Are we heading for a sugar crash?

New research has shown that people who eat a diet that is high in sugar are more than twice as likely to die from heart disease. With statistics showing that our sugar intake has increased dramatically over the last 10 years, it's time we got sugar smart. So what are the different types of sugar? How do we know if it's been added to our food? And are sweeteners a healthy alternative?

• Toxic? Sugar is often touted as being toxic. Although excess sugar damages our body, this does not mean that sugar itself is toxic. It simply means that eating it in excess, as with many other things, isn't good for us. Nevertheless, as most Irish people are eating sugar in excess, it is harming their health. By World Health Organisation (WHO) standards we're eating three times too much. To put it into real terms - the average person eats over 130 teaspoons of sugar each week, or nearly 20 teaspoons of the white stuff each day. One of the reasons for this is that sugar is easy to overeat when it is within our food. For example, four jellies provides five teaspoons of sugar, which is easier to eat in jelly form, but more challenging to eat off a spoon. Therefore, it is necessary to look at the foods you eat on a day-to-day basis and make changes.

• What is sugar? Sugar is a carbohydrate. Carbohydrate can be a sugar. What makes them different is how many sugar molecules the carbohydrate contains. When the molecules are short in length, they are called 'simple carbohydrates' or 'sugar'. When they are longer in length, they are called 'complex carbohydrates' or more often just 'carbohydrates'.

We need to eat carbohydrates. Both complex carbohydrates and simple sugars are used to create glucose which is the preferred fuel source for the brain. They are also the energy source we use when our heart rate rises, we are out of breath and being active.

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Dietitian Orla Walsh

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When it comes to optimising health, it's important to tailor the amount of carbohydrate we eat to our body's needs. It's also important to eat the healthiest carbohydrates to ensure that the carbohydrate is being delivered to the body slowly, so that the body can use the carbohydrate that is provided for energy without having to struggle to control the excess.

When the bloodstream contains too much carbohydrate or too little, or is fluctuating, energy levels suffer. This can result in low energy levels and energy slumps across the day. Not only can this negatively effect mood, it can also lead to sugar cravings. This is why many people find themselves hunting for something sweet at 11am, 3pm and 8pm to go with their tea or coffee. They're simply trying to bring their energy levels back up. Unfortunately this often leads to a three-hourly cycle of eating, where the focus is on sweet foods.

Getting out of this cycle can seem daunting. However, it's not as hard as people think. The first step is to be mindful of the quantity of carbohydrate you're eating and the quality of the food which is the vehicle that supplies it. The healthier choice when it comes to complex carbohydrates is the foods that contain the most fibre. Although many people wish to go 'sugar-free', this is challenging as even some of the healthiest foods may naturally contain a little bit of sugar.

• What is the difference between natural sugar and free sugar? Free sugars are the sugars that have been added to foods by the factory, cook or person eating the sugar. They're also the simple sugars that are naturally found in honey and fruit juice. For example, two to three gulps of fruit juice contains the same amount of free sugar as eating one teaspoon of sugar.

Natural sugars, on the other hand, are found within milk and whole fruit. They have not been added to these foods. They are not considered a 'free sugar' as they're protected within the matrix of the food. For example, the natural sugar found in fruit is within the fruit's cells. When the fruit is juice, the sugar is released from the fruit's cells and is then considered 'free sugar'.

WHO recommends that free sugar intake should account for no more than 5pc of your daily calorie intake. Based on average population diets, this equates to less than 25g of sugar for a woman eating 2,000 calories a day and less than 31g of sugar for a man eating 2,500 calories a day - about six teaspoons of sugar for a woman and about eight teaspoons for a man.

• Does eating sugar make you fat? It has become crystal clear that if you are overweight you are at greater risk of conditions and diseases such as high blood sugar levels, high blood pressure, high cholesterol, heart disease, stroke, arthritis, gallbladder disease, sleep apnoea, breathing problems, certain cancers and mental illnesses.

For example, the risk of diabetes increases by about 90pc for every 5 kg/m2 increase in body mass index (BMI). In real terms this is the risk associated with gaining two stone.

The impact of sugar on weight was reported by a surveillance study which described trends in free sugar intake and BMI. They found that BMI increased as free sugar intake increased in both males and females and across all age groups and all weight categories. This has been replicated in other studies. In fact when a systematic review was conducted analysing the available data on this topic, they found that when someone reduced their intake of free sugars there was an associated decrease in body weight. It is not surprising that it works both ways. A further analysis of trials found that when the amount of free sugar consumed increased, so too did weight.

Therefore it is becoming clear that the more overweight you are, the sicker your body is likely to become, and the more free sugar you consume the more likely you are to be overweight.

• Does sugar cause heart disease? Free sugars are a controversial and hotly debated topic. As mentioned above, free sugar intake may lead to being overweight which can lead to disease. However, research suggests that free-sugar intake and disease may have an even more direct link.

For example, heart disease is Ireland's No 1 killer. A study conducted over 15 years showed that people who have daily diets that were high in sugar were more than twice as likely to die from heart disease as those whose diets were lower in free sugar. This is a significant result that needs to be made clearer to all those at risk of developing heart disease and certainly to all those diagnosed with heart disease.

Although research suggests that overweight bodies are less able to manage excess sugars, a somewhat ground-breaking study found that in just three months healthy people following a high sugar diet can experience alterations in their fat metabolism, increasing their risk of heart disease. The study suggests that the liver deals with fat differently on a high sugar diet than it does on a lower sugar diet. They found that the alterations in fat metabolism was comparable to people who have non-alcoholic fatty liver disease.

• Does high sugar cause diabetes? At least one in every 15 Irish people has developed diabetes and worryingly at least one in five Irish people is developing diabetes. Diabetes is when the body struggles to manage the carbohydrate and sugar that is eaten. Therefore research has aimed to investigate whether carbohydrates and sugars are involved in the development of diabetes.

A systematic review assessed all longitudinal studies to see if there was a relationship between carbohydrate intake and diabetes, among other conditions. They reported that compared with rare consumers of whole grains, those consuming three to five servings of whole grains each day had an 26pc lower risk of type 2 diabetes. They also had a 21pc lower risk of heart disease and gained consistently less weight over an eight to 13-year period. Therefore it looks like wholegrain carbohydrates are not to blame.

A different systematic review investigated the relationship between fruit juice and risk of type 2 diabetes. What they found was that a higher intake of sugar-sweetened fruit juice was significantly associated with risk of type 2 diabetes while intake of 100pc fruit juice was not. This study was further supported by another piece of research showing that those who drank sugar-sweetened beverages daily had a 26pc greater risk of developing type 2 diabetes when compared to those who didn't. Therefore when it comes to the risk of diabetes the free sugar that is within our diet appears to be having the greatest impact on diabetes risk.

• How do you know if a food is low in sugar? The ability to read labels can have a significant impact on your health. If you can read a label, and know what you need to be looking out for, you can make a more informed and healthier choice. Not all processed foods and carbohydrates are unhealthy. Consider both the sugar and fibre content when making your choice.

A food is high in sugar if it has more than 22.5g 'of which sugars' per 100g and it is considered low in sugar if it has less than 5g 'of which sugars' or less per 100g. A food is high in fibre if it contains greater than 6g of fibre per 100g. Therefore if, for example, your breakfast cereal, contains less than 5g of sugar per 100g and more than 6g of fibre per 100g, it is a healthy choice.

Each 4g of sugar is equivalent to 1 teaspoon of sugar. Often people are surprised by the foods that are racking up their sugar intake. Most people know that there are over 12 teaspoons of sugar in certain fizzy drinks, 10 teaspoons of sugar in cartons of fruity drinks and eight teaspoons of sugar in a lot of chocolate bars. The bigger shockers are the two to three teaspoons of sugar found in most flavoured yoghurts, bowls of cereal and baked beans. When combined with a glass of fruit juice most people have their sugar quota met, and then some, before they've even left their house in the morning.

• Are sweeteners preferable to sugar? A systematic review looked at the published research on the effect of artificial sweeteners on weight and a range of medical conditions. This type of review is great at collating large amounts of data. They tend to be high quality, but only as long as the quality and strength of the underlying evidence is high quality. In addition, variation between studies can lead to producing results that have simply occurred by chance. Therefore, as with all areas of research, this isn't 100pc conclusive and scientists will continue to investigate further for a greater understanding and a more concrete answer.

The researchers included data from randomised controlled trials (RCTs) and cohort studies. RCTs look at the difference between taking artificial sweeteners and not taking them. There were seven RCTs included in this review. In these scenarios they looked at sweeteners taken daily as a capsule or in 'diet drinks' and a placebo. The sweeteners did not contain any calories. The time frame for investigation ranged from six to 24 months. The RCTs reported that sweeteners did not have any impact on weight.

The cohort studies, on the other hand, followed a group of people over a time frame varying from nine months to 38 years to see if there is any link between their artificial sweeteners and particular outcomes. The researchers grouped adults into highest and lowest sweetener intake. This large review included 30 cohort studies each containing different numbers of people ranging from approximately 350 to 100,000. The cohort studies reported that those who consumed the most artificial sweeteners had a:

* 14pc increased risk of diabetes

* 14pc increased risk of stroke

* 12pc increased risk of high blood pressure

* 31pc increased risk of metabolic syndrome which is a combination of high blood pressure, abdominal obesity and diabetes

Interestingly, the cohort studies found that those who had a lot of sweeteners within their diet had an increase in BMI, obesity and waist circumference when compared to those who completely avoided sweeteners.

This review contained studies that had flaws such as variability in study design, low number of participants, bias, poor blinding, unknown drop-out rates, unknown control over other factors, poor recall etc. However, it is the job of any health care professional to 'first do no harm'.

Therefore based on the evidence above, we should aim to reduce sweet foods and drinks within the daily diet, whether natural or artificial.

To see if the sugar has been added to the food or if it's natural sugar, check the ingredients list. But be aware, sugar has many names. Check out the list below and keep it handy when you go shopping.

Free sugars include

* Anything ending in -ose

* Simple table sugar

* Sugar cane, beet sugar, coconut sugar etc

* Golden syrup or other syrups such as agave, maple

* Molasses or treacle

* Honey

* Fruit juice

Free sugars don't include

* Lactose in milk & dairy products

* Sugar naturally present in fruit, including dried, canned and stewed

* Sugar naturally present in vegetables

* Sugar naturally present in grains and cereals

* A problem with food labels is that they do not clearly distinguish between free sugars and naturally occurring sugars. Sometimes a food product may appear higher in sugar despite not containing any added sugars. Muesli is a perfect example. If you look at the back of the pack, you may see that the muesli contains about 11g 'of which sugars' per 100g. That's 11pc sugar. However, if you look at the ingredients list you can see that no sugar has been added.

Ingredients: Oat flakes, Toasted wheat flakes, Raisins (15%), Skimmed Milk Powder, Hazelnuts (1.5%),Almonds (1%).