Saturday, July 23, 2011

Review: Sugar Nation

Sugar Nation: The Hidden Truth Behind America's Deadliest Habit and the Simple Way to Beat ItNote: I bought this book with my own money. I haven't gotten any good freebies to review lately.

I have a serious family history of diabetes on my father's side. My grandfather on that side was a diabetic, as is my father and all of his living siblings. I think that my other aunt, who died at 46 of a sudden heart attack, may have been an undiagnosed diabetic. I have friends and family members who have had serious complications, from blindness to amputation, from the disease.  A friend's father, also a diabetic, suffered not only amputations but kidney failure and decided to die rather than go through dialysis for the rest of his life.  This book focuses mostly on Type 2 diabetics, who suffer from insulin resistance that causes eventual failure of the pancreas, as opposed to Type I diabetics, which is an autoimmune disorder that renders the pancreas completely unable to make insulin.  Almost all of the diabetics I have known have been Type 2.   Not surprisingly, I read Sugar Nation: The Hidden Truth Behind America's Deadliest Habit and the Simple Way to Beat It quickly, like a horror story.  It is, actually, quite a horror story.

The book is an examination of the epidemic of diabetes in this country, framed by author Jeff O'Connell's own diagnosis with prediabetes and his efforts to understand how to avoid falling victim to the disease, which he learns at the same time is slowly killing his estranged father.  The O'Connells didn't fit the stereotype of Type 2 diabetics -- they were both tall and thin when diagnosed.  However, O'Connell senior has a weakness for starchy foods and sugary sodas, and his son seems to follow in the bad-food footsteps, eating a lot of junk food despite his work as a writer and editor for the fitness industry.
My ignorance is inexcusable, given that I wrote for Men's Health, but it also goes a long way toward explaining why the disease has spread across America with the persistence of a glacier and the devastation of a wildfire.  As it stands, one in three American adults has type 2 diabetes or its precursor, prediabetes.  Remarkably, one in four diabetics is in the dark about his or her condition.  One of them might be you.
Reading this book scared me to the point that I went to the drugstore and bought a cheap glucose monitoring kit that included 10 test strips and a lancet. I had tested myself a few times before with my father's kit and had always been normal, just like I was when I was checked at the doctor's.  Still, I was convinced after reading about the vague symptoms the author had (headaches, joint aches, thirst, frequent urination) that I might be one of those people whose blood sugar problems show up only after a meal. I tested myself right before a meal and two hours after, getting readings of 90 and 110, respectively.  Both readings were totally normal. Whew.  The testing kits are inexpensive and available enough now that I'm not sure why people with a family history aren't advised to get one and check now and then, just to be sure.

The main point of the book was not necessarily to scare readers, though it does a pretty good job of that, especially when O'Connell describes visiting his father as he wastes away in the hospital.  It is to question the current standard of diabetes care, which pairs vague, halfhearted lifestyle advice -- "exercise regularly and eat a healthy diet" (How much exercise? What exactly is a healthy diet for diabetics?) -- with a heavy emphasis on drug therapies, because "the unspoken assumption is that the patient will never stick with the lifestyle program." In fact, though, those lifestyle changes are more effective than drugs, O'Connell says, when started early after a patient's diagnosis, citing a study that showed that "a combination of lifestyle changes (dietary adjustments, exercise, and the resulting weight loss) reduced diabetes incidence by 58 percent" while "the superstar of type 2 diabetes drugs, metformin, reduced it by only 31 percent." O'Connell doesn't come out and say it, but since the program he cited was the Diabetes Prevention Program, the patients in the study were probably prediabetic as opposed to people already in the diabetic range.

O'Connell's main thread throughout the book is that diabetics are not getting good advice, even from their doctors and the organizations designed to help them.  The standard lifestyle advice offered to diabetics is to make moderate lifestyle changes, like gentle aerobic exercise and a diet that includes carbohydrates even though they are limited.  He advocates shorter, more intense exercise sessions  (mostly strength training and high-intensity interval training) on an almost daily basis and a very carb-restricted diet, "80 or fewer grams of carbs (excluding fiber) a day to keep prediabetes at bay." He attends a convention held by The American Diabetes Association (ADA) and scoffs at the offerings on the buffet pulled right from a diabetic cookbook. "The chicken lettuce wraps and chicken rosemary strips would be compatible with my low-carb diet, but the pasta jambalaya and berry tiramisu -- with 51 and 23 carb grams per serving, respectively -- wouldn't." It is easy to agree with his position that telling diabetics to eat a diet heavy in carbs and low in fat (which does not affect blood sugar) and then adjust for it with drugs is crazy. When he describes watching a woman wearing an insulin pump pull out a granola bar, look at the label, and key in 25 grams of carbs to get the right amount of insulin, it was easy to shake my head right along with him. It does seem crazy, especially since insulin is known to cause weight gain, a very bad side effect for a medicine to treat a disease aggravated by excess weight.  But I think very few people would be able to follow as strict a diet as he advocates unless they had a gun to their head.  He makes a convincing case for us, though, that diabetics do.  It is not clear what kind of diet he would advise for people who are not diabetic or prediabetic to prevent the disease, though he hints that it would not have to be as strict as his.

That was the one weakness of the book for me, that the emphasis on his own personal plan, cobbled together with advice he picks up from experts along the way, and that he doesn't pull out some recommendations for the rest of us who might like to avoid being blindsided by the disease.  Maybe the publishers advised him against seeming to give health advice for legal reasons, figuring that determined readers would manage to connect the dots themselves.  Maybe he realized that if one of the writers and editors of Men's Health, with its "Eat This, Not That" column, was oblivious to nutritional reality until he had a wake-up call from a high blood sugar reading, the rest of us probably would be too.  He is successful in managing his blood sugar with his lifestyle changes, but he caught the disease before it developed into full-blown diabetes.

I wasn't sure I bought the author's claim that diabetics aren't advised to cut carbs. I have known a few diabetics who are pretty vigilant about counting carbohydrate grams and avoiding bread and potatoes.  However, then I went to the ADA's "Create Your Plate" page and it says that diabetics should visualize cutting a dinner plate in quarters, filling half with nonstarchy vegetables, one quarter with lean meat or eggs, tofu, etc., and one quarter with starchy foods, then drinking a glass of lowfat or nonfat milk and having fruit or fruit salad ("canned in light syrup") for dessert. If you realize that the milk and fruit are actually 2 extra "quarters" of the plate (making 6 parts, with two of them vegetables), that means that the lean protein sources and nonstarchy vegetables are half of the plate (and less than half of the calories) and carbohydrate-rich foods make up the other half of the plate.  This seems like it would be a fine meal plan for a nondiabetic, but not so great for someone whose body has a hard time processing carbs.  It's still probably idealistic compared to what most diabetics actually eat.  Because diabetes is so common, it's easy to think it isn't a big deal, until you know a diabetic who has dealt with some of the more serious complications.

This book was definitely an eye-opener for me and made me even more determined not to develop diabetes. I already avoid fast food restaurants and don't drink sweetened soda (I drink LaCroix flavored sparkling water when I want bubbles. I limit added sugar, though I will admit that I probably eat more starchy carbs than I should and need to work on that. I exercise almost daily already, but this book reminded me how important it is to keep the intensity up and to incorporate strength training.  I am making it more of a priority to get enough sleep, which is important for keeping blood sugar regulated. Luckily, these steps are all of the same ones I need to work toward a more healthy weight.  I also made an appointment for a physical to see if there are any lurking concerns I'm not aware of, since my last one was a couple of years ago.  I can't change my family history, but I can manage the other risk factors.  I hope that more people will read the book, including some of the board members of the ADA.


  1. There are some recommendations for non diabetics in an article the author wrote for Men's Health:

  2. I have several thoughts on this issue...
    First, insulin resistance is a gradual progression. It takes more and more insulin to regulate to the same level of blood glucose because your body doesn't respond to insulin as well. If you wait until your blood glucose is no longer controlled, you miss the bus on the start of the disease. Your doctor can run insulin levels that will add another piece of the picture.
    Second, it's important to differentiate between type 1 and type 2 when talking about diet corrections. I highly doubt someone with an insulin pump was type 2, so to tell her she may never have carbs is crazy. Monitoring carb intake and adjusting insulin with precision is EXACTLY what a type 1 needs to be doing. Putting type 2s on insulin is a last resort, since the problem wasn't an insulin shortage, but the body's not responding to insulin correctly. Adding more insulin doesn't fix that.
    Third, the author doesn't seem to take into consideration the relatively recent but well-established knowledge that different sources of carbohydrate affect blood glucose (thus insulin) differently. Highly processed foods (like white bread, fruit juice) raise blood glucose quickly and dramatically, which causes a spike in insulin production. Less processed foods (steel-cut oats, whole apples) usually have less of an impact on blood glucose. Yes, Americans consume too much sugar, but we also consume mostly foods that are far, far away from their original healthy state. Wonderbread raises your blood glucose as much as table sugar. Broccoli (carb for carb) has almost no impact on blood glucose. Yet equal amounts of carbohydrate from different sources appear to be viewed as equal by this author?

    When my doctor and I were discussing my symptoms of PCOS and my elevated insulin levels, she recommended the South Beach Diet to me. My grandmother's doctor in another state recommended SBD to her. It's based on regulating blood glucose and insulin (which also does a VERY good job of regulating appetite. Great for dieters.) by choosing carbohydrates that affect blood glucose less. The Glycemic Index diet is also based on this concept, though I don't think that book was as well written.

    Bottom line, I do believe that our country's approach to type 2 diabetes is seriously flawed ("Lets wait until it's out of control to do anything. Lets treat it with meds when lifestyle change works better."), and I welcome anything that encourages new dialogue. It sounds like this guy is a little behind the times on science, but from his allegations, so is the ADA...

  3. Excellent review, Jennifer. My father, one of his sisters and my sister all had/have Type 2 diabetes. It was so hard to watch my dad, who loved to eat, neglect his diet as he did.

    Like you, I have (so far) had good check-ups and like you, I try to eat healthfully. I've fallen off the exercise bandwagon since it's been so darned hot. Your review of this book could be a wake-up call for me.

  4. Thank you for this review! I went out and bought the book! I am one who, I believe, will never be diabetic. That's not because I'm virtuous though -- I just don't think I have the genes, based on the testing I've done. But my husband already is type 2 and after a year of great low carb eating, he has been back to his old habits now for a couple years. I am hoping I can interest him in this book.

  5. great review, Jen. I liked Tempest's informed comment, too. Carbs are not all created equal. The less processed food I eat, the better I feel.


"Count your calories, work out when you can, and try to be good to yourself. All the rest is bulls**t." -- Jillian Michaels at BlogHer '07