Group. They’re the group that made this
thing called the Dirty Dozen. They’ve taken data
from the USDA that says how much
pesticide is still left on a food in the edible
portion that we eat. So something like pineapple, we
don’t need the outside of it, hopeful– I mean, I guess some
people that juice will do that. But generally, we don’t
eat outside of it. So if it has a bit a pesticide
residue on the outside but you cut that off and it’s not
internal pesticide residue, then you won’t– you don’t
necessarily need to get the organic version of
pineapple, for one example, because that’s not pesticide
on the part we eat. But something like berries, and
spinach, and apple, and celery, and like cherry tomatoes,
I’m trying– peaches, some of those foods have
a lot of pesticide residue in the portion that we get
even if we wash the heck out of that apple skin. If you don’t get
the organic version, it’s more likely to
have pesticide residue. So there is this. The Dirty Dozen is
a guide that can say don’t spend
your money– I mean, if you can get organic
everything, good for you. If you’re like how
do I prioritize, don’t spend your money on
organic avocados necessarily. But you could get–
you should spend it on the spinach, and berries,
and apple, for example. So it helps you pick and choose. So then when you
have the produce, the best thing to
do– mostly this is from a bacteria
perspective, is to wash it under running
water with friction. So there’s all those
washes and stuff out there and according to the
USDA and all that, they don’t remove more
bacteria and things like that. I think it’s more
for our– I would say it’s more of a behavior thing. If you use a special
wash, you might pay a little extra attention
to how you’re cleaning it, so you might do a
better job just washing it and using friction overall. So you don’t have to use
those special washes, but what should use is
running water and friction. Or with something like a berry,
if you have a little spray thing– this is totally
anecdotal, this is not science. This is my opinion. If you spray it with
those spray washer things, I think you can get a lot more
of the dirt off of something like a berry with all
the crevices and stuff. Or if you soak and rinse,
change the water a few times, that’s going to
get a lot more off than if you just wash them the
way my husband washes fruit. He barely swipes
it under the water. So that’s not necessarily
pesticide removal, that’s just the bacteria. Because many of the
pesticides are fat soluble or like lipid soluble
and they’re stuck in the skin. So you can peel it,
but then you lose some of the benefits
that’s in the peel. So use the Dirty Dozen to
buy your organic produce is what I usually
tell my patient. Is there that we over– I
guess it’s amount that eat. If we eat a regular serving
everyday, is that going to be– are we loading up
on pesticides too? Well, what me and, I would
say, most oncology dietitians say or most health
professionals, it’s still better for you to
eat the fresh produce than for you to avoid it because
of the concern of pesticides, the benefits you get
from it still outweigh some kind of pesticide
residue on it. Pesticides are, again, a whole
other controversial topic. But I do think there is benefit
to getting the organic version for many foods. And you’ll see on our
survivorship nutrition handout that’s up here, the very
last bullet point I think is opt for organic when
possible or when available, and if it’s not bankrupting you. But so we don’t an
exact amount, but I would say use the
Dirty Dozen as a guide, but still eat the apple if you
are not going to eat a fruit and that was only one
available, still better for you to eat the fruit than not. Any other questions? I’m sure we’re– so many
things to talk about, but we’re running out of time. Thank you so much, Alison. Thank you, Holly. [APPLAUSE] Thank you, everybody.


  1. I like her precise language on describing studies (i.e. linked, correlation, avoid) whereas many other scientists are sloppy with their language and description of relating what is exactly being stated. For example, the doctor from the video "is a calorie a calorie?" was biased or lazy in his word choice in describing the evidence.

  2. Jesus we’ll all be dead if we wait for science to pull it’s head out of its ass about this stuff. Sugar is not a nutrient, it’s more like a drug or chemical. Stop eating anything that didn’t grow on earth, it’s that simple.

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