Rina Agustina IFPRI-FAO conference, "Accelerating the End of Hunger and Malnutrition" November 28–30, 2018 Bangkok, Thailand

1. How Asia gets its sugar
Rina Agustina
Chair Human Nutrition Research Center, IMERI
Department of Nutrition Faculty of Medicine
Universitas Indonesia – Dr. Cipto Mangunkusumo
General Hospital, Jakarta, Indonesia
IFRI-FAO, 29 November, 2018
ICE ON IMERI 2018

2. Outline
How Asia gets its sugar
• Burden of Obesity and Type 2 diabetes in the Asian population
• Sugar consumption (including in infant foods)
• Nutrition transition
• Intervention and policy response
• Food system transformation (production and consumption) in Asia
R Agustina 2018

3. Burden of obesity and diabetes
in Asian populations

4. Figure 10
Trends in body-mass index
(BMI), underweight,
overweight, and obesity
1975 to 2016
Double burden of malnutrition
Age-standardised mean BMI and
prevalence of obesity has
accelerated in East, South and
Southeast Asia
Abarca-Gómez et al,
The Lancet 2017; 390, 2627-2642
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5. Asia is in the grip of a diabetes epidemic
Global Report on Diabetes, WHO, 2016
Percentage of death attributed to high blood
glucose level HBG (aged 20-69 years) by WHO
region and sex, 2012
Diabetes prevalence has doubled since 1980
Trends in prevalence of diabetes
by WHO region 1980–2014
Overweight and obesity are the strongest risk factors for type 2 diabetes
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6. Sugar consumption in Asia

7. Sugar consumption per capita in selected countries
(grams per day)
PRC, People’s Republic of China
Source: Euromonitor International (2015) in Thavorncharoensap,
ADB Institute, 2017
Asia had the highest correlation between
Diabetes prevalence and per capita sugar
consumptions (PCC 0.66 (p < 0.001)
Strongest correlation in
• Central Asia (PCC = 0.97; p < 0.001)
• South Asia (PCC = 0.68; p = 0.05)
• South East Asia (PCC = 0.92; p < 0.001)
Weeratunga et al
BMC Public Health. 2014; 14: 186.
PCC, Person’s correlation coefficient
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8. Total sugar, fat and salt
consumption from processed
foods and beverages has
plateaued in high-income
countries, but has increased
rapidly in upper–middle-
income countries (espc in
China and Thailand) and
lower–middle-income
countries
Euromonitor projections indicate
that per capita sugar
consumption from processed
foods in U-MICs will be 50% (7.4
kg and 14.8 kg) consumption in
HICs in 2017
Baker & Friel, Obesity Reviews, 2014;
Processed foods and beverages in
the ‘nutrition transition’ underway in Asia
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9. Consumption (kg per capita) of
processed food product highest
in sugar, salt and fat in Asia
1999–2012 - projections 2017
lower–middle-income countries
Countries ranked by gross national income (GNI) per capita from left (highest) to right (lowest).
upper–middle-income countries
Baker, Obesity Reviews, 2014
High-income countries

10. Carbonated soft drinks were the most significant sugar
vector irrespective of country income bracket in Asia
Baker & Friel, Obesity Reviews, 2014; Globalization and Health, 2016
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11. Consumption of non-alcoholic caloric beverages
in 187 countries worldwide
Between 1990 and 2010, SSB consumption increased in
several countries in Latin America and the Caribbean and
Southeast Asia. Intakes of all three beverages were
lowest in East Asia and Oceania.
Singh et al, PLOS ONE 2014
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12. Carbonated Soft Drink in children and adolescents
South Asian Students Aged 13-15 y
Country Year of Survey % of Students
Brunei Darussalam 2014 46.3
Cambodia 2013 45.6
Indonesia 2015 38.8
Malaysia 2012 31.3
Philippines 2011 42.2
Samoa 2011 53.5
Solomon Islands 2011 45.1
Thailand 2015 57.7
Viet nam 2013 34.6
Source: WHO. Global School-Based Student Health Survey (GSHS)
Unfortunately, sugar-sweetened beverages are an
unregulated, booming market in Asia.
Chinese children Aged 3-7 y
Yu, Public Health Nutritoon, 2016

13. SOURCES OF ADDED SUGAR
Rank Source Country % Contribution to
total sugar
1 Sucrose was the most added
sugar ingredient
irrespective of
country income
70% in all country
2 High-fructose sugar was the
second most added sugar
ingredient
Highest in HIC 16% in L-MICs
21% in U-MICs
24% in HICs
3 Processed foods Differed 73% in L-MICs
64% in U-MICs
53% in HICs
4 Bracket beverages In all country
income
36% - 38%
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14. A shift away from traditional
(ethnic) foods has led to a
sweetening of the global diet
Nutrition transition in Asia

15. Asian Diet Benefits:
• Green tea
• Rich variety of vegetables and fruits
• Spices
• Low red meat consumption
• Beans and nuts
• Fish and seafood
• Fruits as dessert
• Whole grains
• Tradition of controlling portion size
• Soy consumption (fermented tempe toufu,
soup, drink)
Asian Diet Risks:
• White rice and other refined grains
• Sweets and snacks high in sugar
• Tea or coffee with too much added
sugar
• Use of animal fat and palm oil
• Unhealthy trans fats (in snacks, butter,
etc.) are not labelled on packages5
• Too much salt
• Excessive consumption of preserved
foods (such as pickled vegetables and
cured meats)
Asian diets:
Benefits versus Risks
For NCD
R Agustina 2018

16. Asian traditional dietary patterns are being lost as the food
environment becomes more industrialized and urban
• Red meat
• Processed meat
• Fried foods (French fries, chicken, etc.)
• Large portion size
• Unregulated trans fats
• Refined carbohydrates
• High fructose corn syrup and added sugar
• Sugary drinks
• Marketing of unhealthy food to children
Feeley et al 2016
Proportion of mothers observing promotions of
commercially produced snack food products since
birth of child 6–23 months of age
Traditional diet – Western fast food:
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17. Sugar Consumption in Thailand
Frequently consumed sources of
added sugar:
• sweetened beverages (including
soft drinks, juices, milk and dairy
products, coffee/tea/chocolate
drink)
• sweetened snacks (including
traditional Thai desserts, baked
desserts/cakes, crispy snacks),
and
• table sugar.
Nationwide surveys and individual studies
Kriengsinyos et al Asia Pac J Clin Nutr. 2018;27(2):262-283.
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18. Trend of sugar consumption in Indonesia
(kg/cap/year) – Susenas of BPS 1990-2016
Sugar consumption decrease in Urban area annually by 0.31%;
increase in rural area by 0.55% -
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19. 1.5
11.8
22.7
0.0
5.0
10.0
15.0
20.0
25.0
Maluku
NTT
Kaltim
Bali
Lampung
Sulut
Jabar
Gorontalo
Sultra
Banten
Kalteng
Sumut
Jambi
Malut
Sulteng
Kep.Riau
DKI
Sumsel
Papua
Bengkulu
Indonesia
Sulbar
Jatim
Sulsel
Riau
NTB
Kalbar
Aceh
Sumbar
Babel
Pabar
Jateng
Kalsel
DIY
Persen
Provinsi
Proportion of population with sugar intake
>50 g/person/day by Province
Total Diet Study Survey, 2014
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20. SUNDANESE BETAWI CHINESEMINANG KABAU JAVANESE
Indonesia: Heterogeneity and diversity exist in its large
geography, social practices, cultures, diets, and beliefs
MIX
68.5 g
Median Sugar intake/day (selected muti-ethinic groups living in Jakarta) n=270
Unpublished data, Diochrome Study, HNRC, IMERI, Agustina 2018
51.0 g 39.0 g 36.2 g 33.1 g44.7g
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21. Interventions and Policy
Responses
21

22. Meta-analysis of randomized controlled trials
in Adults
children with the
highest intakes of sugar-
sweetened beverages
had a greater likelihood
of being overweight or
obese than children
with the lowest intakes.
Increase intake of free
sugar, increase of
bodyweight
Decrease intake of free
sugar, decrease of
bodyweight
Reference : WHO, 2015
Meta-analysis of prospective cohort studies, with
follow-up times of 1 year or more in children
Sugar intake and obesity
• WHO recommends a reduced intake of free sugars
throughout the lifecourse
• In both adults and children, WHO recommends
reducing the intake of free sugars to less than 10% of
total energy intake
• WHO suggests a further reduction of the intake of free
sugars to below 5% of total energy intake

23. Comprehensive government policy and
regulatory response
Prevent or
mitigate
processed food
consumption
Sugar-sweetened
beverage taxes
Food labelling
Marketing
restrictions on
unhealthy food
School-based
interventions
Healthy Living
community
movement
Comprehensive Intervention and policy responses offer the greatest potential for making and accelerating
progress in reducing overweight and obesity
R Agustina 2018

24. Plan of action for the prevention of obesity
in children and adolescents
Breastfeeding
promotion
influence
behaviour: Better
food and more
physical activity in
schools
“Junk food” –
“SSB” taxes and
restrictions on
marketing
Increased access
to recreational
spaces and
nutritious foods
Promotive
environments and
policies for
inexpensive
healthy food
SSB, Sugar Sweetened Beverage
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25. Customized transformation of food system:
New initiative - focus on sugar
Aligning high-level
policies and strategies
in support of a
sustainable food future
primary goals would be to
eliminate subsidies and
stimulus packages to the
domestic sugar industry,
and to bring sugar
plantations back under the
forest moratorium.
To mainstream the
principles of a healthy
and sustainable diet
the central goals might be to bring
sugar in government-supplied
meals (e.g. in hospitals and school
feeding programmes) under the
Indonesian 40 g per day
recommended maximum, to limit
availability of high-sugar foods in
outlets in schools and other
government buildings, and to ban
or limit advertising of high-sugar
foods to children.
Partner with food
providers and local
pioneers
immediate priorities would be
to work with industry on
reformulation of high-sugar
products, and to involve city
governments and civil society
organisations in outreach,
including social media, to
increase public awareness of
and support for the wider
initative.
Policy Brief -Healthy diets from sustainable production: the case of Indonesia
EAT - Chatham House, UI - MOH RI, presented at Universitas Indonesia 2018
Indonesia: as a model for solving global health problem
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26. Rapid Transformation Platform
of the food system
Current global food system is failing to
deliver healthy diets and
unsustainable in regard to both
environmental and human health.
A Healthy Food
Production system
important to engage the
agricultural and private sector to
produce healthy and affordable
foods, especially with incentives
for production and consumption
linked with the national health
insurance system.
A Healthy Food
Information System
Deployment of a frontline
information system will link
production-to-plate across the
agricultural, private industry
and health sectors; and enable
data-driven management of a
healthy and sustainable food
supply and diet.
Healthy District
Leaders
to manage inter-sectoral
transformation to
healthy and sustainable
diets and use of scientific
platform for evidence-
based policy.
A Healthy eating
promotion – Health food
consumption
No one-size-fits all framework for
transformation
Customized Food system
transformation
Indonesia: as a model for solving global health problem
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Strengthening Research and Development

27. Inclusion of rapid transformation platform in Universal
Health Coverage
• Investments in transformative policies
and actions for human resource
performance are needed.
• Policies to support environment factors,
food security, healthy diet and
sustainable food system
• Promotive and preventive care in
Universal Health Coverage system
R Agustina 2018

28. Summary
A shift away from traditional (ethnic) foods
has led to a sweetening of the global diet
Comprehensive Intervention and policy
responses offer the greatest potential for
making and accelerating progress in
reducing overweight and obesity
Current global food system is failing to
deliver healthy diets and unsustainable.
No one-size-fits all framework for
transformation- Customized Rapid
Transformation Platform of Food system
for Healthy diet and sustainable food
system
• Prevalence of overweight and obesity in
children, adolescent and adults has been
rising in Asia region
• Asia is in the grip of a diabetes epidemic,
• Sugar is considered to be one of the main
contributors to rising obesity and
diabetes rates in Asia, however data on
added sugar consumption are limited in
this region
• Processed foods and Carbonated soft
drinks were the most significant sugar
vector irrespective of country income
bracket
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29. 29
Harray AJ, Boushey CJ, Pollard CM, Delp EJ, Ahmad Z, Dhaliwal SS, Mukhtar SA, et al - 2015
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THANK YOU