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SUGARS IN GROWING UP MILK AND
ITS EFFECTS ON CHILDREN’S
HEALTH AND NUTRITION
This article appeared as a sponsored symposium highlights in the September/October 2011 issue of the JPOG
Sponsored Symposium Highlights
Sugars in growing up milk and its effects
on children’s health and nutrition
It is a growing concern that sugars and sugar-rich ingredients that give rise to sugars when digested, are increasingly being
added to growing-up milk formula products (GUMPs). In a recent symposium entitled “Facts About Sugars” which was
organized by the Malaysian Paediatric Association, three speakers addressed the issue of these added sugars.
Sugars and added sugars in food labelling
and disaccharides while the rest is dextrins. This composition
produces a sugar mixture that is neither too viscous nor
sweet, thus making it ideal to be easily incorporated into many
processed foods, including GUMPs.
Principal Scientist
New Zealand Institute for Plant and Food
Research Limited
New Zealand
Carbohydrate is an umbrella term that includes:
– monosaccharides (e.g. glucose, fructose and galactose)
– disaccharides (e.g. sucrose [table sugar] , lactose [milk sugar]
and maltose)
– oligosaccharides such as dextrins
– polysaccharides i.e. starch.
Figure 1
According to Dr John Monro of the New Zealand Institute
of Plant Research, the “carbohydrate” that is printed on the
nutrient information panels (NIP) of food products is available
carbohydrate, which may include available monosaccharides,
disaccharides, oligosaccharides, polysaccharides and mixtures
of them such as glucose syrup or corn syrup (Figure 1).
Corn syrup is industrially produced through a process of
chemical and enzymatic digestion of corn starch, where the
long chains of sugar units that make up starch are broken
down into shor ter chains and individual sugar units. A typical
composition of corn syrup is made up of 26% monosaccharides
Once consumed, the enzyme amylase that is present in the
human intestine rapidly breaks down dextrins into glucose,
which is then absorbed into the liver and stored as fats
or glycogen. In fact, regardless of the source of available
carbohydrate, whether it is derived from intact starch or corn
syrup, excess amylase in the gut ensures all starch and starch
fragments alike are quickly digested into glucose.1
Impact of added sugars in GUMPs
Added sugars in GUMPs often result in reduced protein levels,
thus diluting the nutritional value of the formulas. As shown
in Figure 2, in order to gain equal protein consumption across
products A (which has no added sugars), B and C (which
contain added sugars), the net carbohydrate intake from
products B and C is at least 3-4 times higher compared to
product A.
Figure 2
Dr John Monro
Dr Monro fur ther suggested that consumption of added sugars
in GUMPs in such large amounts may predispose the child to
develop a preference for sugary food, which can cause health
problems such as overweight and diabetes later in life.
Importance of consumer awareness
Lack of consumer awareness on the various terminologies used
to describe carbohydrates is often the cause of parents making
uninformed decision on GUMPs. One of the commonest
misconceptions is the term “sugars”. Commonly perceived
only as table sugar (sucrose), sugars in fact include glucose,
fructose and lactose, which may be added alone and therefore
identified in the ingredient list, or may be hidden within a
mixture such as corn syrup in which case they would not be
specifically identified in the ingredient list.
Available carbohydrates that are “oligosaccharide” and
“polysaccharide” have also been misrepresented as dietary
fibres, because dietary fibres also consist of oligo- and
polysaccharides. However, the big difference is that available
carbohydrate oligo- and polysaccharides are digestible, whereas
dietary fibre oligo- and polysaccharides are indigestible, by
definition, so they are nutritionally very different.
To conclude his talk, Dr Monro stressed that it is impor tant
that mothers are guided by the carbohydrate value in the NIP.
As a rule of thumb, the standard natural lactose present in
milk is 39 g per 100 g of powder or 10-12 g per serving size.
Hence any level above this indicates the presence of added
sugars. All available carbohydrates in GUMPs including sugars
and sugar-rich ingredients are declared as “Carbohydrate” in
the NIP, and thus serve as a guide to how much the body will
digest as glucose.
The importance of energy balance in children’s diet:
the role of sugars
maximum free sugars the child should consume per day is 7-8
teaspoons,” said Professor Davies.
Professor Peter SW Davies
Director
Children’s Nutrition Research Centre
Australia
Incidences of overweight and obesity are on the rise. A
World Health Organisation (WHO) repor t published in 2010
estimated that worldwide there were 43 million overweight
preschool children and 92 million were “at risk ” of being
overweight. 2 The same repor t also predicted that by the
year 2020, Asia will have a staggering 24.3 million overweight
children.
“Overweight and obesity are primarily the result of energy
balance disturbances,” said Professor Peter Davies, director of
the Children’s Nutrition Research Centre at the University of
Queensland, Australia. “If a person loses the ability to balance
energy intake and energy expenditure, body weight can be
lost or gained dramatically.” To put it simply, energy intake is
the summation of energy expenditure and changes in energy
stored. Disturbances that cause either increased energy
intake or decreased energy expenditure, either in isolation or
combined, will result in increased energy stored.
Carbohydrate as source of energy
According to WHO recommendations, nutrient intake
goals, expressed as percentages of total energy, are 15-30 %
of calories from fat, 10-15% from protein, 55-75% from
carbohydrate. Free sugars, which fall under the carbohydrate
category, should constitute less than 10 % of total calories.
“In more tangible terms, for a 3-4 year old child whose
energy requirement ranges between 1500-1600 kcal/day, the
The human body, unfor tunately, does not store carbohydrate
very well. At most, the body is only capable of storing about
450g or 1800 kcal of carbohydrate as glycogen, which is
equivalent to the energy expenditure of a 8-9 year old child.
Hence, there is a constant need for carbohydrates because
human cells utilize glucose as a major source of energy.
However, “since the human body is capable of digesting
complex carbohydrates into utilizable glucose, we really do not
want to be consuming those [carbohydrates] as added sugars,”
stressed Professor Davies.
To fur ther illustrate his point, he pointed out that 100 g
of banana has 47 kcal (11g) of carbohydrate, plus a host of
vitamins and minerals such as carotene, thiamine, vitamin C,
sodium and potassium. Similarly, 11 g of added sugars will give
44 kcal of pure energy, but no nutrients.
Energy balance equation: the energy expenditure side
While it is easy to consume large amounts of calories in a matter
of minutes, it is difficult to expend or use up that energy. For
example, the consumption of 500 kcal of added sugars would
require 111 minutes of cycling to use up that energy. In 2006,
Malik et al conducted a systematic review of 30 studies to look
at the relationship between sugar-sweetened beverages (SSB)
and weight gain. 3 The review found that SSB accounted for
almost 10 % of total calories consumed and more impor tantly,
there was a positive relationship linking consumed SSB to
obesity.
A study by Welsh et al looked at the same relationship in
preschool children, and found that in children who were
overweight or at risk for overweight, there was a significant
relationship between SSB and weight gain.4 “To put it simply, a
12 oz or 375 mL can of soda has 150 kcal and 40 g of sugars or
the equivalent of 10 teaspoons of sugar in one serving. If you
were to consume those extra calories without increasing your
energy expenditure to compensate for those extra calories,
you would be looking at an additional weight gain of 6-7 kilos
in a year, and that is from only one serving above requirements
per day,” said Professor Davies.
Watch what you eat
costs are low and it is relatively easy to produce, HFCS has
increasingly replaced sucrose in processed foods over the
years. Correspondingly, the propor tion of calories consumed
from these added sugars has also increased dramatically.
In conclusion, Professor Davies reiterated that trends suggest
overweight and obesity in preschool children are on the
increase. Parents can do something about this by following
recommended energy guidelines for complex carbohydrates
and keeping free sugar intake to less than 10 % of total energy.
Corn syrup or high fructose corn syrup (HFCS) was first
available in the United States in the late 1960s. Since production
Are Malaysian children taking too much sugars?
What are the health concerns?
Dr Muhammad Yazid Jalaludin
Paediatric Endocrinologist
Universiti Malaya Medical Centre
Malaysia
The US Depar tment of Agriculture (USDA) definition of added
sugars are all sugars used as added ingredients in processed
and prepared foods, including sugars that is eaten separately or
added to food at the table. According to Dr Muhammad Yazid
Jalaludin, a pediatric endocrinologist with University Malaya
Medical Centre, “chances are, we are consuming quite a bit of
fructose, in the form of refined sugars and HFCS, used in food
products as diverse as canned drinks, fruit juices to protein
bars.” This also means that growing up milk powders are not
spared as well.
Dangers of HFCS
“As the child grows, fructose that is present in diet can cause
fat cells in the body to mature into visceral fats which are
less sensitive to insulin.” According to Dr Muhammad Yazid,
fructose metabolism is more complex than most carbohydrates.
Once in the liver, its primary site of metabolism, fructose is
conver ted into triglycerides and very-low-density-lipoprotein
(VLDL), both of which can cause cells to be less sensitive to
insulin. As a result, there will be less glucose uptake from the
bloodstream into fat and muscles, thus increasing the risk for
diabetes.
Maria et al found that consumption of SSB increases childhood
obesity risk by 70 % . 5 Another study by Var tanian et al
revealed that added sugars in SSB not only increase risk of
overweight and obesity, but also risk factors for cardiovascular
disease such as diabetes, dyslipidaemia, high blood pressure
and non-alcoholic fatty liver disease. 6 The American Academy
of Pediatrics in 2006 recommended that consumption of
sweetened beverages such as fruit juices in children of ages
7-18 years old should not exceed 8-12 ounces per day. 7 In
practical terms, this comes up to just about 2 cups per day and
anything above this is not good for health.
Dr Muhammad Yazid noted that sugar intake among Malaysians
is well above WHO recommendations. “The average Malaysian
takes 10 teaspoons of sugar in their drinks per day, excluding
kuihs and desser ts. This is a worrying trend because about
30 % of our children are overweight/obese for reasons of high
consumption of sugary foods, not to mention tooth decay,” says
Dr Muhammad Yazid. As a result, in July 2010, the Ministry of
Health Malaysia has launched the “Stop at one ! Less is better”
campaign to urge Malaysians to consume less added sugars.
The growing problem of obesity
Worldwide, obesity is on the rise and Malaysia is not spared
as well. Several studies revealed that between the years of
1990 and 2000, the prevalence of overweight and obese
Malaysian children was estimated between 6 and 10 % . 8-10 This
prevalence rate has since jumped up to 26.5% in 2007/2008.11
It is believed that obesity is due to combined factors of
genetic predisposition and the environment. However, genetic
evolution alone cannot account for the dramatic rise of obesity
in the recent years, which means that environmental factors
such as excessive calorie intake and sedentary lifestyle are the
two main causes.
A local study by Dr Muhammad Yazid found that as high
as 90 % of rural, school-going Malaysian children consume
sugary beverages at a frequency of 3-5 times per day
(Figure 3). 12 The same study also noted that if these children
were breastfed in their early years, the tendency to become
obese is less. This finding concurred with Hediger, who
Added sugars, obesity and health impact
Figure 3
The trend of obesity is on the rise, and so is type 2 diabetes
mellitus (T2DM). The Malaysian National Health and Morbidity
Survey (NHMS) II and III done in 1996 and 2006 respectively,
found that in a span of 10 years, prevalence of diabetes in
adults above 30 years of age has almost doubled from 8.3% in
199617 to 14.9% in 2006.18 By 2025, the International Diabetes
Federation estimates that 14-20 % of Malaysians will have
diabetes.
Similarly, this trend is observed in children. In a study done
at his hospital, Dr Muhammad Yazid found that diabetes is
present in 21.8% of obese children.19 Dr Muhammad Yazid and
his team also found that amongst obese children attending the
Paediatric Obesity Clinic from year 2005 to 2010, 17% have
impaired glucose tolerance and as high as 70 % had acanthosis
nigricans, a visible marker of insulin resistance (IR) that is
characterized by dark, thick, velvety skin found in body folds
and creases such as armpits, groin and neck (Figure 4). 20
suggested that breastfeeding may confer some protective
effects.13
There is an urgency for Malaysian parents to recognize this
growing problem. A local survey by Ng et al looked at parents’
perception of their own and their children’s body weight
status. About 300 parents were interviewed, and 73% of
parents and 20 % of children ages 2-12 years were found to be
overweight or obese, as measured by their body mass index
(BMI). Perception-wise, only a mere 22% of overweight and
13% of obese parents viewed their weight status correctly.
In children, only 31% and 4% were viewed as overweight and
obese respectively by their parents.16
Figure 4
According to Segal et al, obese children have a higher tendency
to progress into obese adults.14 This study found that while
obese 1-2 year olds have an 8% chance of being obese adults,
this chance increase exponentially as they mature – an obese
teenager has 70 % chance of being an obese adult! The problem
does not end there. Among overweight children aged 6-12
years, one in four has impaired glucose tolerance and 60 %
have at least one risk factor for cardiovascular disease.15
Consumption of large amounts of added sugars is harmful
to the body. Worldwide, including Malaysia, the trends of
obesity, insulin resistance and T2DM are on the rise, and are
affecting both adults and children alike. Hence, a diet that
focuses on low or no added sugars may help curb the rise in
the prevalence of childhood obesity and diabetes in Malaysia,
concluded Dr Muhammad Yazid.
References: 1. Monro JA, et al. Baselines representing blood glucose clearance improve in vitro prediction of the glycemic impact of customarily consumed food quantities. Br J Nutr 2010;103(2):295-305. 2. de Onis M, et al. Global prevalence and trends of
overweight and obesity among preschool children. Am J Clin Nutr 2010;92(5):1257-1264. 3. Malik VS, et al. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84(2):274-288. 4. Welsh J, et al. Overweight among
low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999-2002. Pediatrics 2005;115(2):e223-229 5. Ochoa MC, et al. Predictor factors for childhood obesity in a Spanish case-control study. Nutrition 2007;23(5):379-384.
6. Vartanian L, et al. Soft drinks, nutrition and health. American Journal of Public Health 2007;97:667-675. 7. American Academy of Pediatrics. Dietary recommendations for children and adolescents: a guide for practitioners. Pediatrics 2006;117(2):544 -559.
8. Bong ASL & Safurah J. Obesity among years 1 and 6 primary school children in Selangor Darul Ehsan. Malaysian Journal of Nutrition 1996;2:21-27. 9. Fatimah A et al. The effectiveness of childhood obesity intervention program and the psychosocial factors
involved in maintaining weight changes in urban areas. Prosiding Persidangan Kebangsaan Penyelidikan dan Pembangunan Institusi Pengajian Tinggi Awam 2001. Kuala Lumpur, 25 – 26 October 2001:654-659. 10. Tee ES, et al. Regional study of nutritional
status of urban primary school children. 3 . Kuala Lumpur, Malaysia. Food Nutr Bull 2002;23(1):41-47. 11. Ismail MN et al. Prevalence and trends of overweight and obesity in two cross-sectional studies of Malaysian children, 2002-2008. Symposium 2, MASO
Scientific Conference on Obesity , 12-13 August. 12. Jalaludin MY, et al. Childhood obesity among primary schoolchildren in a rural area is associated with lack of infant breastfeeding and physical activity but not screen-time. Malaysia Association for the Study
of Obesity (MASO), 2011 Scientific Conference on Obesity, souvenir program and abstracts. 13. Hediger ML, et al. Association between infant breastfeeding and overweight in young children. Journal of American Medical Association 2001;285(19):2453-2460.
14. Segal DG & Sanchez JC. Childhood obesity in the year 2001. The Endocrinologist 2001;11(4):296-306. 15. Steinberger J, et al. Obesity, insulin resistance, diabetes, and cardiovascular risk in children. An American Heart Association Scientific Statement
from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (Council on Cardiovascular Disease in the Young) and the Diabetes Committee (Council on Nutrition, Physical Activity, and Metabolism). Circulation 2003;107:1448-1453. 16. Ng
SF, et al. Oral presentation at 4th Biennial Scientific Meeting of Asia-Pacific Pediatric Endocrine Society (APPES), November 2006. 17. National Health Morbidity Survey 1996. Diabetes. Volume 9. Institute for Public Health, Ministry of Health, Malaysia. 18.
Zanariah H, et al. Prevalence of diabetes mellitus in Malaysia in 2006 – results of the 3rd National Health Morbidity Survery (NHMS III). Available at: www.crc.gov.my/documents/abstract/prevalenceOfDiabetes_ppt.pdf. Accessed 29 July 2011. 19. Jalaludin
MY, et al. Type 2 diabetes mellitus in obese children. Pediatr Diabetes 2005;6(suppl3):68. 20. Noor Asyikin A, et al. Insulin resistance among overweight/obese children. Malaysia Association for the Study of Obesity (MASO), 2011 Scientific Conference on
Obesity, souvenir program and abstracts.
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