The Saccharine Disease, The Master Disease of our Time

Surgeon-Captain T.L. Cleave, M.R.C.P.

Published by Keats Publishing, New Canaan CT, in1975

"Regarding mental disease in the people of the Transkei, I can say that in the past 11 years I have not diagnosed a single case of schizophrenia in a tribal African living on an unrefined carbohydrate diet, whereas this disease is the commonest psychosis among the urbanized Africans." Letter from Dr Daynes dated September, 1971; p25

What can, indeed, be achieved by the removal of the cause in the case of the dental diseases [sticky plaque from eating sugar] discussed here is well seen in the two-year study, 1955-7, by GL Slack and WJ Martin in which schoolchildren were given slices of apple after meals. These children, as long as they were given the slices of apple, not only got significantly less caries than the control children did, but they got much less gum disease, too. p71

It will also be noted that the present approach is ... quite distinct from Professor Yudkin ... who regards ... natural carbohydrates as the enemy, and leads to the assessment of the danger in individual carbohydrates by their calorific value. It is true that the calories in, for example, an apple, are much the same as those in a teaspoon of sugar, and therefore at first sight the danger in cases of obesity would appear to be the same in each. But ... there is an enormous difference between the two in one vital respect - the amount a person needs to consume of each before the appetite is appeased. As already said, a person may over-consume sugar very easily - but not apples. As regards dates, these certainly are a natural food - but not for the white races! ... Thus, if the percentage of sugar present in the apple is 10 per cent, and in the banana, 20 per cent, in the date it is 60 per cent. ... The same applies to certain dried fruits if consumed by themselves, such as raisins; and in fact the banana, with a sugar content of 20 per cent, which exceeds that of all the natural fruits in the British Isles, represents the rough limit of safety in that respect. p77-8

Some twenty years ago, that is, in 1955, if the incidence of diabetes was being related to the consumption of any particular class of foodstuff, it was being related to the consumption of fats. This was largely due to a paper by Himsworth (1949) who showed that during the 1939-45 war, when the diabetes mortality fell steeply in all countries that experienced food rationing, the only class of foodstuff to show a coincident fall in consumption was the fats; the carbohydrates and proteins showed an actual rise (graph at left):- The present author (meaning Cleave) contested the above relationship of diabetes to fat consumption on evolutionary grounds ... he pointed out that carbohydrates should not be taken as a single group but as two very different groups: one being natural, unconcentrated carbohydrates, such as unrefined grains, potatoes, and fruits, and the other being unnatural, concentrated carbohydrates, notably refined flour and sugar. And that as the body was evolved to the consumption of natural carbohydrates, no harmful over-consumption of these would occur, no matter how much of them might be needed to satisfy the caloric requirements; whereas the opposite was true of refined carbohydrates, which are only too likely to be over-consumed - especially in the case of sugar, which is many times more refined that even the whitest flour. And that over-consumption, especially of sugar, imposed a pathogenic strain on the pancreas and was the essential cause of diabetes. ... taking some 5 oz. of refined sugar per head per day, [we] often consume in a matter of minutes material that, in its natural form (for example, some 2½ lb. Of sugar-beet or up to a score of ordinary apples), would normally be eaten over several hours."

Turning specifically to the 1939-45 war, he pointed out that if there were charted against the fall in diabetes mortality, not the consumption of all carbohydrates but only that of refined one, then, with the great replacement of sugar and white flour by coarse flour and potatoes as the war proceeded. The chart would show a considerably greater fall in the case of the former (sugar and white flour) than in the case of the fats, and what was the opposite of a relationship between the diabetes mortality and carbohydrate consumption would become a very close relationship (graph at right, above)

[I] then applied the above argument to the rest of Himsworth's contention, pointing out how any increase in the consumption of fat in the Western nations must, for evolutionary reasons, have been small indeed by comparison with the consumption of sugar, this latter being of a magnitude to match the increase of mortality of diabetes itself - which, starting around the middle of the nineteenth century, progressed to such an extent that the disease, from being twenty-seventh in the list of causes of death in the statistics of the Metropolitan Life Insurance Company in 1900, became the third commonest cause by 1950.

[I[ also pointed out the relative rarity of diabetes in rural China and India, where most of the inhabitants do not show do not yet show the food-sophistication exhibited by the West. ... Again, as regards the virtual absence of diabetes in primitive communities, these communities are usually ones that live almost entirely on carbohydrates, such as various grains and tubers. It is true that the carbohydrates are eaten substantially unrefined, as in the form of whole maize or millet, or home-pounded rice, but again, since all the starch contained in these is digested to, and absorbed as, sugar, it is clear that the ultimate sugar absorption in such communities, which do not eat refined carbohydrate, is higher that in civilized people, who do.

The best way to expose the fallacy of [Himsworth's] arguments is to consider another condition altogether - dental caries. It is accepted everywhere that this condition is related to the consumption of refined carbohydrates, especially sugar. During the last world war, for example, a big fall in the incidence of dental caries occurred in all the belligerent countries, pari passu with the fall in consumption of these refined products; also, in communities all over the world caries is slight or absent until these products appear amongst them.

... what strains the pancreas is what strains any other piece of apparatus - not so much the total amount work it is called upon to do, but the rate at which it is called upon to do it. ... In this connection, Dr Campbell has recently produced a series of blood-sugar curves showing how violent is the rise after eating neat sugar compared with the gentle undulations after eating the same calorific value of carbohydrate in the form of the natural apple and potato. Even peeling the potato, which brings it into the refined category ... makes a noticeable difference in the blood-sugar curve.

[The same] Dr Campbell showed that there seemed to be a remarkably uniform period in a population exposed to a diabetogenic factor in their midst, before the disease itself appears amongst them. This period was formulated as "The Rule of Twenty Years" and was first worked out in the case of the urban Zulu, with the incrimination of sugar as the factor most likely to be involved, the data being published later in the South African Medical Journal, in 1960. The rule has since been supported by other writers in other countries, as in ... V. Albertsson in Iceland and AM Cohen in Israel.

Perhaps the most striking of these aetiological studies, however, because of its thoroughness, has been AM Cohen's (1960) upon the Yemeni or "Black Jews." These people moved to Israel from the Yemen, where they ate mainly fat and protein foods, and where their sugar intake was one of the lowest in the world. When they move to Israel the most striking change in their diet was a marked increase in sugar consumption, and in a group of people in whom diabetes was unknown the incidence of the disease rose to that prevailing in Israel [after 25 years and with relatively little change in fat consumption].

... the Zulu and Pondo cane cutters in Natal, who have always been allowed to chew as much sugar-cane as they please, have been shown to be singularly free from diabetes - indeed in over 2000 of these cane-cutters tested by Dr Campbell and his colleagues, all that has been found is a trace of sugar in the urine in 3 of them ... in striking agreement [is] a statement by FG Banting, co-discoverer of insulin, in the Edinburgh Medical Journal, vol. 36, of January, 1929: "In 1924, while visiting Panama, I was told by Dr Clarke, pathologist of the Ancon Hospital, that on examining 5000 men who were applying for work on the Panama Canal, he had found [sugar] in the urine in only two cases. ... This is the more remarkable because a large percentage of the laborers were natives of Dominica, where a main article of diet was sugar-cane. From the time the children are weaned until they die they eat sugar-cane. ..."

Meanwhile, as regards coronary disease itself, and more particularly, coronary thrombosis, the main explosion in the incidence has by common consent occurred since 1900, and especially since 1920. Ancel Keys recently argued that this is too long after the main rise in sugar consumption for the disease to be related to this consumption. But in his paper, Keys makes no reference to the all-important incubation period. Indeed, in bypassing this aspect of the problem, his argument appears to become meaningless. For the incubation period in diabetes has already been shown to average 20 years, and since over 50 per cent of maturity onset diabetics die of coronary diasease, and since, also, the latter disease is seldom seen below the age of 30, we must regard 30 years as the minimum incubation period in most cases of the disease - and it may be very much longer. This 30-year minimum incubation period, which points to the fuse, as it were, of the beginning of the coronary explosion being lit around the year 1890, when sugar consumption was rapidly approaching the 100-lb. Mark, is just as vital in seeking the cause of coronary disease as, for example, the 40-year incubation period is in seeking the cause of diverticular disease. No comparable fuse is to be seen in fat consumption.

With further reference now to the clinical association between coronary disease and diabetes, since it is considered here that both conditions arise from a common cause (the consumption of refined carbohydrates), and not that one of these conditions arises from the other, it follows that either condition may be the first to arise, depending on the personal makeup in the person concerned, although usually it is the diabetes that occurs first. In this connection, the author wishes to refer to the illuminating studies of Professor H Keen and others who have shown that people with high blood-sugar curves (the forerunner of overt diabetes) have a much higher incidence of coronary disease than those without this sign - vide FH Epstein in Circulation (1967), 36, 609.

** Note that Cleave is calling attention to the yet-to-be-christened syndrome X here, some 20 years prior to the ceremony!