March 2018 Issue

FREE

excessive sugar consumption

in AfricaShould we stop it now or

wait for the sour end?

The romantic tragedy of

1

2

9

6

10

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12

FROM THE DOCTOR’S OFFICE

By Melissa Owoaje

MYTH BUSTER

CASE STUDY

EDITOR’S PIECE

QUIZ

BODY OF EVIDENCE

By Gabriel Oludare

FOOD FOR THOUGHT

By Emmanuel Ose

Contents

1

Children love sweet things. Almost every child

gets excited when they hear that something

sweet is coming their way. Children do not

possess the information or judgement to know

that eating sweet things may be enjoyable but

excessive sugar consumption is not good for their

health. Unfortunately, many adults are aware of

all the information available about the dangers

of excessive sugar consumption but have not

changed the way that they consume sugar.

Free sugars is so ubiquitous in foods and drinks

that avoiding excessive sugar consumption

cannot happen unconsciously. It takes vigilance

and care to monitor what is being consumed

daily to be able to achieve healthy levels of sugar

consumption. With education and good discipline,

over time, the World Health Organisation (WHO)

recommended limit for daily free sugar intake can

be achieved.

This fight back on sugar intake is not as optional

as it may appear because the rate of obesity-

related illnesses is on the rise and excessive sugar

is implicated in the rise of obesity. One mark of a

responsible generation is how well they set up the

next generation to succeed. As one of the most

informed generations of all time, it will be criminal

if we do not intervene to save the next generation

from obesity-related illnesses. This edition of

First Class Health provides a good insight into the

damage that excessive sugar intake can cause and

how changes in lifestyle can avert ill health. The

one message that comes through clearly is that

the story needs to be rewritten; sugar intake has

to be reduced to healthy levels as there is nothing

sweet about excessive sugar consumption.

Emmanuel Ose

Emmanuel Ose is a pharmacist with

experience in both hospital and

community pharmacy.

Emmanuel OseEditor

Dr Gabriel Oludare

Gabriel Oludare is a physiologist

and university lecturer. He has a

keen interest in the effects of food

on the functioning of the body.

Dr Melissa Owoaje

Melissa Owoaje is a medical

doctor with a particular interest in

education and writing.

There is nothing sweet about excessive sugar consumption

Editor’s Piece

Follow us @1stC1assHealth

Contributors

2

BODY OF EVIDENCEThe consequences of excessive sugar intake

By Gabriel Oludare

Sugar is an important part of the human

diet as it makes food more palatable and

provides energy. However, since the latter

part of the twentieth century, there have

been questions about the benefits of sugar,

especially refined sugars. People began to

wonder whether high sugar diets are good

for human health. According to the Food

and Agricultural Organization, an average

of 24 kilograms of sugar, equivalent to over

260 food calories per day, was consumed

annually per person of all ages in the world

as at 1999 with estimates rising to 25.1kg

in 2015.

In March 2015, the World Health Organization

(WHO) published a recommendation

that, in order to avoid a negative impact

on health, people should obtain no more

than 10% of their daily calorie intake from

free sugars. A majority of people exceed

the 10% recommended threshold in many

countries, with exceptions in Asia and Sub-

Saharan Africa. Although Sub-Saharan

Africa consumes a lower percentage of

dietary free sugars, the greater load of

sugar from cereals consumed and hidden

sugars in food substances are of great

concern. After cereals and vegetable oils,

sugar derived from sugarcane and beet

provides more kilocalories per capita per

day on average than other food groups.

Over-consumption of sugar has been

implicated in the occurrence of obesity,

diabetes, cardiovascular disease, dementia

and tooth decay - all of which are on the

rise in Africa. South Africans consume the

largest amount of sugar in Africa. They

consume between 12 and 24 teaspoons

of sugar per day - four to eight teaspoons

are from sugar sweetened beverages -

which is above the WHO guideline of a

total limit of 6 teaspoons of sugar per

day. Legislation on sugar tax by the South

African government which was effected in

April of 2017 was targeted at curbing the

rising rates of obesity, diabetes and heart

related diseases. South Africa follows the

footsteps of Mexico, France, Hungary and

the state of New York in the USA that

have pioneered the strategy. The sugar

tax by South Africa is one of the ambitious

strategies to reduce obesity by 10% by

2020 and includes other legislation such

as the salt reduction legislation, trans-

fat regulations and stricter label and

advertising regulations.

Overview of sugar intake in Africa

3

Sugar and recommended limits

Sugar is the generic name for sweet, soluble

carbohydrates, many of which are used in food.

Sugars can be classified as monosaccharides,

disaccharides and polysaccharides. Simple

sugars which are called monosaccharides include

glucose (also known as dextrose), fructose,

and galactose. Disaccharides include sucrose,

maltose (from malted grains) and lactose (from

milk). Polysaccharides include starch, glycogen

and cellulose.

The granulated sugar most commonly used as

food is sucrose - a disaccharide comprising of

glucose and fructose. In the body, sucrose is

broken down into the simple sugars fructose and

glucose. These simple sugars are absorbed into

the bloodstream and circulated by the arteries

to the body’s cells to provide energy. The excess

of this glucose can be stored as glycogen in the

liver and muscles and can be called upon when

required like during exercise or periods of fasting.

Excessive simple sugars in the body can also be

converted into fat and stored.

Table 1: Classification of sugars

Classes of sugar Sugars within the class

MonosaccharidesGlucose (aka dextrose), fructose and galactose

DisaccharidesSucrose, maltose

and lactose

PolysaccharidesStarch, glycogen

and cellulose

The World Health Organization recommends that

both adults and children reduce their intake of

free sugars to less than 10% of total energy intake.

A further reduction to below 5% of total energy

intake brings additional health benefits. Free

sugars are all monosaccharides and disaccharides

added to foods by the manufacturer, cook or

consumer plus sugars naturally present in honey

syrups and fruit juices.

Also, the American Heart Association recently

proposed an upper limit for added sugar in

the diet of 100 calories (420 kJ, 25 g) per day

for women or 150 calories (630 kJ, 37.5 g) for

men. This is equivalent to approximately 5-6%

of dietary energy. This can be viewed as an

ideal upper limit but is probably too low to be

accepted by the majority of people. For that

reason, an appropriate upper limit for the intake

of added sugar is 10% of energy. However, for

people who are at increased risk of the negative

health consequences of sugar, an intake of <6%

of energy is advisable. This applies to people who

are overweight or obese who have pre-diabetes

or who live in areas where the drinking water is

not fluoridated.

For illustration, a 355-ml can (33.5cL) of a sugar

sweetened beverage (one serving) contains

approximately 40g of sugar (150 calories, 630

kJ). Drinking one can per day translates to

approximately 6-8% of the daily recommended

calorie intake. Therefore, ideally, both adults

and children should limit the consumption of

sugar sweetened beverages to one can per day,

or the equivalent amount of added sugar from

other foods. An additional recommendation is

that infants and young children should not be

given beverages with added sugar. As children

grow, they demand sweetened foods and drinks.

In order to help to prevent dental caries, the

frequency of sugar intake should be limited and

sugar-rich foods should be consumed only with

meals, where possible

4

Erizanu P (2017) South Africa plans to fight obesity with a sugar tax http://edition.cnn.com/2017/03/02/health/south-africa-sugar-tax/index.html last accessed 7th November 2017.

FAO (2007). Food Balance Sheets. Food and Agriculture Organization of the United Nations.

Frank B.H. and Vasanti S.M. (2010) Sugar-sweetened beverages and risk of obesity and type 2 diabetes: Epidemiologic evidence Physiol Behav. 100(1): 47–54.

Papier K, Este C.D., Bain C, Banwell C, Seubsman S, Sleigh A, and Jorda S (2017) Consumption of sugar-sweetened beverages and type 2 diabetes incidence in Thai adults: results from an 8-year prospective study Nutr Diabetes. 2017 Jun; 7(6): e283

Steyn, N.P., Temple N.J. (2012) Evidence to support a food-based dietary guideline on sugar consumption in South Africa. BMC Public Health. 12:502

Sugar and the liver

An abundance of added sugar may cause the

liver to become resistant to insulin, an important

hormone that helps turn sugar in the bloodstream

into energy. This means that the body isn’t able to

control blood sugar levels as well as it should and

this can lead to type 2 diabetes. Also, fructose (a

component of table sugar and high-fructose corn

syrup) in added sugars triggers the liver to store

fat more efficiently and in unusual places. Over

time, a diet high in fructose could lead to globules

of fat building up around the liver - a precursor to

nonalcoholic fatty liver disease.

Sugar and the heart

A well known study with 4301 participants

showed that sugar is associated with higher levels

of bad cholesterol (LDL) and low levels of good

cholesterol (HDL). This can damage the arteries

which help circulate blood and lead to heart

disease, heart attacks and strokes. Heart disease

and stroke are the number one causes of death

among people with type 2 diabetes, accounting

for 65% of those deaths. Research also suggests

that eating less sugar can help lower blood

pressure - a major risk factor for heart disease.

In addition, people who eat a lot of added sugar

(where at least 25% of their calories come from

added sugar) are twice as likely to die of heart

disease as those whose diets include less than

10% of total calories from added sugar.

Sugar and the pancreas

The pancreas pumps out insulin into the blood

after a meal to process the high levels of sugar

and move them into energy stores in body cells.

The consumption of excessive sugar will cause

the pancreas to pump out higher levels of insulin

to process the sugar in the blood. The high levels

of insulin in the blood can lead to low blood sugar

which is unsafe. Over time, high blood insulin levels

may cause body cells to have poor sensitivity to

insulin and affect the removal of glucose from the

blood. The body will then resort to converting

blood glucose into fat. Excess body fat can lead to

obesity which is a risk factor for several illnesses

including type 2 diabetes.

Medical consequences of excessive sugar intake

References

5

The GBD 2013 Obesity Collaboration, Marie N.G et al (2014) Global, regional and national prevalence of overweight and obesity in children and adults 1980-2013: A systematic analysis Lancet. 2014 Aug 30; 384(9945): 766–781.

Weeratung P, Jayasinghe S, Perera Y., Jayasena G. and Jayasinghe S (2014) Per capita sugar consumption and prevalence of diabetes mellitus – global and regional associations BMC Public Health201414:186

Welsh, J.A., Andrea J.S., Lisa G, Miriam B.V. (2011). Consumption of added sugars is decreasing in the United States. American Journal of Clinical Nutrition. American Society for Nutrition. 94: 726–734.

WHO (2015) See Guideline: Sugars intake for adults and children. Geneva: World Health Organization.

Wikipedia (2017) Sugar https://en.wikipedia.org/wiki/Sugar#Consumption last accessed 7th November 2017.

Sugar and the kidneys

In a diabetic patient, too much sugar can lead to

kidney damage. The kidneys play an important

role in filtering blood. Once blood sugar levels

reach a certain amount, the kidney starts to let

excess sugar into the urine. If left uncontrolled,

diabetes can damage the kidneys, which prevents

them from doing their job in filtering out waste in

the blood. This can lead to kidney failure.

Sugar and body weight

The more sugar you eat, the more you’ll weigh.

Emerging research suggests that regularly eating

too much sugar impairs your body’s ability to tell

your brain you are full. The possible role of sugar in

the causation of excessive weight gain has focused

mainly on Sugar Sweetened Beverages (SSBs).

Very compelling evidence on the consumption

of SSBs in weight gain came from the recent

findings of two large studies that were carried out

in the USA. The investigators tracked 121 000 men

and women for a period of 20 years. The pooled

results indicated that the intake of SSBs could

explain almost one third of weight gain. (Subjects

gained an average of 1.52 kg during each four-

year period, of which 0.45 kg was linked to SSB).

Other foods strongly associated with weight gain

were potatoes, read meat and processed meat.

Sugar and the brain

Eating sugar gives the brain a huge surge of

a feel-good chemical called dopamine, which

explains why one is more likely to crave a candy

bar than a fruit. Because whole foods like fruits

and vegetables don’t cause the brain to release as

much dopamine, the brain starts to need more and

more sugar to get that same feeling of pleasure

leading to a craving for sugary food items such

as ice cream or sweets. In rat studies looking at

sugar addiction, when animals binge on sugar,

they experience chattering teeth, tremors, shakes

and anxiety when it’s taken away.

Sugar and the skin

Sugar in the bloodstream attaches to proteins

to form harmful new molecules called Advanced

Glycation End products or AGEs. AGEs attack

nearby proteins and damage them. The proteins

at risk include protein fibres in collagen and

elastin - these keep the skin firm and elastic. The

damage done by AGEs can result in dry, brittle

protein fibres that lead to wrinkles and saggy skin.

Sugar and the teeth

Sugar indirectly causes tooth decay due to

bacterial action on the sugar residues in the

mouth. Candy can rot the teeth because the

bacteria that causes cavities love to eat sugar

lingering in the mouth after one has eaten

something sweet. The bacteria’s waste product

which is acidic is responsible for decalcification

and demineralization of the tooth which results in

tooth decay.

6

1.9adults in the world

billion

FROM THE DR’S OFFICETackling excessive sugar consumption

By Melissa Owoaje

As a society we consume too much sugar. There is extensive research on the relationship between

sugar consumption and health. Eating too much sugar can contribute to weight gain and obesity.

Being overweight increases the risk of health problems including heart disease, type 2 diabetes, high

cholesterol, high blood pressure and certain cancers by four to eight times. Obesity-related diseases

are among the top 10 causes of death – this prevalence is only rivalled by HIV/AIDS. Consuming too

much sugar can also cause tooth decay.

7

So how much sugar should we be consuming?

The World Health Organisation (WHO) has

recommendations for maximum free sugar

intake. The ‘strong’ recommendation is that free

sugars should not make up more than 10 percent

of the energy (calories) we consume per day.

However, for additional benefits, the ‘conditional’

recommendation is that free sugars should not

make up more than 5 percent of the energy

(calories) we consume per day. This is about 30g

of sugar a day for those aged 11 and over (roughly

equivalent to seven sugar cubes). Children aged 7

to 10 should have no more than 24g of free sugars

a day (six sugar cubes). Children aged 4 to 6

should have no more than 19g of free sugars a day

(five sugar cubes).There is no guideline limit for

children under the age of 4 but it is recommended

they avoid sugar-sweetened drinks and food with

sugar added to it. On average, all age groups

consume over double the recommended intake.

To reduce the chances of suffering from diseases

such as heart disease, type 2 diabetes and tooth

decay one should try to reduce the intake of free

sugars.

As already defined, free sugars are all

monosaccharides and disaccharides added to

foods by the manufacturer, cook or consumer

plus sugars naturally present in honey syrups and

fruit juices. Common free sugars can be found

in sweets, cakes, biscuits, juices and fizzy drinks.

These foods and drinks can be very detrimental

to health. Free sugars are different from the

other kind of sugars - naturally occurring sugars.

Naturally occurring sugars are not considered to

be harmful in normal dietary quantities and can

be found in milk, whole fruit and vegetables.

Sugar, obesity and type 2 diabetes

Obesity has increased tremendously in all

divisions of society. The WHO has estimated that

there are 1.9 billion overweight adults in the world,

600 million of which were obese. People who

eat more sugar are more likely to be obese than

those who eat less. It is very important to take

steps to tackle obesity as it can lead to serious

and potentially life threatening conditions such

as type 2 diabetes, coronary heart disease, some

types of cancer and stroke.

Type 2 diabetes is a condition that leads to high

blood sugar levels. Although we know that sugar

does not directly cause type 2 diabetes, we

know that it leads to obesity. Obesity is the most

potent risk factor, accounting for 80-85% of the

total risk of developing type 2 diabetes. Sugar

contains many calories which can lead to obesity

and increase the risk of type 2 diabetes. There are

further health complications associated with type

2 diabetes including blindness, kidney disease,

amputation, sexual dysfunction, nerve problems,

complications in pregnancy and dementia.

8

Mrs RN is a 65 year old lady who came to see

her doctor with increased thirst and fatigue.

A urine test showed a high sugar content in her

urine. Blood pressure during consultation was

170/90mmHg (this is very high as normal blood

pressure should be 120/80mmHg). Her Body

Mass Index (BMI) based on her weight divided

by her height was 35, classifying her as clinically

obese (see previous edition – heavy weight but

no paunch - for a detailed description of BMI). Mrs

RN was sent for a blood glucose test. The results

confirmed that she had type 2 diabetes (she had

a HbA1c level of 7.8%).

Mrs RN was advised that she had 3 new diagnoses

1. High blood pressure 2. Type 2 diabetes 3.

Obesity. She was advised of the health risks

associated with all 3 diagnoses and agreed a

management plan with her doctor. She declined

blood pressure lowering medication in an attempt

to tackle her blood pressure with a change in

her diet. By changing her diet she would be also

addressing her diabetes and weight. She agreed

with her doctor to try to lose weight and return

for a review in 4 months.

Mrs RN sought advice from a nutritional expert

who analysed her diet. The analysis revealed

that Mrs RN was consuming 70g of sugar a day

through her diet. This is more than double the

recommended amount suggested by the WHO.

Mrs RN decided to pursue a low calorie, low sugar

diet for the next 4 months in an attempt to tackle

her 3 health problems.

After 4-5 months Mrs RN was reviewed by

her doctor. Her blood pressure had improved

significantly to 147/78. She had lost 12kg, making

her new BMI = 30. Furthermore, her blood sugar

had reduced significantly to a HbA1c of 5.5%. The

target blood sugar for a person with diabetes is

an HbA1c of 6.5%. Although she was still in the

obese range she was not far off the overweight

range and was making good progress. Mrs RN

agreed to continue on this plan so as to stabilise

her blood sugar levels and continue lowering her

blood pressure. The low calorie, low sugar diet

will also help her continue to lose weight. Mrs

RN reported feeling stronger, healthier and less

lethargic.

CASE STUDY

References

Johnson, R. J., Segal, M. S., Sautin, Y., Nakagawa, T., Feig, D, I., Kang, D., Gersch, M. S., Benner, S. and Sanchez-Lozada, L. G. 2007. “Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease.” American Journal of Clinical Nutrition. URL: <http://ajcn.nutrition.org/content/86/4/899.full>.

World Health Organisation, 2015. “Obesity and Overweight,” URL: http://www.who.int/mediacentre/factsheets/fs311/en/

British Dental Health Foundation, nd. “Dental Decay,” URL: https://www.dentalhealth.org/tell-me-about/topic/mouth-conditions/dental-decay

NHS Choices. 2016 “Diabetes.” URL: <http://www.nhs.uk/conditions/diabetes/pages/diabetes.aspx>

9

There is a TV programme that shows the life

of truckers in Australia and the journeys they

embark on to deliver very expensive cargo. As you

know, Australia is a very vast country. It has a land

area of 7.7 million square km. Just to appreciate

its vastness, the country with the largest land area

in Africa is Algeria with 2.4 million square km.

Anyway, this programme is interesting because

a camera follows these truckers to record their

trials and tribulations as they try to get heavy

expensive cargo from one part of the country to

another.

On one very interesting edition of the programme,

a company was trying to transport a power

station, worth several million dollars, to a place

that was hundreds of miles into the middle of the

country. The power station was very heavy and

could have been easier to carry in 3 separate

trips. If transported in 3 separate parts, the driver

would be able to take the fastest route, enjoy the

journey and do so without much extra assistance.

However, the decision was reached to transport

the power station in one journey. This decision

made the journey very difficult indeed. Firstly,

the power station was too heavy for one truck

so it needed one truck to drag it and another

to push it. Both drivers had to keep in constant

communication on a radio device. Secondly, they

had to have an engineer follow then in a separate

van. The engineer had to carry out checks at

certain intervals and move sharp stones out of

the way when needed. Thirdly, the drivers had

to use a tarred road as much as possible and

drive slowly because small dips in the road could

present serious problems. The trucks as well

as the driving team were under a lot of stress

throughout the journey.

What is sugar doing to you?

Sugar is clearly a source of enjoyment as it

improves the taste of food and drinks. The global

annual sugar production is over 170m metric tons

and has been over this threshold for most of the

last 5 years. This shows that people clearly enjoy

their sweet confectioneries and other sweet foods.

So what is the harm in eating sugar? Well, eaten

in moderation, sugar may be easily processed by

the body to provide energy but the continuous

overloading of the body with sugar can only have

the same effect on the body that the heavy power

station was having on the trucks transporting it.

Excessive sugar consumption causes a number of

challenges, including obesity and obesity is a risk

factor for many illnesses.

What kind of journey do you want?

Just like trucks used to transport heavy goods,

the body is like a vehicle that we have been issued

with to help us get to our lifes’ destination. We

have a lot of evidence now that shows without

doubt that the load we are carrying in our bodies

can determine how enjoyable the journey will be.

Those who take care of their bodies can expect

to minimise their risk of illnesses that can make

the journey very stressful. However, like the

truckers in the Australian programme, if you make

decisions that lead to excessive demands on your

vehicle, you may make it to the destination but

the journey may not be very enjoyable for you

or those closest to you. It is therefore worth

considering carefully what kind of life journey you

would like to have. You will know what decision

you have made by how you respond when you

next go to see a friend and you are asked the

question – ‘what would you like to drink’?

FOOD FOR THOUGHT“Welcome to our home… what would you like to drink”

By Emmanuel Ose

10

No sugar in diet is healthier than some sugar.

Natural sugar is better for you than processed sugar.

Humans need sugar to survive. Eliminating all sugar from diet is almost impossible since fruits, potatoes, and other starchy foods all have high sugar contents. That doesn’t mean you shouldn’t avoid foods with super-high sugar concentrations. A 20-ounce bottle of soda (about 60cL), for example, has roughly 65 grams (about 16 teaspoons) of sugar, which is more than twice the amount of sugar the World Health Organization advises that adults and children consume in a whole day. A low dose of sugar is not harmful but a high dose can be dangerous

Natural sugars consumed at normal dietary quantities are not considered to be harmful. However, some sugars in natural products like fruit and synthetic products like candy are the same. The difference is that candy and other related products usually have more sugar per serving, which means more calories per serving. Also, free sugars are metabolised quickly and cause blood sugar to rise quickly while natural sugars can come with fibre and therefore are metabolized slowly.

All “types” of added sugar have the same effect on your body. Some schools of thought believe that brown sugar is healthier than white sugar. Brown sugar is the sugar crystals that have retained a sticky syrup substance called molasses during sugar cane refining. This molasses give it its brown colour. In fact, brown sugar is mostly white sugar with some molasses so if you could refine it further, you would get your standard white, table sugar.

Some types of added sugar are better for you than others

Myth Buster

Myth Fact

11

Sugar directly causes cavities

If drinks have artificial sweeteners instead of sugar, you can drink as much as you like

Eating too much sugar is the direct cause of type 2 diabetes

Sugar is as addictive as heroin.

Cavities are actually caused by acidic foods and drinks that wear away the enamel on the teeth. Sugar indirectly causes tooth decay due to bacterial action on the sugar residues in the mouth. When one eats something with sugar, bacteria that naturally reside in the mouth consume this sugar as well. Bacteria’s waste product is acidic, which decalcifies or demineralizes tooth enamel, creating tooth decay.”

Some artificial sweeteners can be just as harmful to your body as sugar. Although artificial sweeteners like stevia, truvia, and aspartame (as found in diet sodas) have fewer calories than their sugary counterparts, research shows that people who drink diet soda are twice as likely to be obese than those who do not.

Diabetes is caused by a mix of genetics and environmental factors so a high sugar diet alone cannot directly cause diabetes. You are more likely to develop diabetes if you are overweight or obese because excess body fat can lead to insulin resistance. This makes a diet heavy in sugar an indirect, rather than a direct cause of type 2 diabetes

There are multiple conflicting studies concerning the subject of sugar addiction. One French study published in 2013 links cravings for sweets with the “reward” centre of our brains that are induced by addictive drugs. The study concluded that sugar can be even more addictive than cocaine. This finding is highly contested due to the fact that addiction-like behaviour in rodents occurred when the animals were restricted to eating sugar during a certain time period each day. However, when the test subjects were allowed to eat sugar whenever they wanted like in humans, the addictive behaviour vanished.

QUIZ1

43

6

2

5 7

How many calories is contained in 1 cube of sugar?

Which of the following actions does not help to

reduce weight gain?

Which organ in the body produces insulin

to remove excess sugar from the blood?

What is the WHO recommended daily

maximum consumption of free sugars for an adult who wants to achieve increased health benefits?

What is the daily recommended calorie

intake for a man?

What is the daily recommended calorie intake for a woman?

Which of these conditions is not

directly or indirectly linked to excessive

sugar consumption?

3% of daily calorie intake

5% of daily calorie intake

7% of daily calorie intake

11% of daily calorie intake

The liver

The kidneys

The pancreas

The heart

10 calories

15 calories

16 calories

20 calories

100 calories

1000 calories

1500 calories

2000 calories

Type 1 diabetes

Type 2 diabetes

Obesity

Tooth decay

Reduction in sugar consumption

Reduction in salt consumption

Reduction in alcohol consumption

Increase in physical activity and exercise

1050 calories

1500 calories

1800 calories

2500 calories

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

13

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