Sugar and Diabetes

Position Statement

Diabetes Canada recommends Canadians:

• Limit their intake of free sugars

to less

than 10% of total daily calorie (energy)

intake. This is approximately 50 grams

(12 teaspoons) of free sugars

consumption per day based on a 2000-

calorie diet

• Limit intake of sugar sweetened

beverages (SSB) and drink water in their

place.

• Promote the intake of whole foods and

reduce the intake of free sugars

throughout life for overall health.

Diabetes Canada recommends that federal,

provincial/territorial, and municipal

governments:

• The Government of Canada introduce a

tax on SSBs and use the revenues

generated to promote the health of

Canadians.

• The Government of Canada ensures

clear nutrition labelling for packaged

foods including the amount of free

sugars on the Nutrition Facts Table.

• Federal, provincial, and territorial

governments immediately

operationalize the World Health

Free sugars are those sugars that are removed from

their original source and added to foods as a

sweetener or as a preservative.

As per the WHO Sugars Intake Guideline, Canadians

may benefit from limiting free sugar intake to less than

5% of total daily calorie intake based on a 2,000-calorie

diet per day (approximately 26 g or 6 teaspoons).

Organization (WHO) set of

recommendations to prevent the

marketing of foods and beverages to

children.

• A Federal, Provincial, and Territorial

Working Group on Food and Beverage

Marketing to Children is convened to

develop, implement and monitor

policies to restrict food and beverage

marketing to children.

• Federal, provincial, and territorial

governments support improved access

to and affordability of nutritious foods

in all regions.

• The Government of Canada implement

legislation to require labeling of free

sugars on menu labels in restaurants so

Canadians can make more informed

choices about the foods they eat.

• Recreational events, schools, recreation

facilities, and government spaces not

offer SSBs for purchase.

• Recreational events, schools, recreation

facilities, and government spaces

provide free water for consumption.

• Retailers and food manufacturers

voluntarily cease marketing food and

beverages to children until legislation is

enacted.

Diabetes Canada, recognizing its responsibility

as a health leader and employer will:

• Remove SSBs at Diabetes Canada

events.

• Offer free water at all Diabetes Canada

events and venues.

• Continue to encourage Canadians to

limit consumption of SSBs.

• Encourage Canadians to limit

consumption of foods high in free

sugars in preference to whole natural

foods.

• Serve foods that are healthy and

nutritious at Diabetes Canada events.

• Expand and promote food preparation

programs to encourage consumption of

whole foods throughout the community.

• Work with partners with similar values

and goals to promote health and health

policies to create healthy food

environments in Canada.

• Not partner with companies whose

products are harmful to health and/or

linked to the development or risk of

diabetes, consistent with Diabetes

Canada’s corporate partnership policy.

• Promote additional research on the

direct impact of free sugars

consumption on diabetes and other

chronic conditions.

Why is the Consumption of Sugars

Important to Diabetes Canada?

This position statement is based on a review

of the evidence published between 1995-2015

about the role of free sugars in the diet of

people living with diabetes and those at risk

for type 2 diabetes. Recommendations for

intake of sugars by adults and children are

provided. This statement can inform policy-

makers and program managers in their

assessment of consumption of free sugars

within their jurisdictions and influence a

reduction of consumption, as necessary,

through a range of public health and public

policy interventions.

Diabetes Canada developed the present

evidence-informed recommendations using a

systematic and deliberative approach. The

steps in this process included:

• Identification of priority questions and

outcomes;

• Retrieval of the evidence;

• Assessment and synthesis of the

evidence;

• Formulation of recommendations;

• Review and input from experts; and

• Planning for communication,

dissemination, implementation,

evaluation and updating of the

recommendations.

Diabetes

From 2000 to 2010, the prevalence of

diabetes in Canada doubled from 1.3 million

to 2.5 million people (1). Today, more than

one in four Canadians — or over ten million

people —lives with diabetes or prediabetes; if

nothing is done, by 2020, it will be almost one

in three. Diabetes will cost an estimated $14

billion in 2015. The Canadian economy and all

Canadians are paying the cost of treating

diabetes-related complications.

Diabetes is a condition characterized by an

elevation in blood glucose (blood sugar) levels

due to either a lack of insulin or a reduced

effectiveness of one’s own insulin. People with

diabetes need to manage their glucose level in

an effort to achieve their target blood

glucose

. Diabetes is a leading cause of

blindness, end-stage renal disease, heart

disease, stroke, and non-traumatic

amputation in Canadian adults (2).

There are three common types of diabetes.

Type 1 diabetes occurs in people when their

beta cells, located in the pancreas, no longer

function. Consequently, very little or no

insulin is released into the circulation. As a

result, glucose builds up in the blood instead

of entering the cells to be used as energy.

About five to 10 per cent of people with

diabetes have type 1 diabetes. Type 1

diabetes generally develops in childhood or

adolescence but can develop in adulthood.

Type 2 diabetes occurs when the body cannot

properly use the insulin that is released or

does not make enough insulin. Glucose builds

up in the blood instead of being used as

energy. Over 90% of people with diabetes

have type 2 diabetes. Type 2 diabetes

develops in adulthood most commonly, but

children can be affected.

A third type of diabetes, gestational diabetes,

is a temporary condition that occurs during

pregnancy. It affects up to 18% cent of all

pregnancies and increases the risk of

Goals for target blood glucose are set for individuals

depending on age, treatment methods and other co-

existing health problems.

developing type 2 diabetes for mother and

child in the future (2).

Overweight and obesity are risk factors for

the development of prediabetes

, type 2

diabetes and gestational diabetes (2).

Approximately 60% of adult Canadians (3) and

one-third of children and youth aged 5 to 17

years are overweight or obese (4). Children

who are obese are at increased risk of

remaining overweight or obese as adults (5,6).

Type 2 diabetes is being diagnosed earlier

than ever before, and more frequently in

children (6,7).

Behaviour modification, including dietary

management for people at-risk of type 2

diabetes, attempts to reduce the likelihood of

progression to diabetes. Dietary management

may target weight loss, but also promotes the

consumption of healthy foods. For people

diagnosed with diabetes, adhering to a

healthy diet optimizes glycemic control and

reduces the risk of developing complications.

World Health Organization Sugars

Intake Guideline

In 2015 the WHO released guidelines on the

intake of free sugars for adults and children

(7). These guidelines recommend:

• Reduced intake of free sugars

throughout the life-course (strong

recommendation);

Prediabetes occurs when there is impaired fasting

glucose, impaired glucose tolerance, or A1C of 6-6.4%;

50% of people with prediabetes will transition to type 2

diabetes.

• In both adults and children, intake of

free sugars not exceed 10% of total

energy (strong recommendation); and

• Further reduction to below 5% of total

energy (conditional recommendation).

The WHO states that the first two

recommendations are based on the health

risks of free sugars consumption in

predisposing those who consume them to

overweight and obesity, and dental caries.

WHO’s third recommendation states that a

further reduction of free sugars to below 5%

(about 6 teaspoons) of total energy intake per

day would provide additional benefits. The

limits would apply to all sugars added to food,

as well as sugars naturally present in honey,

syrups, fruit juices and fruit concentrates.

Diabetes Canada supports these

recommendations for Canadians and

acknowledges the importance of the

outcomes described by the WHO. Diabetes

Canada recommends reducing free sugars

consumption by the general population to

promote dental health and decrease the risk

overweight and obesity and subsequent

illnesses. Furthermore, for people living with

diabetes, limiting sucrose intake to 10% or

less of total daily energy is recommended by

the 2013 Clinical Practice Guidelines for the

Prevention and Management of Diabetes in

Canada. Intake of sucrose >10% of total daily

energy may increase blood glucose and

triglyceride concentrations in some

individuals with type 2 diabetes (3).

Sugars in our Food Supply

Sugars are ubiquitous in our food supply and

are consumed as a naturally-occurring

component of many foods including milk,

yogurt, fruits, and vegetables. It is also

frequently added during food preparation, at

the table and during food processing.

Sugars come in many forms. Glucose,

fructose, and sucrose are commonly used

sugars. Glucose occurs naturally in fruits and

plant juices. Most ingested carbohydrates are

converted into glucose during digestion and it

is the form of sugar that is found in our blood.

Fructose is found in fruits, some vegetables,

cane sugar, and honey. It is one of the

components of table sugar (fructose

combined with glucose forms the

disaccharide sucrose). It is also consumed as a

high-fructose syrup. Sucrose is found in the

stems of sugar cane and roots of sugar beet.

It also occurs naturally with fructose and

glucose in fruits and some roots vegetables

such as squash. Maltose is found in certain

grains (e.g. barley) and is less sweet than

glucose, fructose or sucrose. Lactose is found

in milk and other dairy products (8).

Free sugars are those sugars that are

removed from their original source and added

to foods as a sweetener or as a preservative.

There are many different forms of 'free

sugars' including cane juice, corn syrup,

brown rice syrup, barley malt, agave nectar,

and fruit juice concentrate.

The WHO defines 'free sugars' as sugars and

syrups added to foods during processing or

preparation (7). This definition is inclusive of

all sugars added to foods during cooking (or

processing), such as honey, syrups, fruit

purees, and juices that are added to a food.

This definition does not include sugars found

naturally in white milk, vegetables, and fruit.

These sugar-containing foods also contain

vitamins, minerals, and fibre which provide

health benefits. These naturally occurring

forms of sugar are referred to as bound sugar

and are considered part of a healthy diet (9).

The body metabolizes naturally occurring and

added sugars in the same way however,

digestion and absorption of free sugars may

be faster as they are not bound into the food

matrix. Foods that have high amounts of free

sugars tend to offer less nutritional value.

Foods with no free sugars tend to be higher in

beneficial nutrients than those high in free

sugars. Many people consume sugars with no

knowledge of its presence in the food that

they consume.

It has been estimated that Canadians eat 110

grams of sugars per day (26 teaspoons or 21

per cent of total energy intake, based on a

2,000 calorie-a-day diet) (10). This included

sugars from all sources including milk

products, vegetables, and fruit as well as free

sugars. This estimate varied across sub-

groups. People with diabetes were estimated

to consume 73 grams of sugar (18 teaspoons)

per day. Teenage boys between 14 to 18 years

consumed 172 grams daily (41 teaspoons).

Almost half of the average daily sugar intake

of children from 1 to 8 years old and

adolescents from 9 to 18 years old came from

beverages, specifically milk (20% and 14%,

respectively) fruit juice (15% and 9%

respectively), regular soft drinks (4% and 14%

respectively), and fruit drinks (6% and 7%

respectively). Milk was the primary source of

sugar among children aged 1 to 8, but in

those age 9 to 18, regular soft drinks ranked

first. Beverages accounted for 35% of adults'

daily sugar intake (10). Notably these data are

from 2004, and consumption may have

changed since then.

What are the Effects of Sugar

Consumption on the Risk of

Developing Diabetes?

Numerous clinical trials, cohort studies, and

meta-analyses have been performed to

describe the impact of consumption of sugars

on weight gain, as well as risk for and

development of diabetes (11-27). Te Morenga

et al. recently performed a systematic review

and meta-analysis (2013) for the WHO and

estimated that adults who reduced intake of

dietary sugars decreased 0.80 kg body weight

among randomized controlled trials (26). The

same systematic review and meta-analysis,

however, did not show a body weight

decrease in the randomized controlled trials

of children. Conversely, an increase intake of

sugars was associated with an increase of

0.75 kg of body weight in both adults and

children. A reduced intake of free sugars was

associated with weight loss and increased

intake of sugars was associated with weight

gain in European adults in the EPIC-InterAct

cohort study (12). Other researchers have

performed systematic reviews and meta-

analyses and calculated pooled estimates

showing a statistically significant positive

relationship between increased consumption

of calories in the form of sugars and weight

gain. In the absence of weight gain seen in

calorie matched trial comparisons, the

relationship between weight gain and

consumption of sugars appear to be

mediated through an increase in calorie

consumption (28-30).

A meta-analysis by Sonestedt (31) reviewed

the evidence between the intake of total

sugars, sucrose or fructose and type 2

diabetes. Nine studies were included, four of

which evaluated the association between

intake of total sugars, sucrose or fructose and

type 2 diabetes. The data were inconclusive

after adjusting for weight gain or BMI. Two of

three studies found significant positive

associations with total fructose intake (17,24).

No studies found an association between

sucrose or total sugars intake and diabetes

and some researchers reported an inverse

association. Sievenpiper et al. recently

described the association between total

sugars, total sucrose, and total fructose in an

updated systematic review and meta-analysis

of prospective cohort studies including more

than 300,000 people. These authors failed to

detect an independent risk for diabetes for all

of these cases (32).

The link between intake of sugars and fasting

plasma glucose, post-prandial glucose and

insulin levels was reviewed by Kahn and

Sievenpiper (33) and Sonestedt et al. (31).

Both groups determined that there is

insufficient evidence to link sugars with these

proxies of diabetes risk.

In summary, large amounts of free sugars are

often found in highly processed, high energy,

high calorie foods. Excessive calorie

consumption often occurs with these high-

free-sugars foods, leading to weight gain.

Given the established relationship between

type 2 diabetes and overweight and obesity,

as well as the relationship between excess

calories and weight gain, consumption of

sugars must be duly considered by all people

trying to manage their weight and their risk

for diabetes.

Moderate amounts of sugars can safely be

consumed by people with diabetes and those

at risk.

Sugar-Sweetened Beverages and

the Risk of Developing Diabetes

SSBs include soft drinks along with other

sugar-sweetened beverages such as sports

drinks, fruit drinks, lemonade, blended coffee

drinks, and iced tea. They contain large

amounts of readily absorbable sugars and are

considered nutrient poor. A single 'serving' of

soft drink (i.e. cola) contains approximately 40

grams (about 10 teaspoons) of sugar.

Almiron-Roig and colleagues suggest that

liquids have relatively weak satiating effects,

in part due to faster consumption and the

greater chewing effort and longer oral

exposure for semi-solids and solids which

have been associated with higher satiety.

Sensory and cognitive processes (e.g. odour,

texture, and the perceptions of solid food

versus a drink) have physiological responses

affecting their satiating properties (34). SSBs

are high in sugar and calories but are in liquid

form so they may be less satiating than iso-

caloric solid or semi-solid foods; thus, intake

of SSBs may result in over-consumption of

calories.

Many researchers have investigated the

impact of SSBs and the incidence of diabetes.

In the past, controlled trials, cohort studies,

systematic reviews and meta-analyses of

controlled trials in people with and without

diabetes have shown mixed results (35,36).

However, there is now substantial credible

evidence for an association between SSB

consumption and type 2 diabetes risk.

Preliminary data supports the increased risk

of gestational diabetes and consumption of

SSBs (37).

Most recently, a meta-analysis by Wang and

colleagues estimated that the increased risk

of diabetes associated with high of SSBs is

1.30 times that for low consumption (95%CI

1.12-1.39) (36). This risk persisted after

adjusting for BMI. Evidence from the

European Prospective Investigation into

Cancer (EPIC)-InterAct study funded by the

European Union, that included eight

European countries, across 26 research

centres also showed that in adjusted models,

one 336 g (12 oz) sugar-sweetened soft drink

daily was associated with hazard ratio (HR) for

type 2 diabetes of 1.22 (95%CI 1.09-1.38).

After further adjustment for energy intake

and BMI, the association of sugar-sweetened

soft drinks with type 2 diabetes persisted (HR

1.18, 95%CI 1.06-1.32) (12). Malik et al (30) and

Sonestedt et al. (31) have also reported

similar findings in their reviews.

Chen et al. reported results from the Nurses

Health Study II that evaluated the impact of

SSBs on gestational diabetes. This large

prospective study found that cola was

significantly and positively associated with

GDM risk, after adjustment of known risk

factors for GDM including age, family history

of diabetes, parity, physical activity, smoking

status, alcohol intake, BMI, and Western

dietary pattern. Compared with women who

consumed <1 serving/month, those who

consumed ≥5 servings/week of sugar-

sweetened cola had a 22% greater GDM risk.

No statistically significant elevation in risk was

observed for other SSBs and diet beverages

(37).

Imamura and colleagues recently

prospectively examined the association

between consumption of SSBs and type 2

diabetes and estimated the population

attributable fraction in the United States and

United Kingdom (38). Higher consumption of

SSBs were associated with a greater incidence

of type 2 diabetes by 18% and 13% per

serving per day before and after adjustment

of adiposity respectively.

In summary, based on high quality

observational evidence of the adverse

association between high SSB consumption

and risk of type 2 diabetes and potentially

gestational diabetes, it is prudent that we take

action to reduce SSB intake.

Sugars, Diabetes and the Food

Environment

Reducing intake of sugars is a healthy choice

from many perspectives. From the societal

perspective, it would have many health

benefits, including preventing and reducing

dental caries, reducing obesity, and

preventing weight gain, with a favourable

impact on other illnesses, such as diabetes,

heart disease, and stroke. From a diabetes

perspective alone, reduction of free sugars,

specifically SSBs, may have an independent

influence on type 2 diabetes risk and

gestational diabetes risk. All this said, dietary

changes must occur within a societal context.

Sugars in the Food Supply

The packaged foods available today are

sweeter than before. According to Basu et al.,

sugar supply has risen across the globe from

an average of 218 kilocalories per person per

day in 1960 to over 280 kilocalories per

person per day by 2013. Assuming a food

wastage rate of 30%, these consumed calories

exceed the recommended daily upper limit of

150 kilocalories per man and 100 kilocalories

per woman by the American Heart

Association. Much of this is in the form of high

fructose corn syrup within SSBs; however,

added sugar is found throughout the food

supply (27).

Food Insecurity

Development of programs, policies, subsidies

and strategies that enhance food security –

available, affordable, culturally appropriate

food – are needed. Although there are several

definitions of food security, the Food and

Agriculture Organization of the United

Nations currently uses the following

description: "food security exists when all

people, at all times, have physical and

economic access to sufficient, safe, and

nutritious foods which meets their dietary

needs and food preferences for an active and

healthy life" (39). The term "food desert" is

used to describe an area that has limited

access to healthy, nutritious food. For

example, people living in some

neighbourhoods have easier access to fast

food and nutrient poor foods rather than

healthy whole foods (40). Thus, people

consume foods that are not healthful for

reasons beyond their personal preference.

These reasons may include, for example: food

distribution, poverty, food skills, cultural

context, marketing unhealthy foods, and

social norms.

Despite the relative wealth within Canada

compared to other countries in the world (41):

• Approximately 5% of Canadian children

and 8% of Canadian adults lived in food

insecure households from 2007 to 2012;

• In 2011–2012, 8.3% of Canadian

households experienced food insecurity;

• Nunavut had the highest rate of food

insecurity (36.7%); over four times the

Canadian average (8.3%) in 2011–2012;

and

• Individuals in food-insufficient

households were also more likely to

report diabetes, heart disease, high

blood pressure and food allergies.

Childhood Obesity

In 2007, the Standing Committee on Health of

the Parliament of Canada issued its report

(42) on childhood obesity. They stated that:

• "The Committee shares the fears of

many experts who predict that today’s

children will be the first generation for

some time to have poorer health

outcomes and a shorter life expectancy

than their parents."

• "Children are consuming too many

calories. This was attributed to

increased portions, increased intake of

fatty and processed foods as well as

greater consumption of sugary drinks.

The link between obesity and the

increased consumption of sweetened

drinks is particularly disturbing. It has

been estimated that sugary drinks may

be responsible for as much as one

pound per month weight gain in

adolescents."

• The Committee shares the concerns

about the potential association between

food advertising to children "and

increased childhood overweight and

obesity."

Since then, Potvin-Kent described that

children’s exposure to food and beverage

advertising has increased since the

implementation of the Canadian Children's

Food and Beverage Advertising Initiative, a

voluntary effort by the self-regulatory industry

group Advertising Standards Canada (43). The

authors conclude that the current self-

regulatory system is failing to protect children

from food marketing high in fat, sugar and

sodium on television. Government regulation

needs to be considered.

Taxation on SSBs

Internationally, some governments have used

policy levers to influence SSB consumption.

Mexico, France, regions in the U.S. (e.g.

Berkeley, California and Vermont) and Europe,

have applied taxes on sugar sweetened

beverages as a means to deter consumption

and redirect revenues toward health

promoting initiatives. Preliminary results from

the Mexico experience, which added a 10%

tax to non-dairy and non-alcoholic drinks with

added sugar, demonstrated a 6% decline in

purchases in 2014 compared to pre-tax

trends. These results were observed across

socioeconomic groups and occurred in

tandem with an increase in water

consumption (44).

Nutrition Labelling

Recently, the Government of Canada

proposed changes to the Nutrition Facts Table

that are a first step in helping Canadians

understand the foods they consume. Diabetes

Canada further recommends that nutrition

labels should transparently list the quantity of

all sugars that have been added to the food

product. The amount should include free

sugars (including added monosaccharides

and disaccharides as well as sugars naturally

present in, for example, honey, syrups and

fruit juices) as these sugars should be

considered in the choice to consume a food

product. This added information to the label

will help consumers make more informed

choices about the foods they eat and the

sugars they consume.

Marketing to Children

Children’s exposure to food and beverage

advertising influences consumption patterns.

The current self-regulatory system is failing to

protect children from being exposed to

marketing of food high in fat, sugar and

sodium (43). Government regulation across

Canada need to be expanded to emulate

Quebec’s Consumer Protection Act (1980), and

regularly updated to include new mediums

through which foods and beverages are

advertised to children.

Healthy Foods and Beverages in

Public Places

Improving the nutritional quality of foods and

beverages in public places is a low-cost public

health strategy that can help to change social

norms and create healthier food and

beverage environments. This can help to

model and reinforce healthy eating in other

spaces and at home. Most public spaces have

health promoting services (gyms, sports

activities, wellness programs) that are

undermined and contradicted by the sale of

unhealthy foods.

Food Security

The food industry must also play a role

though reformulating products to reduce

their content of sugars. Offering a wide range

of products including those lower in sugars is

an important component of a comprehensive

approach. Refraining from marketing to

children and removing SSBs from recreational

facilities and events are important first steps.

Conclusion

Urgent action is needed now on several fronts

to reduce consumption of sugars and thereby

lessen the burden of obesity and diabetes in

Canada.

All levels of government, from federal to

municipal, as well as patient and community

groups and individual champions are

important catalysts for change and should

therefore be involved in reducing

consumption of sugars.

Diabetes Canada is committed to helping

Canadians make healthy food choices.

Reduction of free sugars consumption should

not result in an over-consumption of other

unhealthy foods. Diabetes Canada will

continue to promote health education, food

skills and healthy public policy to support

Canadians.

There is an opportunity to lower the risk of

type 2 diabetes and gestational diabetes. This

requires a long-term commitment from many

stakeholders at many levels. Population based

interventions, including education, improved

food distribution along with policies, such as

SSB taxation and healthy food procurement

by public institutions will together promote

healthier food consumption, reduced intake

of free sugars and better health.

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os-national-institute-of-public-health-

study-indicates-the-federal-sugar-

sweetened-beverage-tax-is-successfully-

reducing-purchases-in-mexican-

households/#sthash.aeW1bGQm.dpuf

Last Updated: January 2020