Obesity

Sugars. Several studies have been conducted to determine the relationship between total (intrinsic plus added) and added sugars intake and energy intake (Table 6-10). The Department of Health Survey of British School Children showed that as total sugar intake increased from less than 20.7 percent of energy to up to 25.2 percent of energy, intake increased by approximately 100 kcal/d (Gibson, 1993). In contrast, the Bogalusa Heart

DIETARY REFERENCE INTAKES

TABLE 6-9 Cross-Sectional and Cohort Studies on the Relation of Glycemic Index (GI) to the Risk of Diabetes, Coronary Heart Disease (CHD), and Cancer and Its Association with High Density Lipoprotein Cholesterol (HDL-C) Concentration and Glucated Hemoglobin (HbAlc) in Diabetes

References

Study Design

Diabetes Salmerôn et al., 1997a

42,759 healthy, male health professionals Cohort, 6-y follow-up

Quintile mean

65,173 healthy, female nurses Cohort, 6-y follow-up

Quintile mean

Meyer et al., 2000

35,988 postmenopausal women Cohort, 6-y follow-up

Buyken et al. 2001

2,810 type I diabetic men and women Cross-sectional study

84,941 healthy, female nurses Cohort, 16-y follow-up

CHD and related parameters

Frost et al., 1,420 British adults Mean: 86

1999 Cross-sectional study

DIETARY CARBOHYDRATES: SUGARS AND STARCHES

Main Effect"

Comments"

RR of diabetes 1.00 1.16

1.19

p for trend = 0.03 after adjustment for cereal fiber intake For high GL plus low cereal fiber intake, the RR of diabetes was 2.17 (1.04-4.54)

p for trend = 0.005 after adjustment for cereal fiber intake Significant association between glycemic load and risk of diabetes (RR = 1.47 for 5th quintile)

GI and GL were not associated with risk of diabetes

605-

Using bivariate model, serum HDL-C was inversely associated with GI (p for trend = 0.0001), and TAG was positively associated with GI (p for trend = 0.01)

Significant association between GL and risk of diabetes (p trend < 0.001); this is an updated analysis from Salmerón et al. (1997b) that includes 3,300 new cases of type 2 diabetes

Negative relationship between GI and HDL-C (p < 0.0001)

continued

310

DIETARY REFERENCE INTAKES

TABLE 6-9

Continued

References

Study Design

GI

Liu et al.,

75,521 female nurses

GI quintile mean

2000

Cohort, 10-y follow-up

by GL score

72

75

77

78

80

van Dam et al.

, 646 elderly Dutch men

Tertile median

2000

Prospective analysis

77

82

85

Ford and Liu,

13,907 men and women

2001

Cross-sectional study

< 76

76-79

80-83

84-87

> 87

Liu et al.,

280 postmenopausal

2001

women

Quintile mean

Prospective analysis

68

73

75

77

81

Cancer

Franceschi

Italian men and women

et al., 2001

with colon cancer

1,953 cases

< 70.8

4,154 controls

70.8-73.8

73.9-76.5

76.6-79.6

> 79.6

b GL = glycemic load, TAG = triacylglycerol, BMI = body mass index.

b GL = glycemic load, TAG = triacylglycerol, BMI = body mass index.

Study reported a significant decrease in energy intake with increased total sugar intake (Nicklas et al., 1996). A negative correlation between total sugar intake and body mass index (BMI) has been consistently reported for children and adults (Bolton-Smith and Woodward, 1994b; Dreon et al., 1988; Dunnigan et al., 1970; Fehily et al., 1984; Gibson, 1993, 1996b; Miller

DIETARY CARBOHYDRATES: SUGARS AND STARCHES 311

Main Effect" Comments4

RR of CHD associated with high glycemic RR of CHD load only for those with BMI > 23

RR of CHD

No association between GI and risk of CHD

1.00

(p for trend = 0.7)

1.12

1.11

Serum HDL-C

(mmol/L)

p for trend < 0.001

1.36

The decrease in HDL-C was similar for subjects

1.31

with BMI < 25 and those with BMI > 25

1.30

1.27

1.28

Plasma HDL-C

Plasma TAG

Nonsignificant negative association

(mmol/L)

(mmol/L)

between GI and HDL-C concentration

1.45

1.16

(p for trend = 0.1)

1.42

1.20

Nonsignificant positive association between

1.42

1.14

GI and TAG concentration

1.40

1.27

(p for trend = 0.03)

1.29

1.37

OR of colon and

p for trend < 0.001

rectum cancer

Similar findings for glycemic load

et al., 1990) (Table 6-11). A study of 42 women compared the effects of a high sucrose (43 percent of total energy) and low sucrose (4 percent of total energy), low fat (11 percent total energy) hypoenergetic diet (Surwit et al., 1997). There were no significant differences between groups in total body weight lost during the intervention. On the other hand, a study using

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st le o

Glycemic Index (quintiles)

FIGURE 6-3 Relation between high density lipoprotein (HDL) cholesterol concentration and five quintiles of glycemic index in men and women. Reprinted, with permission, from Frost et al. (1999). Copyright 1999 by Elsevier Science (The Lancet).

23 lean men, 23 obese men, 17 lean women, and 15 obese women found that lean and obese individuals of the same gender had similar total sugar intake (Miller et al., 1994). However, the obese individuals derived a greater percentage (38.0 to 47.9 percent) of their sugar intake from added sugars compared with lean individuals (25.2 to 31.4 percent).

Increased added sugars intakes have been shown to result in increased energy intakes for children and adults (Bowman, 1999; Gibson 1996a, 1997; Lewis et al., 1992). Despite these observations, a negative correlation between added sugars intake and BMI has been observed (Bolton-Smith and Woodward, 1994b; Gibson, 1996a; Lewis et al., 1992). For adolescents, nonconsumers of soft drinks consumed 1,984 kcal/d in contrast to 2,604 kcal/d for those teens who consumed 26 or more oz of soft drinks per day (Harnack et al., 1999). Using NHANES III data, Troiano and colleagues (2000) found that soft drinks contributed a higher proportion of daily energy intake for overweight than for nonoverweight children and adolescents. Kant (2000) demonstrated a positive association between energy-dense, micronutrient-poor food and beverage consumption (visible fats, nutritive sweeteners, sweetened beverages, desserts, and snacks) and energy intake.

Ludwig and colleagues (2001) examined the relationship between consumption of drinks sweetened with sugars and childhood obesity. They concluded that for each additional serving of the drinks consumed, the

DIETARY CARBOHYDRATES: SUGARS AND STARCHES 313

odds of becoming obese increased by 60 percent. Drinks sweetened with sugars, such as soft drinks, have been suggested to promote obesity because compensation at subsequent meals for energy consumed in the form of a liquid could be less complete than for energy consumed as solid food (Mattes, 1996).

Published reports disagree about whether a direct link exists between the trend toward increased intakes of sugars and increased rates of obesity. The lack of association in some studies may be partially due to the pervasive problem of underreporting food intake, which is known to occur with dietary surveys (Johnson, 2000). Underreporting is more prevalent and severe by obese adolescents and adults than by their lean counterparts (Johnson, 2000). In addition, foods high in added sugars are selectively underreported (Krebs-Smith et al., 2000). Thus, it can be difficult to make conclusions about associations between sugars intake and BMI by using self-reported data.

Based on the above data, it appears that the effects of increased intakes of total sugars on energy intake are mixed, and the increased intake of added sugars are most often associated with increased energy intake. There is no clear and consistent association between increased intake of added sugars and BMI. Therefore, the above data cannot be used to set a UL for either added or total sugars.

GI. Although there have been several short-term studies on the relationship between dietary GI and hunger, satiety, and energy intake at single meals, many of the studies are confounded by differences between test diets in variables other than GI (Roberts, 2000b). Among relatively controlled studies (Guss et al., 1994; Holt and Brand Miller, 1995; Ludwig et al., 1999; Rodin, 1991; Spitzer and Rodin, 1987), voluntary energy intake was 29 percent higher following consumption of high GI test meals or preloads compared to those of low GI, as summarized in Figure 6-4 (Roberts, 2000b). These data strongly suggest an effect of GI on short-term energy intake, but there are currently little data on the effect of GI on energy intake from longer-term clinical trials. Such data are necessary before the effects of the GI of carbohydrate-containing foods on energy regulation can be appropriately evaluated because the effects of GI on energy intake might become smaller over time. Obtaining data from clinical trials is especially important because although one nonblinded study reported greater weight loss success in obese patients treated with a low GI diet compared with a conventional low fat diet (Spieth et al., 2000), the two epidemiological studies reporting BMI in their evaluations of the relationship between GI and development of chronic diseases observed no significant association between GI and BMI (Liu et al., 2000; Salmerón et al., 1997a, 1997b).

DIETARY REFERENCE INTAKES

TABLE 6-10 Sugar and Energy Intake

Reference

Design and Study

Sugar Intake (% of Energy)

Total sugar

Gibson, 1993

2,705 boys and girls Department of Health Survey of British School Children

Nicklas et al.. 1996

568 boys and girls, 10 y Bogalusa Heart Study

Farris et al., 1998

568 boys and girls, 10 y Bogalusa Heart Study

16.1

35.6

Added sugar Lewis et al., 1992

Nationwide Food Consumption Survey (1977-1978)

Gibson, 1996a

1,087 men and 1,110

women Dietary and Nutritional Survey of British Adults

Gibson, 1997

1,675 boys and girls,

1.5-4.5 y U.K. National Diet and Nutrition Survey of Children

Bowman, 1999

Continuing Survey of Food Intakes by Individuals (1994-1996)

a,b,c Different lettered superscripts within each study indicate that values were significantly different.

DIETARY CARBOHYDRATES: SUGARS AND STARCHES 315

Energy Intake (kcal)

Boys

Girls

10-11 y

14-15 y

10-11 y

14-15 y

1,954a

2,401a

1,753a

1,819a

2,095*

2,526b

1,838b

1,961b

2,066b

2,549b

1,871b

1,901a'b

High consumers of added sugars had greater energy intakes than consumers of moderate and low added sugars

Men

Women

2,219a

1,438a

2,430b

1,681b

2,455b'c

1,738b

2,549b'c

1,773b

2,596c

1,774b

Boys

Girls

1,129a

1,097a

1,168'a'b

1,102a

1,187a'b

1,139a

1,188'ab

1,115a

1,217b

1,116a

1,860a

2,040b

2,049b

316 DIETARY REFERENCE INTAKES

TABLE 6-11 Interventional and Epidemiological Data on Sugar Intake and Body Mass Index (BMI)

Sugar Intake

Reference Study Design (% of energy)

Total sugars Dunnigan et al., 1970

9 men and women, 4-wk crossover

31% sucrose sucrose-free

Fehily et al., 1984

Dreon et al., 1988

Miller et al., 1990

Gibson, 1993

7-d weighed dietary record

155 obese men, 30-59 y 7-d dietary record

107 men and 109 women, 18-71 y 24-h recall and 2-d dietary questionnaire

2,705 boys and girls Department of Health Survey of British School Children

Bolton-Smith and Woodward, 1994b

11,626 men and women,

25-64 y Scottish Heart Health and MONICA studies

Quintile 1

Gibson, 1996b 1,087 men and 1,110 women,

16-64 y

Dietary and Nutritional Survey of British Adults

Quintile 1

DIETARY CARBOHYDRATES: SUGARS AND STARCHES 317

Significant negative association between sucrose intake and BMI

Significant negative correlation between sucrose intake and BMI

Significant negative correlation between sugar intake and percentage of body fat for women; no association for men

Boys

Girls

10-11 y

14-15 y

10-11 y

14-15 y

18.6a

20.2a

18.2a

21.2a

17.9a'b

20.0a'b

18.1a

20.2b

17.5b

19.2b

17.9a

19.8b

Men

Women

27.0

26.5

26.4

26.0

26.0

25.5

25.5

25.1

24.7

24.4

Significant negative correlation between sugar intake and BMI

Significant negative correlation between sugar intake and BMI

Men Women

Weak negative association between sugar intake and BMI

continued

318 DIETARY REFERENCE INTAKES

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