Sugar

Sugar is the generic named used to describe sweet-tasting compounds.
Sugar is both found in refined and processed forms (white sugar, cane sugar), and in various whole foods such as fruits.

Sugar and its different forms

The simple sugar forms are glucose, fructose and galactose. They're also called monosaccharides, because they're the most basic forms of sugar and cannot be further simplified.

Sucrose (white sugar), lactose (found in dairy milk), and maltose (found in grains) are disaccharides, because they're composed of two monosaccharides each--glucose + fructose, glucose + galactose, and glucose + glucose, respectively.

Glycemic index

Glycemic index (GI) is a value to represent how much a certain food will rise blood glucose levels, ranging from 0 to 100--with 100 being pure glucose.

Eating high GI foods makes the blood sugar level spike, and high spikes of blood sugar level lead to inflammation and a higher risk of cardiovascular disease by impairing endothelial function and thickening the blood (hypercoagulability). [1][2] This state is called postprandial dysmetabolism (a state of metabolic dysfunction for a period following a meal, which leads to higher inflammation and a higher risk of cardiovascular events [3]).
This is even more so important to pay attention to when it comes to people that are diabetic, and that are at a higher risk for cardiovascular events from postprandial high blood sugar levels. [4]
High blood sugar also leads to oxidative damage, since high blood sugar levels promote the production of free radicals. [5]

Having a spike in blood sugar levels also prompts the body to produce insulin rapidly, to keep the amount of blood sugar consistent. This then leads to a rapid drop in blood sugar levels, which leads to a drop in energy levels (also known as 'sugr crash').
Eating sugar also inhibits the orexin neurotransmitters, which stimulate you and give you a feeling of 'being awake'.[6] This, coupled with the insulin response, shows how eating significant amounts of sugar leads to a significant drop in energy after the initial 'kick'. This is why sugars are not an ideal energy source to keep yourself active throughout the day.

On top of that, eating high GI foods often can lead to a constant high level of glucose in the blood, which has been suspected to be a cause for type 2 diabetes, but this is still debated. [7]

However, it's a different story for fruits and the sugars eaten with them.
Not only because fibers counteract the inflammation by reducing it [8][9], but also because the antioxidants that the fruits contain fight the free radicals promoted by the high blood sugar level. [10]
By removing the fibers and turning the fruits into juices, the benefits of the fibers to lower inflammation are also removed. This, and the fact that more nutrients are removed by juicing, is why eating the whole fruits is recommended. That said, it's still preferable to eat fruits that are high in nutrition and low in sugars, both for weight gain and because eating fruits doesn't simply negate completely the risks associated with high blood sugar levels--meaning that the higher the sugar eaten with the fruits is, the worse it still is (to know what the best fruits to eat are, check the 'best fruit to eat' section).

In fact, whole foods that are plant based lower significantly the problems associated with postprandial high blood sugar levels. [11]

Weight gain

Refined sugars are very calorie dense, while offering no nutrients whatsoever (for the most commonly used ones). Similarly to oil, it's very easy to eat significant quantities of it and to not feel full because you didn't get any nutrients. Or if you feel full at the end of the day after eating lots of sugar, you'll have had less calories dedicated to nutrients, and more calories spent uselessly in empty calories (sugar), which will mean you're more likely to not meet the nutritional daily requirements.

Refined sugars are significantly higher in calorie density, since nutrients have been removed and only the calories of the sugar themselves are left.

Sugars with no nutrients:

• 1 cup corn syrup: 965 kcal
• 1 cup white sugar: 774 kcal
• 1 cup brown sugar (unpacked): 551 kcal

Sugars with nutrients:

• 1 cup date sugar (dried and pulverized, whole foods): 415 kcal with fibers, some vitamins and some minerals
• 1 cup maple syrup: 819 kcal with lots of vitamin B2 and manganese, and a bit of other minerals
• 1 cup blackstrap molasses: 960 kcal with optimal amounts of almost all minerals and vitamin B6, and some other vitamins
• 1 cup agave syrup: 1042 kcal with some vitamins

Sugars are best avoided to prevent weight gain, considering that they are very calorie dense while bringing no amount to very small amounts of nutrients (with the exception of blackstrap molasses and its mineral quantities).
A high BMI (obesity) leads to an increased risk of all-cause mortality.

Dental health and related problems

Sugar directly cause tooth decay, promoting the development of acid-producing bacteria in your mouth. [12] Over time, this causes a cavity in enamel (the protective layer covering teeth), therefore leaving the tooth weak to decay.
Sugar attracts bad bacteria (e.g. Streptococcus mutans, Streptococcus sorbrinus), which cause plaque. If plaque isn't washed away frequently, the pH in the mouth becomes more acidic, leading to demineralization and leaving the tooth more vulnerable. [13]

That said, it seems that free sugars (refined) may have a significantly worse effect, as there is no strong evidence showing that sugars eaten through starchy foods and fruits have the same effect.

"There is convincing evidence, collectively from human intervention studies, epidemiological studies, animal studies and experimental studies, for an association between the amount and frequency of free sugars intake and dental caries. Although other fermentable carbohydrates may not be totally blameless, epidemiological studies show that consumption of starchy staple foods and fresh fruit are associated with low levels of dental caries. Fluoride reduces caries risk but has not eliminated dental caries and many countries do not have adequate exposure to fluoride. It is important that countries with a low intake of free sugars do not increase intake, as the available evidence shows that when free sugars consumption is <15-20 kg/yr ( approximately 6-10% energy intake), dental caries is low." [14]

"Natural sugars include sugars physically located in the cellular structure of grains, fruits, and vegetables plus those naturally present in milk and milk products. Evidence suggests that sugars naturally present in grains, whole fruits, and vegetables and also in milk do not make an important contribution to the development of dental caries (or other noncommunicable diseases). This is because of the innate characteristics such as fiber content, water content, and other protective factors such as polyphenolic compounds or calcium or both. The impact of fruit, vegetables, and grains on mechanical stimulation of salivary flow helps mitigate the potential risk of the sugars." [15]

Considering date sugar (whole foods sugar, dried dates pulverized), and its lack of water and not very significant amount of fibers, it's unclear the impact it would have on caries. Date sugar does have a high amount of polyphenols though, so those plus the fibers make it certainly better for cavities than refined sugars.

"The studies carried out in recent decades have confirmed the antibacterial role of polyphenols: they may reduce bacterial growth rate and adherence to tooth surface, and also can perform inhibitory effects on the enzymatic activity of glucosyltransferase and amylase."[16]

While frequency of eating sugars makes it worse, in a study of over 22'000 participants, even just one sugary drink occasionally resulted in a 44% increase in the risk of losing teeth. [17]

There is no reason to believe that caries are caused by something else other than sugar, because of lack of evidence of any other potential cause.

Plaque that is not removed hardens with time, causing tartar. Tartar tends to collect over the gum line, causing the gum to irritate and even bleed.
This can lead to gingivitis (an inflammatory condition of the gingival tissue or the gums). And when gingivitis is not treated, it can lead to periodontitis, where the gums retract, resulting in the loss of connective tissues and bone support.

Tooth decay and poor oral hygiene also present a risk for cardiovascular disease.
Firstly, bad bacteria can enter your bloodstream through the gaps formed by periodontitis. If the bacteria reaches the heart's arteries, it can harden and cause atherosclerosis. [18]
Secondly, gum infection can lead to endocarditis, where the bacteria spreads to the inner linings of the heart, preventing the heart's valves to work properly.[19]

"Our study shows a significant correlation between number of missing teeth and CVD; in fact, old people with more than 18 missing teeth have 2.5 times greater risk of CVD. These data agree with the literature; in fact, Holmlund et al.11 reported an increased risk of mortality from coronary heart disease in subjects with <10 teeth compared to those with >25 teeth." [20]

And finally,

"Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established."[21]

Tooth decay and poor oral hygiene has also been linked to stomach cancer, and other different types of cancer.[22]

"In addition, infection with H. pylori, which can be found in periodontal pockets, may be a confounder for the possible relationship between tooth loss and gastric cancer risk. However, only one study from Finland provided risk estimates adjusted for H. pylori infection and reported that tooth loss is associated with increased risk of gastric cancer. The oral cavity, which provides a gateway between the external environment and the gastrointestinal tract, functions in food ingestion and digestion. Oral hygiene potentially affects the gastrointestinal flora and nutritional status and may thus have implications for the development of chronic diseases. Evidence shows that poor oral health or hygiene plays a role in cancer development, including cancer of the oral cavity and oropharynx, esophagus, lung, pancreas, and kidney."

Avoiding refined sugars and processed starchy foods, paired with good oral hygiene, is the best prevention for tooth decay and its related problems.

Fructose and its cascade of health problems

Evidence shows that fructose is significantly worse than other types of sugars.
This is because fructose can only be broken down by the liver. While eating fruits would be fine because the fructose amount wouldn't cause a problem, eating significant amounts of fructose as an added sweetener can cause liver damage, and other problems.

There is evidence that high amounts of fructose lead to generic NAFLD (non-alcoholic fatty liver disease, fat build-up in the liver) and NASH (non-alcoholic steatohepatitis, an advanced type of NAFLD that includes inflammation, that can eventually lead to complications such as cirrhosis, liver cancer, liver failure, or cardiovascular disease).

"recent evidence suggests that diets high in sugar (from sucrose and/or high-fructose corn syrup [HFCS]) not only increase the risk of NAFLD, but also non-alcoholic steatohepatitis (NASH)." [23]

"Virtually every cell in the body can use glucose for energy. In contrast, only liver cells break down fructose. What happens to fructose inside liver cells is complicated. One of the end products is triglyceride, a form of fat. Uric acid and free radicals are also formed. None of this is good. Triglycerides can build up in liver cells and damage liver function. Triglycerides released into the bloodstream can contribute to the growth of fat-filled plaque inside artery walls. Free radicals (also called reactive oxygen species) can damage cell structures, enzymes, and even genes. Uric acid can turn off production of nitric oxide, a substance that helps protect artery walls from damage. Another effect of high fructose intake is insulin resistance, a precursor to diabetes." [24]

Fortunately, this only happens with high quantities of fructose--so eating some fruits and having a bit of added sugar won't be a problem.

"In humans, there is strong evidence, based on several intervention trials, that fructose overfeeding increases fasting and postprandial plasma triglyceride concentrations... ...Such effects are observed with high daily fructose intakes, and there is no solid evidence that fructose, when consumed in moderate amounts, has deleterious effects." [25]

Alternatives to refined sugar

Date sugar and blackstrap molasses

Date sugar

Date sugar presents a good alternative to refined sugar in baking.
Baking requires large amounts of sugar, and consider how unhealthy refined sugar is, date sugar is much more preferable--the higher the quantity, the more difference using date sugar instead makes.

Date sugar is whole foods, since it's whole dates that are dried and then pulverized, and therefore minimally processed.

Date sugar has the following nutrients for 100 kcal (35g):

• 2.8g fiber (7%)
• small amounts of B vitamins
• some minerals (i.e. 4% potassium)

The fact that date sugar has a decent amount of fibers (8% of total weight), which help fight against inflammation caused by the spikes of high blood sugar, and has some antioxidants (ORAC value of 859 per 100 kcal), which help fight the free radicals promoted by the high blood sugar level, makes it the lesser evil among the sugars if you need to use sugar in big quantities (like in baking). On top of that, it's unclear whether whole foods would cause caries, but if so, it would be significantly less risky than refined sugars--conclusions that can be drawn from the available evidence, suggest that the fibers and the polyphenols present in the dates would significantly reduce the cariogenicity of the sugar found in the dates, if not completely null it.

A caveat of date sugar is that it's often expensive and/or hard to find, depending where you're living.

Blackstrap molasses

Blackstrap molasses is a refined syrup, but while it's refined it provides significant amounts of minerals.

Blackstrap molasses has the following nutrients for 100 kcal (35g):

• small amounts of B vitamins, 24% vitamin B6
• significant amount of minerals, including 33% calcium and 15% potassium (both hard-to-get minerals in optimal quantities)

The amount of calcium and potassium in blackstrap molasses makes it the most useful sweetener in terms of nutritional usefulness. Blackstrap molasses also has a decent amount of antioxidants (ORAC value of 3979 per 100 kcal), which help fight the free radicals promoted by the high blood sugar level.

Artificial sweeteners

Artificial sweeteners are hundreds of times sweeter than sucrose (white sugar), allowing them to be used in small quantities for a significant sweetening effect.
While they're ideal to add sweetness to certain dishes, avoiding the above described downsides of sugar, they can't be used when sugar is one of the main components of the dish (i.e. baking).

Conclusions

From the evidence above we can conclude that:

• if you don't need to get extra minerals and your diet is already sufficient to get all the calcium and potassium, date sugar is probably the best sweetener to use in significant/big quantities: 1. because of a lower calories per quantity compared to other sugars, 2. because of a better inflammatory response thanks to the fibers it has, and 3. because of a lesser cariogenic effect thanks to the fibers and polyphenols it has
• if you're struggling to reach the adequate amount of calcium and potassium, blackstrap molasses is probably the best sweetener to use in significant/big quantities
• if you just want to add a bit of sweetness to your dish, an artificial sweetener is probably the best way--no sacrifice in calories (0 kcal, 0 nutrients) make it a certain positive, being able to achieve sweetness virtually without any downsides, that would otherwise have to be achieved with some sacrifice in healthfulness

The two tables below will show sugars sorted by the least worse (excluding cariogenicity).
Table 1 is based on amount per sweetness. Because sugars are often used to achieve a certain threshold of sweetness, they're sorted according to the positives and negatives they give based on X sweetness level. Sweetness level is standardized at 100S, for the sweetness level that 100g of sucrose (table sugar) would give, for an understandable comparison.
Table 2 is based on amount. Because sugars are often used according to certain quantities required by recipes, and the amount of sweetness for each sugar is proportional to its amount used, they're sorted according to the positives and negatives they give based on level 1 cup.
Fibers and ORAC value are included, because they help reduce inflammation caused by/ and help fight free radicals promoted by the spikes in the blood sugar levels after eating sugar, respectively.

Table 1

Name	Final Rating (the higher, the less bad)	Amount of kcal per 100S / Weight gain	Amount of fructose (100S) / NAFLD	ORAC value (100S) / Free radicals prevention	Fibers quantity (100S) / Inflammatory response	Vitamins quantity (100S) / Nutritional usefulness	Minerals quantity (100S) / Nutritional usefulness
Agave syrup	-5.5	-2.5 / -4 (207 kcal)	-4 / -4 (37.1g)	0 / 0 (negligible amounts)	0 / 4 (none)	1 / 4 (poor)	0 / 4 (none, or traces)
Blackstrap molasses		-4 / -4 ( kcal)	-2 / -4 ()	4 / 4 ( ORAC/100S)	0 / 4 (none)	2 / 4 (good)	4 / 4 (exceptional)
Brown sugar (unpacked)		-2 / -4 ( kcal)	-2 / -4 (g)	2 / 4 ( ORAC/100S)	0 / 4 (none)	0 / 4 (none, or traces)	1 / 4 (poor)
Corn syrup		-4 / -4 ( kcal)	0 / -4 (g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
Date sugar		-1.5 / -4 ( kcal)	-1.5 / -4 (g)	2 / 4 ( ORAC/100S)	2 / 4 (good)	1 / 4 (poor)	1 / 4 (poor)
High-fructose corn syrup 42	-5.5	-3 / -4 (255 kcal)	-2.5 / -4 (28.9g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
High-fructose corn syrup 55	-6	-3 / -4 (234 kcal)	-3 / -4 (34.6g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
High-fructose corn syrup 90	-5.5	-2 / -4 (176 kcal)	-3.5 / -4 (42.6g) !	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
Maple syrup (dark)	0	-3 / -4 (260 kcal)	-2.5 / -4 (29.6g)	2.5 / 4 (1500 ORAC/cup)	0 / 4 (none)	1 / 4 (poor)	2 / 4 (good)
Maple syrup (extralight)	0	-3 / -4 (260 kcal)	-2.5 / -4 (29.6g)	1 / 4 (607 ORAC/100S)	0 / 4 (none)	1 / 4 (poor)	2 / 4 (good)
White sugar	-8	-4 / -4 (387 kcal)	-4 / -4 (49.9g) !	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)

Table 2

Name	Final Rating (the higher, the less bad)	Amount of kcal per cup / Weight gain	Amount of fructose (1 cup) / NAFLD	ORAC value (1 cup) / Free radicals prevention	Fibers quantity (1 cup) / Inflammatory response	Vitamins quantity (1 cup) / Nutritional usefulness	Minerals quantity (1 cup) / Nutritional usefulness
Agave syrup	-5	-4 / -4 (1042 kcal)	-4 / -4 (186.8g) !	0 / 0 (negligible amounts)	0 / 4 (none)	3 / 4 (very good)	0 / 4 (none, or traces)
Blackstrap molasses	3	-4 / -4 (960 kcal)	-2 / -4 (61.8)	4 / 4 (38317 ORAC/cup)	0 / 4 (none)	2 / 4 (good)	4 / 4 (exceptional)
Brown sugar (unpacked)	-1	-2 / -4 (551 kcal)	-2 / -4 (70.1g)	2 / 4 (3393 ORAC/cup)	0 / 4 (none)	0 / 4 (none, or traces)	1 / 4 (poor)
Corn syrup	-4	-4 / -4 (965 kcal)	0 / -4 (5.3g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
Date sugar	3	-1.5 / -4 (414 kcal)	-1.5 / -4 (46.3g)	2 / 4 (3509 ORAC/cup)	2 / 4 (good)	1 / 4 (poor)	1 / 4 (poor)
High-fructose corn syrup 42	-6	-3.5 / -4 (871 kcal)	-2.5 / -4 (98.5g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
High-fructose corn syrup 55	-6.5	-3.5 / -4 (871 kcal)	-3 / -4 (129.0g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
High-fructose corn syrup 90	-7.5	-3.5 / -4 (871 kcal)	-4 / -4 (211.0g) !	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)
Maple syrup (dark)	0	-3 / -4 (818 kcal)	-2.5 / -4 (93.4g)	2.5 / 4 (4731 ORAC/cup)	0 / 4 (none)	1 / 4 (poor)	2 / 4 (good)
Maple syrup (extralight)	-1.5	-3 / -4 (818 kcal)	-2.5 / -4 (93.4g)	1 / 4 (1814 ORAC/cup)	0 / 4 (none)	1 / 4 (poor)	2 / 4 (good)
White sugar	-5.5	-3 / -4 (774 kcal)	-2.5 / -4 (99.8g)	0 / 0 (negligible amounts)	0 / 4 (none)	0 / 4 (none, or traces)	0 / 4 (none, or traces)