how much is too much? - philippine coconut...

Prevalence of Diabetes Mellitus inthe Philippines and Medical

Recommendations for Use ofAlternative Sweeteners

How Much is Too Much?

Olive Q. De Guzman-Quizon, MD, MPH, DPAFP, DPBCNAssistant Professor – UERMMMC- Institute for Studies on Diabetes Foundation Inc

Family Medicine- Diabetes- Clinical Nutrition Consultant, Manila Doctors Hospital

Nutrition Support and Weight Management Center Consultant, St. Luke’s Medical Center- QC

Questions to answer

• How big is the problem of Diabetes Mellitus?– Worldwide

– Region

– Philippines

• How much do I have to consume?– Alternative sweeteners

– Carbohydrates

– Simple sugars

• How big is the problem of Diabetes Mellitus?– Worldwide

– Region

– Philippines

• How much do I have to consume?– Alternative sweeteners

– Carbohydrates

– Simple sugars

366 million

552 million

National Prevalence of Diabetes Mellitus, by age,Philippines, 2008 (NNHeS)

Age(y)

Prevalence of Diabetes Mellitus*Based on FBS a Based on 2Hour

Post PrandialGlucose b

Based on the DMQuestionnaire c

True Diabetes d

20-2930-3940-4950-5960-69>70

Overall

0.43.25.79.09.14.44.8

0.41.13.95.05.95.53.0

0.51.44.28.19.57.14.0

0.93.88.2

13.015.911.87.1

20-2930-3940-4950-5960-69>70

Overall

0.43.25.79.09.14.44.8

0.41.13.95.05.95.53.0

0.51.44.28.19.57.14.0

0.93.88.2

13.015.911.87.1

a Based on FBS level > 125 mg/dL

b Based on 2H-PPG= > 200 mg/dL

c Based on DM questionnaire = having a previous diagnosis by a nurse or physician OR on current medication

d True diabetes = positive in any of the three assessment methods : FBS, 2H-PPG and DM questionnaire.

% p

reva

lenc

eDM prevalence in the Philippines

% p

reva

lenc

e

year

National Nutrition Survey 1998, National Nutrition and Health Survey, 2003&2008. FNRI

How much do I consume?

Alternative Sweeteners

Alternative SweetenersNon nutritive Nutritive

Artificial Natural Sugar alcohol

•Acesulfamepotassium (Sunett,Sweet One)•Aspartame (Equal,NutraSweet)•Neotame•Saccharin (SugarTwin,Sweet'N Low)•Sucralose (Splenda)

Date sugarGrape juiceconcentrateHoneyMaple sugarMaple syrupMolassesAgave nectar

ErythritolHydrogenated starchhydrolysatesIsomaltLactitolMaltitolMannitolSorbitolXylitolStevia preparationsthat are highly refined(Pure Via, Truvia)

•Acesulfamepotassium (Sunett,Sweet One)•Aspartame (Equal,NutraSweet)•Neotame•Saccharin (SugarTwin,Sweet'N Low)•Sucralose (Splenda)

Date sugarGrape juiceconcentrateHoneyMaple sugarMaple syrupMolassesAgave nectar

ErythritolHydrogenated starchhydrolysatesIsomaltLactitolMaltitolMannitolSorbitolXylitolStevia preparationsthat are highly refined(Pure Via, Truvia)

Sugarsubstitutes

FDAapproval

Brand name Sweetness Acceptabledaily intake(mg/kg/day)

Remarks

Saccharin 2002 Sweet andlow, nectasweet,sucaryl

200-700 x 12 mg Crosses theplacenta;slow fetalclearance;caution

Aspartame 1983, 1996 Equal, nutrasweet

160 -220 x 50 Hydrolyzedintometabolites

Hydrolyzedintometabolites

Acesulfame 1988 Sweet andsafe,sunnett,sweet one

200 x 15 Crosses theplacenta butconsideredsafe

Sucralose 1999 Splenda 600 x 5 Poorlyabsorbed

Neotame 2002 8000 x 18 Limitedstudies inpregnant

Managing pre-existing diabetes and pregnancy.. Technical reviews and consensus forrecommendation of care. Kitzmiller JL. Jovanovic L. Eds. 2008. American Diabetes Association

Carbohydrates and DM

• Artificial sweeteners are generally safe– acesulfame potassium, aspartame, neotame,

saccharin, and sucralose

– All underwent rigorous scrutiny and were shownto be safe when consumed by the public, includingpeople with diabetes and women duringpregnancy (Diabetes Care, Volume 31, Supplement1, January 2008)

• Artificial sweeteners are generally safe– acesulfame potassium, aspartame, neotame,

saccharin, and sucralose

– All underwent rigorous scrutiny and were shownto be safe when consumed by the public, includingpeople with diabetes and women duringpregnancy (Diabetes Care, Volume 31, Supplement1, January 2008)

Recommendation - ADA

• Sugar alcohols and nonnutritive sweetenersare safe when consumed within the dailyintake levels established by the Food and DrugAdministration (FDA). (A)

• Sugar alcohols and nonnutritive sweetenersare safe when consumed within the dailyintake levels established by the Food and DrugAdministration (FDA). (A)

Nutrition Recommendations and Interventions for Diabetes. Position Statementof American Diabetes Association. DIABETES CARE, VOLUME 31, SUPPLEMENT1, JANUARY 2008

Classified as “GRAS”

Generally Recognized As Safe(GRAS)

• For a GRAS substance, generally available dataand information about the use of thesubstance are known and accepted widely byqualified experts, and there is a basis toconclude that there is consensus amongqualified experts that those data andinformation establish that the substance issafe under the conditions of its intended use.

• For a GRAS substance, generally available dataand information about the use of thesubstance are known and accepted widely byqualified experts, and there is a basis toconclude that there is consensus amongqualified experts that those data andinformation establish that the substance issafe under the conditions of its intended use.

1958 Food Additives Amendment to the Federal Food, Drug, and Cosmetic Act.US FDA

Alternative SweetenersNutritive

Natural Sugar alcohol (1.5 kcal-3 kcal/gram)2 kcal/grams

Date sugarGrape juice concentrateHoneyMaple sugarMaple syrupMolassesAgave nectar

ErythritolHydrogenated starch hydrolysatesIsomaltLactitolMaltitolMannitolSorbitolXylitolStevia preparations that are highlyrefined (Pure Via, Truvia)

Date sugarGrape juice concentrateHoneyMaple sugarMaple syrupMolassesAgave nectar

ErythritolHydrogenated starch hydrolysatesIsomaltLactitolMaltitolMannitolSorbitolXylitolStevia preparations that are highlyrefined (Pure Via, Truvia)

Carbohydrates

How much do I have to consume?

Complex

Polysaccharides

Simple

Disaccharides Monosaccharide

ADA- American Diabetes AssociationCDA- Canadian Diabetes AssociationNCEP – National Cholesterol Education Program

50-60% Carbohydrates

EASD- European Association for the Study of Diabetes

45-60% Cholesterol

2004 Recommendation: Carbohydrates

James W. Anderson, MD, FACN, Kim M. Randles, Cyril W. C. Kendall, PhD, FACN, and David J. A. Jenkins, MD, PhD, DSc, FACN.Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of theEvidence Journal of the American College of Nutrition, Vol. 23, No. 1, 5–17 (2004).

BDA- British Diabetic Association


45-60% Cholesterol

Japan

60% Carbohydrates

AHA- American Heart Association

45-55%

India

>65% Carbohydrates

S. Africa


Carbohydrate intake should belower than the recommended

intake?– RDA:130 g/day (Institute of Medicine: Dietary Reference Intakes:

Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and AminoAcids. Washington, DC, National Academies Press, 2002)

– No trials specifically in patients withdiabetes restricting total carbohydrate to130 g/day

– Carbohydrate are important sources ofenergy, fiber, vitamins, and minerals and areimportant in dietary palatability

– RDA:130 g/day (Institute of Medicine: Dietary Reference Intakes:Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and AminoAcids. Washington, DC, National Academies Press, 2002)

– No trials specifically in patients withdiabetes restricting total carbohydrate to130 g/day

– Carbohydrate are important sources ofenergy, fiber, vitamins, and minerals and areimportant in dietary palatability

sucrose lactose maltose

fructose

glucose

galactose

glucose

glucose

glucose

ADA- American Diabetes Association

No restriction


<25g /day

CDA- Canadian Diabetes AssociationSouth Africa

Japan

1 serving of fruit

India

From food

2004 Recommendation:Monosaccharide and Disaccharides

CDA- Canadian Diabetes AssociationSouth Africa

≤10% added

AHA – American Heart AssociationNCEP – National Cholesterol Education Program

No comment

EASD – European Association for the Study of Diabetes

< 10% calories

James W. Anderson, MD, FACN, Kim M. Randles, Cyril W. C. Kendall, PhD, FACN, and David J. A. Jenkins, MD, PhD, DSc, FACN.Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of theEvidence Journal of the American College of Nutrition, Vol. 23, No. 1, 5–17 (2004).

Carbohydrate in diabetesmanagement

Sucrose-containing foods can be substituted forother carbohydrates in the meal plan or, ifadded to the meal plan, covered with insulinor other glucose lowering medications. Careshould be taken to avoid excess energy intake.(A)

• Nutrition Recommendations and Interventions for Diabetes. PositionStatement of American Diabetes Association. DIABETES CARE, VOLUME31, SUPPLEMENT 1, JANUARY 2008

Sucrose-containing foods can be substituted forother carbohydrates in the meal plan or, ifadded to the meal plan, covered with insulinor other glucose lowering medications. Careshould be taken to avoid excess energy intake.(A)

• Nutrition Recommendations and Interventions for Diabetes. PositionStatement of American Diabetes Association. DIABETES CARE, VOLUME31, SUPPLEMENT 1, JANUARY 2008

Carbohydrate in diabetesmanagement

• Dietary sucrose does not increase glycemiamore than isocaloric amounts of starch

• Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B,Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M: Evidence- based nutrition principlesand recommendations for the treatment and prevention of diabetes and relatedcomplications. Diabetes Care 25:148 –198, 2002

• Intake of sucrose and sucrose containing foodsby people with diabetes does not need to berestricted because of concern aboutaggravating hyperglycemia.

• Dietary sucrose does not increase glycemiamore than isocaloric amounts of starch

• Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B,Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M: Evidence- based nutrition principlesand recommendations for the treatment and prevention of diabetes and relatedcomplications. Diabetes Care 25:148 –198, 2002

• Intake of sucrose and sucrose containing foodsby people with diabetes does not need to berestricted because of concern aboutaggravating hyperglycemia.

Recommendations – added sugarAmerican Heart Association(1)

Dietary Guidelines for Americans(2)

Males: 9 teaspoonFemales: 6 teaspoon

Drink water instead of regular soda,"vitamin-type" water, sports drinks,coffee drinks, and energy drinks.

Eat less candy; dairy-based dessertssuch as ice cream; and grain-baseddesserts such as cookies, cakes, andpies.

Drink water instead of regular soda,"vitamin-type" water, sports drinks,coffee drinks, and energy drinks.

Eat less candy; dairy-based dessertssuch as ice cream; and grain-baseddesserts such as cookies, cakes, andpies.

1. Johnson RJ, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, et al. Dietary Sugars Intake and Cardiovascular Health: A ScientificStatement from the American Heart Association. Circulation. 2009;120:1011-1020.

2. United States Department of Agriculture. Center for Nutrition Policy and Promotion. Dietary Guidelines for Americans. 2010. National AcademyPress, Washington, DC, 2010.

FNRI Recommendation for FilipinosAge group Sugar and sweets

(in teaspoons)1-6 4-5

7-12 5-67-12 5-6Teens 5-6Adults 5-8Elderly 5-6

Pregnant 6Lactating 6

http://www.fnri.dost.gov.ph/index.php?option=content&task=view&id=1275

Comparison of Mean One Day perCapita Sugar/ Syrup consumption

Sug

ar c

onsu

mpt

ion

gram

s/da

y

year

Sug

ar c

onsu

mpt

ion

gram

s/da

y

Facts and Figure 2001, 2003, 2005. FNRI

1 sugar exchange = 5 g CHO20 Kcal

• 1 tsp table sugar(white, brown, purecane, syrup)

• 1 tsp honey

• 1 tsp panutsa

• 1 tsp matamis na bao

• 1 pc bukayo

• 2 tsp condensed milk

• 2 tsp jam, jellies,preserves

• 1 pc banana chip

• 1 pc hard candy, sampaloccandy, toffee candy,caramel candy, chewinggum, bubble gum,marshmallow

• 2 tbsp nata de coco

• 1 pc pastillas (durian, gatas,langka)

• ¼ cup taho with syrup andsago

• 1 tsp ube halaya

• 1 pc yema

• 1 tsp table sugar(white, brown, purecane, syrup)

• 1 tsp honey

• 1 tsp panutsa

• 1 tsp matamis na bao

• 1 pc bukayo

• 2 tsp condensed milk

• 2 tsp jam, jellies,preserves

• 1 pc banana chip

• 1 pc hard candy, sampaloccandy, toffee candy,caramel candy, chewinggum, bubble gum,marshmallow

• 2 tbsp nata de coco

• 1 pc pastillas (durian, gatas,langka)

• ¼ cup taho with syrup andsago

• 1 tsp ube halaya

• 1 pc yemaFood Exchange List , FNRI

Type of carbohydrate contributesmore in post prandial glucose thanthe total amount of carbohydrates

–Primary determinant of postprandial response: amount ofcarbohydrate ingested

–Primary determinant of postprandial response: amount ofcarbohydrate ingested

Types of sugar SucroseDietary sucrose does not increase glycemia more than

isocaloric amounts of starch (Diabetes Care 25:148 –198, 2002)

FructoseFructose produces a lower postprandial glucose

response when it replaces sucrose or starch but fructosemay adversely affect plasma lipids (Diabetes Care 25:148 –198,2002)

Intakes above 25% of total energy consumed will causehypertriglyceridemia and gastrointestinal symptoms(Position of the American Dietetic Association: use of nutritive and nonnutritivesweeteners. J Am Diet Assoc 2004, 104:255-275.)

SucroseDietary sucrose does not increase glycemia more than

isocaloric amounts of starch (Diabetes Care 25:148 –198, 2002)

FructoseFructose produces a lower postprandial glucose

response when it replaces sucrose or starch but fructosemay adversely affect plasma lipids (Diabetes Care 25:148 –198,2002)

Intakes above 25% of total energy consumed will causehypertriglyceridemia and gastrointestinal symptoms(Position of the American Dietetic Association: use of nutritive and nonnutritivesweeteners. J Am Diet Assoc 2004, 104:255-275.)

Fructose Metabolism

Types of sugar Sugar alcoholno evidence that the amounts of sugar alcohols likely to be

consumed will reduce glycemia,energy intake, or weight (DiabetesCare, Volume 31, Supplement 1, January 2008)

greater than 50 grams/day of sorbitol or greater than 20grams/day of mannitol may cause diarrhea (American DieteticAssociation)

Resistant starch (high amylose)no published long-term studies in subjects with

diabetes to prove benefit from the use of resistantstarch (Diabetes Care, Volume 31, Supplement 1, January 2008)

Sugar alcoholno evidence that the amounts of sugar alcohols likely to be

consumed will reduce glycemia,energy intake, or weight (DiabetesCare, Volume 31, Supplement 1, January 2008)

greater than 50 grams/day of sorbitol or greater than 20grams/day of mannitol may cause diarrhea (American DieteticAssociation)

Resistant starch (high amylose)no published long-term studies in subjects with

diabetes to prove benefit from the use of resistantstarch (Diabetes Care, Volume 31, Supplement 1, January 2008)

Other Variables influencing effect of CHO-containingfood on blood glucose response

Specific type of foodingested

Type of starch (amyloseversus amylopectin)

style of preparation(cooking method andtime, amount of heat ormoisture used)

Ripeness

Degree of processing

Fasting or preprandialblood glucose level

Macronutrientdistribution of the mealin which the food isconsumed

Available insulin

Degree of insulinresistance.

Intrinsic variables Extrinsic variables

Specific type of foodingested

Type of starch (amyloseversus amylopectin)

style of preparation(cooking method andtime, amount of heat ormoisture used)

Ripeness

Degree of processing

Fasting or preprandialblood glucose level

Macronutrientdistribution of the mealin which the food isconsumed

Available insulin

Degree of insulinresistance.

Eat only food with lowglycemic index?

– low–glycemic index diet trials in diabetic subjectsshowed that such diets produced a 0.4%decrement in A1C when compared with high–glycemic index diets (Brand-Miller J, Hayne S, Petocz P, Colagiuri S: Low-glycemic index diets in the management of diabetes: a meta-analysis of randomizedcontrolled trials. Diabetes Care 26:2261–2267, 2003)

– A low-GI diet can improve glycemic controlin diabetes without compromisinghypoglycaemic events (Thomas D, Elliott EJ. Low glycaemic index,

or low glycaemic load, diets for diabetes mellitus. Cochrane Database of SystematicReviews 2009, Issue 1. Art. No.: CD006296.DOI:10.1002/14651858. CD006296.pub2)

– low–glycemic index diet trials in diabetic subjectsshowed that such diets produced a 0.4%decrement in A1C when compared with high–glycemic index diets (Brand-Miller J, Hayne S, Petocz P, Colagiuri S: Low-glycemic index diets in the management of diabetes: a meta-analysis of randomizedcontrolled trials. Diabetes Care 26:2261–2267, 2003)

– A low-GI diet can improve glycemic controlin diabetes without compromisinghypoglycaemic events (Thomas D, Elliott EJ. Low glycaemic index,

or low glycaemic load, diets for diabetes mellitus. Cochrane Database of SystematicReviews 2009, Issue 1. Art. No.: CD006296.DOI:10.1002/14651858. CD006296.pub2)


CDA- Canadian Diabetes AssociationEASD – European Association for the Study of DiabetesJapan

Recommended to be included in meals

2004 Recommendation: Glycemic Index


Not recommended for general use


Discusses

India

Quotes references

AHA – American Heart AssociationNCEP – National Cholesterol Education Program

No commentJames W. Anderson, MD, FACN, Kim M. Randles, Cyril W. C. Kendall, PhD, FACN, and David J. A. Jenkins, MD, PhD, DSc, FACN.Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of theEvidence Journal of the American College of Nutrition, Vol. 23, No. 1, 5–17 (2004).

• Use of the glycemic index and glycemic loadmay provide a modest additional benefit forglycemic control over that observed whentotal carbohydrate is considered alone. (B)

ADA recommendation (2011)

• Use of the glycemic index and glycemic loadmay provide a modest additional benefit forglycemic control over that observed whentotal carbohydrate is considered alone. (B)

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Medium glycemic Index 56-69

BananaPineappleRaisinsNew potatoesPopcornSplit pea or green pea soup

Brown riceCouscousBasmati riceShredded wheat cerealWhole wheat breadRye bread

High glycemic Index ≥ 70

WatermelonDried datesInstant mashed potatoesBaked white potatoParsnipsRutabagaInstant riceCorn Flakes™Rice Krispies™

Cheerios™Bagel, whiteSoda crackersJellybeansFrench friesIce creamDigestive cookiesTable sugar (sucrose)

Cookingmethod/ timeRipenessTemperatureAlkalinityAmylopectin

Physical formSoluble fiberFat &ProteincontentAcidityAmylose

Low glycemic Index ≤ 55

Skim milkPlain YogurtSoy beverageApple/plum/orangeSweet potatoOat bran breadOatmeal (slow cook oats)

All-Bran™Converted or Parboiled ricePumpernickel breadAl dente (firm) pastaLentils/kidney/baked beansChick peas

BananaPineappleRaisinsNew potatoesPopcornSplit pea or green pea soup

Brown riceCouscousBasmati riceShredded wheat cerealWhole wheat breadRye bread

GI and GL values coconut sugar

Coconutproduct

Serving size AvailableCHO (g)

GlycemicIndex(GI)

GlycemicLoad (GL)

Coconut sap ½ bottle,80 grams

12 68 (medium) 9 (low)

Coconut sapsugar 1

2 tsp,7 grams

7 35 (low) 2 (low)Coconut sapsugar 1

2 tsp,7 grams

7 35 (low) 2 (low)

Coconut sapsugar 2

2 tsp,7 grams

6 42 (low) 2 (low)

Coconut sapsyrup 2

2 tsp,7 grams

5 39 (low) 2 (low)

Coconutwater

250 ml 12 45 (low) 6 (low)

Glycemic index of commonly consumed carbohydrates foods in the Philippines FNRI 2011

What is wrong with this?


and in the context of a healthy diet

In summary....


Thank you for your kindattention!

Thank you for your kindattention!

how much is too much? - philippine coconut...

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