Mark Labriola: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast, exploring the many facets of the disease of obesity. In this series of podcasts, we have carefully selected recent articles including the latest version of the OMA Obesity Algorithm. I'm Mark Labriola, and in this episode, Dr Harold Bays interviews Dr Wickham Simonds about food sources of fructose containing sugars in glycemic control. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, the clinical leader in obesity medicine.
Harold Bays: Today, we are fortunate to have Dr Wickham Simonds. Wickham, good to have you here today.
Wickham Simonds: Harold, thank you for having me here today.
HB: Why don't you tell the folks who you are and what you do?
WS: Well, as Harold said my name is Wickham Simonds. I'm an obesity medicine specialist in the triangle region of North Carolina. I have two clinics there and a solo private practice. I've been practicing obesity medicine for 15 years. I've treated about 30,000 patients in that 15 years and I'm a board trustee here at the Obesity Medicine Association and a longtime member of the organization, which is how I came to know you, Dr Bays. Thanks again for inviting me on to do this podcast.
HB: I think you're the perfect person for the program we got today. I always like to say another Southerner, it is really nice to have you here. It's always nice to have somebody without an accent. So that's very helpful for me.
WS: I had to give up a career in broadcasting to serve humanity in medicine. No accent at all.
HB: No accent whatsoever. All right, so today we're going to talk about an article. The lead author is Choo, C-H-O-O. This was published in 2018 and it was in the British Medical Journal. The title is “Food Sources of Fructose-Containing Sugars and Glycemic Control, Systematic Review and Meta Analysis of Controlled Studies”. They assessed the effects of different types of food sources and fructose-containing sugars on glycemic control. It was a meta-analysis. What they found is that when you're substituting whole fruits and such, people either did as well or better when they substituted whole fruits for other types of less healthier foods. But when people consume sugar sweetened beverages, and sometimes even fruit juices, metabolically, sometimes they didn't do as well. What's the lesson here?
WS: I think the lesson really is that it is not generally a good idea to consume fruit juice or sugar sweetened beverages of any kind. Our ancestors ate fruit whole, which is kind of what I always tell my patients. This is what your DNA is adapted to. They weren't squeezing it into a glass.
WS: And adding carbonation and so forth to it. It doesn't surprise me that this study came to the conclusion that adding in fructose in the form of drinks was not a good idea. It impaired glycemic control and raised insulin level, particularly when it was above and beyond the calories you are currently consuming.
HB: But you hear a lot of people that think if it's fruit juice, got to be healthy.
WS: I would disagree with that. I don't have a problem with someone eating fruit instead of something else in their diet. I suppose I might not would be okay with that if their hemoglobin A1C was 10% and their fasting blood sugar was 400 mg/dL. I might have them restrict it for a while. For the most part eating fruit in place of something else is probably a really good idea. I believe these authors when they say, "Well, it had a positive effect on either the hemoglobin A1C, the fasting blood glucose or the fasting insulin."
HB: Well, because fructose has got a low-glycemic index.
WS: Right, and you throw it in with the fiber-
HB: And with the fiber, that's a very good point.
WS: I mean, it's to some extent like adding some cardboard to the fructose. 00:04:30]. Not in terms of the taste, but in terms of how your stomach has to-
WS: Your intestines have to break it down to get it to a slower absorbable form, and that really keeps the glycemic index lower, right?
WS: So you don't get this big rise in the blood sugar and therefore in the insulin, which seems to be kind of a path that leads us to the wrong place.
HB: Right. And look, the analogy I like to make is the same thing with vitamins. I don't know where people got the idea that if you just took vitamins, and extracted it from a food, and concentrated it and you put it in a capsule or a pill, that somehow that's better than the food for which it originated. And I think we find more and more data science that supports that yes, there may be some benefits with regard to vitamins and such, especially in patients with specific vitamin deficiencies. But almost invariably those benefits are most found when it's incorporated within its original food.
WS: I agree with that. Vitamins are a great business proposition for someone. If you eat whole food, you won't have to spend your money on that though.
HB: Right, and you might actually get the health benefits too.
HB: And avoid maybe even some toxicities and such. With regard to this study here, let's just take a practical example. You've got a patient who comes to you and they've heard about fruit juices (because we're not the only folks that have talked about this). We're not the only folks that have read this article, and they've heard that fruit juice is maybe not such a right thing to do and they're in a weight management program. Say they've already lost weight but you're trying to maintain weight loss. At the end of the meal they ask you a very simple question. So Wickham, they ask you, "Is it okay instead of eating some of these other desserts and such, is it okay if I can just have fruit?" What do you say to these folks?
WS: I tell them yes, at the end of the meal. I mean, in particularly at that point-
WS: Is because your protein and fat and so forth, and fiber. I say if you ate some vegetables with that meal, all that will be in your digestive track and you're going to put the fruit in on top of that. The chance that it's going to have a significant impact in terms of a rise in your blood sugar and insulin; I don't buy it. It hardly ever does-
HB: No, not in a mixed meal.
WS: So in terms of the total glycemic load, if you will, this is no harm or offense here. I would much rather them do that than try to have something sweet like a can of Coke or …
HB: Or fruit juice, right.
WS: That's right, yeah. That's right. So I don't generally discourage that. Again, it would take a patient who's having very poor glycemic control because they had out of control type 2 diabetes for example. Then and only then would I have a person restrict all forms of sugar in their diet for a while until the blood sugars came under better [crosstalk 00:07:38] control.
HB: So you would hold fruit on a transient basis, but-
WS: Right. But I mean look, 99% of my patients it's fine-
WS: To have the fruit after the meal.
HB: And I think consuming the fructose in a form for which it has the natural fibers for which it was intended to take at the same time, we call that fruit.
WS: Yes, correct. That's right. That's what fruit is, right?
HB: That's what fruit is.
HB: I mean I often wondered if there was some sort of technology company who said, "Okay, we've got this great idea. We're going to have this synthetic food, and it's going to have fiber and it's going to have fructose and it's going to taste sweet, but it's going to have fiber. And we'll wrap it all up in an orange organic wrapping, and we'll charge 20 bucks. And we're going to call it … an orange." That's what we're going to call it, right?
HB: But we already have that, as a natural fruit, right?
WS: Right. You can get it for a lot less than $20 at the produce section at your local grocery store.
HB: I mean, I'm not saying that just because something is natural that that automatically makes it healthier. But I am saying for edible fruits, that's absolutely the case in my judgment. I mean, what's your sense?
WS: Yeah, I would agree with you on that. I don't think America's problem is that we're consuming too much fruit. I always said this, if we look at the grand scheme of all of our health problems and it's hard to look and say, "Well, the fruit here, eating whole fruit is really what's killing us all." No, it's things like the sugar sweetened beverages and fruit juice. This is much more likely to be the culprit of the things that make us sick.
HB: So the question is this: according to this article, if you add fruit juices … add, not substitute … but if you add fruit juices on top of what you're already consuming, does that improve or potentially worsen a person's metabolic health?
WS: It worsens their metabolic health. Yeah, if they add it on top and they're not substituting, I would definitely say that. Myself and anybody I know who practices obesity medicine would tell you that that worsens your metabolic health.
HB: And again, we're not anti-fruit. I think we've been pretty clear.
HB: We're pro-fruit and maybe there's some fruit juices for some folks where it's okay. But when you're adding calories onto somebody engaged in weight loss and weight loss maintenance and such, I mean, sometimes you got to make some choices. Sometimes an okay choice is to not have sugar drinks added to what you're already doing.
WS: That is the take home point. I totally agree.
HB: Okay, well Wickham, thank you very much for being here.
ML: Thank you Dr. Bays and Simonds. For more information about obesity medicine podcasts and other resources from the clinical leader in obesity medicine, please visit obesitymedicine.org/podcasts. Love this episode of Obesity, a Disease? Head over to iTunes to subscribe, rate, and leave a review. The views expressed in this podcast episode are those of the show hosts and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association or its members. Please check back soon for another episode of Obesity, a Disease.
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Credit Renewal Date: July 31, 2021
E, Blanco Mejia
et al. Food sources of fructose-containing sugars and glycaemic control: systematic review and meta-analysis of controlled intervention studies [published correction appears in BMJ. 2019 Oct 9;367:15524]. BMJ.
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