The war on sugar (more posts below today)

Barts-MS rose-tinted-odometer ★★★ 

Just back from the NMSS ‘Pathways to Cures’ meeting in Washington DC during which we pledged to  STOP, RESTORE and END multiple sclerosis. 

The END refers to prevention. We discussed at the meeting modifiable risk factors that could be tackled to reduce the incidence (new cases) of MS and one risk factor childhood and adolescent obesity. One theory has been that obesity affects MS risk by interacting with vitamin D (vD); either by lowering levels due to the breakdown of vD in fat or secondary to systemic inflammation associated with obesity. 

In this genomics study below it is clear that obesity itself increases your risk of MS and is independent of vD levels. 

So how do we tackle obesity and the obesity epidemic? It is clear that obesity is caused by sugar and the change in the dietary guidelines that occurred in the 1970s and 1980s when governments launched a war on fats and started to promote a low-fat diet as being ‘heart-healthy’. We now know that the low-fat diet was wrong and that what was driving heart and vascular disease was processed carbohydrates, in particular, sugar consumption, and not saturated fats. Fortunately, the world is now beginning to acknowledge that saturated fats are healthy and that processed and ultra-processed foods, which are largely made up of carbohydrates and polyunsaturated fats are unhealthy culprits and are what is causing the obesity epidemic. 

This graph shows you the strong association between per capita sugar consumption and obesity. It is extraordinary that politicians are not doing more to tackle global sugar consumption.

Another factor driving obesity is our sedentary lifestyle and reduced exercise. 

To tackle obesity we need governments to declare ware on sugar and the food industry and to put in place national policies to tackle our sedentary lifestyle. This is easier said than done. Politicians are not as powerful as they used to be; most of them rely on lobby money to get elected and once elected they represent the vested interest groups that got them elected. Sadly this often includes sugar money. 

The sugar industry is heavily subsidised, which keeps the price of sugar artificially low. Sugar subsidies interfere with the global market and have resulted in a sugar glut. This is one of the reasons why junk food is so cheap and real-food is so expensive. 

Obesity is not only a risk factor for causing MS it also affects people with established MS.  Obesogenic diets cause a metabolic shitstorm that impacts on MS indirectly. Obesity causes metabolic syndrome (hypertension, insulin resistance, glucose intolerance, diabetes and dyslipidaemia) and a systemic inflammatory syndrome that worsens MS. Therefore, there is a good reason why, if you are obese you should consider doing something about it. 

I recommend you read “Why we get fat and what to do about it”, by Gary Taubes or you can watch one of his lectures on YouTube. Understanding the metabolic issues that underlie obesity will allow you to understand what to do about it.

Then there is the responsibility you have to your siblings, children and relatives. If you have MS your direct family are at increased risk of getting MS and you should get them to modify their risk factors, i.e. make sure they stay slim, or if they are obese they need to lose weight, get them to exercise and to start taking vD supplements. Tell them about the link between smoking and MS; they should either stop smoking or get them to pledge not to start smoking in the future. 

MS prevention is about education, education, education and education begins in the home. We estimate that ~15-20% of new cases of MS could be prevented by preventing childhood obesity and smoking. This is why we need to declare war on sugar and smoking as part of our END MS campaign. Do you agree?

Jacobs et al. BMI and Low Vitamin D Are Causal Factors for Multiple Sclerosis: A Mendelian Randomization Study. Neurol Neuroimmunol Neuroinflamm, 7 (2) 2020 Jan 14.

Objective: To update the causal estimates for the effects of adult body mass index (BMI), childhood BMI, and vitamin D status on multiple sclerosis (MS) risk.

Methods: We used 2-sample Mendelian randomization to determine causal estimates. Summary statistics for SNP associations with traits of interest were obtained from the relevant consortia. Primary analyses consisted of random-effects inverse-variance-weighted meta-analysis, followed by secondary sensitivity analyses.

Results: Genetically determined increased childhood BMI (ORMS 1.24, 95% CI 1.05-1.45, p = 0.011) and adult BMI (ORMS 1.14, 95% CI 1.01-1.30, p = 0.042) were associated with increased MS risk. The effect of genetically determined adult BMI on MS risk lessened after exclusion of 16 variants associated with childhood BMI (ORMS 1.11, 95% CI 0.97-1.28, p = 0.121). Correcting for effects of serum vitamin D in a multivariate analysis did not alter the direction or significance of these estimates. Each genetically determined unit increase in the natural-log-transformed vitamin D level was associated with a 43% decrease in the odds of MS (OR 0.57, 95% CI 0.41-0.81, p = 0.001).

Conclusions: We provide novel evidence that BMI before the age of 10 is an independent causal risk factor for MS and strengthen evidence for the causal role of vitamin D in the pathogenesis of MS.

CoI: this work was done by our Preventive Neurology Unit

41 thoughts on “The war on sugar (more posts below today)”

  1. Please note that at a personal level I cut out sugar from my diet about 2 years ago and feel so much better for it. I would recommend you try it as well.

    1. Yep profG looks like stickboy as anyone who sees him will testify, I cut out sugar about the same time and still MrLard. Diet is important it is part of te answer

    2. Prof G

      Does your restriction of sugar, include eating fruit? Or are you only talking about processed/ refined sugars?

      Guess my follow on question will be clear from answer to first part, but do you not think there’s a distinction, and the benefits of fruit, as part of a balanced diet, are important? Think fibre, vit c and other minerals/ nutrients.

      1. Yes and no. I go through the arguments in my Evolutionary Medicine post.

        If you are not overweight and trying to lose weight fruit is fine, but not in excess. I also think we should be eating fruit seasonally that is how we evolved and that is how our biochemistry evolved.

        Another thing to note is that modern fruit varieties have been bred and selected for sweetness, i.e. they are designed to deliver sugar. Raymond Blanc, for example, grows and cooks with legacy apple varieties and is against many of the new apples that just have too much sweetness in them. Please read his take on this!

        I know this is a mixed message, but be careful. I eat fruit seasonally and I avoid fruit juice. You may notice that a lot of fruit juices claim to have no added sugar, but have added unflavoured apple juice; this is marketing trick to fool you. Added apple juice is added sugar.

      2. Ha, very funny. If only it could be peer reviewed lol. Also bear in mind whilst these apples may taste sweeter the sugar content will be similar to the legacy apples.

      3. And the results seem to be rather more nuanced than Raymond suggests ie who’d have thought organic apples were worse for you on sugar content?

  2. I’m not fat and never have been, yes I did smoke when I was younger. I would politely suggest, people in your field focus on finding the cause of MS in the hope of finding a cure.

    Rather than going over the same tired ground. Don’t smoke, don’t get fat, do more exercise!!

    Most people with half a brain know obesity and smoking are bad for you, this should be done in school and though the GP and other resources, not a neurologist.

    If you spent however long in medical school and then specialising to tell people the above, then we are all f$&#£d!!!

    The whole body positivity movement is taking us backwards in the west.
    If you want to smoke and/or be fat, that is up to the individual. You can lead a horse to water and all that!

    Please don’t insult the intelligence of pwMS

    1. This made me really thoughtful. I am a doctor and can assure you, the aim of our studies is to be able to help ill patients as best we can. If you have an accident and break a bone, we will put it back together. But even if we do this as best as possible, in many cases it is never going to be *exactly* the same or exactly as good as before. So we have all these new treatments and technologies, but the goal always has to be that you don’t get into a situation where you need them in the first place. It is a last resort, one that is getting more and more sophisticated, but a last resort it remains. No pill or surgery can do magic and give total health back to someone who has a huge list of problems. I can understand that it might feel overwhelming or like you can’t make a difference, but the most important person for your health and development is you. Doctors are there to support you when matters get complicated, but in relation to your lifespan they get to spend relatively little time with you. You are in charge of your daily lifestyle habits, you know what’s causing you discomfort in your body, in your psyche – you can’t hand it over to anyone else who spends less time with you. Not only will you considerably lower the risk of needing a doctor’s help by managing your lifestyle factors, even if you still get a disease you will stand a far better chance of tolerating treatment and recovering if you are fit and sorted out at least in all areas that are under your control. There are enough areas that we as individuals have not much control over, like environmental toxins, infections, accidents, some genetic components, but if you take care of the rest, you already took care of a substantial part. E.g. a british study found that 38% of new cancer cases are related to nutrition and other modifiable risk factors. Let me say that again: more than one in three. In the UK alone this equals 2.500 cancer cases per week or 135.500 per year that could be avoided.(Ref) If any therapy achieved such numbers, it would make headlines!
      All the best and take care!
      Ref: Brown, K. F. et al. The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015. British Journal of Cancer 118, 1130–1141 (2018).

    1. People need to get moving. I know plenty of stick thin people who consume a lot of refined sugar, but they walk a lot.

      Get out of the car, leave it at home and walk at a quick pace.

      Or get a bike or exercise bike to use at home. Get the heart working.
      Plus it helps the environment.

  3. Prof G,

    The problem with all this is that people use a technique which is under used by researchers – observation. I have three friends with MS – the two females are slim build and never smoked. The male is underweight (always has been), never smoked and was a cross country runner. I can’t comment on their Vit D exposure.

    When I have my annual MS clinic the waiting room is usually mainly composed of women between 20-50. I see a range of body sizes, but the majority are slim. I suspect this will be very different in a waiting room for type 2 diabetes.

    I’m a male, have never smoked, got plenty of sunshine, was normal weight, and did a good amount of exercise (my good health, fitness level was confirmed by the annual work medical). I was diagnosed at 35 with RRMS. I had a bad case of mono at 15 and an aunt had MS (didn’t make 50). EBV and genes are the ‘real’ risk factors. If I offered you two approaches to reducing your risk of getting MS:

    – ebv vaccine; or
    – keep to a normal weight, take Vit D supplementation, exercise regularly

    Which one would you take?

    Addressing ebv will address MS ie will prevent people from getting it. The other factors (Vit D, weight, exercise) are marginal at most. You would need to explain to me why professional sports people have been diagnosed with MS and why MS rates in Tonga, Samoa, Kuwait (countries with the highest obesity levels) haven’t got the highest levels of MS.

    1. Thanks for this good point, Maybe DrBen will do a post on BMI age under 10 and MS on their new paper, rsik factors are just that but as a child I was rather slim, playing football every day, exercising alot but I have to say I was a hummingbird when it came to sugary drinks

    2. Obesity, smoking and low vD are just risk factors; they are not necessary nor sufficient to cause MS. In other words they lower your threshold for getting MS. There will be many thin, non-smoking people with normal vD levels who get MS. Why? Because they were unlucky.

      Unlike EBV which is necessary, but not sufficient, in relation to MS. In other words, you have to have EBV to get MS, which is why I think it is the cause of MS and why we need to do an EBV vaccination trial. The not sufficient in relation to EBV explains why the vast majority of people with are EBV-positive don’t get MS.

      Causation theory is complex and I will do some posts on the theory later this year.

      1. “The not sufficient in relation to EBV explains why the vast majority of people with are EBV-positive don’t get MS.”

        This to me is the crux of everything. I can’t believe the research to date hasn’t made any in-roads in finding out why. Is it time to let virologists and immunologists have a crack at reaching any answer? I have a friend who is a defence academic (defence expert) but for the last ten years has called himself a terrorism expert. I’m surprised that immunologists allowed neurologists (calling themselves neuro-immunologists) to muscle in on their patch. How would neurologists like it if immunologists started researching Parkinson’s? If MS is caused by ebv and a misfunctioning immune system, it should fall to the specialists who study these.

  4. I’m curious about how you marry this approach with your support for the Overcoming MS Program, which is a diet with very low saturated fat content and suggests that saturated fat is one of the things that drives MS?

    1. There is no evidence at all that saturated fat drives MS. Although I support OMS in principle I have always stated there is no evidence to support the OMS diet. In fact, there is not enough evidence to support any specific diet for MS, which is why we have to go outside of MS for dietary advice.

  5. Sugar is a essential ingredient in the normal functioning of the body. It’s only bad if you don’t burn all the sugar u intake. Since the rise in popularity of smart phones and tablets. Kids are only doing one thing. Playing games. I remember as a kid, we couldn’t wait to go out of our houses to ride bikes, playing cowboys and indias. Making rustic bow and arrows, running, fighting, etc. All the roads kids use to play together. This was repeated at every street in every town and country. Does such a thing happen now? Although my ms started very late 40 plus. I’m sure the first symptoms happened in my 20s. But my life style included eating alot of fruit, veg and nuts, and fanatically training 5 days a week lifting heavy weights. Also by staying indoors your vitamin d will be low. Eating only processed food is what’s driving the ms epidemic. And it’s likely to increase exponentially with time. Clock is ticking.

    1. Re: “Sugar is an essential ingredient in the normal functioning of the body.”

      Not true. Carbohydrates (sugar) is one the macronutrient you can do without. In other words, it is a non-essential food. People who are fructose intolerant and don’t eat any sugar are much healthier than their sugar-eating peers. Traditionally the Inuit had a zero-carbohydrate diet and were extremely healthy; since they have started eating a carbohydrate-rich Westen diet they have become one of the most unhealthy ethnic groups in Canada.

      Most professional bodybuilders eat a zero-carbohydrate diet and do okay. Their poor health is due to steroid and other substance abuse to burn fat and intermittent dehydration.

      1. Thanks Prof G. Your absolutely right about body builders taking steroids. Only maybe 5 % are natural among the pros. They forget the body is a equilibrium. If you pump too much steroids the body will produce more estrogen. Hence the addiction. They have to keep taking steroids to counter the excessive estrogen. When they stop they lose all the muscle. Luckily I had a good education and knew the dangers of steroids. Problem is MS is not the only autoimmune on the rise. All major diseases are on the rise. Humans bodies are designed for active life styles. Prime example is the oldest marathon runner flying turban fauj singh who is now 108. Without drugs are we likely to see these natural life spans again?

      2. I don’t know many bodybuilders or fitness people who eat zero carbs. We need carbs despite what the medical professionals say! As for the obesity I’ve never weighed more than 137lbs at my highest. Why not just use “prevent” instead of “end”? Seems disingenuous. Enjoy your posts but this one……

    2. Re: “fruit, veg and nuts”

      These are complex (unprocessed) carbohydrates and tend to have a low GI index (unless you juice them), i.e. they release their sugars slowly and induce less insulin. It is the processed carbohydrates that are bad for you; they have a high GI index, because they realise their sugar without much need for digestion and the sugar is absorbed very quickly, which then stimulates high levels of insulin. In fact, too much insulin; our bodies evolved when complex carbohydrates were the norm and insulin was in response to absorption of sugars over several hours, i.e. low GI. The excess insulin then lowers your glucose levels too much because you have absorbed all the processed sugars from your intestine. The low blood glucose then triggers hunger and drives you to seek more food in the form of snacking. In a recent study people who ate a diet high in processed and ultra-processed food consumed over 500 calories more a day compared to people on a real-food (non-processed food) diet. The extra calorie intake would have almost certainly been driven by the excess insulin-induced hypoglycaemia from high GI foods.

      People who convert to a low-carb or low-GI diet are amazed at how they don’t get hungry and that their food cravings between meals disappear. If you don’t believe me try it!

      1. Thank you for replying! I misunderstood….thought you meant all carbs including complex.

  6. Much sense here. But I would say that the only people to be taking diet advice from should be RD’s. The Prof makes some good points but I believe he is far too in thrall to the low carb movement to be recommending blanket diets. Common sense tells us not to eat too much refined carbs and processed foods but healthy carbs should not be demonized. Taubes theories are actually fairly strongly challenged within the nutrition research community.

    1. Re: “Taubes theories are actually fairly strongly challenged within the nutrition research community.”

      Yep, Taubes’ theory was challenged by the medical profession including dieticians and they lost the case scientifically and legally. This is almost certainly why all the diabetic associations have had to change their dietary advice and are now recommending low-carb diets as a treatment for diabetes. It is interesting how often legal cases trigger a change in behaviour, which is why lawyers are so important to society.

      I don’t think Gary Taubes is against carbs and nor am I. We are just against processed and ultra-processed carbs; sugar being the dominant processed carb. Fortunately, it is a relatively free world so you can take your dietary advice from whoever you want 😉

      1. Zoe Harcombe is not a Registered Dietician as far as I’m aware? She will recommend the Harcombe Diet. If you can’t see the problem with this then I dispair

      1. Having watched Taubes debate Guyenet last year to say he has won the case scientifically is a bit of a stretch. Don’t think there is settled consensus here.

  7. My BMI has never been above the healthy range. Right now it’s about 20. Should I still avoid sugar?

  8. Prof G I usually agree with you but I have to respectfully disagree with you on this one. As a personal example – I’m very thin always have been, exercise regularly, walk a lot, never smoke and always even took vit d supplements. great cholesterol and low bp and A1C – on paper am exceedingly healthy. Did everything to prevent MS I guess genes were too strong. I have so much to worry about – dmds, mris, insurance, infection risk, getting adequate sleep exercise nutrition, managing energy, monitoring progression, treating comorbidities – finances in case I have to stop working – should I be worrying about sugar too? Why, when treats in moderation give me joy? Do you really want to give people like me one more thing to worry about?Sure – if it were absolutely proven that it would prevent progression I’d gladly do it but from what I’ve heard it’s not.
    I think demonizing any one ingredient unless proven to worsen ms is a recipe for further stress and unreasonable burden for pwms. We already know we need to “do this do that”. Research on behavioral change also shows demonizing any one ingredient doesn’t lead to overall health benefits. Better we should continue on exercise and reaching or keeping a healthy weight. If some people choose to eliminate sugar (or dairy or gluten or meat or whatever) in order to reach that goal and it works bully for them. Personally I’d focus more on the goal of overall health vs targeting any elimination diet as a solution. We need people like you fighting for prevention, to push urgency for better treatments, I think declaring a “War on sugar” is counterproductive and also takes attention away from your other very worth campaigns.

  9. Please note the ‘War on Sugar’ is not about the MS diet, but simply one strategy to try and reduce childhood obesity, which in turn will lead to a possible lowering in the incidence of MS. Is this not a worthy ambition?

    To answer your questions about what diet I would recommend to pwMS I penned a Medium post that will almost certainly disappoint you. It is about a philosophy and not a specific diet.

  10. Thinks about this.

    The average thirteen year old will eat their own body weight of sugar about every two years, and of course even more in less well off families. The average three year will take just twelve months to do this. This is incompatible with good health and represents an epidemiological disaster.


    I had a great time as a GP by helping people lose weight, have their hypertension, obesity and diabetes ‘undiagnosed”, and improving fitness and wellbeing, simply by offering energetic oral and written advice about sugar. The big bonus is that if you avoid products with added sugar, (I call them EFLS – “Edible Food Like Products) you end up eating real food, with all the huge benefits that brings.

    The 250 patients I followed in my clinic up lost an average of 7% of their body weight, maintained over the four years before I retired with my diagnosis of MS. Few patients had any idea of the vast quantities of sugar they were eating, and were frequently shocked to find out. Motivation followed.

    Whatever the various opinions about the “right” MS diet surely the one thing everyone can agree on is that pwMS would be well advised to reduce their intake of added sugar to as close to zero, that is very close, as possible. It’s the next best thing to quitting smoking.

    That the RDA for sugar remains 90g a day shows how far we have to go.

    1. I loved your Lifestyle and MS – Research Talk which I watched on youtube via the MS Society’s channel a few days ago. Very inspiring as well!

    1. Yes those ‘unscientific’ dietary guidelines that no-one follows! If we all followed the guidelines there would be no obesity epidemic. Problem is overeating too much food, and over abundance of so called ‘junk foods’ which contain too much sugar and fat (the combination of these being problem) and which promote overeating. Show me where in the guidelines it tells us to do this? Plus obesity is far too complex to blame one food group. It is much deeper than this involving societal issues, poverty, education etc. It’s very easy from a position of privilege to say ‘don’t eat that tinned meal, or cheap pasta’

  11. While advocating for taking vitamin D is laudable, it would be much more valuable to specify that an internal serum concentration of 100 nmol/L of vitamin D has optimal immune regulation benefits.

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