University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA COLLEGE OF HEALTH SCIENCES SCHOOL OF BIOMEDICAL AND ALLIED HEALTH SCIENCES DEPARTMENT OF DIETETICS THE EFFECT OF HONEY, WHITE AND BROWN TABLE SUGAR ON LIPID PROFILE AND GLUCOSE LEVEL IN RATS BY DAVID KWAME TUFFOUR (10352763) A THESIS SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES IN PARTIAL FULFILLMENT OF THE AWARD OF MASTER OF SCIENCE DEGREE IN DIETETICS OCTOBER, 2020 University of Ghana http://ugspace.ug.edu.gh DECLARATION i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this thesis to the Almighty God and my lovely family. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I want to thank my entire supervisory team: Prof. (Maj. Rtd) George Awuku Asare, Dr. Matilda Asante, and Mrs. Ruth Nyarko who provided the needed guidance and expertise for a successful research output. My appreciation also goes to all staff of the Department of Dietetics, School of Biomedical and Allied Health Sciences, University of Ghana. I also want to thank, Mr. Safo Asare of the Department of Pharmacology and Toxicology, School of Pharmacy, University of Ghana, for his support in animal handling. To Mr. Derek Amartey Doku, of the Chemical Pathology Laboratory, University of Ghana, I am grateful for your output. My special appreciation also goes to Ms Anna Addae Ashia for her support to this work. Lastly, to all my colleague MSc. Dietetics students, thank you for the friendship we shared during the course of our study. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT ............................................................................................................. iii TABLE OF CONTENTS ............................................................................................................... iv LIST OF FIGURES ..................................................................................................................... viii LIST OF TABLES ......................................................................................................................... ix ABREVIATIONS ........................................................................................................................... x ABSTRACT .................................................................................................................................. xii CHAPTER ONE ............................................................................................................................. 1 1.0 INTRODUCTION .................................................................................................................... 1 1.1 BACKGROUND ................................................................................................................... 1 1.2 PROBLEM STATEMENT ................................................................................................... 4 1.3 JUSTIFICATION .................................................................................................................. 5 1.4 HYPOTHESES ..................................................................................................................... 6 1.5 AIMS AND OBJECTIVES ................................................................................................... 6 1.5.1 SPECIFIC OBJECTIVES .................................................................................................. 6 CHAPTER TWO ............................................................................................................................ 7 2.0 LITERATURE REVIEW ......................................................................................................... 7 2.1 NATURAL SWEETENERS ................................................................................................. 7 2.2 PROPERTIES OF NATURAL SWEETENERS .................................................................. 8 2.2.1 Sweetness...................................................................................................................... 10 2.2.2 Texture .......................................................................................................................... 10 2.2.3 Fermentation ................................................................................................................. 11 2.2.4 Preservation .................................................................................................................. 11 iv University of Ghana http://ugspace.ug.edu.gh 2.2.5 Solubility ...................................................................................................................... 12 2.3 TYPES OF NATURAL SWEETENERS ........................................................................... 12 2.3.1 White table sugar .......................................................................................................... 12 2.3.2 Brown table sugar ......................................................................................................... 13 2.3.3 Honey............................................................................................................................ 14 2.4 SUGAR PRODUCTION..................................................................................................... 15 2.5 SUGAR CONSUMPTION ................................................................................................. 15 2.6.1 DIGESTION AND METABOLISM OF SUCROSE ...................................................... 16 2.6.2 Sucrose digestion .......................................................................................................... 16 2.6.3 Sucrose absorption ........................................................................................................ 17 2.6.4 Sucrose Metabolism ..................................................................................................... 17 2.6.5 Sugar Storage ................................................................................................................ 17 2.7 NATURAL SWEETENERS AND OBESITY ................................................................... 18 2.7.1 Obesity .......................................................................................................................... 18 2.7.2 Prevalence of Obesity ................................................................................................... 18 2.7.3 Effect of natural sweeteners on obesity ........................................................................ 19 2.8 NATURAL SWEETENERS AND GLUCOSE LEVELS .................................................. 21 2.8.1 Glucose Level ............................................................................................................... 21 2.8.2 Categorization of blood glucose test ............................................................................ 21 2.8.3 Effect of natural sweeteners on glucose level .............................................................. 22 2.8.4 Diabetes ........................................................................................................................ 23 2.8.5 Prevalence of diabetes .................................................................................................. 24 2.8.6 Effect of natural sweeteners on diabetes ...................................................................... 25 2.9 NATURAL SWEETENERS AND LIPID PROFILE ......................................................... 25 2.9.1 Categorization of lipid profile ...................................................................................... 26 v University of Ghana http://ugspace.ug.edu.gh 2.9.2 Dyslipidaemia ............................................................................................................... 26 2.9.3 Prevalence ..................................................................................................................... 27 2.9.4 Effect of natural sweeteners on lipid profile ................................................................ 27 2.9.5 Cardiovascular disease ................................................................................................. 29 2.9.6 Prevalence ..................................................................................................................... 29 2.9.7 The effect of natural sweetener on cardiovascular disease ........................................... 31 2.10 THE EFFECT OF NATURAL SWEETENERS ON INSULIN ....................................... 32 2.10.1 Gross Anatomy of the Pancreas.................................................................................. 32 2.10.2 Histology of the Pancreas ........................................................................................... 33 2.10.3 Effect of natural sweeteners on insulin ....................................................................... 34 CHAPTER THREE ...................................................................................................................... 35 3.0 METHODOLOGY ................................................................................................................. 35 3.1 STUDY DESIGN ................................................................................................................ 35 3.2 STUDY SITE ...................................................................................................................... 35 3.3 STUDY POPULATION ..................................................................................................... 35 3.4 ACCLIMATIZATION OF ANIMALS AND FEEDING ................................................... 35 3.5 ETHICS ............................................................................................................................... 36 3.6 Diet Regimen of Sweeteners ............................................................................................... 36 3.6.1 TRANSLATING INTO ANIMAL DOSE ................................................................... 38 3.6.2 Preparation of diet ........................................................................................................ 39 3.7 ADMINISTRATION OF TREATMENT ........................................................................... 39 3.8 BLOOD SAMPLE AND TISSUE COLLECTION ............................................................ 39 3.9 PREPARATION OF RAT PANCREAS HOMOGENATE ............................................... 40 3.10 BIOCHEMICAL ANALYSIS .......................................................................................... 40 3.11 HISTOLOGICAL ANALYSIS ......................................................................................... 41 vi University of Ghana http://ugspace.ug.edu.gh 3.12 STATISTICAL ANALYSIS ............................................................................................. 41 CHAPTER FOUR ......................................................................................................................... 42 4.0 RESULTS ............................................................................................................................... 42 4.1 LOW DOSE WEIGHT CHANGES .................................................................................... 42 4.2 EFFECT OF NATURAL SWEETENERS ON HBA1C .................................................... 43 4.3 EFFECT OF NATURAL SWEETENERS ON FASTING BLOOD GLUCOSE (FBG) ... 44 4.4 EFFECT OF NATURAL SWEETENERS ON LIPID PROFILE ...................................... 45 4.4.1 Effect of natural sweeteners on Total Cholesterol (TC) ............................................... 45 4.4.2 Effect of Natural Sweeteners on Triglyceride (TG) ..................................................... 46 4.4.3 Effect of Natural Sweeteners on High Density Lipoprotein Cholesterol (HDL-C) ..... 47 4.4.4 Effect of Natural Sweeteners on Low Density Lipoprotein Cholesterol (LDL-C) ...... 48 4.5 EFFECT OF NATURAL SWEETENERS ON INSULIN ................................................. 49 4.6 EFFECT OF WHITE SUGAR, BROWN SUGAR AND HONEY ON HISTOLOGY OF THE PANCREAS. .................................................................................................................... 50 CHAPTER FIVE .......................................................................................................................... 53 5.0 DISCUSSION AND CONCLUSION .................................................................................... 53 5.1 DISCUSSION ..................................................................................................................... 53 5.2 CONCLUSION ................................................................................................................... 58 5.3 LIMITATIONS ................................................................................................................... 58 5.4 RECOMMENDATION ...................................................................................................... 59 PREPARATION OF 10% BUFFERED FORMALDEHYDE PH 7.26 ................................... 93 PROTOCOL FOR PERIODIC ACID SCHIFF STAINING .................................................... 93 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 2. 1: Chemical structure of glucose ................................................................................... 9 Figure 2. 2: Chemical structure of sucrose .................................................................................... 9 Figure 2. 4: Global sugar consumption from 2013/2014 forecast to 2020/2021 ......................... 16 Figure 4. 1: Mean weights of experimental rats measured from week 1 to week 12 administration . ..................................................................................................................................................... 43 Figure 4. 2: The effect of white sugar, brown sugar and honey on HbA1c of rats after 12 weeks administration. .............................................................................................................................. 44 Figure 4. 3: The effect of white sugar, brown sugar and honey on fasting blood glucose of rats after 12 weeks administration. ...................................................................................................... 45 Figure 4. 4: The effect of white sugar, brown sugar and honey on total cholesterol of rats after 12 weeks administration. .............................................................................................................. 46 Figure 4. 5: The effect of white sugar, brown sugar and honey on triglycerides of rats after 12 weeks administration. ................................................................................................................... 47 Figure 4. 6: The effect of white sugar, brown sugar and honey on high density lipoproteins cholesterol of rats after 12 weeks administration. ........................................................................ 48 Figure 4. 7: The effect of white sugar, brown sugar and honey on low density lipoproteins cholesterol of rats after 12 weeks administration. ........................................................................ 49 Figure 4. 8: Bar chart showing the effect of white sugar, brown sugar and honey on low insulin level of rats after 12 weeks administration. .................................................................................. 50 Figure 4. 9: Photomicrographs of PAS staining showing representative sections of pancreatic tissue of rats studied after 12 weeks administration. Black double headed arrows indicate islet. Yellow double head arrow indicate duct system. Solid yellow arrows indicate epithelial lining of the duct. Circle indicate acini. Five-point stars indicate degenerated acini. ............................... 52 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3. 1: Recommended sugar intake/day of white sugar, brown sugar and honey .................. 36 Table 3. 2: recommended sugar intake/day per average weight of carbohydrate. ........................ 37 Table 3. 3: High dose estimation per average weight of carbohydrate. ........................................ 37 Table 3. 4: Low dose estimation per average weight of carbohydrate. ........................................ 38 Table 3. 5: Estimated animal high dose. ....................................................................................... 38 Table 3. 6: Estimated animal low dose. ........................................................................................ 39 ix University of Ghana http://ugspace.ug.edu.gh ABREVIATIONS CVD Cardiovascular disease NAFLD Non-alcoholic fatty liver disease HDL-C High density lipoprotein cholesterol LDL-C Low density lipoprotein cholesterol TC Total cholesterol TG Total triglycerides SSB Sugar sweetened beverage WHO World Health Organisation IDF International Diabetes Federation CAD Coronary artery disease BS LD Brown sugar low dose BS HD Brown sugar high dose H LD Honey low dose H HD Honey high dose WS LD White sugar low dose WS HD White sugar high dose PBS Phosphate buffer solution x University of Ghana http://ugspace.ug.edu.gh HbA1c Glycated haemoglobin FBG Fasting blood glucose PAS Periodic Acid Schiff S-D Sprague-Dawley WS White sugar BS Brown sugar H Honey CAD Coronary Artery Disease xi University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Honey and table sugar are commonly used sweeteners by many consumers. These sweeteners are examples of disaccharide sugar which forms part of the complex macromolecule, carbohydrate. Excessive consumption of dietary sugars including table sugar and honey is associated with several metabolic abnormalities and adverse health conditions such as obesity, diabetes and cardiovascular disease. There is a general debate by many researchers and consumers that honey is better than brown sugar which is also better than white sugar. However, scientific data supporting these claims are inconclusive on the effect of these natural sweeteners on the various biomarkers of cardio vascular health and glycaemia. Aim: The aim of the study was to determine the effect of honey, white and brown table sugar on lipid profile, glucose level and pancreatic insulin level and histology using animal models. Methodology: Thirty-five (35) male Sprague Dawley rats aged 12 - 14 weeks, weighing 150g - 250g were obtained. The groups were set up as follows: Group 1 (G1) – control group, group 2 (G2) - white sugar low dose 0.055 g (WS LD), group 3 (G3) - white sugar high dose 0.22 g (WS HD), group 4 (G4) - brown sugar low dose 0.057 (BS LD), group 5 (G5) - brown sugar high dose 0.230 g (BS HD), group 6 (G6) - honey low dose 0.076 g (H LD) and group 7 (G7) - honey high dose 0.304 g (H HD). One (1) ml of the prepared white sugar, brown sugar or honey solution was administered daily to the treatment group of rats orally by gavage for 12 weeks. After a 12 week administration period, the rats were sacrificed for blood and tissue analysis. Four millimetres (4ml) of blood samples was collected for analysis of lipid profile (total cholesterol, total triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol) glycated haemoglobin (HbA1c) and fasting blood glucose (FBG). The harvested organ was weighed and divided into two parts. Half went into buffered formalin and the other half went into xii University of Ghana http://ugspace.ug.edu.gh a container and stored at -80°C for insulin analysis. The pancreas was homogenized using dounce tissue grinder in cold PBS, for each 1 g of pancreas. The sample was centrifuged at approximately 10000 X g for 5 min. The supernatant was collected and insulin was measured. Two way ANOVA was used to compare the means within and between the treatment groups. Where ANOVA was significant, the post hoc test was performed using Bonferroni analysis. A p- value ≤ 0.05 was deemed statistically significant. Results: In this study, the assessed body weights of animals showed clear and continuous weight gain throughout the treatment groups, even though the difference was not significant between the groups. Also, the effect of intake of the three natural sweeteners white sugar, brown sugar and honey on the HbA1c, glucose level and lipid profile of the rats showed a significant increase in the high dose groups compared to the control group. Furthermore the effect of white sugar brown sugar and honey on the insulin levels of rats showed a significant decrease in insulin level of the high dose groups compare to the control group. However, the effect of white sugar, brown sugar and honey on insulin showed no significant difference between low dose groups when compared with the control group. Conclusion A twelve week treatment of honey, white and brown table sugar was found to cause an appreciable increase in FBG, HbA1c and lipid profile and release of insulin at the same dose. The increase was found to occur mostly in the high doses than in low doses with a few disparity. xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 BACKGROUND Honey, white and brown table sugar are commonly used natural sweeteners. Sweeteners are chemical compounds, found in nature or chemically synthesized, which have a sweet taste that determines their usage as sweetening agents (Mooradian et al., 2017). The most common natural sweeteners may contain simple sugars such as monosaccharides (glucose, fructose, and galactose) and disaccharides (lactose, maltose, and sucrose) (Carocho et al., 2017). Added sugars include natural sugars such as white sugar, brown sugar and honey (Bowman, 2017). The history of honey goes as far back as 3000 BC. It was used as medicine by the Egyptians and Chinese, while Greeks regarded it as food for the gods (Meo et al., 2017). Glucose and fructose are the major monosaccharide combination found in honey and sugar (Kolayli et al., 2012). Honey contains trace quantities of a variety of mineral and vitamins, including zinc, magnesium, iron, potassium, niacin, copper, riboflavin and zinc (Al-Waili et al., 2013). This gives it an added value making it a popularly used sweetener (Al-Waili et al., 2013). Because of its antioxidant properties and a range of health benefits associated with long-term use, honey is considered better than brown or white sugar (Chepulis and Starkey, 2008, Kappico et al., 2012, da Silva et al., 2016). White sugar is one of the most popular sweeteners used globally today. It also known as refined sugar, table sugar, granulated sugar or regular sugar (Baikow, 2013a). It is obtained from sugar cane or sugar beet juice which is refined to remove molasses (Panda, 2011). White sugar has several uses in the food processing industry. It is a versatile ingredient and contributes many 1 University of Ghana http://ugspace.ug.edu.gh functional properties to food products such as texture, colour and taste (Brisbois et al., 2014). One tablespoon of white granulated sugar contains about 49 calories (Kumar et al., 2010) while a tablespoon of honey has 68 calories, illustrating why honey is greater in density and weight than sugar. (Kumar et al., 2010). Brown sugar is the moist and dark sugar produced as a result of sugar cane broth evaporation. (Orlandi et al., 2017). Unlike white sugar, brown sugar is not involved in many chemical processes therefore it is considered a more suitable and healthier alternative (Rodríguez-Entrena et al., 2016, Orlandi et al., 2017). Sugars may be used in foods during preparation, processing, or added at the table (Newens and Walton, 2016). This makes it an inseparable component of our diet and many people consume more sugar than they realize due to it sweet taste. Several metabolic disorders and detrimental health problems have been associated with excessive intake of these added sugars (Bray and Popkin, 2014). Natural sweeteners are frequently found well above the ideal value in concentrations in food (Bernstein et al., 2016). This consequently led to an absolute dependency or obsessive ingestion of excess sugar (Swarna Nantha, 2014). The amount of sweetness depends on the chemical composition of the sweetener (Clemens et al., 2016b). Globally, due to an increase in calorie consumption, the incidence of obesity is growing rapidly (Swinburn et al., 2011, Malik et al., 2013b, GBD, 2017). Health complications associated with the excessive consumption of natural sweeteners has been an issue of global concern. Natural sweeteners form a core of meals and the effects of frequent or excessive consumption has been underestimated by majority of the populace. A review of sugar consumption by developed countries found that intake levels in adults living in the United States increased from 13.5% to 24.6% (Bleich et al., 2008). In order to minimize the risk of disease, dietary recommendations for 2 University of Ghana http://ugspace.ug.edu.gh Americans have been changed to limit intake of added sugar to less than 10% of calories per day (Health and Services, 2017). Similarly, the American Heart Association also suggests that the consumption of added sugar in men and women should not exceed 150 kcal or 100 kcal per day (Vos et al., 2017). In 2010, it was estimated that among Africa adults 20 years and above, 27% were overweight and 8% obese (WHO, 2010). The increase in the worldwide prevalence of obesity was linked to the excess intake of added sugars (Mooradian et al., 2017). Several studies have shown a significant relationship between the excessive consumption of sugar-sweetened beverages and body weight gain in adults (Chen et al., 2009, De Koning et al., 2012, Pan et al., 2013). Obesity is a known major risk factor of diseases such as diabetes and cardiovascular disease (Te Morenga et al., 2013, Malik et al., 2013a, Saravanan et al., 2014). In 2015, the prevalence of diabetes in adults aged 20-70 years was 8.8 % and is expected to rise to 10.4 % by 2040 (WHO, 2016a). In 2012, 2.6 million (4.5%) deaths worldwide were related to CVDs (Laslett et al., 2012). The effect of added sugar consumption on a person with diabetes can exacerbate symptoms because diabetes makes it harder for the body to regulate blood sugar levels (Bray and Popkin, 2014). It is also reported in a study that the long term consumption of honey improves weight regulation and decreases blood sugar levels as well as increase levels of HDL cholesterol (Chepulis, 2007). Potential connection regarding added sugar consumption and dyslipidaemia characterized by elevated low-density cholesterol lipoprotein (LDL-C) and triglycerides (TG) (Kell et al., 2014, Rippe, 2014). Some studies have also linked it with low high density lipoprotein cholesterol (HDL-C) concentrations (Kell et al., 2014, Rippe and Angelopoulos, 2016, Vos et al., 2017). A correlation between sugar intake and fasting and post-prandial concentrations of triglycerides, 3 University of Ghana http://ugspace.ug.edu.gh which are seen as absolute biomarkers of cardiovascular diseases, has also been found (Siri- Tarino, 2011, Kim and Jee, 2015). Excessive intake of sugar is related to increased levels of triglyceride, which is known to facilitate the onset of coronary heart disease (DiNicolantonio and OKeefe, 2017). However, the association between sugar intake and Low Density Lipoprotein Cholesterol (LDL-C) or High Density Lipoprotein Cholesterol (HDL-C) remains unclear (Johnston et al., 2013, Atangwho et al., 2017). A possible association between added sugar consumption and adult mortality from cardiovascular diseases has also been identified (Yang et al., 2014). Findings of the effect of natural sweeteners on health are controversial especially its effect on glycaemia and lipid profile thus further study on the health effects of these natural sweeteners are warranted. 1.2 PROBLEM STATEMENT There is a global concern about high consumption of natural sweeteners and its association with a number of health conditions (WHO, 2015). Several studies have shown an indirect correlation between excess sugar intake and obesity, a risk factor for type 2 diabetes, dyslipidaemia and CVDs (Fitch and Keim, 2012, WHO, 2015, Rogers et al., 2016). Due to these health implications, consumers have become more conscious of the use of these natural sweeteners (Bruyère et al., 2015). There is a general debate by many researchers and undocumented claims by many consumers that honey is better than brown sugar which is also better than white sugar (Langlois and Garriguet, 2011, Valli et al., 2012, De Maria, 2013, Roman et al., 2013). It is still unclear if some natural sweeteners are beneficial to good health than others. Scientific data supporting these claims are inconclusive on the effect of these natural sweeteners on the various biomarkers of cardio vascular health and glycaemia (White, 2013, Klurfeld et al., 2013, van Buul et al., 2014). Furthermore, much of the information about the role of sugars on nutrition and 4 University of Ghana http://ugspace.ug.edu.gh health are inconsistent (Arola et al., 2009, Basu et al., 2013). It is therefore necessary to conduct further studies to determine the effect of honey, white and brown table sugar on biomarkers of cardio vascular health and glycaemia. 1.3 JUSTIFICATION Sugar forms an essential dietary component in processed or unprocessed foods due to it sweet taste. Nutrition and food knowledge deficit among many consumers has negatively affected food choices and dietary pattern. It is believed that less processed natural sweeteners such as brown sugar and honey are all healthier than white sugars coupled with product advertisement which has increased the use and consumption of added sugars (Bailin et al., 2014). In recent years, metabolic syndrome has emerged as a major global health issue because of excessive sugar intake (Kahn and Sievenpiper, 2014). The rise in metabolic syndrome has accompanied the drastic increase in obesity, dyslipidaemia and insulin resistance worldwide (Johnston et al., 2013).The cost of health care of individuals suffering from the complications of excessive consumption of added sugar or nutritive sweeteners has caused socio economic burden on families (WHO, 2016b). Therefore, it has become necessary to explore the effect of these natural sweeteners on biochemical indices of diabetes and cardiovascular health. This study's results will provide information that will help to distinguish if honey is healthier than brown and white table sugar. It will also provide information on the effect of these natural sweeteners on the release of insulin. Additionally, the effect of these natural sweeteners on blood glucose levels and lipid profile will be established. This knowledge may assist dieticians and nutritionists in designing appropriate interventions for individuals with nutrition and diet related diseases. Findings of this study may also enable other health professionals, consumers and policy makers to make informed decisions when dealing with natural sweeteners. Furthermore, findings from this study 5 University of Ghana http://ugspace.ug.edu.gh can help in the formulation of food based guidelines and nutritional policies with respect to consumption of added sugars. 1.4 HYPOTHESES Hө: Honey will contribute less to glycaemia than brown and white sugar. Hө: Honey produces a better lipid profile than brown and white sugar. 1.5 AIMS AND OBJECTIVES The main aim of this study was To determine the effect of honey, white and brown sugar on lipid profile, glycaemia, pancreatic insulin levels and histology using animal models. 1.5.1 SPECIFIC OBJECTIVES 1. To determine the effect of honey, white and brown sugar on glycaemia by measuring glycated haemoglobin and serum glucose level. 2. To determine the effect of honey, white and brown sugar on cardio vascular disease risk indices by measuring total cholesterol (TC), total triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). 3. To determine the effect of honey, white and brown table sugar on insulin level using pancreatic tissue homogenate. 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 NATURAL SWEETENERS Sweeteners are chemical compounds, found in nature or chemically synthesized, which have a sweet taste that determines their usage as sweetening agents (Mooradian et al., 2017). Monosaccharides (fructose, galactose and glucose) and disaccharides (maltose, sucrose and lactose) are the most typical sugars in our diet (Gabius, 2011). Table sugar and honey are a major source of dietary sugar (Edwards et al., 2016). Table sugar is primarily composed of sucrose and is obtained through industrial methods, typically from sugar cane (Saccharum officinarum L.) or beet (Beta alba L.) (Edwards, 2018). They can be used for methods such as food preservation, fermentation in brewing and wine manufacturing (Erickson and Slavin, 2015). Many years ago, human diet has included a variety of natural sweeteners from cane sugar, maple syrup, honey, stevia, molasses, date sugar, agave nectar (Grembecka, 2015). However, in the beginning of the 20th century sucrose became the main sweetener used by many consumers and food industry. Currently, table sugar is produced in almost 120 countries with its global production exceeding 165 million tons a year (80% from sugar cane, the rest from sugar beets) (Newens and Walton, 2016). The biggest sugar cane producer in 2013 was Brazil followed by India and China (Li and Yang, 2015). The terminology used to describe natural sweeteners can be sometimes confusing and unspecific (Lineback and Jones, 2003). They may be classified into natural or synthetic agents, powders and syrups, and caloric and non-caloric (Priya et al., 2011). Added sugars are food substances that are incorporated into food during processing or added at the table (Vos et al., 2017). They may 7 University of Ghana http://ugspace.ug.edu.gh include white sugar, brown sugar, honey, maple syrup, and high fructose corn syrup (Ervin, 2012, Edwards et al., 2016). These added sugars have similar amount of energy approximately 4 calories per gram, and contain negligible quantities of micronutrients (Clifford and Maloney, 2016). 2.2 PROPERTIES OF NATURAL SWEETENERS Natural sweeteners are commonly recognizable carbohydrates that are also a source of energy that is simple and fast to digest (Louie and Tapsell, 2015). Natural sweeteners are mostly disaccharides (sucrose) of glucose and fructose unit (Pigman, 2012). It’s a naturally occurring carbohydrate found in many fruits, vegetables and grains. Sucrose is a carbohydrate with the formula C12H22O11 (Ervin and Ogden, 2013). The refined form of sucrose is known as table sugar or simply sugar. It may come as white or brown granulated crystals in table sugar or a viscose fluid in honey. Sugar applies to a variety of carbohydrates, such as monosaccharides, disaccharides and polysaccharides, in scientific terms (Pigman, 2012). Monosaccharides are often referred to as simple sugars, with glucose being the most common (Edwards, 2018). It is not possible to hydrolyse them further into simpler chemical. They are known to be the building blocks of disaccharides and polysaccharides (BeMiller, 2018). Disaccharides are sugars consisting of two units of monosaccharides joined by a carbon oxygen carbon bond known as a glycosidic bond. (Yalpani, 2013). This linkage can be broken apart into its two simple sugars in a process called hydrolysis (BeMiller, 2018). Sucrose, maltose, and lactose are common types of disaccharides. Sucrose is the disaccharide of glucose and fructose (McGrath and Fugate, 2012). Polysaccharides are long chain polymeric carbohydrates consisting of units of monosaccharide connected together by glycosidic bonds (Yalpani, 2013). A polysaccharide can be a homopolysaccharide, in 8 University of Ghana http://ugspace.ug.edu.gh which all the monosaccharides are the same, or a heteropolysaccharide in which the monosaccharides vary (Syrovaya et al., 2018). Figure 2. 1: Chemical structure of glucose Figure 2. 2: Chemical structure of sucrose 9 University of Ghana http://ugspace.ug.edu.gh Natural sweeteners have some distinctive properties which enable consumers and food producers to utilize sugar and honey in various ways (Guerra and Mujica, 2010). This includes sweetness, texture, fermentation, preservation and moisture retention, solubility. 2.2.1 Sweetness Sweetness is marked by the one of the five basic taste sensations that is usually pleasing and commonly perceived when eating foods rich in sugars (Mooradian et al., 2017). It is a sensory experience in the taste receptors on the tongue that is passed on to the brain through the gustatory nerves (Ahmed et al., 2013). Among the factors that influence sweetness are concentration, temperature, pH value and individual sense of taste (Guerra and Mujica, 2010). Honey, white and brown table sugars are naturally sweet therefore it is commonly used in commercial food production and as added sugar. The degree of sweetness is dependent on the chemical structure of the sweetener (Clemens et al., 2016b). Sucrose, either white or brown table sugar is normally used as the standard for sweetness (White, 2014). It has a relative sweetness of 100. However fructose is sweeter with a relative sweetness of 160. 2.2.2 Texture Texture is an expression of how something feels. It is an important component in the food industry (Forde et al., 2013). By offering volume and consistency in many items such as beverages, jam and bread, sugar influences texture (Lees, 2012). Sugar can add viscosity, consistency and mass to liquid food during commercial production (Mathlouthi and Reiser, 2012). Sugar is used to achieve the right balance between pectin and acid in the processing of jam, marmalade and jelly (Seetal, 2010). When mixed with pectin, the ability of sugar to gel is important to the quality of jam (Seetal, 2010). This may influence the mouth sensation, and thus the sense of taste. (Stieger and van de Velde, 2013). 10 University of Ghana http://ugspace.ug.edu.gh 2.2.3 Fermentation For years, the fermentation method has been adopted to preserve foods (Lees, 2012). The fermentation process also includes the use of yeast as an energy source and sometimes sugar (Zabed et al., 2014). The form and quantity of added sugar will improve the yield of dough and loaf softness by changing the rate of fermentation (Gisslen, 2012). Sugar activates the yeast in baking, in which the enzymes of the yeast convert the sugar into ethanol and carbon dioxide (Cauvain, 2012). The carbon dioxide raises the dough and renders the baked goods porous (Cauvain, 2012). For this function, sugar in the final product may not always be available. (Lees, 2012). Sugars that remain after fermentation, however, contribute to the final product 's overall taste, colour and texture (Gisslen, 2012). Fermentation of sugar is therefore key in baking and other food processing (Gisslen, 2012). 2.2.4 Preservation Preservation prevents the growth and activity of microorganism that promote spoilage (Gould, 2012). Foods are preserved to avoid the growth of microorganisms that damage food items (Gould, 2012). This process prevents pathogenic microorganisms that can cause diseases (Ray and Bhunia, 2013). In order to grow, microorganisms need water (Hamad, 2012). They can absorb water using the outer layer of the membrane (Christy et al., 2014). Large quantity of sugar in a food product brings about water loss to the product (Clemens et al., 2016b). This inhibits the growth of microorganisms, as they are deprived a key component for the growth and duplication drops (Christy et al., 2014). The introduction of sugar in food substances can increase the osmotic pressure, thereby minimizing the advantage of microorganism growth. (Goldfein and Slavin, 2015). By creating the most unfavourable conditions for microorganisms, it may increase the shelf life of the food (Hamad, 2012). Sugar can play an important role by 11 University of Ghana http://ugspace.ug.edu.gh acting as a humectant in maintaining and stabilising the moisture content in foods (Hamad, 2012, Clemens et al., 2016b). 2.2.5 Solubility Dietary sugars are strongly soluble in water and other polar solvents (Clemens et al., 2016b). They are however insoluble non-polar organic solvents (Clemens et al., 2016b). Due to it solubility, it is a useful ingredient in the food industry (Caraher and Perry, 2017). Dietary sugar is added to various pre-package foods to improve taste and shelf life (Caraher and Perry, 2017). This is made possible because of its ability to dissolve and mix well with other ingredient in food processing (Clemens et al., 2016b). Sugars are more soluble when the temperature of it solvent is increased (Newens and Walton, 2016). 2.3 TYPES OF NATURAL SWEETENERS 2.3.1 White table sugar Sucrose is found in almost all plants (Li and Yang, 2015). It can be present in sugar cane and sugar beet in concentrations high enough for economic benefit (Bakker, 2012). Sugar cane Saccharum officinarum and sugar beets Beta vulgaris are popularly cultivated crops (Li and Yang, 2015). Sugarcane is a giant cultivated grass in tropical and subtropical regions (Bakker, 2012). Whereas sugar beet is a root crop that grows in temperate regions (Ma et al., 2014). Processing of sugarcane into table sugar can range from a relatively simple to a multistep process (Baikow, 2013a). The final result varies, depending on the specific steps in the process (Rein, 2016). Mechanically or manually, the sugar cane crop is harvested and cut into lengths (Bakker, 2012). It is either milled and the juice is extracted using a sugar miller or extracted by diffusion (Hugot, 2014). In a series of evaporators, the thin syrup is condensed and water is further extracted (Hugot, 2014). The resulting supersaturated solution is seeded with sugar 12 University of Ghana http://ugspace.ug.edu.gh crystals, facilitating crystal formation and drying (Baikow, 2013b). Light and dark brown, powdered, and granulated white sugars are all highly refined to give a white granulated sugar (Rein, 2016). White sugar can also be obtained from sugar beet (Cooke and Scott, 2012). Sugar juice is obtained after soaking sliced sugar beet in hot water (Draycott, 2008). The juice is concentrated by boiling under vacuum to remove much water (Cooke and Scott, 2012). Sugar is crystallized from the concentrated solution (Rein, 2016). To isolate the pure sugar crystals from the syrup, it is then spun in centrifuges (Cooke and Scott, 2012). These crystals are then dried and processed in silos until they are packed or sent to consumers in bulk (Baikow, 2013b). 2.3.2 Brown table sugar Brown table sugar is a moist and dark coloured sugar obtained as a product of the evaporation of sugarcane juice (Orlandi et al., 2017). Evaporated cane juice is essentially a coarse, heavier and coloured version of white sugar (Abdullah et al., 2014b). It is less refined than white table sugar and also contains some trace minerals, vitamins and molasses (Abdullah et al., 2014a). Brown sugar can also be produced by adding sugarcane molasses to white sugar (Yang et al., 2020). The ratio of molasses to sugar crystals is carefully regulated (Yang et al., 2020). This preparation of brown sugar is also much coarser than its unrefined counterpart. (Brekhman and Nesterenko, 2013). Brown sugars can be slightly centrifuged or hold a far greater degree of molasses without centrifugation (Orlandi et al., 2017). Depending on its origin, brown sugar is identified with different names (Valli et al., 2012). Example of such names include panela, rapadura, jaggery, muscovado, turbinado and unrefined sugar (Abdullah et al., 2014a, Jaffé, 2015). Brown sugar is used similarly to granulated white sugar but is known to give a touch of extra flavour (Rein, 2016). The colours vary from light brown to dark brown (Singh et al., 2015). The colour and taste variations between the various brown sugars depend on the amount of molasses present 13 University of Ghana http://ugspace.ug.edu.gh (Valli et al., 2012). The more molasses, the stickier the crystals, darker the colour and stronger the flavour (Yang et al., 2020). 2.3.3 Honey The European Communities legislation described honey as the natural sweet substance made from nectar by Apis mellifera bees (Machado De-Melo et al., 2018). It can be produced from the secretions of living plant parts. (El Sohaimy et al., 2015). It is a natural material that mainly consists of 80% carbohydrates (Alvarez-Suarez et al., 2014). It includes a variety of other compounds that are expected to confer health benefits when ingested (Machado De-Melo et al., 2018). These compounds may include polyphenols, aromatic compounds, organic acids, amino acids, minerals, vitamins (Omotayo et al., 2010, White, 2013). The type of environment and vegetation affect the constituent of honey (Manyi-Loh et al., 2011a). However, certain external factors such as seasonal, environmental and processing may play a role in its composition (Manyi-Loh et al., 2011a). Since ancient days, honey has not only been seen as a food or a sweetener, but also used as a medicine (Bahrami et al., 2009). The composition of honey is uniquely dependent on the floral source (Schneider et al., 2013). Notably, there are different varieties of honey based on its composition and origin (El Sohaimy et al., 2015). Depending on the variety of plants from which nectar is obtained, the composition of this substance can differ significantly (El Sohaimy et al., 2015). Honey has been used as a regular sugar substitute over the years (da Silva et al., 2016). Consumers decision to buy honey are influenced by economic factors indication the financial situation of many household who can buy them (Roman et al., 2013). 14 University of Ghana http://ugspace.ug.edu.gh 2.4 SUGAR PRODUCTION The world sugar production from 2015/2016 with a forecast to 2020/2021 shows that, approximately 188 million metric tons of sugars were produced globally (USDA, 2020). Brazil and India are the largest sugar-producing countries in the world, yielding approximately 588 million metric tons of sugar (USDA, 2020). Production in Brazil is expected to recover from 9.6 million tons to 39.5 million metric tons (USDA, 2020). Initial worries about the 2019 dry spell in August-October were compensated by steady rainfall in January-March (USDA, 2020). This was welcomed by an improved sugarcane harvest (USDA, 2020). 2.5 SUGAR CONSUMPTION The global consumption of sugar amounted to 171.58 million metric tons in 2018/2019, which is expected to grow by 2019/2020 to around 176.45 million metric tons (USDA, 2020). Consumption of sugar is expected to rise to about 177.79 million metric tons in 2020/2021 with the rise in world trade and improved agricultural engineering, among other factors. (USDA, 2020). India is the leading consumer of sugar globally with an estimated consumption of 27 million metric tons in 2019/2020 (USDA, 2020). Overall sugar consumption has increased globally within the last five years by 2.33 million metric tons. 2.6 SUGAR EXPORT AND IMPORT The global export of sugar is 54.12 million metric tons in 2019/2020 forecast to 65.22 million in 2020/2021. Brazil is the world leading exporter of sugar with an estimated export of 19.3 million metric tons in 2019/2020 forecast to 28.85 million metric tons in 2020/2021 (USDA, 2020). While there has been an appreciable decrease in global sugar import from 54.63 million metric tons in 2015/2014 to 50.71 million metric tons in 2019/2020. It is forecast to 54.8 million in 15 University of Ghana http://ugspace.ug.edu.gh 2020/2021 (USDA, 2020). Indonesia and China are the world leading importers of sugar with an estimated import of 4 million and 4.1 million metric tons in 2019/2020 forecast to 4.65 and 4.2 million metric tons respectively (USDA, 2020). Figure 2. 3: Global sugar consumption from 2013/2014 forecast to 2020/2021 2.6.1 DIGESTION AND METABOLISM OF SUCROSE 2.6.2 Sucrose digestion The digestion of sucrose does not commence until the sugar reaches the small intestine (Pigman, 2012). Polysaccharides cannot be taken up by the body as it must first isolate sucrose into its component (Fox, 2015). Sucrase, an enzyme in the small intestine, makes it easier for sucrose to break down into glucose and fructose (Fox, 2015). The monosaccharides are transported across the intestinal epithelium into the bloodstream (Pigman, 2012) It is then transferred to the various 16 University of Ghana http://ugspace.ug.edu.gh body's cells (Pigman, 2012). The developed glucose and fructose monosaccharides are absorbed and can then be used to harness energy in metabolic pathways (BeMiller, 2018). 2.6.3 Sucrose absorption Glucose and fructose are more recognizable by the body for absorption (BeMiller, 2018). Once it is available in this simple form, the intestinal lining can now absorb both sugars (Pigman, 2012). This happens by various dynamic transporters into the hepatic portal system's bloodstream (Johnson et al., 2010). This system is one of a few that does not return blood directly to the heart (Fox, 2015). Instead, the blood containing all the obtained nutrients is transferred to the liver for further processing (Fox, 2015). 2.6.4 Sucrose Metabolism The primary energy source, glucose, is transferred from the liver to cells in the body (Johnson et al., 2010). Uptake into cells is facilitated by insulin (Rippe and Angelopoulos, 2013). In a mechanism called glycolysis, glucose converted to pyruvate. (Dashty, 2013). Pyruvate, the end product of glycolysis is an acidic compound (Gray et al., 2014). In order to generate energy, it can then enter either aerobic or anaerobic state (Ruan, 2014). The metabolism of fructose occurs through fructolysis (Harvey and Ferreir, 2011). This process is similar to, but more complex than glycolysis (Harvey and Ferreir, 2011). The breakdown of fructose can make end product which can yield energy (Sun and Empie, 2012). However, fructolysis occurs mainly in the liver, unlike glycolysis, which can take place in almost all tissues (Hannou et al., 2018). 2.6.5 Sugar Storage Excess glucose which was not utilized in energy production is stored as glycogen (Dashty, 2013). This process binds single subunits of glucose via a chemical bond into long chains, known as glycogen (Adeva-Andany et al., 2016a). Glycogen is hydrolysed back into glucose 17 University of Ghana http://ugspace.ug.edu.gh during fasted state (Moore et al., 2012). As the body completes its glycogen storage ability, all remaining glucose is converted into fat (Adeva-Andany et al., 2016b). Fructose is not retained in the body for a long time, since the liver converts all fructose into glucose-like molecules. (Hannou et al., 2018). 2.7 NATURAL SWEETENERS AND OBESITY 2.7.1 Obesity Obesity is defined by the World Health Organization as an excessive fat build-up which affects health (WHO, 2020). The Body Mass Index ( BMI) is commonly used to calculate a person's weight; calculated as a person's weight in kilograms divided by meters by the height square (kg / m 2). Overweight and obesity for adult is described by the World Health Organisation as BMI ≥ 25 kg/m 2 and BMI ≥ 30 kg/m 2 respectively (WHO, 2020). Obesity is a phenomenon of processes, induced by different systems (Rutter, 2018) 2.7.2 Prevalence of Obesity Obesity is known as a public health epidemic and is a global health concern (Nguyen and Lau, 2012, Piché et al., 2018). Obesity is expected to occur in around 500 million adults worldwide in 2011 (Seidell and Halberstadt, 2015). The prevalence of obesity reported by the WHO in 2014 was 13% globally. In 2016, the WHO reported that 11% of men and 15% of women aged 18 and over were obese (WHO, 2020). In the United Kingdom (UK), the prevalence of obesity almost doubled from 13% to 24% between 1993 and 2011 (Hruby and Hu, 2015) . Also, in 2013 to 2014, approximately one third of adults in the United States of America (USA) were both overweight and obese (Flegal et al., 2016). In a study conducted among Portuguese speaking people, prevalence of obesity was recorded at 28.6% and obesity was higher in females than in males similar to other countries (Gaio et al., 2018, Oliveira et al., 2018). 18 University of Ghana http://ugspace.ug.edu.gh The prevalence of overweight and obesity and obesity in Africa varies from country to country. A meta-analysis review of the prevalence of adult obesity in Africa reported a prevalence rate of 21.8% among people with less schooling, female gender and disadvantaged status with rising rates over time (Tulp et al., 2018). A 2014 study conducted in Algeria revealed a 32.5% and 30.9% prevalence of overweight and obesity among adults, respectively (Dalichaouch- Benchaoui and Abadi, 2014). The prevalence of overweight and obesity was found to be 9.4% among high school adolescents in Ethiopia. (Alemu et al., 2014). The crude prevalence of overweight and obesity among civil servants in Lagos, Nigeria, was 70.7% (Ajani et al., 2015). In Issele-uku, a community in Nigeria, the prevalence of obesity among adults was 5.5% (Agofure, 2018). Among Sudanese individuals, the prevalence rate was reported at 21.2% (Ahmed et al., 2017). In Zambia it was 24.7% (21.0% among males and 27.3% among females) (Zyaambo et al., 2012). 2.7.3 Effect of natural sweeteners on obesity Table sugar and honey are common sweeteners that have been part of human diets since ancient times (Priya et al., 2011). These sweeteners enhance the taste and palatability of foods (Amarra et al., 2016). Compared to non-sweetened foods, this triggers a significant rise in the quantity of such foods eaten at a time (Amarra et al., 2016). It is also recognized that its impact on neurotransmitters and pleasant brain sites after prior exposure induces sugar addiction (Berridge and Kringelbach, 2015). This can result in an total dependency on or compulsive intake of excess sugar (Avena et al., 2008). Furthermore, sugar containing foods have been advertised in ways such as associating the consumption of sugar sweetened beverage with happiness (Nestle, 2013). This may have led to the increase patronage and consumption of such products thereby increasing calorie intake. An approximate 15 % of the overall energy consumption in the United 19 University of Ghana http://ugspace.ug.edu.gh States is generated from added sugars (Marriott et al., 2010). Excess glucose obtained from the consumption of added sugar is stored as glycogen in the liver and muscles or as fat in adipose tissue (Adeva-Andany et al., 2016b). This can increase adiposity. A systematic review was conducted by the WHO in 2010 to address a range of questions regarding the impact of sugar on excess adiposity (Te Morenga et al., 2013). The review was to determine whether the decrease or increase of dietary sugar consumption influenced the assessment of body fat (Te Morenga et al., 2013). The study also analysed whether the existing evidence supported the recommendations to limit the consumption of added sugars to less than 10 % of total energy daily (USDA, 2017). The results showed that the advice to reduce added sugars among free living persons was associated with an average weight reduction of 0.80 kg (Te Morenga et al., 2013). While the suggestion to raise consumption was linked to increase weight of 0.75 kg (Te Morenga et al., 2013). Increase in the consumption of sugar-sweetened drinks does not reduce the calorie intake from other foods, leading to an increase in children's total energy intake and weight gain (de Ruyter et al., 2012). In an animal study, a 20% diet based on honey caused a substantial increase in total body weight (Chepulis, 2007). This was relative to the normal control group of Sprague Dawley rats for 13 weeks (Chepulis, 2007). However, when 10% of the honey-sweetened diet was fed to Sprague Dawley rats for six weeks, there was a significant decrease in body weight. (Chepulis and Starkey, 2008). With respect to the influence of honey on weight, the available evidence is unclear, notably in experimental studies (van Buul et al., 2014, Atangwho et al., 2020). Globally, the prevalence of obesity is increasing at a rapid pace due to an increase in energy intake (Swinburn et al., 2011, Malik and Hu, 2012). Other possible reasons could include increased purchasing power and energy dense food availability, as well as reduced energy 20 University of Ghana http://ugspace.ug.edu.gh expenditure resulting from urbanization and mechanization. Obesity is a risk factor for diabetes and cardiovascular disease (Hu, 2011). 2.8 NATURAL SWEETENERS AND GLUCOSE LEVELS 2.8.1 Glucose Level Blood glucose level is the concentration of glucose found in blood at a given period of time (Beck et al., 2018). As part of metabolic homeostasis, the body actively controls blood glucose (Nadkarni et al., 2014). Glucose is stored in glycogen form in the skeletal muscle and liver cells (Adeva-Andany et al., 2016a). In fasting individuals, blood glucose is kept at a stable level at the expense of glycogen stores in the liver and skeletal muscle (Adeva-Andany et al., 2016a). Insulin regulates the glucose homeostasis in the body (Röder et al., 2016). Glucose is the end product of digestion of table sugar and honey (Abdulrhman et al., 2013). Natural sweeteners have a high glycaemic index therefore the tendency to rapidly increase blood glucose. Hyperglycaemia is a situation with increased blood glucose levels above normal range and hypoglycaemia is characterized by persistently low blood glucose (Luitse et al., 2012). Diabetes mellitus is characterized by chronic hyperglycaemia which is the most common condition associated with poorly regulated blood glucose level (Luitse et al., 2012). 2.8.2 Categorization of blood glucose test Tests to quantify glucose in the blood were established long ago, and hyperglycaemia became the only criteria recommended for diagnosing diabetes (Sacks, 2011). The response to oral glucose tolerance was the subject of the initial diagnostic criteria while subsequent measurement of blood glucose in a fasting person was also appropriate (Sacks, 2011). Fasting blood glucose and oral glucose tolerance test are the most commonly known glucose-based criteria for diagnosis (ADA, 2014). Diagnostic values of (FBG) ≥126 mg/dL or a 2-h plasma glucose ≥200 21 University of Ghana http://ugspace.ug.edu.gh mg/dL during an oral glucose tolerance test (OGTT) on more than one occasion are used (ADA, 2018). A single spontaneous plasma glucose ≥200 mg/dL viewd diagnostic in a patient with typical symptoms of diabetes (ADA, 2014). Recently, the HbA1c test has become accepted as a tool to diagnose diabetes (Sherwani et al., 2016). In addition, the American Diabetes Association (ADA) recently revised its diagnostic screening requirements for prediabetes to include HbA1C within a 5.7%-6.4% (ADA, 2019). People with this range of HbA1c are at high risk of developing overt diabetes. HbA1C could be more optimal as it is less tedious than the glucose tolerance test or measurement of postprandial glucose levels (Vijayakumar et al., 2017). Other benefits of HbA1c include the fact that it does not require fasting in patients, represents more long-term glycaemia than plasma glucose levels, and is a standardized and accurate laboratory test (Sherwani et al., 2016). Random blood glucose test can be done at any random time irrespective of the last time food was consumed (Bowen et al., 2015). Fasting blood glucose test is done with blood sample taken after an overnight fast (ADA, 2014). Fasting blood glucose concentration above the reference range may suggest diabetes. Oral glucose tolerance test can be done when the fasting blood sugar level is measured after an overnight fast (Bartoli et al., 2011). This is followed by the consumption of a sugary liquid after which blood glucose levels are tested periodically for the next two hours (Bartoli et al., 2011). These test or a combination can be used to diagnose the onset or development of diabetes. 2.8.3 Effect of natural sweeteners on glucose level Foods consisting of simple carbohydrates break down rapidly during the digestive process (such as natural sweeteners) and are easily absorbed into the bloodstream. The level of glucose and fructose increase significantly in the blood after the consumption of honey or table sugar 22 University of Ghana http://ugspace.ug.edu.gh (Abdulrhman et al., 2013). Several animal studies have been done to investigate the effect of natural sweeteners consumption on biochemical parameters including blood glucose (Adesoji and Oluwakemi, 2008, Atangwho et al., 2017). In a study, Sprague-Dawley rats showed a substantial increase in the total weight gain and body fat levels in sucrose-fed rats (Chepulis, 2007). This was comparable for those fed honey or sugar-free diets (Chepulis, 2007). HbA1c levels were significantly reduced whiles HDL-cholesterol increased significantly in honey-fed rats (Chepulis, 2007). This was compared to rats fed sucrose or a sugar-free diet, although no other variations were observed in lipid profiles (Chepulis, 2007). However, a study where healthy rats were fed with 20% honey for 33 days showed that, epidididymal fat weight was 20.1% lower (P ≤ .05) rats fed honey (Nemoseck et al., 2011). Triglyceride and leptin concentrations were decreased (P ≤ .05) by 29.6 % and 21.6 % (Nemoseck et al., 2011). In honey-fed rats, non-HDL- cholesterol (P ≤ .05) was increased by 16.8%. There were no major variations in glucose, TC, insulin and HDL-cholesterol (Nemoseck et al., 2011). Similarly, HbA1c was elevated in the SSB group compared to the control group after six months of treatment in male Wistar rats (Driescher et al., 2019). This means that longer feeding times must be used to produce significant results. In a similar study, there was no significant differences in fasting blood glucose (Erejuwa et al., 2010, Omotayo et al., 2010). Similarly, there was no increase in FBG levels in rats administered with thoracica stingless bee honey compared with the control group (Aziz et al., 2017). Honey was given to the rat as a supplement in this study to ensure to bring about effect. 2.8.4 Diabetes Diabetes is a chronic condition that develops when the pancreas can no longer produce insulin (IDF, 2015). It can also happen when the body is unable to make effective use of the insulin it 23 University of Ghana http://ugspace.ug.edu.gh creates (IDF, 2015). The hormone insulin lowers the level of glucose in the blood (Komatsu et al., 2013). It is produced by the pancreas beta cells and released into the circulation when the level of glucose rises (Komatsu et al., 2013). Insulin allows glucose to reach the cells of the body where it can be used for energy (Kubota et al., 2013). It can be also be stored for later usage as glycogen (Kubota et al., 2013). The inability to produce or use insulin efficiently contributes to hyperglycaemia (Bornfeldt and Tabas, 2011). Blood glucose levels remain relatively constant in people without diabetes, as the body retains a normal range. 2.8.5 Prevalence of diabetes In low and middle-income countries, the prevalence of diabetes has risen sharply than those in high-income countries over the last decade (WHO, 2016b). It is estimated that the global prevalence of diabetes is 9.3 % in 2019 (463 million people) (Saeedi et al., 2019). This is expected to go up to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045 (Saeedi et al., 2019). In urban locations, the prevalence is greater (10.8%) than in rural locations (7.2%) (Saeedi et al., 2019). High-income countries (10.4%) are also higher than low-income countries (4.0%) (Saeedi et al., 2019). Over the last century, improvements in human behaviour and lifestyle have contributed to a drastic rise in the worldwide incidence of diabetes (Aguiree et al., 2013). In 2017, about 15.5 million individuals between the ages of 20-79 years lived with diabetes in the African region (IDF, 2018). This reflects a 3.3 % regional prevalence (IDF, 2018). The region 's highest prevalence of diabetes is observed in adults aged 55 to 64 years old (IDF, 2018). The area has the highest prevalence of undiagnosed diabetes, with 69.2 % of adults actually living with diabetes unaware of their condition (IDF, 2018). The prevalence of diabetes varied from 2.6% in rural Sudan to 20.0% in urban Egypt (Bos and Agyemang, 2013). The prevalence 24 University of Ghana http://ugspace.ug.edu.gh of diabetes among adults aged 50 years and above in Ghana was 3.95% with the prevalence being insignificantly higher in females than males 2.16%, vs. 1.73% (Gatimu et al., 2016).This reflects the gender differences in diabetes prevalence in many African countries (Hall et al., 2011). Ghana has reported a high risk of diabetes with greater general and central obesity (Frank et al., 2013). 2.8.6 Effect of natural sweeteners on diabetes A review showed that over consumption of sweetened drinks contribute greatly to weight gain and may contribute to an increased risk of type 2 diabetes (Malik et al., 2010). The direct mechanisms of sugar that lead to diabetes involves fructose metabolism (Stanhope, 2012). Without regulating intake, the liver absorbs sucrose, possibly leading to a build-up of liver fats and a decline in insulin sensitivity (Tappy and Lê, 2010). Sensitivity to insulin determines how the cells utilize glucose efficiently, reducing it quantities in the bloodstream (Lecoultre et al., 2013). Blood glucose can become persistently elevated when insulin decreases, eventually resulting in type 2 diabetes (MacDonald, 2016). A review suggest high sugar intake can possibly increase the risk the risk of diabetes (Sonestedt et al., 2012). However, the role of sugar in diabetes is still inconsistent (Stanhope, 2016). In more than 175 countries, a study investigated individuals and found that more sugar in the food resulted in higher rates of diabetes (Basu et al., 2013). In particular, diabetes levels increased by 1 % for every additional 150 calories of sugar consumed per day per person (Basu et al., 2013). There was no change to this trend even when calorie, exercise and obesity was controlled (Basu et al., 2013). 2.9 NATURAL SWEETENERS AND LIPID PROFILE Lipids are a category of fats and fat-like substances that are essential cell constituents and energy sources (Walther and Farese Jr, 2012). They may be synthesised by body or obtained from 25 University of Ghana http://ugspace.ug.edu.gh dietary source (Akoh, 2017). Excess glucose is stored as glycogen or fat in the muscles, liver and adipose tissue (Adeva-Andany et al., 2016a). The amount of particular lipids in the blood is determined by a lipid profile test. Lipoproteins are transported in the blood by two essential lipids, cholesterol and triglycerides (Rodwell et al., 2015). A mixture of cholesterol, triglycerides, proteins, and phospholipid molecules is found in each form of lipoprotein (Rodwell et al., 2015). This test is used for the detection of dyslipidaemia (different cholesterol and triglyceride disorders), many of which are known risk factors for cardiovascular disease (Teramoto et al., 2013). 2.9.1 Categorization of lipid profile Particles of the lipid profile are classified by their density as low-density lipoproteins (LDL), high-density lipoproteins (HDL) and very low-density lipoproteins (VLDL) (Nordestgaard, 2017). Total cholesterol, which tests all cholesterol in all lipoprotein particles, is a traditional lipid profile examination. (Nordestgaard et al., 2016). Cholesterol in HDL particles is measured by high-density lipoprotein cholesterol (HDL-C) (Nordestgaard et al., 2016). The cholesterol in LDL particles is calculated by Low Density Lipoprotein Cholesterol (LDL-C) (Martin et al., 2013). In addition, triglycerides that measure all triglycerides in lipoprotein particles (Arsenault et al., 2011). The level of LDL-C is typically estimated using total cholesterol, HDL-C, and triglyceride data (Martin et al., 2013). 2.9.2 Dyslipidaemia Dyslipidaemia refers to abnormal blood lipid levels (Klop et al., 2013). The word describes a broad spectrum of conditions, but the most common type of dyslipidaemia is hyperlipidaemia (Klop et al., 2013). Which refers to high levels low-density lipoproteins cholesterol (LDL-C), high-density lipoproteins cholesterol (HDL) and triglycerides (Schofield et al., 2016). 26 University of Ghana http://ugspace.ug.edu.gh Hyperlipidaemia is usually asymptomatic, so a lipid profile is the best way to diagnose it (Schofield et al., 2016). Dyslipidaemia is clinically expressed as high or low levels of triglycerides and/or high or low cholesterol level (Björnson et al., 2017). 2.9.3 Prevalence More than 12% of adults age 20 and older had higher total cholesterol and more than 18% had lower high-density lipoprotein cholesterol levels less than 40 mg/dL in America (Carroll et al., 2017). In men aged between 30 and 39 years, the peak prevalence of dyslipidaemia is (48.2 %) in China (Qi et al., 2015). Similarly, the prevalence of dyslipidaemia increased with age in women, with the highest prevalence occurring after 60 years of age (46.3%) in China (Qi et al., 2015). In Ireland, a 30% decrease in the death rate of heart disease was due to a 4.6% decrease in the national level for total cholesterol (Nichols et al., 2013). Similarly, in Finland, the drop in population blood cholesterol levels has explained % of the decrease in ischaemic heart disease mortality (O'Flaherty et al., 2013). In South Africa, dyslipidaemia prevalence rates of between 14% and 69% have been found using community level assessments (Reiger et al., 2017). The prevalence of dyslipidaemia in Nigeria varied from 60% among seemingly healthy Nigerians to 89% among diabetic Nigerians (Oguejiofor et al., 2012). The prevalence of hypercholesterolemia, hypertriglyceridemia and hyperlipidaemia were 56%, 7.11% and 1.9% respectively in a study in Senegal (Doupa et al., 2014). A study undertaken in the Ga-East municipality showed a moderate level of hypercholesterolemia (2.8%) among school children who are overweight and obese (Steiner-Asiedu et al., 2012). 2.9.4 Effect of natural sweeteners on lipid profile Triglycerides are enormously influenced by increased consumption of processed carbohydrates and added sugars (Kell et al., 2014). Low HDL levels and high triglyceride levels are indicators 27 University of Ghana http://ugspace.ug.edu.gh of poor cholesterol levels (Klop et al., 2013). A research has also shown that women who consume more added sugar appear to have higher LDL-C levels (Yu et al., 2018). Sugar sweetened beverage intake has a strong association with human weight gain (Hu and Malik, 2010). An animal study found leptin and triglycerides levels were 21.6% and 29.6% lower (p ≤ .05) respectively (Nemoseck et al., 2011). Non-HDL-cholesterol was also found to be 16.8% higher (p ≤ .05) in honey-fed rats in comparison with sucrose-fed rats (Nemoseck et al., 2011). Another systematic study and meta-analysis showed that higher sugar consumption was correlated with a higher blood lipid profile. This was comparable to low intake of sugar which showed a reduce level of lipid profile (Te Morenga et al., 2014). Honey is known to contain some trace elements phenolic acids and flavonoids therefore it provides more in terms of health and wellness (Manyi-Loh et al., 2011b). A research on male students aged 18-30 years on the consumption of natural sweeteners was conducted at Isfahan University of Medical Sciences in Iran (Rasad et al., 2018). Honey intake was found to be able to minimize total cholesterol, TG and LDL-C (Rasad et al., 2018). In addition, there was an increase HDL-C in young healthy subjects (Rasad et al., 2018). Intake of sucrose, however, increased TC, LDL, TG and decreased HDL-C (Rasad et al., 2018). Similarly, honey administration raised HDL cholesterol significantly (p < 0.05) (Erejuwa et al., 2016). Although glucose, TG and very-LDL-C (p<0.05) decreased significantly (Erejuwa et al., 2016, Mohammadimanesh et al., 2019). However it was concluded that further clinical trials should be conducted to confirm these findings (Rasad et al., 2018). In a study, there was a significant increase in HDL-C and LDL-C after subjects consumed 3 different isocaloric solution (Jameel et al., 2014). The solutions contained 50 g of either sucrose, fructose or glucose (Jameel et al., 2014). In another study, neither solution significantly influenced cholesterol or triglyceride 28 University of Ghana http://ugspace.ug.edu.gh values in the treatment groups (Münstedt et al., 2009). Subjects obtained honey solution or sugar solution equal to honey once daily for a duration of 14 days (Münstedt et al., 2009). In comparison, substantial reductions in plasma LDL and total cholesterol levels were found in the test as opposed to the control group (P<0.01) (Alagwu et al., 2014). Some studies however, showed no effects of sucrose or fructose on LDL- cholesterol or HDL- cholesterol levels (Kelishadi et al., 2014, Lowndes et al., 2014) . The aforementioned studies placed more emphasis on fructose which is only one component of table sugar and honey. These irregularities in lipid profile are significantly associated with an increased consumption of dietary sugar (Xi et al., 2015). Dyslipidaemia has been clearly established as a significant cardiovascular disease risk factor in developed and developing countries. (Hendrani et al., 2016). 2.9.5 Cardiovascular disease Cardiovascular diseases are a category of cardiac and blood vessel disorders (Nichols et al., 2014). This include, cerebrovascular disease, ischemic heart disease, coronary heart disease and other conditions (Wilkins et al., 2017). Cardiovascular disease is considered to be the number one cause of death worldwide (WHO, 2013). Heart attacks and strokes account for four out of five CVD deaths (WHO, 2017c). One third of these premature deaths occur in persons under 70 years of age (WHO, 2017c). Lifestyle factors such as heavy use of alcohol, tobacco use, unhealthy diet, and inadequate physical activity are risk factors for CVD (Dahlöf, 2010). High blood pressure, high cholesterol in the blood and high blood sugar are other factors. (Dahlöf, 2010). 2.9.6 Prevalence An estimated 17.5 million individuals died from CVD in 2012, accounting for 31% of all deaths worldwide (WHO, 2017c). An approximate 7.4 million of these deaths were caused by coronary 29 University of Ghana http://ugspace.ug.edu.gh artery disease ( CAD) and 6.7 million by stroke (WHO, 2017a). The World Health Organization estimates that approximately 20 million CVD-related deaths would occur globally (WHO, 2017b). It is estimated that about 80% of global CVD-related deaths happen in low- and middle- income countries (WHF, 2018). This is concurrent with 87% of CVD-related disabilities which happen mostly in this region (WHF, 2018). Young people are known to be the most populated age group of people in Sub Saharan Africa (Ofori-Asenso and Garcia, 2016). Instead, the trend of morbidity and mortality associated with CVD has increased (WHF, 2018). Sub-Saharan Africa remained the only region of the world within 1990 and 2013 where CVD-related deaths increased (Roth et al., 2015a). CVD-related fatalities account for almost 9.2% of all deaths (Meier et al., 2019). It is also the leading cause of death in the African region among individuals aged over 45 years (Roth et al., 2015b). Approximately 7-10% of all adult patient admissions to hospitals in Africa were also for cardiovascular diseases (Mocumbi, 2012). In these admissions, heart failure alone accounts for about 3-7% (Mocumbi, 2012). Ghana is estimated to have a 20 % chance of people dying from diabetes, cancer, CVD or chronic respiratory disease between the ages of 30 and 70 years (WHO, 2016c). In Ghana’s capital, Accra, CVD developed from being the 10th to 7th cause of death in 1953 and 1966, respectively (Agyei-Mensah and Aikins, 2010). In 2014, even in a peri-urban area in the eastern region of Ghana, CVD was ranked as the leading cause of death (Ofori-Asenso and Ofei, 2015). A one-year study of in-patient records described stroke as comprising 9.1% of overall adult admissions (Agyemang et al., 2012). It was responsible for 13.2% of all adult death in the review (Agyemang et al., 2012). 30 University of Ghana http://ugspace.ug.edu.gh 2.9.7 The effect of natural sweetener on cardiovascular disease An inconclusive body of evidence indicates that increased consumption of added sugars can increase the risk of CVD (Chiavaroli et al., 2012, Wang et al., 2014, Zhang et al., 2013). In a study, rats were fed high doses of sucrose and honey has been used to establish a correlation between added sugar ingestion and risk of CVD (Nemoseck et al., 2011, Atangwho et al., 2020). Similarly, human subjects fed a variety of sugars have been used to establish risk of CVD (Madero et al., 2011). In the Framingham Heart study a significant increase in risk of CVD and sugar intake was observed (Ma et al., 2015). Cross-sectional studies sugar sweetened beverage intake with higher calorie intake, increased weight and poor nutrition (Narain et al., 2016). It has also been suggested that excessive intake of fructose plays a role in hypertension, dyslipidaemia and obesity (Malik et al., 2010, Tappy et al., 2010). Likewise, a study found a link between a high intake of sugar and a higher risk of mortality from heart disease (Yang et al., 2014). In the aforementioned study, subjects that consumed les calories from sugar were at a lower risk getting CVD (Yang et al., 2014). Similarly, a study among overweight and obese adults showed that consumption of fructose containing sugar leads to dyslipidaemia (Stanhope, 2016). In addition, it can lead to increased visceral adiposity and decreased insulin sensitivity (Stanhope, 2016). The consistent intake of foods high in sugar can increase fasting plasma triglycerides and low-density lipoproteins cholesterol (Miller et al., 2011, Welsh et al., 2011). In short, while the mechanisms remain uncertain compared to other sources of carbohydrates, the consumption of sugar seems to be related to dyslipidemia, a recognised risk factor for CVD. (Johnson et al., 2009). 31 University of Ghana http://ugspace.ug.edu.gh 2.10 THE EFFECT OF NATURAL SWEETENERS ON INSULIN 2.10.1 Gross Anatomy of the Pancreas The pancreas is situated behind the peritoneum. The head of the pancreas is located between the C shaped structure of the second and third part of the duodenum. The spleen is next to the pancreatic tail. The areas of the pancreas are the head, body, tail and uncinate process (Pandol, 2011).The classification of the rat pancreas as an intermediate pancreas is due to the fact that the splenic portion of the pancreas is quite compact and the duodenal aspect being dispersed within the mesentery (Pandiri, 2014). Currently different authors describe the lobes of rat pancreas the duodenal, gastric and splenic lobes (Pandiri, 2014), the right lobe, body and left lobe (Chandra et al., 2013), gastric lobe, duodenal head and tail (Pandiri, 2014) and head, body and tail (Brenneman et al., 2014). The rat pancreas is likened to the human pancreas based on its anatomical descriptions (Suttie et al., 2017). Anteriorly, the pancreas is bounded by the stomach, transverse colon, greater omentum, and loops of small intestines (Pandol, 2011). Posteriorly, it is bounded by the portal vein, inferior vena cava, aorta, superior mesenteric artery and vein, kidneys and Lumbar vertebra (Pandol, 2011). The inferior surface is enclosed by the peritoneum (Gray, 2000). The pancreas lies on the duodenojejunal flexure and some loops of the jejunum. Its left boundary lies on the left colic flexure (Gray, 2000). The superior border starts from the omental tuberosity and it is related to the celiac artery (Gray, 2000). The hepatic artery runs to the right just above the gland whilst the splenic artery runs towards the left in a groove along this border (Gray, 2000). The main arterial blood supply is from branches of the splenic artery. The pancreaticoduodenal and pancreatic arteries also supply the pancreas with blood (Moore, Dalley, & Agur, 2014). Nerve supply is by the parasympathetic and sympathetic nervous systems. Within the divisions 32 University of Ghana http://ugspace.ug.edu.gh of the vagus nerve, is the efferent parasympathetic system that originates in the dorsal vagal complex (tenth cranial nerve nucleus) of the brain. 2.10.2 Histology of the Pancreas The exocrine pancreas is a compound tubulo-acinar gland and consists of serous acini of atypical form and appearance (Craigmyle, 1986), ductal and the stellate cells (Clemens et al., 2016a). The cells are truncated pyramids whose infra-nuclear cytoplasm is intensely basophilic and whose apical cytoplasm contains large eosinophilic zymogen granules (Craigmyle, 1986). The center of the acinus contains centro-acinar cells (Craigmyle, 1986). The exocrine acinar produces inactive zymogens which are released through the pancreatic ducts to the duodenum (Clemens et al., 2016a). The inactive zymogens now become activated in the duodenum (Clemens et al., 2016a). The intercalated ducts lined with cuboidal cells invaginate into the acinus of the pancreas (Craigmyle, 1986). The intralobular ducts are very rare in the pancreas (Craigmyle, 1986). Interlobular ducts are lined with tall columnar epithelium which runs in the connective tissue septa of the gland and joins up to form the main and accessory ducts which open into the duodenum (Craigmyle, 1986). Bicarbonate produced from the cells of the ducts facilitates the passage and release of digestive enzymes to the duodenum (Clemens et al., 2016a). The pancreatic stellate cells are also involved in the production and breakdown of extracellular matrix proteins (Clemens et al., 2016a). The endocrine pancreas consists of about one million islets of Langerhans. Three cell types known as alpha, beta and delta cells are found in the islets. The alpha, beta, and delta cells produce glucagon, insulin and somatostatin respectively (Craigmyle, 1986). 33 University of Ghana http://ugspace.ug.edu.gh 2.10.3 Effect of natural sweeteners on insulin When food containing natural sweetener is ingested, the digestive system breaks it down into glucose and fructose, which enters the blood. Dietary sugar may have a direct or indirect impact on the pancreas (Michaud et al., 2002). Due to their basic chemical structure, dietary sugar can be easily and rapidly used by the body for energy, sometimes contributing to a faster increase in blood sugar and pancreatic insulin secretion, which can have negative health effects. The pancreas produces specialized hormones that help regulate a variety of body functions. These hormones are insulin and glucagon. Insulin controls how much glucose, is taken up by the body’s cells while glucagon stimulate the synthesis of glucose (Röder et al., 2016). Impairment to the normal function of the pancreas may affect it release of insulin (Czech, 2017). Furthermore, excess fat in storage and blood circulation may contribute to insulin insensitivity (Hardy et al., 2012). In this case blood sugar levels may be high even though pancreas produces adequate insulin. The risk factors associated with an inflamed pancreas include age (with mortality increased in patients 60 years and above) (Gardner et al., 2008, Wu et al., 2008), and overweight (body mass index >30 kg/m2 ). The relationship between body weight and diabetes may suggest that insulin resistance plays a role in the function of the pancreas (Gapstur et al., 2000). Too much intake of foods sweetened with sugar is associated with overweight or obesity (Te Morenga et al., 2013). Epidemiological studies have shown that as the body mass index ( BMI) increases, the risk of diabetes and insulin resistance increases (Tsugane and Inoue, 2010). An overworked pancreas may cause damage to the islet and other components and hence loss of function (Gerber and Rutter, 2017). 34 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY 3.1 STUDY DESIGN An experimental study design was used for this study. 3.2 STUDY SITE The experiment was carried out at the Animal Experimentation Unit of the Department of Microbiology, University of Ghana, Korle-Bu. 3.3 STUDY POPULATION Thirty-five (35) male Sprague Dawley rats aged 12 - 14 weeks, weighing 150g - 200g were acquired from the Noguchi Memorial Institute for Medical Research, University of Ghana. Rats were kept in the Animal experimentation unit of the Department of Microbiology, (University of Ghana). The rats were weighed and placed into seven (7) groups of five (5) animals in each cage using a random sampling technique. The animals were kept in a rat cage of dimensions of 20.3 cm (W) × 28.7 cm (L) × 17.3 cm (H) with soft wood shavings as bedding. The animals were acclimatized to their environment for two weeks. The groups set up were as follows: Group 1 (G1) – control group, group 2 (G2) - white sugar low dose (WS LD), group 3 (G3) - white sugar high dose (WS HD), group 4 (G4) - brown sugar low dose (BS LD), group 5 (G5) - brown sugar high dose (BS HD), group 6 (G6) - honey low dose (H LD) and group 7 (G7) - honey high dose (H HD). 3.4 ACCLIMATIZATION OF ANIMALS AND FEEDING Rats were kept in the unit throughout the study under the following conditions; a temperature of 28OC ± 4 OC, relative humidity of 70 ±4% and under alternating 12-hour period of light and 12- 35 University of Ghana http://ugspace.ug.edu.gh hour period of darkness (12-hour light/dark cycle). Furthermore, the animals were fed on standard rat chow and water ad libitum for a period of two (2) weeks before the commencement of the experiment. The animals were given distilled water. Rat chow diet was formulated and supplied by AGRIMAT, Accra, Ghana. 3.5 ETHICS The study was approved by the Ethics and Protocol Review Committee of the School of Biomedical and Allied Health Sciences (Ethics Identification Number: SBAHS-DT.//SA/2018- 2019). All animal procedures and techniques used in this study were in accordance with the National Institute of Health Guidelines for the Care and Use of Laboratory Animals (N.R.C., 2010). 3.6 Diet Regimen of Sweeteners The Microdiet Nutritional Analysis Software (Version 3 Downlee Systems, UK) was used to estimate the same amount of carbohydrate for the different treatment groups in both the high and the low dose groups. This was to ensure that animals in the treatment group received the same amount of carbohydrate for the different diet treatments. For the purpose of this study, the rats were given the same amount of carbohydrate which translates into weight as follows: Table 3. 1: Recommended sugar intake/day of white sugar, brown sugar and honey RECOMMENDED SUGAR INTAKE/ DAY Natural Sweetener Weight (g) Carbohydrate (g) Calorie (kcal) Honey 52.10 39.80 150 White sugar 38.10 40.06 150 Brown sugar 41.50 42.04 150 36 University of Ghana http://ugspace.ug.edu.gh The average weight of carbohydrate given per natural sweetener: 39.80+ 40.06+42.04/3 = 40.63 g. The weight of each natural sweetener was converted to the same amount of carbohydrate per natural sweetener. Half of the recommended sugar intake per day was calculated as low dose and twice of the recommended sugar intake per day as calculated as high dose. Table 3. 2: recommended sugar intake/day per average weight of carbohydrate. RECOMMENDED SUGAR INTAKE/DAY Natural Sweetener Weight (g) Carbohydrate (g) Calorie (kcal) Honey 53.19 40.63 153.13 White sugar 38.64 40.63 152.13 Brown sugar 40.11 40.63 144.90 Table 3. 3: High dose estimation per average weight of carbohydrate. HIGH DOSE Natural Sweetener Weight (g) Carbohydrate (g) Calorie (kcal) Honey 106.39 81.27 306.29 White sugar 77.29 81.27 304.31 Brown sugar 80.23 81.27 289.97 37 University of Ghana http://ugspace.ug.edu.gh Table 3. 4: Low dose estimation per average weight of carbohydrate. LOW DOSE Natural Sweetener Weight (g) Carbohydrate (g) Calorie (kcal) Honey 26.60 20.32 76.58 White sugar 19.33 20.32 76.09 Brown sugar 20.06 20.32 72.50 3.6.1 TRANSLATING INTO ANIMAL DOSE For a 70kg adult = 106.39 g honey 106.39 g/70 kg 1.52g/kg For a 200 g rat = 0.2 kg Animal dose = 0.2 kg x 1.52g/kg = 0.304 g honey Table 3. 5: Estimated animal high dose. RAT HIGH DOSE Natural Sweetener Rat weight (g) Amount (g) Honey 200 0.304 White sugar 200 0.220 Brown sugar 200 0.230 38 University of Ghana http://ugspace.ug.edu.gh Table 3. 6: Estimated animal low dose. RAT LOW DOSE Natural Sweetener Rat weight (g) Amount (g) Honey 200 0.076 White sugar 200 0.055 Brown sugar 200 0.057 3.6.2 Preparation of diet The high dose diet treatment was prepared by dissolving 0.304 g, 0.220 g and 0.230 g of honey, white table sugar and brown sugar respectively in 1ml of distilled water. Similarly, the low dose diet treatment was prepared by dissolving 0.076 g, 0.055 g, and 0.057 g of honey, white sugar and brown sugar respectively in 1 ml of distilled water. The solute was allowed to completely dissolve before administration. 3.7 ADMINISTRATION OF TREATMENT One (1) ml of the prepared white sugar, brown sugar or honey solution was administered daily to the treatment group of rats orally by gavage for 12 weeks. Rats in the control group received one (1) ml of distilled water orally by gavage for 12 weeks. 3.8 BLOOD SAMPLE AND TISSUE COLLECTION After 12 weeks of oral administration of sweetener daily, rats in each group were anesthetized with ethyl ether and blood was drawn by cardiac puncture. Four millimetres (4 ml) of blood samples was collected and discharged as follows: 2 ml into gel-separator tubes and 1 ml into fluoride tubes and kept on ice (One millilitre (1 ml) of the blood sample was discharged into an 39 University of Ghana http://ugspace.ug.edu.gh EDTA tube for analysis outside the scope of this work). The samples were centrifuged at 3000 rpm for 10 minutes to separate serum. Sera were transferred into Eppendorf tubes, labelled and stored in a laboratory freezer at -80°C until analysis. The stored samples were allowed to thaw at room temperature of 20˚C before assaying. Rats were later euthanized and the pancreas harvested. The harvested organ was weighed and divided into two parts. Half went into buffered formalin and the other half went into a container and stored at -80°C for later analysis. 3.9 PREPARATION OF RAT PANCREAS HOMOGENATE The frozen pancreas was placed on a glass plate and minced into small pieces by use of razor blade until a paste like consistency was formed. The minced pancreas was collected into a beaker containing 1 ml of cold PBS (phosphate buffer solution). The pieces were swirled gently and allowed to settle at the bottom of the beaker before being decanted to remove blood. The pancreas was homogenized using dounce tissue grinder in cold PBS, for each 1 g of pancreas. The sample was centrifuged at approximately 10000 X g for 5 min. The supernatant was collected and insulin was measured using ELISA Kit. 3.10 BIOCHEMICAL ANALYSIS Lipid profile comprising total cholesterol (TC), total triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) were analysed with an auto- analyser machine and test kits according to the manufacturer’s instructions (Mindray Bio- Medical Electronics Bs-200e, Shenzhen, China). Glycated haemoglobin (HbA1c) and fasting blood glucose (FBG) were also analysed following the manufacturer’s manual (ELITech, SEES, France). Insulin level was determined using an insulin ELISA kit from (Crystal Chem High Performance Assay, France) according to the manufacturer’s instructions. In brief, 5 L sera was introduced into each well alongside standards. Wells were coated with rat insulin antibodies. The 40 University of Ghana http://ugspace.ug.edu.gh reaction was allowed to incubate for two (2) hours at 4oC. After “washing” 100 L conjugate was added to each well and further incubated at room temperature for 30 min. After the final wash, 100 L substrate was added and incubated at room temperature for 40 min. After adding 100 L of stop solution, the final chromogen was read at 450 nm with a reference wavelength of 630 nm. 3.11 HISTOLOGICAL ANALYSIS Pancreatic tissue samples were processed through the Leica TP 1020 tissue processor with various solvents. Samples were then embedded in paraffin wax and sectioned at 5m. Sectioned samples were placed on slides to dry. Samples were later stained with Periodic Acid Schiff (PAS) and after mounting, samples were examined using an Olympus microscope at times forty magnification (x40). 3.12 STATISTICAL ANALYSIS The GraphPad Prism software (version 8) was used for the analysis. All results were expressed as means and standard error of the mean, at 95% confidence interval (CI). Two way ANOVA was used to compare the means within and between the treatment groups. Where ANOVA was significant, post hoc test using Bonferroni analysis was done. Corrections were determined using Pearson correlation analysis. A p-value ≤ 0.05 was considered statistically significant. 41 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS 4.1 LOW DOSE WEIGHT CHANGES The mean weights recorded at week 1 for control, white sugar low dose, brown sugar low dose and honey low dose group were 270.40±23.31 g, 266.40±4.93 g, 207.60±4.01 g and 218.20±12.02 g respectively but there was no significant difference between them. There was no significant difference in the mean weight of rats from week 1 to week 6 between the control group and the low dose treatment groups. However, there was an increase in weight of rats from week 7 to week 12 in the brown sugar low dose and honey low dose groups 230.25±2.66 and 279.67±17.42 respectively as compared to the control group. The mean weight of low dose groups of brown sugar and honey were found to be significantly higher (p < 0.001 and p < 0.001, respectively) compared to the control group. The mean weights recorded at week 1 for control, white sugar high dose, brown sugar high dose and honey high dose groups were 270.40±23.31 g, 230.00±10.48 g, 171.00±5.68 g, and 221.20±7.72 g respectively were not significantly different. There was no significant difference in the mean weight of rats from week 1 to week 6 between the control and high dose treatment groups despite an increase in weight. However, there was an increase in weight of rats from week 7 to week 12 from the white sugar high dose, brown sugar high dose and honey high dose groups 272.00±13.05 g, 226.75±2.02 g and 259.67±10.68 g respectively as compared to the control group. High dose groups of white sugar, brown sugar and honey were found to be significantly higher (p < 0.001) compared to the control group (Figure 4.1). 42 University of Ghana http://ugspace.ug.edu.gh Figure 4. 1: Mean weights of experimental rats measured from week 1 to week 12 administration of white sugar, brown sugar and honey. Data represents mean ± standard error of mean (SEM) for values statistically different as indicated with 𝑝 < 0.001. 4.2 EFFECT OF NATURAL SWEETENERS ON HBA1C Figure 4.2 shows the effect of intake of the three natural sweeteners (white sugar, brown sugar and honey) on the HbA1c level of the rats. Both the WS HD and WS LD were significantly higher (p<0.001) and (p=0.003) respectively in comparison with control group. Similarly, BS HD was significantly higher (p<0.001) when compared with the control group. Differences between BS LD, H LD and the control group were not significantly different (p>0.05). Honey high dose group (H HD) was significantly higher (p<0.001) when compared with the control group. 43 University of Ghana http://ugspace.ug.edu.gh 6 *** *** *** CONTROL 4 ** WS LD WS HD BS LD 2 BS HD H LD H HD 0 L D D D DO L H L H L D D R S H H T S S S H N W W B B O C Various Groups Figure 4. 2: The effect of white sugar, brown sugar and honey on HbA1c of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.3 EFFECT OF NATURAL SWEETENERS ON FASTING BLOOD GLUCOSE (FBG) The following results show the effect of intake of the three natural sweeteners white sugar, brown sugar and honey on the fasting blood glucose levels of the rats measured. There was no significant difference between WS HD and WS LD groups when compared with the control group. Also, BS HD group was significantly higher (p= 0.010) when compared with the control group. However, there was no significant difference between BS LD group and the control group. Honey high dose H HD were a significantly higher difference (p= 0.04) when compared with the control group. However, there was no significant difference between the H LD group and the control group (Figure 4.3). 44 HbA1c Levels (mmol/L) University of Ghana http://ugspace.ug.edu.gh 15 ** * CONTROL 10 WS LD WS HD BS LD 5 BS HD H LD H HD 0 L D D D D LD DO L R S H S L H H T S S H H N W W B B O C Various Groups Figure 4. 3: The effect of white sugar, brown sugar and honey on fasting blood glucose of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.4 EFFECT OF NATURAL SWEETENERS ON LIPID PROFILE The following results show the effect of intake of three natural sweeteners white sugar, brown sugar and honey on the lipid profile of the rats by the levels of biochemical parameters measured. These included Total Cholesterol (TC), Low Density Lipoprotein cholesterol (LDL- C), High Density Lipoprotein cholesterol (HDL-C), Triglyceride (TG). 4.4.1 Effect of natural sweeteners on Total Cholesterol (TC) The following results show the effect of intake of three natural sweeteners white sugar, brown sugar and honey on the total cholesterol levels of the rats measured. Control 3.92±0.25 mmol/L, 45 Fasting Blood Glucose Levels (mmol/L) University of Ghana http://ugspace.ug.edu.gh WS LD 4.43±0.31 mmol/L, WS HD 3.94±0.24 mmol/L, BS LD 3.95±0.21 mmol/L, BS HD 5.06±0.94 mmol/L, H LD 3.60±0.28 mmol/L, H HD 4.69±0.72 mmol/L. The Total Cholesterol (TC) level in all the treatment groups was not statistically significant compared to the control group (Figure 4.4). 8 6 CONTROL WS LD WS HD 4 BS LD BS HD 2 H LD H HD 0 L D LDO H LD D LD DH H TR S S S S H H N W W B B O C Various Groups Figure 4. 4: The effect of white sugar, brown sugar and honey on total cholesterol of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.4.2 Effect of Natural Sweeteners on Triglyceride (TG) The following results show the effect of intake of three natural sweeteners white sugar, brown sugar and honey on the triglyceride levels of the rats measured. Control 1.245±0.35 mmol/L, WS LD 1.17±0.14 mmol/L, WS HD 0.79±0.09 mmol/L, BS LD 0.83±0.08 mmol/L, BS HD 0.78±0.13 mmol/L, H LD 1.02±0.21 mmol/L, H HD 0.91±0.14 mmol/L. The Triglyceride (TG) 46 Blood Total Cholesterol Levels (mmol/L) University of Ghana http://ugspace.ug.edu.gh level in all the treatment groups was not statistically significant compared to the control group (Figure 4.5). 2.0 CONTROL 1.5 WS LD WS HD 1.0 BS LD BS HD 0.5 H LD H HD 0.0 L D D D D D D O L H L H L H TR S S S S H H N W W B B O C Various Groups Figure 4. 5: The effect of white sugar, brown sugar and honey on triglycerides of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.4.3 Effect of Natural Sweeteners on High Density Lipoprotein Cholesterol (HDL-C) The following results show the effect of intake of three natural sweeteners white sugar, brown sugar and honey on HDL-C levels of the rats measured. High Density Lipoprotein Cholesterol (HDL-C) in all the treatment groups was not statistically significant compared to the control group (Figure 4.6). 47 Blood Triglyceride Levels (mmol/L) University of Ghana http://ugspace.ug.edu.gh 2.5 2.0 CONTROL WS LD 1.5 WS HD BS LD 1.0 BS HD 0.5 H LD H HD 0.0 L D D L H LD D LD DO R S S H H T S S H H N W W B B O C Various Groups Figure 4. 6: The effect of white sugar, brown sugar and honey on high density lipoproteins cholesterol of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.4.4 Effect of Natural Sweeteners on Low Density Lipoprotein Cholesterol (LDL-C) The following results show the effect of intake of the three natural sweeteners (white sugar, brown sugar and honey) on the LDL-C levels of the rats measured. There was no significant difference between WS LD and WS HD group when compared with the control group. The following; BS LD, BS HD, H LD and H HD groups were significantly lower (p<0.001), (p<0.001), (p<0.001) and (p<0.001) in comparison with control group (Figure 4.7). 48 Blood High Density Lipoprotein Cholesterol Levels (mmol/L) University of Ghana http://ugspace.ug.edu.gh 3 CONTROL WS LD 2 WS HD BS LD 1 *** BS HD *** *** H LD *** H HD 0 L D D D D D D O L HR S L H L H T S S S H H N W W B B O C Various Groups Figure 4. 7: The effect of white sugar, brown sugar and honey on low density lipoproteins cholesterol of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.5 EFFECT OF NATURAL SWEETENERS ON INSULIN The effect of intake of the three natural sweeteners (white sugar, brown sugar and honey) on the insulin levels of the rats measured.. There was no significant difference between BS LD group and H LD group when compared with the control group. However, WS LD , WS HD , BS HD and H HD were significantly lower compared with control group (p=0.03, p<0.001, p<0.001, p<0.001, respectively) (Figure 4.8). 49 Blood Low Density Lipoprotein Cholesterol Levels (mmol/L) University of Ghana http://ugspace.ug.edu.gh 2.0 1.5 * CONTROL WS LD *** *** 1.0 *** WS HD BS LD BS HD 0.5 H LD H HD 0.0 L D D D D D D O L H L H LR S H T S S S H H N W W B B O C Various Groups Figure 4. 8: Bar chart showing the effect of white sugar, brown sugar and honey on low insulin level of rats after 12 weeks administration. Each column represents mean with SEM as error bars for values statistically different as indicated with 𝑝 < 0.001. 4.6 EFFECT OF WHITE SUGAR, BROWN SUGAR AND HONEY ON HISTOLOGY OF THE PANCREAS. Histological assessment of the effect of honey, white and brown table sugar showed that control, WS LD, BS LD and H LD groups had compact islets with well-defined borders. The islet cells in the control, WS LD, BS LD and H LD groups were evenly distributed than those in the WS HD group. The acini were found to be more compact and congested with little degenerations in the control group, WS LD, BS LD and H LD. However, the islet were distorted with less defined borders while the acini were degenerated, less compact and congested WS HD, BS HD and H LD compared to the control group (Figure 4.9). 50 Insulin Levels (ng/ml) University of Ghana http://ugspace.ug.edu.gh CONTROL WS LD WS HD 51 University of Ghana http://ugspace.ug.edu.gh BS LD BS HD H LD H HD G1 Figure 4. 9: Photomicrographs of PAS staining showing representative sections of pancreatic tissue of rats studied after 12 weeks administration. Black double headed arrows indicate islet. Yellow double head arrow indicate duct system. Solid yellow arrows indicate epithelial lining of the duct. Circle indicate acini. Five-point stars indicate degenerated acini. 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION AND CONCLUSION 5.1 DISCUSSION Added sugar continues to be a major problem worldwide. It is termed as the hidden ingredient with many names and has a wide range of uses. Sugars are added to foods during preparation, processing, or added at the table and this makes it an inseparable component of our diet. Many people consume excess sugar due to its sweet taste. Over consumption of sugar has led to an increased prevalence of obesity globally (Malik and Hu, 2012). The increase in chronic conditions as a result of overweight or obesity has overburdened the livelihood of many individuals and families. Due to it health implications, consumers have become more conscious of the use of these sweeteners and prefer some natural sweeteners over another. Much of the information about the role of sugars on nutrition and health are inconsistent. It is unclear if some natural sweeteners are beneficial to health than others. However, there is a gradual but substantive preference on the use of honey as a better choice of sweetener than brown and white table sugars. This preference is justified by the fact that honey contains some trace elements and is not subjected to any form of processing therefore it is more natural and healthier (Roman et al., 2013). Animal studies using normal Sprague-Dawley rats have demonstrated varying effect of honey and sucrose on weight gain, HbA1c, FBG and lipid profile (Chepulis, 2007, Chepulis and Starkey, 2008, Nemoseck et al., 2011, Atangwho et al., 2020). Having obtained inconclusive results in the aforementioned studies, it was incumbent to further investigate anecdotal claims. In this study, rats were fed WS LD (5.5%), WS HD (22%), BS LD (5.7%), BS HD (23%), H LD 53 University of Ghana http://ugspace.ug.edu.gh (7.6%) and H HD (30.4%) for 12 weeks. In an earlier study, Wistar rats were fed a similar dose including 8% and 16% table sugar, 10% and 20% honey diets, for 29 weeks (Atangwho et al., 2020). Similarly, a diet which contained 8% sucrose, 8% mixed sugars as in honey, or 10% honey freely were fed to Sprague-Dawley (S-D) rats for 6 weeks (Chepulis, 2007). In the aforementioned studies different animal models were used to study the effect of these natural sweeteners on parameters such as weight, glycaemia, lipid profile and insulin. In this study, measured animals body weights showed straight and continuous gain across the treatment groups, with the continuous weight gain not significantly different among the groups. This indicates that the three sweeteners, honey, white and brown table sugar did not have any distinguishable result on body weight gain. This finding is consistent with a report by (Atangwho et al., 2020) which showed weight gain across the treatment groups of female Wistar rats fed 20% honey and 16% sugar sweetened diet, were comparable to the control fed rat chow only. Similarly, a study by (Adesoji and Oluwakemi, 2008) reported that the control non diabetic rats fed with honey and both honey and fructose led to progressive weight gain 50.27% and 19.32% respectively. An earlier study by (Atangwho et al., 2017) showed weight gain across the treatment groups where rats were fed with 15% and 30% sugar, 12% and 24% honey compared to the control group for 13 weeks. On average, the recommended intake of dietary sugar in the form of added sugar should not exceed 150 and 100 calories for men and women respectively (Johnson et al., 2009). This is equivalent to 38 g WS, 41 g BS and 52 g H per day. Weight increase is expected if no effort is made to reduce the intake of added sugar (Hu, 2013). This was demonstrated in a trial of sugar free or sugar sweetened beverage and body weight in children (de Ruyter et al., 2012). However, (Chepulis and Starkey, 2008) reported a significant reduction in body weight gain of 54 University of Ghana http://ugspace.ug.edu.gh 10% honey-sweetened diet fed to Sprague-Dawley rats compared to rats given 7.9% sucrose- based diet for six weeks. Likewise (Nemoseck et al., 2011) reported a lower weight gain for honey-fed rats than rats fed sucrose after 33 days of treatment. This may be a result of the effect of fructose which is a major component in honey in modulation of appetite regulating hormones such as leptin, ghrelin and peptide (Klok et al., 2007). Further to this, the rats in the treatment groups were fed natural sweetener treatment diet ad libitum which may explain reduced diet intake and subsequently weight gain. Honey, white and brown sugar contains glucose and fructose, which when consumed in the same quantity will affect energy balance similarly. It is therefore comprehensible that honey, white and brown table sugar fed in equivalent quantities of carbohydrate may have contributed equally to weight gain. In this study, the effect of intake of the three natural sweeteners white sugar, brown sugar and honey on the HbA1c level of the rats showed a significant increase in the high dose groups compared to the control group. This is consistent with an earlier study by (Chepulis, 2007) where the authors reported that HbA1c levels were significantly higher in the sucrose-fed group (4.14 ± 0.07 mmol/L), mixed sugars-fed group (4.09 ± 0.11 mmol/L) and the honey-fed group (4.11 ± 0.19 mmol/L) compared with rats fed a sugar free diet (4.02 ± 0.12 mmol/L). Similar to a recent study by (Driescher et al., 2019), sugar sweetened beverage consumption increased HbA1c levels after three and six months of continous sugar intake. (Bahrami et al., 2009) also reported a significant increase in HbA1c levels in human subject fed with natural honey for eight weeks compared with the control group. There was no significant increase in HbA1c levels among the low dose groups except for WS LD. This may be due to the high glyceamic nature of white sugar. This is at variance with an earlier study by (Chepulis and Starkey, 2008) which recorded a significant decrease of HbA1c 55 University of Ghana http://ugspace.ug.edu.gh levels in a long-term honey (3.97 ± 0.12 mmol/L), sucrose (4.19 ± 0.14 mmol/L) and sugar free (4.07 ± 0.17) feeding in Sprague-Dawley rats for 52 weeks. It could be that the natural sweetener administered in low dose groups were relatively small to cause an increase in HbA1c levels. In this study, the effect of intake of the three natural sweeteners white sugar, brown sugar and honey on the fasting blood glucose (FBG) level of the rats showed there was no significant difference between WS LD, BS LD, H LD and control group. This is similar to a recent study by (Atangwho et al., 2017) which reported that FBG concentrations did not significantly differ between the test groups and/or the normal control. Likewise, a previous study (Erejuwa et al., 2016) showed that there was no significant difference in the glucose lowering effect on honey- fed rats. Honey and table sugar contain glucose and fructose in a relatively close amount plus other components depending on it source. This implies that its’ consumption over a period will affect FBG in a similar way especially where the same amount of carbohydrate was given to the rats in this study. In this study, the effect of the intake of the three natural sweeteners white sugar, brown sugar and honey on the TC, TG, HDL-C and LDL-C level of rats showed there was no significant difference between TC, TG, HDL-C levels in all the treatment groups and that the LDL-C levels of WS LD and WS HD groups were comparable to the control groups. This is similar to a study that found no significant difference between the HDL-C, TC and TG levels in the treatment group compared with control group in honey fed rats. (Mohammadimanesh et al., 2019). Furthermore, found no significant differences in triglyceride levels when rats were fed 10% honey or sucrose-based diet after 6 or 52 weeks (Chepulis, 2007, Chepulis and Starkey, 2008). Further, a similar study observed no significant difference in TC and HDL-C between the rats fed the honey and sucrose-based diet (Nemoseck et al., 2011). It is imperative to point out that 56 University of Ghana http://ugspace.ug.edu.gh the afore-mentioned study was designed to examine the potential differences of a honey based diet and a sucrose based diet. However, these diets were not compared with a more neutral control diet such as a sugar free diet and this may imply that honey may be a healthier replacement for sucrose. Further, in a study on diabetic rats it was observed that TC levels of normal non-diabetic rats, slightly increased following honey treatment which is similar to the observation made in this present study (Aziz et al., 2017). Furthermore, not all studies ascertained the modulation of lipid profiles with the consumption of honey (Chepulis, 2007, Münstedt et al., 2009). In this present study, LDL-C levels of rat were significantly lower BS LD (0.31+0.2 mmol/L), BS HD (0.59+0.36 mmol/L), H LD (0.64+0.09 mmol/L) and H HD ( 0.53+0.05 mmol/L) groups when compared with the control group (2.15+0.16 mmol/L). White sugar, brown sugar and honey treatment groups had the same effect on lipid profile except the effect of brown sugar and honey on LDL-C. This may be as a result of antioxidant, polyphenols found in honey as well as trace elements in brown sugar which may be cardioprotective compared to white sugar which has none of these components. This is in line with a study by (Alagwu et al., 2014) which reported lowered LDL-C in honey fed-rat when compared with the control group (p<0.01). This is an indication of the positive impact of honey on the level of LDL-C in rats. However, the same can be said for brown sugar which equally showed a lower LDL-C of rats compared to the control group in this study. This similiarity does not put honey above brown sugar in terms of cardioprotective property. The effect of intake of the three natural sweeteners white sugar, brown sugar and honey on the insulin levels of rats showed no significant differences between BS LD group and H LD group when compared with the control group. This explains the lower levels of FBG and HbA1c 57 University of Ghana http://ugspace.ug.edu.gh measured in rat in this groups. This is concurrent with a study (Aziz et al., 2017) where serum insulin levels of normal non-diabetic rats, were almost twice that in non-treated diabetic rats, and were not affected by honey treatment. However, there were significant differences between WS LD, WS HD, BS HD and H HD groups compared with control group. This was shown by high FBG and HbA1c levels in this groups (WS LD, WS HD, BS HD and H HD) due to lower insulin secretion as revealed by distorted islet with less defined borders. The function of insulin is to help transport glucose into the cells to be used in energy production. Inadequate amount of insulin will make cause make the glucose level rise in the blood. This implies the ability to produce near normal insulin by the pancreas in the rat low dose groups was supported by near normal histological features of the pancreatic islets that appears compact and evenly distributed with well-defined borders and than in the rat high dose groups. 5.2 CONCLUSION In the current study, honey, white and brown table sugar were found to cause an appreciable increase in FBG, HbA1c and lipid profile and release of insulin at the same dose adminitration after the twelve week period. The increase was found to occur mostly in the high doses than in low doses with a few disparity. Additionally, high doses of honey, white and brown sugar were found to cause weight gain after the twelve week period. Although this study was conducted in an animal model, this finding is noteworthy, as this may serve as a basis for future studies. 5.3 LIMITATIONS To allow the testing of HbA1c the study had to change to a chronic study. 58 University of Ghana http://ugspace.ug.edu.gh 5.4 RECOMMENDATION There is the need for further research to understand the mechanism on the effect of brown table sugar on lipid profile especially on LDL-C to ascertain if there is threshold of added sugars below which there are no negative effects on cardiovascular health. 59 University of Ghana http://ugspace.ug.edu.gh REFERENCE ABDULLAH, W. G., RIANSE, U., ISWANDI, R. M., TARIDALA, S. A. A., RIANSE, I. S., ZULFIKAR, L., BAKA, L. R., LA ABDI, A., CAHYONO, E. & WIDAYATI, W. 2014a. Potency of natural sweetener: Brown sugar. AENSI Journals. Advances in Enviromental Biology, 10. ABDULLAH, W. G., RIANSE, U., ISWANDI, R. M., TARIDALA, S. A. A., WIDAYATI, W., RIANSE, I. S., BAKA, L. R. & BAKA, W. K. 2014b. Potency of natural sweetener: Brown sugar. Advances in Environmental Biology, 374-386. ABDULRHMAN, M., EL HEFNAWY, M., ALI, R., HAMID, I. A., ABOU EL-GOUD, A. & REFAI, D. 2013. Effects of honey, sucrose and glucose on blood glucose and C-peptide in patients with type 1 diabetes mellitus. Complementary therapies in clinical practice, 19, 15-19. ADA 2014. Diagnosis and classification of diabetes mellitus. Diabetes care, 37, S81-S90. ADA 2018. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes— 2018. Diabetes care, 41, S13-S27. ADA 2019. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes— 2019. Diabetes care, 42, S13-S28. ADESOJI, F. & OLUWAKEMI, A. 2008. Differential effect of honey on selected variables in alloxan-induced and fructose-induced diabetic rats. African Journal of Biomedical Research, 11. ADEVA-ANDANY, M. M., GONZÁLEZ-LUCÁN, M., DONAPETRY-GARCÍA, C., FERNÁNDEZ-FERNÁNDEZ, C. & AMENEIROS-RODRÍGUEZ, E. 2016a. Glycogen metabolism in humans. BBA clinical, 5, 85-100. 60 University of Ghana http://ugspace.ug.edu.gh ADEVA-ANDANY, M. M., PÉREZ-FELPETE, N., FERNÁNDEZ-FERNÁNDEZ, C., DONAPETRY-GARCÍA, C. & PAZOS-GARCÍA, C. 2016b. Liver glucose metabolism in humans. Bioscience reports, 36, e00416. AGOFURE, O. 2018. Prevalence of obesity among adults in Issele-Uku, Delta State Nigeria. Alexandria journal of medicine, 54, 463-468. AGUIREE, F., BROWN, A., CHO, N. H., DAHLQUIST, G., DODD, S., DUNNING, T., HIRST, M., HWANG, C., MAGLIANO, D. & PATTERSON, C. 2013. IDF diabetes atlas. AGYEI-MENSAH, S. & AIKINS, A. D.-G. 2010. Epidemiological transition and the double burden of disease in Accra, Ghana. Journal of urban health, 87, 879-897. AGYEMANG, C., ATTAH-ADJEPONG, G., OWUSU-DABO, E., AIKINS, A. D. G., ADDO, J., EDUSEI, A., NKUM, B. & OGEDEGBE, G. 2012. Stroke in Ashanti region of Ghana. Ghana medical journal, 46, 12-17. AHMED, M. H., ALI, Y. A., AWADALLA, H., ELMADHOUN, W. M., NOOR, S. K. & ALMOBARAK, A. O. 2017. Prevalence and trends of obesity among adult Sudanese individuals: Population based study. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11, S963-S967. AHMED, S. H., GUILLEM, K. & VANDAELE, Y. 2013. Sugar addiction: pushing the drug- sugar analogy to the limit. Current Opinion in Clinical Nutrition & Metabolic Care, 16, 434-439. AJANI, S. R., SUSAN, H. J. A. & OLUWASEUN, A. 2015. Gender differences in factors associated with overweight and obesity among civil servants in Lagos, Nigeria. International Journal of Nutrition and metabolism, 7, 66-73. 61 University of Ghana http://ugspace.ug.edu.gh AKOH, C. C. 2017. Food lipids: chemistry, nutrition, and biotechnology, CRC press. AL-WAILI, N., SALOM, K., AL-GHAMDI, A., ANSARI, M. J., AL-WAILI, A. & AL-WAILI, T. 2013. Honey and cardiovascular risk factors, in normal individuals and in patients with diabetes mellitus or dyslipidemia. Journal of medicinal food, 16, 1063-1078. ALAGWU, E., OKWARA, J., NNELI, R. & OSIM, E. 2014. Effect of honey intake on serum cholesterol, triglycerides and lipoprotein levels in albino rats and potential benefits on risks of coronary heart disease. ALEMU, E., ATNAFU, A., YITAYAL, M. & YIMAM, K. 2014. Prevalence of overweight and/or obesity and associated factors among high school adolescents in Arada Sub city, Addis Ababa, Ethiopia. Journal of Nutrition & Food Sciences, 4, 1. ALVAREZ-SUAREZ, J. M., GASPARRINI, M., FORBES-HERNÁNDEZ, T. Y., MAZZONI, L. & GIAMPIERI, F. 2014. The composition and biological activity of honey: a focus on Manuka honey. Foods, 3, 420-432. AMARRA, M. S. V., KHOR, G. L. & CHAN, P. 2016. Intake of added sugar in Malaysia: a review. Asia Pacific journal of clinical nutrition, 25, 227. AROLA, L., BONET, M. L., DELZENNE, N., DUGGAL, M., GÓMEZ‐CANDELA, C., HUYGHEBAERT, A., LAVILLE, M., LINGSTRÖM, P., LIVINGSTONE, B. & PALOU, A. 2009. Summary and general conclusions/outcomes on the role and fate of sugars in human nutrition and health. Obesity reviews, 10, 55-58. ARSENAULT, B. J., BOEKHOLDT, S. M. & KASTELEIN, J. J. 2011. Lipid parameters for measuring risk of cardiovascular disease. Nature Reviews Cardiology, 8, 197-206. ATANGWHO, I. J., IBENEME, C. E., EGBUNG, G. E., IBENEME, E., ENO, M. A. & NWANKPA, P. 2020. Effect of long-term feeding of the Obudu natural honey and table 62 University of Ghana http://ugspace.ug.edu.gh sugar-sweetened diets on obesity and pro-inflammatory biomarkers in rats. BMC nutrition, 6, 1-11. ATANGWHO, J., ENO M.A, UTU-BAKU A.B, EGBUNG G.E , OKPARA H.C, UDAH D & ESSIEN E.U 2017. Is Honey Really Better than Table Sugar in Body Weight Control? A Case of Study Based on the Obudu Honey and Refined Sugar Comparison. Journal of Food Nutrition and Dietetics, Vol. 2. Issue. 1. 14000112. AVENA, N. M., RADA, P. & HOEBEL, B. G. 2008. Evidence for sugar addiction: behavioral and neurochemical effects of intermittent, excessive sugar intake. Neuroscience & Biobehavioral Reviews, 32, 20-39. AZIZ, M. S. A., GIRIBABU, N., RAO, P. V. & SALLEH, N. 2017. Pancreatoprotective effects of Geniotrigona thoracica stingless bee honey in streptozotocin-nicotinamide-induced male diabetic rats. Biomedicine & Pharmacotherapy, 89, 135-145. BAHRAMI, M., ATAIE-JAFARI, A., HOSSEINI, S., FORUZANFAR, M. H., RAHMANI, M. & PAJOUHI, M. 2009. Effects of natural honey consumption in diabetic patients: an 8- week randomized clinical trial. International journal of food sciences and nutrition, 60, 618-626. BAIKOW, V. E. 2013a. Manufacture and refining of raw cane sugar, Elsevier. BAIKOW, V. E. 2013b. Manufacture and refining of raw cane sugar, Elsevier. BAILIN, D., GOLDMAN, G. & PHARTIYAL, P. 2014. Sugar-coating science. Union of Concerned Scientists. BAKKER, H. 2012. Sugar cane cultivation and management, Springer Science & Business Media. 63 University of Ghana http://ugspace.ug.edu.gh BARTOLI, E., FRA, G. & SCHIANCA, G. C. 2011. The oral glucose tolerance test (OGTT) revisited. European journal of internal medicine, 22, 8-12. BASU, S., YOFFE, P., HILLS, N. & LUSTIG, R. H. 2013. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PloS one, 8, e57873. BECK, R., EICHEN, J. M., HILLE, D. R., ROGOYSKI, J. & WILLIAMS, J. A. 2018. Managing blood glucose levels. Google Patents. BEMILLER, J. N. 2018. Carbohydrate chemistry for food scientists, Elsevier. BERNSTEIN, J. T., SCHERMEL, A., MILLS, C. M. & L’ABBÉ, M. R. 2016. Total and free sugar content of Canadian prepackaged foods and beverages. Nutrients, 8, 582. BERRIDGE, K. C. & KRINGELBACH, M. L. 2015. Pleasure systems in the brain. Neuron, 86, 646-664. BJÖRNSON, E., ADIELS, M., TASKINEN, M.-R. & BORÉN, J. 2017. Kinetics of plasma triglycerides in abdominal obesity. Current opinion in lipidology, 28, 11-18. BLEICH, S. N., WANG, Y. C., WANG, Y. & GORTMAKER, S. L. 2008. Increasing consumption of sugar-sweetened beverages among US adults: 1988–1994 to 1999–2004– . The American journal of clinical nutrition, 89, 372-381. BORNFELDT, K. E. & TABAS, I. 2011. Insulin resistance, hyperglycemia, and atherosclerosis. Cell metabolism, 14, 575-585. BOS, M. & AGYEMANG, C. 2013. Prevalence and complications of diabetes mellitus in Northern Africa, a systematic review. BMC public health, 13, 387. 64 University of Ghana http://ugspace.ug.edu.gh BOWEN, M. E., XUAN, L., LINGVAY, I. & HALM, E. A. 2015. Random blood glucose: a robust risk factor for type 2 diabetes. The Journal of Clinical Endocrinology & Metabolism, 100, 1503-1510. BOWMAN, S. A. 2017. Added sugars: definition and estimation in the USDA food patterns equivalents databases. Journal of Food Composition and Analysis, 64, 64-67. BRAY, G. A. & POPKIN, B. M. 2014. Dietary sugar and body weight: have we reached a crisis in the epidemic of obesity and diabetes?: health be damned! Pour on the sugar. Diabetes care, 37, 950-956. BREKHMAN, I. I. S. O. & NESTERENKO, I. F. 2013. Brown sugar and health, Elsevier. BRENNEMAN, K. A., RAMAIAH, S. K., ROHDE, C. M., MESSING, D. M., O’NEIL, S. P., GAUTHIER, L. M., STEWART, Z. S., MANTENA, S. R., SHEVLIN, K. M. & LEONARD, C. G. 2014. Mechanistic Investigations of Test Article–Induced Pancreatic Toxicity at the Endocrine–Exocrine Interface in the Rat. Toxicologic pathology, 42, 229- 242. BRISBOIS, T. D., MARSDEN, S. L., ANDERSON, G. H. & SIEVENPIPER, J. L. 2014. Estimated intakes and sources of total and added sugars in the Canadian diet. Nutrients, 6, 1899-1912. BRUYÈRE, O., AHMED, S. H., ATLAN, C., BELEGAUD, J., BORTOLOTTI, M., CANIVENC-LAVIER, M.-C., CHARRIÈRE, S., GIRARDET, J.-P., HOUDART, S. & KALONJI, E. 2015. Review of the nutritional benefits and risks related to intense sweeteners. Archives of Public Health, 73, 1-10. CARAHER, M. & PERRY, I. 2017. Sugar, salt, and the limits of self regulation in the food industry. British Medical Journal Publishing Group. 65 University of Ghana http://ugspace.ug.edu.gh CAROCHO, M., MORALES, P. & FERREIRA, I. C. 2017. Sweeteners as food additives in the XXI century: A review of what is known, and what is to come. Food and Chemical Toxicology, 107, 302-317. CARROLL, M. D., FRYAR, C. D., NGUYEN, D. T. & STATISTICS, N. C. F. H. 2017. Total and high-density lipoprotein cholesterol in adults: United States, 2015-2016, US Department of Health and Human Services, Centers for Disease Control and …. CAUVAIN, S. 2012. Breadmaking: an overview. Breadmaking. Elsevier. CHANDRA, S., HOENERHOFF, M. J. & PETERSON, R. 2013. Endocrine glands. Toxicologic Pathology. CRC press. CHEN, L., APPEL, L. J., LORIA, C., LIN, P.-H., CHAMPAGNE, C. M., ELMER, P. J., ARD, J. D., MITCHELL, D., BATCH, B. C. & SVETKEY, L. P. 2009. Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial–. The American journal of clinical nutrition, 89, 1299-1306. CHEPULIS, L. 2007. The effect of honey compared to sucrose, mixed sugars, and a sugar‐free diet on weight gain in young rats. Journal of food science, 72, S224-S229. CHEPULIS, L. & STARKEY, N. 2008. The long‐term effects of feeding honey compared with sucrose and a sugar‐free diet on weight gain, lipid profiles, and DEXA measurements in rats. Journal of Food Science, 73, H1-H7. CHIAVAROLI, L., MIRRAHIMI, A., DE SOUZA, R. J., COZMA, A. I., HA, V., WANG, D. D., MATTHEW, E. Y., CARLETON, A. J., BEYENE, J. & KENDALL, C. W. 2012. Does fructose consumption elicit a dose-response effect on fasting triglycerides? A systematic review and meta-regression of controlled feeding trials. Canadian Journal of Diabetes, 36, S37. 66 University of Ghana http://ugspace.ug.edu.gh CHRISTY, P. M., GOPINATH, L. & DIVYA, D. 2014. A review on anaerobic decomposition and enhancement of biogas production through enzymes and microorganisms. Renewable and Sustainable Energy Reviews, 34, 167-173. CLEMENS, D. L., SCHNEIDER, K. J., ARKFELD, C. K., GRODE, J. R., WELLS, M. A. & SINGH, S. 2016a. Alcoholic pancreatitis: new insights into the pathogenesis and treatment. World journal of gastrointestinal pathophysiology, 7, 48. CLEMENS, R. A., JONES, J. M., KERN, M., LEE, S. Y., MAYHEW, E. J., SLAVIN, J. L. & ZIVANOVIC, S. 2016b. Functionality of sugars in foods and health. Comprehensive Reviews in Food Science and Food Safety, 15, 433-470. CLIFFORD, J. & MALONEY, K. 2016. Sugar and sweeteners. Fact sheet (Colorado State University. Extension). Food and nutrition series; no. 9.301. COOKE, D. A. & SCOTT, J. 2012. The sugar beet crop, Springer Science & Business Media. CRAIGMYLE, M. B. L. 1986. Colour atlas of histology, Wolfe medical. CZECH, M. P. 2017. Insulin action and resistance in obesity and type 2 diabetes. Nature medicine, 23, 804-814. DA SILVA, P. M., GAUCHE, C., GONZAGA, L. V., COSTA, A. C. O. & FETT, R. 2016. Honey: Chemical composition, stability and authenticity. Food chemistry, 196, 309-323. DAHLÖF, B. 2010. Cardiovascular disease risk factors: epidemiology and risk assessment. The American journal of cardiology, 105, 3A-9A. DALICHAOUCH-BENCHAOUI, S. & ABADI, N. 2014. Factors Associated With Overweight and Obesity Among Adults in Constantine. International Journal of Science and Research (IJSR), Volume 3 : , pp 910-915. 67 University of Ghana http://ugspace.ug.edu.gh DASHTY, M. 2013. A quick look at biochemistry: carbohydrate metabolism. Clinical biochemistry, 46, 1339-1352. DE KONING, L., MALIK, V. S., KELLOGG, M. D., RIMM, E. B., WILLETT, W. C. & HU, F. B. 2012. Sweetened beverage consumption, incident coronary heart disease and biomarkers of risk in men. Circulation, CIRCULATIONAHA. 111.067017. DE MARIA, G. 2013. Panela: the natural nutritional sweetener. Agro FOOD Industry Hi Tech, 24, 44-48. DE RUYTER, J. C., OLTHOF, M. R., SEIDELL, J. C. & KATAN, M. B. 2012. A trial of sugar- free or sugar-sweetened beverages and body weight in children. New England Journal of Medicine, 367, 1397-1406. DINICOLANTONIO, J. J. & OKEEFE, J. H. 2017. Added sugars drive coronary heart disease via insulin resistance and hyperinsulinaemia: a new paradigm. Archives of Disease in childhood. DOUPA, D., SECK, S. M., DIA, C. A., DIALLO, F. A., KANE, M. O., KANE, A., GUEYE, P. M., MBAYE, M. N., GUEYE, L. & JOBE, M. 2014. Dyslipidemia, obesity and other cardiovascular risk factors in the adult population in Senegal. The Pan African Medical Journal, 19. DRAYCOTT, A. P. 2008. Sugar beet, John Wiley & Sons. DRIESCHER, N., JOSEPH, D. E., HUMAN, V. R., OJUKA, E., COUR, M., HADEBE, N., BESTER, D., MARNEWICK, J. L., LECOUR, S. & LOCHNER, A. 2019. The impact of sugar-sweetened beverage intake on rat cardiac function. Heliyon, 5, e01357. 68 University of Ghana http://ugspace.ug.edu.gh EDWARDS, C. H., ROSSI, M., CORPE, C. P., BUTTERWORTH, P. J. & ELLIS, P. R. 2016. The role of sugars and sweeteners in food, diet and health: Alternatives for the future. Trends in food science & technology, 56, 158-166. EDWARDS, W. P. 2018. The science of sugar confectionery, Royal Society of Chemistry. EL SOHAIMY, S., MASRY, S. & SHEHATA, M. 2015. Physicochemical characteristics of honey from different origins. Annals of Agricultural Sciences, 60, 279-287. EREJUWA, O., SULAIMAN, S., WAHAB, M., SIRAJUDEEN, K., SALLEH, M. M. & GURTU, S. Antioxidant protection of Malaysian tualang honey in pancreas of normal and streptozotocin-induced diabetic rats. Annales d'endocrinologie, 2010. Elsevier, 291- 296. EREJUWA, O. O., NWOBODO, N. N., AKPAN, J. L., OKORIE, U. A., EZEONU, C. T., EZEOKPO, B. C., NWADIKE, K. I., ERHIANO, E., ABDUL WAHAB, M. S. & SULAIMAN, S. A. 2016. Nigerian honey ameliorates hyperglycemia and dyslipidemia in alloxan-induced diabetic rats. Nutrients, 8, 95. ERICKSON, J. & SLAVIN, J. 2015. Total, added, and free sugars: are restrictive guidelines science-based or achievable? Nutrients, 7, 2866-2878. ERVIN, R. B. 2012. Consumption of added sugar among US children and adolescents, 2005- 2008, Department of Health and Human Services, Centers for Disease Control and …. ERVIN, R. B. & OGDEN, C. L. 2013. Consumption of added sugars among US adults, 2005- 2010. FITCH, C. & KEIM, K. S. 2012. Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. Journal of the Academy of Nutrition and Dietetics, 112, 739-758. 69 University of Ghana http://ugspace.ug.edu.gh FLEGAL, K. M., KRUSZON-MORAN, D., CARROLL, M. D., FRYAR, C. D. & OGDEN, C. L. 2016. Trends in obesity among adults in the United States, 2005 to 2014. Jama, 315, 2284-2291. FORDE, C., VAN KUIJK, N., THALER, T., DE GRAAF, C. & MARTIN, N. 2013. Texture and savoury taste influences on food intake in a realistic hot lunch time meal. Appetite, 60, 180-186. FOX, S. 2015. Human physiology, McGraw-Hill Education. FRANK, L. K., HERACLIDES, A., DANQUAH, I., BEDU‐ADDO, G., MOCKENHAUPT, F. P. & SCHULZE, M. B. 2013. Measures of general and central obesity and risk of type 2 diabetes in a Ghanaian population. Tropical Medicine & International Health, 18, 141- 151. GABIUS, H.-J. 2011. The sugar code: fundamentals of glycosciences, John Wiley & Sons. GAIO, V., ANTUNES, L., NAMORADO, S., BARRETO, M., GIL, A., KYSLAYA, I., RODRIGUES, A. P., SANTOS, A., BØHLER, L. & CASTILHO, E. 2018. Prevalence of overweight and obesity in Portugal: results from the first Portuguese Health Examination Survey (INSEF 2015). Obesity research & clinical practice, 12, 40-50. GAPSTUR, S. M., GANN, P. H., LOWE, W., LIU, K., COLANGELO, L. & DYER, A. 2000. Abnormal glucose metabolism and pancreatic cancer mortality. Jama, 283, 2552-2558. GARDNER, T. B., VEGE, S. S., CHARI, S. T., PEARSON, R. K., CLAIN, J. E., TOPAZIAN, M. D., LEVY, M. J. & PETERSEN, B. T. 2008. The effect of age on hospital outcomes in severe acute pancreatitis. Pancreatology, 8, 265-270. GATIMU, S. M., MILIMO, B. W. & SAN SEBASTIAN, M. 2016. Prevalence and determinants of diabetes among older adults in Ghana. BMC Public Health, 16, 1174. 70 University of Ghana http://ugspace.ug.edu.gh GBD 2017. Health effects of overweight and obesity in 195 countries over 25 years-Global Burden of Disease. New England Journal of Medicine, 377, 13-27. GERBER, P. A. & RUTTER, G. A. 2017. The role of oxidative stress and hypoxia in pancreatic beta-cell dysfunction in diabetes mellitus. Antioxidants & redox signaling, 26, 501-518. GISSLEN, W. 2012. Professional baking, John Wiley & Sons. GOLDFEIN, K. R. & SLAVIN, J. L. 2015. Why sugar is added to food: food science 101. Comprehensive Reviews in Food Science and Food Safety, 14, 644-656. GOULD, G. W. 2012. New methods of food preservation, Springer Science & Business Media. GRAY, L. R., TOMPKINS, S. C. & TAYLOR, E. B. 2014. Regulation of pyruvate metabolism and human disease. Cellular and molecular life sciences, 71, 2577-2604. GREMBECKA, M. 2015. Natural sweeteners in a human diet. Roczniki Państwowego Zakładu Higieny, 66. GUERRA, M. J. & MUJICA, M. V. 2010. Physical and chemical properties of granulated cane sugar" panelas". Food Science and Technology, 30, 250-257. HALL, V., THOMSEN, R. W., HENRIKSEN, O. & LOHSE, N. 2011. Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review. BMC public health, 11, 564. HAMAD, S. H. 2012. 20 Factors Affecting the Growth of Microorganisms in Food. Progress in food preservation, 405. HANNOU, S. A., HASLAM, D. E., MCKEOWN, N. M. & HERMAN, M. A. 2018. Fructose metabolism and metabolic disease. The Journal of clinical investigation, 128, 545-555. HARDY, O. T., CZECH, M. P. & CORVERA, S. 2012. What causes the insulin resistance underlying obesity? Current opinion in endocrinology, diabetes, and obesity, 19, 81. 71 University of Ghana http://ugspace.ug.edu.gh HARVEY, R. A. & FERREIR, D. R. 2011. "Fructose Metabolism" Biochemistry, Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. . HEALTH, U. D. O. & SERVICES, H. 2017. Dietary guidelines for Americans 2015-2020, Skyhorse Publishing Inc. HENDRANI, A. D., ADESIYUN, T., QUISPE, R., JONES, S. R., STONE, N. J., BLUMENTHAL, R. S. & MARTIN, S. S. 2016. Dyslipidemia management in primary prevention of cardiovascular disease: Current guidelines and strategies. World journal of cardiology, 8, 201. HRUBY, A. & HU, F. B. 2015. The epidemiology of obesity: a big picture. Pharmacoeconomics, 33, 673-689. HU, F. B. 2011. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes care, 34, 1249-1257. HU, F. B. 2013. Resolved: there is sufficient scientific evidence that decreasing sugar‐sweetened beverage consumption will reduce the prevalence of obesity and obesity‐related diseases. Obesity reviews, 14, 606-619. HU, F. B. & MALIK, V. S. 2010. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiology & behavior, 100, 47-54. HUGOT, E. 2014. Handbook of cane sugar engineering, Elsevier. IDF 2015. International diabetes federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation. IDF 2018. IDF Diabetes Atlas—8th edition. IDF Africa. 72 University of Ghana http://ugspace.ug.edu.gh JAFFÉ, W. R. 2015. Nutritional and functional components of non centrifugal cane sugar: A compilation of the data from the analytical literature. Journal of food composition and analysis, 43, 194-202. JAMEEL, F., PHANG, M., WOOD, L. G. & GARG, M. L. 2014. Acute effects of feeding fructose, glucose and sucrose on blood lipid levels and systemic inflammation. Lipids in health and disease, 13, 195. JOHNSON, B., OBER, W., GARRISON, C. & SILVERTHORN, A. 2010. Human physiology: An integrated approach. New York: Pearson. JOHNSON, R. K., APPEL, L. J., BRANDS, M., HOWARD, B. V., LEFEVRE, M., LUSTIG, R. H., SACKS, F., STEFFEN, L. M. & WYLIE-ROSETT, J. 2009. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation, 120, 1011-1020. JOHNSTON, R. D., STEPHENSON, M. C., CROSSLAND, H., CORDON, S. M., PALCIDI, E., COX, E. F., TAYLOR, M. A., AITHAL, G. P. & MACDONALD, I. A. 2013. No difference between high-fructose and high-glucose diets on liver triacylglycerol or biochemistry in healthy overweight men. Gastroenterology, 145, 1016-1025. e2. KAHN, R. & SIEVENPIPER, J. L. 2014. Dietary sugar and body weight: have we reached a crisis in the epidemic of obesity and diabetes?: we have, but the pox on sugar is overwrought and overworked. Diabetes Care, 37, 957-962. KAPPICO, J., SUZUKI, A. & HONGU, N. 2012. Is honey the same as sugar? KELISHADI, R., MANSOURIAN, M. & HEIDARI-BENI, M. 2014. Association of fructose consumption and components of metabolic syndrome in human studies: a systematic review and meta-analysis. Nutrition, 30, 503-510. 73 University of Ghana http://ugspace.ug.edu.gh KELL, K. P., CARDEL, M. I., BOHAN BROWN, M. M. & FERNÁNDEZ, J. R. 2014. Added sugars in the diet are positively associated with diastolic blood pressure and triglycerides in children. The American journal of clinical nutrition, 100, 46-52. KIM, S. Y. & JEE, S. H. 2015. Consumption of Added Sugars and Lipid Profiles in Korean Population from a Cohort Study. Journal of Lipid and Atherosclerosis, 4, 17-25. KLOK, M., JAKOBSDOTTIR, S. & DRENT, M. 2007. The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. Obesity reviews, 8, 21- 34. KLOP, B., ELTE, J. W. F. & CABEZAS, M. C. 2013. Dyslipidemia in obesity: mechanisms and potential targets. Nutrients, 5, 1218-1240. KLURFELD, D., FOREYT, J., ANGELOPOULOS, T. & RIPPE, J. 2013. Lack of evidence for high fructose corn syrup as the cause of the obesity epidemic. International journal of obesity (2005), 37, 771. KOLAYLI, S., BOUKRAÂ, L., ŞAHIN, H. & ABDELLAH, F. 2012. Sugars in honey. Dietary sugars: Chemistry, analysis, function and effects, 3-15. KOMATSU, M., TAKEI, M., ISHII, H. & SATO, Y. 2013. Glucose‐stimulated insulin secretion: A newer perspective. Journal of diabetes investigation, 4, 511-516. KUBOTA, T., KUBOTA, N. & KADOWAKI, T. 2013. The role of endothelial insulin signaling in the regulation of glucose metabolism. Reviews in Endocrine and Metabolic Disorders, 14, 207-216. KUMAR, K. S., DEBJIT, B. & CHANDIRA, M. 2010. Medicinal uses and health benefits of honey: an overview. Journal of Chemical and Pharmaceutical Research, 2, 385-395. 74 University of Ghana http://ugspace.ug.edu.gh LANGLOIS, K. & GARRIGUET, D. 2011. Sugar consumption among Canadians of all ages, Statistics Canada. LASLETT, L. J., ALAGONA, P., CLARK, B. A., DROZDA, J. P., SALDIVAR, F., WILSON, S. R., POE, C. & HART, M. 2012. The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology. Journal of the American College of Cardiology, 60, S1-S49. LECOULTRE, V., EGLI, L., CARREL, G., THEYTAZ, F., KREIS, R., SCHNEITER, P., BOSS, A., ZWYGART, K., LÊ, K. A. & BORTOLOTTI, M. 2013. Effects of fructose and glucose overfeeding on hepatic insulin sensitivity and intrahepatic lipids in healthy humans. Obesity, 21, 782-785. LEES, R. 2012. Sugar confectionery and chocolate manufacture, Springer Science & Business Media. LI, Y.-R. & YANG, L.-T. 2015. Sugarcane agriculture and sugar industry in China. Sugar Tech, 17, 1-8. LINEBACK, D. R. & JONES, J. M. 2003. Sugars and health workshop: summary and conclusions. The American journal of clinical nutrition, 78, 893S-897S. LOUIE, J. C. Y. & TAPSELL, L. C. 2015. Association between intake of total vs added sugar on diet quality: a systematic review. Nutrition reviews, 73, 837-857. LOWNDES, J., SINNETT, S., PARDO, S., NGUYEN, V. T., MELANSON, K. J., YU, Z., LOWTHER, B. E. & RIPPE, J. M. 2014. The effect of normally consumed amounts of sucrose or high fructose corn syrup on lipid profiles, body composition and related parameters in overweight/obese subjects. Nutrients, 6, 1128-1144. 75 University of Ghana http://ugspace.ug.edu.gh LUITSE, M. J., BIESSELS, G. J., RUTTEN, G. E. & KAPPELLE, L. J. 2012. Diabetes, hyperglycaemia, and acute ischaemic stroke. The Lancet Neurology, 11, 261-271. MA, J., FOX, C. S., JACQUES, P. F., SPELIOTES, E. K., HOFFMANN, U., SMITH, C. E., SALTZMAN, E. & MCKEOWN, N. M. 2015. Sugar-sweetened beverage, diet soda, and fatty liver disease in the Framingham Heart Study cohorts. Journal of hepatology, 63, 462-469. MA, S., KARKEE, M., SCHARF, P. A. & ZHANG, Q. 2014. Sugarcane harvester technology: a critical overview. Applied engineering in agriculture, 30, 727-739. MACDONALD, I. A. 2016. A review of recent evidence relating to sugars, insulin resistance and diabetes. European journal of nutrition, 55, 17-23. MACHADO DE-MELO, A. A., ALMEIDA-MURADIAN, L. B. D., SANCHO, M. T. & PASCUAL-MATÉ, A. 2018. Composition and properties of Apis mellifera honey: A review. Journal of Apicultural Research, 57, 5-37. MADERO, M., PEREZ-POZO, S. E., JALAL, D., JOHNSON, R. J. & SÁNCHEZ-LOZADA, L. G. 2011. Dietary fructose and hypertension. Current hypertension reports, 13, 29-35. MALIK, V. S. & HU, F. B. 2012. Sweeteners and risk of obesity and type 2 diabetes: the role of sugar-sweetened beverages. Current diabetes reports, 12, 195-203. MALIK, V. S., PAN, A., WILLETT, W. C. & HU, F. B. 2013a. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. The American journal of clinical nutrition, 98, 1084-1102. MALIK, V. S., POPKIN, B. M., BRAY, G. A., DESPRÉS, J.-P. & HU, F. B. 2010. Sugar- sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation, 121, 1356-1364. 76 University of Ghana http://ugspace.ug.edu.gh MALIK, V. S., WILLETT, W. C. & HU, F. B. 2013b. Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology, 9, 13-27. MANYI-LOH, C. E., CLARKE, A. M. & NDIP, N. 2011a. An overview of honey: therapeutic properties and contribution in nutrition and human health. African Journal of Microbiology Research, 5, 844-852. MANYI-LOH, C. E., CLARKE, A. M. & NDIP, R. N. 2011b. An overview of honey: Therapeutic properties and contribution in nutrition and human health. African Journal of Microbiology Research, 5, 844-852. MARRIOTT, B. P., OLSHO, L., HADDEN, L. & CONNOR, P. 2010. Intake of added sugars and selected nutrients in the United States, National Health and Nutrition Examination Survey (NHANES) 2003—2006. Critical reviews in food science and nutrition, 50, 228- 258. MARTIN, S. S., BLAHA, M. J., ELSHAZLY, M. B., TOTH, P. P., KWITEROVICH, P. O., BLUMENTHAL, R. S. & JONES, S. R. 2013. Comparison of a novel method vs the Friedewald equation for estimating low-density lipoprotein cholesterol levels from the standard lipid profile. Jama, 310, 2061-2068. MATHLOUTHI, M. & REISER, P. 2012. Sucrose: properties and applications, Springer Science & Business Media. MCGRATH, J. M. & FUGATE, K. K. 2012. Analysis of sucrose from sugar beet. Dietary Sugars. MEIER, T., GRÄFE, K., SENN, F., SUR, P., STANGL, G. I., DAWCZYNSKI, C., MÄRZ, W., KLEBER, M. E. & LORKOWSKI, S. 2019. Cardiovascular mortality attributable to dietary risk factors in 51 countries in the WHO European Region from 1990 to 2016: a 77 University of Ghana http://ugspace.ug.edu.gh systematic analysis of the Global Burden of Disease Study. European journal of epidemiology, 34, 37-55. MEO, S. A., ANSARI, M. J., SATTAR, K., CHAUDHARY, H. U., HAJJAR, W. & ALASIRI, S. 2017. Honey and diabetes mellitus: obstacles and challenges–road to be repaired. Saudi journal of biological sciences, 24, 1030-1033. MICHAUD, D. S., LIU, S., GIOVANNUCCI, E., WILLETT, W. C., COLDITZ, G. A. & FUCHS, C. S. 2002. Dietary sugar, glycemic load, and pancreatic cancer risk in a prospective study. Journal of the National Cancer Institute, 94, 1293-1300. MILLER, M., STONE, N. J., BALLANTYNE, C., BITTNER, V., CRIQUI, M. H., GINSBERG, H. N., GOLDBERG, A. C., HOWARD, W. J., JACOBSON, M. S. & KRIS- ETHERTON, P. M. 2011. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation, 123, 2292-2333. MOCUMBI, A. O. 2012. Lack of focus on cardiovascular disease in sub-Saharan Africa. Cardiovascular diagnosis and therapy, 2, 74. MOHAMMADIMANESH, A., VAHIDINIYA, A. A., DOAEI, S., GHOLAMALIZADEH, M., SHAHVEGHARASL, Z., SALEHI, I., FAYYAZ, N. & KHOSRAVI, H. M. 2019. The effect of different types of honey on the lipid profile of streptozotocin-induced diabetic rats. Archives of Medical sciences. Atherosclerotic Diseases, 4, e113. MOORADIAN, A. D., SMITH, M. & TOKUDA, M. 2017. The role of artificial and natural sweeteners in reducing the consumption of table sugar: A narrative review. Clinical nutrition ESPEN, 18, 1-8. 78 University of Ghana http://ugspace.ug.edu.gh MOORE, M. C., COATE, K. C., WINNICK, J. J., AN, Z. & CHERRINGTON, A. D. 2012. Regulation of hepatic glucose uptake and storage in vivo. Advances in nutrition, 3, 286- 294. MÜNSTEDT, K., HOFFMANN, S., HAUENSCHILD, A., BÜLTE, M., VON GEORGI, R. & HACKETHAL, A. 2009. Effect of honey on serum cholesterol and lipid values. Journal of medicinal food, 12, 624-628. NADKARNI, P., CHEPURNY, O. G. & HOLZ, G. G. 2014. Regulation of glucose homeostasis by GLP-1. Progress in molecular biology and translational science. Elsevier. NARAIN, A., KWOK, C. & MAMAS, M. 2016. Soft drinks and sweetened beverages and the risk of cardiovascular disease and mortality: a systematic review and meta‐analysis. International journal of clinical practice, 70, 791-805. NEMOSECK, T. M., CARMODY, E. G., FURCHNER-EVANSON, A., GLEASON, M., LI, A., POTTER, H., REZENDE, L. M., LANE, K. J. & KERN, M. 2011. Honey promotes lower weight gain, adiposity, and triglycerides than sucrose in rats. Nutrition research, 31, 55-60. NESTLE, M. 2013. Food politics: How the food industry influences nutrition and health, Univ of California Press. NEWENS, K. & WALTON, J. 2016. A review of sugar consumption from nationally representative dietary surveys across the world. Journal of Human Nutrition and Dietetics, 29, 225-240. NGUYEN, T. & LAU, D. C. 2012. The obesity epidemic and its impact on hypertension. Canadian Journal of Cardiology, 28, 326-333. 79 University of Ghana http://ugspace.ug.edu.gh NICHOLS, M., TOWNSEND, N., SCARBOROUGH, P. & RAYNER, M. 2013. Trends in age- specific coronary heart disease mortality in the European Union over three decades: 1980–2009. European heart journal, 34, 3017-3027. NICHOLS, M., TOWNSEND, N., SCARBOROUGH, P. & RAYNER, M. 2014. Cardiovascular disease in Europe 2014: epidemiological update. European heart journal, 35, 2950-2959. NORDESTGAARD, B. G. 2017. A test in context: lipid profile, fasting versus nonfasting. Journal of the American College of Cardiology, 70, 1637-1646. NORDESTGAARD, B. G., LANGSTED, A., MORA, S., KOLOVOU, G., BAUM, H., BRUCKERT, E., WATTS, G. F., SYPNIEWSKA, G., WIKLUND, O. & BORÉN, J. 2016. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points—a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. European heart journal, 37, 1944-1958. O'FLAHERTY, M., BUCHAN, I. & CAPEWELL, S. 2013. Contributions of treatment and lifestyle to declining CVD mortality: why have CVD mortality rates declined so much since the 1960s? Heart, 99, 159-162. OFORI-ASENSO, R. & GARCIA, D. 2016. Cardiovascular diseases in Ghana within the context of globalization. Cardiovascular diagnosis and therapy, 6, 67. OFORI-ASENSO , R. & OFEI, I. 2015. In Ghana a louder approach to a silent killer; Hypertension. OGUEJIOFOR, O., ONWUKWE, C. & ODENIGBO, C. 2012. Dyslipidemia in Nigeria: prevalence and pattern. Annals of African medicine, 11, 197. 80 University of Ghana http://ugspace.ug.edu.gh OLIVEIRA, A., ARAÚJO, J., SEVERO, M., CORREIA, D., RAMOS, E., TORRES, D., LOPES, C. & CONSORTIUM, I.-A. 2018. Prevalence of general and abdominal obesity in Portugal: Comprehensive results from the National Food, nutrition and physical activity survey 2015–2016. BMC public health, 18, 614. OMOTAYO, E. O., GURTU, S., SULAIMAN, S. A., WAHAB, M. S. A., SIRAJUDEEN, K. & SALLEH, M. S. M. 2010. Hypoglycemic and antioxidant effects of honey supplementation in streptozotocin-induced diabetic rats. International Journal for Vitamin and Nutrition Research, 80, 74. ORLANDI, R. D. M., VERRUMA-BERNARDI, M. R., SARTORIO, S. D. & BORGES, M. T. M. R. 2017. Physicochemical and Sensory Quality of Brown Sugar: Variables of Processing Study. Journal of Agricultural Science, 9, 115. PAN, A., MALIK, V. S., HAO, T., WILLETT, W. C., MOZAFFARIAN, D. & HU, F. B. 2013. Changes in water and beverage intake and long-term weight changes: results from three prospective cohort studies. International journal of obesity, 37, 1378. PANDA, H. 2011. The Complete Book on Sugarcane Processing and By-Products of Molasses (with Analysis of Sugar, Syrup and Molasses): How is sugar made from sugarcane?, How Sugar Cane Is Made, How sugar is made, How to Make Sugar from Sugar Cane, How to make sugar from sugarcane, How to manufacture sugar from sugarcane, How to start a successful Sugarcane processing business, How to start a Sugar manufacturing business, How to Start a Sugar Production Business, How to Start a Sugarcane processing?, How to Start and Make Profit from Sugar-Cane, How to start process of making sugar from sugarcane, ASIA PACIFIC BUSINESS PRESS Inc. 81 University of Ghana http://ugspace.ug.edu.gh PANDIRI, A. R. 2014. Overview of exocrine pancreatic pathobiology. Toxicologic pathology, 42, 207-216. PANDOL, S. J. 2011. The Exocrine Pancreas, Morgan & Claypool. PICHÉ, M.-E., POIRIER, P., LEMIEUX, I. & DESPRÉS, J.-P. 2018. Overview of epidemiology and contribution of obesity and body fat distribution to cardiovascular disease: an update. Progress in cardiovascular diseases, 61, 103-113. PIGMAN, W. 2012. The Carbohydrates: Chemistry and Biochemistry Physiology, Elsevier. PRIYA, K., GUPTA, V. R. M. & SRIKANTH, K. 2011. Natural sweeteners: A complete review. J. Pharm. Res, 4, 2034-2039. QI, L., DING, X., TANG, W., LI, Q., MAO, D. & WANG, Y. 2015. Prevalence and risk factors associated with dyslipidemia in Chongqing, China. International journal of environmental research and public health, 12, 13455-13465. RASAD, H., ENTEZARI, M. H., GHADIRI, E., MAHAKI, B. & PAHLAVANI, N. 2018. The effect of honey consumption compared with sucrose on lipid profile in young healthy subjects (randomized clinical trial). Clinical nutrition ESPEN, 26, 8-12. RAY, B. & BHUNIA, A. 2013. Fundamental food microbiology, CRC press. REIGER, S., JARDIM, T. V., ABRAHAMS-GESSEL, S., CROWTHER, N. J., WADE, A., GOMEZ-OLIVE, F. X., SALOMON, J., TOLLMAN, S. & GAZIANO, T. A. 2017. Awareness, treatment, and control of dyslipidemia in rural South Africa: The HAALSI (Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study. PloS one, 12, e0187347. REIN, P. 2016. Cane sugar engineering, Verlag Dr. Albert Bartens KG. RIPPE, J. M. 2014. Fructose, high fructose corn syrup, sucrose and health, Springer. 82 University of Ghana http://ugspace.ug.edu.gh RIPPE, J. M. & ANGELOPOULOS, T. J. 2013. Sucrose, high-fructose corn syrup, and fructose, their metabolism and potential health effects: what do we really know? : Oxford University Press. RIPPE, J. M. & ANGELOPOULOS, T. J. 2016. Relationship between added sugars consumption and chronic disease risk factors: Current understanding. Nutrients, 8, 697. RÖDER, P. V., WU, B., LIU, Y. & HAN, W. 2016. Pancreatic regulation of glucose homeostasis. Experimental & molecular medicine, 48, e219-e219. RODRÍGUEZ-ENTRENA, M., SALAZAR-ORDÓÑEZ, M., CORDÓN-PEDREGOSA, R. & CARDENAS, J. L. 2016. Analysing granulated brown sugar–panela–market in Western Honduras. British Food Journal. RODWELL, V. W., BENDER, D. A., BOTHAM, K. M., KENNELLY, P. J. & WEIL, P. A. 2015. Harper's illustrated biochemistry, McGraw-Hill Education. ROGERS, P., HOGENKAMP, P., DE GRAAF, C., HIGGS, S., LLUCH, A., NESS, A., PENFOLD, C., PERRY, R., PUTZ, P. & YEOMANS, M. 2016. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies. International Journal of Obesity, 40, 381. ROMAN, A., POPIELA-PLEBAN, E., KOZAK, M. & ROMAN, K. 2013. Factors influencing consumer behavior relating to the purchase of honey part 2. Product quality and packaging. Journal of Apicultural Science, 57, 175-185. ROTH, G. A., FOROUZANFAR, M. H., MORAN, A. E., BARBER, R., NGUYEN, G., FEIGIN, V. L., NAGHAVI, M., MENSAH, G. A. & MURRAY, C. J. 2015a. 83 University of Ghana http://ugspace.ug.edu.gh Demographic and epidemiologic drivers of global cardiovascular mortality. New England Journal of Medicine, 372, 1333-1341. ROTH, G. A., HUFFMAN, M. D., MORAN, A. E., FEIGIN, V., MENSAH, G. A., NAGHAVI, M. & MURRAY, C. J. 2015b. Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation, 132, 1667-1678. RUAN, Y.-L. 2014. Sucrose metabolism: gateway to diverse carbon use and sugar signaling. Annual review of plant biology, 65, 33-67. RUTTER, H. 2018. The Obesity Problem and its Relationship. Core Topics in Anaesthesia and Perioperative Care of the Morbidly Obese Surgical Patient, 1. SACKS, D. B. 2011. A1C versus glucose testing: a comparison. Diabetes care, 34, 518-523. SAEEDI, P., PETERSOHN, I., SALPEA, P., MALANDA, B., KARURANGA, S., UNWIN, N., COLAGIURI, S., GUARIGUATA, L., MOTALA, A. A. & OGURTSOVA, K. 2019. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice, 157, 107843. SARAVANAN, G., PONMURUGAN, P., DEEPA, M. A. & SENTHILKUMAR, B. 2014. Anti‐ obesity action of gingerol: effect on lipid profile, insulin, leptin, amylase and lipase in male obese rats induced by a high‐fat diet. Journal of the Science of Food and Agriculture, 94, 2972-2977. SCHNEIDER, M., COYLE, S., WARNOCK, M., GOW, I. & FYFE, L. 2013. Anti‐microbial activity and composition of manuka and portobello honey. Phytotherapy Research, 27, 1162-1168. 84 University of Ghana http://ugspace.ug.edu.gh SCHOFIELD, J. D., LIU, Y., RAO-BALAKRISHNA, P., MALIK, R. A. & SORAN, H. 2016. Diabetes dyslipidemia. Diabetes Therapy, 7, 203-219. SEETAL, P. 2010. Sugar: the irreplaceable truth: dietician's column. South African Food Review, 37, 47-47. SEIDELL, J. C. & HALBERSTADT, J. 2015. The global burden of obesity and the challenges of prevention. Annals of Nutrition and Metabolism, 66, 7-12. SHERWANI, S. I., KHAN, H. A., EKHZAIMY, A., MASOOD, A. & SAKHARKAR, M. K. 2016. Significance of HbA1c test in diagnosis and prognosis of diabetic patients. Biomarker insights, 11, BMI. S38440. SINGH, A., LAL, U. R., MUKHTAR, H. M., SINGH, P. S., SHAH, G. & DHAWAN, R. K. 2015. Phytochemical profile of sugarcane and its potential health aspects. Pharmacognosy reviews, 9, 45. SIRI-TARINO, P. W. 2011. Effects of diet on high-density lipoprotein cholesterol. Current atherosclerosis reports, 13, 453-460. SONESTEDT, E., ØVERBY, N., LAAKSONEN, D. & EVA BIRGISDOTTIR, B. 2012. Does high sugar consumption exacerbate cardiometabolic risk factors and increase the risk of type 2 diabetes and cardiovascular disease? Food & nutrition research, 56, 19104. STANHOPE, K. L. 2012. Role of fructose-containing sugars in the epidemics of obesity and metabolic syndrome. Annual review of medicine, 63, 329-343. STANHOPE, K. L. 2016. Sugar consumption, metabolic disease and obesity: The state of the controversy. Critical reviews in clinical laboratory sciences, 53, 52-67. 85 University of Ghana http://ugspace.ug.edu.gh STEINER-ASIEDU, M., ADDO, P., BEDIAKO-AMOA, B., FIADJOE, F. Y. & ANDERSON, A. K. 2012. Lifestyle and nutrition profile of overweight and obese school children in the Ga-East District of Ghana. Asian Journal of Medical Sciences, 4, 99-104. STIEGER, M. & VAN DE VELDE, F. 2013. Microstructure, texture and oral processing: New ways to reduce sugar and salt in foods. Current opinion in colloid & interface science, 18, 334-348. SUN, S. Z. & EMPIE, M. W. 2012. Fructose metabolism in humans–what isotopic tracer studies tell us. Nutrition & metabolism, 9, 89. SUTTIE, A. W., LEININGER, J. R. & BRADLEY, A. E. 2017. Boorman's Pathology of the Rat: Reference and Atlas, Elsevier Science. SWARNA NANTHA, Y. 2014. Addiction to sugar and its link to health morbidity: a primer for newer primary care and public health initiatives in Malaysia. Journal of Primary Care & Community Health, 5, 263-270. SWINBURN, B. A., SACKS, G., HALL, K. D., MCPHERSON, K., FINEGOOD, D. T., MOODIE, M. L. & GORTMAKER, S. L. 2011. The global obesity pandemic: shaped by global drivers and local environments. The Lancet, 378, 804-814. SYROVAYA, A. O., PETYUNINA, V. N., MAKAROV, V. A., ANDREEVA, S. V., LUKIANOVA, L. V., KOZUB, S. N., TISHAKOVA, T. S., LEVASHOVA, O. L., SAVELIEVA, E. V. & CHALENKO, N. N. 2018. Carbohydrates: monosaccharides. Structure and functions of di-and polysaccharides. ХНМУ. TAPPY, L. & LÊ, K.-A. 2010. Metabolic effects of fructose and the worldwide increase in obesity. Physiological reviews, 90, 23-46. 86 University of Ghana http://ugspace.ug.edu.gh TAPPY, L., LÊ, K. A., TRAN, C. & PAQUOT, N. 2010. Fructose and metabolic diseases: new findings, new questions. Nutrition, 26, 1044-1049. TE MORENGA, L., MALLARD, S. & MANN, J. 2013. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. Bmj, 346, e7492. TE MORENGA, L. A., HOWATSON, A. J., JONES, R. M. & MANN, J. 2014. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. The American journal of clinical nutrition, 100, 65-79. TERAMOTO, T., SASAKI, J., ISHIBASHI, S., BIROU, S., DAIDA, H., DOHI, S., EGUSA, G., HIRO, T., HIROBE, K. & IIDA, M. 2013. Diagnostic criteria for dyslipidemia. Journal of atherosclerosis and thrombosis, 17152. TSUGANE, S. & INOUE, M. 2010. Insulin resistance and cancer: epidemiological evidence. Cancer science, 101, 1073-1079. TULP, O. L., OBIDI, O. F., OYESILE, T. C. & EINSTEIN, G. P. 2018. The prevalence of adult obesity in Africa: A meta-analysis. Gene Reports, 11, 124-126. USDA 2017. Dietary guidelines for Americans 2015-2020, Skyhorse Publishing Inc. USDA 2020. Sugar: World Markets and Trade. United States Department of Agriculture, Foreign Agricultural Service VALLI, V., GÓMEZ-CARAVACA, A. M., DI NUNZIO, M., DANESI, F., CABONI, M. F. & BORDONI, A. 2012. Sugar cane and sugar beet molasses, antioxidant-rich alternatives to refined sugar. Journal of agricultural and food chemistry, 60, 12508-12515. 87 University of Ghana http://ugspace.ug.edu.gh VAN BUUL, V. J., TAPPY, L. & BROUNS, F. J. 2014. Misconceptions about fructose- containing sugars and their role in the obesity epidemic. Nutrition research reviews, 27, 119-130. VIJAYAKUMAR, P., NELSON, R. G., HANSON, R. L., KNOWLER, W. C. & SINHA, M. 2017. HbA1c and the prediction of type 2 diabetes in children and adults. Diabetes Care, 40, 16-21. VOS, M. B., KAAR, J. L., WELSH, J. A., VAN HORN, L. V., FEIG, D. I., ANDERSON, C. A., PATEL, M. J., CRUZ MUNOS, J., KREBS, N. F. & XANTHAKOS, S. A. 2017. Added sugars and cardiovascular disease risk in children: a scientific statement from the American Heart Association. Circulation, 135, e1017-e1034. WALTHER, T. C. & FARESE JR, R. V. 2012. Lipid droplets and cellular lipid metabolism. Annual review of biochemistry, 81, 687-714. WANG, D. D., SIEVENPIPER, J. L., DE SOUZA, R. J., COZMA, A. I., CHIAVAROLI, L., HA, V., MIRRAHIMI, A., CARLETON, A. J., DI BUONO, M. & JENKINS, A. L. 2014. Effect of fructose on postprandial triglycerides: a systematic review and meta- analysis of controlled feeding trials. Atherosclerosis, 232, 125-133. WELSH, J. A., SHARMA, A., CUNNINGHAM, S. A. & VOS, M. B. 2011. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation, 123, 249-257. WHF 2018. World Heart Federation Statement Provisional agenda item 12.6 The Global Strategy on Diet, Physical Activity and Health. WHITE, J. S. 2013. Challenging the Fructose Hypothesis: New Perspectives on Fructose Consumption and Metabolism–. Oxford University Press. 88 University of Ghana http://ugspace.ug.edu.gh WHITE, J. S. 2014. Sucrose, HFCS, and fructose: history, manufacture, composition, applications, and production. Fructose, high fructose corn syrup, sucrose and health. Springer. WHO 2013. Cardiovascular Diseases (CVDs), Fact Sheet. WHO 2015. Guideline: sugars intake for adults and children, World Health Organization. WHO 2016a. Global report on diabetes, World Health Organization. WHO 2016b. Global report on diabetes: executive summary. World Health Organization. WHO 2016c. Risk of premature death from target NCDs Data by Country. WHO 2017a. Cardiovascular Diseases (CVDs), Factsheet. WHO 2017b. Chronic Diseases: A vital Investment. WHO 2017c. Deaths from Cardiovascular Diseases and Diabetes. WHO 2020. Obesity is defined by the World Health Organization as an excessive fat build-up which affects health. WHO- overweight and obesity Report. WILKINS, E., WILSON, L., WICKRAMASINGHE, K., BHATNAGAR, P., LEAL, J., LUENGO-FERNANDEZ, R., BURNS, R., RAYNER, M. & TOWNSEND, N. 2017. European cardiovascular disease statistics 2017. WU, B. U., JOHANNES, R. S., SUN, X., TABAK, Y., CONWELL, D. L. & BANKS, P. A. 2008. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut, 57, 1698-1703. XI, B., HUANG, Y., REILLY, K. H., LI, S., ZHENG, R., BARRIO-LOPEZ, M. T., MARTINEZ-GONZALEZ, M. A. & ZHOU, D. 2015. Sugar-sweetened beverages and risk of hypertension and CVD: a dose–response meta-analysis. British Journal of Nutrition, 113, 709-717. 89 University of Ghana http://ugspace.ug.edu.gh YALPANI, M. 2013. Polysaccharides: syntheses, modifications and structure/property relations, Elsevier. YANG, L., SHEN, S.-Y., WANG, Z.-N., YANG, T., GUO, J.-W., HU, R.-Y., LI, Y.-F., BURNER, D. M. & YING, X.-M. 2020. New Value-Added Sugar and Brown Sugar Products from Sugarcane: A Commercial Approach. Sugar Tech, 1-5. YANG, Q., ZHANG, Z., GREGG, E. W., FLANDERS, W. D., MERRITT, R. & HU, F. B. 2014. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA internal medicine, 174, 516-524. YU, Z., LEY, S. H., SUN, Q., HU, F. B. & MALIK, V. S. 2018. Cross-sectional association between sugar-sweetened beverage intake and cardiometabolic biomarkers in US women. British Journal of Nutrition, 119, 570-580. ZABED, H., FARUQ, G., SAHU, J. N., AZIRUN, M. S., HASHIM, R. & NASRULHAQ BOYCE, A. 2014. Bioethanol production from fermentable sugar juice. The Scientific World Journal, 2014. ZHANG, Y. H., AN, T., ZHANG, R. C., ZHOU, Q., HUANG, Y. & ZHANG, J. 2013. Very high fructose intake increases serum LDL-cholesterol and total cholesterol: a meta- analysis of controlled feeding trials. The Journal of nutrition, 143, 1391-1398. ZYAAMBO, C., BABANIYI, O., SONGOLO, P., MUULA, A. S., RUDATSIKIRA, E., MUKONKA, V. M. & SIZIYA, S. 2012. Prevalence and Determinants for Overweight and Obesity among Residents of a Mining Township in Kitwe, Zambia, in 2011: A population-based Survey. 90 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX A Calculation of Animal Equivalent Dose of Honey Recommended human dose = 53.19 g Average human weight = 70 kg Dose = 53.19 g/70 kg = 0.76 g/kg Animal weight = 200 g = 0.2 kg Animal equivalent dose = 0.2 kg x 0.76 g/kg = 0.152 g/kg High animal dose = 0.152 g/kg x 2 = 0.304 g/kg Low animal dose = 0.152 g/kg /2 = 0.076 g/kg Calculation of Animal Equivalent Dose of Brown Sugar Recommended human dose = 40.11 g Average human weight = 70 kg Dose = 40.11 g/70 kg = 0.573 g/kg Animal weight = 200 g = 0.2 kg Animal equivalent dose = 0.2 kg x 0.573 g/kg = 0.115 g/kg High animal dose = 0.115 g/kg x 2 = 0.229 g/kg Low animal dose = 0.115 g/kg /2 = 0.057 g/kg 91 University of Ghana http://ugspace.ug.edu.gh Calculation of Animal Equivalent Dose of White Sugar Recommended human dose = 38.64 g Average human weight = 70 kg Dose = 38.64 g/70 kg = 0.552 g/kg Animal weight = 200 g = 0.2 kg Animal equivalent dose = 0.2 kg x 0.552 g/kg = 0.110 g/kg High animal dose = 0.110 g/kg x 2 = 0.220 g/kg Low animal dose = 0.110 g/kg /2 = 0.055 g/kg APPENDIX B COLLECTION OF BLOOD FOR BIOCHEMICAL ANALYSIS (CARDIAC PUNCTURE) Rats were anaesthetized by ether inhalation until consciousness was lost. A 2 ml syringe was fixed to a 23G × 1” hypodermic needle was inserted into the left ventricle by moving about 1 cm superiorly above the xiphisternum and 1 cm laterally to the left and into the 5th intercostal space. The plunger of the syringe was drawn back to collect about 4 ml of blood into various sample bottles. 92 University of Ghana http://ugspace.ug.edu.gh APPENDIX C PREPARATION OF 10% BUFFERED FORMALDEHYDE PH 7.26 10% buffered formaldehyde, pH 7.26 Formalin (37 - 40% w/v - BDH, England) ……….……….100 mL Distilled water……………………………………………. 900 mL Sodium hydrogen orthophosphate (NaH2PO4) ….…………….4g Disodium hydrogen orthophosphate (Na2HPO4) …………….6.5g Apparatus and equipment Electronic balance (Mettler CH – 8606) 1000 mL flask Magnetic stirrer pH meter (Philips, PW9418) Conical flasks and beakers Plastic weighing container Measuring cylinder PROTOCOL FOR PERIODIC ACID SCHIFF STAINING With the aid of Leica Auto Sectioner XL with the following programmed methods, the paraffin embedded pancreatic blocks were sections at 5 micrometre prior to PAS staining for histomorphometry. Staining Technique 93 University of Ghana http://ugspace.ug.edu.gh De-wax sections in xylene for 1 minute. Bring tissue sections down to water, rinse in distilled water Apply periodic acid for 5 minutes and rinse with distilled water Apply Schiff reagent for 20-30 minutes Wash under running water for 10 minutes Counter stain in haematoxylin for 15 minutes. Wash in water for 2-3minutes Blue under running water Dehydrate in graded series of alcohol, clear in xylene for subsequent mounting with DPX APPENDIX D PROTOCOL FOR TISSUE PROCESSING Rinse tissue in ice-cold PBS and weigh before homogenization Mince the tissues to small pieces and homogenize Sonicate the resulting suspension till the solution is clarified Centrifuged the homogenate for 5 minutes at 10,000×g. Collect the supernates and assay immediately ASSAY PROCEDURE Add 50μL standard or sample to each well. Add 50μL prepared Detection Reagent A immediately. 94 University of Ghana http://ugspace.ug.edu.gh Shake and mix. Incubate 1 hour at 37°C; Aspirate and wash 3 times Add 100μL prepared Detection Reagent B. Incubate 30 minutes at 37°C Aspirate and wash 5 times Add 90μL Substrate Solution. Incubate 10-20 minutes at 37°C Add 50μL Stop Solution. Read at 450 nm immediately 95