|Year : 2015 | Volume
| Issue : 1 | Page : 3-4
Reduce free sugars for a healthy life
Sanjay Kalra1, Bharti Kalra1, Yashdeep Gupta2
1 Consultant Endocrinology, Bharti Hospital, Haryana, India
2 Department of Medicine, Government Medical College and Hospital, Chandigarh, Punjab, India
|Date of Web Publication||5-Dec-2014|
Bharti Hospital, Kunjpura Road, Karnal 132 001, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kalra S, Kalra B, Gupta Y. Reduce free sugars for a healthy life
. J Med Nutr Nutraceut 2015;4:3-4
| World Health Organization Recommendations|| |
The World Health Organization (WHO) recently recommended a reduction in intake of sugars, for both adults and children, to maintain oral and metabolic health. The WHO strongly recommends that the intake of free sugars should not exceed 10% of total energy intake, and "conditionally recommends," or suggests, a further reduction to 5% of total energy.  For a 2000 calorie daily diet, this means that not more than 200, and preferably only 100 calories should come from free sugars. In everyday terms, this is equivalent to 50 g and 25 g, or 10 and 5 teaspoonfuls, respectively, of sugar, every day.
However, the term "free sugars" includes much more than the "visible" table sugar that we consume. This group of foods includes "monosaccharides and disaccharides added to food by the manufacturer, cook or consumer, and sugars naturally present in honey-syrups, fruit juices, and fruit concentration."  It does not include intrinsic sugars (sugars incorporated within the structure of intact fruits and vegetables), and sugars present in milk (lactose, galactose). This means that milk, fruits, and fresh fruit juice are not included in the definition of free sugars, but fruit concentrates, processed fruits, and sweetened milk and milk products are. Free sugars are also present in various processed food stuffs, such as sweetened beverages, "sweet" cereals and fruit-based snacks, and supposedly "salty" or savory items like tomato ketchup and noodles. For the record, products such as jaggery (gur) and palm sugar are included in the ambit of free sugars.
The WHO recommendations have been influenced by evidence relating free sugars intake to two medical conditions: Dental caries and obesity. Similar recommendations had been framed earlier (in 1989) by the WHO study group, and in 2002, by a joint WHO/Food and Agriculture Organization (FAO) expert consultation on diet, nutrition, and the prevention of chronic diseases.  The current recommendation takes a step further, or rather, leaps ahead, by suggesting a reduction of free sugars from 10% to 5% of total calories. 
This suggestion has been criticized by many for being impractical and antiindustry. The WHO recommendations, however, are based upon sound scientific evidence. The authors cite observational and epidemiological data, which link intake of free sugars with dental carries and obesity.
| Sugar Intake and Diabetes Prevalence|| |
As India grapples with obesity, and with related epidemics of diabetes and cardiovascular disease, one must consider the contribution of free sugars to these unwanted health conditions.
Recent analysis reveals a strong positive Pearson's correlation coefficient (0.599, P < 0.001) between prevalence of diabetes mellitus (DM) and per capita sugar consumption. While analyzing data from 165 countries, the study concluded that Asia had the high correlation coefficient (0.660; P < 0.001) among all continents.  Thus, the WHO recommendations hold particular relevance for India, and other developing Asian countries. Refined sugar promotes DM by leading to obesity and insulin resistance and the other possible mechanism is that the refined sugar, due to rapid intestinal absorption induces hyper-secretion of insulin from beta cells that subsequently lead to their exhaustion and sub-optimal secretion.  Over the last 30 years, attention has focused on saturated fat and salt as guilty parties. More recently, evidence suggests that excess sugar intake is more likely than either traditional factor to lead to atherosclerotic disease. Some researchers have also speculated that sugar is addictive, in a similar manner to caffeine and established drugs of abuse. 
| The Indian Perspective|| |
From the Indian viewpoint, the WHO recommendation could not have come sooner. India has always been concerned about its food security. The definition of food security, however, has changed over time. The world food summit in 1974, focused upon availability of adequate supplies of basic food stuffs. The FAO of the United Nations states that all people, at all times, (must) have physical, social, and economic access to sufficient, safe, and nutritious food that meet their dietary needs and food preferences for an active and healthy life."  This definition implies that food must be safe and nutritious, and must ensure a healthy life. In other words, unsafe food, or "nonnutritious" food, which promotes ill-health, is a threat to food security. Thus, excess free sugar availability, access, and utilization become threats to Indian health, as this worsens noncommunicable ill-health including dental caries, obesity, and diabetes.
India, in fact, is the largest consumer of the sugar world-wide, with a consumption equal to 2, 5 times that of the United States, and 1.7 times that of China. The per capita availability of sugar has risen in India over the past few decades. From 5 kg/year in 1960 to 1961, the annual per capita availability rose to 13 kg in 1990-1991, and to 19 kg in 2008-2009, before registering a slight decline to 17 kg in 2010-2011.  The three to four fold rise in sugar availability has been matched by a similar rise in the prevalence of diabetes. It must be noted that availability of cereals, pulses, and food grains in India has not shown a marked increase over the past half-century, while edible-oils, sugar, and eggs have.  A 17 kg consumption of sugar per year means an intake of 46.5 g/day, which is equal to nearly 10% of a 2000 calorie diet. Hence, India needs to reduce sugar content consumption, while increasing the availability of other nutritious food stuffs.
| From Thoughts to Words; Words to Action|| |
While experts may make appropriate recommendations, they will be useful only if they are implemented on the ground. Health care professionals and nutritionists should spearhead a campaign to improve awareness of current evidence related to sugar intake and health status. This should include knowledge of invisible free sugar content in commonly used food stuffs and of alternative food preparation with less sugar. Advocacy to label all processed foods with accurate nutritional information, including accurate amounts of free sugar, should be coupled with efforts to encourage production and consumption of foods with low-sugar concentration. Levying a tax on foods with high free sugar content, using visually disturbing images for negative reinforcement, and restricting access to such foods are options to be considered. These suggestions are similar to those used to curb consumption of tobacco and alcohol.  Certain measures, for example, New York City's law to ban availability of large sweetened carbonated beverages in schools, are noteworthy.
The Journal of Medical Nutrition and Nutraceuticals highlights the potential negative impact of excess sugar free sugar consumption on metabolic health, and tends the support to the WHO suggestion to reduce free sugar intake to 5% of total energy consumption. It welcomes practical suggestions from readers on strategies to achieve this target.
| References|| |
Draft Guideline: Sugars Intake for Adults and Children. Available from: http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en. [Last accessed on 2014 Apr 04].
The Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases: Process, Product and Policy Implications. Available from: http://www.who.int/nutrition/publications/public_health_nut9.pdf. [Last accessed on 2014 Jul 04].
Weeratunga P, Jayasinghe S, Perera Y, Jayasena G, Jayasinghe S. Per capita sugar consumption and prevalence of diabetes mellitus - Global and regional associations. BMC Public Health 2014;14:186.
Thornley S, Tayler R, Sikaris K. Sugar restriction: The evidence for a drug-free intervention to reduce cardiovascular disease risk. Intern Med J 2012;42 Suppl 5:46-58.
Kumar R, Bagaria N, Santra S. Food Security: Status and Concerns of India. Available from: http://www.mpra.ub.uni-muenchen.de/53286/1/MPRA_paper_53286.pdf. [Last accessed on 2014 Apr 04].
Kalra S, Gupta Y. Free sugars: The less the better. Lancet Diabetes Endocrinol 2014;2:452.