TYPE 2 DIABETES AND CHILDREN
Fred Pescatore, MD, MPH, CCN

Part 4
The Sugar Blues 1

Eight-year old Lucas, was brought to me by his parents because of his uncontrollable rages they always seemed to occur in the late afternoons, often near the end of the school day. In addition to these periods of “acting out,” Lucas also found it hard to concentrate on what the teacher was saying in the afternoons. The situation often became so bad that Lucas had to be sent home early because he had become so disruptive to the other students. Once he got home he would run around for a few minutes and then suddenly, as if he’d completely run out of steam, he’d lie down in front of the television, sometimes even taking a nap.

And it wasn’t only on school days that Lucas exhibited this odd behavior pattern. During the weekend, the whole family would be out doing various activities, but inevitably at a certain point Lucas seemed to hit a wall of some kind and that signaled the end of the day for him. It got to the point where the family had to plan their outings around Lucas’ behavior.

Lucas’ parents were desperate. They had been to several doctors who could find nothing wrong with their son. After a thorough history and physical examination, I gave Lucas a glucose tolerance test, which I’ll explain in a minute.

Lucas’s glucose tolerance test was completely abnormal. His three hour glucose level was 38; it should have been somewhere between 80 and 100. No wonder he was exhausted three hours after lunch.

I asked his mother what Lucas liked to take for lunch. There was nothing out of the ordinary, except, his mother said that Lucas always drank three juice boxes and always took some sort of pre-packed dessert. The amount of sugar in those items alone were more than the glucose I gave Lucas for his glucose tolerance test; so, I could just imagine what his blood sugar levels were doing during the day.

Although Lucas was not overweight, I placed him on Phase 2 of my diet and in one week, he was completely back to normal. He was no longer being asked to leave school and his parents could not have been happier. Even Lucas was able to notice the difference. When he would give in to the temptation to have some form of sugar, those old feelings of helplessness just overcame him and Lucas very rarely deviates from his diet today because it just makes him feel that much better.

Glucose
A glucose tolerance test is a series of blood tests administered after the patient has ingested a certain amount of glucose, or sugar. The amount of sugar is different for each patient because the amount is determined by body weight. The test measures your blood sugar for up to 6 hours (the range being 1 1/2 to 6 hours) after you’ve ingested the sugar.

There is much information a doctor can obtain from this test, and I use it on almost all my patients. What I look for is how the blood glucose level responds to the sugar I’ve just given my patient. I will see one of four glucose tolerance curves, as we call them in medicalese.

The child’s blood sugar can demonstrate a normal response, a borderline hypoglycemic response, the classic hypoglycemic response, or the diabetic response,.

Normal
But before I explain what those different curves mean, let me explain what normal should be. In every one of us, insulin is secreted by the pancreas in response to all foods that are ingested. When your child eats, the digestion of the food will cause his blood sugar to rise. The human body makes every effort to keep this blood sugar at a fairly constant level. After eating a sugar load, you can expect your child’s blood sugar to rise by approximately 40 to 50 points. It will then slowly drop down to slightly below normal, at which point it will quickly bounce back to its normal level. For example, a normal blood sugar response curve reads something like this: Fasting blood glucose level of 85, at one half hour after ingesting sugar, 120, at one hour 130, at 2 hours, 135, at 3 hours 100, at 4 hours 70, and at 5 hours back to normal at 80. These numbers can vary, but we are essentially looking for a response where the highest number is only about 65 points from the lowest number. Insulin levels during these times should stay from 20 to 60 units, where the fasting number is the lowest number, and the highest number is usually at 2 hours. Anything that differs from this is an abnormal glucose response and can lead to trouble at some point in your child’s life.

Simply put, when you eat sugar, your blood sugar rises, and your pancreas secretes insulin in order to counteract this and to bring the sugar back down.

One of the many things the pancreas does is to secrete insulin. Another thing it does is to secrete glucagon which is the opposing hormone of insulin. Glucagon signals for an increase in blood sugar whereas insulin promotes entry of sugar into the cell tissues for storage, or a decrease in blood sugar. In this way, the brain is constantly provided with energy. Insulin accelerates the conversion of glucose into glycogen, a storage form;
it accelerates the conversion of glucose into fat and in turn it stimulates protein synthesis.

Hypoglycemia

When too much insulin is secreted, blood sugar can drop below the fasting levels and a condition known as hypoglycemia will develop. The brain is driven primarily by sugar and the symptoms one can get as a result of this (dizziness, fatigue, lack of concentration, an “out of it” feeling) is the brain’s way of crying out for more nourishment in the way of sugar.

The treatment of hypoglycemia is a dietary one. Some people will need to eat several smaller meals throughout the day. (For this reason, your child should never skip breakfast; in fact, your child should not skip any meal.) Most others will need a special diet. The dietary recommendations are what you might expect: the removal of all refined sugars, processed foods, hydrogenated fats, caffeine, and alcohol. I’ll explain more on the dietary restrictions in a later chapter.

The Sour On Sugar

I believe sugar has caused many of the dietary and health problems we are facing today. It is a well accepted scientific phenomenon that recently developing societies that have adopted the habits of western civilization (i.e. a diet higher in sugar and refined carbohydrates) will show a higher incidence of diabetes and heart disease.

Sugar is nothing more than a simple carbohydrate. There are two types of sugars: monosaccharides such as glucose, dextrose, fructose, and galactose, which is, for instance, found in milk; and disaccharides which are various combinations of two monosaccharides. Sucrose is composed of glucose plus fructose.

Complex carbohydrates are formed when three or more glucose molecules combine into a polysaccharide. Complex carbohydrates take longer to digest than simple carbohydrates. Because of this delay, sugar enters the bloodstream more gradually, thus preventing a major outpouring of insulin from the pancreas – our goal with this diet. Complex carbohydrates have a stabilizing effect on the blood sugar concentration and are also loaded with nutrients.

Three common sugars comprise all edible carbohydrates: glucose, galactose, and fructose. Each of these has a different molecular structure and each will be absorbed at a different rate from the bloodstream.

Glucose is by far the most common of the sugars. It is found in grains, breads, cereals, pastas, starches and vegetables. Fructose is the sugar found in fruit and many products labeled as “no sugar added.” Galactose is found in dairy products. Of the three, only glucose can be released directly into the bloodstream. Galactose and fructose must first be converted to glucose in the liver before they can enter the bloodstream. In the case of fructose, this is a slower process, particularly when you are consuming fructose that is contained in whole fruit. This is why the glycemic index (which I will explain later in this chapter) of certain fruits is on the low side, compared to foods that are primarily composed of glucose, like the pasta we are being told is “healthy.” The extra step for fructose and galactose slows down their digestion.

In most western countries, sugar consumption is well over 100 pounds per year per person, constituting roughly 15 - 20% of the total caloric intake of every man, woman and child. This may not seem like much spread out over the course of an entire year, but to put it in perspective, consider that it is higher than the caloric intake provided by meat, fish, eggs, cheese or bread. The per capita consumption of sugar in this country alone has increased 20% from 1970 - 1993 (149 pounds as compared to 125 pounds.) What makes this particularly worrisome is that the calories derived from sugar are nutritionally barren. In most cases the sugar we ingest will satisfy our hunger, thereby displacing (or leaving no room for) foods with real nutritional value.

Teenage boys ingest even more than 149 pounds of sugar a year . Let’s put this in more understandable terms. That 149 pounds equates to over ten pounds of sugar per month, four and a half cups per week, 33 teaspoons per day. This seems hard to imagine, but realize that much of this sugar consumption comes in disguised forms. For children, sugar often comes in the form of colas or other soft drinks, candy bars, preservative packed snacks, pastas and breads made with refined instead of whole grain flours

When we think of sugar, we naturally think of those foods where the pleasantly familiar sweet taste gives it away: candy, cookies, ice cream. Candy, ice cream, cake, cookies, etc. ("all the good stuff") contain huge amounts of sugar. For example, 4 ounces of hard candy contains the equivalent of 20 teaspoonfuls of sugar; a slice of cherry pie, 10 teaspoons; ½ cup of sherbet, 9 6 oz of ginger ale, 5 and a glazed donut, 6 teaspoons.

Sugar By Any Other Name – Avoiding Hidden Sweets

We would probably agree that all these foods I’ve mentioned seem obvious sources of sugar, but sugar makes a major appearance in foods you wouldn’t suspect. In fact, there are numerous euphemisms for sugar. For instance, sugar is honey, concentrated fruit juice, barley malt maple syrup, rice syrup, cane sugar, fructose, etc. Take a look at food labels and if you see anything that ends in -ose or -ol, it’s sugar, too.

What is even more striking, and perhaps even more troubling is the change in the availability of specific sugars in the past two decades. Sucrose, or cane sugar consumption dropped from 81% to 44% of the total market share; whereas, the consumption of corn sweetener (usually in the form of high fructose corn syrup) increased from 18% to 55% of total market share.

This change has primarily occurred in the soft drink industry, as high fructose corn syrup is what is used to sweeten soft drinks today. Could this be the reason that a recent study showed that children who consumed more soft drinks were more likely to be obese? The US Department of Agriculture data shows that teenage boys drink twice as much soda as milk, and that teenage girls drink one and a half times as much. What is even more frightening is that children under 5 are drinking 23% more soft drinks than in the late 1970s. As parents, we have to be constantly aware of what our children are eating and drinking.

Something as seemingly innocuous as a soft drink has now been clinically associated with an increase in obesity in our children. The sugar in the soft drink is the culprit and, in the case of obesity, it is irrelevant whether that sugar is in the form of sucrose or high fructose corn syrup.

The five top selling sodas are also loaded with caffeine. Caffeine is an addictive substance, no less so than nicotine. In addition, it is a neuro-stimulant, meaning it acts in the body like an amphetamine. It can cause jitteriness, anxiety, weight loss, and insomnia--all of which can lead to poor school performance.

Is this really something you want your child to be drinking every day? You would certainly not think twice before forbidding your child to take any other drug, so why should caffeine be acceptable? The answer is, it shouldn’t be, and I discourage its use in any form for all my patients, not just children. Besides, caffeine can wreak havoc on blood sugar metabolism and with this dietary plan we are trying to correct such imbalances.

Sugar is also contained in canned foods such as tomato sauce, baked beans; boxed foods such as rice pilaf mix, crackers and stuffing; meats such as frankfurters, luncheon meats, fresh pork sausage links, and hams; condiments such as pickles, prepared mustard, tartar sauce and ketchup. Some brands of ketchup contain more sugar than ice cream does.

There are also three hundred standardized types of food which may contain sugar without any declaration on the label. These include salad dressings, canned vegetables, peanut butter, vanilla extract and even iodized salt.

Yet another example of the sugar sleight of hand is the so-called healthier potato chip that is no longer fried but baked, and is low in fat. Take a close look at the nutrition label and you’ll see that the second ingredient is corn syrup, and then you’ll find dextrose further down the list. Yes, we’ve eliminated the fat, but we’ve added sugar to get it to taste good. If you examine the label closely, you’ll see that there is now a not insignificant amount of sugar in a product, the potato, that has no naturally occurring simple sugar. Why put sugar into something that doesn’t already have it?

Truth Or Fiction In Food Labels

Manufacturers have found it to be cheaper to replace natural cane sugar with high fructose corn syrup. This is a by-product of the corn farming industry and a way to make more profit out of the existing crop. So what? Sugar is sugar, right? Well, for the most part that is true. However, what has happened is that a natural product like cane sugar has been replaced with a processed product like high fructose corn syrup. In my clinical practice, I have found corn to be a product that many of my patients, both young and old, have a sensitivity to. In later chapters, I will explain how I determine such a sensitivity. I feel this may be one of the many causes of the significant increase in the number of children suffering from asthma, allergies, attention deficit hyperactivity disorder, and other behavioral disturbances. There has to be a cause for these disorders and I feel it is necessary to look not only at what our children are eating, but how it got to the table.

How Can Fruit Be Bad For My Child?

You mustn’t be fooled into thinking your child doesn’t eat any sugar because they eat fruit. This is an important point because so many of my patients are under the impression that if they or their children eat fruit, they are eating a healthy alternative to sugar, and doing the right thing. Certainly, there are certain fruits that are better for you than others but apples and orange juice have more sugar in them than bread, some cookies and some candy bars.

Some may argue that there is a certain health advantages from fruit, and I agree that there is a definite benefit to the bioflavonoids -- the biologically active compounds that give the fruit its color -- found in the fruit. They are very healthy and very health promoting. In fact, there is much research presently being conducted that is looking into the health benefits of these bioflavonoids. However, the sugar that is found in the fruit is the same, biochemically, as the high fructose corn syrup and the cane sugar known as sucrose. When your body is trying to metabolize the sugar, it does not matter whether it came from a fruit, or fruit juice, or from ice cream.

Some fruits are indeed are better than others. Any of the berries or melons followed by plums are fruit that have a lower glycemic index. The sugar is released from these fruits more slowly because of the fiber.

Consider this about fruit juice. A 12 ounce glass of orange juice is derived from 6 large oranges. By drinking fruit juice, your child is getting more sugar -- it is unlikely any child would sit down and eat six oranges. Also, by drinking fruit juice, your child does not get the benefits of the natural fiber. Instead, your child gets all the bad qualities of the fruit, the sugar, without the benefits, the fiber, from the fruit. Also, if you’re thinking these glasses of juice, or juice packs, count for the five-a-day recommendations, think again. The nutritional value of a fruit comes from the fiber and pulp, not the juice. This same scenario applies to all fruits.

Glycemic Index Vs. Glycemic Load

A glycemic index quantitatively assesses foods based on the glucose response and insulin demand that is produced for a given amount of carbohydrate, assigning each food a number. The glycemic load indicates the glucose response or insulin demand that is induced by the total carbohydrate intake. This is per meal. In phase 2 and phase 3 of the Next Generation Diet, the foods your child should be eating should be the lower numbers on this list. In phase 1, it is unlikely your child will be eating much from this list.

The glycemic effect a food has is the effect on blood glucose and insulin response that the particular food elicits-- in other words, how quickly the blood sugar rises, and how quickly it returns to normal. Based on this premise, a glycemic index was invented by DJ Jenkins, et al, based on the digestibility of the starch. The higher the glycemic index, the more rapid the rise in the blood sugar level. This is important because the more rapid the rise in the blood sugar level, the more rapid the release of insulin.

A carbohydrate is considered “good” if it has a low glycemic index. The index basically rates foods in relation to glucose, or white bread, with glucose being 100 on a scale of 1-100 (+). For instance, eating white rice with a glycemic index of 103 turns into glucose and initiates an insulin response much quicker than lentils with a glycemic index of 29. White rice is refined, whereas lentils are a whole, nutritious food. Eating low glycemic indexed foods is a great way of controlling blood sugar.

The Insulin Factor

The speed at which carbohydrates enter the bloodstream through their digestion, controls the body’s insulin production. The fiber your child eats is not absorbed and has no direct effect on insulin secretion. It will, however, act as a stabilizing factor by slowing the rate of entry of other carbohydrates into the bloodstream. The two have an indirect relationship, so the higher the amount of fiber, the slower the rate of entry. By ingesting foods with a low glycemic index, the rate of glucose and the amount of insulin is tightly regulated and therefore your child’s brain will be fed a constant supply of glucose. This allows your child’s body to develop a sense of fullness and well-being, thereby eliminating food cravings.

When there is too much sugar in the bloodstream, consequently there is also too much insulin. This acts to bring the blood sugar down, but it is also a signal to the body to store fat, since insulin causes excess glucose to be converted to fat. The body has no use for any excess fat in terms of energy consumption, if it has enough simpler forms of energy, like glucose.

Table
Some Common Foods and Their Glycemic Index*
Pretzels 118
Puffed rice cakes 105
Mashed Potatoes 104
White Rice 103
White bread 100
French fries 95
Brown rice 94
Macaroni and cheese 92
Carrots 92
Strawberry jam 90
Parsnips 90
Corn 88
Cola 87
Pie 84
Potato Chips 75
Dry breakfast cereals (puffed rice, puffed wheat, corn flakes are the highest and all-bran cereal is at the low end of this range) 72-127
Pasta 71
Millet 71
White Potato 70
Apples 65
Orange juice 65
Dark bread 58-70
Cookies 54-98
Candy bar 51-74
Milk 49
Hot Chocolate 49
Sweet Potato 48
Broccoli 45
Peanut Butter 40
Whole Wheat spaghetti 40
Black-eyed Peas 33
Yogurt (plain, unsweetened) 35
Lentils 29
Sausages 28
Soybeans 15
Peanuts 13

Note:
? Fruits that score greater than 80 are mangoes, papayas, bananas and apricots.
? Fruits with the lowest score are cherries, plums, grapefruit, melons and berries.
? Oranges have a score higher than apples, pears, grapes, and peaches.
? Vegetables with a score greater than 80 are corn, carrots and parsnips

Some things may surprise you by being lower on this list than you might have expected. Keep in mind that several factors other than the amount of glucose in a particular product will affect a food’s rating.

These factors include fiber, as I’ve previously mentioned, and fat content. The higher the amount of fat, the slower something is metabolized. That’s why your child may be more satisfied eating a cheese omelet for breakfast, than cereal. The omelet will metabolize much more slowly than the cereal. By doing this, the amount of glucose and the amount of insulin in your child’s blood will be released much slower after eating the omelet. This leads to a longer feeling of satiety, a more stable blood sugar, and a healthier and happier child.

Next: The Sugar Blues 2: What those food producers don’t want you to know:

Fred Pescatore, MD, is a traditionally trained physician who practices nutritional medicine. He is the author of the top-selling book, Thin For Good, and the number 1 best-selling children’s health book, Feed Your Kids Well. He has 2 extremely busy and popular practices in New York City and Dallas, Texas and is the President of the AHCC Research Association and President-elect of the International and American Association of Clinical Nutritionists.

Part 1
Part 2

To read Dr. Pescatore’s credentials click here
http://www.diabetesincontrol.com/Pescatore/about.shtml

To read other articles by Dr. Pescatore please visit http://www.diabetesincontrol.com/Pescatore/index.shtml

To read Dr. Pescatore’s credentials click here
http://www.diabetesincontrol.com/Pescatore/about.shtml

To read other articles by Dr. Pescatore please visit http://www.diabetesincontrol.com/Pescatore/index.shtml

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