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Gerontologie+Geriatrie
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Z Gerontol Geriat
https://doi.org/10.1007/s00391-020-01726-1
Received: 13 February 2020
Accepted: 30 March 2020
© Springer Medizin Verlag GmbH, ein Teil von
Springer Nature 2020
A short history of sugar
The craving for a sweet taste and therefore
for sugar (from Sanskrit sarkara = pebble
stones) has a long history. The worldwide
consumption of sugar started with the ex-
traction of sugar cane juice. As early as
6000 BC, sugar cane came from eastern
Asia to India, the Phillipines and prob-
ably Indonesia. In 600 BC, brown sugar
was isolated on the Tigris-Euphrates delta
and roughly 1000 years later, the purifi-
cation of white sugar succeeded in Egypt.
In Europe, the first reports about sugar,
not for nutrition but as a medication or
spice, stemmed from the ancient Greeks
and Romans. From the 12th to the 17th
century sugar gained an increasing im-
portance as an expensive trading good
reserved forthe consumptionbyrichpeo-
ple or even kings [20]. In consequence,
caries was a disease of the rich. The story
goes that Queen Elizabeth I of England
had black teeth so that no picture of her
as a smiling queen exists [19]. In 1747
Andreas Sigismund Marggraf discovered
that beetroot and sugar cane contain the
same sugar, namely saccharose. During
the industrial revolution, the production
of sugar increased worldwide so that an
expensive rare product for the rich turned
into a cheap mass product for everybody.
The consumption of sugar increased from
2.5 kg/person per year in 1850 to about
34 kg/person per year in 2016 [9, 11].
Due to the increasing usage of glucose-
fructose syrup, e.g. corn syrup or high-
fructose corn syrup (HFCS), especially
as a sweetener in processed food, the
percentage of fructose intake from total
sugar consumption increased as well.
Anne Großkopf · Andreas Simm
Klinik für Herzchirurgie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg,
Halle (Saale), Germany
Carbohydrates in nutrition:
friend or foe?
Introduction to carbohydrates
The term carbohydrates comprises a wide
range of molecules, such as sugars, starch
and cellulose, which can affect health
in different ways. In the public per-
ception, sugar is the product extracted
from sugar cane or beetroot and sold as
cube or granulated sugar. Biochemically,
carbohydrates are defined as aldehydes
or ketones from polyalcohols, which
have a 1:1 ratio of carbon (C) to water
(H2O). Carbohydrates can exist as sin-
gle molecules (monosaccharides) or as
more complex molecules (disaccharides,
oligosaccharides and polysaccharides).
An overview on the most important
carbohydrates is given in . Table 1.
The most important polysaccharides
are cellulose, glycogen and starch all con-
sisting of glucose moieties. Animals and
humans use glycogen to store carbohy-
drates. In contrast, starch is the carbohy-
drate storage of plants, which is digestible
by animals and humans. Cellulose as part
of the plant cell wall and pectin as solu-
ble fibers, on the other hand, cannot be
effectively digested by humans and are
part of the dietary fibers or roughage.
Digestion, metabolism and
storage
Chew your food properly! Indeed,
the digestion of carbohydrates starts in
the mouth utilizing salivary α-amylase.
Within the duodenum, the resulting
oligosaccharides are further digested
by amylases from the pancreas until
a mixture of disaccharides and trisac-
charides is formed. The final digestion
is carried out by membrane-associated
disaccharidases and the enzyme maltase-
glucoamylase. The resorption of the
emerging glucose and galactose into the
enterocytes of the small bowel is done
by the sodium glucose transporter 1
(SGLT1), a secondary active sodium-
coupled transporter. In contrast, fruc-
tose is transported passively into these
cells by facilitated diffusion. The glu-
cose transporter GLUT2 transports all
monosaccharides passively from the cells
into the blood [4].
Glycolysis is the central metabolic
pathway, degrading glucose to pyruvate.
The degradation of one glucose molecule
by glycolysis will produce two molecules
of adenosine triphosphate (ATP), which
serve as a universal energy source, in
cases of anaerobic metabolization. In
aerobic conditions, pyruvate will be fur-
ther degraded via the citrate cycle and
the respiratory chain resulting in CO2
and H2O, thereby producing 36 ATP
molecules per glucose molecule. Under
anaerobic conditions, pyruvate will be
converted into lactate. Thus, lactate
will be produced during high and fast
physical exertion, e.g. 100 m sprint, in
the muscles as the oxygen supply is not
sufficient for the energy production by
the respiratory chain. Lactate will be
converted back to glucose in the liver
by the Cori cycle (. Fig. 1). This is
the reason why blood levels of glucose
may increase during exhaustive physical
activities.
Besides metabolization, storage ofglu-
cose is also important. In humans, glu-
cose can be stored as glycogen in both
muscle tissue and the liver. While the
300 g of glycogen in the muscle are needed
for muscle function, the 150 g of glycogen
in the liver are especially important to
keep the glucose concentration stable, i.e.
Zeitschrift für Gerontologie und Geriatrie
 Themenschwerpunkt
Table 1 Overview of the most common carbohydrates
Carbohydrate family Name
Monosaccharides Pentoses Ribose
(C 5) Deoxyribose
Hexoses Glucose
(C 6)
Fructose
Disaccharides Sucrose
Lactose
Maltose
Polysaccharides Starch
Glycogen
Cellulose
for glucose homeostasis in the blood. As
the brain has no glucose storage capaci-
ties itself, a continuous and stable supply
of glucose is of crucial importance.
Blood sugar regulation
The blood glucose concentration is
regulated very tightly between 4 and
12 mM. The reference interval of fast-
ing blood glucose level ranges from 3.3
to 6.1 mmol/l. Individuals presenting
values below the range are termed hy-
poglycemic, and above, hyperglycemic.
The regulation is mainly organized via
the pancreatic hormones insulin and
glucagon as well as noradrenaline and
adrenalin. After a meal the glucose con-
centration increases in the blood and
glucose enters the liver and pancreatic
beta cells in the islets of Langerhans
via several glucose transporters namely
GLUT1 and 3 and during high blood glu-
cose GLUT2 in an insulin-independent
fashion [4, 23, 29].
In the beta cells, insulin release into
the bloodstream is induced. In turn, in-
sulin stimulates the uptake of glucose into
the skeletal muscle and adipose tissue by
increasing the GLUT4 transporters in the
membrane. In parallel, the synthesis of
fatty acids in the liver and the adipose
tissue is stimulated. In summary, in-
sulin stimulates the uptake of glucose, the
synthesis, storage and inhibition of the
degradation of fatty acids. Additionally,
insulin also has a protein anabolic effect
as it stimulates protein translation and
the uptake of amino acids. Glucagon,
the insulin antagonist, will be released
by the alpha cells of the pancreas at low
Zeitschrift für Gerontologie und Geriatrie
Common name Building blocks
– –
– –
Corn sugar –
Fruit sugar –
Table sugar Glucose/fructose
Milk sugar Galactose/glucose
Malt sugar Glucose/glucose
– Glucose
– Glucose
(Part of) dietary fiber Glucose
glucose concentrations. It induces the
degradation of glycogen, the gluconeo-
genesis and glucose release in the liver,
the mobilization of fatty acids in fat cells
and the inhibition of fatty acid synthesis.
In parallel, adrenalin and noradrenaline
are released from the adrenal glands and
inhibit the glucose uptake into the mus-
cle. In turn, glucose from glycogen mo-
bilization as well as fatty acid degradation
will take place in the muscle to produce
energy.
Glucocorticoids, such as cortisol pro-
mote glycogen storage in the liver, in-
hibit glucose uptake in skeletal muscle,
increase lipolysis in adipose tissues and
inhibit insulin secretion as well as in-
duce glycogen secretion in the pancreas.
Thereby, glucocorticoids modify glucose
homeostasis to preserve plasma glucose
for brain function during stress [15]. The
most common dysregulation of blood
glucose is the diabetes-associated high
blood level of fasting and postprandial
glucose. This is primarily caused by in-
sulin resistance, which is predominantly
a result of genetic predisposition in com-
bination with obesity. Apart from that,
chronic glucocorticoid exposure can also
result in hyperglycemia and insulin re-
sistance [1].
Based on the differences in increase of
blood sugar levels by different foods, the
glycemic index and the glycemic load as
descriptive values were introduced. The
glycemic index describes the area un-
der the curve of blood glucose values
after a meal of 50 g carbohydrates from a
food in relation to 50 g glucose (the blood
sugar value resulting from consumption
of 50 g of pure glucose is set at 100, which
would be the highest value possible for
the glycemic index). The more relevant
glycemic load includes the percentage of
carbohydrates within the food. For ex-
ample, the glycemic index of carrots is
about 70 from 100, but due to the low
amounts of carbohydrates in carrots, the
glycemic load is only 4, equalling the
consumption of only 4 g glucose.
Too much glucose, a health
problem
It is discussed that the consumption of
high amounts of sugars will induce over-
weight followed by an increase in the risk
of diabetes, cardiovascular diseases and
an increased mortality. Imamura et al.
showed in a systematic review that ha-
bitual consumption of sugar sweetened
beverages was associated with a greater
incidence of type 2 diabetes, indepen-
dently of adiposity [12]. In addition,
Livesey et al. reviewed several meta-anal-
yses and concluded that diets higher in di-
etary glycemic index and load were asso-
ciated with incident type 2 diabetes [16].
The prospective urban rural epidemiol-
ogy (PURE) study, an epidemiological
cohort study in 18 countries including
more than 130,000 participants showed
that high carbohydrate intake was associ-
ated with higher risk of total mortality [5].
A meta-analysis of two Swedish studies
independently confirmed the increased
mortality risk with high sugar intake es-
pecially for the consumption of sugar-
sweetened beverages [24]. Both studies
adjusted their data for obesity by using
either waist to hip ratio or body mass in-
dex (BMI). In contrast, no associations
between sugar consumption at normal
levels and diseases were found by Rippe
and Angelopoulos in non-obese persons
[25].
Blood glucose and fructose also re-
act with proteins in the so-called Mail-
lard reaction to form glycations, e.g. in
HbA1c and advanced glycation end prod-
ucts (AGE). This reaction is enhanced in
patients with diabetes due to longer du-
rations of increased blood sugar levels
where AGEs can crosslink proteins and
induce tissue stiffening. They bind to re-
ceptors, such as the receptor for advanced
glycation end products (RAGE), leading

to inflammation and reduce protein or
enzyme functionality [28]. An English
longitudinal study on aging with more
than 5000 participants showed in a 10-
year follow-up that high levels of glycated
hemoglobin (HbA1c) as well as predia-
betes and diabetes are associated with
a faster rate of cognitive decline [31].
Kassaar et al. identified glycated
macrophage migration inhibitory fac-
tor (MIF) in the brain of Alzheimer’s
patients with high sugar levels. The au-
thors stated that glucose-modified and
oxidized MIF could be a molecular link
between hyperglycemia and the dysreg-
ulation of the innate immune system
in Alzheimer’s patients [13]. Glycation
and AGEs stemming from sugars are
therefore discussed to be at least in
part responsible for many degenerative
diseases, such as hypertension, dias-
tolic heart failure, kidney dysfunction,
cataract formation and dementia [28].
Glucose in the nutrition: too low
is bad as well?
Interestingly, caused by the results shown
above and similar studies, there is a hype
of low-carb diets on the market. Un-
fortunately, these low-carb diets are not
healthy either. A meta-analysis includ-
ing 17 studies revealed an association
of low-carbohydrate diets with a signifi-
cantly increased risk of all-cause mortal-
ity [22]. Mazidi et al. recently showed,
based on 24,825 participants of the Na-
tional Health and Nutrition Examination
Survey (NHANES) study that a low-carb
diet is associated with an increased all-
cause as well as cancer and cardiovascu-
lar mortality. Furthermore, the authors
confirmed this conclusion by a meta-
analysis of 9 prospective cohort studies
with over 450,000 participants [18]; how-
ever, increasing evidence indicates that
there is no black and white. Nordmann
et al. [21] as well as Mansoor et al. re-
ported in their meta-analyses that each
diet has favorable as well as unfavorable
consequences, which need to be balanced
[17]. Results from the atherosclerosis
risk in communities (ARIC) study with
15,428 people as well as a meta-analysis
showed that both low and high carbo-
hydrate consumption are associated with
Abstract · Zusammenfassung
Z Gerontol Geriat https://doi.org/10.1007/s00391-020-01726-1
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020
A. Großkopf · A. Simm
Carbohydrates in nutrition: friend or foe?
Abstract
Fats, proteins and carbohydrates are the
main energy supplies in human nutrition.
The ratio of these three has often been
discussed within the nutritional sciences over
the years. Carbohydrates were important for
our ancestors since many carbohydrate-rich
foods were easily storable without cooling
in comparison to protein-rich or fat-rich
food, such as meat or fish. While humans
consumed a mostly low-calorie nutrition
and experienced seasonal changes in food
availability and abundance for a long time,
food supply changed in the last 100 years.
We are now living in abundance, leading
Kohlenhydrate in der Ernährung: Freund oder Feind?
Zusammenfassung
Die Energiezufuhr des Menschen kann
prinzipiell über Fette, Proteine oder
Kohlenhydrate erfolgen. Das Verhältnis dieser
3 Komponenten zueinander wird immer
wieder im Rahmen von Ernährungsemp-
fehlungen diskutiert. Kohlenhydrate waren
für unsere Vorfahren ein wichtiger Teil der
Ernährung, da viele kohlenhydratreiche
Lebensmittel im Vergleich zu Protein- und
fettreichen Lebensmitteln wie Fisch und
Fleisch leichter lagerbar waren. Während
Menschen lange Zeit eine eher energiearme
Ernährung hatten und mit saisonalen
Änderungen der Nahrungsmenge und -art
a higher all-cause mortality [26]. Ramne
et al. reported similar results from two
Swedish cohort studies. Interestingly,
both studies indicated the importance
of the sources of nutrients [24]. In line,
a very recent analysis of the US National
Health and Nutrition Examination Sur-
vey (37,233 adults) did not observe any
association of low-carbohydrate or low-
fat diets with higher mortality. The au-
thors suggested that the associations of
low-carbohydrate and low-fat diets with
mortality might depend on the quality
and food sources of macronutrients [27].
Since all energy stems from only three
macronutrients, carbohydrates, fat and
proteins, the outcome of any diet low in
one of the macronutrients will depend
to a drastic increase in man-made and
chronic diseases, such as diabetes mellitus.
High, unregulated blood sugar levels in
combination with the accumulation of
advanced glycation end products seem to
be major causes for the development of
diabetes. Therefore, it is under discussion how
healthy carbohydrates are and if they have to
be avoided in nutrition.
Keywords
Sugar · Diet · Aging · Glycation · Diabetes
mellitus
leben mussten, kommt es in Zeiten des
Überflusses zu einer drastischen Zunahme
an zivilisationsbedingten Erkrankungen wie
Diabetes mellitus. Hierbei stehen hohe Blut-
glukosewerte und auch Folgeprodukte wie
die fortgeschrittenen Glykierungsendproduk-
te im Mittelpunkt. So stellt sich die Frage, wie
„gesund“ Kohlenhydrate sind und ob bzw.
wie sehr sie gemieden werden sollen.
Schlüsselwörter
Zucker · Ernährung · Altern · Glykierung ·
Diabetes mellitus
on the selected alternative energy sup-
ply source. If people eat more meat or
saturated fatty acids and less plant-based
products, a low carbohydrate diet can
induce an elevated mortality and cardio-
vascular risk [18, 26].
In summary, most of the data suggest
that diets with very high or very low in-
take of carbohydrates may adversely im-
pact health. In line with this the German
Society of Nutrition suggested 50% car-
bohydrates and less than 10% of the en-
ergy intake by free sugars like glucose [8].
Similarly, the acceptable macronutrient
distribution ranges (AMDR) published
by the US Institute of Medicine (IOM)
suggested a diet with 45–65% carbohy-
drates [30].
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 Themenschwerpunkt
The aging population faces additional
caveats regarding food consumption.
Older people have reduced calorie re-
quirements on the one hand which
means eating the same calories would
lead to overweight and a need for a high-
quality, nutritionally dense diet on the
other hand [3]. In addition, taste and
smell are reduced during aging. In
a cross-sectional analysis on more than
1000 participants of the obesity, nutri-
tion & information and communication
technologies (OBENUTIC) study with
participants aged 18–80 years old, a clear
decrease in the perception of all basic
tastes was seen [2]. In line, in a study of
1955 persons ranging from 5 to 99 years
of age, Doty et al. could show that about
50% of the tested persons at the ages of
65–85 years and 75% above 85 years of
age have major olfactory impairments
[6]. With a reduced taste and smell,
older people tend to use more flavor, e.g.
more sugar for compensation.
Conclusion
Now, has it become clear what the rec-
ommendations could be according to the
available literature? In a meta-analysis on
guidelines for sugar consumption, the au-
thors stated: “Guidelines on dietary sugar
do not meet criteria for trustworthy rec-
ommendations and are based on low-
quality evidence. Public health officials
(when promulgating these recommenda-
tions) and their public audience (when
considering dietary behavior) should be
aware of these limitations” [7].
Thus, recommendations on the sugar
consumption alone without taking the
Zeitschrift für Gerontologie und Geriatrie
Fig. 1 9 Glucose
degradation and
Cori cycle
sources and whole dietary patterns into
consideration might be misleading.
In summary, the main message can
be: avoid extreme diets and stay with
a moderate carbohydrate consumption
at all ages to preserve a healthy and
stable body weight. Regarding carbo-
hydrates as well as other nutrients, it
is not the amount but much more the
quality that matters. One has to dis-
tinguish between pure sugar providing
only calories and complex carbohydrate
mixtures with a low glycemic load, as
for example found in legumes. Reduc-
ing carbohydrates can only be healthy if
the alternative energy sources have more
beneficial effects than the substituted car-
bohydrates. If dietary carbohydrates are
substituted by saturated fats and meat
and the diet is in turn low in dietary
fibers and plant-based products, the ad-
verse effects of this might outweigh any
beneficial influence of the diet. While
undigestible carbohydrates, e.g. dietary
fibers, are important for health recent
research results clearly advise to avoid
sugar-sweetened beverages [10, 14], es-
pecially if the overall dietary habits lead
to overconsumption of calories.
Corresponding address
Andreas Simm
Klinik für Herzchirurgie, Universitätsklinikum
Halle (Saale), Martin-Luther-Universität Halle-
Wittenberg
Ernst-Grube Str. 40, 06120 Halle (Saale),
Germany
andreas.simm@uk-halle.de
Acknowledgments. AS was funded by the DFG RTG
2155 ProMoAge and AG as well as AS were funded
by the Forschungsverbund Autonomie im Alter of
Saxony-Anhalt.
Compliance with ethical
guidelines
Conflict of interest. A. Großkopf and A. Simm declare
that they have no competing interests.
For this article no studies with human participants
or animals were performed by any of the authors. All
studies performed were in accordance with the ethical
standards indicated in each case.
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