Food-based Recommendation to Support Health in Community-dwelling Older Adults

HSN743: Assignment 2: A food-based recommendation to support health in community-dwelling older adults: the impact of sugar on cardiovascular disease risks.

Cardiovascular disease (CVD) presents a significant challenge for the ageing population, as well as for those who seek to support this population, such as caregivers, health care systems and professionals. Structural and functional changes occur to vessels throughout life, culminating in increased risk of CVD. (1) CVD includes heart, stroke and blood vessel diseases and resulted in over 43,000 Australian deaths in 2017, nearly 30% of all recorded deaths. That equates to one death every 12 minutes. Most people over the age of 65 are currently living with long-term CVD, which is largely preventable. (2)

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‘Australian Heart Disease Statistics 2015’, produced by the National Heart Foundation, in collaboration with The Deakin University Heart Disease Statistics Project outlined multiple clinical and lifestyle risk factors including hypertension, cholesterol, diabetes, kidney disease, diet, smoking, overweight/ obesity, alcohol and mental health, as risk factors for CVD. The majority of these risk factors can be attributed to diet, with the main areas of focus being the consumption of fruits and vegetables, sodium, fats and added sugars. (5) The 2011/12 Australian Health Survey notes that consumption of free sugars contributes to 8.9% of daily energy for 51-70 year olds, and 9.7% for those adults over 70 years. (6)  Currently the World Health Organisation recommend that total energy consumption from free sugar is less than 10%, with a further reduction to less than 5% to provide additional health benefits. (7) Despite the apparent compliance of older Australians in meeting the recommended 10% target, consideration must still be given to further reducing this amount for the additional health benefits that can be achieved.

The effects of high chronic intake of added sugars (HCIAS) in the diet affects the ageing process in multiple ways. Metabolism of fructose in the liver results in both uric acid production which is potentially damaging for cells, and de novo lipogenesis, that is, metabolic formation of fat. Excess intake of fructose, and resultant lipogenesis, can lead to development of disorders by increasing oxidative stress, inflammation, protein glycation, insulin resistance and dyslipidaemia. These features are also characteristic of ageing. Therefore, HCIAS can lead to conditions such as diabetes, heart disease and hypertension as fructose appears to mimic the effect of ageing. (8,9)

Summary of Evidence supporting reduction of added sugars and associated health benefits    

A large number of studies have been undertaken to ascertain whether there is a link between sugar consumption and cardiovascular disease or its associated risk factors. Research methods vary greatly from both a design perspective, risk factors identified and methodology used. In addition to specific studies and meta-analyses listed below, multiple reviews and discussion papers have been produced addressing causal links between sugar consumption and cardiovascular disease risk and outcomes.

Epidemiological studies and experimental trials in both animal and human subjects provide evidence that suggests added sugars, in particular fructose, can increase blood pressure and heart rate and can also contribute to inflammation, insulin resistance and other metabolic conditions. (10)  For the purpose of this report animal studies, and those relating specifically to children have been excluded. Sugar in various forms have been utilised in trials including sugar-sweetened beverages (SSB), dietary free sugars, high chronic intake of added sugars (HCIAS), total fructose intake and high-fructose corn syrup (HFCS). (8,10-14) Regardless of the form of sugar utilised, or reviewed in available data sets, findings consistently showed that risk factors for CVD such as hypertension, lipid profiles, obesity and metabolic disease were impacted.

Despite many reviews and trials outlining the link between sugar and cardiovascular risk factors, Rippe & Angelopoulos (2016) conclude in their review that data from sources they reviewed, as well as studies from their research laboratory did not support a link between sugar consumption at normal levels within the human diet and a variety of adverse health-related effects. (15) This outcome was supported a review and meta-analysis of a further 3 prospective cohort studies that indicated no increased risk of hypertension due to total fructose intake. (21)     

Studies have also been conducted to determine outcomes of projects aimed to change SSB and water consumption in varying age groups globally. In adults, interventions have shown small improvements in relation to reduction of SSB consumption, which is similar to other dietary advice interventions. The need to assess behavioural change initiatives to decrease the intake of free sugars has been outlined, and in particular SSB consumption has been identified as a research gap, and that further investigation in to nutritional education is warranted. (16)

Table 1: Summary of Evidence of Sugar/ Fructose intake and Cardiovascular Disease

BP: blood pressure, HFCS: high fructose corn syrup, Ereq: energy requirement, SSB: sugar-sweetened beverage, RCTs: randomised controlled trials. (

Discussion

Cardiovascular disease in the leading cause of premature death globally and hypertension has been identified as a significant risk factor. There is compelling evidence from clinical trials, population studies and basic science that sugar, and in particular fructose, plays a major role in its development, as well as contributing to general cardiovascular risk. Sugar, or sucrose, is composed of glucose and fructose, and is a common ingredient in processed foods, although it is not as commonly used in these foods as HFCS. Sucrose is equal parts fructose and glucose, whereas HFCS is 55% fructose and 45% glucose. HFCS is not only used commonly in processed foods, it is also used in fruit drinks and soft drinks, that is, SSBs. (10) Free sugars refer to monosaccharides, including glucose and fructose, as well disaccharides, such as sucrose, which is also referred to as table sugar.  These items are added to foods and drinks by manufacturers, cooks or consumers, and include sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates. (7)

The majority of studies reviewed, indicated a correlation between consumption of sugar and CVD risk. Although no studies specifically addressed the needs of older adults, this age group was included in some of the data sets and results from these groups were not noted as exclusions, or required any specific mention. (18, 19) The common conclusion that sugar consumption should be reduced to prevent risks associated with CVD are population general, although recommended amounts of free sugars vary amongst health advisory groups. The American Heart Association recommends 9 teaspoons for men and 6 teaspoons for women. (1) The world health organisation (WHO) recommend less than 10% of total energy intake, with an aim to reduce this to 5%. (7)  The Australian Heart Foundation recommend limiting foods high in added sugar such as cakes, biscuits and sugary drinks. (2) Food Standards Australia New Zealand suggest the WHO recommendation, which they say amounts to about 12 teaspoons of free sugar per day for an adult with a healthy body mass index. (10, 20)

A meta-analysis of randomised controlled trials identified that higher sugar intakes markedly increases both systolic and diastolic blood pressures verses lower sugar intakes. It was also noted that when studies which received sugar industry funding were excluded the variance was more pronounced. (10) The review conducted by Rippe & Angelopoulos, that identified no causal link between sugar and heart disease, based on normal consumption of sugar in the human diet did not define normal levels of sugar intake in the human diet, furthermore, one of the authors has disclosed multiple conflicts of interest, including consulting fees from large multinational food and beverage companies. (15)

Obesity is noted as a risk factor for CVD. Studies conclude that the reduction in blood pressure of both normotensive and hypertensive participants obtain may result in part from the weight loss, yet there also appears to be an effect directly linked to reduction of sugar consumption. (23)

Recommendation

It’s never too late to make changes to one’s food choices, with the goal of achieving better health outcomes. Sugar consumption has been shown to accelerate ageing and contribute to progression or development of chronic diseases, such as cardiovascular disease. Where to begin? Start with the obvious sources of sugar – soft drinks, fruit juices, energy drinks and ready-made iced teas and flavoured waters. Stick to water, tea and coffee (skip the sugar). If you prefer flavour in your water try lemon, lime or other fresh fruit.

Many processed foods, even savoury foods, contain sugar. It can be difficult to imagine how much sugar is contained in foods and drinks, and visual representations, or converting weight on nutrition panels in to teaspoons. 4 grams of sugar is approximately 1 teaspoon. It can be quite surprising to learn how many teaspoons of sugar are contained in commonly consumed foods, such as soft drink, fruit juices, breakfast cereals and apparently healthy sweetened yoghurts. As well as cutting back on sugars in these commonly identified items as starting point, it is also worth considering those items where the sugar source is better understood, such as cakes, chocolate, biscuits and desserts. Maintaining free sugar intake at recommended levels is advised(17)

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          Oh sweetheart!

Or is it? Consumption of sugar has been linked to heart disease, particularly added sugars. It can put up your blood pressure, turn in to unhealthy fat and increase your risk of all sorts of health problems, including heart disease. It can make you age more quickly too – perhaps you feel like that’s happened already. It’s never too late to make a few small changes, they just might make all the difference.

Where to begin? Start with the obvious sources of sugar – soft drinks, fruit juices, ready-made iced teas, cordials and flavoured waters. Stick to plain water, tea and coffee (skip the sugar). If you prefer flavour in your water try lemon, lime or other fresh fruit. Or for some bubbles, try soda water.

Many processed foods, even savoury foods, contain sugar. It can be difficult to imagine how much sugar there is in food and drinks, so try converting the weight on nutrition panels in to teaspoons. 4 grams of sugar is approximately 1 teaspoon. It can be quite surprising to learn how many teaspoons of sugar are contained in commonly consumed foods, such as soft drink, fruit juices, breakfast cereals and apparently healthy sweetened yoghurts. As well as cutting back on sugars in these commonly identified items as starting point, it is also worth re-considering those items where the sugar source is better understood, such as cakes, chocolate, biscuits and desserts. (17)

Have a look at how much sugar is in common drinks – 9 teaspoons in a can of coke – 3 ½ teaspoons in a small juice popper. How about tomato sauce – there’s almost 1 teaspoon of sugar per tablespoon.

Previously the World Health Organisation recommended 12 teaspoons of sugar per day, they now suggest we aim for a maximum of 6 teaspoons of added sugar – that’s the stuff that gets added to all foods. The only allowance is for naturally occurring sugars, such as those in fruits and vegetables. (7,10)                                                                       * https://lukeclarke.com.au/2016/05/31/sugar-that-drink/

References:

1. Paneni MD, Candela CD, Peter L,  Lüscher TF, Camici GG. The Aging Cardiovascular System:  Understanding It at the Cellular and Clinical Levels. JACC. 2017; 69 (15): 1952-67
2. National Heart Foundation of Australia: Carbohydrates and Sugars: Available from: https://www.heartfoundation.org.au/healthy-eating/food-and-nutrition/carbohydrates-and-sugars
3. Australian Bureau of Statistics. Australian Health Survey 2014/15: Available from:
4. Australian Bureau of Statistics. Australian Health Survey 2011/12: Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.011~2011-12~Main%20Features~Consumption%20of%20Added%20Sugars%20-%20A%20comparison%20of%201995%20to%202011-12~20
5. Australian Heart Disease Statistics 2015. Available at: https://www.heartfoundation.org.au/images/uploads/publications/RES-115-Aust_heart_disease_statstics_2015_WEB.PDF
6. Australian Bureau of Statistics: Australian Health Survey: consumption of added sugars, 2011-12. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/lookup/4364.0.55.011main+features12011-12
7. World Health Organisation: WHO calls on countries to reduce sugars intake among adults and children. Available at: https://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/
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17. Thornley S. Tayler R, Sikaris K. Sugar restriction: the evidence for a drug-free intervention to reduce cardiovascular disease risk. Internal Medicine Journal. 2012.
18. Ferder L, Ferder M, Inserra F. The Role of High-Fructose Corn Syrup in Metabolic Syndrome and Hypertension. Current Hypertension Reports. 2010;12(2):105-112.
19. Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R et al. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Inter Med. 2014 Apr: 174 (4); 516-24.
20. Food Standards Australia: Sugar. Feb 2018. Available at: http://www.foodstandards.gov.au/consumer/nutrition/Pages/Sugar.aspx
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