With new Nutri-Grade regulations set to kick in this year and the next regarding the labeling and advertising of pre-packaged and freshly made drinks which contain sugar, we ask Dr. Kevin Tan, endocrinologist at Farrer Park Hospital and Ms. Rachel Ng, Senior Dietitian from the same, to tell us how we should make educated choices about the sugar we want in our drinks.
Sugar cannot be said to be inherently bad. “The body runs on sugar (or glucose) to provide energy for cellular function. However, excessive sugar in one’s diet is harmful. In the case of consuming too much of high fructose corn syrup, a man-made addition to our diet, this can lead to obesity and insulin resistance which can then develop into Type 2 diabetes, hypertension, and hypercholesterolemia, as well as cancers, a fatty liver, and dental caries,” explains Dr. Tan.
By that same token, Ms. Ng adds that sugar is a type of carbohydrate that is found naturally in many types of food including fruits, honey, lactose in dairy products and also in starches such as grains, cereals, rice, and starchy vegetables. Our body requires some sugar in our diet to supply energy for the function of our muscles and brain.
Having said that, on the excessive consumption of sugar, Ms. Ng warns, “Many processed foods and beverages such as sugar-sweetened beverages, cookies, cakes, and desserts contain added ‘free sugars’ which are a source of ‘empty calories’ as these are calorie dense and low in other nutrients.
“Excess sugar intake in the diet is converted and stored by the body as fat. Consuming too much food high in added sugars therefore can lead to weight gain and obesity, increasing the risk of diabetes.”
On this note, Dr. Tan advises that the amount of sugar we consume should not exceed an average of 25 g per day (6 teaspoons), but Singaporeans consume 60 g (15 teaspoons) of sugar daily on average and more than half of this amount is from sugar-sweetened beverages and this is why our government has taken measures to provide heath guidelines on the consumption of sugar-sweetened beverages.
There are genetic or biological risk factors where individuals with a close family member who suffered from an eating disorder are at a higher risk of developing an eating disorder.
Diabetes can be understood as a chronic condition that affects how your body turns food into sugar which is to be absorbed by your cells. The production or presence of insulin is the key factor in this process and too much sugar can stay in the blood depending on the lack or level of insulin.
For Type 1 diabetes, cells needed to produce insulin in the pancreas are attacked by the body’s immune system, stopping this production. For Type 2 diabetes, the body produces insulin but the insulin is not effective in its action of lowering blood sugar.
In drawing the links between sugar and diabetes, Dr. Tan says, “A high amount of sugar in a person’s diet can lead to being overweight and this predisposes one to Type 2 diabetes and gestational diabetes. A diet high in sugar can also put extra load on an already weakened pancreas in its production of insulin and this too, may contribute to diabetes.
“In addition, where diabetes is concerned, high blood sugar could over time cause blood vessels supplying oxygen and nutrients to organs in the body to become narrowed or leaky leading ultimately to organ damage and failure.”
Putting things in perspective, Dr. Tan explains that most diabetes cases (over 90%) are termed Type 2 diabetes which is brought about by heredity, age, and obesity. Type 1 diabetes cases form less than 1% of cases in Singapore and is mainly traceable to genetics and environmental triggers.
Then there is gestational diabetes which is conventionally diabetes diagnosed in the second and third trimesters of pregnancy and usually disappears after delivery. This affects 20-25% of pregnancies and the implications are far-reaching – 4 out of 10 women go on to develop diabetes in the next 5 years and both under-nutrition and over-nutrition of the baby in the womb can also predispose to diabetes when the child grows up.
Gestational diabetes is more common in older women who are overweight, have a family history of diabetes, or who have pre-diabetes or polycystic ovarian syndrome.
Ms. Ng tells us that apart from an easy to understand colour grading system (A, B, C, D) in which Grade A (dark green) points to the lowest sugar and saturated fat content while Grade D (red) corresponds to the highest sugar and saturated fat amount, the percentage of sugar is also indicated on each mandatory label where pre-packaged drinks are concerned.
“Implementing the Nutri-Grade labeling for pre-packaged beverages would enable consumers to make more informed decisions in relation to added sugars and saturated fat," Ms. Ng elaborates.
The Ministry of Health has mandated the use of this system involving labels for pre-packaged drinks from December 30, 2022 and for beverages freshly made by food and beverage outlets, by end-2023.
According to Dr. Tan, our government started public consultation on sugar-sweetened beverages in December, 2018 regarding four possible measures to reduce the consumption of such beverages, part of what has been dubbed the ‘War on Diabetes.’
Dr. Tan explains, “Over 80% of respondents supported the use of mandatory front-of-pack labels which would provide product information to allow consumers to make informed choices. About 70% supported regulating advertising to reduce the influence of advertisements on consumption choices.
“In addition, more than 60% of respondents were in favor of an excise duty to encourage manufacturers to reformulate and reduce the sugar levels in their drinks and less than half supported a ban on the sale of higher-sugar sugar-sweetened beverages. This has led to the current roll-out of the labeling system after further discussion on the modes of labeling.”
In Dr. Tan’s opinion, while the Covid-19 pandemic may have settled, the threat of diabetes remains a pertinent issue with each forecast of the number affected surpassed ahead of time. Our government's whole-of-nation approach for addressing diabetes which was started in 2016 seems to have borne fruit from a holistic strategy encompassing prevention, early detection, as well as preventing, screening for, and managing diabetic complications.
“There is more awareness, more are coming forward for screening and exercising, and diabetes complication rates have fallen slightly. The prevalence of diabetes has increased from 8.8% in 2017 to 9.5% in 2020 but the age-standardized rate seems stable at around 8%,” Dr. Tan observes.
He cautions that in spite of this, there are worrying trends like the rising rate of obesity and the high consumption of sugar and despite the positive statistics; the majority of the population are not exercising and choosing to be screened. Moreover, the Covid-19 pandemic is expected to contribute to an increasing rate of obesity which would negate a few of the positive results from the ‘War on Diabetes.’
With the threat of diabetes in mind, Ms Ng explains that in Singapore, the risk of developing diabetes is faced by 1 in 3 individuals. If nothing is done, it is estimated that in 2050, 1 million Singaporeans will be living with diabetes.
If we were to consider the role that sugar plays in relation to the condition, she says on the consumption of sugar, “The World Health Organization recommends to reduce intake of ‘free sugars’ to below 10% of energy intake at all stages of life. ‘Free sugars’ refer to all sugars added to foods and beverages as well as natural sugars such as those found in honey, syrups, and fruit juices. For an average adult with a caloric intake of 2,000 kcal, the recommended sugar intake is about 10 teaspoons of sugar per day or less. For children, the recommended intake would be lower.”
For a guide, the Nutri-Grade system classifies Grade C beverages as having between 5-10 g of ‘free sugars’ per 100 ml which corresponds to about 1-2 teaspoons of sugar per 100 ml.
One of the important aspects of the Nutri-Grade system is the prohibition on advertising for Grade D drinks from December 30 of this year.
As Dr. Tan sees it, “The aim is to reduce the influence of such advertising on consumer preferences which works together with the front-of-pack nutrient summary labeling to provide consumers with nutritional information on sugar and saturated fat content for them to better make healthier choices.”
On this, Ms. Ng offers, “This ban could also in turn help by expanding the range and variety of healthier choices offered by the beverage industry in the long term as a matter of responding to consumer behavior.”