1. ‘Limit foods and drinks with added sugar’: the YES case Boden Institute for Obesity, Nutrition, Exercise & Eating Disorders Assoc Prof Tim Gill

2. Revision of the Dietary Guidelines for Australians - 2011 NHMRC statement on what the guidelines will recommend: Limit intake of foods and drinks containing saturated and trans fats; added salt; added sugars; and alcohol

3. Is sugar dangerous?

4. No firm evidence directly linking sugar intake to: Diabetes Heart disease Cancer

5. Evidence of harm of high intake of foods and drinks with added sugar Reasonable evidence linking high sugar consumption (especially beverages) with: Weight gain and obesity Nutrient dilution and insufficiency Dental caries and erosion Possibly bone health

6. Why should we restrict our intake of sugary foods and drinks ? 6 What do we mean by the term added sugar? Is sugar dangerous? Or good for you? Do foods and drinks high in added sugar contribute to weight gain and will restricting them help us achieve energy balance ? Does a high added sugar intake impact negatively on nutrient adequacy and will restricting such foods better help achieve appropriate nutrient intakes? Does added sugar intake contribute to dental caries and will restriction help reduce the risk of caries?

7. Terminology Related to Carbohydrates Sugars The term "sugars" is conventionally used to describe the mono and disaccharides. "Sugar", by contrast, is used to describe purified sucrose as are the terms "refined sugar" and "added sugar" Intrinsic and extrinsic sugars Intrinsic sugars occur within the cell walls of plants. Extrinsic sugars were those which were usually added to foods.

8. Can foods and drinks with added sugar be good for you ? Suggestions that increasing sugar may: encourage intake of nutritious unpalatable foods and beverages Reduce the intake of fat and thus achieve better weight control And that our sugar intake is already dropping so why the need to limit intake.

9. Change in Per capita supply of sugar in Australia (kg/capita/year) Data from FAOstats

10. Sydney House prices are steady

11. Per capita consumption of sugar

12. Change in total sugar intake 1995-2007 1995 2007 1995 * P<0.05

13. Sugar-sweetened soft drinks consumption Rangan et al, 2010

14. Sugar-sweetened soft drinks: % consuming * P<0.05 Rangan et al, 2010

15. Sugar-sweetened soft drinks: per-consumer * P<0.05 Rangan et al, 2010

16. Influence of SES on weight status in schoolchildren NSW Spans 2011 unpublished

17. Apparent Per capita consumption of sugar in Australia (kg/capita/year) Source ABS 2000

18. What contributes added sugar in the diets of Australian children?

19. Nutrient sufficiency Does consuming more foods high in added sugars lead to better or worse nutrient intake?

20. Calcium intake in US children 4‐8 Y as a function of added sugar intake US NHANES data

21. Relationship between added sugar intake and Zinc intake Children Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey Unpublished – Boden Institute

22. Relationship between added sugar intake and Zinc intake Children Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey Unpublished – Boden Institute

23. Relationship between added sugar intake and fibre intake Children Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey Unpublished – Boden Institute

24. Relationship between added sugar intake and fibre intake Children Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey Unpublished – Boden Institute

25. Relationship between added sugar and risk of nutrient insufficiency in Children Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey Unpublished – Boden Institute

26. Serve sizeMales | 31-50 years Females 31-50 years Starchy vegetables75g75 Green & brassica vegetables75g77 Orange vegetables75g72 Legumes75g72 Nuts/seeds30g77 Other vegetables75g14 Fruit150g14 Wholegrain cereals/grainsEquiv 40g bread28 Refined cereals/grains*Equiv 40g bread14 Meat and alts minus redEquiv 65g red meats 77 Red meats (beef, lamb, veal, pork)65g77 Dairy foods** Equiv 250g milk17 Additional category:‘ Other foods (600kJ equivalents) 7-143.5-7 Unsaturated fats and oils***10g2814 Consultation draft – Foundation and Total Diets 2010 Weekly food required to meet NRVs Men and women average height, moderate activity PAL 1.7

27. Sugar intake and weight control

28. The sugar- fat seesaw ?? Cross sectional data shows as the percentage of energy from sugar increases the percentage of energy from fat decreases - and vice versa

30. Raben et al, AJCN 2002 Can reducing sugar- reduce weight?

31. The effect of increasing fat and sugar as snacks Mazlan et al, Br J Nut 2006 The effect of 0, 1·5 and 3·0MJ of sugar-rich or fat- rich mandatory snacks of identical energy density on energy intake ad libitum

32. Relationship between added sugar intake and total fat intake Children Children 2-16 2007 Australian National Children’s Nutrition and Physical Activity Survey Unpublished – Boden Institute

33. Energy balance Energy Intake (food energy) carbohydrate Protein fat (alcohol) vs Energy expenditure Basal metabolic rate Thermic effect of food Exercise

34. The prevalence of overweight and obesity in men and women in 2000 (National health Survey 2007/08) obese male overweight male obese female overweight female

35. Report: Soft drinks, weight status and health www.health.usyd.edu.au/panorg/research-themes/intervention/evidence- summaries.php

36. Evidence linking soft drinks to overweight CPHN, Uni of Sydney 2009

37. Sugar and Dental Caries

38. Cost of dental caries in Australia Oral Health expenditure in Australia is the sixth highest health cost and accounted for 7% of total allocated health expenditure ($3.4 billion) (AIHW Australia’s health 2004). Despite declines in rates of caries - primarily dental caries and periodontal diseases - cost of the order of $1.5 billion per year

39. Aetiology of dental caries Complex condition, range of contributing factors Teeth surface structure Quantity, PH and composition of Saliva Dental hygiene Fluoride Fermentable carbohydrates - frequency of consumption, form (stickiness) and amount of sugar

40. Special Role of sugar in dental caries Relationship between sugar intake and dental caries across the lifetime is strong - numerous reviews Sucrose is a particularly carcinogenic sugar because it can form glucan that enables firm bacterial adhesion to teeth and limits diffusion of acid and buffers in the plaque. - Tinnanoff and Palmer Public Health Dentistry 2000 May be a dose-related effect of consumption of sucrose on caries development

41. Proposed relationships between sugar intake and caries a- relationship pre- fluoride era b. Relationship post- fluoride era c. Linear relationship from country data d- best case speculation of relationship in individual with good oral hygiene and fluoride exposure Zero- Caries Res 2004

42. Dental Health Guidelines Numerous national dental and health organisations make recommendations to restrict the intake of sugar rich foods and drinks Australian Dental Association American Dental Association British Dental Association

43. Is it appropriate for the Australian dietary Guidelines to recommend restricting food and drinks high in added sugars? It would be totally inappropriate to allow unrestricted intake of foods and drinks with added sugar

44. Most countries have a dietary guideline restricting sugar intake 2007 Canadian Food Guide – Limit foods and beverages high in calories, fat, sugar and salt. 2000 Malaysian Dietary Guidelines - Reduce sugar intake and choose foods low in sugar. 2007 New Zealand Dietary Guidelines Prepare foods or choose pre-prepared foods and snacks: with little added sugar; limit your intake of high-sugar foods. 2011 Singapore Dietary Guidelines Choose beverages and food with less sugar 2008 UK National Dietary Goals FSA Sugars (added) - No more than 11% of food energy (currently at 12.7%) 2010 Dietary Guidelines for Americans Consume fewer foods with sodium (salt), saturated fats, trans fats, cholesterol, added sugars, and refined grains

45. Thank You