box of various sugars
egal via iStockphoto

Patients with hepatitis C or other liver diseases often ask me what to eat, what to avoid, and how to be healthier. I'm asked, "Is sugar bad for the liver? What about stevia, agave, and coconut sugar? Is honey good for the liver?" In this article, I'll discuss sugar and its many forms.

Since hepatitis C is a liver disease, I'll start with some basic physiology and provide an explanation of the effects of sugar on the liver. The liver acts like the body's processing plant; everything goes through it -- whether you eat it, drink it, inhale it, or put it on your skin.

The Liver: Chief Metabolizer

One of the liver's main jobs is to aid in digestion and metabolize what we eat. The liver processes fats, proteins, and carbohydrates, turning these into energy and other necessary components to keep us alive and healthy. Our energy levels rely on the liver's ability to do its job.

Our primary source of energy comes from glucose. The liver acts as the body's glucose fuel tank and regulator, and helps to keep our circulating blood sugar steady and constant. The liver both stores and manufactures glucose depending upon the body's need.

The liver doesn't do this completely on its own -- it relies on insulin to guide it. After eating, blood glucose levels rise, which in people without diabetes triggers the pancreas to release insulin into the blood. Insulin signals the body to absorb glucose from the blood, which our cells use for energy.

When levels of glucose and insulin are high in the blood, the liver absorbs glucose and stores it as glycogen. The liver is like a silo for excess glucose. The liver dispenses this glucose when the body needs it. In people with diabetes, the liver doesn't process and produce glucose normally.

The Liver and Sugar

Sugar is a simple carbohydrate; it is composed of two molecules -- glucose and fructose. Glucose can be metabolized by every cell in the body and if we don't get it from the diet, our bodies have a complicated way to make it. Glucose is essential to life.

Fructose is different. The liver is the only organ that can metabolize sugar. If your liver has stored all the glycogen it needs, fructose will be converted into fat. This fat can be redirected as blood triglycerides, but most will be stored in the liver, and may cause fatty liver disease.

If you have hepatitis C, your liver is already working hard, so it won't like any additional work. Add in fatty liver disease and you have a formula for disaster.

What About Agave, Coconut Sugar, Honey, and Stevia?

I love honey, so I'm always looking for any medical reason to keep it in my diet. Unfortunately, honey is still sugar. The body doesn't like it any more than table sugar. However, since honey is sweeter than sugar, one may be able to use less, and in that way, it is slightly better. Some people believe that eating local honey may help allergy sufferers, but there isn't scientific data to support this. Also, the potential harm too much sugar can do outweighs any potential benefit of allergy relief.

The liver processes agave and coconut sugar just like any other sugar. From a manufacturing standpoint, these products are less processed. But from the liver's standpoint, it is better to skip agave, coconut sugar, honey, molasses, and maple syrup.

As for stevia, I don't know what to tell you. The Food and Drug Administration (FDA) declared stevia as "generally recognized as safe" (GRAS). Some experts have raised concerns. What disturbs me about stevia is that the products we get commercially have been processed. It isn't like we are in Paraguay sucking on stevia plants. I use stevia and honey sparingly.

The World Health Organization (WHO) set its added sugar intake recommendations to 5 percent of one's daily calorie intake.

Sugar Recommendations

Don't get me wrong, I am not a saint when it comes to sugar. I am careful about it, and I relish my small and infrequent treats. If I were facing execution, I'd dive in to vat of sugary baked goods. But, I don't want to hasten my death by diving in there now.

The World Health Organization (WHO) set its added sugar intake recommendations to 5 percent of one's daily calorie intake. For an adult of a normal body mass index (BMI), that works out to about 6 teaspoons (25 grams) of added sugar per day.

Here is how to calculate your maximum (Note that 4 grams of sugar = 1 teaspoon) Take 5 percent of daily calories, and divide by 4. Example: 5 percent of 2000 calories = 100 calories/4 = 25 gm/6tsp added sugar per day. So now you know the goal, how do you determine how much added sugar is in a product? That is the hard part.

The Hunt for Sugar

If you are adding a teaspoon of sugar to your coffee, you know how much added sugar is in that coffee. Do this six times a day and eat no more sugar, and you are within the WHO recommendations. However, what do you do when you are eating a prepared product?

In 2016, the FDA announced new guidelines for what appears on the Nutrition Facts Label for packaged foods. One of the changes is the addition of "added sugars" in grams and as percent Daily Value, will be included on the label. Scientific data shows that it is difficult to meet nutrient needs while staying within calorie limits if we consume more than 10 percent of our total daily calories from added sugar, and this is consistent with the 2015-2020 Dietary Guidelines for Americans.

Manufacturers with $10 million or more in annual food sales have until January 1, 2020 to comply; manufacturers with less than $10 million in annual food sales have until January 1, 2021. Some restaurants and fast food chains have been providing nutrition information.

If sugar is listed in the first five ingredients and sugar content is high on the label, the food is likely high in added sugar.

Although some food producers have voluntarily included the added sugar content, most haven't. However, most food labels do not differentiate between added sugar and natural occurring sugars, and the only way to identify sugar is by reading the ingredient list. If sugar is listed in the first five ingredients and sugar content is high on the label, the food is likely high in added sugar. Sugar has multiple names, listed below:

  • Agave nectar
  • Brown sugar
  • Cane crystals
  • Cane sugar
  • Coconut sugar
  • Corn sweetener
  • Corn syrup
  • Crystalline fructose
  • Dextrose
  • Evaporated cane juice
  • Fructose
  • Fruit juice concentrates
  • Glucose
  • High-fructose corn syrup (HFCS)
  • Honey
  • Invert sugar
  • Malt syrup
  • Maltose
  • Maple syrup
  • Molasses
  • Raw sugar
  • Sucrose

We all have our own bottom lines and you get to decide what yours are. Avoiding added sugar or at least limiting added sugar is a good bottom line if you can do it. Fruit has natural sweetness and can satisfy a longing for sweets. Try adding cinnamon, ginger, or vanilla to create a sweet flavor.

For years, I blamed my fatigue on hepatitis C, but after I eliminated sugar, I noticed my energy levels were higher. On the rare occasions I eat sugar, I feel exhausted later. I missed it at first, but not anymore. Feeling good is better than sugar tastes. And when I partake in something sweet, I enjoy every morsel.

Lucinda Porter, R.N., is a long-time contributor to the HCV Advocate and author of "Free From Hepatitis C" and "Hepatitis C One Step at a Time." She blogs at and

[Note from This article was originally published by HCV Advocate in Aug. 2018. We have cross-posted it with their permission.]