‘Limit foods and drinks with added sugar’:

the YES case

Boden Institute for Obesity, Nutrition, Exercise & Eating Disorders

Assoc Prof Tim Gill

Revision of the Dietary Guidelines for Australians - 2011

NHMRC statement on what the guidelines will recommend:

• Limit intake of foods and drinks containing saturated and trans fats; added salt; added sugars; and alcohol

Is sugar dangerous?

Is sugar dangerous?

No firm evidence directly linking sugar intake to:• Diabetes• Heart disease• Cancer

Evidence of harm of high intake of foods and drinks with added sugar

Reasonable evidence linking high sugar consumption (especially beverages) with:

• Weight gain and obesity• Nutrient dilution and insufficiency • Dental caries and erosion• Possibly bone health

Why should we restrict our intake of sugary foods and drinks ?

6

•What do we mean by the term added sugar?

•Is sugar dangerous? Or good for you?

•Do foods and drinks high in added sugar contribute to weight gain and will restricting them help us achieve energy balance ?

•Does a high added sugar intake impact negatively on nutrient adequacy and will restricting such foods better help achieve appropriate nutrient intakes?

•Does added sugar intake contribute to dental caries and will restriction help reduce the risk of caries?

Terminology Related to Carbohydrates

Sugars• The term "sugars" is conventionally used to

describe the mono and disaccharides."Sugar", • by contrast, is used to describe purified sucrose as

are the terms "refined sugar" and "added sugar"Intrinsic and extrinsic sugars• Intrinsic sugars occur within the cell walls of plants.• Extrinsic sugars were those which were usually

added to foods.

Can foods and drinks with added sugar be good for you ?

Suggestions that increasing sugar may:• encourage intake of nutritious unpalatable

foods and beverages• Reduce the intake of fat and thus achieve

better weight control

And that our sugar intake is already dropping so why the need to limit intake.

Change in Per capita supply of sugar in Australia (kg/capita/year)

Data from FAOstats

Sydney House prices are steady

Per capita consumption of sugar

Change in total sugar intake 1995-2007

1995 2007

1995

* P<0.05

Sugar-sweetened soft drinks consumptionChanges in energy contribution by sugar-sweetened soft drinks in 2007 Children's

Survey

1.7

2.3

2.9

3.9

0.5

0.9

1.9

2.6

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

2-3 4-7 8-11 12-15

NNS age groups (years)

En

erg

y c

on

trib

uti

on

(%

)

1995

2007

Rangan et al, 2010

Sugar-sweetened soft drinks: % consuming

* P<0.05Rangan et al, 2010

Sugar-sweetened soft drinks: per-consumer

* P<0.05 Rangan et al, 2010

Apparent Per capita consumption of sugar in Australia (kg/capita/year)

Source ABS 2000

What contributes added sugar in the diets of Australian children?

Nutrient sufficiency

• Does consuming more foods high in added sugars lead to better or worse nutrient intake?

Calcium intake in US children 4 8 Y as a ‐function of added sugar intake

US NHANES data

Relationship between added sugar intake and Zinc intake Children

Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey

Unpublished – Boden Institute

R2 = 0.5141

9.0

9.2

9.4

9.6

9.8

10.0

10.2

10.4

10.6

10.8

11.0

11.2

1 2 3 4 5 6 7 8 9 10

Age and sex specific deciles of added sugar intake

Zin

c (m

g)

Relationship between added sugar intake and Zinc intake Children

Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey

Unpublished – Boden Institute

R2 = 0.6582

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

1 2 3 4 5 6 7 8 9 10

Age and sex specific, energy adjusted deciles of added sugar intake

Zin

c (m

g)

Relationship between added sugar intake and fibre intake Children

R2 = 0.8336

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10

Age and sex specific, energy adjusted deciles of added sugar intake

Fib

re (

g)

Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey

Unpublished – Boden Institute

Relationship between added sugar intake and fibre intake Children

Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey

Unpublished – Boden Institute

Fibre

0.001.002.003.004.005.006.00

Q1 Q2 Q3 Q4

Age and sex specific energy adjusted quartile of added sugar intake

Ad

just

ed o

dd

s ra

tio

Relationship between added sugar and risk of nutrient insufficiency in Children

≥ 5 nutrients at risk

0.00

2.00

4.00

6.00

8.00

Q1 Q2 Q3 Q4

Age and sex specific energy adjusted quartile of added sugar intake

Ad

just

ed o

dd

s ra

tio

Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey

Unpublished – Boden Institute

≥ 7 nutrients at risk

0.001.002.003.004.005.006.00

Q1 Q2 Q3 Q4

Age and sex specific energy adjusted quartile of added sugar intake

Ad

just

ed o

dd

s ra

tio

Serve size Males |31-50 years

Females 31-50 years

Starchy vegetables 75g 7 5

Green & brassica vegetables 75g 7 7

Orange vegetables 75g 7 2

Legumes 75g 7 2

Nuts/seeds 30g 7 7

Other vegetables 75g 14 14

Fruit 150g 14 14

Wholegrain cereals/grains Equiv 40g bread 28 28

Refined cereals/grains* Equiv 40g bread 14 14

Meat and alts minus red Equiv 65g red meats

7 7

Red meats (beef, lamb, veal, pork) 65g 7 7

Dairy foods ** Equiv 250g milk 17 17

Additional category:‘Other foods

(600kJ equivalents)

7-14 3.5-7

Unsaturated fats and oils*** 10g 28 14

Consultation draft – Foundation and Total Diets 2010

Weekly food required to meet NRVsMen and women average height, moderate activity PAL 1.7

Sugar intake and weight control

The sugar- fat seesaw ??

Cross sectional data shows as the percentage of energy from sugar increases the percentage of energy from fat decreases - and vice versa

Raben et al, AJCN 2002

Can reducing sugar- reduce weight?

The effect of increasing fat and sugar as snacks

Mazlan et al, Br J Nut 2006

The effect of 0, 1·5 and 3·0MJ of sugar-rich or fat-rich mandatory snacks of identical energy density on energy intake ad libitum

Relationship between added sugar intake and total fat intake Children Children 2-16 2007 Australian National Children’s

Nutrition and Physical Activity Survey

Unpublished – Boden Institute

R2 = 0.9668

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10

Age and sex specific deciles of added sugar intake

To

tal f

at (

g)

Energy balance

• Energy Intake (food energy)carbohydrateProteinfat(alcohol)

vs• Energy expenditure

Basal metabolic rateThermic effect of foodExercise

The prevalence of overweight and obesity in men The prevalence of overweight and obesity in men and women in 2000 (National health Survey and women in 2000 (National health Survey

2007/08)2007/08)

25.6 24.0

42.1

30.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Males Females

2008

Pe

r c

en

t

Overweight but notobeseObese

obese maleoverweight maleobese femaleoverweight female

Report: Soft drinks, weight status and health

www.health.usyd.edu.au/panorg/research-themes/intervention/evidence-summaries.php

Evidence linking soft drinks to overweight

CPHN, Uni of Sydney 2009

Sugar and Dental Caries

Cost of dental caries in Australia

• Oral Health expenditure in Australia is the sixth highest health cost and accounted for 7% of total allocated health expenditure ($3.4 billion) (AIHW Australia’s health 2004).

• Despite declines in rates of caries - primarily dental caries and periodontal diseases - cost of the order of $1.5 billion per year

Aetiology of dental caries

Complex condition, range of contributing factors• Teeth surface structure• Quantity, PH and composition of Saliva• Dental hygiene• Fluoride• Fermentable carbohydrates

- frequency of consumption, form (stickiness) and amount of sugar

Special Role of sugar in dental caries

• Relationship between sugar intake and dental caries across the lifetime is strong- numerous reviews

• Sucrose is a particularly carcinogenic sugar because it can form glucan that enables firm bacterial adhesion to teeth and limits diffusion of acid and buffers in the plaque. - Tinnanoff and Palmer Public Health Dentistry 2000

• May be a dose-related effect of consumption of sucrose on caries development

Proposed relationships between sugar intake and caries

a- relationship pre-fluoride era

b. Relationship post-fluoride era

c. Linear relationship from country data

d- best case speculation of relationship in individual with good oral hygiene and fluoride exposure

Zero- Caries Res 2004

Dental Health Guidelines

Numerous national dental and health organisations make recommendations to restrict the intake of sugar rich foods and drinks

• Australian Dental Association• American Dental Association• British Dental Association

Is it appropriate for the Australian dietary Guidelines to recommend restricting food and drinks high in added sugars?

It would be totally inappropriate to allow unrestricted intake of foods and drinks with added sugar

Most countries have a dietary guideline restricting sugar intake

2007 Canadian Food Guide• – Limit foods and beverages high in calories, fat, sugar and salt.2000 Malaysian Dietary Guidelines• - Reduce sugar intake and choose foods low in sugar.2007 New Zealand Dietary Guidelines• Prepare foods or choose pre-prepared foods and snacks: with little

added sugar; limit your intake of high-sugar foods.2011 Singapore Dietary Guidelines • Choose beverages and food with less sugar2008 UK National Dietary Goals FSA• Sugars (added) - No more than 11% of food energy (currently at 12.7%)2010 Dietary Guidelines for Americans• Consume fewer foods with sodium (salt), saturated fats, trans fats,

cholesterol, added sugars, and refined grains

Thank You