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“Choose beverages and foods to moderate your intake of sugars”2000 Dietary Guidelines for Americans

• Rachel K. Johnson, PhD, MPH, RD

• Professor of Nutrition• Dean, College of

Agriculture and Life Sciences

• The University of Vermont

DRIs

Food and Nutrition Board

Dietary Reference Intakes

119-02

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What do the DRIs recommend for macronutrient distribution?

• Total fat – Children 1-3 30-40%– Children 4-18 25-35%– Adults 20-35%

• Protein intake– AMDR 10-35% of

total Kcals for adults• Carbohydrate

– AMDR 45-65% of total Kcals

Types of Carbohydrates

• Monosaccharides– Glucose, fructose, galactose

• Disaccharides and Oligosaccharides– Sucrose (table sugar, cane sugar, beet sugar)– Lactose (milk sugar)

• Polysaccharides – Indigestible (cellulose, hemicelluloses, pectins)– Partially digestible (inulin)– Digestible (dextrins, glycogen)

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Definitions - What is sugar?

• WHO 1997 Report on Carbohydrates in Human Nutrition– “sugars” - mono and disaccharides– “sugar” , “refined sugar”, “added sugar” - purified

sucrose– “extrinsic” sugars - added to foods– “intrinsic” sugars - occur within the cell walls of

plants– “nutritive sweeteners” - corn syrup, lactose, fruit

juice concentrates, crystalline fructose etc.

USDA Definition of Added Sugars

Added sugars are sugars that are eaten separately at the table or used as ingredients in processed or prepared foods, such as soft drinks, cakes, cookies, fruit drinks, and ice cream.

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Added Sugars

• White, brown, and raw sugar• High fructose corn syrups and corn syrup solids • Malt, corn, maple, and pancake syrups• Fructose sweetener and liquid fructose• Honey and molasses • Added sugars do not include naturally occurring

sugars such as lactose in milk or fructose in fruit.

Cleveland et al., Am J Clin Nutr 1997;65:1254S-1263S.

Added sugars consumption -Food supply data 1970 - 1996

• Added sugars consumption rose from 26 to 32 teaspoons/person/day

• Overall 23% increase in consumption

– Kantor LS, ERS/USDA - Report No. 772, 1998.

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Food Supply Data

Food consumption survey data - added sugars intake all persons > 2 years

USDA/CSFII 89-91 vs. 94-96

0

5

10

15

20

25

tsp/day % total kcal

89-9194-96

Krebs-Smith, J Nutr 2001;131:527S-535S.

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Food Guide PyramidAdded sugars - “use sparingly”

Calories Added sugar % total energy1,600 kcal 6 tsp. 6%2,200 kcal 12 tsp. 8.7%2,800 kcal 18 tsp. 10.3%

Davis & Saltos, USDA/ERS Bulletin No. 750, 1999.

Recommended vs. actual intakes of added sugars

0

5

10

15

20

25

tsp %kcal

Rec.Actual

• For a 2,000 calorie diet– Recommended intake

is approx. 11 tsp of added sugars, 8% of total calories

– Actual intake is 20.5 tsp, 15.7% of total calories

Krebs-Smith, J Nutr2001;131:527S-535S.

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33%

17%19%

10%

9%

5%4% 3%Soft DrinksSweets/candySweetened grainsFruit drinksMilk productsCerealsOther beveragesOther

Sources of added sugars in the U.S. diet

Guthrie & Morton, JADA 2000;100:43-48.

Nine foods and beverages account for 75% of the added sugars in the

American diet

• Soft drinks (33%)• Fruit drinks (10%)• Candy (5%)• Cakes (5%)• Ice cream (4%)

• Ready-to-eat cereal (4%)

• Sugar, honey (4%)• Cookies, brownies

(4%)• Syrups, toppings (4%)

–Krebs-Smith, J Nutr2001;131:527S-535S.

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SUGARS AND HEALTH

Dental cariesDyslipidemias

ObesityBone healthDiet Quality

Dental Caries and Sugars

• Quantity and frequency of consuming sugar is positively associated w/ dental caries.

• Caries occurrence is confounded by frequency of meals and snacks, oral hygiene, fluoride supplementation and fluoride toothpaste.

– Walker & Cleaton-Jones, Br Dent J 1992;172:7.

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Dyslipidemias and Sugars

• Hypertriacylglycerolemia (HPTG) is more extreme with monosaccharides intake, particularly fructose

• Purified diets induce HPTG more readily than diets higher in fiber when the CHO is derived from unprocessed whole foods.

• Parks & Hellerstein, Am J Clin Nutr 2000;71:412-433.

• Consumption of energy-dense, nutrient-poor foods inversely related to HDL cholesterol and positively related to serum homocysteine.

• Kant 2000, Am J Clin Nutr 2000;72:929-936.

Childhood obesity

• If we don’t effectively prevent and treat childhood obesity this may be the first generation of children who don’t live as long as their parents.

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Obesity in Children

0

3

6

9

12

15

18

1963-65,1966-70**

1971-74 1976-80 1988-94 1999-2000

perc

ent

6-11 year olds 12-19 year olds*Obese is defined by the 95th percentile of the sex-specific 2000 CDC BMI-for-age-growth charts.

**Data for 1966-70 is for adolescents ages 12-17.

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Americans’energy intake has increased

• Primarily due to ↑ CHO consumption– Anand & Basiotis, Nutr Insights, USDA 1998.

• ↑ energy intake for children & adolescents attributed to ↑ consumption of nondiet soft drinks– Morton & Guthrie, Fam Econ Nutr Rev 1998;11:44-57.

Children’s beverage consumption

0

50

100

150

200

250

300

350

Soft Drinks Fluid Milk Fruit Juice Fruit Drink

1977-781994-96

Grams

US Department of Agriculture

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Growing size of single-serving containers

Annual soft drink production in the U.S. (12 ounce cans per person)

source: National Soft Drink Association Beverage World

0

100

200

300

400

500

600

1947 1957 1967 1977 1987 1997

cans/person

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Sugar-sweetened drinks and childhood obesity

• Longitudinal cohort study of 548, 11-17 year old Massachusetts school children

• For each additional serving of sugar-sweetened drink, the odds of becoming obese increased by 60 percent– Ludwig et al., The Lancet 2001;357:505-508.

• Compensation for energy consumed as liquids may be less complete than for energy consumed as solid food– Mattes, Physiol Behav 1996l59:179-187.

The link between sugars and obesity is confounded by underreporting of food intake

• Underreporting is more prevalent and severe among the obese in comparison with the lean– Johnson RK, Nutr Today 2000;35:40-46.

• High sugar foods and beverages may be selectively underreported– Krebs-Smith et al., Eu J Clin Nutr 2000;54:281-287.

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Bone health and added sugars

• Maximizing peak bone mass is critical during adolescence when calcium accretion is the highest– Teegarden et al., Am J Clin Nutr 1999;69:1014-1017.

• Adolescent female’s daily intake of calcium should not be < 1300 mg to achieve maximal calcium retention– Jackman et al., Am J Clin Nutr 1997;66:327-333.

Daily Calcium Intakes for Females as a percent of the DRI

USDA/CSFII 1994-96

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Trends in milk and soft drink consumptionUS Food Review 1998

0

10

20

30

40

50

60

1940 1960 1980 2000

Gal

lons

per

cap

ita

Soft drinks

Milk

Bone Health

• Cola-type soft drinks have been negatively associated with bone mineral density and positively associated with fractures.

– Wyshak J, Adoles Med 1994;15:210-215.– Wyshak J, Arch Pediatr Adolesc Med 2000;154:610-613.– Petridou et al., Scand J Soc Med 1997;25:119-125.

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Added Sugars and Diet Quality

• CSFII 1994-96, Americans >2 yrs, n=14,704– high consumers of added sugars (>18% energy)

• lowest mean intakes of vitamins A, C, B12, folate, ca, phos, mg, & iron

• 60% or > did not meet their RDA for vit A, B6, E, ca, mg, &zinc

• ↓ intakes of grains, fruits, vegetables, meat, poultry & fish• ↑ intakes of soft drinks, fruit drinks, punches & ades, cakes,

cookies, milk desserts & candies

– Bowman, Fam Econ Nutr Rev 1999;12:31-38.

Diet quality and beverages

• Beverage choice can have an impact on the nutrient adequacy of children and adolescents– Milk

• positively associated with vitamin A and B12, folate, calcium, magnesium

– Ballew et al., Arch Pediatr Adolesc Med 2000;154:1148-1153.

• Only children with a source of milk in their diet met their calcium requirements

– Johnson et al., Child Nutr and Mngt,1998;2:95-100.

– Juice• positively associated with vitamin C, folate, and magnesium

– Ballew et al., Arch Pediatr Adolesc Med 2000;154:1148-1153.

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Diet Quality and Soft Drinks

• Children who are high consumers of soft drinks have lower intakes of – riboflavin, folate, vit A and C, ca and phos

• Harnack, J Am Diet Assoc 1999;99:436-461.

– Soft drinks negatively associated with vitamin A, calcium, and magnesium

• Ballew et al., Arch Pediatr Adolesc Med 2000;154:1148-1153.

• Women who meet their RDA for calcium– consume more milk, fruit, grains

– consume less nondiet soft drinks• Guthrie, Fam Econ Nutr Rev 1996;9:33-49.

Added sugarsDRI Recommendation

• A maximum intake of 25% or less of energy from added sugars is suggested

• Based on added sugar intake data combined with nutrient intake data

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

600

650700750800

850900

95010001050

Calcium, mg/day

0-5 5-10 10-15 15-20 20-25 25-30 30-35

% added sugars

**

Magnesium intake in children 4-8 Y as a function of added sugar intake

100

150

200

250

300

Magnesium, mg/day

0-5 5-10 10-15 15-20 20-25 25-30 30-35

% added sugars

* *

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Iron intake in children 4-8 Y as a function of added sugar intake

7

9

11

13

15

Iron, mg/day

0-5 5-10 10-15 15-20 20-25 25-30 30-35

% added sugars

*

Zinc intake in children 4-8 Y as a function of added sugar intake

4

6

8

10

Zinc, mg/day

0-5 5-10 10-15 15-20 20-25 25-30 30-35

% added sugars

**

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The unbalanced American diet

Petition to FDA to include added sugars on the food label

• 72 health experts and organizations petitioned FDA

• Asked FDA to adopt 10 teaspoons (40 gms) as the “Daily Value” for added sugars.

• Daily values are currently used to indicate the maximum recommended intakes of fat, sodium, and other nutrients.

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Glycemic Index

• Glycemic Response– Effect of carbohydrate-containing foods on blood

glucose concentration

• Glycemic Index– Classification to quantify the relative blood glucose

response to carbohydrate-containing foods

• Glycemic Load– Indicator of glucose response or insulin demand that is

induced by total carbohydrate intake.

Factors that reduce the rate of starch digestibility and the glycemic response

• Intrinsic– High amylose to

amylopectin ratio– Intact grain / large particle

size– Intact starch granules– Raw, ungelatinized or

unhydrated starch– Physical interaction with fat

or protein

• Extrinsic– Protective insoluble fiber

seed coat as in whole intact grains

– Viscous fibers– Raw foods (vs. cooked

foods) – Minimal food processing– Reduced ripeness in fruit

– Minimal (compared to extended) storage

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Factors that reduce the rate of starch digestibility and the glycemic response

• Type of sugar or starch in the food• Fiber content• Acidity• Ripeness (for fruits and vegetables)• Cooking and processing methods• Other food components (protein and fat)• Other foods that accompany it

Glycemic Index (GI) of common foodsWhite bread = 100

• White rice – 126• Baked potato – 121• Corn flakes – 119• Carrots – 101• Wheat bread – 99• Soft drink – 97• Spaghetti – 83• Corn - 78

• Banana – 76• Orange juice – 74• Orange – 62• All-Bran cereal – 60• Apple – 52• Skim milk – 46

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GI and the DRIs

• “Although there may be beneficial metabolic and disease prevention effects of consuming a greater proportion of carbohydrates from low GI sources, further studies are needed before general recommendations on this issue can be made for the general healthy population.”

GI and the DRIs

• “Although several lines of evidence suggest adverse effects of high GI carbohydrates, the critical mass of evidence necessary for recommending substantial dietary change is not available. However, the principle of slowing carbohydrate absorption, which may underpin the positive findings made in relation to GI, is a potentially important principal with respect to the beneficial health effects of carbohydrates.”

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Research Needs

Research needs

• Improved nutrient data bases for CHO analysis

• Consensus on appropriate statistical methods for analyzing food consumption data to identify nutrient displacement issues

• Is it useful to distinguish between “added” and “total” sugars?

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Research needs

• Test more effectively the association between intakes of sugars (both total and added) and BMI

• Elucidate the metabolic and long-term health differences resulting from the ingestion of high versus low GI carbohydrates using large, diverse samples and whole food diets.