RepublicPhilippinesSugarRegulatoryAdmin.txt FOOD AND … · We would like to comment on the issue...

RepublicPhilippinesSugarRegulatoryAdmin.txtFOOD ANDAGRICULTUREORGANIZATIONOF THEUNITED NATIONSORGANISATIONDES NATIONSUNIES POURL’ALIMENTATIONET L’AGRICULTUREORGANIZACIONDE LAS NACIONESUNIDAS PARALA AGRICULTURAY LA ALIMENTACION

OFFICE OF THE FAO REPRESENTATIVE IN THE PHILIPPINESNEDA sa Makati Bldg., 106 Amorsolo Street, Legaspi Village, Makati CityPostal Address: P.O. Box 7285 DAPO, 1300 Domestic Road, Pasay City

TEL.: (632) 817-1507; 892-0611 to 25893-9593; 817-1654FAX: (632) 817-1654E-MAIL: FAO-PHL~fieId.fao.org

NU I/I

03 July 2002

Dear Mr. Randell,

Please refer to the Draft Report on the WHO/FAO Expert Consultation on Diet,Nutrition and the Prevention of Chronic Diseases, held in Geneva from 28 January to IFebruary 2002. The draft report was referred to the Sugar Regulatory Administration (SRA)and we are sending you herewith a copy of the Administrator’s (SRA) comments/reactionsfor your information and appropriate action.

With kind regards.

Yours sincerely,

RepublicPhilippinesSugarRegulatoryAdmin.txt

Mr. Alan W. RandellSenior Officer (Food Standards)Joint FAO/WHO Food Standards ProgrammeFAO HeadquartersViale delle Terme di Caracalla00100 Rome, Italy

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REPUBLIC OF THE PHILIPPINESSUGAR REGULATORY ADMINISTRATIONNorth Avenue, Diliman, Quezon CityP.O. Box 70, U.?., Diliman, Quezon City

June 6, 2002DR. SANG MU LEERepresentativeFood and Agricultural Organization4/F NEDA sa Makati BuiIding~106 Amorsolo St., Legaspi Village,Makati City

Dear Dr. Sang Mu Lee:f//CWe understand that the WHO and FAO are soliciting comments for the finalization of theDraft Report on the WHO/FAO Expert Consultation on Diet, Nutrition and the Preventionof Chronic Diseases, particularly those that will have a bearing the formulation ofimplementation strategies. We learned about this issue from the Philippine Sugar MillersAssociation, Inc., a member of the World Sugar Research Organizati

RepublicPhilippinesSugarRegulatoryAdmin.txton (WSRO), whichprovided us a copy of the said Draft Report. The WSRO requested the PSMA to sendcomments to the WHO. While sending their own comments, the PSMA referred theReport to 6ur office for our own opinion, which FAQ and WHO may find worthconsidering.

We would like to comment on the issue of health risk due to excess sugar intake. TheSRA believes that the issue is not much of a concern for d~veIoping countries like thePhHippines as it is for the developed countries. in our country, consumption of sugar isway below the per capita consumption recommended by the report. On theother hand,.sugar is one of the basic commodities in our country being the cheapest source ofenergy, especially for the poor. Hence-, reduction of sugar intake may not be appropriatenutrition recommendation for our people.

We have provided our Department of Health .(DOH) a copy of the Draft report asking:them to prepare comments.and recommendations1 as well. We believe that our DOH.can provide you an expert opinion backed by results of their scientific studies on nutritionand health.

We hope that we have provided a worthwhile input to your report.

Thank you for your kind attention.

• Verytrulyyours,

~AEDESM AAdministratorC /li ~ ‘I f~,~’uc#4

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Tel: 926-ifl~ -~2~7-~O4IPASS ~2OA~27: 9~-4~O*

-IIIInternational Su~atDQr~ani zation

RepublicPhilippinesSugarRegulatoryAdmin.txtmni~ ‘4’lr 1 Canada Square

im ~ALLLLI1 in”’ CanaryWharfL!jiLndonEl4sAA

In~ [NilEXECUTIVE DIRECTORU ULJ~..&9LLiU -u L§r,LJ

By: \~-~--fl~ u~ —~ I Ct/Memo(02)17(English only)

6 June 2002

World Health Organization Consultations

Further to Memo(02)07 and Memo(02)11 the Executive Director would like tobring the two annexed documents to the attention of Members to inform them aboutactivities regarding the “Draft Report (as of April 26 2002) of the Joint WHO/FAGExpert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases”(Geneva, 28 Jan — 1 Feb 2002).

The Executive Director proposes that Members take individual action alongthe lines outlined in the annexed documents.

All initiatives taken by the ISO are in close cooperation with the World SugarResearch Organization (WSRO) and the Sugar Bureau.

The International Sugar Organization will also be sending the speech of theChairman of the International Sugar Council from the Opening Ceremony of the 21stSession of the Council, to the Director General of the WHO, Dr. Brundtland.ISOMemo(02)17

Annex I

ISO recommends to intervene against a planned recommendationof WHO to limit sugar intake below the current level

Nutrition experts of a joint WHO/FAO consultation recommend limiting theintake of “free sugars~~* to 15 — 20 kg/per capita and year (which equals about<6 - 10% of energy intake). That is less than today’ s average wor

RepublicPhilippinesSugarRegulatoryAdmin.txtld per capitasucrose consumption.

The Joint WHO/FAO Expert Consultation Report Diet, nutrition and theprevention of chronic diseases” (draft as of 26. April 2002) suggests publichealth nutrition policy strategies aiming at the prevention of several non-communicable diseases (obesity, diabetes, cardiovascular diseases, cancer,dental diseases and osteoporosis) by modification of the diet. For this purposethe Draft Report presents nutrition recommendations in the form of single anduniversal dietary nutrient goals prescriptive for the nutrition of the populationworldwide.

The exact role and the proportion of diet and nutrition in the development ofchronic diseases remains under discussion. All foods have a nutritional valueand can therefore contribute to a balanced diet. There is no such thing as a“good” or “bad” food. Although diet certainly plays a role, there is a risk that thereport, by focusing solely on diet, will lead to misconceptions as to the relativeimportance of non-dietary factors in the development of chronic diseases. It isthe interplay of several factors which may contribute to the development ofchronic diseases. Some of these factors are not modifiable as genetics andsome are modifiable as physical activity level. There is no scientific evidencethat in free societies the modification of the diet is practicable, nor is therecredible evidence that the proposed changes in consumption of sugar willresult in improved health.

The Draft Report discriminates in its dietary advice between “free sugars~’* and“other sugars~~*, proposing a limitation of “free sugars” intake to less than 10%food energy.

*Note:

• “Free sugars” defined in the report as All mono- and disac

RepublicPhilippinesSugarRegulatoryAdmin.txtcharides added by manufacturer,cook and consumer, plus sugars naturally present in honey, syrups and fruit juices.”• “Other sugars” defined as “sugars naturally present in whole grain foods, whole fruit andvegetables, milk and milk products

The available scientific evidence does not support this categorization ofsugars. All sugars, whether naturally present or added, are carbohydrateswhich supply the organism with energy. There is no nutritional difference thatis attributable to their chain length or disposition within foods. The definitionproposed in this Draft report is identical to an earlier terminology that was

1specifically rejected by a recent FAO/WHO expert consultation oncarbohydrates (FAO 1998). Any suggestion of population targets for “freesugars” is consequently invalidated.

There is a lack of scientific justification for setting population sugar targets onpublic health grounds. Many nutrition societies in the world as well as tworecent FAQ/WHO expert consultations rejected any quantitative/numeric targetfor sugar intake, due to lack of scientific evidence.

The scientific case put forward for the sugar target in respect of obesity isvague and speculative. Obesity is the result of an imbalance between energyintake and energy expenditures. Sugar is a regular carbohydrate in dietsworldwide contributing 4 kcal/g in common with other carbohydrates. Highcarbohydrate diets — including sugar - are useful in weight management andthe prevention of excess weight and obesity. The report does not provide anyscientific data to justify a separate nutrient goal for “free sugars” within the totalcarbohydrate goal of 55—75 energy % for weight management.

The scientific case put forward for a limit in “free sugars~~ consumption as ameans of reducing the prevalence of dental caries is demonstrably

RepublicPhilippinesSugarRegulatoryAdmin.txterroneousand misleading. All fermentable carbohydrates can contribute to dental cariesif oral hygiene is inadequate. In these circumstances it is not the amount ofcarbohydrate consumed but its frequency which is a risk.

ISO action and recommendation

The ISO participated in the “Consultation with Industry Organizations on Diet,Nutrition and Prevention of Chronic Diseases” at the World HealthOrganization Headquarters Geneva, 16 April 2002.

The ISO is preparing comments upon the Draft Report and will submit them toWHO (deadline 15 June, 2002).

WHO intends to finalize the Draft Report by the end of the year. The Report,once finalized, is intended to form the basis for the future public healthstrategies to reduce the global burden of chronic diseases. Therefore it ishoped that the comments made by ISO will be considered in the final report.

In addition ISO ask national governments to intervene via their WHOrepresentatives. It is our task to avoid that the scientifically non justifiedsugar targets in this Draft Report are not implemented into future WHOpolicy and public health strategies.

2AK liii—

Memo(02) 17Annex II

Comments by I.S.O.


on the

Draft Report (as of 26. April 2002) of the Joint WHO/FAO Expert Consultation and Diet,Nutrition and the Prevention of Chronic Diseases (Geneva, 28. Jan. - 1. Feb. 2002)

The International Sugar Organisation (I.S.O.) is an intergovernmental non-profit-organization andrepresents 61 countries worldwide, from Argentina to Zimbabwe, developing and developed countries.Members represent 61 percent of world consumption.

ISO welcomes the invitation to provide its expertise and comments to the draft report of the expertconsultation on ,,diet, nutrition and the prevention of chronic diseases”. This comment concentrates onthe science base of the suggested worldwide population nutrient intake goal for ,,free sugars” and thecorresponding background papers with focus on sugar-related issues.

1. The concept of worldwide nutrient goals

This Draft Report presents nutrition recommendations in the form of single and universal dietarynutrient goals prescriptive for the nutrition of the population worldwide. The impression is given thatnot adhering strictly to the upper nutrient limits posited will lead automatically to several chronicdiseases considered (obesity, diabetes, cardiovascular diseases, cancer, dental diseases andosteoporosis). This impression exaggerates the influence of diet in these diseases and obfuscates themajor influence of a number of other aetiological influences. This “one size fits all” approach alsoignores the considerable variation in the importance of these different (dietary and non-dietary) factorsin different individuals and population groups. In the past, the concept of prescriptive populationtargets for macronutrients was criticized for a number of valid reasons. Among these, are the fact thatthe human body is able to adapt to diets of widely different macronutrient composition, especiallyunder conditions of encrgy balance.

The impression given in the Draft Report that morbidity and mortality from the seven non-communicable diseases selected would be dramatically reduced, and

RepublicPhilippinesSugarRegulatoryAdmin.txtthat health care costs would becorrespondingly reduced, is not supported by the balance of evidence. This simplistic view has beenproposed, and rejected, before. The WHO Technical Report 797 was published in 1990 and widelyrejected. Among those repudiating this earlier Report were the FAO (EUR/ICP NUT 145; Annex 3).The arguments of FAO were “that different dietary habits exist between each country and manygroups within countries. The differences between such groups, and particularly between developedand developing countries make it impossible to suggest any one valid set of numericalrecommendations, including ranges of quantitative targets for various nutrients. The recommendationof quantitative nutrient targets in general international reports can cause serious nutritional, health andeconomic problems when such quantitative targets are taken as absolute by government authorities,and this has occurred in some countries. In addition, quantitative nutrient recommendations referringto foods or food components for which there is insufficient scientific evidence to support suchrecommendations can cause serious problems to the general and economic development of developingcountries”.

I-low best to promote a balanced diet was the topic of a recent Joint FAO/WHO consultation on the“Preparation and Use of Food-Based Dietary Guidelines” (WHO Technical Report 880, published in1998), which comprehensively addressed the scientific and practical issues involved in promoting ahealthy eating pattern. This consultation also assessed the scientific basis for the relationship betweendiet, nutrition and health, including consideration of all aspects of the diet (energy, macronutrients andmicronutrients) as well as different population subgroups. Strategies and tools to improve dietarypatterns, adaptable to different circumstances, were suggested. This Draft Report is, therefore,disingenuous when it states that previous FAO and WI-lO reports have provided “limited guidance onthe meaning of a balanced diet”.

Other Consultation reports. e.g. “Fats and Oils in Human Nutrition” (FAO Food and Nutrition Paper57; published in 1994) and “Carbohydrates in Human Nutrition” (FAO Food and Nutrition Paper 66;published in 1998) have also considered the impact of these macronutrients with respect to theprevention of chronic diseases. The conclusions of these reports a

RepublicPhilippinesSugarRegulatoryAdmin.txtre in contradiction to this DraftReport in that they put the proportions of macronutrient intakes into a realistic perspective, allowingfar more flexibility in response to the dietary circumstances of the individual. Furthermore, the report“Carbohydrates in Human Nutrition” and the report on “Food-Based Dietary. Guidelines” bothspecifically advised against setting a target to limit sugar intake.

2. The classification of sugars for health purposes

The Draft Report discriminates in its dietary advice between “free sugars” and “other sugars”,requesting the limitation of “free sugars” intake to less than 10 energy %.

The Draft Report defines ,,free sugars~~ as “all mono — and disaccharides added by manufacturer, cookor consumer plus sugars present in honey, syrups and fruit juices” and “other sugars as sugarsnaturally present in whole grain foods, whole fruit and vegetables, milk and milk products” assuggested by the background paper on dental diseases (Annex 6, page 22; see also footnote 28 toTable 2 on page 21 as well as Annex 1). There is no scientific evidence that this categorization ofsugars is of any value to public health.

This terminology contradicts other WHO consultations. The distinction into these two categories is notjustified in the Draft Report’s discussion of either obesity or oral health as naturally occurring sugarsare equally calorific and have similar influence on dental caries. The latter topic was the subject of ascientific review paper on diet and oral health presented at the Second World Dental Conference onOral Health promotion organized by the World Dental Federation (FDI) in 1999 (K~5nig K.G.: Dietand oral health; mt. Dent. J.; 2000). It concluded that all sugars are potentially cariogenic and statedexplicitly “it is not true that naturally present sugars in fruits or lactose in milk are noncariogenic.”

The Draft Report’s proposal that the intake of “free sugars” should be monitored is impractical andunnecessary. Sugars added, for example to fruit salads, could not be discriminated from thosenaturally present by analytical measures. Furthennore, the body cannot tell the difference betweennaturally occurring and added sugars because they are metabolised

RepublicPhilippinesSugarRegulatoryAdmin.txtin the same way.

3. Nutrient recommendations for the prevention of excess weight gain and obesity (Chapter 4.1and Annex 2)

The Draft Report contains several misconceptions on the role of sugar in relation to weight gain andobesity that merit correction.

The scientific background paper on the “Prevention of excess weight gain and obesity” classifiesrefined sugar (sucrose) as “often seen as being a cause of weight gain “. This statement suggests a biasin the subsequent assessment of research reports on sucrose.

The general view of carbohydrates (including sugars) in relation to obesity has changed over the pastfew decades, among the research community, from being conducive to over-consumption and weightgain to being protective. This change has been ignored in the Draft Report. Research has consistentlyshown that high carbohydrate/ low fat diets influence energy balance (probably by reducing foodintake through greater satiety effects, reducing energy density and displacing fat from the diet) and

2IL

thus help in body weight control. This applies to high carbohydrate diets, even those with higher thannormal sugar contents.The background paper seems to accept that high carbohydrate diets protect against weight gain. But itthen asks the rhetorical question “whether the same association applies to diets high in sugar”. It failsto answer this question, despite the fact that there is ample evidence in the literature that highcarbohydrate diets protect against weight gain, irrespective of their sugar content.

Current advice on body weight management is to reduce dietary fat in favour of a higher intake ofcarbohydrates. As total sugar intake is commonly inversely related to total fat intake, a higher sugarintake in low fat/high carbohydrate diets seems to be an acceptable option. This was the conclusion of

RepublicPhilippinesSugarRegulatoryAdmin.txtan expert debate at the EURODIET conference in 2000 (James WPT: Carbohydrates; Public HealthNutrition 2001; 4: 402— 405).

Thus the balance of research evidence on the relationship between sugars and body weight is indisagreement with the proposal in the Draft Report that “free sugars” should be restricted to avoidweight gain. The statement that “free sugars” content of the diet is an indicator for the energy densityof the diet is demonstrably incorrect.

The Draft Report’s position on sugar and obesity is in stark contrast to the balance of the evidence andto the conclusions of other expert groups. The FAO/ WHO joint expert consultation reportCarbohydrates in Human Nutrition concluded “there is little direct evidence that obese individualseat excessive quantities of sweet foods. Indeed, a number of studies show an inverse relationshipbetween sugar consumption and overweight”. The FAO/ WHO consultation report entitledPreparation and Use of Food-Based Dietary Guidelines concluded that there is no evidence thatfoods high in sugar contribute significant amounts of fat to the diet, although some foods are relativelyhigh in fat and sugars”.

The further argument put forward in the background paper that sugar is used by food manufacturers asa fat replacer, and would thus lead to an (over)-compensation for the fat calories exchanged, seems tobe of anecdotal origin. No evidence is put forward to substantiate this bizarre idea. The acceptablesweetness of a food item cannot be increased by adding more sugar, nor has sugar the specificproperties to imitate the technological functionalities of fats in food manufacturing. The Draft Reportalso claims that fat-reduced foods often have a higher energy density as a result of their sugar content.Though couched in vague terms, this claim implies that the product will be higher in energy densitythan the normal (high fat) product. Since sugar has less than half the energy value per grani than fat, aproduct would need to contain over twice as much sugar as the fat replaced to achieve an increase inenergy density. There are no examples of such foods on the market. Therefore the hypothesis thatsugar, by replacing fats, lead to foods of higher energy density is both implausible and factuallyincorrect.

RepublicPhilippinesSugarRegulatoryAdmin.txtSugar is a carbohydrate, contributing 4 kcallg as all carbohydrates, irrespective of the molecular size.High carbohydrate diets — including sugar - are useful in weight management and the prevention ofexcess weight and obesity. The assumption that some selective food and drink items are the cause ofthe obesity epidemic is not proven. The report does not provide any scientific data to justify’ a separatenutrient goal for “free sugars” within the total carbohydrate goal of 55 — 75 energy % for weightmanagement.

4. Nutrient recommendations for the prevention of dental diseases(Chapter 4.5 and Annex 6 and Annex 1)

In Chapter 4.5 of the Draft Report, on page 38, it is stated that” dietary sugar is the main cause oftooth loss in dental caries” and “that dental caries is preventable by limiting the amount and frequencyof consumption of free sugars”. These and other statements in Table 8 and in the background paper arein stark contrast to the international scientific consensus on the relationship between diet and dentalcaries and thus also conflict with the scientific evidence.

3ITL I I -71The Draft Report recommends a population target for a maximum intake of “free sugars” (<10 % ofenergy intake) in order to prevent dental diseases. This target ignores the clear evidence that allcarbohydrate foods — whether cooked starches, sugars naturally present in foods or added - arepotentially cariogenic. Sugars that are liberated from cooked or processed starches by salivary amylasecan contribute to caries risk. It is universally acknowledged that the best measures to prevent caries arethe regular removal of dental plaque with a toothbrush and the use of a fluoride toothpaste twice a day.These important public health approaches were not mentioned in the Draft Report.

Dental caries is recognized as an infectious, communicable disease with multifactorial aetiology. Themain modifiable factor is the presence of carbohydrate-fermenting (acidogenic) bacteria in dentalplaque. The bacterial fermentation products may lead to demineralisation of the tooth. Oral hygiene

RepublicPhilippinesSugarRegulatoryAdmin.txtwith regular removal of dental plaque by tooth brushing with a fluoride-containing toothpaste isrecognised to be the most effective caries preventive measure. It helps to remove food debris and tominimize dental plaque; inhibits the metabolism of sugars to acids by acidogenic bacteria; whilefluoride promotes the remineralization of the teeth. If oral hygiene habits with fluoride are practised,then current dietary habits are not a problem for caries. And where caries still occurs, it ispredominantly lack of oral hygiene or lack of exposure to fluoride that is the issue (Carbohydrates inHuman Nutrition, 1998; FAO). If dental plaque is present, virtually every eating occasion may lead toa pH-drop and an acidic attack on dental enamel.

Research has shown that it is not the aniount of sugar consumed, but it is the frequency of eatingoccasions of fermentable carbohydrates. The major part of the mixed diet (more than 99 %) isswallowed as such and not in contact with oral bacteria. Only minute amounts are used by dentalplaque bacteria. This demonstrates again, that not the amount ingested is of importance, but the foodretained in the dentition and in dental plaque. As there are no significant selfcleansing mechanisms inthe oral cavity for the sites at risk, the active removal of dental plaque bacteria is important. This isanother prove that a quantitative nutrient target to limit “free sugars” intake to 6-10 energy % as ameans to control dental caries although the diet should be rich in total carbohydrates (55- 75 %energy) and high in fruits and vegetables is not corroborated by dental research.

The FAOIWHO Consultation Carbohydrates in Nutrition called ,for a more rationale approach to therole offermentable carbohydrates in dental caries. “The report concluded that “That a basic personalprevention package” of oral hygiene habits — cleaning with a toothbrush and using fluoride toothpaste— is probably sufficient to keep 75 per cent of adolescents caries free. In short, dental health problemsdo not require any dietary recommendations in addition to, or other than those required formaintenance of general health” (FAQ, 1998).

It is recommended that the conclusions reached by the Second World Conference on Oral HealthPromotion of 1999 in London of the International Dental Federation (FDI) should be the basis for theoral health advice in the draft report (Int Dent.J. 2000; Volume 3

RepublicPhilippinesSugarRegulatoryAdmin.txt; pp135 - 174). Such advice wouldalso be consistent with the FAG/WhO Consultation on Carbohydrates and Human Nutrition, 66, 1998,which called ,for a more rationale approach to the role of fermentable carbohydrates in dentalcaries.” The report concluded that “if oral hygiene with a fluoride dentifrice is practised, dentalhealth problems do not require any dietary recommendations in addition to, or other than thoserequired for maintenance of general health.”

5. Conclusion

The Draft Report discriminates in its dietary advice between “free sugars” and “other sugarsrequesting the limitation of “free sugars” intake to less than 10 energy % .The Draft Report defines~,free sugars” as “all mono — and disaccharides added by manufacturer, cook or consumer to foodsplus sugars present in honey, syrups and fruit juices” and “other sugars~~ as “sugars naturally presentin whole grain foods, whole fruit and vegetables, milk and milk products “. The distinction into thesetwo categories is not justified in the Draft Report’s discussion of either obesity or oral health as

4I.naturally occurring sugars are equally calorific and have similar influence on dental caries. Thisterminology contradicts other WHO consultations.

The Draft Report proposes to limit the intake of “free sugars” to less than 10 energy % based mainlyon the argnment to prevent obesity and to prevent dental caries. This recommendation for a populationnutrient goal for “free sugars” is in contrast to scientific evidence and consensus statements of manyhealth associations worldwide, which did not set a specific target to limit sugars intake. As there is nonew evidence available to justify such a figure, the sugar target should be deleted from the WHO draftreport.

Carbohydrates are a required component of a balanced diet. It is widely accepted that carbohydrates,including sugars, are useful components of the diet when weight gain is to be avoided.

Where adequate oral hygiene and fluoride are present daily, diet h

RepublicPhilippinesSugarRegulatoryAdmin.txtas become a lesser factor in cariesprevention. Without sufficient fluoride and hygiene, diet becomes more important. Under thesecircumstances it is the frequency of consumption of all carbohydrate-containing foods mid drinks thatconstitute the risk rather than the amount.

The main public health message of Table 2 is the recommendation to eat a high carbohydrate/ low-fatdiet. There is no scientific justification to set a 10 % limit for sugars within the broad range for totalcarbohydrate intakes of 55-75 energy %.

Bibliography

— Deutsche Gesellschaft fuer Ernaebnnig, Oesterreichische Gesellschaft flier Ernaehrung, Schweizerische Gesellschaftfuer Emaehrungsforschung und Schweizerische Vereinigung fuer Eriiaehrung (2000) “Referenzwerte fuer dieNaehrstoffzuffilir”. UmschaulBraus, Frankfurt am Main.

— FAG: Carbohydrates in Human Nutrition. Report of a Joint FAG/WHO Expert Consultation. Rome. 14 — 18 April 1997FAG Food and Nutrition Paper 66. Food and Agriculture Organisation, Rome 1998.

— FAG: Fats and oils in human consumption. Report of a joint expert consultation organised by FAG and WHOI, Rome,1993: FAG Food and Nutrition Paper 57 (1994).

— FDI (F&kration Dentaire International): The FDI’s Second World Conference on Oral health promotion: Core Messagesin Oral Health Education. August 1999; London. International Dental Journal 2000 5O~ 115 — 174.

— Health Council of the Netherlands (2001): “Dietary Reference Intakes: energy, protein, fats and carbohydrates”. HealthCouncil of the Netherlands, The Hague.

— James WPT: Carbohydrates; Public Health Nutrition 2001~ 4 402 —405.

— Joint FAG/WHO Consultation on Preparation and use of Food-Based Dietary Guidelines (1995: Nicosia, Cyprus).Preparation and use of food based dietary guidelines: a report of a joint FAG/WHO Consultation. WHO TechnicalReport Series 880. World Health Organisation, Geneva 1998.

— Kbnig K. G.: Diet and Oral health. International Dental Journal 2000_50~162 — 174.


— Saris W. H. M.; Astrup A.; Prentice A. M.; Zunft H. J. F. et al.;Randomised controlled trial of changes in dietary carbohydrate/fat ratio and simple vs complex carbohydrates on bodyweight and blood lipids: the CARMEN study. mt. J. Obesity (2000) 24. 1310 - 1318.

— Surwit RS et al.: Metabolic and behavioral effects of a high-sucrose diet during weight loss. Am J Clin Nut 1997;65:908-915

— Van Loveren C.: Diet and dental caries: cariogenicity may depend more on oral hygiene using fluorides than on diet ortype of carbohydrates. European Journal of Paediatric Dentistry (2000) 1(2): 55 — 62.

— World Health Organization (1998) Obesity: Preventing and managing a global epidemic. Geneva. World HealthOrganization

5

REF II ~ PHONE HO. @32 9i373273 /-~~ Jun. 1 1Z7W12 1>121: @3211 Fl I

Critical Comnientaryof theDraft Report of WHO/FAQ Joint Consultation

S “Diet, Nutrition and the Prevention of Chronic Disease”6

7 on behalf of (1wB World Sugar Research Organisation910 S urn iii aix1112£3 This commentary focuses on three areas of the Draf

t Report:14 a. tile process of drafting and consultation,

and the general approach to policy issues.15 b. the analysis of the scientific evidence re

lating to sugar and dental caries.16 c. the opinion expressed on the role of sugar

RepublicPhilippinesSugarRegulatoryAdmin.txt in olwsit,’,

1718 The World Sugar Research Organisation has serious

concerns as to the inte~I-it- of the19 science in each of these areas.20212223 1. Process and Policy lssues2425 1.1 At the discussion meeting on 16 April, the Chairman of the Expert Consultation Group26 made clear that the starting assumption of the Consultation had been that population27 nutrient goaJs were needed. This assuni~ition has been challenged by another recent28 \VI-IOIVAO Expert Group. Its adoption as axiomatic by the Group cannot be justified29 on scientific or public health grounds and reflects a political bias that permeates the30 Draft Report’s consideration of a range of policy issues.3132 1.2 in addition, the 1)raft Report makes a number of sweeping assertions oi~ policy issues., •,that are not backed by any form of evidence. The experts convened for the

34 Consultation do not appear to have the relevant expertise in policy- ftirruulation. These

35 policy proposals include some that hare already been demonstrated to lie ineffective.

35 and others that are likely to achieve the opposite to the affect intended. The presence of

37 these ill thought out excursions into policy issues weakens the credibility ~f the Report

38 and should be removed. These includes at least, some of the nutricut goals proposed.

3940 13 1’he provision of this Comnientary and the

participation of WSIIO in the discussion41 meeting in Geneva on 15 April may not be r

cpresented as implying acceptance of any42 part of the Draft Report or its conclusions or rec

ommendations.13

Page 1 of 16123

473

RepublicPhilippinesSugarRegulatoryAdmin.txt~ REF I.~j PHONE HO. : @32 @@7327@’ i11-. ii uw LI-il. u.A-1 P12

Page 2 of 16~4 2. Sugar and Dental Caries4546 2.1 Section 43 of the Draft Report (“Nutrient recomniendations for the prevention ~f47 dental diseases”) appears to be based on Annex 6 (“the scicixtilie basis for diet,48 nutrition and the prevention 9f dental diseases”) written by Paula Moynihan. and is49 reflected hi the table in Annex 1 (“Summary of the strenvAh of evidence br ubesitN,50 type 2 diabetes, CVD, cancer, dental disease and osteoporosis”).5152 2.2 The presentation of evidence in Annex 6 does not meet modern standards of53 objectivity. The e~idence is not assessed in a systematic manner and, in coTisequebec.54 substantial selection bias is apparent in the evidence cited and in the appreciable body55 of evidence that is ignored. In general, evidence in favour of the author’s opinion is56 selected while evidence to the contrary, even if more extensive arid 0f higher quality, is57 ignored.5859 2.3 A basic error in the interpretation of epidemiological evidence has occurred in Annex60 6, which is then repeated in these other two sections. Both asnoiwi and frequency of61 sugars consumption arc claimed to he independent variables predicting dental caries62 risk in all populations. No evidence to demonstrate that these variables are indeed63 independent is cited. it is clear that these two variables are strongly correlated with64 each other. Evidence that frequency is the independent variable predicting carius rim65 (but only to any appreciable extent when the prttective influence of fluoride and oral66 hygiene is absent) is obscured and ignored. Evidence that amount is not important is67 arbitrarily discarded.6869 2.4 As a result of this error, a target for population consumption of “fl-ce sugars” is70 proposed. This target is ii ot supported by the ba

RepublicPhilippinesSugarRegulatoryAdmin.txtlance or available evidence; is is71 . unnecessary, unhelpful, impractical and arbitrary.7273 2.5 No evidence is presented to justify the assertion that ‘Tree sugars” have a74 fundamentally different influence on the caries process from sugars present in fruits75 and vegetables. Evidence that these two presentations of food sugars have similar76 effects is ignored.7778 2.6 The evidence that (cooked) starches have similar effects to sugars within the oral79 environment, and that they may have greater potential effects on caries, is also ignored.8083. 2.7 The hypothesis that there is an “5” shaped dose response curve relating the amount of82 sugar(s) consunied to the “level of dental caries” Is invoked without any plausible83 evidence to support it. This hypothesis provides a couvenient excuse to ignore the84 absence of any observed reIationsI~ip between these two variables in the overwhelruirw85 niajority of population studies. A.t the same dine a linear relationship, claimed in two 86 ecological studies, is accepted when it suits the author’s argument.3788 2.8 The international scientific consensus on the role of diet in dental caries is 89 misrepresented by ignoring important, recent, expert reviews while quoting extensively 90 from out-oUdate reviews.91 -

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192 2.9 The classification of the evidence wn “free sugars, amount and Irequcucy” (as positively93 related to dental caries) as “Convincing” (Annex 1) conflicts with the Dr~ift. RcpintZs94 own (unconventional) definition of “Convincing” a,.~d the admission in ~Mmcx 695 (Section 3) Chat much of the evidence is unsatisfactory on this point. The evidence that96 frequency of consumption of any ftrmentable carbohydrate is important, under97 appropriate circunistances, is indeed convincing. l’h.ere Is no evidence that amount of98 any of those fermentable carbohydrates has a separ

RepublicPhilippinesSugarRegulatoryAdmin.txtate eltect.99100101102 3. Weight Gain and Obesity103104 3.1 Section 4.1 (“Nutrient recommendations for the h)revelltion of excess weight gain and105 obesity”) and the relevant entry in Annex I might be expected to be based on the106 analysis of evidence in Annex 2 (“The scientific basis Thr diet nutrition and the107 prevention of excess weight gain and obesity”). However, the inclusion of a target of108 “less than 10% free sugars” in Section 4.1 (i.e. supposedly to avoid weight gain and109 obesity) is not justified in the review of evidence in Annex 2. Indeed Annex 2 concludes110 that the evidence on sugar is inconclusive (Section 3,2.2 of Annex 2). Other recent112. Expert reports have been more definite in dismissing any role for sugar in the aetiolog~112 of obesity.113114 3.2 The inclusion of a quantitative tat-get fot’ “free sugars”, to avoid obesity, in Section 4.1115 and in Table 3 of Annex 2 is neither justified by any objective review of the available116 evidence nor by the Draft report’s own review of tl~e evidence. The inclusion of this117 target is a blatant illustration of the preconceptions that have tainted so macti of the113 presentation of scientific evidence in this Draft Report. This refercnee to “free sugars119 in Section 4.1, and in Table 3 of Atmex 2 should lie removed. It is noteworthy that this120 target is not included in AnIlex 1.121122 3.3 ‘1’ he review of evidence in relation to the impact of sugars in soft drinks on weight gnus123 (in Annex 2 Section 3.2.2) provides scant support for the conclusion drawn. Further124 research is clearly merited in this area.125126 3.4 The assertion (Section 4.1) Chat “free sugars” content of’ the- diet is an indicator of127 energy density is not supported by studies that have exaniined this issue. Equally, the128 implication that the energy density of certain foods will determine the overall energy129 intake iii the diet (Annex 2 section 3.2.1) i~ not supported by the evidence currently

RepublicPhilippinesSugarRegulatoryAdmin.txt130 available, all of which relates to covert unanipulatious oh’ all, or a substantial proportion131 of, the total diet.132133134Page 3 of 16rn—fl____ -— — I

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135 1. Process and Policy Issues136137 13 The process by which food industry stakellolders have heeti invol~-ed in this discussion138139 The initiative by WhO to involve Food industry organisatmous In discussions on the i)ratt kcporL of140 this Expert Consultation is most welcome. However, in order to Inaxirruse the beneltt to public141 health of’ such involvement in the future. it is important that some lessons aie learned from this142 occasion. Food Industry organisations were provided with inadequate notict th it the Expert143 Consultation was to take place and of its subject matter. if given more x~arn’n” a process of144 consultation between the members of the various industries and with their ~r ientilir and neadernic145 advisors could have been initiated in time tO Contlibute much more eltectiv eh 11 adt quate time has1~6 been given for consideration of the Draft. Report. Indeed, the footnote on tin otie p-w’~, if adhered to147 literally, would preclude all meaningful consideration of the Draft Report Lw any of the

148 organisations.149150 These factors did nor engender confidence that the- WHO genuinely wishes to receive subsu±utive1St input from the food industry. The subsequent extension of the consultation period was welcome.152 Sut the considerable value of wholehearted involvement of thod industr; as a stakeholder ;vill only153 be realised if the industry is incorporated into the discussions at a much earlier stauc.154

155 12 The position of the WSR() on this Draft Report156

RepublicPhilippinesSugarRegulatoryAdmin.txt157 The WSRO accepted the invitation of the WHO to participate in a discussion of it’s l)rati kcpoi-t in158 Gene~ra on 16 April 2002. However, examination of those parts of the Draft that relate to suqar has159 shown that the analysis of the scicinifle literature, and the conclusions and reconImendalions thet160 arise from this analysis, are unsatisfactory. Other sections ot the Draft have not been exanianed in161 detail, but it is immediately a~)parct~t that tiie,-c ai-e other flaws as \veli.162163 The WSRO’s participation in the discussion meeting, and its provision of comments in WIltilDO.164 should not therefore be construed in any way as implying acquiescence to the Draft in its current165 form. Considerable modification would be required before the Draft, would be considered or166 adequate scientific quality at:’d accepted by WEiRD and its members.167168 1.3 The effects of time constraints on value of the discussion on 15 April 20112169170 The extremely short time allowed for consideration of this Draft Report is unlikely to lead to ss171 valuable a contribution from food industn’ stakeholdets as might have been achieved with better172 planning.173174 This is particularly unfortunate, since the Draft Report breaks new ground by detailing a number or175 policy proposals designed to achieve improvements in the dietary intake of various population176 groups. The food industry has wide experience of the consequences of similar policy initiatives ann177 would have been in a position to provide Practical guidanee on the likely outcome of these ideas.

178 given more tint179180 It is immediately apparent from a cursory examination of these proposals that some would, in181 practice, have the opposite cfThet to that intended. For examples restrictions on advertisina wou hi182 preclude the introduction of new varieties of existing products. even if seen by the Group as LLnlow183 healthy”. Othcrs (such as taxation of selective foods) are already in place in a number of countries184 and are extremely unlikely to achieve anything in relation to changes in consumption patterns hr

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189 tight of the limited expertise in policy fonnulation represented within the group of participants in

186 this Expert Consultation, it is strongly advocated that all these policy proposals are ic-eXaIfliUC(l t3v

187 a group that has experience in ibis area.188189 1,4 Nutrient recommendations for the prevention of

chronic disease190191 The Draft report proposes the setting of target nu

trient intakes for tbc prevention of a range ol192 chronic, non-communicable diseases. In the time av

ailable it has not been possible to etamine the193 specific justification posited for each of these t

argets.194195 The following commentary is therefore confined to

issues raised in relation to sunat As will196 become apparent from, the commentary, the XVSRO ca

nnot recommend acceptance of the DeaR197 Report’s analysis of the role of sugar in the diet

, or W.e conclusions drawn from such, a fiaweri198 review.199200 The lack of comnient on other sections of the Draf

t Report should not be taken to indicate that other201 issues and recommendations do not merit comment, o

r that WSRO aerces with the ana lyces an;]202 conclusions presented on these other issues.203204 The general approach of setting quantitative nutri

cnt goats has been criticised (World Health205 ()rganisationi Food and Agriculture Organisation.

1998). WSRO agrees with these criticisms and iS206 disappointed to see the retrograde approach adopte

d Lbroughout this Drafi Report. Indeed, as.207 became apparent during the discussions on April 16

. the a priori assumption by the t+.xpcrt Group208 that quantitative population nutrient goals were n

eeded represents an arrogation of the scic.nnt¶c209 evidence by a politically coloured policy assunipt

ion.210211212 2. Dental Caries213214 2.1 Objectivity in interpretation of the evidence

ou Dental Caries215216 The main scientific justification for the position

RepublicPhilippinesSugarRegulatoryAdmin.txt adopted in the Draft Report on sugar and dental

217 caries is articulated in the paper by Moynihan attached at Annex 6.A particularly serious fault with

218 Annex 6 is its lack of objectivity. No attempt is made to review the evidence in any sort ol

219 systematic manner. Published scientific papers are selected for citation in an old-ths’nioncd narrauvc

220 approach, apparently to fit a preconceived araumenL More modern methods of assessment of

221 evidence are designed to minimise the risk of bias by the reviewer by requiring that all relevam

222 evidence is considered, and that any selection of evidence on hquality! criteria should be

223 trauspareuL These methods should have been used if the conclusions reached axe to be generally

224 credible.225226 Examples of the severe consequences of this bias

arc seen in the treatment ot the epiderniologicat227 studies in individuals. It is not made clear that

the overwhelming majority of about 70 such studies228 in the scientific literature foundno statisticall

y significant correlation between amount or frequency229 of sugar consumption and caries. Those that repor

t a correlation found only weak explanations of230 the variance in caries despite a substantial rang

e of sugar consumption within the pQ;7Uiati~fl5231 studied.232 -

Page s of 16] -IIIREFU-I~3 PHONE NO. : 632 9673279 ¾ 11 2002 0T

h OOPN RE

WHO/FAG Renort on Diet. Nutrition and the Piex enhion of Chronic Diseases

In my e-mail dated I 8th April 2002, 1. communicated to you abotit the stattis of theabove report. The contents of that e-mail were. as 1bllo~vs:

“Dr Richard Coltrdll and nwself attended the WHO Consultation withIndustry Non Governmental Orgtuaizations on April 16th to cornineid. on ti~e DraftWi-JO report “Diet, Nutrition and the Prevention of Chronic Diseases”. Asummary report of this meeti rig is attached (md ustrvNGOConsu IWI

RepublicPhilippinesSugarRegulatoryAdmin.txtAO,doc) It. alsoattach the WSRO’s comments which were submitted on the Draft reliOrt(WSRO Response to WHO report - 15 apriJ doe).”

In response to our request, Wi-JO has agreed to be transparent and have put the rep onon their website. They are now inviting comments on the report from anyorganisadon. The e-mail 1 have received late ‘~esterday giving the web reference toaccess the report and requestine comments is attached.

Lu. viexv of the fact that initially WSRO was given l5’~’ April 2002 as the deadline wemade our comments with a focus on the oral health section of the report (cop-i’ of thatreport has been circulated to you). Under pressure, WHO has extended the period ofreceiving comments on the report to 15111 June 2002. WSRO on your behalf willsubmit detailed scientific comments in due Course of time.

However, if you can make your comments directly to the WHO or through yourgovernment representative at the WI-JO Assembly in Max 2001 it will have a doubleimpact. If you reqttire any information regarding your comments. please let me know.

in the interest of sugar the IbIloving sections of’ the draft report. are of particularinterest to lhe Sugar Industi:

(1) Section 4 of the Expert Consultation Report (Pages 21 ~4) “A $wn,narvof Population NtItt’iC?7t Intake Goals/or Preventing Chronic’ I)iseases.’ and Annex I;here it is recommended, without any scientific basis, a quantitative limit. of-cUDenergy from free sugars. The terni free sugars refers to all mono— and di—saceharidesadded to foods by the manufacturer, cook or consumer, plus sugars naturally presentin honey, syrups and fruit juices.

(2) Section 4.1. of the Expert Consultation Report (Pages 25-28). ‘Nutrien.tReconunendations]br the Prevention a/Excess Weight Get/n and Obesity” andAnnex 2; which implicates high-sugar diets in the deveiopnient of obesity’ and makes

RepublicPhilippinesSugarRegulatoryAdmin.txta recommendation to limit intake of free sugars to 10% of dietary energy.

(3) . Section 4.5 of the Expert Consultation Report (Pages 38 — 41), 7NutrientRecommendations tar the Prevention o/Dentcd flis roses,” and Annex 6; here agwn a.limit on the intake, of free sugai-s to 10% of dietarx’ eo.ergx’ is recommended. base.don a scientific paper by Paula Mo~nihan of Newcastle University. UK. This paper hasselected biased and poor quality references and has completely ignored soyuid,accredited, research on oral health.

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233 The discussion of population studies is hardly morn satisfactory, Tim papers by Woudwaid and234 Walker (1994) and by Ruxton ci al. (1999) are described as “crude”, subject to detailed criticism235 and their conclusions discarded, In contrast, the paper by Srccbnv (i9i~2) is accepted without236 question, despite the flict that it used an identical approach to the other two, and has been shown to237 have selected the data used from among a larger set available at tIje time.238239 The Annex makes virtually no refercnce to any experimental studies on the relative aciduQcnicity or240 caries potential of different foods and drinks. This is a serious omission, as these studies psovide241 usefid insiubta into the conclusions drawn on thc effects on dental caries risk of the vartous242 presentations of sugar(s) and starches that are possible iu a modern diet.243244 2.2 Interpretation of epidemiological evidence relaling to frequency of consumption of

245 sugar(s) and amount246247 .4 number of observational epidemniologicat studies are cited dint appear to sh~•’x a relationship248 between the amount of sugar(s) consumed by a population and the level tel’ her incidence or249 prevalence) of dental caries in the population. These studies

RepublicPhilippinesSugarRegulatoryAdmin.txtare either cross ~ecnon’il (e”nluoicnl)250 studies or longitudinal in. design. The interpretation of these studies as “convinrinu evidence that251 amount of sugar(s) predicts caries risk is erroneous. it ignores the conloundine influence 01252 frequency of consumption. Frequency is vcrv strongly correlated to amount and dso cer-iclates (but253 weakly) with Caries experiencc in a number of studies that have assessed frequency. Both these254 observations are admitted by the author. In consequence, amount can only be assumed to be an255 independent variable if there i5 evidence that amount is indeed an independent predictor of caries256 risk.257258 The key evidence on this point (the “Vipeholn-i Study”: Gusrathon ci al., 1954 is obscured in Annex259 6 by excessive rcpctilion of unnecessary detail from this large’ and e’mrnpiicnted ser;es ot260 intervention sttidies. The axial observations in. this unique study Were that the Consumption ot over261 30% per day of sugar had no observed influence on caries increment Over 5 ears when consurneti262 exclusively at meal times. In contrast, as little as SOg per day increased caries levels when itiven263 between meals. These observations provide the only substantive evidence, separating frequency and264 amount as variables influencing caries risk. They show unequivocally that any practicable level of265 consumption of sugar will nor alter caries risk if eaten infrequently, while quite small amounts will266 alter caries nsk if distributed throughout the day. These obsert-ations make a nonsense of the26? suggestion that caries will be reliably reduced by limiting the amount of sucar consumed. A zmilar268 conclusion was reached by Ruxton et at on the basis of an examination of population data on269 changes in sugar consumption and caries levels in different populations.270271 The author seems to be under the impression that cross sectional studies that report conducting272 simple correlation tests separately between both frequency and amount and caries provide evidence273 that both are independent variables predicUng cries risk. This is. of course, incorrect None of these274 studies has reported assessing whether the two variables are, even partly, independent Indeed, such275 statistical tests would be uninlbrmative since the correlation between frequency and a mount is276 invarktly strong. while both are very weakly correlated with caries levels. ‘Ihe issue nuist be settled

RepublicPhilippinesSugarRegulatoryAdmin.txt277 by experimental studies that deliberately separate the two variables Only the \‘ipehohu studies did278 this.279280 it is noteworthy that the experimental subjects in the Vipeholin study had no access to fluoride281 toomh~aste or to any other source of fluoride in sufficient quantities to influence caries asIc They282 also failed to practice oral hygiene at all. The results of exposure to sugar at-c tint, therefore.Page 6 of 16wEEaII&muL. ] I

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283 confounded by these protective iniThences. The presence of these lonus ol’ protection will attenuate284 the influence of sugar. Clearly the basic conclusion that amount of sugar hos no influence on ear~es285 risk remains valid, and applies with even more l’orce in populations that have the benclft of

286 protection front fluoride.287288 It is also asserted in Annex 6 that attempts to limil either frequency of consumption of sugar(s) or289 amount will automatically influence this other. No evidence for this assumption is presented. P it riot290 difficult to predict circumstances in which this would not be the case.~ The observation that large291 variations in sugar(s) consumption occur within populations with negligible influence on the292 variance in caries (e.g. Rugg-Gunn et al. (1984) clearly demonstrates the futility of attempting to293 control caries by limiting the amount of sugar(s) consumed.294295 2.3 Quantitative population targets for the anwunt of sugar(s) to be consuine.d296297 The Draft Report proposes a quantitative limit on the amount of “free sugars” as a target for the298 average consumption per head of the population- As explained above, the scienti ftc justification 1K299 any target expressed as amount to be consumed is fallacious.300301 The particular target proposed (15-20Kg per person per year, when fluoride is a\’a ilabie) is also

RepublicPhilippinesSugarRegulatoryAdmin.txt302 unnecessary, since greater improvements in caries prevalence have been achieved by thc usc303 fluoride toothpaste than were seen during svatirrie when sugar availability was restrtcted in sum -i304 draconian fashion- This is dramatically illustrated by comparison of the caries prevalence in a ~ uar305 old children in. the UK in 1993 (Walker et at. 2000) with those who had crown up with ~um306 restriction due to wartime mat:ioning (Weaver 1950). in an area that also benefited from fiuur’de ir’307 the water supply. Current prevalence is less than half that achieved by the POliCiCS advoc,..rd in this308 Drafi Report. K5nig (2000) has drawn similar conclusions from data iii Swiucerland.309310 In a review of a nationally representative survey of pre~sehool children, Gibson and Williatos.311 (1999) concluded that roorhbrushing with fluoride toothpaste was a tuore effective means ol312 controlling caries than dieu Van Loveren (2000) has drawn similar conclusions from a wider review313 of the evidence. Kay and Locker (1996) have reviewed all the scientific himeraiure on the314 effectiveness of oral health promotion and concluded that fluoride use is the only ini.erv0ntion for315 which there is evidence, of effectiveness. They specifically highlight the lack of L\iderlCC that316 attempts at dietary manipulation have ever proved effective. Kay has subseque.ntlv been bluntly317 critical of any continued focus on dietary advice for caries prevention (Kay, 19 )8l318319 The target proposed in the Draft Report is unhelpful 1 hr two reasons: such a tat ‘et disu acts attention220 from effective public health approacbe.s and it irill)liC’5 that otal heahh may be achieved remotely.321 by society, while neglecting personal oral care322323 The target is also impractical: such a level of consumption has. been exceeded in the UK, and324 therefore in all probability in most developed countijes, for more than a ecnmur½ The authors325 provide no insight into their thinking as to how their target might beachieved326327 The target is arbitrary, since no credible ease (hr the figures chosen is presented and since is icoores328 evidence that, even if achieved, it would not result in any predictable reduction in caries at alt329 (Ruxton et al. 1999).330

RepublicPhilippinesSugarRegulatoryAdmin.txtFEE I£2PHONE NO. : 932 0973p7pJAY-. 11 288202: 02PM PlO

331 2.4 Cariogenie potential of sugars in fruit antI vegetables332333 The repetition in Annex 6 of’ a peculiarly British myth that sugars ‘are not carionenic when e.atcu334 within fruit and vegetables is extremely unhelpful. Evidence from experimental work and some335 epicleuniological studies attest to the obvious fact that eating fruit and vegetables releases their336 sugars into the mouth, with the concomitant potential for giving rise to canes. This issue has been337 considered by several authors and expert groups (notably the joint FAU/WHO Consultation on338 Carbohydrates in Human Health, 1997) all ofvdiom have rejected the hypothesis put forward here.339340 The repetition of this dated idea has the potential to mislead the public into thinking that they341 snack frequently on bananas, for example, with impunity. Health education material produced by342 the UK Government’s Health Education Authority, following the bizarre conclusions on thts issue343 by the Committee on Medical Aspects of Food Policy in 1989 (DoLl), contained advice that lhuits344 are “sugar free”. It is unethical to mislead the public in such a blatant manner.345346 2.5 Cariogonie potential of cooked starch347348 The flillacious belief that starch xvas non-•cariogenic probably originates front earN animal work that349 fed raw (uncooked) starcin Since raw starch is indigestible to bunians. these studies have lint’::350 relevance to the question of the eariogenic potential of stavch-eontainint foods to humans.351352 Certainly, observational epidemiological studies have not provided any consistent evidence that35$ starch in the human diet influences caries asIc But, as noted above, such studies equally do not354 demonstrate a convincing case for any influence of sugar(s). The authors argument that the lack of355 correlation between sugar(s) and caries in many studies arises from the a lack of variation in its

RepublicPhilippinesSugarRegulatoryAdmin.txt356 amount of sugar(s) consumed within and betweec populations is tendentious (since substantial357 varialiori is observed). ~ut this areuwent applies with some force to the consumption of starches.358 Almost all populations have a rather high consumption of stareb.359360 The convincing evidence that sunar(s) are capable of giving rise to caries comes. not from361 epidemiology, but front experimental studies. A variety of experimental models hayc also prov~dea362 ample demonstration of the ability of cooked starches to gtve rise to caries. Indeed, it x”ouid be truly363 jcmarkable if sugar(s) were uniquely capable of causing caries, while starches, which can be Known364 to be broken down to sugar(s) in the mouth, were not.365366 The attempt to classify free sugar(s) as harmful to teeth but starches and ‘intrinsic” su ~ar( 5) as367 harmless is not based on sound science. It has already led to health promotion materials (in the UK)368 that are likely to harm children’s teeth, by encouraging stiacking on fermentable carbohydrates other369 than “flee sugars”.370371 2.6 Dose response curve for sugar and caries372373 The claim is made (Annex 6 section 51.1) that the fbrni of any dose response curve desetibing the374 impact of sugar consumption on canes must be “S” shaped. Such a claim may be plausible. since375 most biological dose response curve display such a forot No convincing evidence is presented to376 support this assertion, however. The few, extremely old, population reports cited do not take377 account of the dominant influence of frequency of cunsunption on caries, when fluoride protection378 was not available. No mention is made here of othei; more thorough and more recent studies. ‘This379 represeuls yet another example of selection bias.380Page 8 of 16wuinaii II ] 71

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381 P also demonstrates an iriteraa’t. inconsistency wit-h knnes 6. Earlier (section 31 A) tVic author382 accepts studies that appear to show other curve shapes. These,

RepublicPhilippinesSugarRegulatoryAdmin.txt studies. of course. nave tile annie353 of attributing any influence of sugar to the amount consumed when the variable of rclevant,e is

3$4 frequency, and amount merely correlates with frequency-385386 2.7 International Scientific Consensus on Dietary Sugars and l)ental Caries387388 The description of the current international scientific view of tt.e value of setting targeLs for the389 consumption of “free sugars” in section 5.12 of Annex 6 is grossly tnisleading~ 01 the reviews cited390 in ‘fable i3 only two relate to reviews of the scientific evidence that are less than ten yeani old.391392 Emphasis is given to an earlier review by the H~ .c”altli Council of the Netherlands wink ijan’rlte toe393 recent review by this official body (Health Council of the Nerherlands,200l) Ihat 5ijst..a~d, an’~~94 specific target for sugars. The recent review by the German. Austrian and Swizs muthn lies is395 omitted (Deutsche Gesellsebaft fur Ernabrong, 2004 This review also abandoned lriq mar~et tot

396 sugars consumption.397398 Thc Federation Dentaire Ijitemationale Consensus Conference statement that emTiha.iv.s to it it is399 the frequency of consumption of all carbohydrate-eontaiiiing foods and drinks t.ta LUtiStIttiLt-. tac400 risk (of dental caries) rather than amount” (see iKilnig, 2900) is similarly ignored. No mention is401 made of the FAQ/WI-IC) Expert consultalion on “Carbohydrates in Human Heal.rV (Food and402 Agriculture Organisation, 1997) that concluded that no specific recommendations on sugar

403 consumption to prevent dental caries were needed.404405 The overall effect of this ~rark selection bias is to present an entirely t~lse impression that all expert406 coruLnittec reviews of this topic have come to the same conclusions as Moynihan in Annes 6. in fac.s407 ‘the opposite is the ease. Most have abandoned the dated idea of setting a target tnt the amount ol408 sugar(s) to be consumed to prevent Dental Caries in liwour at more effective approaches.109

410 2.8 The use of the term “Convincing evidence”411412 The strength of the evidence used to assess nutrient goals is deserted as “coovineing~’ (page 25) ~t:413

RepublicPhilippinesSugarRegulatoryAdmin.txt414 “Evidence is based on epidemiological studies showing consistent associations between the exposed415 and the disease, with little or no evidence to the contrary- The evidence is based on sr.vcrai416 randomised control trails of siifflcient size, duration and quality showing consistent efleets

417 Associations should be biologically plausible~”418419 It is not clear whether all these three conditions must be met or if they are alternatives This set of420 conditions is not that adopted by most expert- groups. who consider that only consistent evidence421 from randonmised control trials constitutes fully persuasive evidence.422423 In any event, the evidence in relation to amount of sugar(s) consumed and caries risk tuceLs neither424 of the first two criteria. The evidence from observational epidemiological studies is far froni425 consistcnt~ The only available intervention study (Gustafsson et aL 1954) contradicts the condusion

426 reached by the Draft Repore427

WF~HF F EFV

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428 2.9 Conclusions on sugar and Dental Caries429430 The balance of the scientific evidence suggests tbat freqaent consumption of ‘11 sn” in V htttict’431 “free” or contained within the cell walls of fruits and vegetables, together with coukue Si’ i dies tll432 contribute to the risk of Dental Caries. There is no evidence that the anwwr of any ul toe .e433 fermentable carbohydrates has an independent in tlcence on Caijes rish Jhe evtden’,x. tat arlV tOt-ru434 of practicable dietary manipulation eao on its own, provide adequate protection rvcuuvt ( dOt-S iS435 thoroughly unconvincing. Indeed, the evidence suggests that draconian dietary restriction of sugars436 would provide negligible protection. Fluoride in water supplies provines some protection, while437 regular use of fluoride tooth paste has been shown to provide almost complete protection.438439 No useful purpose would be served by adopting an arbitrary tar

RepublicPhilippinesSugarRegulatoryAdmin.txtget £ hr population consumption of440 sugars, as advocated in the Draft Report. in fact, such a target merely serves to distt-act attention

441 from more useful public health measures.442413444 3. Weight Gain and Obesity445446 3.1 Scientific consensus on sugar and weight control447448 T1ic background paper (Annex 2 “The scientific basis for diet nutrition and the prevention at exceN~449 weight gain and obesity”) implicates both high—flit and high--sucar diets in the ctevelor’ruLnt 0450 obesity. It makes a recommendation to limit intake of “free sugars” to less than 10% ut dicuu451. energy (Table 3), and to “nAiiintise intake, of high sugar foods” (Table A). These opinions ic” noivr’452 sugars differ substantially from those of two WI-iO.’FAO consultations which have been ~ ulmNhm ii

453 during the last four years.I 54455 The Report of the Joint FAO/WH() Expert Consultation on Carbohydrates in Human Nutrition456 (1998) states that, “There are no data to suggest that different types of carbohydrate differentially457 affect total energy intake” and “Diets containing at least 55% of energy fi:om a vat-i cry of458 carbohydrate sources. as compared to high-Ihi diets, reduce the likelihood that body fai

459 act immlation will occur.”460461 it continues, “Much controversy surrounds the extent to which sugars and starch promote ot’esity.462 There is no direct evidence to implicate either of these groups of carbohydrates in the etiology of

463 obesity.”464465 As recently as 2000, the WHO published Technical Report 894 “Obesity: Preventing and Managing466 the Global Epidemic” (which was based on an earlier report of a WHO Expert Consultation on467 Obesity in 1998). TR 894 states “The consumption of sugars does, however, lead to a subsenuent468 suppression of energy intake by an equal amount roughly equivalent to the amount provided by the469 sugars” and concludes that, “The fundamental causes of the obesiry epidemic are societal, resulting’470 from an environment that promotes sedentary lifestyles and the consumption of high-fat, energy-471 dense diets)’ The Report attributes the rise in obesity in many developing nations to urbanisariori,

RepublicPhilippinesSugarRegulatoryAdmin.txt472 and a move away from traditional lifestyles.473474 A met-a-analysis oflO iowjat dietary intervention sindics lasting move than 2 months (Asrmp ci al.475 2000) %upports the conclusions of both these reports in concluding that replacing dietary fat with476 carbohydrate, without intentional restriction of energy intake, can assist in weight loss- ‘The cun-ent477 scientific consensus is that high-ffit high energy diets., combined with inactive and sedentaryLI III~IItIiILL I JUIIUIIUIJIIUIIIIIIL

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478 lifestyles. are the two principle factors increasing the risk of obesity. A combination of hiuh479 ca;-bohydrate diets and regular physical activity can assist in the maintenance of an ideal body480 weight. (Astrup et al. 2000, World Health Organisation. 2000, Food and agriculture Organisatton,481 1998). A number of intervention studies have demonstrated that Ibods containing sugar, even in482 substantial amounts, can form part ol’ the carbohydrate portion of such weight inatatenance or483 weight reducing diets without prejudicing their effectiveness (Saris et al. 2000.. et al. 1 996,

484 No . cen dentonstrated in advisina peoWest and de Looy 2001). advantaae hash pIe who wish to lo

se485 weight or to avoid weight gain to avoid sugar, or high sugar lbods486

487 3.2 Inverse correlation between fat and sugar imtale488489 The background paper (Annex 2) also ignores the extensive hod’- of evidence froni initny cross-490 sectional studies in different populations that have consistently ShOwn an inverse rclarnn~ni7491 between sugar consumption and fat intake (Stani-Moraga et at 1999.. Gibson 1996. Gtbne\ I”~492 Bolt-on smith and Woodward 1994). It should he noted that these st-udies have not shown r’~493 relation between starch consumption and fat. They have also consistently shown that indivtduii494 who have higher sugar intakes tend to have lower RMI despite higher overall energy intake~ hew

RepublicPhilippinesSugarRegulatoryAdmin.txt495 studies provide no evidence to support the contention that people will lose weight- more Ci wetively496 if they are advised to reduce consumption of “high sugar foods” as suggested in annex 2 Table 4.497

498 3.3 Intervention trials iin’olving sugars499500 These cross sectional studies are consistent with a number of intervention trials that have, shown no501 advantage in advising subjects to reduce sugar intake in order to reduce body weight or avoid502 weight gain ( West and de Looy 2001, S~iiset al. 2000, Drunt-niond and Kirk 1999. Drenowski ci al503 1997, Naist-nith and Rhodes J 995). Attempt-inc to reduce both sugar and fat intake ar the same nine,504 as’ advocated in this Dmft Report, has been shown to he ~mpraetieal, even for trained dietitians (Cole

$05 Hamilton et al. 1986)506

507 3.4 “American Paradox~’508509 The “American Paradox” has been described as the contradiction between the fall in the proportion510 of fat in the diet of the average America. seen in rrcent years, and the rise in the prcvai:.~v~c of511. obesity. The description of these two observations as paradoxical assumes that it would be512 expected that a fall in the proportion of find energy from fat would, in itself~ be sufficient- to prevent$13 a rise in the number of people that aie obese. The CXI)ianation speculatively advanced in the Draft514 Report to account for these counter-intuitive obser-ations is that there has been an overwhelming515 increase in the consumption of sugars. Other authors have posited other cxptanation& Astrup (2001)516 has put forward the more plausible suggestion itiat a decrease in physical. activity has counteracted517 “the beneficial effect of a slight reduction in d tare fat”. Prentice and JeUb (1998). in considering a518 similar situation in the UK, have conic to die same conclusion as Astrup.$19520 There is documented evidence of a change in a range of behaviours among the American521 population, especially children (Nicklas et at 2t1t)l) what may have contributed to the increased522 prevalence o.C obesity. it is uoreasonable to arbitrarily select sugar—containing (bods as a sionift-cant523 contributor without considerably stronger evidence than that present-cd in Annex 2524I


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525 3.5 Sugar in drinks526527 This brief paragraph in Annex 2 Sect-ion 3.21 is particularly incorrectly titled, since several of the528 studies discussed involve fructose syrup sweetened drinks not Sugan The studies discussed under529 this heading have a number of limitations that are not mentioned. The only intervention study cited530 CVordolT and Alleva 1990) provided an unrealistically large dose of soft drink (1150 gni, about 4531 cans) each day. Despite this extreme challenge weiabt gain over the pei-iod of the study t 3 weeks~.532 among subjects consuming the sugars-sweetened drinks, was small (660gm). This smuov provides no533 evidence of’ the long term consequences of a less regimented use of soft dunks eonraininc sugars534535 The Ludwig (2001) study was observational in nature, and used an unreliable 0 tcall que tionnaire)$36 technique to assess dietaty and physical activity habits of Ii year old children. ‘I lju authors focussed537 attention on the 37 children who became obese during the course of the study, ignoring an almost538 equal number (35) who were obese at the beginning oft-he study but nor at the end.539£40 Other relevant observational studies are ignored in the discussion of “Sugar in drinks”, despite being541 cited earlier in the Section under “Sugar in foods”. The consistent observation that- higher sugar542 consuming adulls and children are thinner, despite higher tot-al food energy intake, conflicts with thc-543 sungestion thatsugar- in soft drinks is cundudve to obesity. Especially anion; children, soft drb I544 constitute a major contributor to sugat intake- If soft drinks led to obesity, the high r swai545 consumers should be fatter. They are nut they are thinner (Bolt-on-Sn. .).ith and Woodwar 1 19”-4546 Gibson 1996, Gibucy l995). in an an~ilxsis of the contribution of sugars to the energy densu’rs otto547 diet-s of pre-school children (who have the highest proportion of food energy from sugars of my ar’~548 group in the UK population), Gibson 0000) specifically examined tbe contribution of soft- druol’549 She found that the least energy dcn~c dxd~ included a signiflcautl~ higher contribution Ireni ‘-os550 drinks. When soft drinks were excluded from the calculation, the energy density of these diets

551 remained inveisely correlated wit-h sugars content

RepublicPhilippinesSugarRegulatoryAdmin.txt-.$52553 Clearly the eunvnt body of evidence is insufficient to draw firm conclusions on the role of calorie554 drinks on the risk of obesity amone children or adults, hut the available evidence tends to susgest555 that these drinks do not ~O5C a Specitue risk to weight control.556

557 3.6 Satiety and energy density558559 Eating carbohydrate triggers signals that induce satiety and reduce hunger to a greater extent than560 equivalent- amounts of fat (Blundell and Stubbs, 1999). There is no evidence that sugar behaves561 fundamentally ditThrent-ly in this respect than other forms of carbohydrate, If low glycaemic index$62 foods are indeed more satiating than those of high CI. then the moderate C. L of sugar would be563 expected to place it towards the middle of the range of satiating affects of conunon carbohydrate564 foods.565566 There is some evidence to suggest that high energy-density diets arc rruorc likely to lead to over-567 consumption and weight gain thai) low energy—density diets, irrespective of their macronument568 composition (Srubbs et al. 1996, Rolls et al. 1999). lt should be noted, however, that this evidence569 has been obtained following the short term and covert manipulation of all (Siubbs et al. 1996) or a570 substantial proportion (Rolls et aL 1999) of the total food energs- intake of subjects. There is no571 evidence yet available relating the atThets of individual foods; to subiects who are aware of the572 changes being made to their diets; or to the long term consequences. Annex 2 suggests that sunar573 may raise the energy density of the diet and thus encourage over-consumption of food enerey. itPage 12 of 167J

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574 also suggests that sugar rich foods are of particular concern in this regard. These conclusions arc, zc575 best, premature, in light of the lack of evidence on the impac

RepublicPhilippinesSugarRegulatoryAdmin.txtt of individual enemy-dense lbod:w576577 In addition all the limited evidence available suggests that high suMr diets are less enemy-dense578 than low sugar diets (Saris et al. 2000, Gibson 20t)OV This is to be expected in view oft-bc dominant579 influence of fat content on dietary energy density and thc inverse relationship between fat and sugar

580 intakes.581

582 3.7 Conclusions on sugars and obesity583584 In summing up the evidence on the role of sunar in foods in energy balance (page 13, Annex 2) the585 authors state “Overall, the mixed results especially among the few available trials does not- allow a586 judgernent to be made about the sugar content of food and obesity.” If this is indeed the case, there587 should not be a recommendation to reduce the intake of sugars.588589 The balance of the scientific evidence does not support the view that sugar consumption should be590 reduced in populations and individuals who wish to avoid weight gain and obesity. Indeed the591 evidence suggests the counter-intuitive conclusion that small increases in sugar consumption may592 be heipfiul., particularly in rendering low fat diets palatable.593594Ii IIItEIItiiItIII I

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References

Astrup A (2001) The role of dietaty fat in the prevention and treatment of obesity. Eflicacyand safety of low-fat dicK Inte,-nanonal Jnnrnal qf Obesity. 25(Suppl I ):546-55t)

Ast-rup A (Jrunwald GEl Melanson EL Saris WE-TM Hill JO (2000) The role of low-fat diets inbody weight control: a meta-analysis of ad libihjm dietary interve

RepublicPhilippinesSugarRegulatoryAdmin.txtnt1on studies. InternationalJournal of Ohesity. 24(12)1545-1552

Blurt-dell IE and Stubbs Ri (1999) High and low carbohydrate and fat intakes: limits imposedby appetite and palatability and their implications for energy balance. Ew-opean Jou,-nal ofClinical Nnn-irion 53, Suppl I, 5148-5165

Bolton—Smith C and Woodward M (1994) Dietary composition and fat to sugar ratios inrelation to obesity. Internat,anai4Jou,nal o/Obcsztp I ~-8~t)_~28.

Cole Hamilton I. Gunner K, Leverkus C and Starr 1(1986) A study among dietitians andadult members of their households of the practicalities and implications of followingproposed dietary guidelines for the 13K. Human Nutrition: Applied Nutrition 40A 365-389.

Department- of Health (1989) Dietary Sugars and Human Disease. Committee on MedicalAspects of Food Policy. Report on Health and Social Subjects No 37. W’1SO London.

Deutsche Gesseilsehaft fur Ernaheung, mit Osterreichisehe Geselisehaft fur Ernaheung,Sehwiezerisehc Gessellsehaft fur Emahmn~sforschuzg und Schweizei-ische Verienigung furErnahrung (2000) “Refe-reozwerte fur die Nahrsroffzufhhr”. tlmsehau/FI ratis, Frankfurt amMain.

Drewnowski A, henderson 8k Shore AD, Fisehier C, Preziosi P. Hcrcberg S (1997) The fat -sucrose. seesaw in relation to age and dietary variety of French adult-& Ohcxitv Resecuch5(6):5 11—8

Drummond S. Kirk T (1999) Assessment of advice to reduce dietary fat- and non-milkextrin$ic sugar in a ftee-livin.g male population. Public Health NuIr 2(2): 187-97

FAG (1998) Carbohydrates inNutfition. Paper no. 66

Eood and Agriculture Organisation! World Health Organisation (1997) “Carbohydrates in

human health”. Food and Agriculture Organisatioa Rome.

RepublicPhilippinesSugarRegulatoryAdmin.txtGibney Mi (1995) Epidemiology of obesity in relation to nutrient intake. Jaxer-awianal

Journal of Obesity I 9(suppi 5):S 1-83.

Gibson S. \Viiiiaxns S (1999) Dental caries in pre-school children: association with socialc-lass, toothbt-ushing habit and consumption of sugars and sugar-containing food& CariesResearch. 33:101-113.595596wElErila __

OF SLIOF3R REF I HERE PHONE NO. : 622 8672278 Jun. ii. 2002 02: 54Phl ~

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Gibson SA 6996) Axe diets high in non-milk extrinsic sugars conducive to obesity? Ananalysis from the Dietary and Nutritional Survey of British Adults. Journal of HumanNutrition and Dietetics 9~4):2S3-2 92.

Gibson SA (2000) Associations between energy density and niacronutrient composition inthe diets of pre-sehool children: sugars versus starch. Intetnational Journal of Obesity andRelated Metabolle Disorders. 24(5) 633-638.

Gustaisson et al. (1954) “The Vipebolm dent-al caries study. The effect of different levels ofcarbohydrate intake on caries activity in 436 individuals over 5 years”. Act-a OdontologicaScandinavieail 1. 232-3M.

Health Council of the Netherlands (2001). “Dietary Reference Intakes: energy. protein. fatsand earbohydnrtes”. Health Council 0f the Netherlands, The Hague.

Kay EJ (1998) Caries prevent-ion — based on. evidence or an act of faith? British DentalJournal 185:432.3.

Kay EJ and Locker DL (1996) Is dental health education effective? A systematic review olcurrent evidence. Community Dent Jstiy and Cecil £pidemioiogy. 24:23 1—235.

Kbnig KG (2000) “Diet and oral health”. International Dental Journ

RepublicPhilippinesSugarRegulatoryAdmin.txtal 50. 162-174-

McDevitt KM. Boti Si, Iia.rding N’t, Coward WA, Bluek Li, Prentice AM (2001) Ce no~-olipogenesis during controlled overfeeding with sucrose or glucose in lean and obese wonwfl.Am I Clin Nutr 74(6)237-46

Naisndth and Rhodes (1995) Adjustment of energy intake following the covert removal o!~sugar from the diet. Journal of Human Nun-ition and Dietetics 8:1 67—175

Nicklas TA Baranowski T Cullen KW Berenson (3(2001) Eating patterns, dietary quality andobesity [Review]. JOrIJ7Zdl 0/tile? American college of Nutrition. 20(6) :599—608

Prentice A and lebb S (1998) Obesity in Britain: gluttony or sloth. British Medical JournalRoberts SB High-glycemic index foods, hunger, and obesity: is there a connection? (2000)Anti Rev 58(6):] 63-’1

Rolls Di. Bell EA. Castellanos VII, Chow M, Pelkman CL, iborwart ML (1999) Energydensity but not fat content of foods affizctcd energy intake in lean and obese women.American Journal of Clinical Nutrition 69(5): 863-871.

Rugg-Gunn Al et al. (1984) “Relationship between dietary habits and caries incrementassessed over two years in 405 English adolescent schoolchildren”. Archives of Oral Biology29. 983-992.

Ruxton et al. (1999). “Guidelines for sugar consumption in Europe”: is a quantitativeapproach justified? European iournal of Clinical Nutrition 53. 503-51.3.Iflir

C.iSTh OF SUQOR REFINERS PHONE NO. 632 8673278 Jun. Ii 2002 L112 54W PS

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Saris WI-fM, Astrup A, Prentice AM. ‘[nail HIP. Fonniguera N, Verbocket-van de VenueWPI-1C, Raben A, Poppitt SD, Seppelt B. Johnston S. Vasilaras TI-b Keogh GE (2000)Randomised controlled trial of changes in dietary earbohydrai c/fat ratio and simple x’scomplex carbohydrates on body weight and blood lipids: the CARMEN study. InternarionsiJournal 0f Obesity 24(1(1): 1310-8

Siggaard R, Raben A, Astrup A (1 99&~ Weight loss during 12 weeks’ ad libi turncarbohydrate-rich diet in overweight and normal-weight subject-s at a Danish work site.Obesity Research 4 (4): 347-356

Sreebny LM (1982) “Sugar availability, sugar consumption and dental caries. CommunityDentistry and Oral Epidemiology. 10. 1-7.

Stam-Moraga MC, Kolanowski I. Drarnaix lvl~ Dr Backer C. Koralizer MD (1999)Sociodemographie and nutritional determinants of obesity in Belgium. mt j Obes RelatMetab Disord 23 Suppi 1:1-9

Stubbs RI. Harbion CO. Prentice AM (1996) Covert manipulation of the fat to carbohydrateratio of isoenergetically dense diets: ciThet on food intake in feeding men ad libitumAmerican Journal of Clinical Nutrition 20(7): 65 1-660.

Thkencbi D (1961) Epidemiological study on dent-al caries in Japanese ehildrem before.during and after World War ii. international Dental Journal 11:443-457

Van Loveren C (2000) Diet and dental caries: cat-iogenicity may depend more on oralhygiene using fluorides thar.i on diet or type of’ carbohydrates. Luroj;ca~i Journal ofPandiatric: i9entisirv. 1 (2):5 5—62.

Walker et al. (2000) “National Diet and Nutrition Survey; -oun people aged 4 18 yearsVolume 2: Report of the oral healih survey. London. The Stationary Office.

West JA and de Looy AL (2001) Weight loss in overweight subjects fblloxvin~ low-suci-oseor suerose—eontatnmg diet-s. I;uet-nadanai Journal of Qhu~iw 75 11

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WI-tO Technical Report Series 894 (2000) Obesity: Preventini and Managing a GlobalEpidemic. \VHO Geneva

Wood~vard M and Walker AR.P (1994) ‘tSugar and dental caries: evidence horn 90 countrL~s.British Dental Joumall 76. 297-302.

World Health Organisation Teehnieal Report Sci-ics 894 (2000) 0besity: Preventing, andmanaging a global epidemic. Geneva. World Health Orcantsation

World Health Organisation! Food and Agriculture Organisation (1998). Preparation and useof food.-based dietary guidelines. Technical report series 880. Geneva. XVorld HealthOrganisation.

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