“Health implications of sugar and need for appropriate policy perspectives” by Nayanjeet Chaudhury. - Paper presented at • Thirteenth International seminar on “Prevention of non-communicable diseases”, Madras Diabetes Research Foundation with University of Alabama at Birmingham, USA, and Florida International University (FIU), USA, 23-25 Jan, 2015, Chennai

1. Health implications of sugar and
need for appropriate policy
perspectives
Dr. Nayanjeet Chaudhury
Director, M&E and Health Services Delivery
Population Services International, India

2. Sugar: The Bitter Truth on Youtube.
https://www.youtube.com/watch?v=dBnniua6-oM
5,359,662 views
Robert H. Lustig,
Professor of Clinical Pediatrics and Pediatric Endocrinologist at
University of California, San Francisco (UCSF)

3. Suggested in 1966 - excessive consumption of sugar
might contribute to atherosclerosis and diabetes.

4. Relationship between fat intake and sugar
intake in thirty-four countries (Yudkin, 1964)
Yudkin, John (1964). "Patterns and Trends in Carbohydrate Consumption and their Relation to
Disease". Proceedings of the Nutrition Society 23 (2): 149–162. doi:10.1079/pns19640028.

5. Fructose : Facts
• Glycemic index of fructose 19 and Glucose,100,
• The plasma insulin response to fructose is markedly enhanced in
diabetics compared with nondiabetics
• During exercise, fructose prevents drop in glycemia by sustaining
glucose production. (Sports Drinks Concept)
• Moderate doses of fructose reduces the perception of fatigue and
stress during exercise and improved exercise
• Fructose may be less efficient than glucose to suppress food
intake – may cause leptin resistance - fructose-induced
nonalcoholic fatty liver disease (NAFLD)
• Fructose is “lipogenic”
• In rodents (human studies sparse), Fructose increases hepatic
insulin resistance.
Tappy, L., & Lê, K.-A. (2010). Metabolic effects of fructose and the worldwide increase in obesity.

6. High fructose vs high glucose
• Blood samples collected every 30-60 min for 24h from
normal-weight women on 2 randomized days.
• Subjects consumed 3 meals with kCal as follows
– 55% carbs, 30% fat, and 15% protein
– 30% of kcals as either a high fructose (HFr) or high
glucose (HGl) beverage.
– Meals were isocaloric in the two treatments.
• HFr meals produced a rapid & prolonged elevation of
plasma triglycerides compared to HGl day (P < 0.005).
Teff, K. L., Elliott, S. S., Tschöp, M., Kieffer, T. J., Rader, D., Heiman, M., … Havel, P. J. (2004). Dietary fructose reduces
circulating insulin and leptin, attenuates postprandial suppression of ghrelin, and increases triglycerides in women. In
Journal of Clinical Endocrinology and Metabolism (Vol. 89, pp. 2963–2972). doi:10.1210/jc.2003-031855

7. Free Fructose
vs
Fructose bound in Sucrose
• No difference observed in plasma glucose in human studies
Akgun, S., & Ertel, N. H. (1985). The effects of sucrose, fructose, and high-fructose corn syrup meals on plasma glucose and
insulin in non-insulin-dependent diabetic subjects. Diabetes Care, 8, 279–283. doi:10.2337/diacare.8.3.279

8. Fructose and weight gain
• Insulin, leptin & possibly ghrelin are key signals to the
CNS in long-term regulation of energy balance.
• Decrease in circulating insulin, leptin & increased
ghrelin concentrations, could lead to increased caloric
intake and ultimately to weight gain and obesity
during chronic consumption of diets high in fructose.
Teff, K. L., Elliott, S. S., Tschöp, M., Kieffer, T. J., Rader, D., Heiman, M., … Havel, P. J. (2004).
Dietary fructose reduces circulating insulin and leptin, attenuates postprandial suppression of
ghrelin, and increases triglycerides in women. In Journal of Clinical Endocrinology and
Metabolism (Vol. 89, pp. 2963–2972). doi:10.1210/jc.2003-031855

9. Fructose on People with Insulin resistance
• Effects of a 7-day high-fructose diet in healthy offspring of
patients with type 2 diabetes
– increased ectopic lipid deposition in liver and muscle and fasting
VLDL-triacylglycerols
– decreased hepatic insulin sensitivity
Lê, K. A., Ith, M., Kreis, R., Faeh, D., Bortolotti, M., Tran, C., … Tappy, L. (2009). Fructose overconsumption causes dyslipidemia and ectopic lipid deposition in
healthy subjects with and without a family history of type 2 diabetes. American Journal of Clinical Nutrition, 89, 1760–1765. doi:10.3945/ajcn.2008.27336

10. Sugar and Uric acid
• Sugar-sweetened soft drink consumption
is associated with serum uric acid levels
and frequency of hyperuricemia
• diet soft drink consumption
– no evidence yet.
Choi, J. W. J., Ford, E. S., Gao, X., & Choi, H. K. (2008). Sugar-sweetened soft drinks, diet soft
drinks, and serum uric acid level: the Third National Health and Nutrition Examination Survey.
Arthritis and Rheumatism, 59, 109–116. doi:10.1002/art.23245

11. Fructose controversy
Multivariate relative risk of incident gout in 46393 men from
health professionals follow-up study, according to fifths of free
fructose intake in subgroups. Reference group for comparisons
was men in lowest fifth of fructose intake and (top) with body
mass index <25 kg/m2, (middle) no alcohol use, and (bottom)
total daily dairy intake ≤1.6 servings. Relative risks were
adjusted for age, total energy intake, bodymass index, diuretic
use, history of hypertension, history of renal failure, intake of
alcohol, intake of total vitamin C,and percentage of energy from
total carbohydrate and protein
Choi and Curhan. Soft drinks, fructose consumption,
and the risk of gout in men: prospective cohort
study. BMJ. 2008; 336 (7639): 309–312.
Nayanjeet/Surat/16Dec2012

12. Relative Odds of Having an Elevated Blood Pressure Among
6,036 12-17 year-old Adolescents, NHANES 1999-2006
* Adjusted for age, sex, race/ethnicity, BMI percentile
† Quintile ranges: 1 (1.8-4.0 mg/dL), 2 (4.1-4.6 mg/dL), 3 (4.7-5.2 mg/dL), 4 (5.3-6.0 mg/dL), 5 (6.1-14.9 mg/dL)
Abbreviations: 95% CI, 95% confidence interval.
Loeffler, L. F., Navas-Acien, A., Brady, T. M., Miller, E. R., & Fadrowski, J. J. (2012). Uric acid level and elevated
blood pressure in US adolescents: National health and nutrition examination survey, 1999-2006.
Hypertension, 59(4), 811–817. doi:10.1161/HYPERTENSIONAHA.111.183244

13. Metabolic fate of an oral fructose load
Tappy, L., & Lê, K.-A. (2010). Metabolic effects of fructose and the worldwide increase in obesity.
Physiological Reviews, 90, 23–46. doi:10.1152/physrev.00019.2009

14. Fructose-induced dyslipidemia – Possible mechanisms
Dyslipidemia may be
more pronounced in
insulin resistant people.
Caution: These findings
are based on high doses
of fructose intake.
Response to usual doses
yet uncertain.
Tappy, L., & Lê, K.-A. (2010). Metabolic effects of fructose and the worldwide increase in obesity.

15. Potential mechanisms for fructose-induced insulin resistance
Tappy, L., & Lê, K.-A. (2010). Metabolic effects of fructose and the worldwide increase in obesity.
Physiological Reviews, 90, 23–46. doi:10.1152/physrev.00019.2009

16. Potential relationships of high fructose intake with human disease
Tappy, L., & Lê, K.-A. (2010). Metabolic effects of fructose and the worldwide increase in obesity.
Physiological Reviews, 90, 23–46. doi:10.1152/physrev.00019.2009

17. Global Sugar Consumption vs Production
Sugar: World Markets and Trade. http://apps.fas.usda.gov/psdonline/circulars/Sugar.pdf

18. Major sugar Produciing countries
http://agricoop.nic.in/imagedefault/trade/SugarNew29.pdf
• India is the largest consumer and second largest
producer of sugar

19. Production, area under cultivation and
yield of sugarcane & sugar in India
Source: Department of Food & Public Distribution (for Sugar Production) and Agricultural Statistics (for production and area of Sugarcane).
*: As per 4th Advance Estimate (2013-14) of DAC released on 14/8/2014
#: As per 1st Advance Estimate (2014-15) of DAC released on 19/9/2014
http://agricoop.nic.in/imagedefault/trade/SugarNew29.pdf

20. Sugar contents in malt beverages – a study of food labels
Items
Total calorie per
100 gm or 100
ml (Kcal)
Carbohydrates (g)
Fibre
(g)
Protein
(g)
Price (Rs)
Total Sugar
Abbott PediaSure Vanilla Delight 468 50.2 35.01 - 23.4 63.33
Boost 385 83 26.5 - - 44
Complan Chocolate 419 62 24 - 18 105
Complan Kesar badam 399 68 27 - 16 58.75
Complan Natural 419 62 25 - 18 47.5
Complan Nutrigro Badam Kheer 429 62.5 32.4 - 25.5 62.75
Complan Pista badam 399 68 26.7 - 16 56.5
Complan strawberry 419 68 26 - 16 45
Horlicks Chocolate 385 80 29.7 ? - 45
Horlicks Junior 387 72.5 5 - 15.2 45.2
Horlicks Kesar Badam 378 79 25 - 11 48.75
Horlicks Lite 361 71 0 3 13 53.3
Horlicks original 376.9 79 14 - 11 37.4
Nutramul 400 75 25 3 11.5
Protienx Vanilla Original 367 57.5 31.9 - 32 118.8
Protinex Chocolate Original 350 54.5 31 - 32 101.3
Protinex Junior Vanilla Flavor 401 48.5 33.7 - 25 118.8

21. Taxing Sugar products may reduce obesity and other risk
factors – a meta-analysis report
Cabrera Escobar, M. a, Veerman, J. L., Tollman, S. M., Bertram, M. Y., Hofman, K. J., & Escobar, M. a C. (2013). Evidence that a tax on sugar
sweetened beverages reduces the obesity rate: a meta-analysis. BMC Public Health, 13(2010), 1072. doi:10.1186/1471-2458-13-1072

22. Taxing Sugar products may reduce obesity and other risk
factors – a meta-analysis report
Cabrera Escobar, M. a, Veerman, J. L., Tollman, S. M., Bertram, M. Y., Hofman, K. J., & Escobar, M. a C. (2013). Evidence that a tax on sugar
sweetened beverages reduces the obesity rate: a meta-analysis. BMC Public Health, 13(2010), 1072. doi:10.1186/1471-2458-13-1072

23. WHO guidance on sugars. 2014
• Both adults and children should not consume more
than 10% of total energy as free sugars
• Further reduction to < 5% of total energy consumed as
free sugars;
• For a 2,000 calorie diet this would limit sugar intake to
12.5 or 6.25 teaspoons of free sugars, respectively
World Health Organisation, W. (2014). Draft sugar guideline. Retrieved from WHO opens
public consultation on draft sugars guideline:
http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en/

24. Industry’s response to WHO’s guideline
http://www.nestle.com/aboutus/ask-nestle/answers/nestle-response-to-who-public-
consultation-on-guideline-on-free-sugars

25. Does sugar need subsidy?
• Production may reach 26 Million Metric Ton in
2015.
• 19% jump from a year ago, on 15 Jan 2015
• 7.5 million ton stockpile
• 1.5 million tons expected export @ Rs4000 per ton.
Current subsidy Rs. 3371 per ton
• Global market is opposed to subsidy by India.
• Inside India, sugar prices are below cost of
production.
• The counter side – Indian farmers already hit

26. Much to ponder !!