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Original Article
Effect of Eucaloric High- and Low-Sucrose Diets With
Identical Macronutrient Profile on Insulin Resistance
and Vascular Risk
A Randomized Controlled Trial
R. Neil A. Black,1 Michelle Spence,2 Ross O. McMahon,1 Geraldine J. Cuskelly,2 Cieran N. Ennis,1
David R. McCance,1 Ian S. Young,2 Patrick M. Bell,1 and Steven J. Hunter1
The long-term impact of dietary carbohydrate type, in
cise are associated with the dramatic increase in preva- particular sucrose, on insulin resistance and the develop-
lence of diabetes in developed countries. Western diets are ment of diabetes and atherosclerosis is not established.
characterized by excess energy intake and increased levels Current guidelines for the healthy population advise re-
of both sugar and fat (7). Increased consumption of striction of sucrose intake. We investigated the effect of
refined sugar, including fizzy drinks, may contribute to the high- versus low-sucrose diet (25 vs. 10%, respectively, of
increased risk of diabetes (8). Combined lifestyle interven- total energy intake) in 13 healthy subjects aged 33 ؎ 3
tion, including caloric restriction and increased physical years (mean ؎ SE), BMI 26.6 ؎ 0.9 kg/m2, in a randomized
crossover design with sequential 6-week dietary interven-
activity, particularly with weight loss, can improve the tions separated by a 4-week washout. Weight maintenance,
degree of insulin sensitivity and reduce the risk of future eucaloric diets with identical macronutrient profiles and
diabetes and vascular disease (9 –12). The relative impor- fiber content were designed. All food was weighed and
tance of different aspects of this approach is unclear. In distributed. Insulin action was assessed using a two-step
particular, while there is evidence regarding the effect of euglycemic clamp; glycemic profiles were assessed by the
different dietary caloric balances and macronutrient pro- continuous glucose monitoring system and vascular com-
files, there is a lack of evidence regarding aspects of pliance by pulse-wave analysis. There was no change in
weight across the study. Peripheral glucose uptake and
suppression of endogenous glucose production were simi-
Cross-sectional, longitudinal, and case-control studies lar after each diet. Glycemic profiles and measures of
demonstrate no consistent association between dietary vascular compliance did not change. A rise in total and LDL
carbohydrate type and risk of diabetes (13,14). Interven- cholesterol was observed. In this study, a high-sucrose
tional studies in animal models, however, strongly link intake as part of an eucaloric, weight-maintaining diet had
high-fructose and -sucrose diets to decreased insulin sen- no detrimental effect on insulin sensitivity, glycemic pro-
sitivity and hyperlipidemia, as well as obesity. However, files, or measures of vascular compliance in healthy nondi-
these diets are either hypercaloric, which leads to obesity, abetic subjects. Diabetes 55:3566 –3572, 2006
or have grossly elevated contents of fructose or sucrose(up to 70 – 80% of total caloric intake) (15). These resultstherefore cannot be extrapolated to humans taking more palatable levels of sucrose or fructose. Studies in human nsulin resistance is a key feature of type 2 diabetes subjects show variable effects with alterations of dietary and precedes the onset of glucose intolerance (1–3).
sucrose intake when using simple measures of insulin Insulin resistance is also an independent risk factor sensitivity (16). One small study in seven subjects without for atherosclerotic vascular disease (4 – 6). Factors diabetes demonstrated that a high– glycemic index diet that reduce the degree of insulin resistance may reduce (25% sucrose) was associated with detrimental effects on the likelihood of developing diabetes or atherosclerosis.
insulin sensitivity compared with a low– glycemic index Changing dietary patterns and reduced levels of exer- diet (1.2% sucrose) over 4-week dietary periods (17). It isoften assumed that a high-sucrose diet will have a highglycemic index but certain high-sucrose foods may have From the 1Regional Centre for Endocrinology and Diabetes, Royal Victoria comparable glycemic indexes to starchy foods (e.g., a Hospital, Belfast, U.K.; and the 2Nutrition and Metabolism Group, The Queen’sUniversity of Belfast, Belfast, U.K.
carbonated orange drink and a mashed potato). Further Address correspondence and reprint requests to Dr. Steven J. Hunter, studies in type 2 diabetes have shown either no effect or a Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, detrimental effect of increased dietary sucrose, but these studies have been either small or of short duration (18 – Received for publication 15 February 2006 and accepted in revised form 23 Recently, a number of low-carbohydrate high-fat diets R.N.A.B. and M.S. contributed equally to this work.
(including the Atkins diet) have been proposed as a DOI: 10.2337/db06-0220 2006 by the American Diabetes Association.
substitute for challenging modifications in lifestyle, but the The costs of publication of this article were defrayed in part by the payment of page long-term impact of such diets on cardiovascular and charges. This article must therefore be hereby marked “advertisement” in accordancewith 18 U.S.C. Section 1734 solely to indicate this fact. diabetes risk is still under investigation and debate (21– R.N.A. BLACK AND ASSOCIATES
22). A meta-analysis has also highlighted that weight loss at the beginning and end of each diet period. Blood pressure was measured associated with such diets is associated more with caloric using an oscillometric device (Omron Healthcare U.K., Milton Keynes, U.K.) restriction than reduced carbohydrate content (23). It and taken as the average of the second and third readings after 30-min supine.
Insulin resistance, vascular compliance, and 72-h continuous subcutaneous could be inferred that the same relationship holds for glucose monitoring were assessed in the last week of each dietary period.
changes in insulin sensitivity. The concept of carbohydrate Diets. A 7-day cyclic menu plan was formulated for both sucrose diets using
quality is also attracting attention, and a focus on glycemic the dietary analysis program WISP (weighed intake software program; Tinu- index forms the basis of an alternative dietary approach viel Software, Warrington, U.K.). The low- and high-sucrose diets provided 10 (24 –26). A more conventional and proven approach is to versus 25% of total dietary energy as sucrose, respectively (sucrose derived advocate a balanced macronutrient profile, in conjunction from both solid food and beverages). Diets were otherwise identical in theirmacronutrient and fiber intakes, both providing ϳ55% energy from carbohy- with caloric restriction and other lifestyle measures, in drate, 30 –35% energy from fat, 10 –15% energy from protein, and 18 g/day fiber.
both weight-reduction and weight-maintenance diets.
Volunteers attended daily, or on alternate days, throughout the interven- Traditionally, dietary sugar or sucrose content is the tion and were supplied with all appropriate foodstuffs (preweighed into daily major focus of carbohydrate-based dietary guidelines. The portions) for their particular diet. At each visit, the nutritionist discussed term “sugars” is conventionally used to describe mono- concerns and assessed dietary compliance. Throughout the study, caloric and disaccharides. “Sugar,” by contrast, is used to describe intake was adjusted if body weight (measured twice weekly) increased ordecreased on two successive occasions. Foods, ad libitum, included nonca- purified sucrose (table sugar), as are the terms “refined loric beverages (water, diet cola, black tea, and coffee) and seasoning. Alcohol sugar” and “added sugar” (27). In 2003, the World Health was not permitted. Representative menus for a single day for the high- and Organization/Food and Agriculture Organization issued low-sucrose diets are shown in Table 1. The energy distribution between the guidelines for prevention of chronic disease in terms of different meals was similar for both diets.
macronutrient balances, and although acknowledging a Assessment of insulin action. At the end of each dietary period, insulin
lack of evidence, included a recommendation to restrict sensitivity was assessed by a two-step euglycemic-hyperinsulinemic clamp, aspreviously described (32). A cannula was inserted into the left arm for free sugars to Ͻ10% of total caloric intake (7). The infusions and in the right arm for samples. The right hand was placed in a American Heart Association adopted a similar approach temperature-controlled plexiglass box (55°C) to arterialize the venous blood.
commenting on the potential detrimental effects of a A primed-continuous infusion of high-performance liquid chromatography– high-sucrose content diet with expected adverse effects purified [3-3H]glucose was administered during a 2-h equilibration period when content exceeded Ͼ20% of total energy intake (28).
(Ϫ120 min to zero time). The initial tracer prime was adjusted, based on Such effects included a fall in HDL levels, a rise in fasting plasma glucose (22). A two-step sequential, continuous infusion ofinsulin was commenced: 0.4 mU ⅐ kgϪ1 ⅐ minϪ1 (zero time to 120 min) then 2.0 triglycerides, and decreased vitamin and mineral content.
mU ⅐ kgϪ1 ⅐ minϪ1 (120 –240 min). Plasma glucose was measured at 5-min In the U.K., the Department of Health recently suggested intervals on a bedside analyzer (Beckman Glucose Analyzer 2; Beckman, High reducing mean added sugar intake from 12.7 to 11% (29).
Wycombe, U.K.) and maintained at the desired fasting concentration by an To inform dietary guidelines and develop advice regard- exogenous infusion of 20% wt/vol glucose. Exogenous glucose was prelabeled ing the impact of varying sucrose intake, we performed a with [3-3H]glucose to match the predicted basal plasma glucose specific randomized controlled trial of 10 and 25% sucrose diets (as activity as described (32), with the modification that the primed-continuoustracer infusion was reduced to 50% of the basal rate after 20 min and to 25% percent of total energy intake). The diets were isocaloric of the basal rate after 140 min of insulin infusion (to maintain tracer steady and weight maintaining with matched macronutrient pro- files. (Specifically, the total carbohydrate quantity was the Analytical techniques. Arterialised venous blood was used for all analyses
same in the trial diets, and the form of carbohydrate was in the glucose clamp studies. Plasma for measurement of glucose specific varied.) We examined the effect of these two diets on the activity was deproteinized with barium hydroxide and zinc sulfate by the primary outcome variable of insulin resistance, assessed method of Somogyi (32). Aliquots of tracer infusate and labeled exogenousglucose infusion were spiked into nonradioactive plasma and processed in using the isoglycemic-hyperinsulinemic clamp combined parallel to allow calculation of [3-3H]glucose infusion rates. Serum insulin was with isotope dilution techniques in healthy male volun- measured by enzyme-linked immunosorbent assay (Abbot Imx; Abbott Labo- teers. We also assessed 24-h glycemic profiles, serum ratories, Berkshire, U.K.). Glucose was measured using an automated glucose oxidase method using a Beckman Glucose Analyzer 2. Commercial kits wereused to estimate C-peptide (Dako Diagnostics, Ely, U.K.) and nonesterifiedfree fatty acids (Wako Chemicals, Neuss, Germany).
RESEARCH DESIGN AND METHODS
Calculations. The nonsteady state equations of Steele et al. (33), as modified
Fourteen healthy male volunteers were recruited (female subjects were by De Bodo et al. (34), were used to determine the glucose appearance (R ) excluded to avoid the effect of the menstrual cycle on study end points).
and disappearance (R ), assuming a pool fraction value of 0.65 and an Before commencing the study, a brief clinical history and examination was extracellular volume of 190 ml/kg. This was measured over three 30-min time carried out to ensure that those selected did not have significant obesity (BMI periods: before insulin infusion (Ϫ30 to 0 min), during the final stages of the Ͼ35 kg/m2) or cardiac, hepatic, or renal disease. Other exclusion criteria low-dose insulin infusion (90 –120 min), and during the final stages of the included a history of diabetes, blood pressure Ͼ140/80 mmHg, or hyperlipid- high-dose insulin infusion (210 –240 min). The [3-3H]glucose infusion rates emia (LDL Ͼ3.0 mmol/l and triglycerides Ͼ2.0 mmol/l). All patients gave were calculated as the sum of the tracer infused continuously and the tracer written informed consent, and the protocol for the study was approved by the in the labeled exogenous glucose infusion. Rates of endogenous (hepatic) research ethics committee of The Queen’s University of Belfast and the glucose production were then calculated by subtraction of the exogenous Administration of Radioactive Substances Advisory Committee.
glucose infusion rates required to maintain euglycemia from isotopically Habitual dietary intake was assessed at baseline using a 4-day food diary determined rates of glucose appearance.
(including at least one weekend day). Thereafter, volunteers were assigned to Continuous glucose monitoring system. A continuous glucose monitoring
a randomized crossover trial consisting of a 6-week period of either low- or system developed by MiniMed (CGMS; MiniMed, Northrodge, CA) was used to high-sucrose intake, followed by a second 6-week period on the complemen- monitor the concentration of interstitial fluid glucose for 48 –72 h using a tary diet. The dietary periods were designed to meet projected isocaloric subcutaneous sensor and was calibrated with a standard glucometer.
needs (estimated by multiplying basal metabolic rate by an appropriate Arterial stiffness. Arterial stiffness was determined using pulse-wave anal-
activity factor [30]) and were separated by a 4-week washout phase during ysis (model SCOR-Px; PWV Medical, Sydney, Australia), as described previ- which volunteers returned to their usual diet. Volunteers were advised to ously (35,36). All volunteers rested for 15 min in the supine position, and maintain their usual level of physical activity throughout the study. Subjects measurements were taken immediately following determination of brachial were randomized in blocks of four using a random-number generator to artery blood pressure. The right radial artery blood pressure waveform was ensure that equal numbers of volunteers received high- or low-sucrose diets recorded using a tonometer and calibrated according to the brachial systolic during the first phase. Anthropometric measurements (weight, height, and and diastolic pressures. Analysis of the central aortic waveform obtained waist and hip circumference), fasting blood samples (plasma glucose, insulin, using the SphygmoCor software identified the outgoing and reflected pressure C-peptide, HbA , renal function, and lipids), and blood pressure were taken waves (augmentation), occurring during systole. The augmentation index SUCROSE, INSULIN RESISTANCE, AND VASCULAR RISK
TABLE 1Sample menus for a typical day on each intervention diet Cornflakes (35 g), bran-based cereal (3 g) Strawberry jam (20 g)Orange juice (200 g) Yogurt with fruit purée (175 g)Carbonated orange drink (330 g) Gravy, reconstituted (70 g)Carbonated orange drink (330 g) Apple (170 g)Polyunsaturated margarine (15 g) (expressed as a percentage) was defined as the ratio of augmentation to pulse Weight and physical activity remained constant through- pressure and was used to estimate overall systemic arterial stiffness (37). The out the study. While no formal instrument to compare timing of the reflected waveform (a measure of the transit time between the physical activity was used, as weight and energy consump- ascending aorta and the first main reflectance site) was also identified andtherefore used to indirectly estimate aortic pulse-wave velocity and, hence, tion were the same after each diet, it can be assumed that aortic stiffness (38). Arterial waveforms were also recorded by consecutively the level of physical activity between the dietary periods applanating the carotid and radial arteries gated to a three-lead electrocardio- gram to enable calculation of pulse-wave velocity as previously described Clamp studies. Serum insulin levels in the fasting state
and during each infusion period were the same during Statistical methods. Statistical analysis was as recommended by Hills and
both dietary periods. Plasma glucose was maintained at a Armitage (40), enabling comparison of the effects of the treatment to beadjusted for period effects. Results are described as means Ϯ SE. Variables constant level by exogenous glucose infusion with a that were nonnormally distributed are described as median (lower quartile, coefficient of variation Ͻ5% as the plateau for each clamp upper quartile) and were logarithmically transformed before analysis. Where (glucose infusion rates at plateau after 25 and 10% sucrose parameters were assessed at the baseline and end of each period, ANCOVA were 13.9 Ϯ 1.6 vs. 15.4 Ϯ 2.9 ␮mol ⅐ kgϪ1 ⅐ minϪ1, was used with baseline values as covariates. The power of the study, respectively, after low-dose insulin and 47.5 Ϯ 3.5 vs.
calculated from previous clamp data, gave a 90% chance of detecting a 10% 42.5 Ϯ 3.0 ␮mol ⅐ kgϪ1 ⅐ minϪ1 after high-dose insulin change in insulin action at the 5% level of significance.
Both study diets were well tolerated (one subject left for Baseline clinical and anthropometric characteristics (n ϭ 13) reasons unrelated to the study). The clinical and anthro- pometric characteristics of the volunteers are given in Table 2. Volunteers were adult males who were, on average, overweight (mean BMI 26.6 Ϯ 0.9 kg/m2) but were normotensive with normal fasting lipid profiles and in- dexes of glycemia. Simple fasting measures of insulin sensitivity (insulin and homeostasis model assessment of insulin resistance) indicated that the subjects were mod- erately insulin resistant. The habitual dietary intake data (Table 3) suggested that mean consumption of macronu- trients was comparable with intakes reported for the adult population of the U.K. (41). Within the group, the total dietary energy provided by sucrose (preintervention) ranged from 2 to13%. Daily intervention intakes of energy and macronutrients during the high- and low-sucrose diets are displayed in Table 3. Diets were matched for energy, Data are means Ϯ SE or median (interquartile range). HOMA-IR, macronutrient profile, and fiber intake (Table 4).
homeostasis model assessment of insulin resistance.
R.N.A. BLACK AND ASSOCIATES
TABLE 3Habitual daily energy and nutrient intakes of the volunteers atbaseline Data are means Ϯ SE. n ϭ 13.
FIG. 2. Suppression of endogenous glucose production during euglyce-
infusion; Fig. 1). Endogenous glucose production was mic-hyperinsulinemic clamp. Data are means ؎ SE.
similar in the fasting state and similarly suppressed afterlow- and high-dose insulin infusion on the 25 and 10% effect on insulin resistance or measures of vascular risk in sucrose diets (Figs. 2 and 3). Peripheral glucose utilization healthy nondiabetic subjects. Evidence-based dietary was no different after either low- or high-dose insulin guidelines are urgently required to tackle the global epi- infusion on the 25 and 10% sucrose diets. Serum nonest- demic of diabetes. The absence of specific evidence in erified fatty acids were suppressed similarly after 25 and relation to sucrose has resulted in a lack of clear guide- lines from some groups and variation in recommendations Hemodynamic studies. Blood pressure, central augmen-
by others. Average sugar intake is much higher in the U.S., tation pressure, augmentation index corrected to heart where 15% of men and 21% of women aged 19 –50 years rate of 75 bpm, time to reflectance, and pulse-wave veloc- have a sucrose intake Ͼ25% (42). In the present study, we ity were not changed by diet (Table 6).
chose to compare a sucrose intake of 25%, which is a level Metabolic profiles. Fasting plasma glucose, serum insu-
substantially above recommended intakes and a level lin, and interstitial glucose levels over 24 h did not change some guidelines consider may be detrimental to health, with alteration of dietary sucrose content (Table 7). Total with a 10% intake, which compares with the lowest and LDL cholesterol were higher after 25% sucrose com- recommended restriction, while keeping total carbohy- pared with 10% sucrose. HDL cholesterol and fasting triglycerides were similar on the two diets.
Evidence from animal studies has generally shown that increased sucrose intake has a detrimental effect on DISCUSSION
insulin sensitivity and cardiovascular risk factors. How-ever, the levels of sucrose intake in these studies, of up to This study demonstrates that a high-sucrose diet, with 25% 60 –70% of dietary energy intake as sucrose or fructose, of total energy intake from sucrose, has no detrimental have generally been at a level that is nonphysiological and,for most human subjects, unpalatable. Furthermore, thediets studied were in many cases hypercaloric, makinginterpretation of the relative impact of sucrose intake andweight gain impossible (15). Human studies have pro-duced conflicting findings. Interventional studies haveshown variable effects on insulin sensitivity, and, in many,the method of assessing insulin resistance has been sub-optimal but the study period relatively short and thesample size small (43).
TABLE 4Intervention intakes of energy and macronutrients during thehigh- and low-sucrose diets FIG. 1. Plasma glucose, serum insulin, and glucose infusion rates
during euglycemic-hyperinsulinemic clamp. Data are means ؎ SE.
SUCROSE, INSULIN RESISTANCE, AND VASCULAR RISK
TABLE 5Serum nonesterified fatty acid levels at basal state and afterlow-dose insulin infusion (0.4 mU ⅐ kgϪ1 ⅐ minϪ1) plateau at90 –120 min and high-dose insulin infusion (2.0 mU ⅐ kgϪ1 ⅐minϪ1) plateau at 210 –240 min Data are means Ϯ SE. NS, not significant.
A strength of the present study is the randomized controlled design and rigorous dietetic supervision. Due to FIG. 3. Peripheral glucose uptake during euglycemic-hyperinsulinemic
the wide interindividual but low intraindividual variation clamp. Data are means ؎ SE.
in the degree of insulin resistance in normal subjects, atwo-period crossover design separated by a washout pe- between the two dietary periods. The study was powered riod was chosen with each subject acting as their own to exclude a 10% difference in insulin action, which is a control (44). The 6 weeks of dietary intervention per level assumed likely to have a clinically relevant impact.
assessment period compares favorably with other relevant The results in fact showed a trend toward an increase in human studies; however, it is not possible to predict the insulin sensitivity with the high-sucrose diet, although this effect of a high-sucrose intake over a more prolonged was not statistically significant. No plausible biological period. Although it is impossible to measure compliance mechanism exists to explain why a high-sucrose diet might with the diets under study, volunteers were reviewed improve insulin sensitivity, and it is likely that this finding every 2–3 days throughout the dietary periods and were is due to chance. Furthermore, we found no difference in questioned regarding palatability and compliance with the fasting levels of serum nonesterified fatty acid concentra- food that was provided for the duration of the study. In tions during the dietary periods and a comparable degree addition, the absence of any change in weight is further of suppression during hyperinsulinemia, indicating no evidence of careful dietary planning and supervision.
detrimental effect on adipose tissue insulin action.
The primary outcome measure of insulin resistance was The premise of this study is that a high-sucrose diet may assessed using the reference standard technique of the alter the risk of type 2 diabetes and cardiovascular dis- hyperinsulinemic-isoglycemic clamp combined with iso- ease. Although the primary outcome of the study was tope dilution techniques. The sensitivity to insulin varies assessment of insulin resistance, a feature of both condi- widely in different insulin-responsive tissues, and abnor- tions, it is possible that other mechanisms may link malities of these responses may occur separately in insu- high-sucrose intake to cardiovascular disease. We also lin-resistant states. There was no significant effect of used the noninvasive technique of pulse-wave analysis to altering dietary sucrose content on either fasting hepatic assess arterial stiffness, which is increasingly being recog- glucose production or its suppression during low-dose nized as an important determinant of cardiovascular risk insulin infusion, which are both measures of hepatic (45). Stiffening of the arterial tree increases the velocity insulin action. This result suggests no abnormality of and amplitude of reflected pulse waves from the periph- hepatic insulin action, which is recognized to be an early ery, with the result that larger waves return to the aorta feature of type 2 diabetes (3). The high-dose insulininfusion results in maximally stimulated glucose uptake and reflects skeletal muscle or peripheral insulin sensitiv- Effect of sucrose diets on metabolic variables ity. We found no difference in peripheral insulin resistance Effect of sucrose diets on hemodynamic variables Data are means Ϯ SE or median (interquartile range). NS, not Data are means Ϯ SE. NS, not significant.
R.N.A. BLACK AND ASSOCIATES
earlier. This augments central systolic pressure, which subjects compared with a low-sucrose diet. These results increases left ventricular workload and, thus, myocardial suggest that important pathogenic processes that precede oxygen demand. In the present study, we found no differ- diabetes and vascular disease are not significantly wor- ence in markers of arterial stiffness, such as augmentation sened by sucrose itself. These findings should be incorpo- pressure/index, time to reflectance, or brachial pulse-wave rated in dietary guidelines for the prevention of diabetes velocity. It should be noted that this study was powered and cardiovascular disease. It is likely that other dietary for the primary outcome of insulin sensitivity; although in factors, such as caloric excess, and lifestyle factors, such a smaller cohort, we have previously shown (39) that as physical inactivity and weight gain, may be more acute elevation of plasma glucose is associated with important determinants of insulin action than carbohy- significant adverse changes on pulse-wave analysis. In this drate type. The results of this study cannot be extrapo- study, continuous monitoring of interstitial glucose levels using a continuous glucose monitoring system showed no information regarding the impact of severe restriction of difference in 24-h or postprandial glycemic exposure.
sucrose intake in low-carbohydrate weight-reduction diets A rise in total and LDL cholesterol and a trend toward increased triglycerides were observed during the 25%sucrose diet compared with the 10% sucrose diet. Al- ACKNOWLEDGMENTS
though the mean changes were relatively modest and This study was supported by an unrestricted research levels remained within normal ranges, it is possible that grant from The Sugar Bureau and Suikerstichting, the more marked abnormalities could arise in subjects with Netherlands. R.N.A.B. was in receipt of an R&D Fellow- hyperlipidemia at baseline. Other studies have demon- ship from the Northern Ireland Department of Health and strated increased triglyceride levels with sucrose contents Social Services Research and Development Office.
20%; however, the LDL increase is more unusual (46). A We are grateful to Dr. C. Patterson, The Queen’s Univer- similar change in lipoprotein profiles has been noted in sity of Belfast, for statistical advice, to Dr. C. Mercer, high-fructose diets in man (47). Fructose is the more Department of Medicine, The Queen’s University of Bel- lipogenic component, as it bypasses a major rate-control- fast, for carrying out nonesterified fatty acid assays, and to ling step in glycolysis (48). The food selection that was Mr. Brian Sheridan and the staff at Belfast Link Laborato- necessary to achieve the balance resulted in a change in ries for carrying out insulin and C-peptide assays.
fat quality but no change in total fat quantity. The high-sucrose diet had 29% higher energy content from saturatedfat and 29% lower polyunsaturated fat than the low- REFERENCES
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