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“Handling Sugar and Sweeteners Intakes – Indian Experience” Rekha Sharma R.D Director, Clinical Nutrition and Dietetics Diabetes Foundation ( INDIA) Former Chief Dietician All India Institute of Medical Sciences ,New Delhi, INDIA Science for Health , Diet and Life style • • • • Four healthy lifestyle factors No smoking Maintaining a healthy weight Exercising regularly Healthy diet Together appear to be associated with as much as an 80 percent reduction in the risk of developing the most common and deadly chronic diseases Early awareness • The roots of these factors often originate during the formative stages of life, it is especially important to start early in teaching the important lessons concerning healthy living. • Schools should be a priority Indians have sweet tooth! • Almost 75% of the sugar available in the open market is consumed through bakeries, candy makers, sweet makers, ice cream and soft drink manufacturers • Gur, an unrefined form of sugar, is mostly consumed in rural areas . • India is currently the world’s largest consumer of sugar with domestic consumption increasing more than 4 % annually. Consumption of sugar • • • • 2005- 2006 – 19 million tons 2007 – 2008 – 22 million tons 2008 – 2009 – 23 million ton Per capita consumption of sugar: Rural – 2.2 kg/ month/ household Urban – 5.11 kg/month/household • Sugar consumption in India has more than doubled in 20 years . PER CAPITA CONSUMPTION OF SUGAR IN URBAN INDIA States Kgs. Per annum Punjab 71.5 Haryana 68.5 Maharashtra 40.9 Gujarat 40.9 Kerala 41.5 Uttar Pradesh 35.2 Tamil Nadu 29.1 Karnataka 23.3 All India 31.5 Incidence of Obesity • On an average 5 % of Indian population is obese but when seen in urban settings the numbers are amazingly high . • Punjab : 30.3 % Males, 37.5 % Females Kerala : 24.3 % Males, 34.0 % Females Goa : 20.8 % Males, 27.0 % Females • Diabetes Foundation ( INDIA) on going trial in 7 major cities of India and has found 24 % school children to be over weight and obese , where the numbers are much higher in private schools. Incidence of obesity & Related disorders • Young Women (18 – 25 years) = 13.2% Delhi, DST trial ,2000 • Urban slum ( 35 years) = 40.2% European Journal of Clinical Nutrition ,2001 • Urban Slum (30-60) = 28.2% • Post menopausal (52 years) = 62 % Hypertension >140/90 mm Hg Hyperlipidaemia Cholesterol > 200 mg Diabetes Blood sugar >126 mg% Osteoporosis (T-score < -2.5) Delhi, DST trial , 2002 Delhi, DBT trial, 2006 = 43% = 47% =4% = 22% • 4,621( >35 years) overweight urban areas= 64 % rural areas = 36 % Hypertension >140/90 mm Hg Hyperlipidaemia Cholesterol > 200 mg Diabetes Blood sugar >126 mg% DST trial in 6 cities,2009 = 50% = 25% = 3 - 14 % Prevalence (%) of Abdominal Obesity in 14-18 y old Asian Indian Adolescents: 5 City Data Age (y) New Delhi Mumba i (n = 4997) (n = 435) Agra Jaipur (n = 4415) (n = 2646) Allahaba d (n = 3379) Overall (n = 15872) 14 26.8 51.9 18.3 15.1 22.9 23.1 15 26.2 35.9 18.5 13.5 23.9 18.9 16 31.6 17.6 5.3 14.0 37.3 20.4 17 34.0 17.2 8.7 14.3 35.8 19.5 Overal 28.8 l 31.3 13.9 13.7 29.1 20 Diabetes Foundation ( INDIA) - Ongoing trial Consumption of Energy-dense Foods Public Schools Gov. Schools 39 % 33% Eating chips, >1 d/week 53 48 Eating French fries, >1d/week 20 15 Eating burgers, >1 d/week 20 25 Eating pizzas, >1 d/week 15 12 Eating noodles, >1 d/week 44 50 Drinking colas, >1 d/week 36 35 Eating Habit Eating out, >1 d/week 65 % of Children in class X and XII are sedentary Un healthy Eating Habits • • • • • Erratic eating habits Frequent fast and fried food consumption Excess intake of colas Excess consumption of refined foods Not consuming enough fruits and vegetables Sedentary Life style • • • • • Low physical activity No participation in active sports activities Long hours devoted to TV, computer, video games Sitting in canteens/coffee shops Taking automated vehicles for nearby destinations Sedentary causes • Hectic pace of life- long hours – desk jobs • A major culprit is time spent in front of the television and computers. • Increase in vehicles • Reduced play areas and walking space • Sedentary behaviour – school onwards • House wives- more help Causes of Obesity - WHO • Energy imbalance between calories consumed on one hand, and calories expended on the other hand. • A global shift in diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other micronutrients • A trend towards decreased physical activity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization. • Urbanization , sedentary life styles and excessive consumption of sugary foods along with increased fat consumption specially saturated fats is leading India to obesity . Obesity being the primary factor of type II Diabetes is leading India to become the diabetic capital of the world by 2030. Incidence of Life style Diseases • Heart disease : • Hypertension : • Diabetes : Rural: 5 – 6% Urban: 9-10%. Rural :5-8 %. Urban : 15% 6 – 12 % Satisfying Sweet tooth • Craving for sugar often translates into a tug-of-war; the urge to satisfy a sweet tooth versus the urge to resist empty calories. • Artificial sweeteners are avoiding this .Indias artificial sweetener industry (estimated at Rs 60 crore) is also growing at a healthy 20 per cent annually. • The Government of India has allowed the use of artificial sweeteners in around 25 food items. The items include carbonated water, soft drink concentrate, sugar/sugar free confectionery, chewing gums, biscuits, breads, cakes and pastries and some traditional sweets. ... Artificial Sweeteners • Table sugar to artificial sweeteners (like aspartame and saccharine) may be one way of achieving • Stevia the worlds sweetest natural sweetener that has zero calories lingering after-taste to this sweet herb. Stevia and its extracts are said to be completely diabetic-safe. Low calorie sweeteners • Sweetos is a low calorie, high intensity sweetener made from Fructo-OligoSaccharide and Sucralose. • It is approved as a soluble fibre and helps to reduce serum LDL Cholesterol Levels. • Fructo-Oligo-Saccharide is a very good Prebiotic, which helps to improve immunity and is a healthy sweetener for Diabetics sweets, coffee and Tea, Baked Goods, Jams, Jellies, Sauces, Breakfast Cereals, Syrups, Soft Drinks and Ice Creams Intense sweeteners • When added to food, these low Calorie sweeteners provide a taste that is similar to that of table sugar (sucrose), and are generally several hundred to several thousand times sweeter than sugar. • Because of their intense sweetening power, these sweeteners are used in very small amounts and thus add only a negligible amount of calories to foods and beverages. Sweeteners and weight Management • Non-nutritive sweeteners play a crucial role in weight management strategies. It is a difficult task to cut down 500 calories in a weight reduction diet. A reduction in direct sugar i.e. about 100 calories from the diet - by replacing it with an artificial sweetener is one-fourth the target achieved. • Done daily for about 2 months, one has lost approximately 1 kg in weight. • Improves the adherence to the diet program. Hence, the artificial sweeteners play a very important role in obesity as well as diabetes management. Artificial Sweetener intake Obese Over weight Diabetics Type 2 • Middle income group = 2% • High Income group = 70% Equal, Sugar free, Saccharin Ms Swapna Chaturvedi , Dept of Dietetics All India Inst of Medical sciences , New Delhi Food supplements share in the market • In food supplements, the major share is held by food products and supplements (artificial sweetener, meal replacers, and ginsengs)- 50 %, valued at Rs 5.63 billion in 2007. • The next major pie is held by malted beverages- 30 % valued at Rs 3.38 billion. • The third major segment is fruit-based products- 6% , valued at Rs 0.68 billion. • Paediatric nutrition (Lactogen, Lactodex, Dexolac, Pediasure),5% valued at Rs 0.56 billion. • Protein powder, sports products, and clinical products 5% are valued at Rs 0.56 billion, Rs 0.23 billion and Rs 0.23 billion respectively. (Source: Cygnus Business Consulting & Research 2008) Food supplements World Health Organization (WHO) • Nutrient and energy requirements vary between individuals and are related to a person's age, sex, level of physical activity • In India 70- 80 % of person's dietary energy is coming from carbohydrates including sugars . • The calories from sugar are termed hollow calories as they lack proteins , vitamins and minerals . • Healthy eating concept should reduce refined carbohydrates especially sugars and select healthy foods with whole grains and fiber . • Fibre is important for gut function, and helps to reduce the risk of heart disease and some cancers and acts as a filler for weight reduction. • Many studies have also shown that fruit and vegetables have beneficial effects on health. WHO recommends consuming around 400 g (five or six portions) a day. Dietary guidelines for lifestyle modification-NIN • Calories should be sufficient to maintain appropriate body weight for a given height. • Carbohydrate should constitute 55-65% of calories with emphasis on complex carbohydrates. • Proteins should provide around 10-15% of the total calories. • Total fat intake should be between 15-30% of total calories. • Cholesterol should not exceed 300mg/day in the diet. • Saturated fat should be less than 10% of the total calories. Dietary guidelines for lifestyle modification-NIN • Polyunsaturated fat should not exceed 8% of the total calories. • P/S ratio should be between 0.8-1.0. • Linoleic acid (N6) should range between 3-7% of the calories. • Alpha-Linoleic acid (N3) should not be less than 1% of calories. • LA/ALNA ratio should be between 5-10. • Sugars should be less than 10% of total calories and should be kept minimum. • Salt intake should be between 5-7 g/day. • Dietary fibre should be around 40g/day. Per capita calorie Intake Calories K cals/Day Rural Urban 1983 - NSS 2221 2089 1993-1994 2153 2071 1999-2000 2149 2156 2004-2005 2047 2020 NSS Report – 513 - 2004 - 2005 Physical Activity Prescription for Aerobic and Muscle Strengthening Exercises Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management JAPI • VOL. 57 • FEBRUARY 2009 www.japi.org Exercises Vigorous intensity Moderate intensity Type of physical activity Modality Duration Frequency/ days per week Modality Duration/ repetiti ons Frequency/week Aerobic physical activity Brisk walking, stair climbing, jogging(47m/sec), cycling, treadmill and swimming 30 min 5 Football, badminton, basketball, running, rope jumping, dancing 20 min 3 days Muscle strengthening activity Resistance weight training, curls, presses, antigravity exercise, isometric exercise Children-Body weight activity (Pull ups) 1-3 sets of 8-12 repetitions targeting major muscle groups 2-3 Resistance training, curls, presses, anti gravity exercise, isometric exercise Children- Body weight activity (Pull ups) >3 sets of >12 repetitio ns targetin g major muscle groups 2-3 days