Fructose Consumption—Free Sugars and Their Health Effects
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Background: The excessive consumption of free sugars, including fructose, is considered a cause of overweight and metabolic syndrome throughout the Western world. In Germany, the prevalence of overweight and obesity among adults (54%, 18%) and children (15%, 6%) has risen in the past few decades and has now become stable at a high level. The causative role of fructose is unclear.
Methods: This review is based on publications retrieved by a selective search in PubMed and the Cochrane Library, with special attention to international guidelines and expert recommendations.
Results: The hepatic metabolism of fructose is insulin-independent; because of the lack of a feedback mechanism, it leads to substrate accumulation, with de novo lipogenesis and gluconeogenesis. Recent meta-analyses with observation periods of one to ten weeks have shown that the consumption of fructose in large amounts leads to weight gain (+ 0.5 kg [0.26; 0.79]), elevated triglyceride levels (+ 0.3 mmol/L [0.11; 0.41]), and steatosis hepatis (intrahepatocellular fat content: + 54% [29; 79%]) when it is associated with a positive energy balance (fructose dose + 25–40% of the total caloric requirement). Meta-analyses in the isocaloric setting have not shown any comparable effects. Children, with their preference for sweet foods and drinks, are prone to excessive sugar consumption. Toddlers under age two are especially vulnerable.
Conclusion: The effects that have been observed with the consumption of large amounts of fructose cannot be reliably distinguished from the effects of a generally excessive caloric intake. Further randomized and controlled intervention trials of high quality are needed in order to determine the metabolic effects of fructose consumed under isocaloric conditions. To lessen individual consumption of sugar, sugary dietary items such as sweetened soft drinks, fruit juice, and smoothies should be avoided in favor of water as a beverage and fresh fruit.
Cardiovascular diseases are still among the main causes of death in the Western world, despite a recent decline in incidence (1). They are usually due to the metabolic syndrome, whose main manifestations are predominantly truncal obesity, dyslipidemia, arterial hypertension, and impaired glucose tolerance or type 2 diabetes mellitus (2, 3, 4).
The prevalence of overweight and obesity in the Western world has risen sharply in the past few decades and has now become stable at a high level (3, 5). According to current data, 47% of all women and 62% of all men in Germany are overweight (body mass index >25 kg/m²), while 18% of all adults are obese (BMI >30 kg/m²) (6, e1, e2). Among children aged 3 to 17, 15% are overweight (above the 90th Kromeyer–Hauschild percentile), while 6% are obese (above the 97th Kromeyer-Hauschild percentile) (7, e3). Positive caloric balance and the consumption of free sugars are important contributory causes of overweight and the metabolic syndrome. The term “free sugars” refers to monosaccharides (glucose, fructose) and disaccharides (saccharose, i.e., household sugar; lactose) that are either naturally present in food and beverages or are added to them during processing. Unlike oligosaccharides and polysaccharides, free sugars are essentially a rapidly mobilizable energy source that provides little or no physiological nutritional benefit. It is recommended in the current WHO guideline that the amount of free sugars consumed should be less than 10% of the recommended daily calorie intake (RDCI) of adults and children. With an RDCI of 2000 kcal, this corresponds to 50 g of sugar (17 sugar cubes ≈ 12 teaspoons of household sugar ≈ 500 ml of orange juice) per day (Table 1). This recommendation pertains both to sugars that have been added to foods and beverages during their production and to free sugars contained naturally in honey, syrup, fruit juices, and fruit juice concentrates (8, 9). The sugar intake of children is particularly important, as they have an inborn, evolutionarily advantageous preference for sweet foods and drinks, and their nutritional requirement undergoes major shifts during infancy and the pubertal growth spurt (10). Children are more sensitive to sugar and prefer a higher sugar content in water and soft drinks than adults do (11, 12, e4, e5). Pre- and postnatal exposure to certain types of taste via the amniotic fluid and breast milk affects future taste preferences (e6, e7). Breast milk, compared to formula, offers the infant a wider variety of taste sensations and seems to promote children’s acceptance of a more diverse range of foods (13). Taste preferences and dietary habits develop largely in the first two years of life and persist throughout childhood. Children who regularly drink sweet beverages at a young age continue to prefer them when they are older. Because of this so-called flavor learning, children under age 2, whose taste preferences can still be influenced, are a vulnerable group for excessive sugar intake (10). Because of this, the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommends that children and adolescents aged 2–18 years should consume no more than 5% of their recommended daily caloric intake in the form of sugar, corresponding to 16 g of sugar (4 teaspoons) for a 4-year-old boy. Children under age 2 should consume even less sugar (Table 1) (13). At present, the actual amount of free sugars consumed as a percentage of overall caloric intake is 13–14% in adults and 15–17.5% in children, which is far above the recommended upper limit (9, 14, e8). Most of the free sugar intake in childhood is accounted for by sweets (34%) and fruit juices (22%), but sugar-sweetened beverages (SSB) play a role as well, as they have little satiating effect despite their high energy density (14, 15, e9). The individual sugar intake can be reduced by replacing sugary products such as SSB, fruit juices, and smoothies with water as a beverage and fresh fruit (Box).
In the past, emphasis was laid on the adverse metabolic effects of glucose, including elevated blood sugar levels and hyperinsulinism. In this review article, we will devote particular attention to the special metabolism of fructose and its association with the metabolic syndrome and with steatosis hepatis, and we will discuss the preventive measures that can be taken.
This review is based on pertinent publications retrieved by a selective search in PubMed and the Cochrane Library, with special attention to international guidelines and expert recommendations. The following search terms were used: “fructose AND weight gain AND obesity,” “fructose AND hypertension AND uric acid,” “fructose AND metabolism AND triglycerides AND insulin,” and “fructose AND non-alcoholic fatty liver disease.” Clinical trials and meta-analyses from countries with a Western lifestyle, published in either English or German in the period 1987–2020, were considered.
Chemical properties and metabolism
Fructose is a ketohexose found naturally in fruits and vegetables. It plays a major role in industrial food production, e.g., as a component of saccharose or high-fructose corn syrup (HFCS). Sugared soft drinks account for much of the fructose intake. In Europe, such drinks are sweetened with household sugar (saccharose), which consists of equal portions of fructose and glucose connected by a glycoside bond. In the USA, saccharose has been replaced to an increasing extent in recent decades by HFCS, which is less expensive. HFCS is a mixture of free fructose and free glucose, with the fructose contribution varying from 42% to 55%. Fructose alone is a more powerful sweetener than saccharose (× 1.17 in comparison to saccharose) or glucose alone (× 0.67 in comparison to saccharose). Fructose also has a lower glycemic index than glucose, i.e., it elevates blood sugar to a lesser extent than glucose does (fructose: 19 vs. glucose: 100) (e10, e11, e12) (Figure 1).
Fructose, obesity, and lipid metabolism
The increasing prevalence of obesity in the Western world since the 1980s and the parallel increase in the consumption of free sugars suggest that sugar, and fructose in particular, may be playing a harmful role. This suspicion remains even though, in the past decade, the prevalence of obesity in Germany has stabilized, while sugar consumption has declined, mainly among children (4, 7, 9, 14, 16, e13).
It must be asked, however, whether fructose poses a particular danger because of its special metabolism, or whether the observed adverse effects are due merely to increased caloric intake by way of fructose. There is no question that a high caloric intake, exceeding the individual’s energy requirement over a long period of time, will lead to weight gain (17), and excessive calorie intake via fructose is certainly a major part of this. In a retrospective cohort study involving 628 children, Disse et al. found that primary fructose malabsorption, a phylogenetically impaired capacity to absorb fructose, is negatively associated with obesity (odds ratio: 0.35, 95% confidence interval [0.13; 0.97]) (18). Experiments in rats have shown weight gain with high fructose intake (20% of the total caloric requirement) under isocaloric conditions, but meta-analyses to date have not revealed any such effect on human body weight (e14, e15). In human trials, the consumption of large quantities of fructose (40% of the RDCI) in addition to the subjects’ usual diet for periods of 1 to 10 (median: 3) weeks resulted in significant weight gain (+ 0.53 kg, [0.26; 0.79]) (17, 19) (Table 2).
Aside from the adverse effect of fructose on body weight, it is also thought to adversely affect metabolism via substrate accumulation in the liver, leading to lipo- and gluconeogenesis through the activation of SREBP-1c (sterol regulatory element binding protein 1c) and ChREBP (carbohydrate responsive element binding protein) (20, e16) (eBox). Randomized trials have shown that fructose administration (20% of RDCI) leads to a mild elevation of postprandial triglyceride levels (+ 0.09 mmol/L, [0.01; 0.18 mmol/L]), while meta-analyses have shown that the intake of large amounts of fructose (median daily dose, 175 g and 193 g) significantly raises triglyceride levels (+ 0.26 mmol/L, [0.11; 0.41]) (20, 21, e17– e20). Recent meta-analyses have not revealed any adverse effects on triglyceride or HDL- and LDL-cholesterol concentrations after the consumption of fructose for seven days or longer under isocaloric conditions (22). Nonetheless, in a 10-week intervention trial involving 32 subjects, Stanhope et al. found that the long-term consumption of soft drinks containing fructose (25% of RDCI), compared to soft drinks containing glucose, led to an increase in visceral fat deposits (+ 14.0 ± 5.5 % versus 3.2 ± 4.4 %), in agreement with the animal data (e20, e21, e22).
Fructose, uric acid, and insulin metabolism
Adenosine diphosphate (ADP) is produced in the first step of fructose metabolism in the liver and is then broken down into uric acid (Figure 1, eBox). Because uric acid inhibits endothelial nitric oxide synthase, an elevated uric acid level may lead to diminished release of the vasodilator NO, resulting in arterial hypertension (23). Prospective cohort studies suggest an association between elevated uric acid levels and essential hypertension, particularly in adolescents (23, 24). In a randomized trial, the daily consumption of 200 g of fructose (32% of RDCI) in addition to the subjects’ usual diet raised the uric acid level by 65 ± 6 μmol/L, while also leading to a rise in blood pressure values in 24-hour measurements (systolic, + 6.9 ± 2.3 mm Hg; diastolic, + 4.7 ± 1.6 mm Hg). These effects were significantly counteracted in an intervention group by the administration of allopurinol at a daily dose of 300 mg (uric acid level, − 113 ± 12 µmol/L; systolic blood pressure, + 2.1 ± 1.2 mm Hg; diastolic blood pressure, + 1.0 ± 0.8 mm Hg), in accordance with the findings of animal experiments involving a high fructose intake (60% of overall caloric intake) (25, e23). In a review article, elevation of the uric acid level (+ 31 µmol/l, [15.4; 46.5]) was demonstrated only after the consumption of very large amounts of fructose (> 200 g per day) (26). A meta-analysis of three prospective cohort studies involving more than 200,000 subjects did not reveal any correlation between fructose intake and arterial hypertension; in contrast, Kelishadi et al., in another meta-analysis, found an association between fructose consumption and elevated systolic blood pressure, although they did not evaluate the mean fructose dose (27, 28) (Table 2). Finally, a Cochrane Library study found insufficient evidence for the efficacy of blood pressure reduction by drugs that lower the uric acid level (29).
In summary, there is no clear evidence that fructose adversely affects uric acid levels and arterial blood pressure under isocaloric conditions, but very large amounts of fructose can indeed affect both of these parameters adversely.
Fructose has a low glycemic index and thus does not affect the blood glucose level or the insulin level to any substantial extent. For this reason, fructose was long held to be an ideal sweetener, especially for patients with impaired glucose tolerance (30, e24). Epidemiologic data suggest an association of fructose consumption with type 2 diabetes. For example, a meta-analysis of prospective cohort studies showed that persons who drink sugary beverages several times a day are more likely to develop type 2 diabetes mellitus (relative risk: 1.26 [1.12; 1.41]) (31). Romaguera et al. found a positive association between soft drink consumption and the incidence of type 2 diabetes mellitus, even after adjusting for caloric intake and BMI (hazard ratio: 1.18 [1.06;1.32]) (32). Ter Horst et al., in a meta-analysis of trials of at least six days’ duration, found that fructose consumption under isocaloric conditions led to hepatic insulin resistance (standardized mean difference [SMD]: 0.47, [0.03; 0.91]), while the consumption of fructose in a median dose of 184 g per day under hypercaloric conditions led not only to hepatic insulin resistance (SMD: 0.77, [0.28; 1.26]), but also to mildly elevated fasting insulin levels (+ 3.38 pmol/L, [0.03; 6.73 pmol/L]) (33).
There are as yet no reliable clinical data showing a clear correlation between fructose consumption and the development of type 2 diabetes mellitus, because fructose consumption in the available studies was always coupled with glucose consumption, in the form of either saccharose or high-fructose corn syrup.
Fructose and non-alcoholic fatty liver diseases
Fructose, which is metabolized mainly in the liver, is thought to be a contributing factor in the development of non-alcoholic fatty liver diseases (NAFLD). The overall category of NAFLD can be further broken down into potentially reversible non-alcoholic fatty liver (NAFL), defined by a fat concentration of more than 5% of the weight of the hepatic parenchyma, and non-alcoholic steatohepatitis (NASH), where mixed-cell inflammatory infiltrates and ballooned hepatocytes are seen in addition (34). The prevalence of NAFLD in industrialized countries around the world is estimated at 20–30%; it is positively correlated with the metabolic syndrome and with hyperalimentation (abdominal girth, body mass index, triglyceride levels), and it can progress to cirrhosis or hepatocellular carcinoma (35, 36). Fructose is held to be a contributing factor in the development of steatosis hepatis that can itself lead to hepatic energy overload and thus also to increased amounts of fat in the hepatocytes (Figure 2) (e25). Retrospective data, some of which are controversial, show higher fructose consumption among patients with NAFLD, as well as an effect on the degree of fibrosis of the liver (e26, e27, e28, e29). In a case-control study, Abid et al. showed that 80% of the NAFLD patients consumed more than 500 mL of soft drinks per day, compared to only 17% of the normal control subjects. Soft-drink consumption was found to be a good predictor of NAFLD in their regression model (odds ratio: 2.0) (37). Two meta-analyses have dealt with the relation between fructose consumption and steatosis hepatis. Chiu et al. and Chung et al., analyzing reported trials in which fructose was given in isocaloric exchange with other carbohydrates, found no effect of fructose on intrahepatocellular fat content or on the alanine aminotransferase (ALT) level; but, in contrast, hypercaloric fructose intake (+ 25–35% of RDCI) affected both parameters adversely compared to an isocaloric diet (intrahepatocellular fat content: + 54% [29; 79%], ALT: + 4.94 U/L [0.03; 9.85]) (38, 39) (Table 2). Such effects were found with the hypercaloric administration of either fructose or glucose, implying that the excessive caloric intake accounts for the observed effects (38). The informative value of meta-analyses is limited, however, by the heterogeneity of the constituent trials, the controversial state of the evidence, and the often short follow-up intervals. It cannot be stated with certainty whether fructose itself affects human metabolism adversely, or whether such effects are due solely to the excessive caloric intake when large amounts of fructose are consumed. The latter hypothesis is supported by the fact that meta-analyses have revealed adverse metabolic effects mainly in trials with a hypercaloric design.
The high prevalence of overweight and obesity associated with the metabolic syndrome is a problem around the world. In addition to lack of exercise, an important contributing cause is the consumption of large amounts of free sugars, which should be avoided in small children in particular, as their taste preferences can still be influenced. Fructose, either by itself or as a component of common household sugar, plays a special role, as it is mainly metabolized in the liver. Current evidence indicates that very high fructose consumption has adverse metabolic effects, but it remains unclear whether these are due to fructose itself or to the associated increase in caloric intake. Meta-analyses of trials conducted in an isocaloric setting have not confirmed any such effects, or any effect on steatosis hepatis and hepatocellular damage (Table 2). There is a general lack of methodologically sound, prospective, randomized, and controlled clinical trials, with adequate patient numbers and a sufficient follow-up duration, with which the possible adverse effects of fructose consumption could be studied. Individual sugar consumption can be lowered by replacing sugary items such as sugared soft drinks, fruit juices, and smoothies with water as a beverage and fresh fruit (Box). On the population level, health-promoting behavior can be reinforced with public information, food quality ratings, and taxes placed on products with added sugar.
Conflict of interest statement
The authors state that they have no conflict of interest.
Manuscript received on 29 April 2020 and accepted after revision on 3 October 2020.
Translated from the original German by Ethan Taub, M.D.
Dr. med. Sebastian Stricker
Allgemeine Pädiatrie und Neonatologie
Zentrum für Kinderheilkunde und Jugendmedizin
Feulgenstr. 12, 35392 Giessen, Germany
Cite this as: Stricker S, Rudloff S, Geier A, Steveling A, Roeb E, Zimmer KP: Fructose consumption—free sugars and their health effects. Dtsch Arztebl Int 2021; 118: 71–80. DOI: 10.3238/arztebl.m2021.0010
Department of Gastroenterology and Hepatology, University Hospital Wurzburg: Prof. Dr. med. Andreas Geier
Department of Internal Medicine A (Nephrology, Rheumatology, Gastroenterology, Endocrinology), University of Greifswald: Dr. med. Antje Steveling
Gastroenterology, Medical Clinic II, Justus-Liebig-University of Gießen: Prof. Dr. med. Elke Roeb
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