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MY-JPOG-RPT-FON-142a_FA_OL.ai 1 10/11/11 10:19 AM 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. Sponsored by an unrestricted educational grant from Editorial development by UBM Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. © 2011 UBM Medica. All rights reserved. No parts of this publication may be reproduced by any process in any language without the written permission of the publisher. Enquiries: UBM Medica Sdn Bhd, Level 3A, Luther Centre, No. 6, Jalan Utara, 46200 Petaling Jaya, Selangor, Malaysia. Tel: (603) 7954 2910 Fax: (603) 7958 7853 MY-FON-142