How Sugar Consumption Promotes Thickened Fascia

With our national per-capita sugar consumption continuing its upward trend (another 10 percent increase over the past few years), we will look briefly at new studies on how sugar consumption promotes thickened fascia and affects other connective tissues. Before we get going on fascia itself, I want to quickly discuss two recent bone studies simply because of the increasingly popular hypothesis that bone is calcified fascia.

First, realize that bone actually creates hormones “whose influence goes way beyond its own physiology” (Bone Regulation of Insulin Secretion and Glucose Homeostasis from last October’s issue of Endocrinology). Furthermore:

“The risk of fragility fracture increases for people with type 2 diabetes mellitus (T2DM), even after controlling for bone mineral density, body mass index, visual impairment, and falls. … In summary, worsening glycemic control was associated with … degraded macroscale skeletal integrity. These data are the first evidence of progressive alteration of bone tissue composition with worsening glycemic control in humans.”

In other words, blood sugar dysregulation is going to affect bones.

How Does Sugar Consumption Promote Thickened Fascia?

Although sugar is both highly acidic and highly inflammatory, its propensity to result in AGES (Advanced Glycation Endproducts) is the biggest culprit in the thickening and subsequent stiffening of connective tissues.

The June 2019 issue of the Journal of Medical Ultrasound (Sonographic Evaluation of the Achilles Tendon and Plantar Fascia of Type 2 Diabetics) helped confirm this yet again with these conclusions. After comparing the relative thicknesses of the tendons in both diabetics and non-diabetics that were matched for both age and sex, the authors concluded (I included quite a bit here, even though it is cherry-picked).

Study Suggests Connection Between Sugar Consumption and Thickened Fascia

“Diabetes mellitus (DM) is an endocrine disease with a prevalence of 5.1% worldwide… Diabetic neuropathy occurs in 50% of individuals with long-standing DM. Plantar ulcers are characterized by the triad of neuropathy, infection, and ischemia; also known complications of DM. The global incidence of DM foot is estimated to be 15%, and 12%–24% of individuals with diabetic foot ulcers require amputation. Amputation risks in diabetic patients are about 15–40 times higher than in nondiabetic patients, and the risk of lower extremity amputation increases by a factor of 8 once an ulcer develops.

“DM predisposes to plantar fasciopathy, a disorder characterized by thickened plantar fascia (PF), and loss of the normal organized fascial architecture. PF is one of those tissues that may change their physiology and biomechanical function in the presence of chronic hyperglycemia. Studies have revealed that the PF actively contributes to influence the pressure acting on the metatarsal heads.

“The pathophysiology of the plantar fascia and Achilles tendon in DM can be summarized as running the following course: sustained hyperglycemia promotes increased glycosylation of proteins, resulting in accumulation of “advanced glycosylation end products” in patient’s soft tissue and in thickening and vascularization of the affected tissues. Increased Achilles tendon thickness and plantar fascia thickening in DM have been considered an expression of soft-tissue damages.

“Among the diabetics, 46.3% had normal BMI, 32.4% were overweight, and 21.3% were obese. The Achilles tendon and plantar fascia of diabetics are significantly thicker [than non-diabetics]. The presence of diabetic neuropathy worsens the thickness of the Achilles and plantar fascia among diabetics. BMI is significantly related to thickening of the Achilles and plantar fascia among apparently healthy controls but not in diabetics.”

What is “Skinny Fat?”

What sticks out to me most is not the conclusion itself (we all expected it), but the fact that almost 50 percent of all diabetics had a “normal BMI.” In other words, darn near half of all the diabetics in this study were not overweight—or at least did not appear so to the casual observer.

What this does is slam us in the face with the concept of “skinny fat” or something known in the medical community as MONW (Medically Obese, Normal Weight). These are the individuals who do not look at all overweight until you see them in minimal clothing or draw blood. Instead of having blood markers in line with what their bathroom scale is telling them, they appear to be obese—something I am seeing with great regularity in my clinic. This is similar to increasingly seeing high school kids diagnosed with type 2 diabetes. (I recently saw my first 8th grader who had been diagnosed.) As you can guess, this bodes poorly for future musculoskeletal health and one’s ability to exert oneself.

Diabetes, Sugar Consumption and Thickened Fascia

A recent issue of Endocrinology, Diabetes, and Metabolism (Fibro-proliferative Disorders and Diabetes: Understanding the Pathophysiologic Relationship Between Peyronie’s Disease, Dupuytren Disease, and Diabetes) hit us over the head with this relationship yet again—the relationship between blood sugar dysregulation and thickening of connective tissues.

In this case, the relationship is to “Peyronie’s disease and Dupuytren disease, fibroproliferative disorders of the tunica albuginea of the penis and fascia of the hand, respectively.” When we see the term fibro-proliferative, we must realize that the world’s #1 leading cause of death, fibrosis, is “proliferating.” In other words, there is a pathological increase of something known as the ECM or Extracellular Matrix.

“Fibrosis in people with diabetes can affect almost every organ in the body, including the heart, eyes, liver, kidney, skin, and vascular system. Many people with diabetes have arthropathies, such as thickened skin and limited mobility of the joints of the hands and fingers, leading to flexion contracture(s). Endocrinologists may overlook limited joint mobility in people with diabetes or may not consider it a diabetes‐related complication. Chronic hyperglycaemia due to diabetes mellitus can also lead to tissue injury and fibrosis. A meta‐analysis has shown a relationship between Dupuytren disease and diabetes.”

How Else Can We Address Thickened Fascia?

So, beyond some sort of low-carb approach to eating (I’m a fan of a Paleo/Keto mashup), the question in everyone’s mind should be whether or not bodywork has the potential to successfully address the thickening and increased density that occurs in damaged soft tissues, whatever the cause. Stay tuned!