Sukker – søt forvirring Sweet confusion Kaare R. Norum Professor emeritus

Energifordeling- WHO og FAO Protein 10-15 % av energien (kaloriene) Fett Total fett 15-30 % Mettet fett mindre enn 10 % Flerumettet fett 6-10%, og forholdet mellom de ulike fettsyrene viktig Unngå transfett Karbohydrater 55-75 % Frie Sukkerarter ( Free sugars) mindre enn 10%

Free sugars WHOs definisjon: The term ”free sugars” refers to all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugar naturally present in honey, syrups and fruit juices

Litt sukkerhistorie Hulemalerier i Spania viser mennesker som stjeler honning fra en bikube. Bruk av daddelpalme og fiken og annet tørket frukt som søtkilde. Sukker brukt som medisin. Etter hvert også som krydder. Sukker betraktes som helsebringende. Thomas Aquinias hevdet blant annet at sukker kunne inntas selv under fasten - det var jo medisin. Men etter hvert økte også misnøyen mot sukker. Sukker ble holdt ”ansvarlig” for å ha forårsaket skjørbuk og på samme tid ble en forening mot sukker og slaveri dannet. Sukker mister sin eksklusive status. Mye negativ omtale om sukker. Sukker er usunt! asosial adferd blant barn? 8 000 år før kristus (4000-2000 år før Kristus) Det 14. århundre Det 17. århundre Det 19. Århundre Det 20. Århundre

Hvorfor sukker? Søtt er en positiv smak, den første smak vi møter i livet: laktosen er søtere enn sukrose Vi overfører det positive i søtsmaken til andre forhold Et land av melk og honning Sukkerungen Så søt du er Sweetheart Honey Sugarbush

Viktige karbohydrater i kostholdet Glukose ): druesukker, et monosakkarid Fruktose ): fruktsukker, et monosakkarid Sukrose ): vanlig sukker, et disakkarid Laktose ): melkesukker, et disakkarid Stivelse, som er plantenes energilager. Viktigste forekomst i korn og rotfrukter.Stivelse er polysakkarider bygget av glukoseenheter Cellulose, plantenes skjelett, og viktige kostfiber i maten vår. Vesentlig ufordøyelig

Karbohydrater Sukker består av glukose og fruktose Laktose består av glukose og galaktose Stivelse brytes med til maltose og videre til glukose Cellulose er bygget opp av glukose-enheter,men kan vanskelig brytes ned i menneskers tynntarm, noe spaltes av bakterier i tykktarm

Absorpsjon av karbohydrater Alle karbohydrater må brytes ned til monosakkarider før de passerer tarmveggen. Glukose og galaktose med aktiv Na-avhenig transport høyt oppe i tynntarm Fruktose med fasilitert diffusjon lengre nede i tynntarmen Sukkeralkoholene med passiv diffusjon

Glukose Aktiv transport gjennom tynntarmen Transporteres gjennom cellemembraner via insulinavhengig glukosetransportør (Glut 4) Påvirker insulinsekresjon i bukspyttkjertelens beta-celler I lever og muskel bygges overskudd av glukose til glykogen Kan dannes i kroppen av glykogen, andre monosakkarider og av flere typer aminosyrer

Fruktose Diffusjon gjennom tynntarmen, langsommere absorpsjon enn glukose Går gjennom cellemembraner via Glut 5 som ikke finnes i hjerne og bukspyttkjertel, Glut 5 er uavhengig av insulin Fruktose påvirker ikke insulinsekresjon, og derved ikke frigjøring av leptin fra fettvev Fruktose øker laktat i blodet og kan gi økte mengder fett (triglycerider) i blodet

Fruktose Glukose Galaktose Omsetning av heksoser F-1- P + Pi G-6-P Fruktokinase HK/GK Galaktokinase (lever) G-6-Pase (lever) G-6-P Gal-1- P F-1- P + F-6-P UDPG Aldolase B FDPase PFK Gal-1-P UDPG F-1,6-bis-P transferase G-1-P DAP GAP + DAP + + UDP-Galaktose glyceraldehyde UDPGal-UDPG Isomerase UDPG Pyruvat Laktat

Omsetning av fruktose Fruktose Glukose F-1-P Fettsyrer/TG Pi G-6-P ATP Fruktokinase HK/GK (lever) G-6-Pase ADP G-6-P F-1-P F-6-P Aldolase B FDPase PFK F-1,6-bis-P DAP GAP + DAP + glyceraldehyde 2 ATPnetto 2 ADPnetto Pyruvat Laktat Fettsyrer/TG

Leptin, insulin og appetitt Insulin påvirker hjernen direkte, og nedsetter appetitten Leptin, som vesentlig dannes i fettvev nedsetter appetitten via områder i hjernen. Insulin påvirker frigjøring av leptin fra fettvev Fruktose påvirker ikke sekresjon av insulin og leptin og virker derfor ikke nedsettende på appetitten, slik glukose gjør

Glukose versus fruktose Fruktose påvirker ikke appetitt-reguleringen, slik glukose gjør Fruktose omsettes lettere til fettsyrer enn glukose Fruktose danner glycerofosfat langt mere effektivt og hurtigere enn glukose, noe som fører til en mer uttalt triglyceridsyntese fra fruktose enn fra glukose Fruktosens glycosylerings-indeks 10 ganger større enn glukosens Påstanden om at fruktose er sunnere enn glukose på bakgrunn av glykemisk indeks er å snu metabolske fakta på hodet.

Fruktose i kostholdet Viktigste kilde er sukker Fruktose finnes i honning, bra for bier og smakfullt for mennesker Fruktose i en rekke frukter, ikke skadelig Fruktose brukes mer og mer i søtete drikker fordi fruktose er søtere enn sukker ”High fructose corn sweeteners” (HFCS) i cola og brusdrikker i USA, i softis i Norge(?).

High Fructose Corn Sweetener Mais-stivelse hydrolyseres til glukose Mye av glukosen isomeriseres til fruktose vha glucose isomerase. HFCS meget billigere enn sukker, og søtere (sukker=100,glukose=74 & fruktose=173) HFCS-42 og HFCS-55 inneholder henholdsvis 42% og 55% fruktose

Markedføring av fruktose – baksiden av pakningen har følgende tekst: Erstatt sukker med fruktose og lev bedre. -Fruktose finnes i all frukt, bær og honning -Fruktose har lav glykemisk indeks. Det betyr at fruktose: Omsettes langsommere i kroppen Forebygger svingende blodsukker Forenkler kroppens fettforbrenning Er en langvaring energikilde som er spesielt gunstig under idrettprestasjoner og krevende fysisk eller intellektuelt arbeid

Sukker farlig? Det er mengden som er viktigst Vi trenger ikke sukker i det hele tatt Uheldige konsekvenser når over 10 energi% Farlig med mye under svangerskapet Dernest når man inntar sukker Best til måltid, ikke i mellom måltider Hvordan sukkeret er i ”maten” Antagelig mest uheldig i drikke

Sukkerinntak blant 9- og 13-åringer og voksne (g/d).

Glykemisk indeks (GI) GI er et mål for blodsukkerstigning i løpet av to timer etter inntak av matvarer som inneholder 50 g karbohydrater Som standard brukes enten 50 gram glukose (GI=100) eller hvitt brød med 50 gram karbohydrater (GI=100), standardene brukes om hverandre, noe som øker forvirringen, f.eks har hvitt brød GI=70 om glukose er standard.

GI påvirkes av en rekke faktorer Tømming av magesekk til tolvfingertarm Måltidets fettinnhold Måltidets proteininnhold Mengden magesyre Matens partikkelstørrelse, helkorn vs finmalt mel Tykkelsen av pasta-produkter Antall måltider per dag og fysisk aktivitet Modningsgrad av frukt

- As you all know the GI has been much debated since its introduction in 1981. When it was first introduced ity was meant as a tool for glycemic control in diabetic subjects, but since many other benifial effects of a LGI diet has been purposed, such as better cognital function, prevention of CVD, Type 2 diabetes and also improved body weight control. - The man in this picture is carrying a large book with GI tables and is telling his female friend who appently still think the conventional dietary advice with the food pyramide is sufficient, that this wonderful new system allows him not only rank and count his carbnohydrates, but also to burn them. - I have brought this picture because I find it is important to keep in mind that even though we have international tables of GI it is not an easy tool for the general public to adopt nor is some of its claimed effect validated in well controlled long term interventions, especially when it comes to body weight control I therefore believe that we still need more studies on GI, body weight and health and also we need to think closely before we start making the GI a part of public dietary recommendation and I therefore also find that books promising new and healthier lifestyle though nothing less than a ”Glucose Revolution”!!are premature.

Glycemic Index: Predicted versus measured in 14 mixed breakfast meals Flint, Raben, Astrup et al. Br J Nutr 2004;91:979-89.

Glycemic Index: The fat content, not CHO, predicts glycemic index Flint, Raben, Astrup et al. Br J Nutr 2004;91:979-89.

Glycemic Index No association between GI and Insulinemic index Flint, Raben, Astrup et al. Br J Nutr 2004;91:979-89.

Conflict of policy The World Bank describes sugar as “one of the most policy-distorted of all commodities” yet provides soft loans to increase the industry’s production capacity.[i] The World Trade Organization would like to end subsidies and controls on sugar to stimulate growth in a global free market.[ii] The World Health Organization would like personal sugar consumption in most countries to be reduced to improve dietary health.[iii [i] Sugar Policies: Opportunity for Change. World Bank Policy Research Working Paper 3222 February 2004 [ii] Panel on European Communities - Export Subsidies on Sugar interim report World Trade Organization (WTO) Sept 2004.  [iii] Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO Expert Consultation. WHO Technical Report Series No. 916. World Health Organization, Geneva, 2003

Sugar output doubled in developing countries Source FAS/USDA

2004 World Production/ Consumption of Sugar   Production Consumption 2002/03 2003/04 2003 2004 (. . million tonnes, raw value . .) WORLD 147.7 141.1 139.2 143.1 Developing countries 104.6 99.5 91.9 95.4 Developed countries 43.1 41.7 47.3 47.9 Source: FAO Food Outlook September 2004

Structural price collapse

Price forecast to 2014 In 2003/04 price falls under 7¢ per pound due to excess capacity. 2013/14 price reaches 9.1¢ per pound World Sugar: Food and Agricultural Policy Research Institute FAPRI 2004 Agricultural Outlook

Growth forecast to 2014 Global sugarcane harvest up 10.4% (sugar beet down by 3%) Total production up 22.4% Total consumption up 27% World Sugar: Food and Agricultural Policy Research Institute FAPRI 2004 Agricultural Outlook

World Bank Report 2004 A free market in sugar would lead to: The global welfare gains of …. $4.7 billion Jobs in developing countries….1 million World sugar market price up ….+40% Sugar Policies: Opportunity for Change. World Bank Policy Research Working Paper 3222 Feb 2004

Oxfam attacks EU dumping Approx cost of production cent/lb 9¢ - India 8¢ - World price – white 6¢ - World price – raw 5¢ - Zambia, Thailand, Malawi 4¢ - Brazil Source Oxfam Briefing Paper March 2004

Sugar and health policy 1990 - WHO 797 report on Diet, Nutrition and the Prevention of Chronic Diseases - sugar industry mobilised opposition to the recommendation of a 10% limit on added sugars 1992 - 797 Report informed the International Conference on Nutrition and its World Declaration and Plan of Action for Nutrition: “....chronic non-communicable diseases related to excessive or unbalanced dietary intakes often lead to premature deaths in both developed and developing countries.” 1993 - World Health Assembly ENDORSES in their entirety the World Declaration and Plan of Action for Nutrition adopted by the Conference..…urging members…“to contain and reduce the rate at which the prevalence of diet-related diseases and of conditions related to them is rising”

The 916 controversy Jan 2002 - Experts revise draft report on Diet, Nutrition and the Prevention of Chronic Diseases April 2002 onwards – Sugar, food and drink industries contest draft recommendations in consultation and extended dialogue Sept 2002 – Confusion over IoM 25% figure – a nutrient dilution threshold - not a “recommendation” March 2003 – Furore as final draft 916 report put online

WHO challenges food industry BMJ 2003;326;515-

Sweet and Salt reactions to TR 916 The Sugar Association and the Salt Institute said in April 14, 2003 in a letter to the DG of WHO: TR 916 was drafted by a select group of experts TR 916 not peer reviewed TR 916 contains unfounded and misleading recommendations ”We will exercise every avenue available to expose the dubious nature of TR 916, including asking Congressional appropriators to challenge future funding of the US`s 406 million US dollar contribution to the WHO.”

Sweet and Salt reactions to TR 916 Similar reactions was written to Secretary Tommy Thompson by Corn Refiners Asscosiation International Dairy Foods Association National Corn Growers Association Snack Food Association The Sugar Association Wheat Foods Council U.S. Council for International Business Letters to Tommy Thompson from two United States Senators, Larry E. Craig and John Breaux, supported the industry initiative

Sugar attack “It is difficult to believe the standards of the World Health Organization have slipped to such a low point.”

Threat to WHO funding “ ”

WHO stands firm March 2003 – Sweetener causus senators ask US government to press WHO/FAO to block the report March/April 2003 - WHO gets series of protest letters from the Sugar Association with threat to challenge US $406m funding to WHO April 2003 – Gro Harlem Brundtland joins with 916 vice chair Prof Shiriki Kumanyika in Rome launch of 916 report declaring “The solidity of the work done by the experts is well founded and makes these kinds of criticisms [by the sugar industry] unreasonable.”

May 2003 - Coca Cola lobbies health ministers

Data Quality Act ‘correction’ Sept 2003 - Jim Tozzi files ‘Challenge’ to 916 under US ‘Data Quality Act’

Jan 2004 - US letter to WHO

US focus on the Data Quality Act – an industry straightjacket on science? “The consultation process of the development of the WHO/FAO Report and the resulting Report itself would not meet these current US data quality standards” - Steiger

Challenge to Tommy Thompson It is significant that resistance from business interests, which included the sugar industry and soft drinks manufacturers with US government support, was also demonstrated when a previous WHO expert report, based on a scientific consultation in 1990, made similar recommendations intended to prevent diet-related chronic diseases. In the US you have demonstrated admirable leadership in your support for the WHO framework convention on tobacco control……Therefore I urge you to show equal courage and determination to support global efforts to address another of the biggest public health challenges facing us all in the 21st century.

Sugar accused in media

Big Fish ad campaign “Sugar has always been associated with weight gain and other health problems. We wanted to overcome this stigma by developing a series of ads that we targeted to moms and children…..”

Sugar industry scare tactics World Sugar Research Organization on implications of 916 recommendations* Forecast 3.6-6.5m ton pa fall in production Focused only on “losers” Ignored population growth Ignored technological alternatives e.g. growth in demand for “flex-fuel” * Impact of the WHO Dietary Recommendations on World Sugar Consumption, Production and Trade. Dr Xavier Irz, University of Reading. April 2003

Sugar consumption increases with the incomes The developing economies in Asia, including China, are predicted to consume considerably more sugar as the per capita income in these countries improves.    In parts of China such as Shenzen, where the conversion to a Western economy is nearly complete, per capita gross domestic product has risen to a Western level. This means that people have enough disposable income to buy mass-produced goods such as candy bars, soda, ketchup and other consumer goods containing sugar. As incomes improve across all of China, sugar consumption will rise in other regions as well. As these nations reach the level of OECD (Organization for Economic Cooperation and Development) economies, sugar consumption will parallel that growth. Alfa Laval – Sugar Industry Equipment Manufacturer 2002

February 2004 – FAO Rome Sugar bid to ambush 916 and global strategy at FAO Committee on Agriculture G-77 group ‘bloc’ vote ISO urges members to lobby health ministers against 916

USDA recommends <10%

US sugar consumption up 20% 31.4 17.3

USDA Dietary Guidelines on sugar 1980/1985 - Avoid too much sugar 1990 - Use sugars only in moderation 1995 - Choose a diet moderate in sugars 2000 - Choose beverages and foods to moderate your intake of sugars BMI>30 – 23% BMI>25 – 56% BMI>30 – 31% BMI>25 – 64% Age-adjusted* prevalence of overweight and obesity among U.S. adults, age 20-74 years NHANES III (1988-94) Age-adjusted* prevalence of overweight and obesity among U.S. adults, age 20-74 years NHANES 1999-2000

2005 - Choose carbohydrates wisely for good health? ? BMI>30 - 50%?

Sugar accused of influencing latest US draft dietary guidelines "This curious avoidance of the growing evidence about the dangers of added sugar would be inexplicable but for the fact that seven members of the panel - which was chosen by the Health and Human Services Department - have major financial and organizational connections to the food, drug and dietary supplement industries. It strains the imagination to believe that the sugar industry did not have undue influence this time around."[i] [i] Sugar and new Dietary Guidelines The Food Pyramid Scheme. New York Times editorial. September 1 2004

Sugar bidding to buy NGO status

In conclusion The evidence implicating sugar in health is now too great to ignore Attempts continue to manipulate messages and the overall health agenda Government agriculture departments should re-focus policies towards health-promoting food production The food and beverage industry could play a key role in ensuring sugar consumption is aligned to strategic public health goals The public, media and even shareholders are getting wise It is time for the industry to wise up too

Takk for meg ;-)