We love it. As a people Americans eat 66 pounds of added sugar a year per person. Each one of us eat that much added sugar. Yes, that much table sugar, sucrose, the bad stuff.
It may be bad but I love it, passionately, and with the fondness only time can add to a relationship. Frankly, only the writing of this site put me on to the dangers of excess added sugar. A physician all of my adult years yet blithe enough about added sugar I knew its main drawback as mere obesity. Now I know better and plan to leave it be and live my life without its company.
The pretty graph at the right comes from the US government’s five year report on the diet of the American people. Men and women eat far more sugar than ideal, especially during childhood and early midlife. Although you might think otherwise, women are no better or worse than men in this one special behavior.
Still life with sweetmeats by Georg Flegel, German, Olomouc (Olmütz) 1566–1638 hangs in the Städelsches Kunstinstitut und Städtische Galerie. The image is available for public educational use. Need I say why it fits this article?
What is Added Sugar?
Added has a special meaning. It means not natural to the food. Manufacturers have to add it into the food. You will know they did it when you see sugar on the ingredient list. They name sugar so many ways you may miss it altogether.
Let’s start with the proper common names. Glucose and dextrose are two names for one sugar. It is the main sugar in our blood and the main sugar in starch. Fructose comes in fruits and is altogether different in chemistry and in the way our bodies metabolize it. Sugar, what we buy in sacks, is the two molecules, glucose and fructose, linked together to make one bigger molecule containing both. So when you eat table sugar you are eating glucose and fructose. The proper name for table sugar is sucrose.
Invert sugar is simply sucrose broken into its two components – glucose and fructose. It tastes sweeter and does not crystallize as much as sucrose so bakers may prefer to use it. Same calories, same molecules.
Here, I use the common name ‘sugar’ to cover all of the sweet things, and the special names – glucose vs. fructose – only when we need them.
Why Do Stone Formers Care?
When you eat sugar, your urine calcium will rise. And, as an added insult, your urine volume will go down.
Urine Calcium Goes Up
Normal People
This figure is from 1969, New England Journal of Medicine. The scientist, Jack Lemann, gave normal people 100 gm of glucose or sucrose in water where the arrow points. Before the sugar, the four 20 minute ‘control’ measurements, urine calcium loss – vertical axis was stable. After the sugar, urine calcium was up a bit even at the first experimental period – 20 minutes after the sugar, and kept going up to peak at about 60 – 120 minutes. That peak waned appreciably by 120 minutes.
CaOx Stone Formers
Even during the control periods their urine calcium was higher than the normals. We know why. Because they had idiopathic hypercalciuria, the genetic problem that is so common in calcium stone forming people.
After the sugar load their urine calcium rose far above the normals and stayed up about as long – two hours. It is not so much that they raised their urine calcium by a greater increment as that they started higher so their peak was a lot higher than normal.
Relatives of Calcium Stone Formers
Their control urine calcium losses were perhaps even higher than the patients who formed stones. We now know that idiopathic hypercalciuria is hereditary, and presume these relatives carried the trait but had thus far escaped the stones. The sugar load raised their urine calcium just as for the other two groups.
Urine Volume Goes Down
All of the subjects drank a lot of water during this study so urine could be reliably obtained at 20 minute intervals. The patients and relatives had flows of about 15 ml/minute, the normals about 12 ml/min. With the sugar loads, urine volume fell by 4 ml/minute in the patients and relatives but only by 1 ml/minute in the normals. As a result, urine volumes fell as urine calcium rose – a perfect storm for stone formation. This would be a recipe for high urine calcium concentration.
Urine Calcium Concentration Goes Way Up
Just as predicted, urine calcium concentrations rose remarkably in the patients and relatives. And fast, too. In even 20 minutes urine calcium concentration peaked in some of them. By contrast, the normals showed almost no rise in calcium concentration.
This site teems with articles about supersaturation as the final pathway connecting excretion rates to crystal formation. Here is the perfect reagent, the ideal foodstuff for raising calcium supersaturations. What better than to raise urine calcium and at the same time lower urine volume?
The Calcium Comes From Bone
The glucose or sucrose drinks had no calcium in them. None. So the extra calcium losses into the urine could not come from food. The only storage cabinet for calcium in our bodies is our bones. So sugar loads can deplete bones of their mineral. Perhaps it would take a long time to matter. But our lives have a lot of sugar in them.
Worse, stone formers have a higher than average risk of bone disease with fractures. At least part of that increased risk arises from idiopathic hypercalciuria. The urine calcium loss in IH arises from reduced renal calcium conservation. In these two graphs, the sugar effect was as large in those with IH as in normals. But because the effect began from a higher baseline of calcium loss, the total loss from sugar was larger.
The Sugar Acts On the Kidneys
If from this you expect that the sugar loads reduce kidney calcium conservation, your expectation is correct. The authors measured glomerular filtration rates during all of the periods shown on the figures. Sugar did not change it. The filterable blood calcium – for those of you into this kind of thing – actually fell slightly with sugar (-0.04 mmol/l) in each group, so the increase of urine calcium had to come from a reduction of kidney cell calcium reabsorption. In other experiments, Lemann lowered calcium filtration and proved that the increased urine calcium arose from reduced tubule reabsorption. This mechanism is exactly parallel to that of idiopathic hypercalciuria, as we have shown in our own work here. But we do not know exactly where along the nephron sugar acts, nor precisely where the defects are in IH itself.
Why Everyone Should Care
Masses of experimental data going back into the 1950’s indicate that fructose – one half of the sucrose molecule and therefore of table sugar – causes diabetes and lipid disorders. It does this not simply because of obesity, but because fructose metabolism differs from that of glucose. But most of the evidence comes from animal experiments that might not fully mimic human behavior.
Perhaps for this reason, Kimber Stanhope and her colleagues performed what seems to me a well designed human experiment asking if fructose consumption can indeed cause these undesired consequences. Her paper reviews the main prior evidence, so I present here mainly her results. I believe the article is free access.
Let me say here, she had powerful and supportive colleagues essential to the final research. Alone, she nor anyone else could possibly accomplish what this paper reports. But she was given the pride of first authorship by those she worked with, and so, for brevity, I refer to what she did, and what she found. Though all the while it was they, even so, without her would they have come together to construct this mighty work?
Who She Studied
Men and women of average age 50 – 55, and BMI ranging from 28 to 30. Essentially chubby and middle age. They were well as far as they knew and had normal blood glucose and insulin levels.
What She Did
During a two week inpatient (meaning the subjects had to live at the research center and consume identical, specifically formulated meals) baseline period she performed a set of complex measurements that included measuring insulin responsiveness, visceral and subcutaneous fat, and hepatic lipid production. This was followed by a 10-week intervention, during which subjects received 25% of their energy requirement as beverages sweetened with either glucose or fructose.
During the first 8 weeks of intervention, subjects lived at home and consumed the beverages along with their usual diets. During the last 2 weeks, they again lived at the research center and consumed the beverages with specifically formulated meals that were as identical as possible to the baseline meals, except that bread, pasta, and rice calories were replaced with the glucose or fructose calories provided by the beverages.
In other words, as best she could, during the first 2 weeks and final 2 weeks of the study, she kept their diets similar with the exception of the kind of sugar – glucose vs. fructose. Precautions were taken so no one knew which. During this final 2 weeks of the study, she repeated all of her measurements so she could compare how each person changed in response to the glucose or fructose consumption.
What She Found
Fructose Increased Visceral Fat
During the eight weeks of the study when the subjects lived at home and consumed the glucose- or fructose-sweetened beverages with their usual diets, the groups gained comparable amount of body weight (about 1.4 kg) body fat (measured by DEXA).
However, with the help of John McGahan, one of the leading radiologist researchers in the country, she specifically investigated fat gain in the abdominal area using the belly button as a landmark. Eight weeks of fructose but not glucose raised total abdominal fat content significantly (VAT). Although the increase of total fat from glucose was not significant, the increase of subcutaneous fat (SAT) was.
By now everyone who reads health magazines or newspapers knows that it is visceral fat that can cause insulin resistance and blood lipid disorders. Subcutaneous fat concerns us for mainly cosmetic reasons. That is not to say visceral fat has no cosmetic effects. It enlarges bellies and waistlines.
Fructose Increased Blood Triglycerides
What are Triglycerides?
Decades of health advice have trained us to watch blood cholesterol but recent evidence implicates triglycerides as perhaps as dangerous or worse for blood vessels. Even more, high triglycerides appear related to all cause mortality including cancer. The main evidence comes from recent meta analyses such as this one, and all such are suspect as being mere observations. These suspicions may be confirmed or allayed by a current trial that tests effects of icosapent ethyl a drug that selectively lowers triglyceride levels, asking if it reduces mortality. In the meantime, suspicion is enough one might want to avoid foods that increase triglycerides.
What Fructose Did to Blood Triglycerides
Unfortunately that is precisely what fructose does. It raises blood triglycerides.
On the left of this large figure, those treated with glucose showed no change in their blood triglyceride levels. Each curve traces out multiple blood measurements
of triglycerides throughout 24 hour days at time 0 and after 2, 8, and 10 weeks of glucose thereafter. The message is easy. All four curves melt together. You cannot tell them apart. This means that glucose had no effect.
But fructose raised triglycerides, a lot. At baseline, the black 0 week curve in the right panel, those who would get glucose and those who would get fructose had similar curves. After weeks of eating fructose, triglyceride levels rose much more with meals and the total triglyceride exposure to blood vessels, the region under the curves, rose a lot.
Why Does This Matter?
Does this mean that fructose causes early mortality from vascular disease? Perhaps. Trials of selective lowering of triglycerides will help decide. But other kinds of data have linked added sugar to disease for decades, and triglycerides may well be only one part of the harm sugar can do. I am not an expert on lipids or on mortality from added sugar. My core skills concern kidney stones and associated bone diseases. But other writers have expertise about the broader damage from sugar. A recent book by one such presents a lot of the main information. ‘The Case Against Sugar’ by Gary Taubes seems the best source, to me and this NYT reviewer.
Elsewhere on this site I have written about earlier public statements about sugar and health, and about the scandals concerning the sugar industry’s efforts to suborn scientists into outright dishonesty.
Fructose Increased Hepatic Lipid Production.
Where do the extra triglycerides come from?
The liver, of course, so you might think the graph above sufficient.
To think so ignores the character and behavior of experimental scientists. Yes, it must be the liver, but we need to prove that. Why? Because it might be otherwise and knowledge fail of its purpose to disclose the workings of nature. So, with considerably more effort than it took to measure the triglycerides in blood, she found and executed ways to measure hepatic lipid production.
This graph shows change from baseline (week 0) to after weeks of fructose or glucose. The units for the change in hepatic liver production are percent of the baseline.The change in percent from baseline is plotted vs. time of day. The points are the averages of all of the people who ate the extra glucose or fructose. ‘DNL’ refers to de novo lipid production. This means producing lipids not from other lipids but from their constituent precursor molecules.
One need not be scientifically trained or even that observant to understand the results this rather bold and spare graph presents. The fructose averages tower over glucose. Whereas glucose raised lipid production by about 2 percent, sugar raised it by 8 percent. Keep in mind that both groups gained the same amount of weight, and both groups had eaten the same modest excess of calories from carbohydrate. Moreover, both groups had consumed identical diets for 7 days prior to both the baseline and intervention measurements.The only difference is in the fructose.
Fructose Caused Insulin Resistance
Resistance to the action of insulin powers adult onset diabetes. But insulin resistance itself may well arise from the effects of the visceral fat cells whose numbers fructose increases. The linked review is not the most recent I can find but among the most frequently cited and by outstanding scientists writing in a premier journal. Given the increased visceral fat stores and abnormal lipid metabolism from fructose one might well expect insulin resistance.
What is Insulin Resistance?
But what exactly is insulin resistance and how will we know it?
It is precisely what its name says. A sugar or food load will evoke insulin release from the pancreatic beta cells. That insulin normally causes prompt disposal of serum glucose into cells – mainly muscle. If cells resist the action of insulin, blood glucose will remain elevated over an abnormal time. LIkewise the beta cells will produce more insulin because they sense the high glucose. So you will know insulin resistance from a prolonged disposal of a glucose load despite a higher than normal amount of insulin in the blood.
Blood Glucose After a Glucose Load
Weeks of extra glucose enough to raise body weight also raised blood glucose after an oral glucose load. Take a look at the upper left panel. The baseline, or week 0 curve lies lower than that from 9 weeks. None of the individual means differed from each other, and the total area under the 9 week curve did not surpass the 0 week curve. But even so, glucose weight gain did something. Maybe gaining weight itself has some drawbacks.
Fructose feeding did a lot more. The 9 week curve rises a lot higher above the 0 week curve; take a look at the upper right panel. The stars mean the points differ more than by chance – so called statistical significance.
Now, compare the 0 week curves from the glucose and fructose groups. They would overlap if you could place one on top of the other. If anything, the week 0 curve of those who eventually got fructose seems a bit lower.
Blood Insulin After a Glucose Load
Here, fructose differs even more dramatically from glucose. The people who ate the extra calories as glucose showed no change at all in blood insulin after a glucose load. The left lower panel shows how the week 0 and week 9 curves overlap completely.
But those who ate their extra calories as fructose had a remarkable increase in insulin output. If you combine their higher blood glucose and blood insulin levels you have the very make and mark of insulin resistance: Glucose stays too high and all the while the beta cells provide more insulin than normal. Why did the extra high insulin not lower the blood glucose? Insulin resistance.
Should One Research Paper Matter That Much?
It would not except that decades of research have all pointed in this same direction but using mainly animal models or studies of people who had already developed insulin resistance. By contrast, this was a trial, a trial of fructose as against glucose. And the result disfavors fructose as a chemical that can and does produce lipid abnormalities and insulin resistance – in humans otherwise normal.
It is as if a long suspected toxin were tried directly in humans to see if what we thought it could do by way of harm might be caused by the giving of it. Were fructose some unnatural chemical, who would permit such a trial unless that chemical had some special value that made toxic effects acceptable – think about chemotherapy drugs. But fructose is a food, a nutrient we all eat. So its toxicity could be tried as if it were a drug.
The answer: It causes lipid disorders and insulin resistance. We should eat as little as possible.
Did I Review Her Work Correctly?
You could say with some justice that I am not an expert on sugar or lipids and perhaps swimming in deep and unaccustomed waters here. You would be right to say so. Being prudent I asked the author for the courtesy of her review, which she gracefully provided. The text contains her edits, and I have her permission to say that with those edits in place I have presented her work properly.
How Much Added Sugar Can I Eat?
The Center for Disease Control echoing the 2015 – 2020 US recommendations has clarified that the goal is less than 10% of calories as added sugar. So, if you eat 2000 calories this would be 200 calories. Sugar has 4 calories per gram which makes 50 gm of added sugar a day. This example fits for a good sized adult man in midlife. A woman would usually eat less – 1200 calories, making added sugar 120 calories or 30 gm/day. By law labels presently show sugar in grams but will soon change to percentage of total calories.
So, all my loves have to go. Way too much sugar.
It is Time to Say Goodbye
Ice Cream
Ben and Jerry’s ice cream contains 26 gm in 1/2 cup, and I have never eaten less than 1.5 – 2 cups for dessert. You know sugar has been added by looking at the ingredient list. For example, sugar is the third item, meaning more important, and also the fifth and later as cane sugar. So of the 20 gm much is added.
I picked this ice cream not because it is worse than others but because I love it, and eat it. However, as in the title, I am breaking up with Ben and Jerry’s, filled with regrets and loving memories.
Honey
In general honey contains about 25 gm of glucose/100 gm of honey and between 40 and 50 gm of fructose. So it offers no advantage over table sugar; in fact it has more fructose and is therefore a poorer choice. Too bad.
Maple Syrup
A typical pure Maple syrup contains about 67% by weight of sucrose – table sugar. It is not added. It is made by the maple trees. But as we removed almost all of the water to make the delicious concentrate we put on pancakes, and waffles, and who knows what else, we essentially made liquid sucrose. The maple flavoring is sheer delight, but another love must end.
This one is serious. Pancakes and waffles are nothing more than sponges to soak in maple syrup. The syrup tastes best when warmed. And poured over buttered cakes, they absorb the syrup that blends with the butter into paradise. To give this up seems almost beyond the possible.
Cookies, and Cakes, and Pies, and Candy
All those cookies, filled with chocolate bits – dark and white chocolate, walnuts, butter. And cakes – my favorites; chocolate cake, yellow cake with chocolate icing. Pie, even, though it is a trailing third.
Did I say candy yet? A universe here, the very essence of luxury and happiness. Did you know I can read the little squiggles on the tops of chocolates that say what is inside? And the shapes, they also let you know what you will bite into.
What About Fruit?
All that saves me is volume. Fruit has fructose, of course. Look at the name. But dilute. You need a lot of apples or pears to make up what you get from all the wonderful stuff I just wrote about. But there is a way. You can throw 8 apples and 4 pears into a blender and make a smoothie. Throw away the pulp and drink the pure stuff. That can do it, if you get the pure juice away from all that fiber. No. Not for me.
What Will I Do When I’m Alone?
There is always fruit. Up here in Michigan the blueberries and peaches have divine qualities. But only in Summer. Fruit otherwise seems plain and foreign to one who has known the love of sugar. I could poach an apple, or a pear. Some have cheese for dessert, or nuts. Some have nothing – so spare, so austere.
And smoothies – I just said no. I mean no.
Have just a little – did someone suggest that to me? A nibble of candy? A cookie with walnuts and white chocolate bits?
That nibble would tempt me back to where I am, a hopeless addict.
No.
So, it is goodbye.
What Will You Do?
Will you say goodbye? Join me in misery for sake of better health? Let me know.
Thank you for this article. Quitting sugar is one of the last diet changes I’m struggling to make to reduce my risk of stones. I’m a bit confused by the fructose versus glucose differences. Is fructose from fruit? If so why did it affect the group in the study worse than glucose? Is fruit bad?
Hi Stephanie, Table sugar – sucrose – is a molecule made of glucose and fructose linked together. The Glucose part just causes subcutaneous fat and weight gain – not ideal – and will raise urine calcium, leach out bone mineral, and lower urine volume. The fructose part causes insulin resistance, fatty liver, and high serum triglycerides – very dangerous. Fruit has fructose but how much can you eat? To get what is in 60 pounds a year of table sugar would be so much fruit you would never be able to cart it home, let alone eat it. So plain fruit in normal portions is safe because so dilute of fructose. Best, Fred Coe
Another sugar related question:
Understand added fructose problem, but I am still a little hazy about counting all the other, non-added sugars.
For example plain yogurt, which I consume with at least 2 out of 3 meals, can have 10 g of non-added sugar per serving, at least according to the labels. (It can’t all be lactose, since I am lactose-intolerant)
Together with a couple of fruits per day, as fruit, not smoothy and I am easily well past 1/2 the (male) limit of 50 g sugar per day, without counting in contribution from any carbohydrates.
Hi Jim, The 50 gm is added sugar. Fruit is not added, and the yogurt has no added sugar unless it is indeed added. The reason this matters: sugar in fruit is in the cells of the fruit and absorption is often delayed so metabolism is not the same as for added sugar. The non added sugars in milk include lactose and glucose + amino sugars. Lactose – glucose + galactose – has no fructose. You may be intolerant yet tolerate the amounts of lactose in yogurt depending on the fat content and sugar concentration. It has no fructose unless added. No sugar does what fructose does. By my reckoning you are nowhere near getting 50 gm/day of added sugar. Regards, Fred Coe
I absolutely know that I cannot have ‘a little’ sugar. I use hypnosis to stop the cravings. It is an immediate cessation of urge for me. I was sugar free for about 2 years and ‘fell off the wagon’ with stress and began to consume vast quantities of white chocolate, cookies, pie, rice krispie treats specifically. I am pre-diabetic and taking Metformin and know better! But it didn’t matter, sugar made me feel better. My A1C is usually between 5.9-6.1. Then I had my bout with uric kidney stones- 4.5 mm Uric stone passed with lots of gravel and a few small oxalate stones on analysis. There are still stones (one estimated at 8mm) in my left kidney waiting. As a teacher, I was always chronically dehydrated. My 2 24 hour bloodwork results were horrible and my triglyceride levels were 250, when historically I was never over 100. Urine PH low at 5. I know that adding sugar back into my diet was a major factor in the stone formation, especially after reading this article. II am so appreciative of your work and all the great articles to read.
Hi Cathy, You are right. The low pH caused the uric acid, and be sure to have this treated to a goal of pH 6. You are insulin resistant and sugar does exactly that. So you are smart to understand this and stop it cold. Bests, Fred
Hi Dr. Coe – this is a very interesting article. When you talk about fructose – do you mean high fructose corn syrup? Or is that in a different category altogether?
Also – I understand the complete avoidance because it is a slippery slope that is not easily managed. I have tried over the years to adhere to author Michael Pollan’s “food rules,” one of which is that you can have whatever sweets you might want as long as you make them yourself. This seems to point toward all the other junk that goes in to processed foods rather than simple table sugar used in baking. What are your thoughts on this?
Hi Adrienne, of all things high fructose corn syrup must be most menacing. Pollan is smart with his rule, and processed foods are indeed a worry. But table sugar used in baking is the problem because it is half fructose. SO I mean sugar is sugar and you need to limit it. Baked goods are a big problem. Sorry. Best, Fred Coe
Dr. Coe,
Thank you for this wonderful article. I understand completely how difficult the it is to break up with sugar. I have a lifetime struggle with this going back to childhood, but you have inspired me to forgo the nibbling and make the breakup complete! This maybe the most difficult goodbye ever, but after reading the effects on bones and stones I feel I have no choice. Small amounts do not work for me. It’s almost like an addiction. Thanks for your research and time. Day one of the breakup begins now!
Hi Carla, Like me! I just have to stop altogether or it will all be back. I used to think that if sugar was a controlled substance I would be in a jail cell. Pure addiction. Best, Fred
Dr. Coe
I am somewhat confused by your final paragraphs. Are you also saying goodby to fruit? Or only table sugar, honey, maple syrup and every form of candy, etc.?
Thanks
Jay
Hi Jay, Yes. I need to make that clearer. Honey is filled with fructose. Maple syrup is 67% sucrose – table sugar. Candy is sugar with addictive properties. Yes. It all has lots of sugar and yes – goodbye. Fred
Great article! Thanks for all this information, and it is inspiring to give up sugar. Since I do not buy ready made items at the grocery store, I raise my own food, meat, eggs, etc., I am not tempted by all the processed food items at the grocery store. My only sugar addiction is for the hummingbird mixture that I make to feed to them.
Hi susank, I guess you are not a hummingbird so you do not drink the stuff. Food for you. I admire your style. Best, Fred
I cave in occasionally, but added sugar is rare and I keep my fruit consumption down as well, but a craving for it does well up occasionally.
I realize you had your reasons–after all your emphasis is on kidney health, but sugar feeds other health problems as well, particularly cancer and candida growth, in addition to those negatives you mentioned above.
An occasional small to moderate treat by someone who is otherwise eating a healthy diet and has no health issues affected by sugar can indulge occasionally without permanent or chronic ill effect–emphasis is on occasional and limited quantity.
Appreciate all you’ve done to help teach us what we need to know to be proactive in responsibly addressing our kidney stone issue.
Hi Christine, I agree with you. For example triglyceride excess associates with increased all cause mortality – including cancer. Not just vascular disease. I also agree that an occasional dessert is rarely lethal. Keeping it occasional and limited – there is an issue. You can, not everyone. Best, Fred
Dr Coe.
Wonderful article again. I have read your articles going back over 30 years but this web site puts things in a new light. I work as a urologist in an area with a higher percentage of Puerto Rican population in New England. They have a stone incidence 2x the national average. They also have a high degree of insulin resistance. Your discussion here would suggest the two are linked. Do we have enough to say the increased incidence of stones is a result of metabolic insulin resistance? If that is the case my prostate cancer patients on hormonal blockade will have more stones. Can we disentangle the role of an acid diet load from sugar induced insulin resistance? What role do you think sugar plays in forming calcium phosphate stones with high urinary pH?
Thanks in advance
Hi Alex, First, thanks for so thoughtful a comment. It certainly shows how much clinical experience can sharpen intellectual quality. I would be surprised if insulin resistance failed to raise stone rates. Uric acid is the easy one, urine calcium can rise, too. Take a look back if you can at 24 hour urine studies from your cases. I do not know enough about prostate cancer blockade to make an intelligent remark. Do you indeed find more stones? I know bone loss occurs so urine calcium must rise. This latter would foster CaP stones. I know of no data on the subject, but perhaps should look. Once again, much thanks for all this. Warmest regards, Fred
Thank you for the interesting research. Do you have any recommendations for sports drinks? I (and several friends who are stone formers) play tennis frequently, and wonder if certain drinks should be favored or avoided? Also, for after tennis, any particular spirits that should be favored/avoided?
Hi Linda, I do have my ideas: shun glucose, sugar, sodium in the drinks. Potassium is great. For high level athletes sodium added is per the advice of sports medicine physicians or coaches. I say this because sodium addition needs to be scaled to predicted sodium losses and they have facility in such calculations. For common athletes better to avoid sodium added. Best, Fred Coe
Wine? Seriously, there is a quality of life issue at stake here! : )
Hi Nancy, Wine is fine. As for quality of life, I dream of ice cream, sometimes, but it was an abusive relationship and I am not going back. Fred
Hi Dr. Coe,
So what is worse, is it salt or sugar for a CaOX stone former? I ask this because most times when you buy some low salt food item in the grocery store, it is spiked up in sugar and vice versa. I am not sure how exactly to compare the effect of both since the daily recommended amounts are different for sugar and salt, but maybe if we have a graph showing for each percent increase of sugar and salt over the daily recommended amounts (X axis) vs urine calcium (Y axis), that might show the trend as to which one is worse and at what level of consumption? I wouldn’t think all data points are available, but maybe some are available?
Thanks
Josh
Hi Josh, You have summarized the worst of the modern world. Both do the same differently and need to go. My approach is food, not in something but just as is. If you opened it it is full of salt or sugar or both. So stop opening things. Because they cause harm in different ways, your graph will not capture the real problems, but my priority is salt goes first – to below 1500 mg as an ideal, and sugar goes later on. Sugar seems the more serious general health risk. Regards, Fred Coe
I am a sugar addict. All the food you talked about has to go…but what can you eat that doesnt have sugar? Seems everything has sugar in it, Any help here?
Hi Linda, I realize I never answered you. All we have left for desert is fruit, that is my miserable lot and your’s, too. Cookies, cakes, icecream, all are just filled with bad stuff. But after many months I have stopped caring. I no longer stare into bakery windows and I can pass by a platter of cookies without filching even one – usually, although a month ago I did that! Everything good has sugar in it, and sugar does everything bad. Sorrow, but better for your health to say goodbye. Fred
What about erythritol? Is a teaspoon in a large glass of water with apple cider vinegar helpful or harmful to hypercalciuric stone formers?
Thanks,
Julie
Hi Julie, Erythritol is absorbed and excreted in the urine. This little blurb from Wikipedia gives the simple outline. It is of no help or harm. Regards, Fred Coe
Dr. Coe: I have found all the “tols” (erythritol, sorbitol, etc.–all the sugar alcohols) to be extremely gas-forming, to the point of violent discomfort, and I completely avoid them all. My wife has a similar reaction. I once bought her some sugar-free ice cream with “tols” and her reaction was such that she contemplated going to the emergency room. She, too, now completely avoids them.
Hi David, Thanks for sharing. Some are very sensitive to them indeed. Fred
What a delightfully painful and very informative article on sugar!
Thank you Fredric Coe, MD. You have laid out the pure and simple truth about sugar and what we all need to do IF we truly value our health. Education is key because so many people just do not know (or want to REALLY know) how very hazardous the consumption of added-sugar is to their health and the health of their loved ones. With the CDC reporting that a third of the population will have diabetes by or before 2030, I wish more people would take this seriously now while we can do so much to save our health–OUR LIVES…
But…as a lover of treats myself, I know it is not easy to break the sugar habit/ addiction. It’s worth at least trying though. Thank you for your wonderful work. I have shared it with my Sugarless June Group on FB where we encourage one another to learn more about sugar and avoid or decrease sugar consumption for the month of June…and hopefully throughout the year. 😀
Hi Sugerless, thanks for the charming addition. Fred
Dear Dr. Coe,
Will you marry me? I don’t think my husband of 30 years will appreciate that I just proposed to you, but I can’t get enough of your erudite, humorous, personal, and realistic guidance for me, a “kidney stoner”! I am on round two, after four years with no uric acid stones. I just had surgery #6 this morning (ureteroscopy). I am convinced, now, that the preventative stone regimen is important . (I just want to add that most of those surgeries happened relatively soon after I had chemotherapy – I’m not a complete glutton for punishment!). Although I think I have the world’s best urologist (Vernon Pais, Jr. at Dartmouth Hitchcock Medical Center), I have never read another doctor’s work which spoke to me so much and which was as life-inspiring as yours! A cornucopia of thanks from a fan,
Tacy Colaiacomo
Hi Tacy, I don’t think he or my wife of 50 years will be happy about all this, but thanks. As for uric acid stones, I hope you do not mean they recurred, as they never need to if you keep urine pH above 6 with potassium citrate. Perhaps you just tired of the pills, but try not to do that. The sugar is a general poison, so it you stopped it, good for you. Warm regards, Fred
Firstly, thank you so much for sharing such a huge amount of knowledge and research. I could write a lot more to express my gratitude for this education on prevention, after 30 years of my having been in the dark, but I do have a question or two too: Is there a threshold where a single meal/snack will trigger the spike in urinary calcium described? I’m curious about the implications for meal frequency i.e. grazing vs 3 meals a day. I’m wondering whether the spike is inevitable at meal times when blood sugars are raised, even where added sugar is moderate? Could the spike in urinary calcium be avoided by eating smaller calorie restricted meals more frequently , or perhaps by choosing low GI (glycemic index) meals? I hope my question is clear enough and not too rambling. Thanks so much again!
Hi Aiden, Meal spikes of calcium from sugar and oxalate as well – from spinach etc – are known about and no data as to their exact role. But prudence says, why have them at all. Refined sugar is not a good thing, so just limit it. Sugar in meals is another matter – a well constructed diet spreads things out and favors variety so spikes may occur but are not so predictable as a candy bar. I gather you form stones. Be sure and get fully evaluated. Then, the ideal is the kidney stone diet, that matches pretty much what we all should be eating here in the US. Regards, Fred Coe
I too am committed to end my sugar trance. The craving factor is the phenomenon limited to my kind of addictioñ. It has subsided considerably with abstinence. I am presently consuming kefir, chicken, unfarmed fish vegetables and some fruit. Before, l lived on refined carbs and chocolate. I am / was addicted to anything rhubarb.
Than you for this enlightenment. I am grateful.
Oh, this is awful. It’s like a bad dream. I scrolled down, frantic, hoping for a glimmer of, well, sugar. You know, maple syrup – because it is sucrose. Ty and Charlene Bollinger, the TruthAboutCancer.com gurus, intimated a few years ago already that Dr. Gonzalez suggested that maple syrup and honey had an opposite molecular “spin” (my comprehension of the precise jargon ends here) from cane and beet and all other sugar sources and, as such, did not promote tumor growth. This may be true; however, the whole insulin resistance factor still has to be mediated. I remember a Candida cleanse I used a few years ago. It contained a dropper bottle of liquid which hit the back of my tongue like alcohol, and cut the craving; would candida overgrowth be the reason we CRAVE it? I THINK I READ THIS. Frankly, due to a relationship with an active alcoholic, I have become entrenched; ice cream, every night before bed – and, fantasizing about my next cookie, I go through the same ecstatic mania at the grocery check out which a drinker manifests when he/she is about to pay for the next sixpack.
Hi Ruth Ann, Honestly, there is no spin. Maple syrup (YUM) is all sucrose, which means 1/2 fructose. HOney, no better. Fructose produces (causes) insulin resistance with only 8 weeks of exposure in otherwise healthy if dumpy middle age people – see the data in the article. I do not believe candida is why we love sugar, it is because it is sweet, and delicious, and a bad thing. Lets face it, we love sweets, and we need to leave them. I did it, as I said, with sorrow and regrets that have never abated. But, they are no good. I wish it were not true. Fred
Just had a 9mm oxlate kidney stones removed in my ureter tube, stent in place for 6 weeks. I’ve always done the Master cleanse every season, lemon, water, cayenne, and maple syrup. I feel that this must have contributed to my 9 mm stone. Smoothies, collegan peptides in my bulletproof coffee, were also factors, and well as high doses of vit c. My stone is 80% oxlate, 20% citrate, and I have my stent removed on the 28 th of Jan. I feel doing cleanses are important, however water fasting may work out better. This isn’t for weight loss, as I’d at an ideal weight and fit. It’s always been for Wellness. With you’re expertise, what are you’re recommendations, other than a low oxlate diet exercise? We have a wellness room with a far infrared sauna, massage table, etc.
Hi Petrina,
I take care of the wellness on the site. I will tell you that cleanses can do more harm than good. We believe in eating a diet plenty in fruits and veggies and drinking enough fluids to produce at least 2.5 liters of fluids a day. I know many of you want a trendy “cleanse” but we are believers of good old low oxalate produce and fluids. Hope this helps.
Best, Jill
How on earth can a kidney stone have citrate in it? Did you mean to say your stone was 80% oxalate and 20% CALCIUM?
They do not have citrate in them. Calcium binds with oxalate or phosphate, or carbonate. Fred Coe
What about stevia?
Hi Linda, Chemical stevia has no oxalate and no calories and does nothing like sugar. Fred
A tablespoon of peach butter or apple butter contains 3 or 4 grams of sugars respectively. Would this be a safe substitute for jams?
Thank you!
Sue
Hi Sue,
Keeping your added sugar to less than 25 grams per day is your goal. Choose how to get it any way you like!
Best, Jill
Not true!!! If you were to eat all 25 grams at once, it would be an overload to sensitive people. I have found that 4-8 grams at a time is maximum before I start noticing ill effects like feeling sick, higher blood sugar, low blood sugar crashes later and addictive responses.
A most excellent article! The information is important and the style is playful. Made for a very interesting read. I also suffer the same addiction but you have opened my eyes. I must withdraw from the sweet world of sweets. I promised my wife I would try to be around a long time to bother her. That darn sugar is trying to kill me!
It can be a gateway drug, but if you cant control yourself there are also sugarfree alternatives to sweets and cookies.
It can really help satisfy the urge once you have it.
Well … it was fun while it lasted.
I stumbled onto this page during research for my low oxalate diet to prevent
my kidney stones from returning. When I tried to add some of the fun back in
I was promptly cut off at the knees by this well written article.
Looks like food has turned into simply a requirement for survival … oh … wait … :-).
Hi Ralph, Oxalate is so small a part of proper stone prevention! Take a look here, and see if it gives you some ideas about a comprehensive look at things. Best, Fred
Your work is admirable. Thanks
Question: If I mix sugar with lime, sweet and sour, how does my body concentrates only on the sugar? Thanks
Hi Asad, sugar is sugar, sweet or not. Lime does not make the fructose part of the sugar any safer. Regards, Fred Coe
What about artificial sweetners or stevia?
Ann
They are safe and pose no issues. Big sugar spent a lot of money finding scientists who would find some risk in animals given massive doses, but human risk is minimal. Regards, Fred Coe
How can I find out how much sugar is in the yogurt I buy that comes out of the machine? Not in a package with a label.
Hi Judy,
If it comes from a machine and it is flavored it will have added sugar. If it is the plain european style it will have less or no added sugar. That is the one I opt for.
Jill
Great article, it has always helped me to understand the “why” behind the “what.” I have a question. Just beginning my educational journey with kidney stones and working my way through this wonderful website. Sugar has always been my bugaboo, autumn and going into the holidays especially – so my work is cut out. But my recent ten hour bout with intense stone pain is highly motivating.
Checking labels, I noticed unflavored milk and plain kefir both have 12g of sugar per serving. Do the natural sugars occurring in milk (without anything else added, of course) count toward the daily total? I am diligently working to increase my calcium through food which I have sadly neglected for years. 3 servings a day of milk/kefir would bring me very near my calcium requirement but over in sugar grams. I can substitute in one serving of plain greek yogurt (4 grams per serving), ending up with 30 grams of sugar just from milk products. But that leaves no room for other natural sugars in food. There is cottage cheese with less sugar grams, but that is much higher in sodium and doesn’t have as much calcium. Canned salmon with bones is a good source of calcium, though I likely wouldn’t eat it more than once a week or so (and have to watch the sodium in some brands.)
What is the trade-off between going over somewhat on the daily sugar grams vs. replacing some of the needed calcium with a supplement so I don’t go over at all?
I greatly appreciate your thoughts.
Best, Paula
Hi Paula, The problem is added sugars. Milk has sugars in it but the amount is modest and absorption is slowed by the fats so insulin increase is muted. Use the dairy products. Regards, Fred Coe
Long story short–would dried fruit (non-crystalized) be considered “added sugar”? I am looking at a package of Sunsweet brand dried apricots: 15 g carbs–2 g fiber, 8 g sugar, 0 g “added sugar”.
.
I am not sure how many carbs/sugar the “plain” dates I have in my pantry are, but they are even sweeter. The figs not as much.
.
In order to cut back on cookies and other junk, I’ve been having those for dessert. Your article has me wondering if this “no-added sugar” dessert should be counted under “added sugar”
Hi Kathryn, I hate to say so but it is a problem. Consider this – how many real apricots can you really eat. Compare to dried apricots. That is why dried fruit – delicious indeed – is a worry. Dates, the same. We get all our refined sugar from plants, and drying fruit is a good way to concentrate it. Dates are a love of mine, because they are filled with sugar, but indeed you cannot eat that many. So adding sugar – from beets or sugar cane – to sweet fruits is rarely done, but drying the fruits or making them into juice certainly gives you ‘added’ sugar. Fred
What if I were disciplined enough to eat the same number of dried apricots as I would whole fruit (I do – 3)? And only for the occasional convenience since I’m not going grocery shopping till tomorrow and. I’m out of fresh.
Hi Kim, as in my answer to your more general question, dried and real are the same, so it is just numbers. But real fruit has a lot of fluid in it, so be sure and enjoy dried fruit with some kind of drink. Fred
Curious as to whether this applies to allulose as well? Or is allulose an acceptable alternative?
THANK YOU!
Hi Jon,
You can use allulose. It will not count as added sugar and also doesn’t add to calories (tech it has 0.4 cal/gram and regular sugar has 4cal/g) as it is absorbed in the small intestine but doesn’t metabolize into glucose. It doesn’t tend to cause bloating and gi issues as other sweeteners do. I like it, but it is pricey.
Jill
Hello. Am I correct that I (40 year old male) can eat 50g of added sugar as opposed to the 38g I’ve seen everywhere?
Hi Ryan, The 36-38 grams is the newest level, the 50 gm was the prior one. This is not added sugar from you but the total of added sugars from all products. Essentially, added sugar is very unhealthy because of fructose (half of table sugar) and in certain people glucose as well. Amounts are entirely political right now because ideally you would limit added sugars as low as possible, there being lots of problems with them and no benefits. Food industry, big sugar, do their best, thus the slowness of the gradual fall in recommended amounts. If you ask me – you did not – I would be below the 38 gm, I am, in fact. Best, Fred
I’m a Registered Dietitian with alas a 4mm kidney stone which I am predicting from hypercalciuria initially from iatrogenic hyperthyroidism from over medication related to Hashimoto’s. And secondly from a diet too high in oxalates and too low in calcium. I have lowered my oxalates and increased my dairy calcium, my sodium has always been low and I cut out all refined sugars to 9g or less per day almost 2 years ago.
However, I still love my (now) lower oxalate fruits. I typically have 3 pieces per day. An apple, a cup of blueberries and a banana or 1 cup pineapple or other seasonal fruits. Is this acceptable? Or too much ? Thank you. I’m struggling to find an answer for an acceptable daily amount.
Hi Barbara, Almost all fruits have low glycemic load (high glycemic index, low amount of sugar in a serving) apart from bananas and some other tropical fruits. As for the stone, do get 24 hour urine and fasting serums to be sure nothing has been overlooked – hypercalciuria may not be from the drug. Regards, Fred Coe