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How Asia gets its sugar


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Rina Agustina
IFPRI-FAO conference, "Accelerating the End of Hunger and Malnutrition"
November 28–30, 2018
Bangkok, Thailand

Published in: Government & Nonprofit
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How Asia gets its sugar

  1. 1. How Asia gets its sugar Rina Agustina Chair Human Nutrition Research Center, IMERI Department of Nutrition Faculty of Medicine Universitas Indonesia – Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia IFRI-FAO, 29 November, 2018 ICE ON IMERI 2018
  2. 2. Outline How Asia gets its sugar • Burden of Obesity and Type 2 diabetes in the Asian population • Sugar consumption (including in infant foods) • Nutrition transition • Intervention and policy response • Food system transformation (production and consumption) in Asia R Agustina 2018
  3. 3. Burden of obesity and diabetes in Asian populations
  4. 4. Figure 10 Trends in body-mass index (BMI), underweight, overweight, and obesity 1975 to 2016 Double burden of malnutrition Age-standardised mean BMI and prevalence of obesity has accelerated in East, South and Southeast Asia Abarca-Gómez et al, The Lancet 2017; 390, 2627-2642 R Agustina 2018
  5. 5. Asia is in the grip of a diabetes epidemic Global Report on Diabetes, WHO, 2016 Percentage of death attributed to high blood glucose level HBG (aged 20-69 years) by WHO region and sex, 2012 Diabetes prevalence has doubled since 1980 Trends in prevalence of diabetes by WHO region 1980–2014 Overweight and obesity are the strongest risk factors for type 2 diabetes R Agustina 2018
  6. 6. Sugar consumption in Asia
  7. 7. Sugar consumption per capita in selected countries (grams per day) PRC, People’s Republic of China Source: Euromonitor International (2015) in Thavorncharoensap, ADB Institute, 2017 Asia had the highest correlation between Diabetes prevalence and per capita sugar consumptions (PCC 0.66 (p < 0.001) Strongest correlation in • Central Asia (PCC = 0.97; p < 0.001) • South Asia (PCC = 0.68; p = 0.05) • South East Asia (PCC = 0.92; p < 0.001) Weeratunga et al BMC Public Health. 2014; 14: 186. PCC, Person’s correlation coefficient R Agustina 2018
  8. 8. Total sugar, fat and salt consumption from processed foods and beverages has plateaued in high-income countries, but has increased rapidly in upper–middle- income countries (espc in China and Thailand) and lower–middle-income countries Euromonitor projections indicate that per capita sugar consumption from processed foods in U-MICs will be 50% (7.4 kg and 14.8 kg) consumption in HICs in 2017 Baker & Friel, Obesity Reviews, 2014; Processed foods and beverages in the ‘nutrition transition’ underway in Asia R Agustina 2018
  9. 9. Consumption (kg per capita) of processed food product highest in sugar, salt and fat in Asia 1999–2012 - projections 2017 lower–middle-income countries Countries ranked by gross national income (GNI) per capita from left (highest) to right (lowest). upper–middle-income countries Baker, Obesity Reviews, 2014 High-income countries
  10. 10. Carbonated soft drinks were the most significant sugar vector irrespective of country income bracket in Asia Baker & Friel, Obesity Reviews, 2014; Globalization and Health, 2016 R Agustina 2018
  11. 11. Consumption of non-alcoholic caloric beverages in 187 countries worldwide Between 1990 and 2010, SSB consumption increased in several countries in Latin America and the Caribbean and Southeast Asia. Intakes of all three beverages were lowest in East Asia and Oceania. Singh et al, PLOS ONE 2014 R Agustina 2018
  12. 12. Carbonated Soft Drink in children and adolescents South Asian Students Aged 13-15 y Country Year of Survey % of Students Brunei Darussalam 2014 46.3 Cambodia 2013 45.6 Indonesia 2015 38.8 Malaysia 2012 31.3 Philippines 2011 42.2 Samoa 2011 53.5 Solomon Islands 2011 45.1 Thailand 2015 57.7 Viet nam 2013 34.6 Source: WHO. Global School-Based Student Health Survey (GSHS) Unfortunately, sugar-sweetened beverages are an unregulated, booming market in Asia. Chinese children Aged 3-7 y Yu, Public Health Nutritoon, 2016
  13. 13. SOURCES OF ADDED SUGAR Rank Source Country % Contribution to total sugar 1 Sucrose was the most added sugar ingredient irrespective of country income 70% in all country 2 High-fructose sugar was the second most added sugar ingredient Highest in HIC 16% in L-MICs 21% in U-MICs 24% in HICs 3 Processed foods Differed 73% in L-MICs 64% in U-MICs 53% in HICs 4 Bracket beverages In all country income 36% - 38% R Agustina 2018
  14. 14. A shift away from traditional (ethnic) foods has led to a sweetening of the global diet Nutrition transition in Asia
  15. 15. Asian Diet Benefits: • Green tea • Rich variety of vegetables and fruits • Spices • Low red meat consumption • Beans and nuts • Fish and seafood • Fruits as dessert • Whole grains • Tradition of controlling portion size • Soy consumption (fermented tempe toufu, soup, drink) Asian Diet Risks: • White rice and other refined grains • Sweets and snacks high in sugar • Tea or coffee with too much added sugar • Use of animal fat and palm oil • Unhealthy trans fats (in snacks, butter, etc.) are not labelled on packages5 • Too much salt • Excessive consumption of preserved foods (such as pickled vegetables and cured meats) Asian diets: Benefits versus Risks For NCD R Agustina 2018
  16. 16. Asian traditional dietary patterns are being lost as the food environment becomes more industrialized and urban • Red meat • Processed meat • Fried foods (French fries, chicken, etc.) • Large portion size • Unregulated trans fats • Refined carbohydrates • High fructose corn syrup and added sugar • Sugary drinks • Marketing of unhealthy food to children Feeley et al 2016 Proportion of mothers observing promotions of commercially produced snack food products since birth of child 6–23 months of age Traditional diet – Western fast food: R Agustina 2018
  17. 17. Sugar Consumption in Thailand Frequently consumed sources of added sugar: • sweetened beverages (including soft drinks, juices, milk and dairy products, coffee/tea/chocolate drink) • sweetened snacks (including traditional Thai desserts, baked desserts/cakes, crispy snacks), and • table sugar. Nationwide surveys and individual studies Kriengsinyos et al Asia Pac J Clin Nutr. 2018;27(2):262-283. R Agustina 2018
  18. 18. Trend of sugar consumption in Indonesia (kg/cap/year) – Susenas of BPS 1990-2016 Sugar consumption decrease in Urban area annually by 0.31%; increase in rural area by 0.55% - R Agustina 2018
  19. 19. 1.5 11.8 22.7 0.0 5.0 10.0 15.0 20.0 25.0 Maluku NTT Kaltim Bali Lampung Sulut Jabar Gorontalo Sultra Banten Kalteng Sumut Jambi Malut Sulteng Kep.Riau DKI Sumsel Papua Bengkulu Indonesia Sulbar Jatim Sulsel Riau NTB Kalbar Aceh Sumbar Babel Pabar Jateng Kalsel DIY Persen Provinsi Proportion of population with sugar intake >50 g/person/day by Province Total Diet Study Survey, 2014 R Agustina 2018
  20. 20. SUNDANESE BETAWI CHINESEMINANG KABAU JAVANESE Indonesia: Heterogeneity and diversity exist in its large geography, social practices, cultures, diets, and beliefs MIX 68.5 g Median Sugar intake/day (selected muti-ethinic groups living in Jakarta) n=270 Unpublished data, Diochrome Study, HNRC, IMERI, Agustina 2018 51.0 g 39.0 g 36.2 g 33.1 g44.7g R Agustina 2018
  21. 21. Interventions and Policy Responses 21
  22. 22. Meta-analysis of randomized controlled trials in Adults children with the highest intakes of sugar- sweetened beverages had a greater likelihood of being overweight or obese than children with the lowest intakes. Increase intake of free sugar, increase of bodyweight Decrease intake of free sugar, decrease of bodyweight Reference : WHO, 2015 Meta-analysis of prospective cohort studies, with follow-up times of 1 year or more in children Sugar intake and obesity • WHO recommends a reduced intake of free sugars throughout the lifecourse • In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake • WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake
  23. 23. Comprehensive government policy and regulatory response Prevent or mitigate processed food consumption Sugar-sweetened beverage taxes Food labelling Marketing restrictions on unhealthy food School-based interventions Healthy Living community movement Comprehensive Intervention and policy responses offer the greatest potential for making and accelerating progress in reducing overweight and obesity R Agustina 2018
  24. 24. Plan of action for the prevention of obesity in children and adolescents Breastfeeding promotion influence behaviour: Better food and more physical activity in schools “Junk food” – “SSB” taxes and restrictions on marketing Increased access to recreational spaces and nutritious foods Promotive environments and policies for inexpensive healthy food SSB, Sugar Sweetened Beverage R Agustina 2018
  25. 25. Customized transformation of food system: New initiative - focus on sugar Aligning high-level policies and strategies in support of a sustainable food future primary goals would be to eliminate subsidies and stimulus packages to the domestic sugar industry, and to bring sugar plantations back under the forest moratorium. To mainstream the principles of a healthy and sustainable diet the central goals might be to bring sugar in government-supplied meals (e.g. in hospitals and school feeding programmes) under the Indonesian 40 g per day recommended maximum, to limit availability of high-sugar foods in outlets in schools and other government buildings, and to ban or limit advertising of high-sugar foods to children. Partner with food providers and local pioneers immediate priorities would be to work with industry on reformulation of high-sugar products, and to involve city governments and civil society organisations in outreach, including social media, to increase public awareness of and support for the wider initative. Policy Brief -Healthy diets from sustainable production: the case of Indonesia EAT - Chatham House, UI - MOH RI, presented at Universitas Indonesia 2018 Indonesia: as a model for solving global health problem R Agustina 2018
  26. 26. Rapid Transformation Platform of the food system Current global food system is failing to deliver healthy diets and unsustainable in regard to both environmental and human health. A Healthy Food Production system important to engage the agricultural and private sector to produce healthy and affordable foods, especially with incentives for production and consumption linked with the national health insurance system. A Healthy Food Information System Deployment of a frontline information system will link production-to-plate across the agricultural, private industry and health sectors; and enable data-driven management of a healthy and sustainable food supply and diet. Healthy District Leaders to manage inter-sectoral transformation to healthy and sustainable diets and use of scientific platform for evidence- based policy. A Healthy eating promotion – Health food consumption No one-size-fits all framework for transformation Customized Food system transformation Indonesia: as a model for solving global health problem R Agustina 2018 Strengthening Research and Development
  27. 27. Inclusion of rapid transformation platform in Universal Health Coverage • Investments in transformative policies and actions for human resource performance are needed. • Policies to support environment factors, food security, healthy diet and sustainable food system • Promotive and preventive care in Universal Health Coverage system R Agustina 2018
  28. 28. Summary A shift away from traditional (ethnic) foods has led to a sweetening of the global diet Comprehensive Intervention and policy responses offer the greatest potential for making and accelerating progress in reducing overweight and obesity Current global food system is failing to deliver healthy diets and unsustainable. No one-size-fits all framework for transformation- Customized Rapid Transformation Platform of Food system for Healthy diet and sustainable food system • Prevalence of overweight and obesity in children, adolescent and adults has been rising in Asia region • Asia is in the grip of a diabetes epidemic, • Sugar is considered to be one of the main contributors to rising obesity and diabetes rates in Asia, however data on added sugar consumption are limited in this region • Processed foods and Carbonated soft drinks were the most significant sugar vector irrespective of country income bracket R Agustina 2018
  29. 29. 29 Harray AJ, Boushey CJ, Pollard CM, Delp EJ, Ahmad Z, Dhaliwal SS, Mukhtar SA, et al - 2015 R Agustina 2018 THANK YOU