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REVIEW
The Impact and Burden of Dietary Sugars on the Liver

Hepatology Communications 7(11):e0297, November 2023. | DOI: 10.1097/HC9.0000000000000297

Abstract
NAFLD, or metabolic dysfunction–associated steatotic liver disease, has increased in prevalence hand in hand with the rise in obesity and increased free sugars in the food supply. The causes of NAFLD are genetic in origin combined with environmental drivers of the disease phenotype. Dietary intake of added sugars has been shown to have a major role in the phenotypic onset and progression of the disease. Simple sugars are key drivers of steatosis, likely through fueling de novo lipogenesis, the conversion of excess carbohydrates into fatty acids, but also appear to upregulate lipogenic metabolism and trigger hyperinsulinemia, another driver. NAFLD carries a clinical burden as it is associated with obesity, type 2 diabetes, metabolic syndrome, and cardiovascular disease. Patient quality of life is also impacted, and there is an enormous economic burden due to healthcare use, which is likely to increase in the coming years. This review aims to discuss the role of dietary sugar in NAFLD pathogenesis, the health and economic burden, and the promising potential of sugar reduction to improve health outcomes for patients with this chronic liver disease.

Sugar is more terrifying than alcohol

Sugar does not come with labelled warnings
Consumption of sugar can start at any age
Sugar is available everywhere in many forms
Sugar comes hidden in many forms
People are often misled on "healthy sugars"
There is no stigma attached to sugar consumption

Sugar does to the liver what alcohol does too

From children to adults, "Sugar is the new Alcohol"

This beautiful review in
@HepCommJournal
on "sugar-related liver disease" is maddeningly important

The Impact and Burden of Dietary Sugars on the Liver: https://journals.lww.com/hepcomm/fullte ... starticles

Non-alcoholic fatty liver disease or NAFLD (new term: metabolic-dysfunction related steatotic liver disease or MASLD) has multiple causes - BUT - the most important of those, is dietary intake of added sugars.

And the most dangerous of the lot?
Fructose - yes, not sucrose (or table sugar)

Glucose is metabolized by all cells in the body
Fructose is metabolized mostly in liver
Fructose is MORE lipogenic than glucose - meaning it can increase fat formation much higher than glucose inside the liver.

Fructose is particularly problematic since it is the sweetest tasting natural sugar, 1.2–2.0 times sweeter than table sugar. The consumption of fructose has increased by 30% in the last 40 years and by 500% over the last century due to the increased consumption of processed foods/sugar-sweetened drinks.

More fats form inside liver cells, liver cell function gets affected, inflammation inside liver starts, glucose sensitivity reduce, insulin secretion and resistance increase and more glucose forms leading to "hyperglycemia" (as seen in diabetes)

Added sugars in diet play central role in onset and progression of NAFLD.

Recommended intake of added sugars: <5% of total calorie intake! - i.e., 25g or 100 calories in a 2000 calorie per day diet.

Worst of the lot: SSBs or sugar-sweetened beverages, desserts and sweet snacks (bakery and confectionary) and honey - has sugars in form of sucrose, high fructose corn syrup and natural fructose.

Sugar affects body beyond liver too:
- In brain, triggering of reward pathway, promoting "pleasantly excessive" calorie intake - "cant stop eating sugary stuff" feeling - obesity!

- fructose increases appetite by increasing ghrelin (the "hunger" hormone) - "eat more sugar"

- added sugars have habit-forming properties similar to alcohol, tobacco, cocaine, and caffeine

- In muscle - increases muscle fat making muscles weaker and "low quality" - poor stamina/effort intolerance

- Increased risk of heart disease, high blood pressure, chornic kidney disease

Children (& adults) become unhealthy, have poor muscle quality, are more stressed, develop obesity, fatty liver disease and chronic liver disease, various metabolic illnesses, have high risk for cancers and have poor performance overall - just because of SUGAR.

But is all fructose bad? Like those in fruits?
No. Whole fruits contain fiber and antioxidants, which may protect against the harmful metabolic effects of sugar consumption - have whole fruits/ cut fruits rather than fresh juices or packaged fruit juices.

When children and adults go on a low added sugar diet, especially low fructose diet, liver functions, cardiac health, performance status, overall well being improves drastically.

Remember, sugar is the new alcohol, but without warnings.