Diabetes Charity Walks Into Storm With Sugary Drink Co Tie-in

Liam Davenport

November 29, 2018

Canadian scientists say sugar-sweetened beverages (SSBs) could increase the risk of developing type 2 diabetes more than other fructose sources. The increase in risk is associated with the effect that SSBs have on fasting blood glucose levels when consumed as part of a normal diet. The research was published just days before a leading UK diabetes charity faced a storm of criticism for signing a lucrative multiyear partnership with a major soft drink company, Britivic.

Fructose is consumed in a variety of ways. In sucrose (table sugar), fructose occurs in a 50:50 ratio with glucose. It also occurs in honey, agave, and maple syrup, as well as in many fruits or vegetables. "Nutrient poor" SSBs contain high-fructose corn syrup, which is a glucose-fructose mix that has varying fructose content (42% - 55% molecular weight).

In their study, Vivian L. Choo, who is an MD candidate in the Department of Nutritional Sciences, University of Toronto, Canada, and colleagues combined data from more than 150 studies that included more than 5000 individuals.

The investigators note that current dietary guidelines recommend that individuals obtain less than 5% to 10% of energy from free sugars, especially fructose-containing sugars in SSBs. Dietary guidelines have shifted from focusing on single nutrients to focusing on dietary patterns. It is unclear whether the evidence relating to SSBs and the excess energy derived from fructose can be generalized to all food sources of fructose-containing sugars "at different levels of energy control," they say.

Their meta-analysis, which was published online November 21 in the BMJ, showed that fructose-containing sugars in most food sources do not have a harmful effect on glycemic control in energy-matched substitutions for other macronutrients.

But SSBs "tended to impair fasting blood glucose and insulin when adding excess energy to the diet," the authors indicate. Therefore, "public health strategies to reduce consumption of SSBs could be useful, especially as they provide empty calories in absence of any nutritional value."

While acknowledging the general low quality of the available evidence, senior author John L. Sievenpiper, MD, PhD, said in a press release: "These findings might help guide recommendations on important food sources of fructose in the prevention and management of diabetes."

The partnership between the charity Diabetes UK and Britvic, which sells Tango and Pepsi among other brands in the United Kingdom, was announced on November 27.

The partnership occurred despite recent research conducted by Diabetes UK itself that found that hundreds more children have type 2 diabetes in the United Kingdom than official records suggest. The number of such cases is likely to rise with increasing overweight and obesity.

Charity Panned: "Like Cancer Research Partnering With Marlboro"

The new 3-year partnership between Diabetes UK and Britvic aims to raise £500,000 via corporate donations and employee fundraising at the soft drink company.

The revenue will be channeled into two of the charity's funds that support children with type 1 diabetes and their families in the children's getting the most from their schooling.

In addition, Diabetes UK will be "working closely" with 2000 of Britvic's employees to help them and their families to live healthy lives.

At the time, Chris Askew, Diabetes UK's chief executive, said that he was "delighted" to announce the partnership.

He added: "We look forward to working alongside Britvic's workforce to promote, amplify and expand the reach of our vital work, and to inspire people across the UK to help us achieve our shared goal of improving the lives of people with diabetes."

However, that did not stop a barrage of criticism of the charity, both in the mainstream press and on social media.

The British newspaper Sunday Times quoted Simon Tobin, a general practitioner from Southport, Merseyside, as saying that he "cannot recommend my patients are supported by Diabetes UK."

"How can they trust a charity that has partnered with Britvic?" he asked.

In another British newspaper, the Daily Mail , radio presenter Jon Gaunt described the alliance as "blood money." Gaunt said his type 2 diabetes went into remission after he eliminated sugar from his diet. "This is a company that still pushes sugary products. Diabetes UK has lost all credibility by doing this," Gaunt said.

Twitter users were no more welcoming of the announcement.

Paul Simmons (@Nevella1867) said: "What an absolute farce, totally shameful, but I guess the 'donations' help you carry the shame."

Sarah Bradley (@SJABradley) added: "This has to be a joke right?," and Caroline Laursen (@CaLaursen), another Twitter user, said: "This is like Cancer Research partnering up with Marlboro."

Diabetes UK Stands by Its Deal

Diabetes UK stood by the deal, however.

In response to the Sunday Times article, Askew said: "Partnership we enter into — including with the food and drink industry — only happens if we truly believe it will bring about positive change, and we firmly believe our partnership with Britvic will do just that."

He went on to say that every partnership the charity enters into "is subject to rigorous scrutiny" and that Diabetes UK "will continue to campaign with an independent voice and to call for any change that we believe is needed to benefit people with, and at risk of, diabetes."

Asked by Medscape what he thought of the Diabetes UK/Britvic tie-up, Sievenpiper did not respond.

Diabetes UK is not the first organization to come under fire for this kind of partnership.

In 2010, Medscape Medical News reported on the American College of Cardiology (ACC) partnering with the Coca-Cola Company, General Mills, and the Subway fast-food restaurant company, among other companies. At the time, the ACC defended its decision, but many experts were critical.

Kelly Brownell, PhD, who at the time was affiliated with the Rudd Center for Food Policy and Obesity, Yale School of Medicine, New Haven, Connecticut, told heartwire/Medscape Cardiology: "It's common for professional organizations and individual scientists to take money from industry believing that the activity that they're going to engage in is so important that it overrides the branding and marketing opportunity that the companies get from these activities.

"Companies don't invest unwisely, so...ACC should be fully aware that they are helping those companies make money and ultimately sell more product.

"I'm sure good things will be done with the money," Brownell added, "but the question is whether damage is also done."

Review Details: Contribution of Fructose as Consumed in Normal Diet

In their BMJ article, Choo and colleagues explain that ecologic evidence, animal studies, and selected human research have suggested that fructose is particularly harmful to metabolic health, more so than other sugars.

However, this conclusion has not stood up to examination in systematic reviews and meta-analyses, which have showed that either there was no adverse glycemic effects specific to fructose or that there was a beneficial effect on glycated blood proteins when substituted for other carbohydrates in people with diabetes.

The researchers point out that although any causal association between fructose and diabetes and cardiovascular comorbidities remains controversial, "much less appreciated in this debate are the consumption patterns and levels at which fructose is normally consumed in the diet."

To investigate further, they conducted a systematic search of the Medline, Embase, and Cochrane Central Register databases for studies that compared the effect of diets with fructose-containing sugars from various food sources to that of control diets with regard to a range of measures of glycemic control, including HbA1c, fasting glucose levels, and fasting insulin levels.

They assessed the studies with respect to four study designs — substitution studies; addition studies; studies involving the subtraction of sources of fructose sources; and unrestricted replacement, or ad libitum, studies. They included both randomized and nonrandomized studies in their analysis.

Four independent reviewers extracted the data and assessed the degree of bias. The results were then pooled using random effects models. The researchers included 155 study comparisons, which involved a total of 5086 individuals who had diabetes and/or were overweight/obese, or who were healthy. Individual studies included 15 to 39 participants.

Could Fruit and Fruit Juice Be Beneficial in Diabetes?

The results showed that most foods that contain fructose sugars do not have a harmful effect on blood glucose levels when these foods do not provide excess calories. However, in some studies, a harmful effect was seen on fasting insulin levels.

Analysis of specific foods suggested that fruit and fruit juice — when these foods do not provide excess calories — may have beneficial effects on blood glucose and insulin control, especially in people with diabetes, whereas several foods that add excess "nutrient poor" energy to the diet, especially SSBs, seem to have harmful effects.

The low glycemic index of fructose, compared with that of other carbohydrates, as well as the higher fiber content of fruit may have a beneficial effect on blood glucose levels by slowing down the release of sugars, say the researchers.

The team reports, however, that overall, the quality of the evidence was at best moderate. The majority of studies were found to be of low quality, so more work is needed.

They conclude: "More large, high quality studies using a greater variety of food sources of fructose-containing sugars are required to assess the durability of these effects and understand whether certain food sources with an apparent signal for benefit, such as fruit, might even have advantages for glycemic control under free living conditions over the longer term.

"Meanwhile, policy and guidelines makers should consider the influence of energy control and food source in the development recommendations to reduce sugars for the prevention and management of diabetes."

The study was funded by Diabetes Canada. Additional support was provided by the Diet, Digestive tract, and Disease (3D) Center. A full listing of sources of funding of individual authors and individual authors' relevant financial relationships is included in the original article.

BMJ. Published online November 21, 2018. Full text

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