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A Harvard Medical School Special Health Report
Reducing Sugar and Salt:
Strategies for minimizing risks to your health
In this report:
Sodas and juice
Salt and sodium
What the labels mean
Self-defense: Sugar-
reducing strategies
Recipes
SPECIAL SECTION
Blood pressure matters
Price: $29
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This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/REDUCING SUGAR AND SALT
SPECIAL HEALTH REPORT
Contents
Medical Editor A brief history of sugar and salt . . . . . . . . . . . . . . . . . . . . . .2
Teresa Fung, ScD, RD.
Adjunct Professor of Nutrition, The lowdown on sugar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Harvard School of Public Health
Editor Rise and fall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
P.J. Skerrett Insulin resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Copy Editor Glycemic index: The type of carbohydrate matters . . . . . . . . . . . . . 8
Robin Netherton Factors that affect a food’s glycemic index . . . . . . . . . . . . . . . . . . 8
Art Director
Nieves Jenkins
Glycemic load: Measuring the full effect . . . . . . . . . . . . . . . . . . . . 8
Creative Director Beyond the glycemic load . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Judi Crouse Sodas and juice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Illustrators Reducing sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Scott Leighton, Jason Laramie
Published by Harvard Medical School Salt and sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Anthony L. Komaroff, M.D., Editor in Chief Sodium in excess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Edward Coburn, Publishing Director Sodium reduction helps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
In association with
A salt step-down in the works . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Belvoir Media Group, LLC, 800 Connecticut Avenue, Nor-
walk, CT 06854-1631. Robert Englander, Chairman and SPECIAL SECTION: Blood pressure matters . . . . . . . . . . . 18
CEO; Timothy H. Cole, Executive Vice President, Editorial
Director; Philip L. Penny, Chief Operating Officer; Greg Understanding the numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
King, Executive Vice President, Marketing Director; Ron Goldberg,
Chief Financial Officer; Tom Canfield, Vice President, Circulation. A call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Copyright ©2012 by Harvard University. Written permission is Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
required to reproduce, in any manner, in whole or in part, the
material contained herein. Submit reprint requests in writing to: Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Harvard Health Publications
10 Shattuck St., 2nd Floor, Boston, MA 02115 Self-defense: Sugar-reducing strategies . . . . . . . . . . . . . . 23
617-432-1485 Fax: 617-432-4719 Do some detective work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Web Site Say no to liquid calories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
For the latest information and most up-to-date publication
list, visit us online at www.health.harvard.edu.
What about artificial sweeteners? . . . . . . . . . . . . . . . . . . . . . . . 25
Customer Service
Other strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
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ing, address changes, billing problems) call 877-649-9457, Self-defense: Conquering your salt habit. . . . . . . . . . . . . . 28
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Big Sandy, TX 75755-9308. Recipes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
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This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/Dear Reader,
Salt and sugar are two of the most humdrum items in kitchen cupboards. But they have been
centers of controversy in academic debates and arguments over public health policies as ex-
perts dispute the hazards of taking in too much of these nutrients and the benefits of cutting
back. In just the last few years, the evidence of how much harm these tasty flavor enhancers
can do has become undeniable.
It’s not the spoonful of sugar at breakfast or the dash of salt at the dinner table that are the big
worries. Instead, it’s the sugars added to sweetened beverages, juices, desserts, and cereals, and
the salt hidden in prepared foods. We need zero added sugar because we get all the sugar we
need from what’s naturally in food, and because the body can make blood sugar from almost
any carbohydrate-containing food. Yet added sugars now provide almost 20% of the average
American’s daily calories. We need only a scant amount of sodium—less than one gram a day
(about 1/30th of an ounce)—to survive. But because it is in so many of the processed foods we
have come to rely on, we take in an average of about 3.5 grams of sodium a day.
Why are the excesses of sugar and salt an issue? Added sugars provide so-called empty calo-
ries, energy with no other nutritional value. There is mounting evidence that they are helping
fuel the astronomical rise in obesity and diabetes in the United States and around the world.
Too much salt can lead to high blood pressure and related health problems like stroke, heart
disease, and kidney failure.
We can’t blame salt and sugar for tasting good. They are, after all, key stimulators of our taste
buds, and for sound evolutionary reasons. Sugar’s sweetness represents caloric energy, the fuel
of life. And every cell in the body needs the sodium in salt. But the consequences of overdoing
them are visible all around us.
This report aims to help you make your own decisions by explaining the serious health risks
associated with taking in too much sugar and salt and offering ways to reduce their use with-
out sacrificing taste.
Sincerely,
Teresa Fung, Sc.D.,RD
Adjunct Professor of Nutrition, Harvard School of Public Health
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/A brief history of sugar and salt
S ugar and salt are inexpensive ingredients that are
ubiquitous in the food supply. That hasn’t always
been the case.
As a result, two commodities that were once hard
to come by are now almost impossible to avoid. “In
recent years,” researchers commented in the jour-
Sugar started out as a hard-to-come-by ingredient. nal Nature in 2012, “sugar has been added to virtu-
Throughout most of human history, it was available ally every processed food, limiting consumer choice.
only when fruit ripened or bees had been busy. But Nature made sugar hard to get; man made it easy.”
once the technology of extracting sugar from plants Why is this a problem? As described more fully in
evolved—first from sugar cane and then from beets— the following chapters, too much of a good thing can
sugar not only became abundant but also helped be hazardous to health. The average American takes in
direct the course of history, leading in the New World more than 350 calories a day from added sugars, often
to colonies, plantations, and the scourge of slavery. in soda, energy drinks, and other sweetened bever-
Salt was once so difficult to get that it was used ages. Those empty calories are contributing to the obe-
as currency. In some early economies it was worth its sity problem in the United States. About one-third of
weight in gold. The word salary comes from the Latin American children and more than two-thirds of adults
“salarium,” which means salt money. It is thought to are overweight or obese. Excess weight is strongly
refer to part of the pay given to Roman soldiers to buy linked to the development of diabetes, heart disease,
salt. Cities were built around salt deposits; wars have some cancers, osteoarthritis, and more. Too much salt
been fought over it. is a key contributor to high blood pressure (hyperten-
Today, sugar and salt are produced in vast quan- sion). By age 65, more than half of Americans have
tities. According to estimates by the U.S. Department high blood pressure; after age 75, three-quarters have
of Agriculture and the U.S. Geological Survey, in 2011 it. People with high blood pressure are more prone to
the world produced nearly 200 million tons of sugar having a stroke or heart attack or developing heart
and 320 million tons of salt. failure or kidney failure.
It only makes sense that cutting back on added
sugars can help cut calories. And a compelling study
Table 1 Comparing salt and sodium
published in The New England Journal of Medicine
By weight, table salt (sodium chloride) is about 40% sodium. estimated that if Americans as a whole cut back salt
This table can help you convert between teaspoons of salt and
milligrams of sodium. intake by ½ teaspoon a day (about 1,200 milligrams
SALT SALT SODIUM
of sodium; see Table 1, left), that small change would
(TEASPOONS) (MILLIGRAMS) (MILLIGRAMS) prevent up to 99,000 heart attacks, 66,000 strokes, and
¼ 1,450 600 92,000 premature deaths each year.
½ 2,900 1,200
Becoming aware of how much sugar and sodium
you consume, and finding ways to adjust them health-
¾ 4,250 1,800
fully, are good strategies for your health. In the following
1 5,800 2,300
pages we’ll show you how to do that.
2 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/The lowdown on sugar
A ll sugars, from refined white sugar to honey and
agave nectar, are a type of carbohydrate. Carbo-
hydrates are chemical compounds that contain only
exchange, turning simple and complex carbohydrates
into glucose. If needed, our bodies can even turn pro-
tein and fat into blood sugar.
three elements—carbon, hydrogen, and oxygen—in a When you eat a bowl of white rice, a slice of
dizzying array of combinations. Sugars and other car- whole-grain bread, or an orange, the body breaks
bohydrates are the main nutrient in bread, pasta, cere- down digestible carbohydrates into sugar molecules.
als, beans, vegetables, and dairy foods. Glucose is rapidly passed into the bloodstream and
Once upon a time, the only sugars we consumed delivered to cells from the brain to the toes. Leftover
were those naturally in the foods we ate. Today, much glucose can be linked into long chains called glycogen
of the sugar in our food supply has been put there and stored in the liver for later use, or converted into
by humans. The USDA began to use the term “added fat and stored in fat cells. The speed with which a car-
sugars” in 2000 to help consumers identify foods that bohydrate-containing food becomes blood sugar can
have added calories with no added nutrition. Added influence weight and long-term health.
sugars—white sugar, brown sugar, maple syrup, honey,
molasses, high-fructose corn syrup, and more—now
represent 16% of the total calories we consume. In Rise and fall
other words, about one-sixth of our calories have no Picture a roller coaster track—plenty of ups and
nutritional value. Added sugar has been linked to an downs, some high and steep, others low and gentle.
overall decline in the quality of the U.S. diet, as well That’s essentially what your blood sugar and insulin
as to weight gain and increases in obesity and heart levels look like over the course of a day. Meals and
disease. The latest Dietary Guidelines for Americans snacks cause highs that drop to lows later on. Learning
took aim at sugars added to foods during processing to eat in a way that makes your blood sugar levels look
in food plants, in the kitchens of restaurants, and even more like a kiddie coaster than a wild, breathtaking
at our breakfast tables. ride can make a difference to your health.
Chemists initially divided carbohydrates into two Because every cell in the body depends on
groups: simple and complex. Simple carbohydrates instant access to just the right amount of blood sugar,
included sugars like glucose (sometimes called dex- Goldilocks-like mechanisms are in place to make sure
trose), fructose (fruit sugar), lactose (milk sugar), that blood sugar doesn’t rise too high or fall too low.
and sucrose (table sugar). Complex carbohydrates Sometimes, though, they can be overwhelmed.
were made up of interlocking chains of sugar mole- A rise in blood sugar stimulates the pancreas to
cules, like those found in starch and fiber. Simple ver- release insulin into the bloodstream. This hormone tells
sus complex is a perfect division for chemists, but it cells to absorb glucose; without insulin, they can’t take
doesn’t at all explain how carbohydrates affect health. it in. The higher the blood sugar level, the more insu-
Our bodies rely on just one type of sugar—glu- lin released. As cells sponge up glucose, the amount of
cose. But we never need to eat glucose, or any sugar glucose in the bloodstream begins to drift downward,
for that matter, since the body can turn many kinds followed by the amount of insulin (see Figure 1, page
of food into glucose. Think of glucose as the univer- 4). As blood sugar approaches the lowest safe level, the
sal currency of the body’s carbohydrate economy, and pancreas begins releasing another hormone, called glu-
the organs of the digestive system as a 24/7 currency cagon. It tells the liver to start breaking down glycogen
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 3
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/Carbs matter Here’s where the type of carbohydrate comes into
play. A meal or snack containing foods that the body
Carbohydrates contribute about half of all calories
to a typical American diet. A worrisome half of these immediately converts into glucose (like white bread
“carbohydrate calories” come from eight sources, none or white rice) causes a rapid, high spike in blood
of which even remotely qualifies as a health food. All sugar. That’s followed by an equally high spike in insu-
are chock-full of rapidly digested carbohydrates. lin (see Figure 1, below). But a big jolt of insulin can
1. Soft drinks, sodas, and fruit-flavored drinks quickly drive blood sugar down to or below the safe
2. Cake, sweet rolls, doughnuts, and pastries zone. If there isn’t any more digestible carbohydrate
3. Pizza in the stomach or intestines, the gut and brain send
4. Potato chips, corn chips, and popcorn out signals that get you looking for something more to
5. Rice
eat—while at the same time the liver is breaking down
glycogen and pumping glucose into the bloodstream.
6. Bread, rolls, buns, English muffins, and bagels
Easily digested carbohydrates are abundant in
7. Beer
the American diet (see “Carbs matter,” left). They are
8. Frozen potatoes and French fries thought to contribute to weight gain because they trig-
ger hunger signals relatively soon after eating. In addi-
and release the resulting glucose into the bloodstream. tion, the glut of insulin that follows a high spike in blood
This provides a steady supply of blood sugar for the sugar prompts the body to convert glucose into fat.
brain and other cells. That release of stored glucose is A meal or snack of slowly digested carbohydrates
why you can go for hours, or even days, without eating (like whole grains or beans) smooths out the blood
and your cells still have a steady supply of fuel. sugar–insulin roller coaster. The digestive system takes
Figure 1 Blood sugar roller coaster
Easily Digested Carbohydrate Slowly Digested Carbohydrate
Insulin Insulin
Blood Glucose Blood Glucose
Change in blood sugar, insulin
Change in blood sugar, insulin
0 1 2 3 4 5 0 1 2 3 4 5
Time (hour) Time (hour)
How blood sugar and insulin rise and fall in the bloodstream depends on the type of carbohydrate that is being digested.
Source: Eat, Drink, and Be Healthy (Free Press, 2005)
4 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/longer to break down these carbohydrates into sugar levels for longer periods. Over time, this can damage
molecules (see Figure 1, page 4). That means blood nerves, blood vessels, and other tissues. It also makes
sugar rises more slowly and hits a lower peak, as does the pancreas produce more and more insulin after
insulin. This is good for health (see “Insulin resis- every meal or snack in an effort to help cells to absorb
tance,” below). It also means it takes longer to get hun- blood sugar. As an overworked pancreas wears out,
gry again. insulin production slows. This causes blood sugar to
Among people with diabetes, high levels of blood skyrocket after eating and to remain high for longer
sugar and insulin contribute to many of the compli- periods. These are signs of type 2 diabetes (once called
cations of this disease, such as nerve damage, loss adult-onset diabetes and non-insulin-dependent dia-
of vision, kidney disease, sexual dysfunction, and betes). In 1980, about six million Americans had dia-
wounds that won’t heal. Routine high blood sugar and betes. Today, it affects more than 25 million, one-third
insulin can also pose problems for seemingly healthy of whom don’t know they have it.
individuals. They can tip people toward developing Insulin resistance isn’t just a blood sugar problem.
diabetes. Research suggests they may also contribute It has also been linked with a variety of other prob-
to other chronic conditions, including breast cancer, lems, including high blood pressure, high blood lev-
colon cancer, and polycystic ovary syndrome. While els of triglycerides (a type of fat), low blood levels of
smoothing out your blood sugar and insulin levels high-density lipoprotein (HDL, “good” cholesterol),
may help you prevent these conditions, the proven heart disease, and possibly some cancers.
benefits are preventing heart disease and diabetes and High blood sugar and insulin levels also contrib-
controlling weight. ute to the buildup of fat around the waist. This belly
fat (technically called abdominal fat or visceral fat)
appears to pose more of a health problem than fat that
Insulin resistance accumulates around the hips and thighs. It has been
In a healthy body, liver and fat cells immediately linked to high blood pressure, high cholesterol, high
respond to insulin’s “open up for sugar” signal and blood sugar, and heart disease (see “Do you have met-
begin to pull in glucose from the bloodstream. In a abolic syndrome?” page 6). Belly fat offers a snapshot
growing number of people, the response to this essen- that can tell you how healthy you are. Simply measur-
tial signal becomes muted. This resistance to insulin ing the waist can be useful because many people gain
causes two key problems. It keeps blood sugar at high abdominal fat as they go through midlife, even those
Is high-fructose corn syrup a special problem?
For centuries, Americans satisfied their craving for sugar Yet some people have vilified high-fructose corn syrup as
with sucrose (table sugar) from sugar cane and sugar beets, one of the key culprits behind the obesity epidemic. It’s
honey, maple sugar, and molasses. Beginning in the 1970s, an easy argument to make, since its adoption by the food
more and more of what sweetens our foods and beverages industry parallels the trajectory of obesity rates. And while
has come from corn, most of it in the form of high-fructose it’s true that the body processes fructose in a different way
corn syrup. Found in everything from sugared sodas to baby than it processes glucose, both refined sugar and high-
food, high-fructose corn syrup now makes up more than fructose corn syrup contain about the same amounts of
half of the added sugar we now consume. fructose.
Chemically, high-fructose corn syrup is very similar to So far, there isn’t any solid evidence that high-fructose corn
sucrose. Every molecule of sucrose contains one molecule of syrup is worse than any other added sugar. What’s impor-
glucose and one of fructose. High-fructose corn syrup is pure tant is keeping your intake of all added sugars in check. The
glucose mixed with pure fructose in almost equal propor- American Heart Association recommends keeping your in-
tions (about 55% fructose and 45% glucose). So it’s likely take of added sugars under 100 calories a day (24 grams, or
that table sugar and corn sweeteners have similar effects on 6 teaspoons) for women and under 150 calories (36 grams,
blood sugar, insulin, and metabolism. or 9 teaspoons) for men.
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 5
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/who are not gaining weight. A waistline that expands
Do you have metabolic syndrome?
more than two or three inches over the years should
Metabolic syndrome, a cluster of conditions that occur
trigger a warning that you need to reevaluate your
together, increases the risk of heart disease, stroke, and
diabetes. One of its key features is a large waist. If you diet and physical activity levels. To see how your waist
have one, you’re more likely to have the other character- measurement stacks up, see Figure 2, below.
istics. Four main factors contribute to insulin resistance.
You have metabolic syndrome if you have three or more One of them can’t be controlled, but the other three can.
of these five traits: ■ Genes. Insulin resistance is more common
1. Waist circumference more than 35 inches in among Native Americans, Pacific Islanders, and other
women or 40 inches in men people of Asian heritage than it is among those of
2. Fasting blood triglyceride level of 150 milligrams/ European descent. Although you can’t change your
deciliter (mg/dL) or higher genes, you can beat a genetic predisposition to insulin
3. HDL (“good”) cholesterol of less than 40 mg/dL in resistance by staying lean, being physically active, and
men or less than 50 mg/dL in women eating a healthful diet.
■ Weight. The further you stray from a healthy
4. Systolic blood pressure (the top number of a read-
ing) of 130 mm Hg or higher, or diastolic pressure
weight, the harder it is for your body to handle glu-
(the lower number) of 85 mm Hg or higher cose. One way to determine if your weight is in the
healthy range is to determine your body mass index
5. Fasting blood sugar level of 100 mg/dL or higher.
(BMI). This is a measure of weight for height. You can
(Note: You are considered to have a trait if you receive
treatment for it, even if your numbers are normal with
find your BMI in Table 2, page 7, or calculate it online
this treatment.) at www.health.harvard.edu/BMI.
Source: National Heart, Lung, and Blood Institute ■ Exercise. During exercise, muscles extract glu-
cose from the blood more efficiently, and with less
Figure 2 Check your belly
Waist circumference Waist-to-hip ratio
Just below the
bottom rib
Narrowest
part of midriff
Waist circumference can be
measured in several places.
Many researchers favor using
the top of the hip bone as
a landmark, so the tape Hips are usually
measure goes over the navel measured at the
widest circumference,
around the buttocks
Waist circumference associated Minimum waist-to-hip ratio associated
with increased health risks: with increased health risks:
For men: More than 40 inches (102 cm) For men: 0.9–1.00
For women: More than 35 inches (88 cm) For women: 0.85
6 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/help needed from insulin, than muscles do at rest. ■ Dietary fat. Although the mix of fats in the diet
The effect lasts for several hours afterward. Being a plays a small role in insulin resistance, it can make a
couch potato doesn’t do much to clear glucose from difference. A high intake of trans fat (from margarines
the bloodstream. People who aren’t very active have and prepared foods) and a low intake of polyunsatu-
higher fat-to-muscle ratios than active people, even if rated fat (from vegetable oils and fatty fish) contribute
their BMIs are in the healthy range. to insulin resistance.
Table 2 Finding your BMI
The body mass index (BMI) is an index of weight by height. The definitions of normal, overweight, and obese were established after researchers
examined the BMIs of millions of people and correlated them with rates of illness and death. These studies identified the normal BMI range as
that associated with the lowest rates of illness and death.
HEIGHT BODY WEIGHT IN POUNDS
4’10” 91–115 119–138 143–162 167–186 191+
4’11” 94–119 124–143 148–168 173–193 198+
5’0” 97–123 128–148 153–174 179–199 204+
5’1” 100–127 132–153 158–180 185–206 211+
5’2” 104–131 136–158 164–186 191–213 218+
5’3” 107–135 141–163 169–191 197–220 225+
5’4” 110–140 145–169 174–197 204–227 232+
5’5” 114–144 150–174 180–204 210–234 240+
5’6” 118–148 155–179 186–210 216–241 247+
5’7” 121–153 159–185 191–217 223–249 255+
5’8” 125–158 164–190 197–223 230–256 262+
5’9” 128–162 169–196 203–230 236–263 270+
5’10” 132–167 174–202 209–236 243–271 278+
5’11” 136–172 179–208 215–243 250–279 286+
6’0” 140–177 184–213 221–250 258–287 294+
6’1” 144–182 189–219 227–257 265–295 302+
6’2” 148–186 194–225 233–264 272–303 311+
6’3” 152–192 200–232 240–272 279–311 319+
6’4” 156–197 205–238 246–279 287–320 328+
BMI 19–24 25–29 30–34 35–39 40+
NORMAL OVERWEIGHT CLASS I OBESITY CLASS II OBESITY CLASS III OBESITY
You can calculate your own BMI with the following formula:
1. Take your weight in pounds and multiply it by 703.
2. Measure your height in inches and multiply it by itself.
3. Divide the number from step two into the number from step one. The answer is your BMI. If your BMI is less than 20 you are
underweight; between 20 to 24.9, you are at a normal, healthy weight; between 25 to 30, you are overweight; and above 30,
you are obese.
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 7
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/Glycemic index: ■ High glycemic index (70 or higher): White bread,
The type of carbohydrate matters white rice, potatoes, rice cakes, most crackers,
Classifying carbohydrates as simple versus complex bagels, cakes, doughnuts, croissants, waffles, most
does little to tell us which carbohydrate-containing packaged breakfast cereals.
foods release their sugars in a flash and which yield Choosing foods low on the glycemic index can
them more like those timed-release cold capsules you help you avoid big blood sugar highs and lows.
see on television commercials.
To find a better way, Canadian nutrition researcher
David Jenkins and his colleagues did something revo- Factors that affect a food’s
lutionary in the early 1980s—they measured how dif- glycemic index
ferent types of carbohydrate-containing foods affected Glycemic index isn’t a set, unvarying value like molecu-
blood sugar compared with pure glucose. They called lar weight. Processing and cooking methods, as well as
this comparison the glycemic index. what you eat with the food, all affect how rapidly your
Measuring glycemic index is a painstaking process body breaks down its carbohydrates and how quickly
that requires a volunteer to consume an amount of a your bloodstream absorbs the liberated glucose.
test food—whole oats, pear, black beans, ice cream, ■ Grinding grain dramatically increases how fast
and so on—that contains 50 grams of carbohydrate. digestive enzymes can attack the starch and break it
His or her blood sugar is then measured at regular apart. Wheat flour has more surface area to attack than
intervals over the next two hours. On another day, wheat berries. Most wheat flour has also been stripped
the same volunteer does the same thing, but this time of its bran—the protective, hard-to-digest, fibrous
consumes 50 grams of glucose. Then the values for the outer coat that slows the action of digestive enzymes.
food and glucose are compared, by dividing the rise in Steel-cut oats, which are sliced oat grains, have a lower
blood sugar sparked by the test food by the rise due to glycemic index than regular oatmeal, which is made of
glucose. smashed oat grains.
The higher the glycemic index, the faster and ■ The more indigestible fiber a food contains, the
more strongly the food affects blood sugar. The lower lower its glycemic index. That’s because fiber carries
the glycemic index, the lower and slower the rise in along partly digested food and protects it from diges-
blood sugar. tion. This spreads out the absorption of glucose into
Since the concept was created, researchers have the bloodstream.
measured the glycemic index of several thousand ■ Fats slow the digestive process. Eating fat with a
foods. As you can see in Table 3, page 9, the glycemic carbohydrate-rich food can temper the rise in blood sugar.
index clearly shows that not all complex carbohydrates ■ Lemon juice, vinegar, and other acidic ingredients
are good, and not all simple ones are bad. Cornflakes, also delay the rise in blood sugar after you eat a carbo-
chemically a complex carbohydrate, have a high gly- hydrate-rich food.
cemic index—in the 80s—meaning they quickly and
strongly boost blood sugar. Fructose, the simplest of
sugars, has a very low glycemic index—23—meaning Glycemic load:
it has little effect on blood sugar. It’s useful to think of Measuring the full effect
foods in three categories: The glycemic index of a food tells only part of the
■ Low glycemic index (55 or less): Most fruits and veg- story. How much of the food is consumed also affects
etables, beans, minimally processed grains, pasta, blood sugar and insulin levels. That’s why research-
low-fat dairy foods, and nuts. ers at the Harvard School of Public Health developed
■ Moderate glycemic index (56 to 69): Sweet potatoes, the concept they call glycemic load. It is calculated by
corn, white rice, pasta, some breakfast cereals multiplying a food’s glycemic index by the number of
such as Cream of Wheat and Mini Wheats. grams of carbohydrate consumed and dividing by 100.
8 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/Table 3 Glycemic index and glycemic load values for commonly eaten foods
The glycemic index and glycemic load offer information about how a food affects blood sugar and insulin. The lower the glycemic index or glycemic
load, the less the food affects blood sugar and insulin levels. Scientists have calculated glycemic index and glycemic load for more than 2,500 foods. A
sample is provided in the table below. The University of Sydney in Australia maintains a free searchable database of glycemic index and glycemic load
values at www.glycemicindex.com. The healthiest choices are those with a glycemic index below 55 and a glycemic load below 10.
GLYCEMIC CARBOHYDRATE GLYCEMIC
FOOD SERVING SIZE INDEX (%) (in grams) LOAD*
WHITE RICE 5 ounces 89 48 43
CRANBERRY JUICE 1 cup 68 35 24
SPAGHETTI, COOKED 1 cup 49 48 24
CORNFLAKES 1 cup 93 25 23
SNICKERS BAR 1 bar (2 ounces) 68 34 23
JELLY BEANS 1 ounce 80 28 22
POTATOES (WHITE), BOILED 1 cup 78 26 20
GRAPE-NUTS CEREAL ½ cup 75 22 16
COCA-COLA 12 ounces 63 26 16
CHEERIOS 1 cup 74 20 15
SHREDDED WHEAT CEREAL 2 biscuits 67 20 13
OATMEAL (ROLLED OATS) 1 cup 58 22 13
BANANA (RIPE) 1 medium 51 25 13
RAISIN BRAN CEREAL 1 cup 61 19 12
ORANGE JUICE 1 cup 46 26 12
CORN TORTILLA 2 medium 46 22 11
WHITE BREAD 1 slice 75 14 10
STRAWBERRY JAM 1 tablespoon 51 20 10
WHOLE-WHEAT BREAD 1 slice 74 13 10
PIZZA HUT SUPER SUPREME PIZZA 2 slices 36 24 9
ENGLISH MUFFIN 1 muffin 77 11 8
ALL-BRAN CEREAL ½ cup 42 21 8
BLACK BEANS 1 cup 43 23 7
APPLE (GOLDEN DELICIOUS) 1 medium 39 16 6
ENGLISH MUFFIN, WHOLE GRAIN 1 muffin 43 11 5
PUMPERNICKEL (DARK RYE BREAD) 1 slice 41 12 5
MILK, SKIM 1 cup 37 13 5
RED LENTILS 1 cup 21 18 4
TABLE SUGAR (SUCROSE) 1 teaspoon 65 4 2.6
FRUCTOSE 1 teaspoon 15 4 0.6
*Glycemic load is calculated by multiplying grams of carbohydrate by glycemic index and dividing by 100.
Source: Atkinson FS, Foster-Powell K, Brand-Miller JC. “International tables of glycemic index and glycemic load values: 2008,” Diabetes Care (2008), Vol. 31, No.
12, pp. 2281–83.
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 9
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/Take spaghetti, for example. It has a glycemic little carbohydrate per serving. Take watermelon as
index of 46. An average serving delivers 31 grams of an example. It has a high glycemic index (80), which
carbohydrate: 46 times 31 divided by 100 equals 14. might make you stay away from it. Yet as its name
As with the glycemic index, putting foods into implies, watermelon is mostly water; a cup of water-
three categories can help determine good choices and melon cubes contains just six grams of carbohydrates.
portion sizes: So the glycemic load is small, under 5.
■ Low glycemic load (10 or lower): Lentils and beans Sugary soda has a moderate glycemic index
(kidney, garbanzo, black, etc.); fiber-rich fruits and because it contains a fair amount of fructose, which
vegetables; nuts and seeds; whole grains like bar- has relatively little effect on blood sugar. But it also
ley, wheat berries, and the like. delivers plenty of carbohydrates, so it has a high gly-
■ Medium glycemic load (11 to 19): Steel-cut oatmeal; cemic load.
whole-wheat pasta and some breads; fruit juices Following a diet with a low glycemic load will help
without extra sugar; brown rice; sweet potatoes. you to make healthier food choices. And because the
■ High glycemic load (20 or higher): Soda, energy drinks, foods are typically higher in fiber and nutrients, you
and other sugar-sweetened beverages; candy; will feel satisfied longer, which can help control weight.
white rice; French fries and baked potatoes; sug-
ary breakfast cereals.
Because glycemic load includes information on Beyond glycemic load
how much carbohydrate is consumed, it is better The glycemic index and glycemic load are guides to
than glycemic index alone at capturing what’s going choosing carbohydrate-containing foods, not strict
on in your bloodstream after you eat a carbohydrate- rules. It’s also important to evaluate the other nutri-
containing food. ents in a food. Some carbohydrate-rich foods deliver
Some foods have a high glycemic index but very far more than just sugar. Fruits and vegetables offer
Figure 3 Sugar intake through sweetened drinks
300 Male Female
273
252
250
200
178
171
Calories per day
159
150 141 138
103 112
100 86
71 70 70
50 42
0
All 2–5 6–11 12–19 20–39 40–59 60 and over
Age (years)
In the United States, average consumption of sugar from sweetened beverages peaks in the teen years.
Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2005–2008.
10 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/fiber, vitamins, minerals, and plenty of active phyto- Given how much soda, fruit beverages, and other soft
chemicals. The same is true for intact or slightly pro- drinks Americans consume, almost half of the added
cessed grains. sugar in the U.S. diet comes from soft drinks and fruit
The biggest value of the glycemic load may be juices. Among youths, sugar intake from sugar-sweet-
for deciding among various options. When picking ened beverages represents nearly 15% of their daily
a snack or planning a meal, choosing foods with low intake of calories (see Figure 3, page 10).
glycemic loads is better for your insulin-making cells A number of studies have linked sugar-sweetened
and your overall health than choosing those with high drinks to weight gain and an increased risk of type 2
glycemic loads. diabetes. The most recent, a trio of reports published
in The New England Journal of Medicine, link regu-
lar consumption of sugar-sweetened beverages to the
Sodas and juice development of obesity in children, adolescents, and
Sprinkling 10 to 12 teaspoons of sugar on a bowl of adults. Other studies have found that men and women
cereal would make it much too sweet to eat. Yet accord- who regularly drank sugar-sweetened beverages were
ing to the Harvard School of Public Health’s Nutrition at increased risk of stroke and heart disease, even
Source, that’s how much sugar is in a 12-ounce can of after other unhealthful lifestyle or dietary factors were
many popular soft drinks. (See www.hsph.harvard. accounted for.
edu/nutritionsource/healthy-drinks/how-sweet-is-it Sugar-sweetened beverages generally deliver pure
for a list of the amount of sugar in popular beverages.) calories without any of the healthful nutrients you
What about fruit juice?
Fruit juice is different from sodas and other sugar- And keep in mind that not all juices are equal. Grapefruit
sweetened beverages, right? It depends on how much you juice, for example, changes the way some people absorb
drink. As an accompaniment to your breakfast, or as the and metabolize certain drugs. It can make it hard for the
occasional thirst quencher, 100% juice—not juice-flavored body to absorb some drugs, leading to lower blood levels.
sugar water—can be part of a healthy diet. Real juice This happens with the allergy medication fexofenadine (Al-
gives you some vitamins, minerals, and maybe a bit of legra); digoxin, which is used to treat heart failure; losartan
fiber. (Cozaar), used to control blood pressure; and the antican-
Keep in mind that 100% fruit juice can deliver a lot of cer drug vinblastine. Grapefruit juice can boost blood levels
calories. Twelve ounces of orange juice delivers about 150 of other drugs, sometimes to dangerous heights. Drugs
calories, the same as a similar amount of sugar-sweetened in this category include calcium-channel blockers such as
soda. If juice is part of your morning routine, use a small felodipine (Plendil), nifedipine (Procardia), and nisoldipine
glass that holds 6 ounces. (Sular), which are used to control high blood pressure; car-
bamazepine (Carbatrol, Tegretol), used to control epilepsy;
The main problem with drinking juice to quench thirst is some widely used cholesterol-lowering medications such
that many people don’t eat less to adjust for the extra cal- as lovastatin (Mevacor), atorvastatin (Lipitor), and simvas-
ories in it. That’s a surefire recipe for gradual weight gain. tatin (Zocor); cyclosporine, an immunosuppressant taken
It’s also easy to confuse 100% juice with “juice drinks,” mainly by people who have had an organ transplant; and
which are little more than juice-flavored sugar water. buspirone (BuSpar), used to fight alcohol abuse, depres-
If you use juice to quench your thirst, dilute it with regular sion, panic disorder, and a variety of other problems.
or sparkling water. Start with two parts juice to one part Something in grapefruit juice also appears to create condi-
water and gradually work your way to one part juice to tions that help form kidney stones. In the Nurses’ Health
three or four parts water. Or skip the juice altogether and Study and the Health Professionals Follow-up Study, every
add a squeeze of lemon or lime to plain or sparkling water. 8 ounces of grapefruit juice consumed a day increased
Vegetable juices are usually lower in calories than fruit the chances of developing kidney stones by 44%. While
juices, but check the label to be sure—and don’t forget to more research is needed to confirm this finding, it’s a good
make note of the sodium content. reason to limit your intake of grapefruit juice.
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 11
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/might get from real fruit juices or, better yet, fruit— insulin levels. When this happens several times a
vitamins, minerals, other phytochemicals, and in day—in addition to the blood sugar boosts that occur
some cases even some fiber. That’s a problem for sev- after eating—it can cause problems. Among women
eral reasons: participating in the Nurses’ Health Study, those who
■ Weight gain. Many people treat “liquid calories” drank one soda a day nearly doubled their risk of dia-
from sugar-sweetened beverages as somehow different betes. Among people who are insulin resistant, taking
from “food calories,” and don’t make up for the calo- in lots of easily digested carbohydrates raises the blood
ries in soda or juice by eating less. Drinking one can level of triglycerides, a kind of fat-carrying particle that
of soda a day doesn’t seem like a big deal, and prob- increases the risk of heart disease.
ably isn’t if you cut back on calories elsewhere and eat
plenty of fruits and vegetables. But if you don’t adjust
your diet, the extra 120 to 150 calories a day from a Reducing sugar
sugar-sweetened beverage could easily translate into Now that you know more about added sugars and how
higher numbers on the scale and extra fat around the they can affect health, it’s time to learn where they are
belly. and how you can cut back. Strategies for doing this are
■ Exhausting insulin. The rapidly digested sugars in described in “Self-defense: Sugar-reducing strategies,”
soda and fruit juices quickly boost blood sugar and beginning on page 23.
12 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/Salt and sodium
T o a chemist, salt is what you get when positive and
negative ions enter each other’s orbit. To the rest of
us, salt is sodium chloride, the white crystals left over
The current Dietary Guidelines for Americans
places the healthy upper limit for sodium at 2,300 mg a
day, or about 1 teaspoon of salt. That drops to no more
when seawater evaporates. than 1,500 mg a day for African Americans, individuals
The human body needs sodium for many essen- with high blood pressure (hypertension), diabetes, or
tial tasks. Nerves need it to transmit impulses. Muscle kidney disease, and anyone over age 51. The American
fibers, including those in the heart and blood vessels, Heart Association says that everyone should try to keep
need it to contract and relax. Sodium helps the body sodium intake under 1,500 mg a day.
maintain a proper fluid balance. But it doesn’t take Too much salt has been linked to health problems
much sodium to accomplish these jobs. The Yano- for centuries. About 5,000 years ago, Emperor Huang
mamo people of the Amazon rainforest get by on just Di Neijin of China wrote: “If too much salt is used for
200 milligrams (mg) of sodium a day (the amount in food, the pulse hardens.” In the modern era, Dr. Lewis
1/10th teaspoon of salt). By comparison, the average Dahl from the Brookhaven National Laboratory began
American gets 17 times more than that—3,400 mg a proposing in the 1950s that diets high in sodium con-
day (about 1½ teaspoons of salt; see Figure 4, below). tributed to high blood pressure. His hypothesis was
challenged by other researchers, and the sodium con-
troversy has raged ever since.
The long-running debate over whether cutting
Figure 4 The rise of sodium consumption back on salt in the diet has meaningful effects on
health has been mostly laid to rest. A large body of
research accumulated over the past two decades shows
4,500
clear benefits from consuming less salt—not just for
4,000 1971–1974 lowering blood pressure but also for reducing the risk
2003–2006
3,500 of stroke and heart problems (see “Self-defense: Con-
Sodium (mg/day)
3,000 quering your salt habit,” page 28).
2,500
2,000
1,500
Sodium in excess
The human body has sophisticated mechanisms
1,000 for making sure enough sodium is always available.
500 Chalk that up to two facts: every cell in the body needs
0 sodium, and sodium was scarce throughout most of
Men Women human evolution. Now that sodium is abundant, those
ages 20–74 ages 20–74 mechanisms may be working against us.
Most Americans get far more sodium than they
need. It’s hard not to. Prepared foods are loaded with
The American diet has become saltier since the seventies.
According to dietary surveys, average dietary sodium intake rose
table salt. An 8-ounce serving of macaroni and cheese
considerably from the early 1970s to the early 2000s. or an order of fast food fries can serve up as much as
Source: Institute of Medicine. 1,000 mg of sodium (see Table 4, page 14).
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 13
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/In healthy individuals, the kidneys respond to to relax and contract with ease. It may also overstimu-
excess sodium by flushing it out in the urine. When late the growth of heart tissue.
this process doesn’t work properly and extra sodium About one-quarter of people with normal blood
is retained, the kidneys hang on to water. Some of pressure and nearly 50% of people who have high
that water makes its way into the bloodstream. As blood pressure are salt sensitive, meaning consuming
the amount of fluid flowing through blood vessels too much sodium elevates their blood pressure and
increases, the pressure inside them increases, forcing puts them at risk for complications. Dozens of studies
the heart to work harder. In addition, excess sodium have shown that blood pressure rises with higher lev-
makes blood vessels less flexible, blunting their ability els of sodium in the diet—and that curbing salt intake
Table 4 Hidden salt in commercially prepared food
% OF RECOMMENDED
FOOD SERVING SODIUM (MG)
DAILY LIMIT (2,300 MG)
Kung Pao chicken with rice 2 cups 2,610 113
Ham sandwich with mustard 9 ounces 2,340 102
Lasagna 2 cups 2,060 90
Sauerkraut, canned 1 cup 1,560 68
Tuna salad sub sandwich 6 inches 1,293 56
Baked beans, canned 1 cup 1,106 48
Chicken noodle soup, canned 1 cup 1,106 48
Macaroni and cheese, canned 1 cup 1,061 46
Pasta sauce 1 cup 1,030 45
Corned beef brisket 3 ounces 964 42
Burger King Whopper 1 900 39
Chicken pot pie 1 small 857 37
Dill pickle 1 (3 ounces) 833 36
Chicken bouillon 4-gram cube 743 32
Ham 2 slices 739 32
Vegetable juice cocktail 1 cup 653 28
KFC Biscuit 1 560 24
Cottage cheese ½ cup 457 20
American cheese 1 slice 442 18
McDonald's French fries Super size 390 17
Waffle, frozen 1 383 17
Raisin Bran cereal 1 cup 361 16
Green beans, canned 1 cup 354 15
Cheese pizza 1 slice 336 15
Sources: U.S. Department of Agriculture, Agricultural Research Service. 2012. USDA National Nutrient Database for Standard Reference, Release 25. Nutrient Data
Laboratory Home Page, www.ars.usda.gov/ba/bhnrc/ndl and the Center for Science in the Public Interest (see www.cspinet.org/salt).
14 Reducing Sugar and Salt w w w.h ealt h .ha r va r d.e du
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/lowers blood pressure. The landmark DASH-Sodium nology, and Medicine in London described other
trial is perhaps the best example of these (see “The harmful effects attributed to high salt consumption
DASH diet,” below). beyond raising blood pressure. High sodium intake
Writing in the Journal of Human Hypertension, increases the mass of the left ventricle (the heart’s
researchers at the Imperial College of Science, Tech- main pumping chamber), which makes the heart work
The DASH diet
DASH stands for Dietary Approaches to Stop Hypertension, a Further analysis of the trial’s results found that the DASH
diet developed by nutritionists to lower blood pressure. Put diet reduced blood pressure in virtually all groups tested re-
to the test in two large clinical trials—the first described in gardless of such factors as age, sex, race, and hypertension
The New England Journal of Medicine in 1997—the DASH status. Its effects were most pronounced, though, in African
diet passed with flying colors. For many people who follow Americans and people with high blood pressure. In fact, the
it, the diet is enough to keep blood pressure in the normal results were so promising that federal dietary guidelines
range without medicine. now recommend that all Americans—not just those with
high blood pressure—follow the DASH diet.
Key features of the DASH diet include plenty of fruits,
vegetables, and whole grains; several servings daily of A follow-up study, the DASH-Sodium trial, compared a typi-
low-fat dairy products; some fish, poultry, dried beans, nuts, cal American diet (the control diet) with the DASH diet at
and seeds; and minimal red meat, sweets, and sugar-laden different sodium levels (3,300, 2,400, or 1,500 mg per day).
beverages. This mix of foods provides ample calcium, People with high blood pressure who ate the DASH diet at
potassium, magnesium, vitamins, and fiber while limiting the lowest sodium level had an average systolic pressure
saturated fat, cholesterol, and sodium. Compared with the reading 11.5 mm Hg lower than participants eating the
typical American diet, the DASH eating plan has a relatively control diet at the highest sodium.
higher calcium content and less salt, total fat, saturated fat, Still more support for DASH came from the Harvard-based
and cholesterol. It also has 173% more magnesium, 150% Nurses’ Health Study. Among nearly 90,000 female nurses
more potassium, 240% more fiber, and 30% more protein. whose diets, other habits, and health were followed for 24
The blood pressure–reducing ability of the DASH diet can’t years, those whose eating patterns most closely resembled
be attributed to any single nutrient. the DASH diet had fewer heart attacks and strokes and
In the original DASH study, 459 volunteers were randomly were less likely to have died of heart disease compared with
assigned to one of three diets. One was based on what most women reporting average American diets.
Americans eat, with 37% of calories from fat. The second Combining a structured weight-loss program with the DASH
was a similar regimen with fruits and vegetables added. diet can drop your blood pressure even more than DASH
The third was a “combination” diet—the DASH diet—con- alone, according to a study of 144 overweight or obese peo-
taining 27% of calories from fat, plus plenty of fruits and ple with high blood pressure who weren’t taking any blood
vegetables, whole grains, low-fat or nonfat dairy products, pressure–lowering drugs. About a third of them followed
and small amounts of meat, fish, poultry, and nuts. the DASH diet along with a weight-management program.
After following the DASH plan for eight weeks, participants Another third did DASH alone, and the other third followed
with high blood pressure experienced average reductions their regular diet. The weight-management program relied
of 11.4 millimeters of mercury (mm Hg) in systolic pressure on a strategy known as “appetite awareness training,”
(the top number of a blood pressure reading) and 5.5 mm which teaches people to identify their natural hunger and
Hg in diastolic pressure (the bottom number). These results fullness cues to help them learn when and how much to eat.
are comparable to the effects of some blood pressure The program also included supervised exercise sessions that
drugs. Participants with borderline high blood pressure also featured biking, walking, or jogging for 45 minutes (includ-
experienced improvements, suggesting that the DASH diet ing a warm-up and cool-down) three times a week.
may keep some people from developing high blood pres- After four months, average blood pressure readings for the
sure in the first place. The second diet, which was higher DASH-plus-weight-management group dropped by 16.1/9.9
in fats but also rich in fruits and vegetables, also lowered mm Hg, compared with 11.2/7.5 mm Hg for the DASH-only
blood pressure, although not as much as the DASH plan. group and 3.4/3.8 mm Hg for the control group. The blood
All reductions occurred without people changing their salt pressure reductions seen in the weight-management group
intake, alcohol consumption, or weight—factors known to were similar to what doctors would expect from a high dose
influence blood pressure. of a blood pressure drug.
ww w. h ealt h . h ar v ar d . e du Reducing Sugar and Salt 15
This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/You can also read
