Limit foods and drinks with Limit foods and drinks with added sugars?added sugars?

The case againstThe case against

Jennie Brand-MillerJennie Brand-MillerBoden Institute of Obesity, Nutrition, Exercise and Eating DisordersBoden Institute of Obesity, Nutrition, Exercise and Eating Disorders

The University of SydneyThe University of Sydney

If everyone is thinking alikeThen somebody isn’t thinking

George S. Patton

The dogma

Added sugars are ‘empty’ calories/kilojoules

Added sugars cause micronutrient deficiencies

Added sugars stimulate appetite

Added sugars make you fat

Cutting added sugars will cause weight loss

Reducing added sugars will prevent tooth decay

My focus

Added sugars make you fat

Cutting added sugars will cause weight loss

Honey in human diets

Allsop and Brand-Miller Brit J Nutr 1996

“Sugarbag”

“Intakes at various times during history may well have rivalled our current consumption of refined sugar”

A long history of bee-keeping

The Ancient Egyptians had a steady supply of honey from their domesticated bees

“Cylindrical hives were made of clay and stacked horizontally on top of each other in rows up to eight in height, a total of up to 500 hives”

From the tomb of Pabasa, 7th century BC

Energy density

188 kJ/100 g

218 kJ/100 g157 kJ/100 g

Rice Bubbles vs CocoPops have the same energy density and similar nutrient content

Replacing starch with sugar doesn’t alter energy densityAdded sugars have no impact on micronutrient density of breakfast cereals

Foods with added sugars are often highly nutritious

Other sources of empty calories

Beer

Wine and spirits

Refined starches

Maltodextrins

Gluten

Mostly empty calories…

Refined oils

Refined grains

white rice

Low fat, low sugar snacks

Crispbreads

Cakes and biscuits

Mozzafarian et al. NEJM 2011

“Several dietary metrics that are currently emphasized, such as fat content, energy density, and added sugars, would not have reliably identified the dietary factors that we found to be associated with long term weight gain”

Potato products had strongest link to weight gain

Mozzafarian et al. NEJM 2011

Sugar-sweetened beverages and weight gain

Soft drinks and fruit juices

Mozzafarian et al. NEJM 2011

Observational studies don’t prove causality,

merely an association

Randomised controlled trials RCTs are the

“gold standard”

Mark Pereira Int J Obesity 2006

“The equivocal evidence on this topic makes it difficult to draw firm conclusions regarding the role of SSB in the etiology of

obesity. Many of the prospective and experimental studies are of unsatisfactory methodological rigor”

Forshee et al. Am J Clin Nutr 2008

“The quantitative meta-analysis and qualitative review found that the association between sugar-sweetened

beverages and BMI was near zero, based on the current body of scientific evidence”

Forshee et al. Am J Clin Nutr 2008

Forshee’s meta-analysis of RCTs

Favours interventionFavours control

Van Baak and Astrup Obesity Reviews 2009

Observational studies suggest a possible relationship between sugar-sweetened beverages and body weight, but there is currently insufficient supporting evidence from RCT

of sufficient size and duration

Mattes et al. Obesity Reviews 2010

The current evidence does not demonstrate conclusively that nutritively sweetened beverages have uniquely

contributed to obesity or that reducing consumption will reduce BMI levels in general

Mattes’ forest plot of RCTsEffectiveness trials aimed at decreasing consumption

Mattes et al. Obesity Reviews 2011

“These results indicate that there is no statistically significant effect overall…it is unlikely that interventions of the types studied to date could produce more than 0.05 of a SD unit

lesser BMI change…”

Ebbeling et al. Pediatrics 2006; 117:673

RCT by Ebbeling et al. 2006n = 103 adolescents, parallel design 25 wk intervention,

achieved ~1000 kJ reduction in soft drink intake

BMI

No significant difference

Control group received no attention placebo

Change in BMI in each groupn = 103 adolescents, parallel design 25 wk intervention

Control group Intervention group

Baseline BMI

Ebbeling et al. Pediatrics 2006

Baseline BMI

NS

The Carmen Study393 adults, parallel design, ad libitum low fat diet,

6 mth intervention, most foods provided

Saris, Astrup, Raben et al. Int J Obesity 2000

weight

The Australian Paradox

The observation that Australians appear to have reduced their intake of added sugars but the prevalence of obesity continues to rise

But have we really reduced our intake of added sugars?

Barclay and Brand-Miller Nutrients 2011

Apparent consumption of refined sucrose

Source: Australian Sugar Industry

Apparent consumptionAll nutritive sweeteners

16% drop

Source: FAO, Statistics 2009

Global comparisons

Source: FAO Statistics, 2009

Soft drinks: nutritive vs ‘diet’

Drop = 64 million litres

Source: Australian Beverage Council Ltd and Dr Gina Levy (Food Logic, personal correspondence), September 2009

Children are drinking less soft drink, flavoured water & electrolyte drinks

% consuming Mean intake

Source: Analysis of the 2007 Children’s Nutrition and Physical Activity Survey undertaken for the Australian Beverages Council by Flinders University (unpublished data)

BMI vs added sugars intakeKids Eat, Kids Play 2007

Quintiles of added sugars intake

BMIZ-score

Jimmy Louie et al. unpublished data

My concern

Continuing emphasis on limiting added sugars may be counterproductive because added sugars are replaced

with undesirable nutrients

eg saturated fat, high GI starches, salt and alcohol

My take home messagesHumans have always had a concentrated source of sweetness

Sugar improves the palatability of nutritious, but bland foods

Australians have reduced their intake of added sugars yet obesity has increased

Meta-analyses of RCT consistently show no effect

There is some evidence that sugar-sweetened beverages, not total added sugars, is associated with adult weight gain

Dietary guidelines should be evidence-based

Limit sugary drinks and confectionery

Not foods with added sugars

Thanks for listening