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Sugar Intake, Obesity, and Diabetes in India

Abstract: Sugar and sweet consumption have been popular and intrinsic to Indian culture, traditions, and religion from ancient times. In this article, we review the data showing increasing sugar consumption in India, including traditional sources (jaggery and khandsari) and from sugar-sweetened beverages (SSBs). Along with decreasing physical activity, this increasing trend of per capita sugar consumption assumes significance in view of the high tendency for Indians to develop insulin resistance, abdominal adiposity, and hepatic steatosis, and the increasing “epidemic” of type 2 diabetes (T2DM) and cardiovascular diseases. Importantly, there are preliminary data to show that incidence of obesity and T2DM could be decreased by increasing taxation on SSBs. Other prevention strategies, encompassing multiple stakeholders (government, industry, and consumers), should target on decreasing sugar consumption in the Indian population. In this context, dietary guidelines for Indians show that sugar consumption should be less than 10% of total daily energy intake, but it is suggested that this limit be decreased.

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Alex’s Notes: Believe it or not, sugar was invented in India. The sickly sweet compound was so important to Indian lifestyle that it is referenced in their religious texts, and it only became known to the world when Alexander the Great (no relation) entered India in 327 BCE and was amazed to find a replacement for honey. Being reverent to the culture, it is not too surprising that any occasion in India is celebrated with intakes of sweets. Indian religious offerings are typically food-based, containing five main ingredients: milk, curd, ghee, honey, and sugar.

Unfortunately, while sugar and sweets are indeed an important cultural aspect of Indian life, they are not nutritionally ideal. And while chronic diseases are a multifaceted phenomenon, there is little doubt that the increased consumption of energy-dense foods and reduced levels of physical activity owed to urbanization and increased purchasing power play a role. The prevalence of type-2 diabetes in 2014, for example, now rivals that of the U.S. at 9.1% (the U.S. is 9.4%). However, given the vastly greater population of India, this translates to over 66 million people, 2.5 times the number of persons in the U.S. and second only to China in magnitude (96 million).

Things with India become even trickier when we try and define sugar, because Indian databases do not clearly define sugar. What is clear is that it is separate from “traditional sugars” such as jiggery and khandsari, which are made from sugarcane in addition to sugar. Regardless, India is the second largest producer and largest consumer of sugar in the world. This is in addition to being the largest producer and consumer of the traditional sugars as well. In fact, the per capita consumption of sugar in India was 18.9 kg in 2011. That is a lot of sugar (but still less than the global average of 23.7 kg).

In addition to the above, sugar-sweetened beverages (SSBs) have a consumption rate of 11 liters per capita per year, and the industry is the third largest in India after packed tea and biscuits (can you tell there was a historical British presence?). This is especially concerning when we consider that studies have shown a strong positive association between children’s consumption of sweets and sugars and the mother’s consumption of these food products. Interestingly, this study also showed that any food or food preparation method was considered healthy if it was “hygienically” prepared, leading mothers to prefer packaged foods and beverages over restaurant foods. Television advertisements, peer pressure, and the “fashion” of consuming westernized foods were also major determinants of intake among children.

So what is an Indian sweet?

There are a couple main-stays among the Indians and their traditions, which I listed in the table below. Not only are they high in sugar, but also in trans-fats as most are prepared with partially hydrogenated oils (yuck!).

Food

Description

Barfi

Made with condensed milk and sugar, cooked until it solidifies

Imarati / Jalebi

Made by deep-frying a refined wheat flour batter in pretzel or circular shapes, which are then soaked in sugar syrup

Sooji Halwa

Made by roasting semolina in a lot of ghee and then adding water, sugar, and nuts

Gulab jamun

Prepared from milk solids kneaded into dough, sometimes with refined flour, and then shaped into small balls and deep fried. These are then soaked in sugar syrup

Soan Papdi

Prepared with gram flour, sugar, ghee (clarified butter), milk, and cardamom

Motichoor Ladoo

Made by frying a batter of gram flour and ghee in small pearl-size drops and then mixing with sugar syrup

Rasgulla

Ball-shaped dumplings made out of dough kneaded from Indian cottage cheese and semolina, and then cooked in a syrup made of sugar

Kalakand

Made out of solidified, sweetened milk and cottage cheese

With the above in mind, it would not be far-fetched to believe that increased intake of these foods may parallel the rise in diabetes and obesity in India. It’s notable that Indians already have higher levels of plasma fatty acids, insulin resistance, and fatty liver than white Caucasians. One study analyzing data from 165 countries regarding the associations between the prevalence of diabetes and per capita sugar consumption found that there was a significant and strong correlation in South Asia (and all of Asia for that matter). Ironically, there was no significance in the association in North America.

So what can be done?

The World Health Organization (WHO) very recently lowered their recommended sugar intake level from 10 to 5% of total energy intake, and the Indian dietary guidelines recommend limiting intake of sweets and snacks. Aside from these recommendations, guidelines are lacking.

The current study authors propose a combination of government, consumer, and industry regulations such as the following:

  • Strict guidelines regarding sugar intake should be formulated.
  • Spread awareness among consumers and the medical establishment regarding the ill effects of high sugar intake.
  • Increasing taxation could be one of the strategies to curb increasing consumption of SSBs.
  • Sale of SSBs should be banned in school premises. Healthy alternative drinks should be made available to children.
  • Warning labels such as “Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay” could be mandatory for SSBs.
  • Increase access to free, safe drinking water in public places, schools, and offices to encourage water consumption instead of SSBs.
  • Restriction of advertisements for commercial foods on television (during prime time and children’s programs).
  • Encouragement of transnational food companies to manufacture healthy snacks and beverages.
  • Decrease taxes on and prices of fruits, vegetables, nuts, and other healthy foods.
  • Inculcate healthy eating habits in children from early childhood.
  • Instead of sugar and fat-loaded sweets, opt for fresh fruits for dessert.
  • Avoid gifting sweets; instead go for nuts and fresh fruits, etc.
  • Cut down sugar in coffee and tea.
  • Read food labels carefully. Avoid intake of processed and packaged foods as much as possible.
  • Cut down on intake of sweetened SSBs. Instead opt for natural drinks such as clean plain water, water with certain herbs such as basil, mint, etc., coconut water, buttermilk, lemon water, etc.
  • Nutritional labeling should include information on sugars present in the product, written in a trenchant manner so as to be intelligible by common consumers.
  • Nutritional information of the foods served in restaurants should also be given in the menu card.

Some may seem familiar for those of us living in the U.S. or around Europe.

Bottom line

It’s a global problem.

 
 

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