Sugar intake and coronary heart disease

.-l therosclerosis Elscvier Publishing

Company,

137

-4msterdam - Printed in The Netherlands

Review

SUGAR

INTAKE

AND

CORONARY

HEART

DISEASE

SCMMARY

In order to incriminate coronary

heart

disease

data on sugar intake

factors.

incidence

circumstances

is specifically

associated

(4) Information

of contexts.

does not significantly aetiology

of CHD,

crimination minority

the lowering of sugar intake,

of the metabolic

sugar. Secondly,

is possible.

groups in Western

whether,

Thirdly,

populations

Epidenziology - I~zdin

that

or voluntarily, risk

which deal with sugar and

and the following conclusions such evidence

as is available

bearing in mind the multifactorial within

more

a given context,

intensive

research

- Lipids - Myocardial

major

in-

on particular

might provide more trustworthy

Cigarette smokiu, u - Covonavy head disease (CHD)

Key words:

data

sequelae.

it is questionable

of sugar

demonstration

animals to sugar in a variety

mechanisms

evidence is incomplete,

incriminate

(2) Corresponding

involuntarily

of

(1) Accurate

of CHD or its associated

on the response of experimental

although

are needed:

rate. (3) Unequivocal

has been made of these aspects

Firstly,

of sugar in the causation

of evidence

and in sub-groups.

or mortality

and pathological

An examination were reached.

types

with a fall in the frequency

(5) Knowledge

their physiological

consumption

several

in total populations

on CHD prevalence, in propitious

excessive

(CHD),

inferences.

- Dietary habits -

iplfnvctiou - Ovemutvitio~~

- Racial differences - Stavch - Sucvosr*

INTRODUCTIOi'i

Opinions about the causation who believe

that

diet is almost

of coronary irrelevant,

heart disease (CHD) range from those like CAMPBELL~

and

=Ithr?vosclerosis,

ROBB-SMITHY,

to

1971, 14: 137-152

A. R. P. WALKER

138 those who assert that majority,

of CHD4-11. sumption intake,

diet is wholly responsible,

of course, are convinced Increases

in its prevalence

of a number

of dietary

responsibility

aetiology

difficulties,

promotive

foodstuff

is retarded?

aetiological

importance

specific incriminatory

(b) random

or nutrient

Since

such as ethnic

components

voluntarily

practices,

on the prevalence

(4) The response (5) The metabolic

that

groups,

~‘.g.

class,

religion,

prevailing,

etc.

demonstrates

involuntarily

that,

if

(from war, prison,

or

this will be followed by a fall in

risk factors,

provided, of course, that the are not too old.

to sugar, there must. as a beginning, given in (1) and (2). Satisfactory

be a significant evidence in (3),

In addition,

it would be

of,

of experimental mechanisms

animals

to sugar in a variety

of contexts.

which deal with sugar and its physiological

or

sequelae.

PRECISE

KNOWLEDGE

ALENCE

OR MORTALITY

Atherosclerosis,

social

unequivocally

whether

(as in field trials),

The first two requirements

Agriculture

of evidence.

of, and/or the mortality

and that the persons involved

to have knowledge

Sugar

a

listed.

of CHD or of its associated

between the information

DATA

to have

heart disease, also those whose diet is

of course, could even provide proof of specific implication.

(a)

and

in (a) total popu-

and (c) special population

or traditional

reduced,

For blame to be attached

pathological

CHD?

is reduced,

claimed

of sugar intake

degree of “westernization”

must be forthcoming

change in diet be susta’ned,

valuable

C,HD

will be made to learn to what extent

of populations,

precise data are required

or

of dietary

evidence of ischaemic

be substantially

the prevalence

to excess promotes

sugar, there are several requirements

from, CHD in the types of population

like conditions)

are beset

of non-dietary

eaten or when consumption

is a precise knowledge

samples

by factors

(3) Evidence

consumed

the latest

living in town or country,

sugar intake

in particular,

r81e can be accorded to this foodstuff.

those with and without

(2) Next,

caloric

and sugar. Is it

to assess the measure of

of the existence

is sugar, an attempt

(1) The first essential

correlation

animal protein,

must be adduced before it can be accepted

are habitually

In order to incriminate

modified

in the con-

apart from increased

rbles? Efforts

because

of the disease, what evidence

the disease

in the development

and possibly even racial 12J3. In view of the multifactorial

(2) that when small amounts

whether

fat, cholesterol,

primarily

environmental

(1) that a particular

lations,

These,

borne by diet in general, or by specific nutrients

by numerous risk factors,

their respective

et a1.3. The great

CLEAVE

have been linked with increases

components.

include total fat, saturated

possible to estimate

such as

that diet is strongly implicated

ON TOTAL

OF

will be discussed together.

SUGAR

INTAKE

IN POPULATION

AND

OF CORONARY

HEART

DISEASE

PREV-

GROUPS

POPULATIONS

consumption Organisation,

data

in different

sugar

1971, 14: 137-152

production

countries

are available

authorities,

and

from

the

Government

Vood

and

bodies.

SUGAR INTAKE ASD CORONARYHEART DISEASE

SUGAR

INTAKE

AND

CORONARY

HEART

DISEASE

cOZlMtY\’

Xemz sugar available g per capita per diem

Iknmarlc

139 137 136 134 134 133 120 118 113 91 88 72

Canada United Kingdom Xew Zealand Ilnited States Sctherlands Swcdcn Switzerland Finland Germany France Italy

Data

on intake

sumption

pev capita

(domestic

IN

as

139

WESTERN

POPULATIONS

CHLI (classification nzortalitv rate per 100,000 population ____~

420)

310 219 239 232 293 139 226 97 196 124 66 72

are arrived

and industrial)

at by dividing

the gross national

sugar con-

by the total

population; the result may be essay, pressed as consumption per di~z or per awuun. A moderately high consumption, 100 g or 3.6 oz sugar $ev diem equals 36.5 kg or 80.3 lb per anwm. CHD mortality data, crude and age specific, on the total populations of man) countries are available in World Health Organisation publications, also in Government health reports. Current representative

figures

on sugar

intake

and

CHD mortality

western countries, which have much the same age structure, from FAOI4 and WHO15 sources, and are given in Table 1. It will be observed

that

for most

western

countries

rate

in

have been obtained

listed

there

is a broad

association between sugar consumption and CHD. This was initially pointed out by YVUKIS~~. Data, however, are somewhat out of harmony in the cases of The Netherlands and Switzerland. Contributions somewhat similar to that of YLIDKIN~S, were made by OSASCOV.~ ct al.17 in Czechoslovakia, and ASHTONI~ m Britain, although the latter noted that in respect of the increased death rate from ischaemic heart disease, statistically, there was a closer association with total calories and fat consumed than with sugar consumption. A very important point is that several under-privileged populations have high intakes of sugar per caju’ta per diem, e. g. Brazil, 111 g, Columbia, 121 g, Costa Rica, 164 g, Nicaragua, 146 g, Uruguay, 109 g, and Mauritius, 103 g14. These high intakes are known to be valid from other sources. Yet the limited information available on these countries does not indicate that CHD is a serious public health problemlj+lg. From the foregoing information on total populations it is inferred that a high sugar intake is frequently associated with a high prevalence of CHD in most sophisticated, although not in some less sophisticated, populations. .~thevosczerosis, 1971, 14: 137-152

140

-4. R. P. WALKER

Factors

complicatiq Irrespective

described

has

(I)

iderpretatio?z

considerable

~Jncertainties

standable

of ?lational

data 0~1 sugar

of the measure of association to the heterogenicity

in respect of national

have ramifications

(2) There

Discrepancies

are discrepancies,

calculated

in patterns

between

as described,

series of households.

social classes.

and homehold

or real, between

In 1961, in the United

148M4

for example,

extensive

72 g sugar (purchased

than can be accounted

for by items not always included in household

reliability

of CHD

mortality

(i) the incidence follow-up,

(690,000

was reported inspection enquiries

and mortality Bantu,

as the primary

of other

surveys,

death

rate

or by

data

countries.

may

Thus, the

revealed a virtual identity

data for the respective

422,000

Caucasians)

between

given

countries.

combined

reduced the numbers

with

in 420)

men and 10 women.

in the certificates,

of the deceased,

In contrast,

in 1962, CHD (classification

cause of death in 27 Bantu

information

from relatives

as sugar), and to be far larger

data for CHD in the groups studied in their five year

and (ii) the mortality

Johannesburg

CHD

rates.

ap-

later.

but the problem is not serious in developed

recent studies of KEYS et al.21 in seven countries

when

studies in that

g, i.r. 64 g, appears

meals eaten away from home. This aspect will be mentioned Diflering

intakes.

the former

household

The difference,

(3)

such

from dietary surveys of large

Kingdom,

yielded a figure of about 84 g, namely,

wgar per capita

12 g from preservesso.

provide difficulties,

c.g.

Clearly,

OY individual

sugar available

and sugar intake as determined

proach gave a figure of 148 g $W diem 20. Yet, country

are under-

that are heterogeneous,

of diet and disease.

Izational,

apparent

There

of populatiom.

populations

composed of different ethnic groups or of very disparate differences

and CHD

the value of the approach

limitations.

due

reservations

idake

prevailing,

Yet

careful

dying probably

from

CHD to 6 men and 4 women22. Briefly

then,

in total

it is questionable

can be used for epidemiological

available per capita rate

populations,

in underprivileged

populations,

even

whether

data on sugar

purposes. Data on CHD mortality

under

propitious

circumstances,

are

unreliable. (b) DATA

ON RANDOM

Unfortunately,

no studies dealing specifically

on CHD prevalence although

SAMPLES OF POPULATIONS

no insuperable

consumption

practical

in households

by questionnaires with caution.

problems

or by individuals

are involved.

of sugar intake

inter- and intra-observer errors were thwarted

regarding

by resentment

during

periods

of hot weather

(affecting

in the community

Atherosclerosis, 1971, 14: 137-152

in seasons soft drink questioned.

of sugar

and may be elicited

however, of data,

attempts

in those questioned

we have noted that data obtained pattern

reproducibility

errors are small, although

theless,

Determination

is straightforward,

such as that of YUDKIN 23.The results,

In our experience

affect the intake

with the bearing

have been carried out on truly random samples of populations,

clearly

must be treated we believe

on further occasions. of home bottling

consumption)

that

to define such Never-

of fruit,

or

may markedly

The general validity

of the

SUGAR

INTAKE

data secured Working

AND

sugar consumption

Councils4 stated

report

described,

AND

electrocardiographic

for example,

that although

the

about

for protein,

by a WHO

used by groups

the making

of CHD in a random

sample

and electrocardiographic

Yet a major

BL4CKHuRN26.

criteria

preclude,

or incidence

can be based on clinical

using the procedures ROSE

of the

does not yield precise data, information

the prevalence

judgement

instances

Medical Research

questionnary

The recent

components.

In determining

by

is not in doubt.

is much more exact than that which can be obtained

fat, and other dietary

recently,

141

DISEASE

however,

of the British

of the dietary

population,

HEBRT

by these means,

Party

technique

CORONARY

Study

drawback

of workers

of satisfactory

group25,

or more

is that the different

prejudice,

comparisons

of

evidence,

and in many

of the occurrence

of

CHD”“. GROUPS (c) D .4TA ON SPECIAL POPULATION To incriminate the level of sugar intake

relation have

should

been

be apparent

undertaken.

in several

Some

others have been neglected.

in causing or promoting

types

population

of populations.

groups

The problem

have

attracted

may be approached

attention;

populations

with known differences

sugar intake differs, or aic~~ULYSIE.The following are groups, either which

vestigations tients

were those of

who had

disease,

or whose investigation

and compared

T.kBLE

YUDKIN

experienced

and then investigating

of myocardial

hfarctiort.

The initial

et al. 27738. They studied the sugar intake

either

to

would be likely to be rewarding.

Gro~$s with and without wideme

(1)

of CHD,

much

either by examining

what extent

have been studied,

of frequency

CHD, a cor-

Many investigations

myocardial

the figures obtained

infarction

or peripheral

in-

of pa-

vascular

with those of like series of persons out-

2

MEhN SU;GR All subjects

INTAKE

(g

pet’ &W)

IN

GROUPS

were males unless otherwise

WITH

AKD

WITHOUT

CORONARY

HEART

DISEASE

stated. -

Aztthors

Control groups 120.of

subjects

Ischaemic

heart diseascgroztps

_____-

we

(yews)

sugar illtake

120. qf subjects

age

(years)

sugar irdake

56 55.4 43-65 40055 under 60 under 60 44~58 under 60

77 78 117 96 69 65.2 79 96.9

20 20 20 66 100 50 170 80

56.4 55.4 42-64 40-55 under under 44-58 under

132 148 121 116 65.9 59.7 67.0 99.1

55.1 56.5 52.4

97.1 100.3 146.6

80 21 49

~UDKIN

AND

YUDKIN I’APP

RODDY3’

AND

MORLAND~~

et al.30

PlzuLet

al.31

FINEG~N

et al.32

FINEGAN

et al.33 (females)

HOWELL

AKD

BGRNS-COX

WILSON~~ et al.35

M.R.C. Studies24 Middlesex Hospital Hammersmith Hospital Scottish Hospitals

25 20 20 85 50 50 1158 160

160 21 94

54.4 56.4 53.2

.~therosclerosis,

60 60 60

100.1 103.5 167.1

1971, 14: 137-152

A. R. P. WALKER

142

wardly iree from these diseases. In two separate studies they found that men with myocardial be noted,

infarction ingested double the sugar intake of the control groups. It should however,

that

follow-up

studies

indicated

a smaller

difference.

Later,

were made by LITTLE et al. 29, PAPP et a1.30, PAUL et al.31, FINEGAN et

investigations

aZ.32133, HOWELL ANDWILSO~T34, BURSS-Cox et a1.35, ELWOOD et a1.37, and latterly, by a Working

Party of the Medical Research

Counci124. But all these workers de-

tected minor or no differences in sugar intake between the two types of groups. The conclusions

reached are most unlikely

to be vitiated

by the different criteria

in assessing ischaemic heart disease. The results obtained

are summarised

used

in Table 2.

The studies of BURNS-C• X et al.35 and of the Medical Research Council group24 are of special interest in that they employed

the same investigational

as were used by YUDKIN et a1.27328. BURNS-C• X et al.35 concluded of data now available to be a major

does not suggest that consumption

or specific factor in the production

Medical Research Council report24 concluded

procedures

“that the totality

of refined sugar is likely

of myocardial

infarction”.

The

that “the evidence in favour of a high

sugar intake as a major factor in the development

of myocardial

infarction

is extre-

mely slender”. While

the foregoing

investigations

primarily

concerned

the sugar intake

CHD, ELWOOD et al. studied sugar consumption

adult males with and without

ischaemic heart disease in a community37.

of and

In the male series, they found no evidence

that those with ischaemic heart disease had a higher sugar intake than the remainder; among women, those with angina had a slightly higher intake than the other women, although the difference was not significant There are two items epidemiological

(P > 0.05).

of less specific

studies at Bedford,

evidence.

KEEN AND ROSEN*, in their

found that the sugar intakes of “atheromatous”

men were not increased out of proportion

to their total caloric intake. In Glasgow,

BEGG et aZ.39 reported that their male group with arterial disease added significantly less sugar to their tea and coffee than their controls. An important cigarette

observation

habit was associated

was made by PAUL d al.31 who found with a greater intake of sugar,

revealed that the primary relationship

that the

and probit

analysis

was more likely to be between ischaemic heart

disease and cigarette consumption

rather than between ischaemic

sugar intake. The same conclusion

was reached by ELWOOD et al.37 and BENKETT et

aZ.36. In the former study, 89 g compared

mean sugar intakes in the Atomic

with 77 g per diem in the heavy and non-smoker

A further important

heart disease and

Energy

group were

groups, respectively.

point apparent from Table 2 is that the mean intakes of

sugar in the different

control

groups differed enormously;

this also applied

to the

groups with ischaemic

heart disease. Thus, the intake of the heart disease group in

the study of HOWELL AND WILSON~~ was 67 g per diem, whereas the corresponding figure in the Medical Research Council study at Glasgow and Edinburgh Yet at the latter centres, the daily sugar intake of the control far larger (with one exception)

than that of the heart disease groups in all the other

studies cited. This finding will be commented Atherosclerosis,

1971, 14: 137-152

was 167 g24.

group was 147 g, i.c.

on later.

SUGAR

INTAKE

(2) Britain,

AND

CORONARY

Grou~ps in western maintains

sume more than

HEART

143

DISEASE

co%?exts z&h

contrasting

that “many persons consume 150 g” per diem.

sugar

intake.

less than 45 g and very many con-

Consumption

by

vegans

is reported

a mean of 31 g has been given 41. Groups with high consumptions 118 g, and bus conductors,

carry

years,

accustomed

in locating,

(3)

investigations

Italian

D&me

group,

upon them.

respectively,

Incidence

would add to the value of the conclusions Caucasia?h

groups

et al.43 noted that the frequency studied.

say, two groups of 300 or more males of

to low or high sugar intakes,

out CHD prevalence

more meaningful,

itt westem

although

the respective the mortality

than that of other Caucasian+.

sugar

(J)

Grozips dl’feviq

New York,

consumptions

of Jews (Ashkenazi)

Our studies, however,

northern

about

were not

countries

g per diem, of total

Yet,

deaths

according

south of the cityas.

extent

Adventists47

than

to which this particular

was not reported. Indians

In Durban,

prevalence

in the average

U.S.A.

indicate

data,

is known

to be lower in

population,

although

the

group may have a lower than average intake of sugar South Africa,

according

are more prone to CHD than Hindu Indians;

the Transvaal

in the

due to CHD in the more prosperous

CHD

Seventh-Day

of groups of Caucasians

to death certificate

than in the poorer and industrial difSeeri?zg in religio~a.

this is not the

are higher than those investigated

(5)

Gro@s

group of approxi-

there appears to be little social

In “younger”

we have noted that the mean intakes

proportion

specifically

from CHD is far higher

have failed to reveal a signif-

In Britain,

class.

area, about SO-100 g $W dim45.

there is a greater north

in social

120-140

EPSTEIN

levelas.

in respect of sugar intakel6,“o.

case. In Johannesburg, in the south,

to

which are

group was double that of an

icantly higher sugar intake in a Jewish compared with a Caucasian mately the same socio-economic

and then

studies,

reached. In

contests.

of CHD in a Jewish

In Johannesburg,

class difference

to be low;

include bus drivers,

123 g42. Apart from the time, labour, and finance involved,

there should be no difficulty 60-69

in

YUDKIN40,

approximately

groups of the same socio-economic

equal intakes

status,

to death certificates,

Moslem

yet our studies on Indians

in

of sugar in Moslem and Hindu

such intakes

being of the order of 60-80

g

per diem45. (6)

Strict vegetarians

of refined cereals are usual@.

-

vegans.

31 g sugar per dienz41. Unfortunately, protagonists,

to investigate

that vegans have a relatively (7)

Town-co&r?/

differential

is almost invariably CHD mortality

low prevalence

there is only the impression

of C.HD@.

Several

investigations

have revealed

a marked

between urban and rural areas; that in the latter areas

lower. In Norway 50, for example, amounts

of sugar and

has been made, even by the relevant

in agriculture

was reported to be only a third of that obtaining

ly, the respective town-country

no attempt

this key type of population;

differences.

in CHD mortality

Among these people low intakes

One study, as already noted, revealed a mean intake of

of sugar consumed

difference in CHD mortality

of sugar intake in large centres of population

are not available.

obtains,

and fishing areas,

in Oslo; unfortunateIn the U.S.A.51,

yet there is insufficient

compared

with country .-IfhevoscZemis.

a

knowledge

areas. In respect 1971,

14: 137--152

144

A. R. P. WALKER

of regions in U.S.A.,

the mean intake

(from sugar and sweets) in the economically

superior and more densely populated north east, namely, 63 g per diemjs, is lower than that in the economically rate,

however,

poorer and more rural south, 73 g per d&253; CHD mortality

is higher

in the north-east

than

in the south

(excluding

the New

Orleans region)54. (8)

Grolb$s at d(fftwnt

problem state,

is to compare

levels

population

groups (i) in their primitive

with (ii) their urban more-developed

and the frequency usually

higher,

state.

sometimes

much higher,

have become a serious problem. to Indians

regard of unsophisticated in urban

This approach

Bantu

changes major

Little

in manner inadequacies

increases

with increases account

of knowledge

of several

in that

other

of appropriate them.

of CHD among

some puzzling points in the information on intakes

northern

Apart

from India. India,

of sugar simply as

in diet or of

Moreover,

there are

data have been reported

in

groups of subjects,

nor of the

from the foregoing,

there are

For example,

on relatively

in a major

poor subjects

study

subsisting

of sugar and fat far less than those usual in the west, CHD was stated

to be common In another

and have the same prevalence

study carried out in India,

correlated

with serum cholesterols*.

prevalence further

also in sophis-

or urban groups,

alterations

simultaneously.

no detailed

South Africa on sugar and cereal intakes

at Chandigarhs6,

in the consumption

in the sophisticated

associated undertaken

Africa,

in CHD55, have been interpreted

is taken

may

pursued by CLEAVE

with those in South

of life that have occurred

prevalences

and mortality

in rural areas compared with those partially

and also of refined cereals that have occurred cause and effect.

is usually low,

whereas in (ii) sugar intake is

has been actively

areas. The understandable

and which are associated

to the

or non-sophisticated

and CHD prevalence

in India compared

approach

In (i) sugar intake

of CHD may be low or negligible,

et al.3 in relation ticated

A popular

of sophisticatiolt.

as that found at Tecumseh,

dietary

particular

is required

U.S.A.57.

to be negatively

W’hile there is no doubt that, characteristically,

of CHD is higher in sophisticated

information

sugar was reported than in primitive

before allocations

populations,

of responsibility

much

may be made to

risk factors.

As just mentioned,

among populations

changes take place simultaneously; appreciated.

Thus,

in Britain

in various stages of transition,

their magnitude

about

a century

and significance

ago, the average

daily consumption

of bread made from lightly milled flour was about 600 gsa, moreover, a large amount

of oatmeal

porridge

was eatenso.

At present

numerous

are insufficiently among the poor

the consumption

of

bread in Britain

averages about 180 g prr

of fat in Britain

averages about 116 gso, the figure was 73 g in 190261, and about 53 g

in 186362. Further, contrasts figures

the current

die~rt

20.

Although present daily consumption

daily consumption

of sugar is about 84 gso, which

with the figure of about 60 g in 188162, and 25 g in 183562@. may

carbohydrate

not be fully representative,

Atherosclerosis,

are obvious.

supplied by bread has not only fallen considerably,

is now very largely the refined product. has risen,

the trends

the total

carbohydrate

1971, 14: 137-152

Although

intake

from

sugar consumption, bread

and

sugar

The

While these amount

of

but the foodstuff always refined, is much

lower

SUGAR INTAKE

AND CORONARY

now than in generations also their

interplay,

in importance

145

HEART DISEASE

past. These and other dietary

may

have

may be alterations

far reaching

changes which could be cited,

effects on the metabolism;

in the bulk-forming

capacity

not least

of the diet, with its

effects on lipid metabolisms*,6j. there

In respect of non-dietary changes likely to be relevant to CHD prevalence, has been a reduction in employment involving much physical activity. Of

importance already

too is the rise in frequency

referred

and intensity

to, can have an appreciable

bearing

of cigarette

smoking,

which, as

on sugar intake.

It will be apparent from the foregoing that the effects of changes in sugar intake tend to be confounded with the effects of changes, not only in intakes of other nutrients, but in other environmental factors. Clearly, support

in the investigations

a specific incrimination

THE EFFECT OF INVOLUXTARY

thus far described,

there is very little evidence

of sugar in the aetiology OR T’OLUNTARY

to

of CHD.

CHASGES IN SLTGARIXTAKE ON CORONARTI’

HEART DISEASE

-4s emphasized earlier the most crucial information required for the incrimination of sugar is evidence that when its intake is markedly reduced there is a fall in the prevalence

of CHD.

(1) War-time obsewatiom. In a number of countries, circumstances of war caused dietary restrictions which involved a reduction in sugar intake, and which were accompanied by a fall in mortality from CHD. However, as noted bv KEY+, other changes, dietary and non-dietary, occurred simultaneously. (2) Long-term co~@zemmt ia jm’sou. Usually, the sugar intake of prisoners is lower than that of the general population. There is some evidence, both in U.S.A.66,6i

and in South Africass, that serum cholesterol levels are lower, and CHD events are less frequent, under prison conditions. However, in prison, as during war-time, numerous other changes (in diet, activity, smoking, also emotional context) occur at the same time, which tend to confound interpretations.

Rtwlts offield trials. In man, although several large scale and protracted studies have been undertaken to determine the changes in CHD incidence that accompan> alterations in the dietary fat, no correspondingly large studies have been carried out using diets that differ only, or chiefly, in sugar intake. A major drawback is that even were such investigations carried out, then to vield worthwhile conclusions, regimens would have to be iso-caloric, for altered sugar intake with a concomitant change in weight would preclude firm conclusions. A fall in weight has been the rule rather than the exception 5n most of the prospective diet-CHD studies so far undertaken. For example, in the U.S.A. National Diet-Heart Studyss, the dietary changes that were associated with a fall in serum cholesterol level were also linked with .~thevosclerosis, 1971, 14: 137-1.52

146

A. R. P. WALKER

decrease in body weight, no long-term pursued.

diastolic

blood pressure,

The results disagree.

dietsTO-77. Such

changes

four reports

patients.

serum lipids were

however,

To illustrate

either

were slight

et ~1.88-90 at Toronto

between

Some

the scope of investigations

recently

described

kinds of dietary carbohydrate

studies

(period

15 days)

with

investigations

diets

showed that sucrose had no uniform

(period 4 weeks) with diets high in saturated

other

studies

a synergic

effect

the latter

studies,

between

dietary

however,

sucrose

and animal

were very high, supplying

et u1.86,91 found that high and low sucrose regimens serum cholesterol

as subjects,

that

or phospholipid.

of those

induced

hyperinsulinism”.

They

vascular

disease compared

with controls

significantly

greater

that in only a proportion heart

disease.

experiments

Their

periods

on the

insulin

of individuals those

to the alteration emphasized responses

in intake

out observations their

over a relatively

daily sucrose

tryglycerides

intake

averaged

These

workers

the need for further

the patients

therefore

concluded

of the remainder

full blame for the change

In this respect,

diets.

In the

experienced

attaching

on the

BIERMAN AND PORTEg2 have of insulin and triglyceride

(iii) In Cape Town, MANN et al.77 carried

long period of time, 22 weeks. Volunteers

reduced

information of starch

altered

4% less than before.

serum The

with a loss in weight. These workers on the epidemiology

and sucrose,

by the substitution

of serum trigly-

(iv) DUNNIGAN et al.87 studied

on CHD prevalence.

changes

sucrose intake comparable of long-term

“sucroseperipheral

than that

being 4 weeks. They concluded that glucose tolerance, were not significantly

with

hyperinsulinism

less, and serum cholesterol

ceride levels and their bearing the effects of iso-caloric

using students

developed

from a mean of 85 g to 12 g. On this regimen,

22%

in

(ii) YUDKIN

diets were 2 weeks.

who exhibited

decreases in lipid levels, however, synchronized emphasized

however,

sucrose intake,

the bearing of body weight on the magnitude during carbohydrate-rich

of sucrose

does a higher sucrose intake promote ischaemic

precludes

of sucrose.

Intakes

in patients

on the saw

5 times greater

this observation

effect,

fat indicated

of calories.

a third

on high- and low-sucrose

students,

a mean weight gain increment high sucrose regimen;

noted,

that

activity.

fat. 40%

intake

also reported

hyperlipidaemic

fat

had no effect on glucose toler-

They

on a high sucrose

on the

high in polyunsaturated

and low in cholesterol

exhibited

undertaken,

and fat in hyperlipoproteinaemic

whereas

ance test,

starch

or were not

will be mentioned.

(i) LITTLE relationship

have been

starch diets, than on low sucrose-high

in lipid levels,

in other studiesTs-87.

While, as noted,

investigations

In some of the trials undertaken,

found to be higher on high sucrose-low observed

and in smoking.

studies have been made, several short-term

their period of observation

plasma insulin and serum lipids

of sucrose for starch

at levels of

to those in western diets. These workers stressed the need

studies.

ADDITIONAL REQUIREMENTS OF EVIDENCE As indicated to the response

in the INTRODUCTION, a further

of experimental

.4thevosclerosis,1971, 14: 137-152

animals

key type of information

to sucrose.

An additional

relates

need concerns

SUGAR

INTAKE

information

AND

COROK;ARY

HEART

on the metabolic

serve to differentiate lipidaemia

mechanisms

between

on eq5erintedal

some workersgs-95

the converse

reported

cholesterolaemic studies, and

have been reported

in certain

and atherogenic the differences

Mechanisnz

of metabolic

his studies

dietary

than sucrose.

in responses

starch

was more hyper-

In the foregoing

and other experi-

and physical

m~ome

to high s~tc~ose itztakc. averred

opens up a new approach

disease, but with obesity,

inactivity,

that

diabetes,

agents into a single and plausible

“carefully

controlled

been consuming

is the validity

studies

hypothesis”.

Nevertheless,

considered

that “the hyperlipidemic

for the differences

the mechanism

that

CHD have

effect of sucrose may depend (2) the amounts of saturated in the diet”. It is probable

in the results

of the lipaemic probably

effect

studies

are mainly

with increments pathway

on rats,

cited,

with in ab-

from the circulation.

From

of rates

“the

of lipogenesis,

of enzymes of the hexose monophosphate

carbohydrate

the mechanism

compared

by differences

due to the stimulation

in the liver, coupled with relative

is needed to elucidate

of sucrose,

et aZ.90

ANTAR

et al.100 took the view that

MUKHERJEE

in the activities

of specific lipid classes on respective

obtained.

are regulated

and in the rate of removal of lipid components (on lipid levels)

hydrate

who develop

related to change in weight, and even to the sex and age of sub-

is not clear, but changes

their experimental

oxidative

a fundamental

of the belief (to which he still adheres)

fat, and (3) the amount of cholesterol

account

that

etc.,

smoking,

these possible

in these respects in the diets used in the various investigations

as well as problems largely

cigarette

of uniting

more sugar than those who do not”.

and polyunsaturated that differences

YUDKIN~~,

of ‘sucrose-

not only with CHD and peri-

hypertension,

on (1) the per cent of total calories as sucrose and starch,

associated

on the

to the problem of atherogenesis”.

have shown that individuals

t’t aZ.90 speculated

ANTAR

Recently,

“the discovery

may well provide a basis “capable

premise to his hypothesis

effects

firm conclusions

in respect of changes in both serum

His view is that the raised levels of insulin associated pheral vascular

sorption,

with

et a1.97,

E~RITCHEVSKY

contexts,

noted preclude

with starch diets,

just mentioned86991,

induced hyperinsulinism’

starch,

Using rats,

atherogenesis.

discussing

jectssg,

to influence

animals.

of lipid values on sucrose compared

has been found by other+.

that

role of high sucrose compared

etiologic

which could

of sucrose in hyper-

and other lipids in experimental

have noted elevations

regimens;

using rabbits,

lipids

involvement

Carbohydrates

animals.

the levels of serum cholesterol

mental

involved in man and animals,

a true or apparent

and atherogenesis.

Studies

starch

147

DISEASE

lowering of the catabolic

regimens”.

of the metabolic

Much further

response

to different

rate

research carbo-

foods.

COMMENT

The Medical

Research

countries was shown by YUDKIN

Councils4

report

stated

that

“sugar

intake

to be more closely related to mortality .-ltherosclwosis,

in various

from coronary 1971, 14: 137-152

A.

148 heart disease than any other nutrient”.

YUDKIN~~ used national

data from the same

sources as have been used in the present study. The first drawback disparity, intakes;

mentioned

earlier, between estimates

this considerably

demiological countries;

purposes.

limits

YUDKIN’S generalization

all were sophisticated

populations.

known to occur in some under-developed health

problem,

promote

demonstrates

that

depends in large measure

of a risk factor,

even innocuous

in anotherial~iaa.

The investigations heart

A very important

countries

(Table

point to emerge,

(with one exception)

investigations;

for example,

intake of the ischaemic this incongruity intake

or

yet far less so or

of YUDKIN et ul.z7Js, of the disease.

is that the mean daily intake study24, namely,

of the 146.6 g,

in the other

groups

of HOWELL AND WILSOK~~, the sugar

heart disease group was only 67 g pev dieln. On the one hand,

still further

in the development

lessens the role that can be accorded the validity

of the “control”

other than his own. The Medical Research

groups by the Medical

his findings, Research

groups

to know

(1) whether

and (2) whether

Council

Working

Party

that

in investigations

Council study24 was vehemently

It would be illuminating

YUDKIN could duplicate

to a high sugar

of CHD. On the other hand, it must be mentioned

YUDKIN~O~ has questioned in this respect.

or

with and without evidence

than that in the heavt disease

in the study

cause

or risk factor

of a nutrient,

in one context,

control gvoz~f~ (i.e. with no evidence of CHD) in the Scottish was far greater

nutrient

factor in the development

moreover,

no major

PeY SE does not

2), apart from the studies

sugar as a significant

of sugar

where CHD presents

prevailin g; a high intake

may be deleterious

for epiin fifteen

the very high intakes

on the sugar intake of populations

disease

failed to incriminate

Yet

and of household

information

to populations

effects of a particular

on the context

high prevalence

related

in such data is the

intakes

intake

a high sugar intake

CHD. Clearly, the deleterious

of ischaemic

of national

the value of national

R. P. WALKER

criticized

in further

studies

the use of correct

control

would significantly

alter

their final conclusion. In diseases of d@cielzcy -

specific incrimination

YUDKIX~O~) is relatively with excess of nutrients

kwashiorkor,

of particular simple.

rickets, scurvy, iron deficiency anaemia,

nutrients

In a number

(using the criteria

that

major

such as fluorosis, also siderosis from iron overload,

apportion-

But the situation

role to a single nutrient

is feasible,

on the global interracial

research

Atherosclerosis,

14:

137-152

the issue, and

such as sugar,

as the cause

In so far as ascribing a promotive

on such a problem

should not be con-

groups within western populations

less CHD than their national

1971,

complicate

aspects where the variables are numerous. Attention

should rather be focussed on minority significantly

is far less straightforward

It cannot therefore be expected

of a single food component,

of CHD will emerge from current or future research. centrated

factors

and possibly racial factors operate.

incrimination

by

associated

with diseases such as CHD, where other nutritional where non-dietary

put forward

or diseases

ment of blame again presents no difficulty.

of conditions

average.

who have

SUGAR

IXTAKE

AND

COROS_%RY

HEART

119

DISEASE

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zation, Genela, 1959, p. 14. ROSE. G. A. AKD H. BLACKB~RN, Cnrdioruzscular Szcvvev Methods (World Health Organisation. Monokraph Series, ?;o. 56), \Vorld Health Organization, Geneva‘, 1968, Ch. 4. YUDKIN, J. AND J, RODDY, Levels of dietary sncrosc in patients with occlusive atherosclerotic disease, Lancet, 1964, ii: 6. YUDKIN, J. AND J. MORLAND, Sugar intake and myocardial infarction, Amer. J. Clip. X&v., 1967, 20: 503. LITTLE. 1. 11.. H. M. SHSNOFF, .4. CSIMA, S. E. RED~XONDAND R. YANO, Diet and serum-lipids in malt survivors of myocardial infarction, Lmcet, 1965, i: 933. PAPP. 0. A.. L. P~DILLA AND A. L. TOHNSON,Dietarv intake in patients with and without myocardial infarction, Lmcet, 1965, ii: 259. PAUL, O., A. MACMILLAN, H. MCLEAN AND H. PARK, Sucrose intake and coronary heart disease, Lancet, 1968, ii: 1049. FINIXAN, A., K. HICKEY, B. MAURER AND R. MULCAHY, Diet and coronary heart disease; dietary analysis on 100 male patients, Amer. J. Clin. A’utr., 1968, 21: 143. _ FINEGAN, A.. N. HICKEY, B. MAURER AHD R. M~LCAHY, Diet and coronary heart disease: dietary analysis on fifty females, .4nzer. J. Clsn. Nuts., 1969, 22: 8. HOWELL, R. W. AND D. G. WILSON, Dietary sugar and ischaemic heart disease, Bril. Jled. .I., 1969, 3: 145. BURNS-C• X, C. J., R. DOLL AND Ii. P. BALL, Sugar intake and myocardial infarction, Bvit. Heart J., 1969, 31: 485. BENNETT, A. E., R. DOLL AND R. W. HOWELL, Sugar consumption and cigarette smoking, Lmcet, 1970, i: 1011. _ltherosclevosis.

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4therosclerosis,

1971, 14: 137-152

SCGAR

INTAKE

AND

COROSARY

HEART

151

DISE.4SE

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