Joseph B. Miller, MD
Old habits die hard. A study on sugar from the mid 90s was the lead article in the New England Journal of Medicine, and touted by the media for months. Somehow the message of the research remained with many doctors and families. But the conclusion–that neither sugar nor aspartame affect children– is erroneous, says Dr. Miller.
The journal article “Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children” received so much attention that it has often simply been referred to as “that sugar study.” (New England Journal of Medicine, February 3, 1994, Vol. 330, pp. 301-7). Yet the conclusion in the abstract of the paper, “even when intake exceeds atypical dietary levels, neither dietary sucrose nor aspartame affects children’s behavior or cognitive function,” is misleading, and the study flawed, for the following four reasons:
“Sugar sensitive children were identified on the basis of reports by their parents.” Thus, the criterion for selection was the subjective report of the
parents. No attempt was made to verify sensitivity to sucrose (“granulated sugar” derived from cane or beet) by an objective sugar challenge test. This is a simple, quick, inexpensive test consisting of taking all sugar out of the diet for five days (say, Monday through Friday), then administering a large amount of pure sugar (not mixtures, like candy bars) one to three times on Saturday and observing the subject’s symptoms, behavior, objective appearance, and ability to write, draw, or color accurately after the challenge, as compared to before.
The study group consisted of “23 children of primaryschool age (6 to 10 years) reported by their parents to respond adversely to sugar” and a second group consisting of 25 normal preschool age children (3 to 5 years of age). The preschool children had no history of hyperactivity or sugar sensitivity. The school-age group contained only five children who “met the criteria for attention deficit disorder with hyperactivity, and two of the five also met the criteria for oppositional defiant disorder; two other children met the criteria for oppositional defiant disorder alone.” So except for seven children, we are supplied with no knowledge of the responses that persuaded the parents that their children were sensitive to sugar. And the responses of these seven children to the various diets are not provided in the paper.
The wrong substance was studied. Dietary “sucrose” is the granulated sugar used universally in kitchens but rarely in food factories. Sucrose is not really the substance that suggests to parents that their children are allergic to sugar. Children do not eat plain granulated sugar by the teaspoon, so the response to sugar itself is not likely to be identified. Rather, they eat “sweets,” usually produced in food factories, consisting of candy bars, jelly beans, fruit snacks such as Fruit Roll-Ups and Gummi Bears, hard candies, fruit-filled pastries, cinnamon rolls, doughnuts, ice cream and sherbet, jellies and preserves, pancake syrups, sweetened cereals, etc.
Almost all these factory-produced sweets contain corn sweeteners in addition to, or in place of, sucrose. In addition, they contain many other allergenic foods and food derivatives, such as milk, wheat, chocolate, soy, peanut, and egg. Furthermore, most contain multiple chemicals, in the form of artificial colors, flavors, preservatives, thickeners, antioxidants, mildew-retardants, etc. Soft drinks, which are now imbibed in great quantities by children, usually contain corn sweeteners, except for the diet drinks, which contain aspartame or Nutrasweet.
Aspartame itself, in the form of Nutrasweet, contains two corn sugars: dextrose and maltodextrin. Parents who try to reduce the intake of sugar by using fructose which they regard as “natural” sugar derived from fruit, do not realize that the fructose in the foods they buy is manufactured from cornstarch. Even ascorbic acid (Vitamin C), which was added to all the aspartame used in the study, is derived from cornstarch and contains 10% corn derivatives in the final product. Custards, puddings, and other sweets are also usually thickened with cornstarch. The confectioners’ sugar used for icings on cakes contains 5% cornstarch.
Mothers of my hyperactive patients often tell me that their children react to sugar. When I then ask them to name specific products to which they have repeatedly and incontrovertibly seen reactions, they usually mention foods with corn sweeteners, not just sugar, like Snickers or Cocoa Puffs — products that generally contain other food substances and chemicals as well. Corn-sweetened products such as ice cream, Valentine’s Day candies, and Halloween treats are all prominent in their reports, as are Thanksgiving, Christmas, and Easter binges. Teachers tell me that they accomplish little the first day after such holiday events.
When this article in the New England Journal of Medicine was released to the major television networks, it was reported as a research breakthrough, putting an end to the popular “misbelief” that sugar can cause hyperactivity. On the TV screen immediately following the report, was a one-second appearance of a mother who said, “But I know my child gets hyper when he eats sweets.”
The mother is correct, and the research conclusion is misleading. The key word is “sweets.” The mother has studied her child; the researchers have studied something other than sucrose-induced hyperactivity.
Lest it be assumed I am claiming that sweets cause all hyperactivity or all attention deficit disorders, let me add that other foods and even inhalants and chemicals are often involved. My discussion focuses on sweets only because the study purportedly concerned sucrose and aspartame. However, foods do constitute the major cause of attention deficit hyperactivity disorder, and the foods included in sweets (milk, wheat, corn, chocolate, peanut, soy, egg, and additives) are prominent among the food culprits.
There was inadequate isolation of the substance to be studied versus placebo. Three diets were used. In a nine-week study, each subject received three weeks of each sweetener (sugar, aspartame, and saccharin), with the diets rotated randomly. However, sugar (sucrose) was present in all the diets. The amount of sugar in the “sugar diet” was moderately greater than in the other diets. In all cases, sucrose quantities allowed were apparently within “normal” levels; i.e., high normal amounts of sucrose in the sucrose diet and lower amounts in the aspartame and saccharin diets. “One diet was high in sucrose with no artificial sweeteners, another was low in sucrose and contained aspartame as a sweetener, and the third was low in sucrose and contained saccharin (placebo) as a sweetener.” They also wrote, “Small amounts of saccharin were used to sweeten items, such as condiments, that were consumed in small amounts by the subjects during all nine weeks.” This contradicts the previous statement that “one diet was high in sucrose with no artificial sweeteners.” In any case, it would be surprising if reactions to either sucrose or saccharin were significantly different metweem diets. Neither corn sweetener nor commercial sweets was studied.
There were possible benefits of the conclusions to participants in the study. This study was very elaborate statistically and certainly extremely
expensive. The conclusions are sweeping and unsupported by data. At the end of the article, the authors state, “We conclude from this carefully controlled nine-week study that neither sucrose nor aspartame produces discernible cognitive or behavioral effects in normal preschool children or in school-age children believed to be sensitive to sugar” (italics added).
Obviously, what is needed to learn whether foods cause ADHD and which foods are truly involved, is to select only real ADHD children and isolate each individual food substance to be studied.
This study certainly gives the impression of a “straw man” exercise. The impression is strengthened by the fact that products used in the study were supplied by huge companies with a vested interest in protecting their mostly corn-sweetener and aspartame-containing products. Those companies are listed in the article as “General Mills, Libby’s Nutrasweet, Coca-Cola, PepsiCo, and Royal Crown.” The study seems to incriminate and then absolve sucrose. It does so with a protocol not likely to show differences even between the sucrose and “non-sucrose” diets.
The investigators who planned and executed the study should certainly have been aware of the ingredients of commercially available sweets and the contents of the foods actually eaten by children. Furthermore, the manufacturers who supplied products used must undoubtedly have very knowledgeable staff nutritionists who know, or should know, the simple facts about food ingredients and what children eat.
This study purportedly investigated whether or not sugar or aspartame causes attention deficit hyperactivity disorder in children. It was fatally flawed, first, by a protocol that chose for the study population 48 children only seven of whom fit the criteria for ADHD. Second, it chose the wrong substance to study, since ADHD responses are much more often due to “sweets” which parents think contain sugar but that also contain corn sweeteners and, usually, milk, wheat, chocolate, soy, peanut, egg, and various chemicals. Third, the design of the diets was such that a true response even to sucrose would not likely have been identifiable, since sucrose was allowed even in the “non-sucrose” diets. Fourth, certain contributors to the study had a vested interest in the outcome. The facts are that allergies to foods, inhalants, and chemicals are major causes of ADHD; food allergies are the most prominent of these causes; and the most frequent food culprits are those contained in commercially produced sweets.
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