ILSI SEAR Monograph Carbohydrates

MONOGRAPH SERIES
ROLE OF CARBOHYDRATES
IN HEALTH & DISEASE
Evaluating Scientific Evidence for Dietary Guidance
INTERNATIONAL LIFE SCIENCES INSTITUTE

Southeast Asia Region
ASEAN • Australasia & Pacific
The International Life Sciences Institute (ILSI) is a non-profit worldwide foundation based in Washington,
DC, USA, established in 1978 to advance the understanding of scientific issues relating to nutrition, food safety,
toxicology, risk assessment and the environment. ILSI accomplishes its work through its branches, the ILSI
Research Foundation (comprising the ILSI Human Nutrition Institute and the ILSI Risk Science Institute), and
the ILSI Center for Health Promotion.
Established in 1993, ILSI Southeast Asia Region is located in Singapore and serves as the regional office for
the coordination of scientific programs, research and information dissemination in ASEAN, Australia, New
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about ILSI, visit our website at www.ilsi.org.
This publication is made possible with the support of the ILSI Southeast Asia Region Nutrition and Healthy
Eating Task Force. The Task Force addresses issues, and facilitates scientific activities, relating to macronutrients,
health and chronic diseases, dietary assessment and food-based dietary guidelines.
Copyright © 2006 International Life Sciences Institute (ILSI)
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ROLE OF CARBOHYDRATES
IN HEALTH & DISEASE:
EVALUATING SCIENTIFIC EVIDENCE
FOR DIETARY GUIDANCE
Editor
Rodolfo F. Florentino
International Life Sciences Institute (ILSI)

Southeast Asia Region
Monograph Series
Singapore
FOREWORD
Carbohydrates provide between 40% to 70% of the total energy intake of different populations in
the world, thus constituting the most important energy source in human diets. Over the past 25
years, much progress has been made in our knowledge of carbohydrates ranging from its chemistry
and impact on physiology, its role in health maintenance and in the treatment of diseases. Recent
scientific debates have centered on the amount and types of carbohydrate intake and their relation
to health conditions such as obesity and hyperlipidemia. Popular diet trends and widespread media
coverage have impacted on the public’s perception of carbohydrates and caused a rapid change
in consumption patterns. As total carbohydrate intake from foods, including staple foods, increases
or decreases, the intake of nutrients associated with the carbohydrate food sources also increases
or decreases. In particular, foods that are naturally rich in glycemic carbohydrates such as cereals,
pulses, seeds, fruit and vegetables, provide a wider range of important micronutrients, dietary fiber
and phytochemicals, widely recognized to have beneficial effect on health.
In light of the current interest, nutrition scientists, academics, health care providers and regulators
need to understand and evaluate the scientific information and latest research in order to assess
dietary implications and formulate dietary guidance. The aims of dietary guidance to promote
health and prevent diseases should also be culturally appropriate and economically viable.
The Regional Symposium on the Role of Carbohydrates in Human Health and Disease – Evaluating
Scientific Evidence for Dietary Guidance was held from July 26 – 27, 2005 in Kuala Lumpur, Malaysia.
The Symposium provided an overview of the current status of carbohydrates science and consumption
trends; evaluated the role of carbohydrates in human health and disease; stimulated discussion on
science-based dietary guidance with regard to carbohydrates for individuals and population groups;
and identified knowledge gaps for further research.
The Symposium successfully brought together international, regional and local scientists and experts
working in the area of carbohydrates and health, and was attended by more than 150 scientists,
nutritionists, dietitians, medical and health professionals from academia, research institutions, the
food industry as well as government and agricultural agencies.
Many have contributed to the success of the Symposium and this Monograph, and we would like
to express our special thanks to Dr. David Lineback from JIFSAN, University of Maryland, USA and
Dr. Peter Clifton from CSIRO Health Sciences and Nutrition, Australia for their strong support and
collaboration. We would also like to express our appreciation to all the Speakers who shared their
research, information and expertise at the Symposium, and who have kindly contributed their
papers to this Monograph. Our gratitude is also due to the Editor of this Monograph, Dr. Rodolfo
R. Florentino, who has done an excellent job in putting this publication together.
By providing an up-date on the current science, we hope that this Monograph will be a useful and
informative guide to the regional and international scientific community, regulators and health
professionals in the setting of food-based dietary guidelines for carbohydrates.
Yeong Boon Yee

Executive Director, ILSI Southeast Asia Region
April 2006
CONTENTS
Carbohydrate Definitions: Are They Important?

David Lineback, JIFSAN, University of Maryland, USA
Available and Non-Available Carbohydrates:

Effects on the Health of the Large Bowel
Peter Clifton, CSIRO Health Sciences and Nutrition, Australia
Understanding Carbohydrates and Health

Frances Seligson, ILSI North America, USA
Glycemic Indexes, Glycemic Impact and Virtual Food Components:

Present and Future
John Monro, New Zealand Institute for Crop & Food Research Ltd, New Zealand
Carbohydrates and Obesity

Peter Clifton, CSIRO Health Sciences and Nutrition, Australia
Carbohydrates and Oral Health – Dental Caries:

Population Approaches to Prevention
Clive Wright, Ministry of Health, New Zealand
Carbohydrates in the Prevention and Treatment of Diabetes

Alan Barclay, Diabetes Australia, Australia
Non-Digestible Carbohydrates:
Blood Pressure, Cholesterol and Cardiovascular Health
Jonathan Hodgson, University of Western Australia, Australia
Carbohydrates and Gut Health: Probiotics and Prebiotics

Lee Yuan Kun, National University of Singapore, Singapore
Grains in the Diet: A Historical Perspective of Grain Nutrition

Rodolfo Florentino, Nutrition Foundation of the Philippines, the Philippines
Sweeteners in Life and Health

Frances Seligson, ILSI North America, USA
Carbohydrate Dietary Guidelines from Around the World

E-Siong Tee, Nutrition Society of Malaysia, Malaysia
Panel Discussion I
Carbohydrates and Nutrition Labeling Issues
Panel Discussion II
Dietary Guidance –Forecasting the Future
Role Of Carbohydrates in Health & Disease: Evaluating Scientific Evidence for Dietary Guidance 7
Carbohydrate Definitions: Are They Important?

David R. Lineback
Joint Institute for Food Safety and Applied Nutrition (JIFSAN)
University of Maryland
College Park, Maryland
USA
Introduction
Carbohydrates have traditionally been defined according to their chemical structures. Occasionally,
this has been modified by the inclusion of some selected properties, such as water solubility (e.g.,
soluble and insoluble pentosans), or physiological response (e.g., digestible and non-digestible).
The challenge then becomes: How does one analytically determine (measure) these substances?
Since carbohydrates are quite complex, ranging from monosaccharides to polysaccharides, the
analytical methodologies available when many of the definitions were first developed made it virtually
impossible to undertake such analytical measurements, and these methodologies continue to pose
significant challenges today. Consequently, it is much easier to determine total carbohydrates by
subtracting other nutrients or components, i.e., 100% - (%protein + %fat + %ash + %moisture) =
%carbohydrates. However, this method of deriving the value of total carbohydrates is not particularly
useful, nor is it accurate. It has been recommended that total carbohydrate content in the diet
should be obtained by analytical measurement of the individual carbohydrates.1
Thus begins a debate that is ongoing and has significant impact on furthering our understanding
of the role of carbohydrates in health and disease. Are definitions of carbohydrates determined
by the analytical methodologies available for their measurement or are the analytical methodologies
developed from the definitions of the carbohydrates to be measured? This is further complicated
by the desire to more clearly define and understand the roles of simple and complex polymeric
carbohydrates in attaining and maintaining good health as well as in mitigating or reducing disease(s)
in which they may be involved.
Discussions on this subject seek to clarify how carbohydrates should be classified and defined -
according to chemical structure, physiological/nutritional/health impact, or combinations of both.
This becomes increasingly important in relation to dietary recommendations directed at: (1) attaining
or maintaining good health, coupled with an appropriate amount of exercise; (2) mitigating, reducing,
or alleviating health conditions such as obesity, hypertension, hyperlipidemia, hypercholesterolemia,
diabetes, oral health, cardiovascular and gastrointestinal health; or (3) improving human performance.
Traditional Definitions
Carbohydrates are traditionally classified on the basis of their degree of polymerization (DP). This
results in three major classifications: sugars (DP 1-2), oligosaccharides (DP 3-9) and polysaccharides
(DP ≥10). As one would expect, complicating exceptions and further subdivisions have been and
are being created, as our understanding of structure, physical function, properties, and physiological
8 Role Of Carbohydrates in Health & Disease: Evaluating Scientific Evidence for Dietary Guidance
function of carbohydrates increases. Sugar, an important component of diets in many parts of the
world, has come to be the common name for sucrose (a disaccharide). The term “sugars” refers
to mono- (glucose, galactose, fructose) and di- (sucrose, lactose, trehalose) saccharides. Polyols
(sugar alcohols such as sorbitol, mannitol, xylitol) are a sub-group of the sugars classification.
Oligosaccharides are commonly divided into two subgroups: malto-oligosaccharides (derived from
starch) and other oligosaccharides (raffinose, stachyose, fructo-oligosaccharides). Polysaccharides
are often divided into starch and non-starch polysaccharides (NSP), although other subgroup-
classifications (such as cellulose, hemicelluloses, pectins, pentosans, hydrocolloids) exist. Starch
is primarily an α−1,4-glucan composed of two polymeric components: amylose (essentially a linear
polymer of α-1,4-linked glucose units with a limited amount of α-1,6–branching) and high molecular
weight, highly branched amylopectin with α-1,4 and α-1,6 bonds. The precise delineation between
amylose and amylopectin is less clear.
Nutritional Classification
The challenge/problem is in relating these chemical divisions/classifications of carbohydrates to
those that reflect physiological and nutritional responses and health. Each of the classes (sugars,
oligosaccharides, polysaccharides) can have several physiological effects, resulting in difficulties in
translation to nutritional terms. If the classification is based on physiological properties, a single
property, such as reduction in blood glucose response, may be used as the major factor/basis for
the classification. A number of terms have arisen from such method: refined sugar, added sugar,
extrinsic and intrinsic sugars, complex carbohydrates, available and non-available carbohydrate,
resistant starch, modified starch, dietary fiber, soluble and insoluble fiber. Nonethless, these terms
have generated considerable analytical challenges and problems. Recommendations against the use
of some of these classifications have also been made.1,2
Four criteria have been suggested for classifying carbohydrates into nutritional categories.2 The
categories should:
• reflect the physiological and metabolic properties of the carbohydrates;
• be consistent with the known chemistry of the components;
• be measurable by sound and reproducible analytical procedures; and
• predict the nutritional consequences of consuming the mixture of carbohydrates in the human
diet.
It can be seen that these criteria present an extremely difficult challenge in bridging physiology/
metabolism/nutrition and chemistry/structure.
Dietary Fiber
Dietary fiber can be used as an example of the definition debates involving chemistry and physiology
(health impact). This discussion has occurred over a period of more than three decades and
continues. Current issues involving food labeling as related to health continue to play an important
role, particularly so far as appropriate analytical methodology is involved. For food labels to be
useful and enforceable, the elements of a definition must be measurable.
The working definition of dietary fiber, utilized for many years, can be considered to have originated
from the work and definition of Trowell and colleagues (1972-1976).3 This definition and the methods
of determination have been validated by international surveys by Prosky and Lee (1979-1980).4,5 The
definition (1981) is as follows:
“Dietary fiber consists of the remnants of edible plant cells, polysaccharides, lignin and associated
substances resistant to (hydrolysis) digestion by the alimentary enzymes of humans.”6,7
This definition encompasses cellulose, hemicellulose, lignin, gums, modified celluloses, mucilages,
oligosaccharides, and pectins and associated minor substances such as waxes cutin and suberin.
In 1985, Canada developed a formal definition of dietary fiber with an additional definition for novel
fiber sources, which are foods that are manufactured to be a source of dietary fiber.8,9,10 This
definition of dietary fiber is very similar to that derived from the work of Trowell, i.e., the endogenous
components of plant material in the diet which are resistant to digestion by enzymes produced
by humans. They are predominantly non-starch polysaccharides and lignin that vary with the
origin of the fiber, and include soluble and insoluble substances. Two additional terms were introduced
– non-native fibers and novel fibers.
Non-native fibers are from traditional foods but do not occur naturally in the foods to which they
have been added. A “novel fiber” or “novel fiber source” means a food that is manufactured to be
a source of dietary fiber and (1) that has not traditionally been used for human consumption to
any significant extent; or (2) that has been chemically processed (e.g., oxidized), or physically
processed (e.g., very finely ground), so as to modify the properties of the fiber contained therein;
or (3) that has been highly concentrated from its plant source.10
Specific physiological effects were designated as being required of a substance designated as dietary
fiber, i.e., regularizing colonic function (laxation), normalizing serum lipids, and attenuating the
post-prandial rise in blood glucose. An additional physiological effect was originally proposed -
suppression of appetite. This was not included subsequently, but could be included along with
others in the future, if studies yielding reliable, reproducible results validate it as an acceptable
criterion. A novel fiber that meets the functional criteria, is analyzed as dietary fiber, and has been
established as being safe, is listed as a dietary fiber with no distinction from other dietary fibers.
The FAO/WHO Expert Consultancy on the Role of Carbohydrates in the Diet (1997) indicated that
dietary fiber is a nutritional concept, not an exact description of a component of the diet.1
Recommendations concerning dietary fiber included (1) the use of the term dietary fiber should
always be qualified by a statement itemizing those carbohydrates and other substances intended
for inclusion, and (2) the use of the terms “soluble” and “insoluble” dietary fiber should be gradually
phased out. Although these terms are presently used, they are not considered useful classifications
either analytically or physiologically.
The USA does not have a formal, approved definition for dietary fiber. AACC International (formerly,
the American Association of Cereal Chemists) developed an updated definition (2000) for dietary
fiber that introduced the term “analogous carbohydrates” into the definition and also, included
physiological responses. The definition is as follows:
“Dietary fiber is the edible parts of plants or analogous carbohydrates that are resistant to digestion
and absorption in the human small intestine with complete or partial fermentation in the large intestine.
Dietary fiber includes polysaccharides, oligosaccharides, lignin, and associated plant substances. Dietary
fibers promote beneficial physiological effects including laxation, and/or blood cholesterol attenuation,
and/or blood glucose attenuation.”11
As part of the process of developing new dietary reference intakes, the Institute of Medicine, U.S.
National Academies of Science (IOM), appointed a panel to propose definition(s) for dietary fiber
and provide the rationale for them.12,13 The proposed definitions reflected the desire to move from
an analytically-based definition to one that recognizes physiological effects of fiber.13 The definitions
are as follow:
• Dietary Fiber consists of non-digestible carbohydrates and lignin that are intrinsic and intact
in plants.
• Functional Fiber consists of isolated, non-digestible carbohydrates which have beneficial
physiological effects in humans.
• Total Fiber is the sum of Dietary Fiber and Functional Fiber.
The definition originally proposed12 the use of the term “Added Fiber”, but was changed to “Functional
Fiber” following receipt of comments and further deliberations. This definition has the potential
to create some interesting problems, should both terms be used. For example, wheat bran in a
wholegrain wheat bread would be dietary fiber while concentrated (isolated) wheat bran added
to the same food to increase the content of dietary fiber would be a functional fiber.
The Codex Committee on Nutrition and Foods For Special Dietary Uses (CCNFSDU) is considering
a definition for dietary fiber (2004) that includes recommended, recognized, and validated analytical
methods.14 This definition also includes physiological responses that a dietary fiber must demonstrate.
The definition under consideration is stated as follows:
Dietary fiber consists either of:

• non-digestible material composed of carbohydrate polymers* with a degree of polymerization
(DP) not lower than 3, that are edible and naturally occurring in the food as consumed;
• carbohydrate polymers (DP > 3), which have been obtained from food raw material by physical,
enzymatic or chemical means; or
• synthetic carbohydrate polymers (DP> 3).
Dietary fiber is neither digested nor absorbed in the small intestine and has at least one of the
following properties:
• increases stools bulk;
• stimulates colonic fermentation;**
• reduces blood total and/or LDL cholesterol levels; or
• reduces post-prandial blood glucose and/or insulin levels.
* When derived from a plant origin, dietary fiber may include fractions of lignin and/or other
compounds which are associated with polysaccharides in the plant cell walls, and if these compounds
are quantified by the AOAC gravimetric analytical method for dietary fiber analysis, fractions of
lignin and the other compounds (proteic fractions, phenolic compounds, waxes, saponins, phytates,
cutin, phytosterols, etc.) intimately “associated” with plant polysaccharides are often extracted with
the polysaccharides in the AOAC 991.43 method. These substances are included in the definition
of fiber in so far as they are actually associated with the poly- or oligo-saccharidic fraction of
fiber. However, when extracted or even re-introduced into a food containing non-digestible
polysaccharides, they cannot be defined as dietary fiber. When combined with polysaccharides,
these associated substances may provide additional beneficial effects.
** The statement "stimulation of colonic fermentation" is added to take into account the effects
resulting from the fermentation of fiber, such as production of metabolites, modification of the
flora, effects associated with acidification of the lumen contents, with modification of certain
enzymatic activities (e.g., effect on glycuro-conjugated estrogens) or the production of a large
quantity of short chain fatty acids and in particular, butyrate, which is thought to contribute to
the proper functioning of the colonic mucosa and which might be beneficial in the prevention of
several types of colon disease, including colon cancer.
The physiological effects of fiber cannot be restricted to the colon. Epidemiological and interventional
studies have demonstrated that protective properties of fiber are, above all, observed on cardiovascular
diseases.
Part of the effort being made in this case is not only to obtain a definition, but to also determine
appropriate, recognized analytical methodology for measuring dietary fiber. This is a draft definition
that is under discussion and will undoubtedly undergo revision at subsequent committee meetings.
These definitions differ in some respects that have significant implications. Physiological effects
commonly listed in the definitions include regularized colonic function (laxation), normalized serum
lipid levels [blood cholesterol attenuation (AACCI), reduced blood total and/or LDL cholesterol levels
(CCNFSDU)], attenuated post-prandial glucose response [blood glucose attenuation (AACCI),
reduced post-prandial glucose and/or insulin levels (CCNFSDU)], increased stools bulk (CCNFSDU),
and stimulated colonic fermentation (CCNFSDU). Specific physiological effects were not identified
in the IOM definition. The rationale given for the omission was that new beneficial effects are likely
to be discovered. The criteria for determining these physiological responses are often not clearly
defined, although Canada has done so for the ones that are recognized in the definition.
Differences regarding how components of the definition are designated include the use of non-
native fibers and novel fibers/novel fiber sources in the Canadian definition; analogous substances
in the AACC International definition, and functional fiber in the IOM definition. In general, these
refer to the same set of substances, yet they can generate significant analytical problems should
they be included in a labeling system. The Canadian system circumvents this difficulty by labeling
Total Fiber only. This is not the only problem that could arise should these terms be included in
labeling or in general use. Another major concern, then, would be the tendency to confuse
consumers about nutrition and health messages concerning dietary fiber.
Several of these definitions attempt to bridge the fields of chemistry and nutrition. The inclusion
of physiological responses in the definition raises some significant analytical methodological
challenges. Determination of dietary fiber and its components has normally been done using
chemically-based analytical methods. It is not clear yet how measurements (analytical determinations)
based on the required physiological responses will be developed and incorporated. A major challenge
will be to develop in vitro methods that are comparable to the in vivo methods used for these
measurements, i.e., human subjects. Another challenge of considerable magnitude will be to combine
both chemically- and physiologically-based analytical methods into the determination of what is
dietary fiber and how much is present, without undergoing an unduly lengthy and costly process.
These are very important questions that are part of the continuing definition(s) debates and
discussions. They will be of major significance for a regulatory scheme of labeling foods that aims
to reflect the physiological properties, health benefits, and nutritional role of dietary fiber.
References
1. FAO. Carbohydrates in human nutrition. FAO Food and Nutrition Paper 66, Rome, 1998.
2. D. A. T. Southgate. The elusive definition of carbohydrates in Carbohydrates and Health: New
Insights, New Directions. ILSI Australasia 1995 ;pp. 2-8.
3. H. C. Trowel, D. A. T. Southgate, T. M. S. Wolever, A. R. Leeds, M. A. Gassull and D.J. A. Jenkins.
Dietary fiber redefined. Lancet 1976;1:967.
4. D. A. T. Southgate, The definition and analysis of dietary fiber. Nutr. Rev. 1977;35(3):31.
5. L. Prosky and J. DeVries in Controlling Dietary Fiber in Food Products, Van Nostrand Reinhold,
New York, NY, 1982.
6. Life Sciences Research Office (LSRO). Federation of American Societies for Experimental Biology
Expert Panel Report – Physiological Effects and Health Consequences of Dietary Fiber, Bethesda,
MD, 1987.
7. Federal Register. Department of Health and Human Services, Food and Drug Administration, 21
CFR Parts 101 and 104. Food Labeling; Reference Daily Intakes and Daily Reference Values, pp. 2206-
2228, at page 2222. January 6, 1993.
8. Health and Welfare Canada. Report of the Expert Advisory Committee on Dietary Fiber. Ottawa,
ON: Minister of National Health and Welfare, 1985.
9. Health and Welfare Canada. Guidelines Concerning the Safety and Physiological Effects of Novel
Fiber Sources and Foods Containing Them, Health Protection Branch, 1988.
10. Canadian Food Inspection Agency. Guide to Food Labeling and Advertising, Section 6.2.4.6 Dietary
Fiber and Novel Fiber, Canadian Food Directorate Guideline No. 9, Guideline Concerning the Safety
and Physiological Effects of Novel Fiber Sources and Food Products Containing Them, (2000).
11. Anonymous, The Definition of Dietary Fiber (Report of the Dietary Fiber Definition Committee
to the Board of Directors of the American Association of Cereal Chemists, submitted January
10, 2001). Cereal Foods World 2001;46:112-129.
12. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids. Panel on Macronutrients. The National Academies Press,
Washington, D.C., 2002.
13. Institute of Medicine. Dietary Reference Intakes Proposed Definition of Dietary Fiber. The National
Academies Press, Washington, D.C., 2002.
14. FAO/WHO Codex Alimentarius Commission. Proposals for a definition and methods of analysis for
dietary fiber content. Agenda Item 3, Twenty-sixth Session, Codex Committee on Nutrition and
Foods for Special Dietary Uses, Bonn, Germany, (CX/NFSDU 04/3-Add.1 July 2004) November 2004.
Available and Non-Available Carbohydrates:

Effects on the Health of the Large Bowel
Peter M. Clifton
Clinical Research Unit
CSIRO Health Sciences and Nutrition
Adelaide
Australia
Introduction
This brief review will focus on the effects of unavailable carbohydrates, including both fiber and
resistant starch, on the large bowel. The 1998 definition of fiber from the American Association
of Cereal Chemists is a mix of analytical and physiological properties:
“Dietary fiber is the edible parts of plants or analogous carbohydrates that are resistant to digestion
and absorption in the human small intestine with complete or partial fermentation in the large intestine.
Dietary fiber includes polysaccharides, oligosaccharides, lignin, and associated plant substances. Dietary
fibers promote beneficial physiological effects including laxation, and/or blood cholesterol attenuation,
and/or blood glucose attenuation.”
This review will only address the fermentation and laxation aspect of this definition.
Health Effects of Fiber in the Colon

The most well-proven effect of fiber is on laxation. Constipation is common (afftecting 5% to 27%
of the population) and is associated with diverticular disease and hemorrhoids.1 In epidemiological
studies, a high insoluble fiber diet was associated with 60% less diverticular disease in 44,000 men.2
Interventions with fiber tend to improve stool weight, consistency and frequency,3 but usually have
little effect on symptoms in diverticular disease4 or irritable bowel syndrome.5 Fecal bulking is greater
with wheat bran with an increase of 4.9g stool/g fiber. Less than 50% of this fiber is fermented.
More fermentable fibers, such as resistant starch, provide less bulking at 1 to 1.7g stool/g fiber,
which is similar to legume non-starch polysaccharides, pectin and fructans.6
Fiber and Colorectal cancer

Fiber has been proposed as a dietary component associated with protection from colorectal cancer.
However, the evidence is patchy and relatively inconclusive with many negative studies. The EPIC
Study with 520,000 people and 1,065 cases has shown a raw 25% reduction in risk from the first
(12g fiber/day) to the fifth quintile (32g fiber/day), which after adjustment increased to 42%. The
effect was greatest on the left side of the colon and least in the rectum. Once an intake of 21g/day
was achieved, a significant fall in risk was observed.7 In the combined Nurses Health Study and the
Health Professional Follow Up study with 1,596 cases, no association with fiber was seen.8 Similarly,
in the Breast Cancer Detection and Follow-Up Study with 487 cases, there was no association with
fiber intake assessed 5 to 11 years earlier, although in the highest quintile the intake of fiber was
low at 18.2g/day.9 In a breast cancer screening project in Sweden involving 61,500 women with 460
cases of colorectal cancer over 10 years, fiber was not associated with cancer risk. The fiber intake
in the fifth quintile was low at 16g fiber, while the first quintile was very low at 4g fiber. In this study
though, a low fruit and vegetables intake (<1.5 serves/day) was associated with 65% more cases.10
This was not seen in the EPIC studies.7
In a meta-analysis of all case control studies, which included 5,287 cases and 10,470 controls in
aggregate, there was a 31% reduction in risk for each 13g/day increase in fiber.11 Twelve of the 13
studies showed a protective effect due to fiber. The highest quintile of fiber was associated with a
27% lower risk of polyps in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening
Trial which had 33,971 sigmoidoscopy negative subjects and 3,591 subjects with polyps.12
Colorectal Cancer and Stool Characteristics

Cummings et al.13 related colorectal cancer risk to stool weight in 20 populations in 12 countries.
Stool weights varied from 72g/day to 470g/day and were inversely associated with cancer risk (r=-
0.78). In the UK cohort of 220 people, average stool weight was 104g/day in men and 99g/day
women but 17% women passed less than 50g/day.
In a combination of 26 study groups containing 206 people on controlled diets of known non-
starch polysaccharide (NSP) intake, there was a correlation of r=0.84 between NSP intake and fecal
weight. NSP intakes of 18g/day were associated with stool weights of 150g/day or more.13 Fecal pH
has been related to cancer risk in South African populations where blacks had a pH of 6.12, Indians
6.21; and coloreds 6.29. These values were significantly lower (p=less than 0.01) than that of whites,
who had a pH of 6.88.14 However, de Kok has demonstrated the opposite findings in patients with
adenomas.15 Fecal bile acids have also been related to colorectal cancer risk.16 A low pH inhibits
transformation of primary bile acids into more carcinogenic secondary bile acids.17
Colorectal Cancer in Southeast Asia

In Singapore, the rate of colorectal cancer is 33.4 and 31/100,000 for men and women, respectively.
It has been increasing at the rate of 0.66/100,000/yr over the last 30 years and is now the most
common cancer.18 In 1983, the fiber intake in Singapore was low at 15g/day,19 while in Hong Kong
in 1995 it was <10g/day. In Australia, the colorectal cancer rate is higher at 56 to 75/100,000 for
women and men, respectively,20 although fiber intake is also higher at about 21g/day.21
In an epidemiological study on colorectal cancer conducted in Singapore, results showed that high
cruciferous vegetable intake reduced colonic cancer (RR 0.5), while rectal cancer was related to fiber
and total vegetables intake.19 In Malaysia, there are no accurate countrywide statistics but, based
on hospital admissions, there has been a 50% increase in the last 8 years. The current estimate
is about 11/100,000/year.
Fiber Interventions in Preventing Recurrence of Adenomas

This area has been examined in a Cochrane review22 which looked at five studies involving 4,349
patients. The interventions included wheat bran fiber, ispaghula husk, or high fiber foods (and thus,
more starch as well). No effect was observed over a period of 2 to 4 years. This contrasts with
animal models using chemical carcinogens in which insoluble fiber is protective in most studies,23
but the amount of fiber is very large and equivalent to more than 80g of fiber per day for humans.
Resistant Starch and Colorectal Cancer

Starch intakes, as opposed to non-starch polysaccharide intake, has been associated with colorectal
cancer based on a multi-country study with an r value of -0.7,24 and the assumption that higher
starch intakes would lead to higher intakes of resistant starch. In the Health Professional Follow
Up study, starch intake was associated with a lower risk of adenomas with risk ratio from top to
bottom quintile of 0.47.25 Four case control studies have examined starch and colorectal cancer
and only one has shown a protective relationship;26 while the others have shown either promotion
of disease27 or no effect.28,29 Three out of seven studies (men and women were analysed separately
in some studies) have shown a protective effect for starch in relation to the development of
adenomas.30,31,32,33
There has long been an interest in the potential effect of short chain fatty acids (SCFAs), and in
particular butyrate, on preventing colorectal cancer. The hypothesis was first proposed by Cummings
in 198034 as one mechanism linking fiber and colorectal cancer, and an inhibitory effect of butyrate
on cancer cells in vitro was also shown in the same year.35 Histone deacylation inhibition, which
is believed to underlie its nuclear effects, had been shown earlier.36 Subsequent studies showed that
butyrate led to either p53 independent apoptosis37 or a more differentiated phenotype.38 Starch
fermentation in the colon tends to produce more SCFAs than fiber fermentation,6 but a cross
sectional analysis of 53 individuals showed that those who consumed more non-starch polysaccharides
in their diet (19±7 g/day) excreted more than 150g/day and had higher quantities of fecal starch
and non-starch polysaccharides, faster transit times, higher concentrations of short chain fatty
acids and lower concentrations of potentially harmful ammonia and phenols.39
Burkett et al.39 has estimated that the intake of resistant starch is about 5g/day from a total intake
of 130g to 140g of starch/day in the Australian diet. Human interventions40-53 with high levels of
resistant or malabsorbed starch have shown that resistant starch increases fecal mass (6/7 positive
studies) and SCFAs (5/8), reduces ammonia and phenols (1/1), reduces fecal water bile acids (3/4),
reduces fecal water cytotoxicity (1/2) and lowers pH (3/6). Increased DNA adducts with resistant
starch were shown in the one study54 that examined this, but it is not clear how this might have
occurred.
Animal studies examining the interaction of resistant starch with chemical carcinogens have produced
a very mixed picture: 2 protective, 3 no effect, and 2 promotional (for a more complete review on
resistant starch and colorectal carcinogenesis, please refer to the publication by Young GP et al.55)
Conclusions
Non-absorbable carbohydrate has significant colonic effects and may provide protection from
colonic cancer. However, data is currently clearest on fecal bulking and the relief of constipation.
There may be other components in fiber-rich foods that provide protection against colorectal
cancer.
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14. Walker AR, Walker BF, Walker AJ. Fecal pH, dietary fiber intake, and proneness to colon cancer in
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17. Christl SU, Bartram HP, Ruckert A, Scheppach W, Kasper H. Influence of starch fermentation on
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large bowel cancer in a rat model. Gut. 1993 Mar;34(3):386-91
24. Cassidy A, Bingham SA, Cummings JH. Starch intake and colorectal cancer risk: an international
comparison. Br J Cancer. 1994 May;69(5):937-42.
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26. Tuyns AJ, Haelterman M, Kaaks R. Colorectal cancer and the intake of nutrients: oligosaccharides
are a risk factor, fats are not. A case-control study in Belgium. Nutr Cancer. 1987;10(4):181-96
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D, Decarli A. Macronutrient intake and risk of colorectal cancer in Italy. Int J Cancer. 1998 May
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31. Macquart-Moulin G, Riboli E, Cornee J, Kaaks R, Berthezene P. Colorectal polyps and diet: a case-
control study in Marseilles. Int J Cancer. 1987 Aug 15;40(2):179-88
32. Sandler RS, Lyles CM, Peipins LA, McAuliffe CA, Woosley JT, Kupper LL. Diet and risk of colorectal
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33. Neugut AI, Garbowski GC, Lee WC, Murray T, Nieves JW, Forde KA, Treat MR, Waye JD, Fenoglio-
Preiser C. Dietary risk factors for the incidence and recurrence of colorectal adenomatous polyps.
A case-control study. Ann Intern Med. 1993 Jan 15;118(2):91-5.

34. Stephen AM, Cummings JH. Mechanism of action of dietary fiber in the human colon. Nature. 1980
Mar 20;284(5753):283-4.
35. Kim YS, Tsao D, Siddiqui B, Whitehead JS, Arnstein P, Bennett J, Hicks J. Effects of sodium butyrate
and dimethylsulfoxide on biochemical properties of human colon cancer cells. Cancer. 1980 Mar
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36. Candido EP, Reeves R, Davie JR. Sodium butyrate inhibits histone deacetylation in cultured cells.
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37. Hague A, Manning AM, Hanlon KA, Huschtscha LI, Hart D, Paraskeva C. Sodium butyrate induces
apoptosis in human colonic tumour cell lines in a p53-independent pathway: implications for the
possible role of dietary fiber in the prevention of large-bowel.
38. Heerdt BG, Houston MA, Augenlicht LH. Potentiation by specific short-chain fatty acids of
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93. l cancer. Int J Cancer. 1993 Sep 30;55(3):498-505.
39. Birkett AM, Jones GP, de Silva AM, Young GP, Muir JG. Dietary intake and fecal excretion of
carbohydrate by Australians: importance of achieving stool weights greater than 150 g to improve
fecal markers relevant to colon cancer risk. Eur J Clin Nutr. 1997 Sep;51(9):625-32.
40. Scheppach W, Fabian C, Sachs M, Kasper H. The effect of starch malabsorption on fecal short-
chain fatty acid excretion in man. Scand J Gastroenterol. 1988 Aug;23(6):755-9.
41 Bartram HP, Scheppach W, Heid C, Fabian C, Kasper H. Effect of starch malabsorption on fecal
bile acids and neutral sterols in humans: possible implications for colonic carcinogenesis. Cancer
Res. 1991 Aug 15;51(16):4238-42.
42. van Munster IP, Tangerman A, Nagengast FM. Effect of resistant starch on colonic fermentation,
bile acid metabolism, and mucosal proliferation. Dig Dis Sci. 1994 Apr;39(4):834-42.
43. Phillips J, Muir JG, Birkett A, Lu ZX, Jones GP, O'Dea K, Young GP. Effect of resistant starch on fecal
bulk and fermentation-dependent events in humans. Am J Clin Nutr. 1995 Jul;62(1):121-30.
44. Birkett A, Muir J, Phillips J, Jones G, O'Dea K. Resistant starch lowers fecal concentrations of ammonia
and phenols in humans. Am J Clin Nutr. 1996 May;63(5):766-72
45. Cummings JH, Beatty ER, Kingman SM, Bingham SA, Englyst HN. Digestion and physiological
properties of resistant starch in the human large bowel. Br J Nutr. 1996 May;75(5):733-47.
46. Noakes M, Clifton PM, Nestel PJ, Le Leu R, McIntosh G. Effect of high-amylose starch and oat bran
on metabolic variables and bowel function in subjects with hypertriglyceridemia. Am J Clin Nutr.
1996 Dec;64(6):944-51.
47. Heijnen ML, van Amelsvoort JM, Deurenberg P, Beynen AC. Limited effect of consumption of
uncooked (RS2) or retrograded (RS3) resistant starch on putative risk factors for colon cancer in
healthy men. Am J Clin Nutr. 1998 Feb;67(2):322-31
48. Hylla S, Gostner A, Dusel G, Anger H, Bartram HP, Christl SU, Kasper H, Scheppach W. Effects of
resistant starch on the colon in healthy volunteers: possible implications for cancer prevention.
Am J Clin Nutr. 1998 Jan;67(1):136-42.
49. Jenkins DJ, Vuksan V, Kendall CW, Wursch P, Jeffcoat R, Waring S, Mehling CC, Vidgen E, Augustin
LS, Wong E. Physiological effects of resistant starches on fecal bulk, short chain fatty acids, blood
lipids and glycemic index. J Am Coll Nutr. 1998 Dec;17(6):609-16.
50. Grubben MJ, van den Braak CC, Essenberg M, Olthof M, Tangerman A, Katan MB, Nagengast FM.
Effect of resistant starch on potential biomarkers for colonic cancer risk in patients with colonic
adenomas: a controlled trial. Dig Dis Sci. 2001 Apr;46(4):750-6
51. Muir JG, Walker KZ, Kaimakamis MA, Cameron MA, Govers MJ, Lu ZX, Young GP, O'Dea K.
Modulation of fecal markers relevant to colon cancer risk: a high-starch Chinese diet did not
generate expected beneficial changes relative to a Western-type diet. Am J Clin Nutr. 1998
Aug;68(2):372-9.
52. Muir JG, Yeow EG, Keogh J, Pizzey C, Bird AR, Sharpe K, O'Dea K, Macrae FA. Combining wheat
bran with resistant starch has more beneficial effects on fecal indexes than does wheat bran alone.
Am J Clin Nutr. 2004 Jun;79(6):1020-8
53. van Gorkom BA, Karrenbeld A, van der Sluis T, Zwart N, van der Meer R, de Vries EG, Kleibeuker
JH. Calcium or resistant starch does not affect colonic epithelial cell proliferation throughout the
colon in adenoma patients: a randomized controlled trial. Nutr Cancer. 2002;43(1):31-8
54. Wacker M, Wanek P, Eder E, Hylla S, Gostner A, Scheppach W. Effect of enzyme-resistant starch
on formation of 1,N(2)-propanodeoxyguanosine adducts of trans-4-hydroxy-2-nonenal and cell
proliferation in the colonic mucosa of healthy volunteers. Cancer Epidemiol Biomarkers Prev. 2002
Sep;11(9):915-20
55. Young GP, Le Leu RK. Resistant starch and colorectal neoplasia. J AOAC Int. 2004 May-Jun;87(3):775-
86
Understanding Carbohydrates and Health

Frances H. Seligson
Nutrition Consultant
ILSI North America
USA
Introduction
The International Life Sciences Institute (ILSI), through a global network of scientists from industry,
academia, and government agencies, is devoted to enhancing the scientific basis for public health
and regulatory decision-making by sponsoring research, workshops, and symposia, and encouraging
publication of the outcomes in the peer-reviewed literature. Among many other nutrition-related
topics, ILSI has an ongoing interest in scientific issues related to dietary carbohydrates - including
starches, fibers, sugars, and whole grains - and their impact on nutrition and health.
Research
Supplemental Research Grants
Dietary guidance, during the early 1990s, focused largely on the amount and type of fat in the
diet. Relatively little attention was given to dietary carbohydrates, even though they usually comprised
more than 50% of total energy intake. Dietary guidance for carbohydrates in the 1900s consisted
mostly of advice to moderate sugars intake and to increase dietary fiber. The scientific advisors
of the ILSI Human Nutrition Institute (HNI) wisely thought that more attention should be paid to
understanding the physiological effects of dietary carbohydrates. As a result, HNI decided to help
stimulate research in this area by awarding supplemental grants to projects that were funded
primarily by other sources. ILSI's decision to support research aimed at understanding the physiological
effects of dietary carbohydrates was prescient given the current, widespread scientific and media
attention on this topic.
ILSI initiated the awards program in 1994 and has since annually advertised a request for proposals
(RFP). The RFP is modified each year as appropriate to reflect the most current scientific issues.
The RFP for 2005 is seeking projects aimed at identifying in vivo endpoints that link dietary
carbohydrates (sugars, starch, fiber, and whole grains) intake to a physiological or health-related
outcome. Although not exclusive, some of the research topics needing further investigation that
would be considered for funding include the impact of dietary carbohydrates on: (1) appetite control
in the context of energy balance, (2) glycemic response as it relates to risk for overweight/obesity
and chronic diseases, (3) food intake behavior and physical activity patterns, and (4) human behavior
and/or performance.
Since the initiation of the awards program, 16 projects have been funded with 14 completed. After
the first few years, the awards were restricted to new investigators so as to identify and support
future leaders in carbohydrates research in addition to generating important scientific information.
Another key aspect of the awards program has been its international scope - the awards are open
to investigators in any country and have thus far been granted to five investigators at institutions
outside the United States (USA). The findings have resulted in the publication of more than 20
research papers, reviews, and abstracts. Seven awards have addressed issues related to food and
energy intake, five have addressed substrate oxidation and energy expenditure, six have examined
blood lipids and lipoprotein kinetics, and two have assessed effects on cognitive and physical
performance. Summaries of the research projects are available at www.hni.ilsi.org.
Carbohydrate Intake and Glycemic Control

There has been increased speculation that dietary carbohydrates, especially refined starches and
sugars, are contributing to the development of insulin resistance and Type 2 diabetes mellitus.
There also has been concern that the high carbohydrate, low fat diets that have been recommended
to reduce the risk for cardiovascular disease might actually be contributing to the development
of glucose intolerance and insulin resistance. To address these issues, ILSI supported a research
project with Michigan State University, USA and the University of Alabama, USA to evaluate the
association between carbohydrates intake and biomakers of glycemic control in a nationally
representative sample of 11,855 healthy US adults who participated in the third National Health and
Nutrition Examination Survey, a cross sectional study conducted during 1988-1994.1 The results
showed that carbohydrates intakes were not associated with HbA1c, plasma glucose, or serum insulin
in men or women after adjusting for confounding variables, and that intakes were associated
inversely with serum C-peptide. When carbohydrate intakes were further adjusted for intakes of
total and added sugars, the association of serum C-peptide with carbohydrates intake was
strengthened in men. The results support current recommendations regarding carbohydrate intakes
in healthy adults.
Sugars and Short-term Satiety

Contradictory perspectives exist on the roles of sugars and insulin in promoting satiety. Some argue
that a low post-prandial glucose and insulin response promotes satiety, whereas others argue that
post-prandial glycemia and insulinemia actually promote short-term satiety. To help develop the
science base on the association between sugars and satiety, ILSI supported a research project with
the University of Toronto, Canada to determine the effect of varying the glucose to fructose ratios
in test solutions (75g per 300mL water) consumed by young men. Over the course of two experiments
the glucose to fructose ratios ranged from 80:20 to 20:80. The post-prandial area under the curve
for blood glucose was directly related to the glucose content of the test solution, and the ad libitum
food intake 90 minutes after ingesting the test solution was inversely related to the glucose content.
These preliminary results were presented at Experimental Biology 2005 in San Diego, California,
USA (Akhava and Anderson, personal communication). Analyses for blood levels of insulin, glucagon,
GLP-1, and ghrelin are in progress.
Fructose Intakes
Over the past several years, there has been an increased interest in the physiological effects of
dietary fructose, especially as related to hypertriglyceridemia and obesity. The last comprehensive
estimates for fructose intake in the USA are from a study based on 1977-1978 food consumption
data.2 Recent concerns over the health effects of fructose, however, are based on food supply
data.3-5 Therefore, changes in both fructose availability in the food supply and dietary fructose
intakes need to be examined. To this end, ILSI is supporting a collaborative agreement with the US
Food and Drug Administration (FDA) and the Joint Institute for Food Safety and Applied Nutrition
(JIFSAN), University of Maryland, USA to update dietary fructose intake estimates. Nationally
representative dietary data will be combined with food supply data and the USDA Pyramid Servings
database.6 The primary goal is to develop a contemporary assessment of fructose intakes as well
as possible changes since 1977-1978; a secondary goal is to assess the relation between fructose
intakes and selected health outcomes for several population groups.
Workshops
Glycemic Response
The concept of the glycemic index, a standardized measurement of the blood glucose response to
individual foods, has led to a re-examination of the role of starches and sugars in the prevention,
etiology, and management of obesity, Type 2 diabetes mellitus, and cardiovascular disease. However,
considerable scientific disagreement exists on the health impact and utility of using the glycemic
index of individual foods and diets and derivatives such as the glycemic load. In 2003, ILSI in
collaboration with JIFSAN invited a group of international experts to Washington, DC, USA to help
advance scientific discussion on this topic. The experts were asked to provide their informed but
divergent viewpoints on questions related to the different types of dietary carbohydrates, blood
glucose and insulin responses, and health outcomes. These viewpoints, along with a call for well-
controlled research with healthy subjects, have been summarized.7
Low Carbohydrate
The use of very low carbohydrate diets to reduce and control body weight increased in popularity
during the early part of the new millennium, and food manufacturers responded quickly to the
increased consumer demand for foods that contain no or very little metabolizable carbohydrate.
However, nutrition and health experts expressed concern about the potential adverse effects of
such diets, questions about safety and efficacy were raised, and terms such as net and available
carbohydrates were being used on food labels despite a lack of regulations to define them.
Even though the current popularity had subsided, ILSI decided to hold a workshop to discuss issues
related to low carbohydrate diets because of the periodic re-emergence of consumer appeal in
such diets. Held in April 2005, the workshop consisted of a group of academic researchers, clinical
practitioners, food industry scientists, and representatives from regulatory agencies and professional
organizations. Presentations provided perspectives on the marketplace and consumers, state of the
science on the efficacy of low carbohydrate diets, definitions suggested for describing the carbohydrate
content of foods and associated analytical issues, regulatory considerations, dieter behaviors, and
use for pediatric populations. Other presentations addressed possible mechanisms accounting for
the efficacy of low carbohydrate diets in achieving weight reduction, at least in the short-term,
including the roles of dietary energy density, carbohydrates, and protein, as well as for the observed
reductions in blood triacylglycerides and increase in HDL-cholesterol levels despite the relatively
high fat content of the diets. Lastly, the group identified areas where there appeared to be agreement
on scientific and consumer issues and where questions still remained. A summary of the workshop
will be submitted for publication in the peer-reviewed literature.
Fiber Definitions
Several definitions to describe the fiber content of food either exist or have been proposed.8-10 The
definitions vary in which substances are included as fiber, the analytical methods used to identify
and measure them, and whether physiological criteria are part of the definition. The Institute of
Medicine's8 (IOM) proposed definitions for dietary fiber and functional fiber have been of particular
concern in the US in terms of issues associated with implementation for food labeling, food
composition databases, assessment of dietary intakes, and dietary guidance. In June 2004, ILSI
convened a group of representatives from academia, industry, scientific associations, and US and
Canadian government agencies to discuss and educate one another about these issues. Presentations
were made on the history and description of fiber definitions, the rationale behind the IOM
definitions, criteria for physiological functionality, methodological issues associated with chemical
analysis and assessment of functionality, regulatory issues, the Canadian experience with physiological
criteria for functionality, and consumer awareness and understanding of dietary fiber. The workshop
concluded with an assessment of where gaps in the understanding of the physiological effects of
fiber still exist. A summary of the workshop has been accepted for publication.11
Sugars and Health

In the early 2000s, several groups had reviewed the potential adverse effects of over-consumption
of sugars.8,12,13 Despite continuing concerns about over-consumption, adverse health effects specifically
attributable to sugars remained controversial. The research community was challenged to further
address the potential relation between sugars and chronic disease. ILSI took up this challenge by
convening a workshop on Sugars and Health that was held in Washington, DC, USA in 2002.
Internationally recognized experts on selected topics related to sugars were asked to draft papers
in advance of the workshop. These papers were circulated among the other authors and workshop
participants for review and critical commentary. The commentaries were provided to the authors
prior to the workshop, during which the papers and commentaries were extensively discussed. The
following topics were addressed: (1) definition of sugars-related terms, (2) assessment of sugars
intakes, rationale for current public guidance, (3) hedonic and satiety aspects as related to energy
balance and weight control, (4) insulin sensitivity and diabetes management, (5) hypertriglyceridemia
and cardiovascular disease, and (6) oral health. Workshop participants extensively discussed the
complex relation between sugars and chronic disease and urged additional research. A summary
of the workshop and the individual papers have been published.14,15
Summary
Interest in understanding the health impact of carbohydrates - both potentially beneficial and
adverse - has intensified since the mid 1900s and ILSI has been an active participant in contributing
to the science base. Through the Human Nutrition Institute and its regional branches, ILSI has
supported young investigators, research, workshops, and publications in the peer-reviewed literature
that have addressed the spectrum of carbohydrates (e.g., total carbohydrates, dietary fiber, sugars,
fructose), a wide variety of parameters (e.g., chemical analysis, definition of terms, assessment of
intakes) and physiological outcomes (e.g., glycemic response, substrate metabolism and energy
expenditure, satiety, energy balance, insulin sensitivity, blood lipids and lipoprotein kinetics, oral
health, and cognitive and physical performance).
References
1. Yang EJ, Kerver JM, Park YK. Kayitsinga J, Allison DB, Song WO. Carbohydrate intake and biomarkers
of glycemic control among US adults: the third National Health and Nutrition Examination Survey
(NHANES III). Am J Clin Nutr.2003; 77:1426-33.
2. Park YK, Yetley EA. Intake and food sources of fructose in the United States. Am J Clin Nutr.58(suppl).1993;
737S-747S.
3. Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play
a role in the epidemic of obesity. Am J Clin Nutr.2004; 79:537-543.
4. Elliott SS, Keim NL, Stern JS, Teff K, Havel PJ. Fructose, weight gain, and the insulin resistance
syndrome. Am J Clin Nutr.2002; 76:911-922.
5. Havel PJ. Dietary fructose: Implications for dysregulation of energy homeostasis and lipid/carbohydrate
metabolism. Nutr Rev.2005; 63:133-157.
6. Cook AJ, Friday JE. 2004. Pyramid Servings Database for USDA Survey Food Codes Version 2.0.
[Online]. Beltsville MD: USDA, ARS, Community Nutrition Research Group. Available at
http://www.ba.ars.usda.gov/cnrg/index.html.
7. Lineback D. Role of diet in blood glucose response and related health outcomes: summary of a
meeting. Nutr Rev.2005; 63:126-131
8. Institute of Medicine (IOM). Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academy Press,2002
9. The definition of dietary fiber. Report of the Dietary Fiber Definition Committee to the Board of
Directors of the American Association of Cereal Chemists, January 10, 2001
10. Proposals for a definition and methods of analysis for dietary fibre content. Agenda Item 3, Twenty-
sixth Session, Codex Committee on Nutrition and Foods for Special Dietary Uses, Bonn, Germany,
(CX/NFSDU 04/3-Add.1) November 2004
11. Jones JR, Lineback DM, Levine MJ. Dietary reference intakes: implications for fiber labeling and
consumption, a summary of the ILSI North American Fiber Workshop, June 1-2, 2004. Washington,
DC Nutr Rev. (in press).
12. Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on
the Dietary Guidelines for Americans. Hyattsville, MD: US Department of Agriculture,2000
13. Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases,
Geneva, Switzerland; 2002.
14. Lineback DR, Jones JM, eds. Sugars and Health Workshop. Am J Clin Nutr.2003; 78:814S-897S
15. Jones JM, Elam K. Sugars and health: is there an issue? J Am Diet Assoc.2003; 103:1058-1060.
Glycemic Indexes, Glycemic Impact and Virtual

Food Components: Present and Future
John A. Monro
New Zealand Institute for Crop & Food Research Ltd
Palmerston North
New Zealand
Introduction
Accumulating evidence that blood glucose loading from highly glycemic diets plays a role in the
development of diabetes,1 of conditions that predispose to diabetes,2 and of the complications that
arise from diabetes,3 has brought dietary carbohydrates sharply into focus.
The concentration of glucose in the blood is central in the network of factors responsible for the
diabetic syndrome of hyperglycemia and its complications, and exerts its effects in a number of
general ways:
• Glycation of proteins throughout the body by glucose and its immediate metabolic products
leads to systemic malfunction at the molecular level.4
• Pathways to ease the metabolic flooding by glucose and downstream glycolytic products lead
to intermediates and by-products that cause diffuse molecular damage, partly by changing the
oxidative environment of the cell.4
• Insulin released in response to blood glucose is a potent cell factor that has its own harmful
effects.5
• Compensatory physiological/hormonal responses to acute blood glucose loading brought about
by large doses of readily available glycemic carbohydrate may lead to a hypoglycemic overshoot.6
Resulting poor homeostatic control of appetite may lead to over-consumption and obesity,
which is one of the major factors in glucose intolerance.7
As the effect of food carbohydrates cannot be divorced from the effects of foods, the question has
arisen as to whether or not the measure of the glycemic potency of foods would be better for
dietary management of glycemia than some derivative of it, such as the glycemic index of
carbohydrates in foods (GIcarb), or whether a combination of the two would be ideal.
GIcarb is a constant value for a food and shows the relative glycemic impact of the food when
consumed in sufficient quantity to provide 50g of carbohydrate, relative to the effect of 50g of
glucose. It is, therefore, a surrogate indicator of the relative glycemic potency of carbohydrate in
a food, is constant for a food, and does not reflect the effects of changing food composition or
intake.8
The post-prandial relative glycemic impact (RGI) of a food, on the other hand, is a food variable
that expresses the glycemic effect of any quantity of a food relative to that of glucose, as the
weight of glucose that would be required to have an effect equal to that of the given amount of
food. RGI is therefore expressed as the glycemic glucose equivalent (GGE) dose consumed in a single
food intake event.9 Because GGE is expressed as a weight of reference, but in fact represents an
effect, it has been termed a virtual food component (VFC).10
As glycemic load (GL) is the product of GIcarb and carbohydrate intake,11 and is calculated as such
for a single food intake event it is approximately the same as RGI, and can equal RGI when a
correction factor to account for the effect of non-linearity in the glucose dose-glycemic response
relationship at the time of GIcarb measurement is included.12
In this paper, the relationship between GIcarb, and RGP, and GL and RGI, as various expressions of
GGE content, will be discussed.
Studies on Links to Health Support GIcarb and GL also Support GGE

There is now a substantial amount of evidence that controlling glycemic impact has positive benefits
for health. Most of the experimental evidence that supports control of GGE intake as a contributor
to better health comes from the studies of GIcarb (GGE intake/100g carbohydrate consumed) and
of GL (estimated GGE/food intake). Because GIcarb and GL are both expressions of GGE content and
GGE dose respectively, most of the associations found between between GIcarb and health, and GL
and health, are associations between GGE and health.
Many studies of GIcarb have involved varying GIcarb while keeping carbohydrate dose constant, in
which case GGE intake was varied as a function of GIcarb. Similarly, the large epidemiological studies
that have shown associations between GL and the incidence of Type 2 diabetes and coronary heart
disease,13 ‘establish associations between health and GGE intake, because GL is an estimate of GGE
dose.
GIcarb, GL, RGP and RGI Are All Expressions of GGE

GIcarb, GL, RGP (GIfood) and RGI are all closely related because they are based on the clinical
measurement of glycemic response to food relative to response to glucose, i.e., GGE, but they differ
in the way that the measurement of response is obtained and used.
Communications of Glycemic Potency Are All Based On Relative Response To Food

The measurement and expression of glycemic potency is subject to two unavoidable constraints:
• Glycemic response is always measured as a response to food, whether or not the glycemic
potency of a food is communicated in food terms (RGP and RGI), or in terms of food carbohydrate
as in the case of GIcarb (GGE/100g carbohydrate in food).
• Individuals differ so greatly in glycemic responsiveness that glycemic potency of foods must be
expressed relative to a reference, rather than as an absolute effect.14 Comparing the effects of
all foods with the effect of the same reference material allows the foods to be compared with
one another, without the influence of individual variability except in the error term associated
with measurement. It also allows the effect to be expressed as an equivalent weight of reference,
that is, as a VFC that can be used alongside real food components.10
Glycemic Glucose Equivalent (GGE) is the Basic Datum Describing Glycemic

Impact
Measuring the glycemic effect of a food relative to the effect of a reference provides a ratio that
may be expressed in the following ways:
• As a Unitless Index: "Index" is defined in the Oxford Dictionary as "Number expressing physical
property etc. in terms of a standard". Thus, if the effect of a food is expressed relative to the
effect of a reference, a glycemic index of a food (GIfood) is obtained, and it would be expressed
as a percentage if multiplied by 100. If an index compares the effect of a carbohydrate dose in
a food with an equal amount of glucose, it would be the glycemic index of carbohydrate, not
of a food. However, it is not possible to make such a measurement directly for food carbohydrate,
so it is approximated by a GIcarb value which is essentially GIfood weighted by the proportion of
available carbohydrate in the food.
• As a Virtual Food Component (VFC): A VFC is in effect an index applied to a varying quantity of
food, because it expresses the glycemic impact "in terms of a standard". In the case of GGE it
is the weight of glucose reference that would have an effect equal to that of the food, that is,
its glycemic glucose equivalent (GGE) content.
GGE is the basic measurement of the relative glycemic potency of a food. It is measured as the
incremental area under the blood glucose response curve for a food (IAUCfood) relative to the
incremental area under the blood glucose response curve for glucose (IAUCglucose). The basic
expression for GGE content of a portion of a food is:
IAUCfood Wt glucose used for IAUCglucose

GGE = X X Wt of food portion
IAUCglucose Wt food used for IAUCfood
GGE expressed per 100g food is a food glycemic index (GIfood), but because the term "glycemic index"
had already become known as the term for glycemic index of food carbohydrate (GIcarb)15, the term
relative glycemic potency (RGP = GIfood) was proposed.16
Definitions
GIcarb and GL can be regarded as different expressions of GGE. The former is GGE/100g available
carbohydrate, and the latter is an estimate of GGE per given weight of a food, not necessarily
consumed in a single intake.
The relationship of a clinically determined GGE value to the derivatives of it that are used to describe
the relative glycemic potency of foods and food carbohydrates are shown in Figure 1.
Figure 1. The relationship between carbohydrate (CHO)-referenced and food-referenced

measures of glycemic potency. Use of the Q factor to adjust for non-linearity in GIcarb makes
GL equal to GGE dose (RGI).
Notes:
* GGE: Glycemic glucose equivalent (GGE) (g/g food) = weight of glucose inducing the same glycemic response as a known
amount of food.
* GIcarb: Glycemic index of food carbohydrate (%) = GGE/100 g carbohydrate in food
* GL: Glycemic load = estimated GGE (GGEest)/known weight of food unadjusted for non-linearity in the GGE dose-
glycemic response relationship.
* RGP: Relative glycemic potency or glycemic index of food (GIfood) (%) = (GGE/100g food)
* RGI: Relative glycemic impact = GGE/known amount of food.
* Q: Linearizing factor to remove the non-linear dose-response influence on GIcarb which leads to error in GL calculation.
* Pac: Proportion of food that is available carbohydrate.
Glycemic Index of Carbohydrate (Food-based, Carbohydrate-Weighted)

Glycemic index of carbohydrate (GIcarb) is measured as the glycemic response to a portion of food
containing 50g carbohydrate, expressed as a percentage of the response to 50g glucose. It can,
therefore, be regarded as the relative glycemic potency of a food adjusted by the proportion of
available carbohydrate (Pac) in the food.
Equation 1:
IAUC/g food (50/Pac)

GIcarb = X X 100 %
IAUC/g glucose 50
GIcarb can therefore be alternatively expressed as glycemic glucose equivalent per 100g of food
carbohydrate.
Equation 1 shows that although GIcarb is sometimes referred to as a measure of the quality of
carbohydrate in a food, it is, strictly speaking, the glycemic quality of a food adjusted by its available
carbohydrate content because, despite such emphasis on carbohydrate, the glycemic index of
carbohydrate in food can only be derived from measurement of a food effect.
Glycemic Load (Food Based, Calculated From GIcarb)

Glycemic load (GL) was originally calculated as a measure of glycemic stress or insulin demand
imposed over a period of time, and calculated as the average glycemic index multiplied by the
carbohydrate intake.11,17 For the purposes of dietary management, it has been contracted to a single
food portion consumed at one time, and is calculated as GIcarb multiplied by the carbohydrate intake.
GL is simply the carbohydrate-weighted GI (GIcarb; Equation 1 above) put back onto a food basis by
multiplying by the proportion of a food that is carbohydrate, and the weight of the food:
IAUC/g food (50/Pac)

GL = X X Pac x Wt. food
IAUC/g glucose 50
IAUC/g food
GL = X Wt. food
IAUC/g glucose
Thus, a food weighing 50g, with a GIcarb of 30%, and in which the proportion of carbohydrate (Pac)
was 0.5 would have a GL of 30% x 0.5 x 50 g = 7.5 g.
GL Contains an Intrinsic Error

GL is an apparently straightforward derivation of GIcarb, and it is widely used as the product of GIcarb
and food carbohydrate intake. If the assumption of linearity that underlies GL were true, GL could
be expressed as total GGE intake (g). However, a GL value calculated from GIcarb is not equal to a
GGE value measured directly as response to food relative to response to glucose, because GL values
contain a distortion that arises from the fact that the glucose (or glucose equivalent) dose-glycemic
response relationship is quadratic. The non-linearity of the response is incorporated into GIcarb
values, and when these are then used to calculate GL as a linear function of carbohydrate dose,
the non-linearity is proportionally amplified and may become a significant error for low GIcarb values
unless a correction factor (Q) is applied.12
A more correct calculation of GL is therefore:
GL = GIcarb x Pac x Food wt. x Q
Q is the factor required for dose-transformation of GI so that GL = GGE.
An additional source of error in GL is in the available carbohydrate value used to calculate Pac. The
error in Pac is incurred twice in arriving at a GL value, firstly in calculating the weight of food required
to deliver a 50g available carbohydrate dose for GIcarb measurement, and again in calculating GL
from GIcarb.
To avoid the above errors in GL, it is advisable to measure GL directly against an appropriate glucose
reference, when GL would equal RGI.
RGP and RGI (Food-based, Determined directly) Adjusted for Non-Linearity

RGI is GGE dose per given weight of food. RGP is GGE per 100g food, so it is a true glycemic index
of a food (GIfood), but because GI had already been used with reference to carbohydrate in food,
the term RGP was proposed16.
Measuring the relative blood glucose response to food has been the subject of an extensive recent
review20 and will not be covered here other than to say that the procedures for measuring glycemic
potency of a food are basically the same as are used when determining GIcarb.
When GGE is determined directly, response to food is compared with response to a glucose reference
dose in the vicinity of the GGE content of the food, so that both the reference and the food effects
will be in about the same region of the dose-response curve, that is, at about the same glycemic
sensitivity. The error incurred due to the non-linearity of the GGE dose-blood glucose response
curve will then be minimized. Approximate matching of the glucose reference dose to GGE intake
in a food portion is easily achieved from a knowledge of the carbohydrate content of the food or
of similar foods, and the GIcarb value of similar foods.
If the GGE content determined for the food, and the GGE dose (grams of glucose) used as the
reference are sufficiently separate, a correction factor may be applied based on a universal equation
for the dose-response curve that adjusts for non-linearity.12
IAUC/g food Wt glucose used

GGE = X X Correction for non-linearity X Wt. food
IAUC/g glucose Wt food used
As a VFC, GGE can be used to compare foods by glycemic potency on an equal weight basis, per
100g for example, as in the case of RGP,16 or to provide a relative measure of the glycemic impact
of a given amount of food, as in the case of RGI,9 which would be the same as a GL value derived
from a single food intake event and calculated from a dose-transformed GIcarb or measured against
a matched GGE (glucose) reference dose.
Meeting the Needs of Consumers

It is important that the form in which glycemic potency is communicated is appropriate to those
who wish to use the information to make food choices. The communication should allow accurate
control of glycemia despite the differences in food composition, food intakes and portion sizes that
vary from food to food, and from person to person in the normal environment. Actual food intakes
will continue to be governed by food producers, natural morphology, and individual preferences
more than by the convenience for glycemia management of having standardized intakes and glycemic
impacts per food portion.
In short, the communication of glycemic impact may be most applicable if based on foods, because
people choose and consume foods and not food carbohydrates, and it should be responsive to
the variations in food intakes and compositions that occur in life.
Criteria for Assessing Measures of Glycemic Potency and Glycemic Impact

A measure of glycemic potency for use as a guide to food selection should:
• make sense to the users;

• be easy to apply accurately;
• be able to be used directly, without complex calculation;
• be adaptable enough to be applied consistently from formulation of general guidelines to
quantitative management of glycemic impact for the more skilled, depending on the needs of
the user population;
• be applicable to foods of identical or different carbohydrate content;
• be applicable to foods of the same or different portion sizes;
• be appropriate for use with the foods and food practices of the user population;
• be additive for use in both individual foods and in meals;
• be safe to use; and
• encourage healthy food choices.
The degree to which the measure of the relative glycemic potency of carbohydrate that is GIcarb
(GGE/100g available carbohydrate) and the measure of the glycemic impact of foods that is RGI
(GGE dose), satisfy the above criteria is summarized in Table 1 below. Table 1 shows that the fact
that GGE may be used as a virtual food component without equicarbohydrate restriction, should
give it numerous advantages over GIcarb in practical management of glycemia.
Table 1. Carbohydrate-based glycemic index (GIcarb; GGE/100g food carbohydrate) and food-
based relative glycemic impact (RGI = GGE/food intake) in glycemia management.
Criterion GIcarb RGI Comment

Predicts the glycemic effect - + GIcarb is carbohydrate (CHO)-based, not a food-
of an intake of food. based measure.
Directly useable. ± + GIcarb is used directly only with foods of equal CHO,
whereas GGE dose may be applied also beyond the
equicarbohydrate limit.
Usable with foods of equal + + GGE dose (RGI) acts as GIcarb for equal CHO contents.
carbohydrate (CHO) content.
Usable with foods of different - + GIcarb was designed specifically for equal CHO
carbohydrate content. comparisons.
Provides a measure of ± ± Under equal carbohydrate conditions GGE functions
carbohydrate quality. as GIcarb to show differences in carbohydrate quality,
but both are based on measurement of a food effect.
Usable irrespective of - + Portion size variation leads to different carbohydrate
difference in portion size. intakes which prevent GIcarb from indicating glycemic
impact.
Additive. - + GGE is useable as an additive function of food intake,
GIcarb is a constant ratio that does not change with
food intake.
Suitable for use in both - + Calculating a GIcarb value for a meal is reasonably
individual foods and in meals. complex, whereas GGE values can be simply added.
Table 1. Carbohydrate-based glycemic index (GIcarb; GGE/100g food carbohydrate) and food-
based relative glycemic impact (RGI = GGE/food intake) in glycemia managemen (continued)
Criterion GIcarb RGI Comment
Can be used to formulate + + Guidelines such as "Choose carbohydrate foods of
dietary guidelines. relatively low glycemic impact" could be based on
GIcarb or GGE.
Can be used for quantitative - + GIcarb is an index that is independent of food intake,
glycemia management. so cannot be used in quantitative glycemia
management. GGE can.
Safety depends on usage. + + Both GIcarb and GGE can be unsafe if used without
regard to other food components.
Encourages healthy food ± ± If used with food composition both may encourage
choices. food choices that are healthier with respect to glycemic
effect. Both may also lead to unhealthy choices if used
apart from other food properties and components.
Provides information on an - + As a virtual food component GGE will inform of a real
actual food effect. relative food effect. GIcarb is not food-referenced so
can not do so.
The Nutritional Context of Glycemia Management

Neither GGE, nor any other relative of it, such as GIcarb, should be used independently of the nutrient
composition of the foods. Glycemic impact may be important, but low glycemic impact on its own
will not make a food healthy. Food choices based on either the RGI (GGE dose) of a food quantity
or on the glycemic potency of the carbohydrate in it (GIcarb) alone, may lead to unhealthy food
choices - low glycemic potency does not mean high health if the saturated fat and salt content
is high and the phytochemical and vitamin content is low.
There has been concern that providing a glycemic load or GGE value on a food label will lead to
unhealthy food choices, because low GGE content may be achieved by displacing carbohydrate
from a food with fat.19 While this is true, it applies equally to GIcarb, because a GIcarb value refers
only to available carbohydrate, and gives no information about other food components present.
A food of low GIcarb may or may not have a high fat content. A low GGE content in a food would
at least alert one to check the fat content, knowing that GGE content, but not GIcarb, depends on
food composition. While substituting with unhealthy ingredients may give a low GGE value, GIcarb
will not alert to substitution effects because it is based on carbohydrate alone.
The problem may be overcome by using measures of glycemic potency in conjunction with food
guidelines. Another possibility is to restrict the use of GGE and GIcarb to foods that meet certain
nutritional criteria. However, in the case of GGE, such a restriction would mean withholding
potentially useful information about a real food property. It seems preferable that the information
be available, and the public is helped to use it correctly, in which case GGE would be treated like
any other beneficial food component seen in a nutrient information panel, such as vitamin C.
By recommending that people base their diets on carbohydrate foods, the foods will form a high
carbohydrate cluster of relatively low fat foods. Foods may subsequently be chosen by glycemic
potency without compromising the carbohydrate basis of the diet. When foods are selected from
a recommended group of carbohydrate foods relatively low glycemic potency, they will be associated
with low GIcarb. Nonetheless, GGE dose will continue to be a better guide to glycemic impact than
GIcarb, because, despite the foods all being grouped as high in carbohydrate, and relatively low in
glycemic impact, variations in composition and portion size will exist that make GIcarb inaccurate
to use, because it was designed for equicarbohydrate comparisons.
The best way to ensure that nutritional balance is achieved is to always base choices on the
nutritional balance in the diet, and never on a single variable such as glycemic impact. As a VFC,
GGE has the advantage of being able to be used concurrently with other nutrients and virtual food
components, so that the multi-dimensional nature of a food, or even of nutrition within a lifestyle,
can be displayed.20 Figure 2 below shows a multi-dimensional display in which real food components,
virtual food components that represent food effects, and aspects of lifestyle such as stress and
exercise, together provide the context in which glycemic impact is managed.
Figure 2. Multidimensional representation of nutrients, virtual food components including

GGE, and lifestyle factors that collectively affect health.
Notes:
* The value of 100 on each dimension would be set as the optimum for an individual after personal assessement of individual
requirements and responsivness.
* Light gray is the ideal, and dark gray is typical of a modern lifestyle.
* GGE : glycemic glucose equivalent (glycemic impact)
* WBE : wheat bran equivalent (fecal bulk)
* IE : inulin equivalent (prebiotic efficacy)
* BBE : blueberry equivalent (antioxidant)
* SFA : saturated fatty acids.
The Future: Food Effects, Individual Responsiveness, Personalized

Nutrition and Virtual Food Components
The nutritional quality of foods has been described in terms of composition - the nutrients that
are measured using a finely ground sample in an analytical laboratory and displayed in a standard
nutrient information panel. However, it is food effects and properties, many of which cannot be
represented by chemical analysis, that are of ultimate concern to the consumer. With the importance
of functional foods, and the realization that it is critical to health to be able to choose foods
according to effects, the need for virtual food components (VFCs) to overcome the limitations of
some real food components as indicators of effect has arisen.
As a VFC is a food effect expressed in terms of the weight of a reference material that would have
an effect equal to that of a given quantity of food, it shows the relative potency of a food with
respect to an effect. The actual potency depends on individual responsiveness to the virtual food
component. With the advent of simple physiology monitoring systems such as blood glucose
meters, it may soon be easy to establish the average glycemic responsiveness of an individual, and
to thereby design personalized meals of known RGI. Once an individual's responsiveness is established,
GGE could be amongst a number of virtual food components to guide food choices for personalized
diet construction, according to predetermined individual susceptibilities or needs.
Personalized VFCs would facilitate nutritional management by being continuous, and using intake
responsive variables applicable across foods of differing composition and quantity. Because they
are expressed as a weight, they may be used alongside nutrients in modern nutrition management
systems to give a more complete picture of the quality of a diet than can be obtained from food
components alone.20 With increased emphasis on identifying individuals at risk, and intervening
to avert harmful long term dietary effects on health, VFCs may be used to manage syndromes such
as diabetes and the metabolic syndrome for which outcomes depend on many aspects of diet in
addition to glycemic impact.
Conclusion
The glycemic potency of foods has been expressed as a GGE intake per 100g carbohydrate consumed,
as in the case of GIcarb, and as GGE per 100g weight or per given weight of food, as in the case of
RGP and RGI. GIcarb and GGE can, under equicarbohydrate conditions, be used to indicate the quality
of carbohydrate in a food. Because it may be used to directly represent the glycemic impact of
food, GGE intake per weight of food may be more versatile than GIcarb as it has the capacity to act
as a virtual food component alongside other dietary variables that contribute, along with glycemia,
to the eventual health outcomes of syndromes such as diabetes.
References
1. Brand-Miller J. Postprandial glycemia, glycemic index, and the prevention of type 2 diabetes. Am J
Clin Nutr. 2004; 80: 243-244.
2. Jenkins DJ, Kendall CW, Augustin LS, Franceschi S, Hamidi M, Marchie A, Jenkins A L and Axelsen
M. Glycemic index: overview of implications in health and disease. Am J Clin Nutr. 2002; 76 Suppl:
266-273S.
3. Livesey G. Low-glycemic diets and health: implications for obesity. Proc Nutr Soc (UK).2005; 64:
105-13.
4 Brownlee M. Biochemistry and molecular biology of diabetic complications. Nature. 2001; 414: 813-
820.
5. Saltiel AR, Kahn R. Insulin signalling and the regulation of glucose and lipid metabolism. Nature.
2001; 414: 799-806.
6. Bell SJ, Sears B. Low glycemic load diets: impact on obesity and chronic disease. Crit Rev Food Sci
Nutr. 2003; 43: 357-77.
7. Zimmet P, Alberti KGMM, Shaw J. Global and societal implications of the diabetes epidemic. Nature.
2001; 414; 782-787
8. Monro JA. Expressing the glycemic potency of foods. Proc Nutr Soc UK. 2005; 64: 115-22.
9. Monro JA. Glycemic glucose equivalent: combining carbohydrate content, quantity and glycemic
index of foods for precision in glycemia management. Asia Pac J Clin Nutr. 2002; 11: 217-25.
10. Monro JA. Virtual food components: functional food effects expressed as food components. Eur J
Clin Nutr. 2004; 58: 219-30.
11. Salmeron J, Manson JE, Stampfer MJ, Colditz GA, Wing AL & Willett WC. Dietary fiber, glycemic
load, and risk of non-insulin-dependent diabetes mellitus in women. J Am Med Assoc. 1997; 277:
472-7.
12. Shaw M. Accurate determination of glycemic load as glycemic glucose equivalent using a dose
transformation of the glycemic index. J Nutr (Submitted)
13. Augustin LS, Franceschi S, Jenkins DJ, Kendall CW and La Vecchia C. Glycemic index in chronic
disease: a review. Eur J Clin Nutr. 2002; 56: 49-71.
14 Liu P, Perry T, Monro JA. Glycemic glucose equivalents: validation as a predictive measure of the
relative glycemic impact of foods. Eur J Clin Nutr. 2003; 57: 1141-1149.
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Jenkins AL, & Goff DV. Glycemic index of foods: a physiological basis for carbohydrate exchange.
Am J Clin Nutr. 1981; 34: 362-6.
16. Monro. J.A. 1999: Available carbohydrate data and glycemic index combined in new data sets for
managing glycemia and diabetes. Journal of Food Composition and Analysis 12, 71-82.
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Nutr. 2002; 76 Suppl 1: 274-80S.
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Nutr Res Rev. 2005; 18: 1-28.
19. Nantel G. Glycemic carbohydrate: An international perspective. Nutr Rev. 2003; 61; S34-S39.
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Carbohydrates and Obesity

Peter M. Clifton
Clinical Research Unit
CSIRO Health Sciences and Nutrition
Adelaide, Australia
Introduction
In the past, Asian and African populations consumed a much higher percentage of their energy
as carbohydrates, and had lower body weights than individuals in Europe and America. However,
their energy intake was also lower and their activity level higher, so it is difficult to attribute the
lower body weights to carbohydrate. In Western countries, it has been quite difficult to relate body
weights to specific macronutrient intakes, although Romieu et al.1 found in a small cross sectional
study of 141 women that fat intake accounted for 4% of the variance in weight after adjustment
for energy intake. In a longitudinal study of 300 normal adults, Klesges et al.2 found that fat intake
was a predictor of weight gain over 3 years. The higher energy density of fat appears to play more
of a role in weight loss and weight regain studies. Leser et al.3 found that after weight loss on a
very low calorie diet, weight regain in 27 women over 3 years was related to fat intake (r=0.55).
Data from the National Weight Control Register also demonstrated that weight regain was related
to fat intake.4
In a meta-analysis of ad libitum low fat diets by Astrup et al.,5 16 trials containing 1,728 individuals
were examined. The average weight loss compared with the control diet was 2.5kg. The effect on
weight was related both to pre-treatment weight and to the percentage reduction in fat with a
weight loss of 0.37kg per 1% absolute reduction in fat calories. Thus, for a subject with a BMI of
30, a 10% reduction in fat would result in weight loss of 4.4kg.
Fructose
One carbohydrate that has been adversely related to obesity is fructose.6 In relation to obesity, it
is probably not intrinsically any different from glucose, sucrose or even starch, but intakes have
increased dramatically over the last 20 years as both fruit juice and soft drink consumption has
doubled and soft drinks have been sweetened with high fructose corn syrup. From 1970 to 2000,
added sugar consumption in the USA increased by 5%, while total calories increased by about 25%,
mostly from refined grain products (Figure 1, USDA). High fructose corn syrup constitutes between
10% to 16% of total calories8, depending on the study. Thus, intakes of free fructose from fruit have
risen from about 16g/day to 17g/day to 60 g/day to 100g/day, as intakes of fruit juices and soft
drinks have increased. In an ecological study in the USA, the incidence of Type 2 diabetes was
associated with the intake of fructose after adjustment for energy density (p=0.04), while fat was
not.7 Fiber was inversely related to the incidence of Type 2 diabetes (P<.01). The glycemic index of
high fructose corn syrup 55 is 73, so it is a high GI carbohydrate. Despite fructose being 73% sweeter
than sucrose, the same amounts as sucrose are usually added to drinks. Fructose enters cells via
a non-insulin mediated Gut 5 mechanism which is present in glial cells but not in neurons, so there
is no apparent satiety signal from a large dose of fructose.9 Overweight subjects fed 28% of energy
as sucrose (152g/day) who did not compensate for this extra energy gained 1.6kg over 10 weeks,
in comparison with subjects fed a non-sucrose sweetener with a lower energy level.10 Ludwig et
al.11 has shown that the baseline consumption of sugar-sweetened drinks was related to BMI in 548
children, and that the BMI gain over 19 months was also related with a gain of 0.24 kg/m2 per serve.
Figure 1. Change in total carbohydrate consumption in the United States between 1909 and 1997,
reflected by the replacement of whole grains (smaller circles) with corn syrup (larger circles)
Source: Centers for Disease Control and Prevention. Diabetes surveillance 1999. Atlanta: US Department of Health and
Human Services, 1999
Metabolism of Fructose
Metabolically, fructose behaves quite differently from glucose by not provoking a dramatic insulin
response (about 40% of glucose) and is additive to the insulin response induced by protein.12 The
glycemic index is low at 20 to 25 (rather than zero) and it appears to provoke (or fails to suppress)
the release of glucose from the liver over the 2 hour test period. It augments the insulin response
to starch or glucose (up to 3 fold higher), particularly when glucose is high by stimulating pancreatic
glucokinase which is required for the insulin response. Therefore, it has been recommended for
diabetic patients in low doses to improve glucose control.13 It also appears to be slightly more
thermogenic than glucose (7.5% versus 6.2%) and leads to increased gluconeogenesis at 4 hours
as it is rapidly taken up by a very active fructokinase split into trioses and converted into glycogen.14
Fructose and Lipids

As fructose is rapidly taken up into the liver via an unregulated fructokinase and split into trioses,
it can either be converted into glycogen through the controlling fructose 1,6 bisphosphatase, or
into triglycerides. Thus, it is possible, depending on the glycogen stores of the liver and the amount
of fructose ingested, for an elevation of post-prandial triglyceride and even fasting triglyceride.
Both of these have been shown in men consuming 17% of energy as fructose in comparison with
glucose.15 This intake of fructose is now not extreme as 1 in 4 children may consume this amount.
Many studies have shown no rise in fasting triglyceride but several studies have shown both a rise
in fasting triglyceride and LDL cholesterol and apoB16,17 or LDL alone.15,18
Feeding fructose at high levels to rats (35% of energy) was shown long ago to lead to both elevated
triglyceride and to insulin resistance (as assessed by a glucose clamp) in comparison with glucose.19
Lingelbach et al.20 showed that this effect persisted over 26 months and was not related to an
increase in body weight which was similar on cornstarch, glucose, fructose or a mixture of glucose
and fructose (fed as 66% of energy).
In humans, dietary fructose was related to insulin resistance (as assessed by an elevated C-peptide)
in 2,000 women in the Nurses Health Study,21 while Faeh et al.22 (25% additional calories from
fructose) found that there was impaired insulin suppression of free fatty acid released from adipose
tissue (thus insulin resistance) in comparison with glucose. Fasting glucose was also elevated by
7%, fasting triglycerides by 79%, while endogenous glucose production rose by 14% and de novo
lipogenesis was elevated six fold. There was no change in whole body insulin mediated glucose
disposal. Teff et al.23 also demonstrated high plasma triglyceride with fructose and lower insulin and
leptin as well as absent post-prandial suppression of ghrelin. All of the last three effects may impair
satiety and induce greater food intake.
Resistant Starch and Obesity

Resistant starch is that fraction of starch that escapes absorption in the small intestine which is
frequently fermented in the large bowel to short chain fatty acids which are absorbed in the colon.
Thus, depending on the contribution of the starch to microbial mass, some of the energy is excreted.
Behall et al.24 has computed that the energy value of resistant starch is 2.8 Kcal/g or (11.7kj/g )
rather than 4 Kcal/g. High amylose diets produce less hydrogen in subjects with hyperinsulinemia
and a high BMI suggesting they are more efficient at metabolising or fermenting the starch with
less energy wastage,25 although the number of subjects was very small. Resistant starch does not
appear to impact on satiety or energy intake, energy expenditure or carbohydrate or fat oxidation
even though post-prandial glucose and insulin responses are lower,26,27 and there is some evidence
that it may enhance insulin sensitivity.28 Resistant starch does not lower glycemic index as only
available carbohydrate is counted for the 50g carbohydrate load.
Fiber and Obesity

High fiber diets (48g/day) promote starch and protein malabsorption, and lead to losses of about
150Kcal compared with low fiber diets (19.7g/day).29 Baer et al.30 demonstrated that increasing fiber
from 18g/day to 36g/day in men led to the loss of about 540KJ/day in metabolisable energy. Dietary
fiber itself is not inert and is partially fermented and contributes from 2.5Kcal/g (cereal fiber) to
3.1Kcal/g (fruit and vegetable).31 Sugar alcohols also have a similarly reduced energy.32
High fiber diets have been associated with a lower BMI in the 5,000 subjects in the Swedish Obesity
Study33 and in other small and large study cohorts,34-38 while ecological analysis shows that high
fiber consuming populations tend to have lower rates of obesity.39 Longitudinal studies have shown
that weight gain is inversely associated with fiber intake40 and whole grain foods.41
Interventions in obese subjects with fiber have produced very variable results ranging from no
effect42 to about 2.2 kg loss of weight.43 A meta-analysis of all studies that supplied a supplement
of 14g/day or more for greater than two days was associated with a short term reduction in energy
intake of about 10% and a weight loss of 1.9kg over an average of 3.8 months.44 Fiber may work
by enhancing satiety,45,46 possibly via an increase in cholecystokinin.47
Conclusions
The association of high carbohydrate diets with reduction in obesity are most likely related to fiber
content of the carbohydrate source and to the content of whole grain cereals, fruit and vegetables,
while starch per se, whether highly available or resistant, probably plays a minor role. Fructose may
contribute to weight gain.
References
1. Romieu I, Willett WC, Stampfer MJ, Colditz GA, Sampson L, Rosner B, Hennekens CH, Speizer FE.
Energy intake and other determinants of relative weight. Am J Clin Nutr. 1988 Mar;47(3):406-12.
2. Klesges RC, Klesges LM, Haddock CK, Eck LHA. Longitudinal analysis of the impact of dietary intake
and physical activity on weight change in adults. Am J Clin Nutr. 1992, 55:818-22.
3. Leser MS, Yanovski SZ, Yanovski JAA. Low-fat intake and greater activity level are associated with
lower weight regain 3 years after completing a very-low-calorie diet. Am Diet Assoc. 2002
Sep;102(9):1252-6.
4. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr. 2001;21:323-41. Review
5. Astrup A, Grunwald GK, Melanson EL, Saris WH, Hill JO. The role of low-fat diets in body weight
control: a meta-analysis of ad libitum dietary intervention studies. Int J Obes Relat Metab Disord.
2000 Dec;24(12):1545-52
6. Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play
a role in the epidemic of obesity. Am J Clin Nutr. 2004;79:537-543
7. Gross LS, Li L, Ford ES, Liu S. Increased consumption of refined carbohydrates and the epidemic
of type 2 diabetes in the United States: an ecologic assessment. Am J Clin Nutr. 2004;79:774-779.
8. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in food locations and sources among adolescents and
young adults. Prev Med. 2002 Aug;35(2):107-13
9. Payne J, Maher F, Simpson I, Mattice L, Davies P. Glucose transporter Glut 5 expression in microglial
cells. Glia. 1997 Nov;21(3):327-31
10. Raben A, Vasilaras TH, Moller AC, Astrup A. Sucrose compared with artificial sweeteners: different
effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight
subjects. Am J Clin Nutr. 2002;76:721-729
11. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks
and childhood obesity: a prospective, observational analysis. Lancet. 2001 Feb 17;357(9255):505-8.
12. Gannon MC, Nuttall FQ, Grant CT, Ercan-Fang S, Ercan-Fang N. Stimulation of insulin secretion
by fructose ingested with protein in people with untreated Type 2 diabetes. Diabetes Care. 1998
Jan;21(1):16-22.
13. Reiser S, Powell AS, Yang CY, Canary JJ. An insulinogenic effect of oral fructose in humans during
postprandial hyperglycemia. Am J Clin Nutr. 1987 Mar;45(3):580-7
14. Schwarz JM, Acheson KJ, Tappy L, Piolino V, Muller MJ, Felber JP, Jequier E. Thermogenesis and
fructose metabolism in humans. Am J Physiol. 1992 May;262(5 Pt 1):E591-8
15. Bantle JP, Swanson JE, Thomas W, Laine DC. Metabolic effects of dietary fructose in diabetic subjects.
Diabetes Care. 1992;15:1468-76
16. Hallfrisch J, Reiser S, Prather ES. Blood lipid distribution of hyperinsulinemic men consuming three
levels of fructose. Am J Clin Nutr 1983;37:740-8
17. Reiser S, Powell AS, Scholfield DJ, Panda P, Ellwood KC, Canary JJ. Blood lipids, lipoproteins,
apoproteins, and uric acid in men fed diets containing fructose or high-amylose cornstarch. Am J
Clin Nutr 1989;49:832-9
18. Swanson JE, Laine DC, Thomas W, Bantle JP. Metabolic effects of dietary fructose in healthy subjects.
Am J Clin Nutr 1992;55:851-6
19. Thorburn AW, Storlien LH, Jenkins AB, Khouri S, Kraegen EW. Fructose-induced in vivo insulin
resistance and elevated plasma triglyceride levels in rats. Am J Clin Nutr. 1989 Jun;49(6):1155-63
20. Lingelbach LB, McDonald RB. Description of the long-term lipogenic effects of dietary carbohydrates
in male Fischer 344 rats. J Nutr. 2000 Dec;130(12):3077-84
21. Wu T, Giovannucci E, Pischon T, Hankinson SE, Ma J, Rifai N, Rimm EB. Fructose, glycemic load,
and quantity and quality of carbohydrate in relation to plasma C-peptide concentrations in US
women. Am J Clin Nutr. 2004 Oct;80(4):1043-9.
22. Faeh D, Minehira K, Schwarz JM, Periasami R, Seongsu P, Tappy L. Effect of fructose overfeeding
and fish oil administration on hepatic de novo lipogenesis and insulin sensitivity in healthy men.
Diabetes. 2005 Jul;54(7):1907-13.
23. Teff KL, Elliott SS, Tschop M, Kieffer TJ, Rader D, Heiman M, Townsend RR, Keim NL, D'Alessio D,
Havel PJ. Dietary fructose reduces circulating insulin and leptin, attenuates postprandial suppression
of ghrelin, and increases triglycerides in women. J Clin Endocrinol Metab. 2004 Jun;89(6):2963-72
24. Behall KM, Howe JC. Resistant starch as energy. J Am Coll Nutr. 1996 Jun;15(3):248-54.
25. Behall KM, Howe JC. Breath-hydrogen production and amylose content of the diet. Am J Clin Nutr.
1997 Jun;65(6):1783-9.
26. de Roos N, Heijnen ML, de Graaf C, Woestenenk G, Hobbel E. Resistant starch has little effect on
appetite, food intake and insulin secretion of healthy young men. Eur J Clin Nutr. 1995 Jul;49(7):532-41
27. Howe JC, Rumpler WV, Behall KM. Dietary starch composition and level of energy intake alter
nutrient oxidation in "carbohydrate-sensitive" men. J Nutr. 1996 Sep;126(9):2120-9
28. Robertson MD, Bickerton AS, Dennis AL, Vidal H, Frayn KN. Insulin-sensitizing effects of dietary
resistant starch and effects on skeletal muscle and adipose tissue metabolism. Am J Clin Nutr. 2005
Sep;82(3):559-67
29. Wisker E, Feldheim W. Metabolizable energy of diets low or high in dietary fiber from fruits and
vegetables when consumed by humans. J Nutr. 1990 Nov;120(11):1331-7.
30. Baer DJ, Rumpler WV, Miles CW, Fahey GC Jr. Dietary fiber decreases the metabolizable energy
content and nutrient digestibility of mixed diets fed to humans. J Nutr. 1997 Apr;127(4):579-86
31. Goranzon H, Forsum E. Metabolizable energy in humans in two diets containing different sources
of dietary fiber. Calculations and analysis. J Nutr. 1987 Feb;117(2):267-73
32. Sinau S, Montaunier C, Wils D, Verne J, Brandolini M, Bouteloup-Demange C, Vermorel M. Net
energy value of two low-digestible carbohydrates, Lycasin HBC and the hydrogenated polysaccharide
fraction of Lycasin HBC in healthy human subjects and their impact on nutrient digestive utilization.
Br J Nutr. 2002 Feb;87(2):131-9
33. Lissner L, Lindroos AK, Sjostrom L. Swedish obese subjects (SOS): an obesity intervention study
with a nutritional perspective. Eur J Clin Nutr. 1998 May;52(5):316-22. Review
34. Miller WC, Niederpruem MG, Wallace JP, Lindeman AK. Dietary fat, sugar, and fiber predict body
fat content. J Am Diet Assoc. 1994 Jun;94(6):612-5
35. Alfieri MA, Pomerleau J, Grace DM, Anderson L. Fiber intake of normal weight, moderately obese
and severely obese subjects. Obes Res. 1995 Nov;3(6):541-7.
36. Nelson LH, Tucker LA. Diet composition related to body fat in a multivariate study of 203 men. J
Am Diet Assoc. 1996 Aug;96(8):771-7
37. Appleby PN, Thorogood M, Mann JI, Key TJ. Low body mass index in non-meat eaters: the possible
roles of animal fat, dietary fiber and alcohol. Int J Obes Relat Metab Disord. 1998 May;22(5):454-60.
38. Kromhout D, Bloemberg B, Seidell JC, Nissinen A, Menotti A. Physical activity and dietary fiber
determine population body fat levels: the Seven Countries Study. Int J Obes Relat Metab Disord.
2001 Mar;25(3):301-6.
39. Kimm SY. The role of dietary fiber in the development and treatment of childhood obesity. Pediatrics.
1995 Nov;96(5 Pt 2):1010-4.
40. Ludwig DS, Pereira MA, Kroenke CH, Hilner JE, Van Horn L, Slattery ML, Jacobs DR Jr. Dietary fiber,
weight gain, and cardiovascular disease risk factors in young adults. JAMA. 1999 Oct 27;282(16):1539-46
41. Liu S, Willett WC, Manson JE, Hu FB, Rosner B, Colditz G. Relation between changes in intakes of
dietary fiber and grain products and changes in weight and development of obesity among middle-
aged women. Am J Clin Nutr. 2003 Nov;78(5):920-7.
42. Howarth NC, Saltzman E, Roberts SB. Dietary fiber and weight regulation. Nutr Rev. 2001
May;59(5):129-39. Review
43. Birketvedt GS, Aaseth J, Florholmen JR, Ryttig K. Long-term effect of fiber supplement and reduced
energy intake on body weight and blood lipids in overweight subjects. Acta Medica (Hradec Kralove).
2000;43(4):129-32
44. Howarth NC, Saltzman E, McCrory MA, Greenberg AS, Dwyer J, Ausman L, Kramer DG, Roberts
SB. Fermentable and nonfermentable fiber supplements did not alter hunger, satiety or body weight
in a pilot study of men and women consuming self-selected diets. J Nutr. 2003 Oct;133(10):3141
45. Levine AS, Tallman JR, Grace MK, Parker SA, Billington CJ, Levitt MD. Effect of breakfast cereals
on short-term food intake. Am J Clin Nutr. 1989 Dec;50(6):1303-7
46. Burley VJ, Paul AW, Blundell JE. Influence of a high-fiber food (myco-protein) on appetite: effects
on satiation (within meals) and satiety (following meals). Eur J Clin Nutr. 1993 Jun;47(6):409-18.
47. Bourdon I, Olson B, Backus R, Richter BD, Davis PA, Schneeman BO. Beans, as a source of dietary
fiber, increase cholecystokinin and apolipoprotein b48 response to test meals in men. J Nutr. 2001
May;131(5):1485-90.
Carbohydrates and Oral Health - Dental Caries:

Population Approaches to Prevention
Clive Wright
Chief Advisor (Oral Health)
Ministry of Health
New Zealand
Introduction
There have been various theories regarding the causation of dental caries. However, the theory
which has accumulated and sustained evidence over more than a century has its origins in the
chemico-parasitic theory of WD Miller in 1890.1
In essence, the theory holds that: fermentable carbohydrates (sugars) metabolised by oral microflora
(bacteria) produce organic acid. When sustained in close proximity to the tooth surface over time,
such organic acid will cause a demineralisation of the dental enamel and the consequent initiation
of dental caries.2
Animal studies, in vitro laboratory studies, observational population studies3-7 and the Vipeholm
Dental Caries Study8 provide extensive and strong evidence of the causal link between fermentable
carbohydrates (especially fermentable sugars), normal oral flora (particularly streptococcus and
lactobacillus) and the formation of organic acids. In recent decades, the nature and formation of
dental plaque has added to the environmental matrix which sustains bacterial growth, adherence
of bacteria to the tooth surface and a medium through which organic acids demineralise the enamel
structure of the tooth surface.9 Dental plaque also acts as the medium through which saliva buffers
and fluoride may interact in a dynamic process related to waves of demineralisation followed by
remineralisation of the tooth surface.2 Depending upon the mix of ions, the pH and the presence
of fluoride, the enamel surface of the tooth may either lose or gain enamel crystals.2
The declining rates of dental caries in many industrialised nations10 together with stable or increasing
level of sugar consumption, have led some to argue that the role of fermentable sugars in the diet
is no-longer a concern as the impact on the causation of dental decay is substantially outweighed
by the benefits of fluoride toothpaste, water fluoridation, greater emphasis on personal oral hygiene,
and better access to dental care.
There is little doubt from the extensive literature on the use of fluorides, especially water fluoridation
and fluoride toothpaste usage, that fluorides have had a significant impact on reducing dental
caries at a population level.10 What is clouded by this major decline in dental decay across large
population groups has been the differential impact of fluorides and fluoridation across social sub-
groups within the broader population. Higher exposures of low-income and other groups to risk
factors have increased the gap between those with decay and those without.
Population Health
Population health has been defined by Health Canada11 as:
"... an approach to health which aims to improve the health of an entire population and to reduce the
health inequities among population groups. In order to reach these objectives, it looks at and acts upon
the broad range of factors and conditions (commonly referred to as the determinants of health) that
have a strong influence on our health."
The population health approach builds on the principles of public health, community health, and
health promotion. Key objectives of a population health approach are to improve health status
outcomes and reduce inequalities and inequities.
Watt and colleagues12 eloquently illustrate the integration of the myriad of factors - social, cultural,
economic, behavioural, and biological - which impact on oral health status (Figure 1.) Diet, hygiene
and the biology of the disease process impact on oral health but are influenced by major behavioural,
social and economic aspects of an individual's total environment.
Figure 1. Social determinants of oral health
Source: Oral Health Promotion, Evaluation Toolkit12
The challenge then, is to balance our understanding of individual responsibility for the causation
of diseases against the cultural, social and economic drivers that influence our diet and behavioural
choices and opportunity. There is a public obligation on governments and their agencies, through
public health laws, regulations, policy and funding disbursements, to make corrections for inequities
in both power and health outcomes across certain population groups within their jurisdictions.
Within the New Zealand context,13 intervention strategies to reduce inequalities in health outcome
are conceptualised at four levels of activity:
• Structural level pathways - which tackle the root causes of health inequalities, for example, social,
economic, cultural and historic factors that have fundamentally determined health outcome;
• Intermediate level pathways - targeting materials, psychological and behavioural factors that
mediate the impact of structural factors on health;
• Health and disability services pathways - which undertake specific actions within a service delivery
framework; and
• Impact pathways - promoting those activities which minimise the impact of disability and illness
on socio-economic position.
Burt,14 drawing on population oral health experience, described strategic oral health promotion
intervention at differing levels, for example: personal; group/family; and population level.
Table 1 illustrates the types of oral health intervention which could be associated with the four
predominant risk factors related to the causation of dental caries. For example, with respect to
fermentable sugars, at a personal level, an individual should be informed about a particular product,
the type and potential of the product to initiate dental decay, and have developed the necessary
decision-making skills to select a product appropriate to his/her needs and/or concerns. At a group
level, for example a school setting, a school should have health-related policies consistent with
their community's informed aspirations and the capacity to raise funds, provide food and drinks
within the school environment supportive to the health needs of their children. At a broader
population level, sensible and balanced information on diet and nutrition should be provided by
health and educational agencies which incorporates the oral health relationships to general health
outcomes. Governments and industry need to work collaboratively to determine the best strategies
for making healthy and easy choices for their communities. This may take the form of accords
between industry and public institutions, or regulations. Finally, alternatives to fermentable sugars,
for example, xylitol or other alcohol sugars or sugar substitutes, should be clearly labelled and
available across confectionary and other products.
Table 1. Relationship between level of intervention (personal, group and population) risk
factors and health promotion activity.
Risk factors/ Personal Group Population

Level of Intervention
Sugars • Information • Supportive • Information
• Personal decision environments • Accord vs Regulation
skills • Food policy • Alternatives
Bacteria • Oral hygiene • Supportive • Information
• Therapeutic environments • Intersectoral collaboration
dentifrices • Health policy • Tax options
Acid • Salivary stimulants • Awareness • Information
• Buffers • Intersectoral collaboration
Tooth • Access to services • Supportive • Easy service access
• Fluoride environments • Priority programs
• Sealants • Health policy • Fluoridation
• Intersectoral collaboration
The population health approach also focuses attention on the social disparities in disease distribution
across a nation or population. Oral diseases are not equally distributed across communities15: low
income, minority ethnic groups, and people with co-morbidities tend to carry higher burdens of
dental disease. Information collected through the New Zealand School of Dental Service illustrate
both the overall improvement in oral health in New Zealand children over the past two decades,
the plateauing of disease levels from the early 1990s, and the variation in distribution of dental
decay by fluoride exposure and ethnic background.16
Figure 2 shows the change in the severity of dental decay in five and 12 year-old New Zealand
children from the 1950s through to 2004. The major decline in dental decay occurred in the decades
between 1960 and 1990. Since the early 1990s, there has been little change in the "average" severity
of dental decay in 5 and 12 year-old New Zealand school children.
Figure 2. Changing severity of dental decay in New Zealand children
Note:
Severity of dental disease in the primary dentition is expressed as the dmft index and in the permanent dentition as the
DMFT index. Each of these indices represents the accumulative decay, extracted or filled teeth present at the time of dental
examination.
However, breaking down these aggregate data by water fluoridation (Is the child's school in a
fluoridated area?) and by ethnic background (M_ori, Pacific and other) shows marked variation in
dental decay (Figures 3 and 4).
Figure 3. Severity of dental caries in New Zealand in 5 and 12 year-old children by water
fluoridation in 2003
Figure 4. Severity of dental decay in the primary dentition (dmft) of 5 year-old New Zealand
children by ethnic group and water fluoridation
For example, 5 year-old New Zealand children had, on average, 1.9 primary teeth affected by dental
decay (dmft). However, in non-fluoridated areas this rate was 2.4 dmft compared with 1.4 dmft in
fluoridated areas; a difference of some 71 percent. Similarly, for 12 year-old children, the DMFT
experience in non-fluoridated areas was, on average, 1.8 teeth, whereas in fluoridated areas, on
average, the experience was 1.3 DMFT.
Similarly, when aggregate data are broken down by ethnic background and fluoridation status, variations
are also apparent (Figure 4.) This example of five year-old children shows both the benefit of water
fluoridation - irrespective of ethnic group, there is, on average, a lower rate of dental decay - and
variation by ethnic group. Where Mãori children have on average, about two-and-half times the rate
of dental decay than "other" (largely European) children in fluoridated and non-fluoridated areas.
The explanation of differentials in decay rates between ethnic groups cannot therefore be explained
simply on the basis of difference in exposure to water fluoridation. Other key diet and cultural
differences need further exploration. A survey on the nutritional and health status on New Zealand
children aged between 5 and 14 years17 may provide some insight into diet-culture related variation
which could at least in part help explain the differences in decay experience.
The NZ Food: NZ Children (2003) report17 documented significant variation in food and sugar
consumption patterns between various social and ethnic groups in New Zealand. Specifically, the
report noted that:
• Mãori and Pacific children were more likely to buy food from a shop, tuck-shop or take away;
• Mãori and Pacific children were more likely to drink powdered fruit drink, cola drinks and soft
drinks;
• sucrose was the main contributor to total sugars consumed;
• the highest intake of sugars was among Mãori children; and
• the main sources of sucrose were non-alcoholic beverages (26%), sugar and sweets (21%) and
biscuits and fruit (11%).
Reconstructing Appropriate Population Models of Oral Health

Promotion
There have been a number of suggestions related to how best the promoters of improving population
oral health may reconfigure an approach to prevention which is built upon the WHO Model of
the Ottawa Charter18 and a closer integration of oral health and general health outcomes.
Sheiham and Watt19 proposed a "Common Risk Factor" approach. Their theory holds that the
causation of oral disorders (dental decay, periodontal diseases) has similar origins (diet, stress,
hygiene, smoking, alcohol etc) to the causation of general disorders (such as diabetes, obesity,
cancers, cardiovascular, respiratory diseases etc.) The prevention of oral disorders therefore should
be based on a strategic framework linking oral and general medical health promotion activities and
resources. A wider range of partnerships and sector involvements would be involved in preventing
dental disease and dental caries.
Similar conceptual models have been advanced by the Ministry of Health (New Zealand) in their
"Leading for Outcomes" approach20 - which again takes a holistic approach to managing a range
of chronic diseases. Figure 5 summarises the relationships between the major social and system
outcomes in reducing health inequalities and the prevention of chronic diseases.
Figure 5. Leading for outcomes approach20

Both the Common Risk Factor and the Leading for Outcomes approaches provide integrative models
which link the biological causes of chronic diseases through the range of behavioural intermediaries
to the social determinants of disparities in health outcome.
Within the population health approach therefore, although there is recognition of the importance
of biological causation and individual health interventions, increasingly the focus is toward prevention
at a population level involving multiple strategies and inter-sector alliances in the prevention of
oral disorders and dental decay. The growing evidence base to support the use of non-caloric
sugars21,22 at a population level, alliances between industry, professions and health agencies11 and
linkages outside traditional oral health service activities23 will be a feature of changing attitudes
and strategies to the prevention of dental caries in the next two decades.
Summary
The original paradigm of the relationship between sugars and dental decay has accumulated high
levels of supportive evidence over a century of research and enquiry. Although the relationship
between sugars and dental decay is modified in contemporary society by socio-cultural differences
in risk exposure, environmental fluorides and level of community empowerment, the paradigm
remains essentially intact. Public health agencies will continue to explore a comprehensive mix of
interventions and strategies to prevent dental caries, including sugar restriction and fluoride
promotion policies, across multiple settings and working across sectors with collaborative alliances.
References
1. Miller WD. Micro-Organisms of the Human Mouth. Philadelphia: SS White. 1890
2. Featherstone JD. The continuum of dental caries - evidence for a dynamic disease process. J Dent
Res 2004;83: Sepc No C: C39-42.
3. Pollard MA, Duggal MS, Fayle SA, Toumba KJ and Curzon MEJ. Caries Preventive Strategies. Brussels:
International Life Sciences Institute Europe. 1995.
4. Von der Fehr FR, Loe H and Theilade E. Experimental caries in man. Caries Res 1970;4: 131-148.
5. Harris R. Biology of the children of Hopewood House, Bowral, Australia. 4. Observations on dental-
caries experience over five years (1957-1961). 1963.
6. Holloway PJ, James PMC and Slack GL. Dental disease in Tristan da Cunha. Brit Dent J.1963;115:
19-25.
7. Takeuchi M. Epidemiological study on dental caries in Japanese children before, during and after
World War II. Int Dent J. 1961;11: 443-457.
8. Gustafsson BE, Quensel C-E, Swenander Lanke L, Lundqvist C, Grahnén H, Bonow BE and Krasse
B. The Vipeholm Dental Caries Study. Acta Odontol Scand. 1954;11: 232-264.
9. Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care.
Caries Res.2000;38: 182-91.
10. Burt BA and Pai S. Sugar consumption and caries risk: a systematic review. J Dent Educ.2001;65:1017-
1023.
11. Health Canada. (www.phac-aspc.gc.ca/ph-sp/phdd/approach/index.html#What) (Accessed June
2005).
12. Watt RG, Harnett R, Daly B, Fuller SS, Kay E, Morgan A, Munday P, Nowjack-Raymer R and Treasure
ET. Oral Health Promotion. Evaluation Toolkit. London: Stephen Hancocks Ltd.2004; P6.)
13. Ministry of Health, New Zealand. Reducing inequalities in health. Wellington: Ministry of Health.
2002.
14. Burt BA. Concept of risk in dental public health. Community Dent Oral Epidemiol. 2005;33: 240-7.
15. Mattila ML, Rautava P, Aromaa M Ojanlatva A, Paunio P, Hyssala L, Helenius H and Sillanpaa M.
Behavioural and demographic factors during early childhood and poor dental health at 10 years
of age. Caries Res. 2005;39: 85-91.
16. Ministry of Health New Zealand (www.newhealth.govt.nz/toolkits/oralhealth.htm). (Accessed
June 2005).
17. Ministry of Health New Zealand NZ Food NZ Children: Key results of the 2002 National Children's
Nutrition Survey. Wellington: Ministry of Health. 2003.
18. World health Organization. Ottawa Charter for Health Promotion. Ottawa: WHO and Canadian
Public Health Association. 1986.
19. Sheiham A and Watt RG. The Common Risk Factor Approach: a rational basis for promoting oral
health. Community Dent Oral Epidemiol. 2000;28: 399-406.
20. Ministry of Health New Zealand.
(www.leadingforoutcomes.org.nz/whats_new.whats_new.php (Accessed July, 2005).
21. Thorild I, Lindau B and Twetman S. Salivary mutans streptococci and dental caries in three-year-
old children after maternal exposure to chewing gums containing combinations of xylitol, sorbitol,
chlorhexidine and fluoride. Acta Odontol Scand. 2004;62: 245-250.
22. Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic
effects? Caries Res. 2004;38: 286-93.
23. Watt RG. Emerging theories into the social determinants of health: implications for oral health
promotion. Community Dent Oral Epidemiol. 2002;30: 241-7.
Carbohydrates in the Prevention and Treatment

of Diabetes
Alan Barclay
Diabetes Australia
Sydney
Australia
Introduction
For most people, carbohydrate-containing foods are the major source of kilojoules in their daily
diet. Evidence is growing that carbohydrate-containing foods are causally related to the development
of Type 2 diabetes via their effect on post-prandial glycemia. Also, the type and amount of
carbohydrate can been manipulated to achieve and maintain optimal glycemic control in people
with existing diabetes.
Definitions
In 1998, the World Health Organisation/Food and Agriculture Organisation (WHO/FAO) recommended
that the term "glycemic carbohydrate" be adopted to describe digestible carbohydrates, and that
they be defined as carbohydrate for metabolism1. Glycemic carbohydrate can be calculated by summing
the average quantity of total available sugars, starch, oligosaccharides, glycogen and maltodextrins2.
Non-glycemic carbohydrate, otherwise known as non-digestible carbohydrate or dietary fiber, was

originally described as: "...that portion of food which is derived from cellular walls of plants which is
digested very poorly by human beings".1 Despite several decades of research, there is currently no
single analytical method for the measurement of dietary fiber in foods.2
By definition, the glycemic index (GI) compares equal quantities of available carbohydrates in foods,
and provides a measure of carbohydrate quality. The glycemic load (GL), on the other hand, is a function
of a food's glycemic index and its total available carbohydrate content and defined by the equation:
Glycemic Load = Glycemic Index (%) x Carbohydrate (g)
The GL gives a more complete picture of the effect of a "typical" serve of carbohydrate-containing
food on blood glucose levels. Foods with a GL ≤ 10 have a low GL, and those with a GL ≥ 20 have
a high GL3. The higher the GL, the greater the expected elevation in blood glucose levels4.
It can be seen from the equation that either a low GI-high carbohydrate food or a high GI-low
carbohydrate food can have a low GL. However, while the effects on post-prandial glycemia may
be similar, there is evidence that the two approaches will have very different metabolic effects,
including differences in ß-cell function5, triglyceride concentrations6, free fatty acid levels6 as well
as effects on satiety7. Hence the distinction has important implications for the prevention and
management of diabetes and associated cardiovascular disease.
Carbohydrates in the Prevention of Diabetes

In the last decade, a significant number of studies have investigated the relationship between GI,
GL and dietary fiber, and the risk of developing Type 2 diabetes. The first was in 1997 by Salmeron
et al.,8 who studied prospectively a cohort of 65,173 American women, aged 40 to 65 years, using
a food frequency questionnaire (FFQ) to assess nutrient intake. The ability of the FFQ to accurately
assess the individual's carbohydrate intake was determined by comparison with weighed food
records and found to be relatively high (r=0.81). Overall, it was found that high GI diets increase
the risk of developing diabetes by 37%, compared to low GI diets. The average GI of those at least
risk was 44, total carbohydrate was moderate at 184g/day (41% of energy), GL was 81, total fiber
intake was 24g/day, and cereal fiber intake was 7.5g/day.
Later that year, Salmeron et al.9 published results of a methodologically similar study, this time
looking at 42,759 American men aged 40 to 75 years. This study also found that high GI diets
increase the risk of developing diabetes by 37%, compared to low GI diets. The average GI of those
at least risk was 46, total carbohydrate was higher at 222g/day (44% of energy), GL was 101, total
fiber intake was 29.7g/day, and cereal fiber intake was 10.2g/day.
In 2004, Schulze et al.10 published the results of their prospective study of a cohort of 91,249
American women, aged 24 to 44, using a similar FFQ to that in the Salmeron et al. studies. Correlation
of the FFQ with weighed food records was good at 0.64 for total carbohydrate. The study found
that the high GI diet increased the risk of developing Type 2 diabetes by 59%. The median GI of
those at least risk was 49, total carbohydrate was higher at 215g/day (47% energy), GL was 107,
total fiber intake was 23.1g/day, and cereal fiber intake was 9.9g/day.
Also published in 2004, Hodge et al.11 studied prospectively a cohort of 36,787 Australian men and
women, aged 40 to 69. Unfortunately, no objective measures of FFQ validity were reported. The
study found that the high GI diet increased the risk of developing Type 2 diabetes by 32%. The GI
of those at least risk was <46, total carbohydrate was moderate at 237g/day (41% energy), GL was
<109, total fiber intake was 31 g/day, and cereal fiber intake was 10.4g/day.
In 2000, Meyer et al.12 published the results of their prospective study of a cohort of 35,988 American
women, aged 24 to 44, using a FFQ that was stated as being similar to that in the Salmeron et al.
studies. Correlation of the FFQ with weighed food records was relatively low at 0.45 for total
carbohydrate. The study did not find that a high GI/GL diet increased the risk of developing Type
2 diabetes. Instead, the study found that a diet high in dietary fiber (>23.6g/day) decreased the
risk of Type 2 diabetes by 22%.
In 2002, Stevens et al.13 published the results of their prospective study of a cohort of 12,251 African-
American and American white men, aged 45 to 64, using a FFQ that was stated as being similar to
that in the Salmeron et al. studies. Unfortunately, no objective measures of FFQ validity were
reported. Again, this study did not find that a high GI/GL diet increased the risk of developing Type
2 diabetes. Instead, it found that a diet high in total dietary fiber (26.1g/day to 27.5g/day) and in
particular cereal fiber (4g/day to 5.1g/day) decreased the risk of Type 2 diabetes by 14% to 25%.
The total carbohydrate intake of the groups with the highest fiber intake was 226g/day to 231g/day
(50% to 51% of energy).
In summary, epidemiological evidence suggests that the consumption of moderate-high carbohydrate

(184g/day to 215g/day or 41% to 47% of energy in women; and 222g/day to 237g/day or 41% to
51% of energy in men), high total (>23g/day) and cereal fiber (>5g/day), low GI (44 to 49), low
GL (81 to 109) diets are effective in the prevention of Type 2 diabetes.8-13 Based on this evidence, it
is unlikely that a low carbohydrate, low fiber, high GI (and as a consequence) low GL diet will have
the same protective effect.
Carbohydrates in the Management of Diabetes

There have been two recent meta-analyses of the role of carbohydrates in the dietary management
of diabetes. In 2003, Brand-Miller et al.14 analysed evidence from 14 studies of either randomised crossover
or parallel experimental design and between 12 days' to 12 months' duration, with a total of 356 subjects.
Low-GI diets reduced HbA1c by 0.43% points over and above that produced by high-GI diets. Taking
both HbA1c and fructosamine data together and adjusting for baseline differences, glycated proteins
were reduced by 7.4% (8.8 to 6.0) more on the low-GI diet than on the high-GI diet.
In 2004, Anderson et al.15 analysed evidence from over 56 clinical trials conducted over the previous
25 years. Their analysis suggested that a higher carbohydrate (55% to 65% of energy), high fiber (25g/day
to 50g/day), lower GI diet facilitates optimal nutritional management of existing diabetes.11 Globally, most
Diabetes Associations are now recommending this approach for people with diabetes.15, 16
Hypothesised Mechanisms
Two major pathways have been proposed to explain the protective effect of low GI/GL diets.17 Firstly,
the same amount of carbohydrate from high GI foods produces higher blood glucose concentrations
and a greater insulin demand. The chronically increased insulin demand eventually results in pancreatic
exhaustion. Secondly, there is evidence that high GI diets may directly increase insulin resistance.
The protective effect of dietary fiber is thought to relate specifically to the cereal fractions. In their
recent review, Venn and Mann18 suggest that the improvement in glucose handling that is associated
with diets high in cereal fiber appears to be related to the presence of the intact structure of the
food. Food processing disrupts cell structures, rendering starches more available for digestion and
absorption. The net result will be a food with a higher GI.
Putting Recommendations into Practice

The simplest way to habitually consume a moderate-high carbohydrate, high fiber, low GI diet is
to follow official Dietary Guidelines, like those for Australians listed in Table 1,19 which are similar
to those released by government health authorities throughout most of the world, and to incorporate
into these, the recommendations of the WHO/FAO.1 The Dietary Guidelines promote a moderate-
high carbohydrate diet and the WHO/FAO recommends that GI be used to compare foods of similar
composition within food groups, and to choose the lower GI option. By choosing the lowest GI
food within a food group, an individual will most likely be choosing the food with the lowest GL,
because by definition, the macronutrient profile is essentially the same within a food group.
Table 1: The Dietary Guidelines for Australians19
Enjoy a wide variety of nutritious foods:

• Eat plenty of vegetables, legumes and fruit;
• Eat plenty of cereals (including breads, rice, pasta and noodles), preferably whole grain;
• Include lean meat, fish, poultry and/or alternatives;
• Include milks, yoghurts, cheeses and/or alternatives. Reduced-fat varieties should be
chosen, where possible; and
• Drink plenty of water.
Take care to:

• Limit saturated fat and moderate total fat intake;
• Choose foods low in salt;
• Limit your alcohol intake if you choose to drink; and
• Consume only moderate amounts of sugars and foods containing added sugars.
Prevent weight gain:

* Be physically active and eat according to your energy needs.
Consumer Understanding of Glycemic index

It has been suggested that the glycemic index is too complicated for the average consumer to
understand and use in food planning.20 The Glycemic Index Symbol Program (GISP) was launched
in Australia in July 2002 to help everyday consumers use the GI when shopping for food. The
program aims to identify foods that have had their GI tested at an accredited facility, contain at
least 10g of carbohydrate per serve, and meet strict nutritional criteria for kilojoules, total and
saturated fat, fiber and/or sodium, depending on their food group.
In January 2002, a representative random sample of approximately 500 adult grocery buyers was
surveyed in Australia, and follow up surveys have been conducted annually since. Before the launch
of the GISP, 28% of respondents had heard of the GI. By Jan 2005, 86% had heard of the GI, and
84% said it would be likely that they would use the GI when making food choices. In 2005, 77%
said that GI measures the rate at which food raises blood glucose levels and 59% correctly identified
low GI foods as being the most beneficial for general health.21 The results of the GISP research
suggest that consumers are able to understand and use the GI when shopping for food.
Conclusions
There is growing evidence that moderate to high carbohydrate, high fiber (particularly cereal fiber)
diets with a lower glycemic index, and as a consequence lower glycemic load, may prevent Type 2
diabetes. Similarly, clinical trials suggest that this pattern of eating facilitates optimal management
of people with existing Type 2 diabetes, and as a consequence is recommended by most Diabetes
Associations, globally. The simplest way for people with diabetes, and those trying to prevent it,
to achieve this dietary pattern, is to follow national dietary guidelines for healthy eating, and to
choose foods with lower GI's within each food group.
References
1. FAO/WHO. Carbohydrates in human nutrition. 1998. Report of a Joint FAO/WHO Expert
Consultation. FAO Food and Nutrition Paper - 66.
2. Food Standards Australia New Zealand. Australia New Zealand Food Standards Code. Commonwealth
of Australia 2004. http://www.foodstandards.gov.au/foodstandardscode/
3. Brand-Miller JC, Holt SHA and Petocz P. Reply to R Mendosa. Am J Clin Nutr. 2003; 77 (4): 994-5.
4. Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic
load values:2002. Am J Clin Nutr. 2002;76 (1): 5-56.
5. Wolever TMS, Mehling C. High-carbohydrate/low-glycaemic index dietary advice improves glucose
disposition index in subjects with impaired glucose tolerance. Brit J Nutr 2002;87:477-87.
6. Wolever TMS and Mehling C. Long-term effect of varying the source or amount of dietary
carbohydrate on postprandial plasma glucose, insulin, triacylglycerol, and free fatty acid concentrations
in subjects with impaired glucose tolerance. Am J Clin Nutr. 2002;76 (1): 5-56
7. Ball SD, Keller KR, Moyer-Mileur LJ, Ding YW, Donaldson D, Jackson WD. Prolongation of satiety
after low versus moderately high glycemic index meals in obese adolescents. Pediatrics. 2003
Mar;111(3):488-94.
8. Salmeron J, Manson JAE, Stampfer MJ, Colditz GA, Wing AL, Jenkins DJ, Wing AL, Willett WC.
Dietary Fiber, Glycemic Load, and Risk of Non-insulin-dependent Diabetes Mellitus in Women. JAMA.
1997;277(6): 472-477.
9. Salmeron J, Ascherio A, Rimm EB Colditz GA, Spiegelman D, Jenkins DJ, Stampfer MJ, Wing AL, Willett
WC. Dietary fiber, glycemic load, and risk of NIDDM in men. Diabetes Care 1997;20:545-50.
10. Schulze MB, Liu S, Rimm EB, Manson JAE, Willett WC and Hu FB. Glycemic index, glycemic load,
and dietary fiber intake and incidence of type 2 diabetes in younger and middle-aged women. Am
J Clin Nutr. 2004;80 (2): 348-56.
11. Hodge AM, English DR, O'Dea K and Giles GG. Glycemic Index and Dietary Fiber and the Risk of
Type 2 Diabetes. Diabetes Care. 2004;27(11): 2701-2706.
12. Meyer KA, Kushi LH, Jacobs DR Jr, Slavin J, Sellers TA, Folsom AR. Carbohydrates, dietary fiber, and
incident Type 2 diabetes in older women. Am J Clin Nutr. 2000 Apr;71(4):921-30.
13. Stevens J, Ahn K, Juhaeri, Houston D, Steffan L, Couper D. Dietary fiber intake and glycemic index
and incidence of diabetes in African-American and white adults: the ARIC study. Diabetes Care.
2002 Oct;25(10):1715-21.
14. Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of
diabetes: a meta-analysis of randomized controlled trials. Diabetes Care. 2003 Aug;26(8):2261-7.
15. Anderson JW, Randles KM, Kendall CWC, Jenkins DJA. Carbohydrate and Fiber Recommendations
for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of the Evidence. Journal
of the American College of Nutrition. 2004; 23(1):5-17.
16. Sheard NF, Clark NG, Brand-Miller JC, Franz MJ, Pi-Sunyer FX, Mayer-Davis E, Kulkarni K and Geil
P. Dietary carbohydrate (Amount and Type) in the prevention and Management of Diabetes: A
statement by the American Diabetes Association. Diabetes Care, 2004; 27(9):2266-2271.
17. Willett W, Manson J, Liu S. Glycemic index, glycemic load, and risk of Type 2 diabetes. Am J Clin
Nutr. 2002;76:274S-280S.
18. Venn BJ, and Mann JI. Cereal grains, legumes and diabetes. Eur J Clin Nutr. 2004 Nov;58(11):1443-61.
19. National Health & Medical Research Council. Dietary Guidelines for Australian Adults. Commonwealth
of Australia, 2003.
20. Coulston AM, Reaven GM. Much ado about (almost) nothing. Diabetes Care 1997;20:241-3.
21. Glycemic Index Ltd. Glycemic Index Symbol Program Consumer Research. Australia, February 2005.
www.gisymbol.com. accessed 26/8/2005.
Non-Digestible Carbohydrates: Blood Pressure,

Cholesterol and Cardiovascular Health
Jonathan M. Hodgson
University of Western Australia School of Medicine and Pharmacology
Royal Perth Hospital Unit
Perth, Western Australia
Australia
Background
Diet and lifestyle factors are the major causes of cardiovascular disease. Changing diet and lifestyle
is also the most effective population-based approach for the prevention of cardiovascular disease.
A range of dietary factors, such as plant food intake, total, saturated and omega-3 fat intake,
sodium and potassium intake, alcohol intake, B-group vitamin intake, and intake of antioxidants
have been related to cardiovascular health. These dietary factors are believed to influence an array
of pathogenic processes such as inflammation and oxidative stress, impaired coagulation and
thrombosis, endothelial dysfunction and atherosclerosis. These processes result in features of the
metabolic syndrome, which include hypertension, hypercholesterolemia, insulin resistance and
diabetes, and obesity.
There has been considerable interest over the past 25 years in the role of carbohydrates in
cardiovascular health. Much of the research in this area has focused on the amount and type of
carbohydrate, as well as the composition of the carbohydrate ingested in relation to cardiovascular
disease and related endpoints. One of the major components thought to be protective are the
non-digestible carbohydrates, or dietary fiber.
Definitions
Dietary fiber consists of non-digestible carbohydrates that are naturally present in plant foods.
Non-digestible means that the carbohydrate is not digested in the small intestine. Isolated sources
of non-digestible carbohydrates can also be included in the diet as added fiber. These sources of
fiber have been particularly useful in addressing hypotheses relating to potential beneficial effects
of fiber in the diet using randomized controlled trials. An important difference between dietary fiber
and added fiber is that dietary fiber is present together with other macronutrients, micronutrients
and phytochemicals, which might also influence outcomes of interest.
Dietary Fiber and Cardiovascular Disease: Population Studies

Many cross-sectional and prospective epidemiological studies have examined the association between
dietary fiber intake and cardiovascular disease endpoints. The results of these studies are consistent
in pointing to an inverse association of fiber intake and foods rich in dietary fiber with risk of
cardiovascular disease.1 Higher fiber intake is also often inversely associated with risk factors for
cardiovascular disease, including body weight and abdominal fat distribution,2 blood glucose and
insulin and risk of diabetes,3 blood pressure,4 and cholesterol and triglyceride concentrations.5
The best available evidence for a link between dietary fiber and cardiovascular disease comes from
prospective cohort studies. Pereira and others6 performed a pooled analysis of 10 prospective cohort
studies that examined the relationship of dietary fiber with risk of heart disease. All these studies
were from US and European populations. Relationships with risk of coronary heart disease of total
dietary fiber, and cereal, fruit and vegetable fiber were assessed. A subset of the studies also included
data on soluble and insoluble fiber. Estimates of risk reduction were based on a 10g/day increment
in fiber intake. Total dietary fiber intake was associated with a 14% and 27% reduction in risk of a
coronary events and death, respectively. Both cereal and fruit fiber were associated with similar
(10% to 30%) and independent reductions in risk. Vegetable fiber was not associated with any
change in risk. In those studies that assessed soluble and insoluble fiber, the risk reduction appeared
to be greatest for soluble fiber. The overall risk reductions were similar in men and women.6
Legumes are not a major contributor to fiber intake in US and European populations. Therefore,
the relationship between legume fiber with cardiovascular disease risk within populations remains
uncertain. Furthermore, there are few population data linking intake of resistant starch with
cardiovascular disease. However, a protective effect of resistant starch as part of whole grain foods
remains plausible.7
A limitation of population studies is that it can be very difficult to dissociate responses to fiber
itself from consuming a diet rich in high-fiber foods. The relationships of fiber intake with
cardiovascular disease endpoints are usually independent of a range of other dietary, lifestyle and
socioeconomic factors that could confound the relationships. However, statistical techniques are
unlikely to fully account for all possible confounding factors. Therefore, randomized controlled trials
are needed to establish causality. To date, there are no randomized controlled trials with fiber for
primary or secondary prevention of cardiovascular disease. We must therefore rely on data on
effects of fiber on features of the metabolic syndrome. The focus of this review is on hypertension
and hypercholesterolemia.
Blood Pressure and Cholesterol: Importance for Cardiovascular

and Total Mortality
High blood pressure and cholesterol are major risk factors for cardiovascular disease. High blood
pressure is the most important risk factor and high blood cholesterol the third most important
risk factor (after tobacco) for total mortality worldwide.8 Both risk factors increase risk of mortality
primarily through increased risk of cardiovascular disease, which is now responsible for more than
30% of all deaths worldwide. In addition, significant health gains could be achieved by reducing the
prevalence of these risk factors.9
The prevalence of hypertension and hypercholesterolemia is projected to increase considerably in

the next 25 years, with much of the increase to occur in countries in the Asian region.10,11 Important
questions then are: "Can fiber intake play a role in reducing blood pressure and cholesterol
concentrations?"; and "Might an increase in fiber intake reduce the risk of cardiovascular disease
via effects on blood pressure and cholesterol?".
Fiber and Blood Pressure: Randomized Controlled Trials

Research into the potential blood pressure-lowering effect of dietary fiber began more than 25
years ago. Early studies identified populations with higher fiber intake and lower blood pressure,
such as vegetarians.12 Epidemiological studies have generally found an inverse association between
fiber intake and blood pressure.4
During the past 20 years, more than 20 randomized controlled trials have reported the effects of
dietary fiber on blood pressure. Two recent meta-analyses have assessed the effect of fiber on
blood pressure.13,14 Similar findings were reported from each of these analyses. The average increase
in fiber intake in all studies was about 11g/day. Overall, systolic blood pressure was reduced by
approximately 1.1mm Hg, which did not reach significance, and diastolic blood pressure fell by
approximately 1.5mm Hg, which was significant. Both analyses also went on to look at factors that
might predict a greater response to fiber. There was little or no change in blood pressure in
normotensive individuals. Amongst individuals with hypertension, the falls in systolic and diastolic
blood pressure were greater (approximately 6 mm Hg and 4 mm Hg, respectively). Other factors
that were associated with greater falls in blood pressure were older age and being overweight, both
of which may be related to hypertension, and longer-term interventions. The source of fiber was
not strongly related to the effects observed. These analyses indicate that an increase in fiber intake,
particularly in Western populations with low fiber intake, can lower blood pressure.
The effects on blood pressure of an increase in dietary fiber from whole foods have also been
investigated. For example, a higher fiber vegetarian diet12 and the DASH-type diet15 have been found
to reduce blood pressure. These higher fiber diets have been shown to reduce systolic and diastolic
blood pressures by between 3 and 5 mm Hg, and 2 and 3 mm Hg, respectively. However, other
components of the diet including fatty acids, antioxidants and phytochemicals are also likely to
have contributed to these effects.
Fiber and Cholesterol: Randomized Controlled Trials

The effects of fiber on blood cholesterol and triglyceride concentrations have been thoroughly investigated
using randomized controlled trials. There have been about 150 trials, with most of these focusing on
the effects of added soluble/viscous fiber. Meta-analyses and systematic reviews of these trials show
that 10g/day of added soluble fiber results in an 8% to 10% reduction in total and LDL cholesterol
concentrations.16,17 The major sources of fiber have included oat bran, psyllium, pectin and guar gum,
and the magnitude of the effect appears to be similar across sources. There is a dose-response
relationship up to about 10g/day. Although higher initial cholesterol concentrations are related to a
greater magnitude of cholesterol lowering, the difference in responsiveness is not large. The effects of
soluble fiber on HDL cholesterol and triglycerides are minimal. Insoluble fiber from cereals has little
impact on total and LDL cholesterol concentrations, but may lower triglyceride concentrations.
More consistent effects on the entire lipid profile are observed when food is used as the source
of dietary fiber. For example, controlled trials that have assessed the effects of legumes (not including
soybeans) generally find significant reductions in total and LDL cholesterol and triglycerides, and
suggest an increase in HDL cholesterol.18 However, other components of legumes, or fiber-rich,
wholegrain diets are likely to contribute to observed benefits.
Limitations of Randomized Controlled Trials

A major limitation of randomized controlled trials is that to specifically test a hypothesis, isolated
sources of fiber are used. Any conclusions then are limited to these added isolated fiber sources.
However, in the diet, fiber is not consumed in isolation. There is potential for interaction with other
components in the diet, and it is likely that dietary fiber will have a greater impact on blood pressure,
cholesterol and other cardiovascular risk factors when accompanied with a range of other nutrients
and phytochemicals. Trials that have used food sources of fiber would support this suggestion.
The limitation of this approach is that any conclusions are not limited to the fiber itself.
Effects of Fiber on Blood Pressure, Cholesterol and Cardiovascular

Health: Summary
The link between higher intake of fiber-rich foods, including wholegrain cereals, legumes, vegetables,
fruits and nuts, and lower risk of cardiovascular disease and better risk factor profile is now quite
strong. What continues to be less certain are the roles of fiber itself and other components of the
diet that go along with the intake of fiber-rich foods in influencing cardiovascular risk. Another major
difficulty is that dietary fiber includes many complex substances, each having unique physical properties.
Many randomized controlled trials have investigated the effect of fiber on two of the most important
risk factors for cardiovascular disease: blood pressure and cholesterol. Dietary fiber and added fiber
can reduce both blood pressure and cholesterol concentrations. The overall effect of fiber on both
blood pressure and cholesterol is small, but is likely to be important in reducing risk of cardiovascular
disease in populations. However, the effects of purified fibers on blood pressure and cholesterol
may or may not be similar to intact dietary fibers because of the presence of other factors and
the potential for interaction. This makes valid generalizations, based on results of randomized
controlled trials, about the effects of added fiber difficult.
Conclusions
Results of population studies and randomized controlled trials suggest that fiber-rich foods can
reduce blood pressure and cholesterol concentrations, and improve the risk of cardiovascular
disease. The sources of dietary fiber most strongly related to reduction in cardiovascular risk are
fruit and cereal fibers. There is good evidence for a causative link between fruit fiber and cardiovascular
disease risk. Evidence for a causative link between cereal fiber and cardiovascular disease is less
clear: there may be other attributes of fiber-rich cereals that reduce risk.
It is difficult to separate effects due to dietary fiber alone from those of other components of fiber-
rich foods. The dietary fiber itself is likely to benefit cardiovascular health. Added fiber can reduce
blood pressure and cholesterol concentrations, but the effects are modest. Added fiber may be
useful for treatment of hypertension and hypercholesterolemia. However, use of added fiber is not
the optimal approach to increasing fiber intake for cardiovascular risk reduction within populations.
From a public health perspective, advice to increase fiber intake from fiber-rich whole foods will
result in more pronounced benefits on blood pressure, cholesterol and cardiovascular disease risk.
References
1 Anderson JW, Hanna TJ. Impact of nondigestible carbohydrates on serum lipoproteins and risk for
cardiovascular disease. J Nutr 1999; 129:1457S-66S.
2 Pereira MA, Ludwig DS. Dietary fiber and body-weight regulation. Observations and mechanisms.
Pediat Clin North Am 2001; 48:969-80.
3 Jenkins DJ, Axelsen M, Kendall CW, Augustin LS, Vuksan V, Smith U. Dietary fiber, lente carbohydrates
and the insulin-resistant diseases. Br J Nutr 2000; 83:S157-63.
4 He J, Whelton PK. Effect of dietary fiber and protein intake on blood pressure: a review of epidemiologic
evidence. Clin Experim Hypertens 1999; 21:785-96.
5 Fernandez ML. Soluble fiber and nondigestible carbohydrate effects on plasma lipids and cardiovascular
risk. Curr Opin Lipidol 2001; 12:35-40.
6 Pereira MA, O'Reilly E, Augustsson K, Fraser GE, Goldbourt U, Heitmann BL, Hallmans G, Knekt P,
Liu S, Pietinen P, Spiegelman D, Stevens J, Virtamo J, Willett WC, Ascherio A. Dietary fiber and risk
of coronary heart disease: a pooled analysis of cohort studies. Arch Intern Med 2004; 164:370-6.
7 Slavin JL, Martini MC, Jacobs DR Jr, Marquart L. Plausible mechanisms for the protectiveness of
whole grains. Am J Clin Nutr 1999; 70:459S-63S.
8 Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Comparative Risk Assessment
Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet
2002; 360:1347-60.
9 Ezzati M, Hoorn SV, Rodgers A, Lopez AD, Mathers CD, Murray CJ. Comparative Risk Assessment
Collaborating Group. Estimates of global and regional potential health gains from reducing multiple
major risk factors. Lancet 2003;362:271-80.
10 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension:
analysis of worldwide data. Lancet 2005; 365:217-23.
11 Fuentes R, Uusitalo T, Puska P, Tuomilehto J, Nissinen A. Blood cholesterol level and prevalence
of hypercholesterolemia in developing countries: a review of population-based studies carried out
from 1979 to 2002. Eur J Cardiovasc Prev Rehab 2003; 10:411-9.
12 Beilin LJ, Burke V, Cox KL, Hodgson JM, Mori TA, Puddey IB. Non pharmacologic therapy and lifestyle
factors in hypertension. Blood Pressure 2001; 10:352-65.
13 Whelton SP, Hyre AD, Pedersen B, Yi Y, Whelton PK, He J. Effect of dietary fiber intake on blood
pressure: a meta-analysis of randomized, controlled clinical trials. J Hypertens 2005; 23:475-81.
14 Streppel MT, Arends LR, van 't Veer P, Grobbee DE, Geleijnse JM. Dietary fiber and blood pressure:
a meta-analysis of randomized placebo-controlled trials. Arch Intern Med 2005; 165:150-6.
15 Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler
JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the effects of dietary patterns on blood
pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-24.
16 Truswell AS. Dietary fiber and blood lipids. Curr Opin Lipidol 1995; 6:14-9.
17 Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-
analysis. Am J Clin Nutr 1999; 69:30-42.
18 Anderson JW, Major AW. Pulses and lipaemia, short- and long-term effect: potential in the prevention
of cardiovascular disease. Br J Nutrition 2002; 88:S263-71.
Carbohydrates and Gut Health: Probiotics and

Prebiotics
Lee Yuan Kun
Department of Microbiology, Faculty of Medicine
National University of Singapore
Singapore
Probiotics
The human intestine constitutes an ecologically complicated flora made up of more than 500
bacterial species, of which over 99% are anaerobic. They comprise an aggregate biomass of
approximately 1.5kg, amounting to a hundred trillion (approx 1012 micro-organisms/cm3 in the colon)
and they possess an enormous range of enzymatic and metabolic activities that have an important
impact on host nutrition and health.1,2 Habitual intestinal bacteria that are detrimental to the human
host possess different enzyme activities to beneficial bacteria.3 An increase in both Bacteriodes sp.
and Clostridium sp. which form part of the human intestinal gut commensal has been measured
in colorectal cancer patients,4 accompanied by a low percentage of Bifidobacteria. Intestinal bacteria
such as Bifidobacterium sp. and Lactobacilllus sp. act as probiotics. Probiotics are microbial supplements
in food that beneficially affect the host by improving the intestinal microbial balance,5,6 and have
been demonstrated to significantly prevent diseases7,8 and improve human health.9-11 Ingestion of
probiotics also helps to strengthen the gastrointestinal barrier to diseases.12 Specific strains of
clinically demonstrated probiotics are presented in Tables 1 and 2.
The population of probiotic bacteria in the gastrointestinal tract could be supplemented by foods
containing the desired strain of probiotics. In addition to host-bacteria and bacteria-bacteria
relationships, diet has a very strong influence on the extent to which different intestinal bacteria
colonize the intestine.1,13 Thus, an alternative approach in health promotion is to enrich the indigenous
beneficial bacterial population through the consumption of prebiotics.
Prebiotics
A prebiotic is a food ingredient that selectively stimulates the growth and/or activity of one or a
limited number of beneficial bacteria in the gastrointestinal tract, and thus improving host health.14
There are some advantages of using prebiotics to encourage the growth of indigenous beneficial
bacteria over that of dietary probiotic supplement. Prebiotics are nonviable dietary components
and therefore culture viability need not be maintained (as opposed to the case of probiotics). For
the same reason, a much wider range of food and beverage carriers can be used. Heat stability
(in the case of viable bacterial cells) and oxygen sensitivity (in the case of obligate anaerobic
probiotics) are non-issues. An added advantage is that there is no question of the ability of
colonization and persistence of exogenous probiotics in the gut. A bacterium needs to be able to
remain in the gastrointestinal tract for a sufficiently long period of time in order to exert its probiotic
effects. Exogenously administered probiotic bacteria have been found to persist in fecal samples
for more than a few weeks after their administration has been stopped.15-18
In order to promote the indigenous probiotics in the intestinal lumen, it is necessary that the
prebiotic supplement must not be hydrolyzed and absorbed in the stomach or intestine. Prebiotics
are therefore often in the form of: (1) resistant starch, (2) non-starch polysaccharides (pectin,
cellulose, hemicellulose, guar, xylan), (3) oligosaccharides, and (4) complex sugars (lactulose,
raffinose, stachose).19-22 Some of the common commercially available prebiotics are presented in
Table 1. Prebiotics could also be endogenous in their origin. These include mucin glycoproteins,
muco-polysaccharides (chondroitin sulfate, heparin), and pancreatic and bacterial secretions.23, 24
The advantage of prebiotics is their selectivity in promoting the growth and activities of beneficial
components of the indigenous gut flora, without promoting the growth of potential pathogens.
The specificity of prebiotics is determined by several factors,25
• Monosaccharide composition: Glucose, galactose, xylose, fructose and fucose each form polymers
of various length and complexities, and the breakdown products could be utilized by various
range of bacteria;
• Glycosidic linkage: It determines selectivity of fermentation (e.g., cell-associated ß-fructofuranosidase
of bifidobacteria could hydrolyze frutooligosscharides) and digestibility in intestine (e.g., a 1-6 glucosyl
linkages in isomaltooligosaccharides cannot be digested by human digestive enzymes); and
• Molecular weight: Long-chain inulin exerts effect in distal colonic regions than low molecular
weight fructooligosaccharide. Thus, a mixture containing the two prebiotics, such as Orafti
Synergie II may promote bifidobacteria along the whole stretch of the intestinal tract.
Table 1. Examples of commercially available prebiotics

Prebiotic Benefactors Sources Manufacturers
Oligosaccharides
Fructoologosaccharides Bifidobacteria Jerusalem artichoke tubers Meiji Seika Kaisha (Japan)
ß-fructofuranosidase Beghin-Meiji Ind. (France)
Conversion of sucrose/ Golden Tech. (USA)
inulin Cheil Foods & Chrm. (Korea)
Chemical synthesis ORAFTI (Belgium)
Cosucra (Belgium)
4' Galacto- Bifidobacteria Human/cow milk Yakult Honsha (Japan)
oligosaccharides Lactobacilli ß-D-galactosidase Nissin Sugar Man. (Japan)
conversion of lactose Snow Brand Milk Prod. (Japan)
Borculo Whey Prod. (Holland)
4' Galactosyl-lactose Bifidobacteria Human milk Mitsui Sugar (Japan)
Bifidobacteria Palatinose synthase
conversion of sucrose
Intermolecular
condensation of glucose
Soy oligosaccharides Bifidobacteria Soybean/whey Calpis Food Ind. (Japan)
Lactobacilli
Xylo-oligosaccharides Bifidobacteria Controlled endo 1.4-b- Suntory (Japan)
xylanase hydrolysis
Prebiotic Benefactors Sources Manufacturers

Disaccharide & polyol
Lactulose Bifidobacteria Catalytic hydrogenation Morinaga Milk Ind. Co.
Lactobacilli of lactose at high temp (Japan)
Solvay (Germany)
Milei GmbH (Germany)
Canlac Corp. (Canada)
Laevosun (Austria)
Inalco SPA (Italy)
Lactosucrose Bifidobacteria ß-fructofuranosidase Ensuiko Sugar Ref. (Japan)
Transfrutosylation of Hayashibara Shooji (Japan)
lactose/ sucrose
Scientific and Clinical Evidence for Prebiotoc Effects

Promote Growth of Lactic Acid Bacteria
Frutooligosaccharides (FOS) and inulin have been demonstrated to selectively stimulate bifidobacteria
in the human colon.14,26 In a study of Bouhnik et al.26 involving 20 volunteers, each received 12.5g/day
FOS or placebo (saccharose) in three oral doses over three consecutive 12-day periods, the fecal
bifidobacterial counts were observed to increase by 10-fold. Many lactic acid bacteria (strains of
lactobacilli and bifidobacteria) have demonstrated probiotic properties (Tables 2 and 3).
Table 2. Probiotic bifidobacteria and their reported effects (after Salminen et al., 2004)
Probiotic Beneficial Effect
B. Lactis Bb-12 Treatment of viral diarrhea
Balancing intestinal microbiota
Reduce risk of traveler's diarrhea
Treatment of food allergy in infants
B. Lactis HN019 Immune enhancement
Balancing intestinal microbiota
Table 3. Probiotic lactobacilli and their reported effects (after Salminen et al. 2004)
Beneficial Effect Probiotic
Reduce recurrence of superficial bladder cancer L. casei Shirota
Lower fecal enzyme activity L. acidophilus NCFB
L. acidophilus NFCM
L. casei Shirota
L. gasseri ADH
Decrease fecal mutagenicity L. acidophilus NCFB
Reduce Streptococcus mutants activity L. Rhamnosus GG
Prevent radiotherapy-related diarrhea L. acidophilus NCFB
Treatment of rotavirus diarrhea L. Rhamnosus GG, L. reuteri
Table 3. Probiotic lactobacilli and their reported effects (after Salminen et al. 2004) (continued)
Beneficial Effect Probiotic
Prevent antibiotic-associated diarrhea L. Rhamnosus GG
Prevent traveler's diarrhea L. acidophilus La-5
Treatment of relapsing C. difficile diarrhea L. Rhamnosus GG
Produce bacteriocins L. acidophilus NFCM
Balance intestinal microbiota L. johnsonii LA1
L. casei Shirota
L.acidophilus La-5
L. reuteri
L. rhamnosus DR10
Immune enhancement L. johnsonii LA1
L. acidophilus La-5
L. rhamnosus DR10
Adjuvant in H. pylori treatment L. johnsonii LA1
Alleviate atopic azema in infants L. Rhamnosus GG
Prevention of atopic disease L. Rhamnosus GG
Reduce cystic fibrosis symptoms L. Rhamnosus GG
Enhance Bifidobacteria L. Rhamnosus GG
Treatment of lactose intolerance L. acidophilus NFCM
Improve constipation L. acidophilus NCFB
Anti-Colon Cancer
Dietary oligofructose and inulin have been shown to suppress the formation of colonic preneoplastic
aberrant crypt foci formation in rat model.27 Studies26-30 suggested that the anti-cancer effects of
prebiotics could be the following:
• Production of butyrate (by clostridia, eubacteria), which is known to stimulate apoptosis in

colonic cell lines;31,32
• Diversion of colonic metabolism from proteolysis (formation of carcinogens) to saccharolysis
amongst clostridia & bacteroides; and
• Encourage growth of probiotics, thus leading to the suppression of carcinogenic enzyme
producing bacteria (clostridia, Esccherichia coli).
Protect Against Pathogens

Probiotics have been widely shown to protect the host from intestinal pathogens (Tables 1 & 2).
A study in mice showed that dietary oligofructose and inulin protect the host from enteric and
systemic pathogens and tumor inducers, which include the verocytotoxin producing Escherichia
coli O157:H7 and campylobacters33.
Enhance Mineral Absorption

In a study feeding 15g of FOS per day to 12 adolescent boys (14-16 years) for 9 days in placebo-
controlled trial against sucrose, the outcome showed a 10.8% increase in calcium balance with no
significant effect on urinary excretion. The following mechanisms have been suggested to enhance
calcium absorption:
• Fermentation lead to production of short chain fatty acid (SCFA) and luminal pH reduction,
which increases calcium solubility;
• Calcium exchange with proton (from SCFA) liberated into lumen; and
• Metabolize insoluble phytate from vegetative dietary components to release calcium.
Effect on Blood Lipid & Sugar

In an animal model using rat,34 dietary supplement of 10g/100g body weight of FOS was observed
to decrease serum triacylglycerol as a consequence of a reduction of de novo liver fatty acid synthesis.
The depression in the activity of all lipogenic enzymes and fatty acid synthase mRNA suggests that
FOS modifies the gene expression of lipogenic enzymes. FOS also significantly decreases serum
insulin and glucose, which are both known to participate in the regulation of lipid synthesis.
Food Application of Prebiotics

A daily dosage of at least 4g to 8g of FOS has been cited as necessary to significantly elevate
bifidobacteria in an adult human gut.25 Most of the prebiotics used in food application are targeted
at bifidobacteria and lactobacilli. In Yakult 80 Ace (containing 3x109 L. casei Shirota), 2.5g oligosaccharides
are added into the 80 mL cultured milk to promote the growth of the probiotic lactobacilli in the
intestinal tract. In this case, the inclusion of prebiotic synergistically aids the defined probiotic
lactobacilli in its establishment in the intestinal tract, and the mixture is termed synbiotics. The
formula could be beneficial to the elderly, when fecal bifidobacterial counts markedly decrease.
In an infant milk formula (Nestle Lactogen 2 Prebio), FOS and inulin are included to promote
bifidobacteria, as in breast-fed infant.
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York, pp. 407-418; 2004.
26. Bouhnik, Y., Flourie, B., Riottot, M., Bisetti, N., Gailing, M.F., Guibert, A. Effect of fructooligosaccharides
ingestion on faecal bifidobacteria and selected metabolic indexes of colon carcinogenesis in healthy
humans. Nutrition and Cancer. 1996; 26: 21-29.
27. Reddy, B.S., Hamid, R., Rao, C.V. Effect of dietary oligofructose and inulin on colonic preneoplastic
aberrant crypt foci inhibition. Carcinogenesis. 1997; 18: 1371-1374.
28. Buddington, R.K., Williams, C.H., Chen, S.C., Witherly, S.A. Dietary supplementation of neosugar
alters the fecal flora and decreases activities of some reductive enzymes in human subjects. American
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starch on the colon in healthy volunteers: possible implications for cancer prevention. American
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in rats associated with a human faecal microflora, Joural of Applied Bacteriology. 1993; 74: 667-674.
31. Kim, Y.S., Tsao, D., Morita, A., Bella, A. Effect of sodium hutyrate and three human colorectal
adenocarcinoma cell lines in culture. Falk Symposium. 1982; 31: 317-323.
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A., Malagelada, J.R. Dietary inulin improves distal colitis induced by dextran sodium sulfate in the
rat. American Journal of Gastroenterology. 2001; 96: 1468-1493.
33. Buddington, K.K., Donahoo, J.B., Buddington, R.K. Dietary oligofructose and inulin protect mice from
enteric and systemic pathogens and tumor inducers. Journal of Nutrition. 2002; 132: 472-477.
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Grains in the Diet: A Historical Perspective

of Grain Nutrition
Rodolfo F. Florentino
Chairman-President
Nutrition Foundation of the Philippines
Quezon City
The Philippines
Introduction
Grains coming from cereals constitute the major part of the diet in most of the world, especially
in developing countries. The most widely cultivated grains are wheat, rice, maize, barley, oats, and
rye. Other grains include sorghum, millet and triticale, and sometimes, a number of non-grass
plants are called grains as well, such as buckwheat, flax and soybean, which in fact is a legume.
Cereals have all been cultivated since ancient times. Rice, for example, is a native of Asia, originating
perhaps in India or Southeast Asia, and has been cultivated for more than 7,000 years. Evidence
of cultivation has been found in eastern China dating from before 5,000 BC, and in a cave in
northern Thailand from about 6,000 BC.
Grains appear in the diet in many forms, and Asia is particularly noted for the numerous varieties
in which they are prepared. As a staple in most populations of Asia, milled rice is simply boiled,
although some practice parboiling. Some cultures boil rice wrapped in banana leaves or coconut
leaves and it is eaten as a staple, sometimes filled with fish or meat, or sweetened and mixed with
coconut milk to make a wide assortment of delicious and attractive desserts. Ground rice, especially
glutinous rice, may find itself made into tasty rice cakes of varied textures and colors.
Wheat has been cultivated as a food source for more than 9,000 years by the peoples of the
temperate zone, probably originating in the Tigris and Euphrates river valley. The main use of wheat
is in the manufacture of flour for making bread, cakes, and other bakery products, noodles and a
variety of pastas, and the now popular breakfast cereals and extruded snack products. It is said
that more foods are made with wheat than any other cereal grain.
Maize ranks with wheat and rice as one of the world's chief grain crop, grown mainly for food and
animal feed. Maize is a native of the Americas, originating perhaps in southwestern North America
and Mexico. It has been used as a staple in that region for many centuries before the arrival of the
Europeans. In Asia, corn is mainly used as animal feed, but white corn is actually mixed with rice as
a staple in some parts of the Philippines. It has also found its way into extruded snack products.
Production, Supply and Consumption of Rice in Southeast Asia

In Asia, rice is the major staple; thus it is not surprising that more than 90% of the world's rice is
produced and consumed in Asia. The biggest rice producers are China and India, followed by
Indonesia, Bangladesh, Vietnam and Thailand (Table 1).1 In fact, rice production in Asia has been
increasing more rapidly than the increase in population. Production of wheat is comparatively low;
production in Asia was highest in China, India and Pakistan in 2004. Again, China was the highest
producer of maize among the Asian countries in the same year, followed by India, Indonesia and
the Philippines, although maize production was only about 26% of total cereal production in the
case of the Philippines, and 17% in the case of Indonesia, in 2004.
Cereals Supply
More or less the same pattern was shown in the case of the supply of cereals as a whole. Among
ASEAN countries, Indonesia had the highest supply in 2002, followed by Vietnam, Myanmar and the
Philippines,1 corresponding with their population size. In terms of per capita supply, however,
Myanmar topped the list, followed by Indonesia, Laos and Vietnam (Table 2). Cereals were the
biggest supplier of dietary energy, supplying 1,180 to 2,066 Kcal/cap/day in ASEAN countries in
2002, with the highest in Myanmar, followed by Indonesia, Vietnam and Laos.1
For the last two decades, rice supply has been contributing more than 70% of the total calorie
supply in Cambodia, Laos, Myanmar and Vietnam, while it was much lower in Malaysia (Table 3).2
However, for most of the countries of ASEAN, supply of rice as food has been decreasing on a per
capita basis.
Looking at the Food Balance Sheet of developing countries in Asia, the total domestic supply of
cereals in 2002 amounted to 830 million MT, 71.7% (595 million MT) of which was used for food.
Of the total domestic supply of wheat amounting to 255 million MT, 87.1% was used for food; while
of the total domestic supply of rice amounting to 347 million MT, as much as 90.2% was used for
food. Of the total domestic supply of corn amounting to 176 million MT, only 22% was used for
food. Thus, cereals supplied 1,502 Kcal in the developing countries in Asia, of which 32% was supplied
by wheat, 58% by rice and 9% by corn.
Table 1. Cereals production in selected Asian countries, Yr 1985 - 2004 in MT(000)1

Rice Wheat Maize
1985 1990 1995 2000 2004 1985 1990 1995 2000 2004 1985 1990 1995 2000 2004
Bangladesh 22,556 26,778 26,399 37,628 37.910 1,463 890 1,245 1,840 1,253 3.3 3.4 2.0 10 10
Brunei 1.1 0.9 0.5 0.3 0.6
Cambodia 1,812 2,500 3,448 4,026 4,170 42 88 55 157 256
China 171,319 191,695 187,298 189,814 177,134 85,807 98,232 102,211 102,211 91,330 64,102 97,213 112,362 106,178 132,162
India 98,818 111,517 115,440 127,400 129,000 44,069 49,850 49,850 76,369 72,060 6,644 8,962 9,534 12,043 14,000
Indonesia 39,033 45,179 49,744 51,898 54,061 4,330 6,734 8,246 9,677 11,355
Korea (ROK) 7,855 7,722 2,016 7,197 6,800 11 0.9 10 2.3 12 131 120 74 64 70
Laos 1,396 1,508 6,387 2,202 2,529 33 82 48 117 204
Malaysia 1,745 1,885 1,418 2,141 2,183 25 35 43 65 75
Myanmar 14,317 13,972 17,957 21,324 22,000 206 124 89 94 130 299 187 275 363 600
Nepal 2,804 3,502 3,579 4,216 4,300 534 855 914 1,184 1,387 874 1,231 1,302 1,415 1,590
Pakistan 4,378 4,891 5,950 7,204 7,487 41,703 14,316 17,002 21,079 19,767 1,009 1,185 1,504 1,643 2,775
Philippines 8,806 9,885 10,541 12,389 14,497 3,922 4,854 4,161 4,511 5,413
Sri Lanka 2,661 2,538 2,810 2,860 2,510 30 33 35 31 26
Thailand 20,264 17,193 22,016 25,844 26,948 0 0.5 0.6 0.8 0.8 4,934 3,722 4,155 4,462 4,064
Vietnam 15,875 19,225 24,964 32530 36,118 587 671 1,177 2,006 3,454
Table 2. Cereals and rice supply in ASEAN countries (excluding Singapore), 1998 - 20021
Cereals Supply in MT (000) Rice Supply in Kg/Cap/Yr Rice Supply in Cal./Cap/day
1998 1999 2000 2001 2002 1998 1999 2000 2001 2002 1998 1999 2000 2001 2002
Brunei 45 56 54 55 52 140.8 171.0 162.6 161.4 147.2 1298 1492 1548 1470 1386
Cambodia 1,991 2,082 2,324 2,208 2,238 159.5 162.5 176.8 163.8 162.1 1469 1496 1625 1550 1535
Indonesia 41,946 41,617 42,918 43,301 44,100 203.7 199.4 202.9 202.0 203.1 1859 1827 1844 1834 1844
Laos 959 989 995 1,026 1,055 190.5 161.9 188.4 189.8 190.8 1684 1697 1667 1679 1688
Malaysia 3,174 3,393 3,496 3,546 3,747 144.5 150.9 152.0 151.0 156.4 1247 1257 1291 1288 1296
Myanmar 10,255 10,260 10,273 10,349 10,441 222.0 218.9 216.1 214.7 213.7 2150 2114 2088 2074 2066
Philippines 10,329 9,948 10,247 10,784 10,593 141.9 134.0 135.3 139.8 134.8 1270 1218 1234 1270 1245
Thailand 7,326 7,435 7,534 7,524 7,607 122.7 123.3 123.7 122.2 122.3 1191 1194 1200 1181 1180
Vietnam 13,970 14,274 14,515 14,774 14,985 183.6 185.1 185.8 186.5 186.7 1781 1795 1798 1801 1804
Table 3. Rice calorie supply as percentage of total calories, 1985 - 20002

1981 1985 1990 1995 2000
Cambodia 76 80 79 78 75
Indonesia 54 56 55 46 50
Laos 74 77 70 73 66
Malaysia 39 31 30 30 30
Myanmar 76 71 78 76 71
Philippines 42 44 41 40 42
Thailand 61 57 50 45 44
Vietnam 65 71 71 68 66
Cereals and Carbohydrate Intake in Some Southeast Asian Countries

While production and supply of rice has been increasing in recent years in an attempt to keep pace
with population growth, rice consumption per capita has in fact been decreasing in many of the
ASEAN countries, perhaps in consonance with the socio-economic transition now prevailing in the
region. Rice is increasingly being replaced by wheat products as well as other foods including animal
foods. For example, in Vietnam, there was a remarkable change in dietary intake from 1990 to 2000
as shown in their national nutrition surveys (Table 4).3 While rice intake was not much different
between 1985 and 1990, there was a significant decrease from 1990 to 2000, accompanied by an
increase in intake of other cereals, as well as in meats, eggs, fish, and oil/fat.
Thus, the carbohydrate intake per capita diminished from 1985 to 2000, as did the proportion of
carbohydrates to total caloric intake. The 2000 survey also showed a large difference in rice intake
between urban and rural areas: 337g/cap/day in the urban areas, while only 416.4g/cap/day in the
rural areas, taking up 69.8% of total calories in the urban areas and 76.4% in the rural areas.
Table 4. Average daily per capita food intake and percent energy from macronutrients,
Vietnam, 1985, 1990 and 2000 (Partial list)3
Food intake, g/cap/day
Food Group 1985 1990 2000
(n=733 HH) (n=12,641 HH) (n=7,658 HH)
Rice 457 451.6 397.3
Other cereals 3.6 6.2 16.0
Tubers 68.2 37.8 8.9
Meats 113.6 24.4 51.0
Eggs/milk 1.7 2.9 10.3
Fish 40.1 50.0 52.6
Oil.fat 1.7 3.0 6.8
% Energy from
Protein 11.2 12.3 13.2
Lipid 6.2 8.4 12.0
Carbohydrate 82.6 79.3 74.8
In Thailand, the average per capita intake of cereals decreased from the years 1986 to 1995, while the
intake of fish and fish products increased (Table 5).4 Thus, the contribution of carbohydrates to total
caloric intake decreased from 66% to 63.3%, while the contribution of protein and fat increased.
In the latest national nutrition survey conducted in the Philippines in 2003, rice occupied 34.2%
to total food intake (equivalent to 303g/cap/day), a slight reduction from 35% in the 1987 and 1993
surveys (Table 6).5 However, the proportion of wheat and wheat products increased dramatically
from 1987 to 2003. So did the intake of meat and poultry. Thus, the contribution of carbohydrate
to total caloric intake diminished from 74% in 1987 to 69.9% in 2003, while that of fat increased
from 14.9% to 18.3%.
Thailand, 1986 and 1995 (Partial list)4
Food Group 1986 1995
Cereals 350.9 305.7
Fats and oil 45.6 14.0
Fish and products 36.9 46.1
Meat, poultry 80.0 71.4
Eggs 23.9 21.4
Milk and procucts 80.9 29.3
Vegetables 115.9 113.4
Fruits 99.2 73.6
% Energy from:
Protein 11.4 13.3
Fat 21.6 23.4
Carbohydrate 66.0 63.3
Philippines, 1987, 1993 and 2003 (Partial list)5
Food Group 1987 1993 2003
Rice and products 303 282 303
Wheat and products 18 22 30
Tubers 22 17 19
Fish 111 99 104
Meat 37 34 61
Poultry 9 14 20
Fats and oils 14 12 18
% Energy from:
Protein 11.2 11.5 11.8
Fat 14.8 14.9 18.3
Carbohydrate 74.0 73.6 69.9
In contrast to the dietary pattern in Vietnam, Thailand and the Philippines, the pattern of dietary
intake in Singapore tends towards Western diets.
In the 1998 Singapore National Nutrition Survey, plain rice/porridge and dishes contributed only
29.4% of total food intake of adult males (equivalent to 549.2g/cap/day, average of the three ethnic
groups) and 26.3% of total food intake of adult females (407.8g/cap/day) (Table 7).6 On the other
hand, bread and breakfast cereals together with noodles and dishes mostly made from wheat flour
contributed as much as 18% of total food intake of adult males (335.9g/cap/day, average of the
three ethnic groups) and 18.8% of total food intake of adult females (291.8g/cap/day). The Chinese
population of Singapore had the highest intake of rice and porridge as well as noodles among the
other ethnic groups, namely the Malays and Indians, while they had the lowest intake of bread and
breakfast cereals. Compared to the developing countries in Southeast Asia, Singapore has a low
proportion of carbohydrate intake to total caloric intake (55.1%, average of both sexes in 1998),
and a correspondingly high proportion of fat intake (30.1%).
Singapore, 19986
Food Group Male Female
Chinese Malay Indian Chinese Malay Indian
Breads & breakfast cereals 53.3 70.1 81.5 44.1 60.3 71.8
Rice/porridge & dishes 561.0 513.8 485.7 414.1 377.4 391.4
Noodles dishes 309.1 161.3 168.9 268.9 145.2 135.4
Vegetables & beans 177.5 163.7 209.6 172.7 216.5 176.6
Fruits 271.7 231.5 293.5 265.0 262.4 271.1
Poultry & dishes 29.6 24.8 26.8 22.6 17.6 21.2
Meat & dishes 43.3 22.1 23.7 30.5 15.3 11.9
Fish/seafood & dishes 48.2 64.9 42.8 44.1 62.8 40.9
Eggs 21.0 26.1 19.7 14.3 15.7 12.1
Milk & dairy products 103.1 152.9 192.5 96.7 152.2 200.2
Miscellaneous 277.0 324.5 271.0 181.9 214.0 224.2
% Energy from: Male Female
Protein 14.8 14.9
Fat 29.8 30.3
Carbohydrate 55.4 54.6
Nutritional Value of Grains

Grains are a low-cost source of food supplying significant amount of nutrients in the diet because
of the large amount consumed. As discussed above, grains are the major supplier of dietary energy
in the Asian diet, arising from their high starch content.
Apart from starch, grains also contain proteins, some fat, and a long list of vitamins and minerals,
together with other phytochemicals that are starting to be recognized as beneficial to health.
About 80% of the grain is the endosperm, 80% of which is starch and 10%, protein, together with
fat, and soluble fiber. The bran (14% to 16% of wheat) is rich in dietary fiber, vitamins and minerals,
and antioxidants, together with some protein and fat, except that it is partially or wholly removed
by milling. The germ or embryo which is about 5% of the grain contains fat and anti-oxidants, and
is also removed by milling.7
Rice contains more carbohydrates (almost 80%), than wheat and corn (75%), but less protein, about
7%, compared to wheat which contains about 11% to 12% protein,8 although the protein quality in
rice is better than that of wheat. Owing to a better amino acid composition, the protein quality
of rice (79.3% casein) is better than wheat (38.7% casein), and better again than maize (32.1%
casein). Grains contain some amino acids that are relatively low compared to requirements, so-
called limiting amino acids, principally lysine, and to some extent S-amino acids and tryptophan,
thus reducing their protein quality. Nevertheless, consuming cereals with even small amounts of
animal foods, beans or legumes which supply the limiting amino acids, greatly improves the protein
quality of the diet.
Due to the macro- and micronutrients in grains, they constitute the major source of nutrients
in poorer countries. Rice, for example, apart from contributing 53% of energy and 37% of protein
in the Filipino diet as shown in the 2003 National Nutrition Survey, supplied 17.5% of calcium, 28.8%
of iron, 32.5% of thiamin, 34.8% of riboflavin, and 43.3% of niacin in the Filipino diet.5 In countries
where micronutrient deficiencies are prevalent, grains like rice and wheat serve as excellent vehicles
for food fortification.
Fortification of wheat flour with iron, zinc, and B vitamins is now practiced in Indonesia, and iron
fortification of wheat flour is now going on in the Philippines.
The efficacy of iron fortification of rice using extruded premix technology has recently been
completed (Agdeppa, et al., unpublished), and hopefully will soon be used for the iron fortification
of rice in the Philippines as mandated by law. Biofortification through both traditional plant breeding
and genetic modification of rice and wheat holds promise in supplying deficient micronutrients such
as iron, zinc and beta-carotene to micronutrient-deficient populations.
Apart from the traditional macro- and micronutrients, grains, particularly whole grains are rich in
dietary fiber. The 1998 Singapore National Nutrition Survey showed an average dietary fiber intake
of 15.7g/cap/per/day, higher in males than females, and highest among the Indians.6 This represented
a slight improvement from 12.9g in 1993.
Dietary fiber comprises the edible parts of plant foods that cannot be digested or absorbed in the
small intestine and passes into the large intestine largely intact. There, it either passes out into
the feces, carrying with it substances such as unabsorbed bile supposedly resulting in reducing
blood cholesterol, or is fermented by colonic bacteria, giving rise to short-chain fatty acids (SCFA)
and other by-products which supposedly contribute to the beneficial effects of dietary fiber.9
The main physiologic effects attributed to dietary fiber includes improved bowel function by increasing
stool weight and slowing gut transit time, therefore helping to relieve constipation.9,10 SCFAs (especially
butyrate and propionate) are important substrates for energy metabolism in colonocytes and might
inhibit the growth and proliferation of gut tumor cells. However these same benefits have been
attributed to resistant starch, the form of starch found in pulses and lentils, partially milled grains,
and some breakfast cereals, that is not digested in the small intestine similar to dietary fiber.11
Another purported beneficial effect of dietary fiber is in lowering the risk of cardiovascular disease
by reducing the blood level of both total cholesterol and LDL-cholesterol,10 helping in weight
management because of its high satiety value,10 and probably helping to lower mild to moderate
hypertension.12 Another purported beneficial effect of dietary fiber is in improving glycemic control
and lowering Glycemic Index, thus helping in the management of diabetes.9,13 Its beneficial effect
in the prevention of cancer, particularly colon cancer, however, remains controversial9. Nonethless,
the majority of epidemiologic studies and meta-analysis have suggested that fiber-rich diets are
protective of colorectal cancer. An odds ratio of 0.57 was computed when the prevalence of colorectal
caner got the the highest fiber group was compared with that of the lowest group.14
Beneficial Effects of Whole Grains

Current research around the world is discovering the many and varied health benefits of whole
grains, particularly in reducing the risk of chronic degenerative diseases such as coronary heart
disease, diabetes, hypertension and even, some forms of cancer.
In the 1970’s, fiber was recognized as the food component that could prevent constipation and
cancer.15 More recently, it has been demonstrated that whole grain intake is positively associated
with enhancing insulin sensitivity, better weight control management, and prevention of heart
disease.16 The Iowa Women's Health Study has shown that fiber from whole grains, but not refined
cereals, is inversely associated with all-cause mortality in older women.17
It is now clear that the beneficial effect of whole grains does not reside in the dietary fiber alone,
but in in host of phytochemicals and phytoestrogens that occur in conjunction with vitamins and
minerals in whole grains. Whole grains are also a good source of antioxidants including vitamin E
and selenium, as well as phytochemicals including phytoestrogens like lignans, phytic acid, phenolic
compounds, flavonoids, phytosterols, tocotrienols, and many others.18,19 The US Food and Drug
Administration now allows food manufacturers to make a health claim on whole grain food products,
as long as the product contains 51% or more wholegrain ingredients by weight per reference amount,
with dietary fiber of 2.3g per 50g or 1.7g per 35g, together with a low fat diet.
Summary and Conclusion

Grains, particularly rice, constitute the major part of the diet of Asia, consumed as the staple and
in a wide variety of forms. While production and supply has kept pace with rise in population, rice
consumption per capita has in fact been decreasing, rice being replaced by wheat products and
other foods. Nevertheless, rice is the major contributor to dietary energy, and is a significant source
of protein, carbohydrate and micronutrients in the diet of the region besides being an excellent
vehicle for micronutrient fortification.
Apart from the traditional nutrients, more and more functional components such as dietary fiber
and resistant starch, phytochemicals and phytoestrogens, are starting to be recognized as promotive
to health or even preventive of chronic diseases. Thus grains, with emphasis on whole grains, should
form the base of a well balanced and nutritious diet.
References
1. Food and Agriculture Organization of the United Nations. http://faostat.fao.org/faostat. Last
update, 14 July 2005. Accessed, August 11, 2005.
2. International Rice Research Institute, http://www.irri.org/science/ricestat/index.asp. Accessed,
August 11, 2005.
3. National Institute of Nutrition, Ministry of Health, Vietnam. 2000 General Nutrition Survey.
Medical Publishing House, Hanoi. 2003
4. Nutrition Division, Department of Health, MOPH. The fourth national nutrition survey of Thailand,
1995. Department of Health, Thailand, 1995
5. Food and Nutrition Research Institute, DOST. 6th National Nutrition Survey, 2003. Food and
Nutrition Research Institute, Manila, 2005.
6. Department of Nutrition, Ministry of Health. Singapore, National Nutrition Survey, 1998. Health
Promotion Board, http://hpb.gov.sg/hpb Accessed August 11, 2005.
7. Slavin J, Whole grains and human health. Nutr Res Rev 2004;17:99-110.
8. US Department of Agriculture. USDA. Nutrient database for standard reference, Release 17. Nutrient
Data Laboratory Home Page, http://www.nzl.usda.gov/fnic/foodcomp. Accessed August 11, 2005.
9. Gallaher DD and Schneeman, BO. Dietary Fiber. In: Present Knowledge in Nutrition, 8th Ed,
Chapter 8.Bowman BA and Russell RM, eds. ILSI press, Washington DC, 2001; 83-91.
10. Anderson JW, Smith BM, and Gustafson NJ. Health benefits and practical aspects of high-fiber
diets. Am J Clin Nutr 1994;59(Suppl):1242S-7S.
11. Jenkins DJA, Vuksan V, Kendall CWC, Würsch P, Jeffcoat R, Waring S, Mehling CC, Vidgen E, Agustin
LSA, and Wong E. Physiological effects of resistant starches on fecal bulk, short chain fatty acids,
blood lipids and glycemic index. J Am Coll Nutr 1998;17:609-616.
12. Streiffer Hj, Muntner P, Kousel-Wood MA, and Whelton PK. Effect of dietary fiber intake on blood
pressure: a randomized double-blind, placebo-controlled trial. J Hypertens. 2004;22:73-80.
13. Anderson, JW and Akanji AO. Dietary fiber - An overview. Diabetes Care. 1991;14:1126-31.
14. Trock B, Lanza E, Greenwald P. Dietary fiber, vegetables and colon cancer: critical review and meta-
analysis of epidemiological evidence. J Natl Cancer Inst 1990;82:650-61.
15. Burkitt, DP. Epidemiology of cancer of the colon and rectum. Cancer 1971;28: 3-13.
16. Marquart L, Jacobs DR, Slavin JL. Whole grains and health: an overview. J Amer Coll Nutr
2000;19:289S-290S.
17. Jacobs DR, Pereira MA, Meyer KA, Kushi LH. Fiber from whole grains, but not refined grains, is
inversely associated with all-cause mortality in older women: The Iowa women's health study. J
Amer Coll Nutr 2000;19:326S-330S.
18. Slavin JL. Mechanisms for the impact of whole grain foods on cancer risk. J Amer Coll Nutr
2000;19:300S-307S.
19. Truswell AS. Cereal grains and coronary heart disease. Eur J Clin Nutr 2002;56:1-14.
Sweeteners in Life and Health

Frances H. Seligson
Nutrition Consultant
ILSI North America
USA
Introduction
The rising prevalence of overweight and obesity - and associated co-morbidities, especially metabolic
syndrome and Type 2 diabetes mellitus - in both children and adults around the world, has led to
much research and discussion on its principle causes. Some hypothesize that an increase in sugars
intake is a major contributing factor. Key issues related to assessing sugars intake and its impact
on nutrition and health are reviewed in this paper.
Definitions of Sugars
One area of confusion encountered when trying to assess the impact of sugars intake on nutrition
and health is the use and meaning of terms used to describe sugars.1 Different terms mean different
things to consumers, the media, researchers, and regulatory agencies. Chemically, sugar refers to
any mono-or disaccharide, such as glucose, fructose, galactose, sucrose, lactose, and maltose.
These mono- and disaccharides sometimes are referred to as simple sugars or simple carbohydrates.
To most consumers, however, sugar simply means table sugar or sucrose.
In the US, the terms sugar, sugars, added sugars, and caloric sweeteners each have specific definitions
for regulatory or policy applications for dietary guidance or food labeling.2 The US Food and Drug
Administration (FDA) defines sugar to mean sucrose for the purpose of ingredient labeling, and
sugars to mean all mono- and disaccharides and polyols in processed or prepared foods for the
purpose of nutrition labeling. Added sugars is used in the Dietary Guidelines for Americans to mean
sugars and syrups that are added to foods at the table or during processing, such as white sugar,
brown sugar, raw sugar, corn syrup, high fructose corn syrup, honey, and molasses. The Economic
Research Service of the US Department of Agriculture (USDA) uses caloric sweeteners to describe
sucrose from refined cane and beet sugars, honey, dextrose, edible syrups, and corn sweeteners
including high fructose corn syrups. High fructose corn syrups contain oligosaccharides (3-9
monomers), which are captured in estimates of added sugars and caloric sweeteners but are not
included in the FDA's nutrition labeling definition for sugars. Another source of sugars in the US
diet is boiled, stripped, deodorized, and decolored fruit juices (usually apple, pear, grape). These
sugars are not included in the added sugars of dietary guidance but are included in the FDA's
regulation for the nutrition labeling declaration of sugars. However, FDA's regulation for labeling
claims of “No added sugars” prohibits the claim for any product containing any amount of sugars
added during processing or packaging or any other ingredient that contains sugars that functionally
substitute for added sugars, e.g., jam, jelly, concentrated fruit juice. These different terms and
definitions have implications for estimating sugars intake. Intakes would be overestimated if
oligosaccharides are included and underestimated if “stripped” fruit juices are excluded.
The terms “extrinsic” and “intrinsic” sugars originated in a UK Department of Health committee
to help consumers choose between what were considered to be healthy sugars and those which
were not. Intrinsic sugars were those sugars occurring within cell walls of plants, whereas extrinsic
sugars were those usually added to foods. A joint FAO/WHO expert panel3 recommended against
use of these terms. Free sugars is a recently introduced term which includes all mono- and
disaccharides added to foods by manufacturer, cook, or consumer, plus sugars naturally present
in honey, syrups and fruit juices.4
In addition to variability in terms and definitions used to describe sugars, another inconsistency
is how scientists express “sugar” dietary treatments or variables in their research papers. Intakes
have been expressed as kilograms per year, grams per day, grams per kilogram body weight, percent
of total carbohydrate, percent of total energy, and teaspoons per day. Some researchers and health
professionals describe intakes as high or low but without defining what high or low means. Such
inconsistency and ambiguities make it difficult to compare results across studies.
Food Balance Sheets

A major source of information used to assess trends in sugars intake are the Food Balance Sheets
compiled by the Statistics Division of the Food and Agricultural Organization (FAO).5 Members of
FAO provide a country level estimate of the amounts of major food groups - such as cane sugar,
beet sugar, and sweeteners made from corn - grown within the country, imported, and exported
as well as an estimate of food diverted to animal feed, food wastage, and other non-human food
usage. The difference between supply and non-human use represents the food that is available
for consumption. The amount of food that is available for consumption is divided by an estimate
of the population of the country to arrive at an average of the amount available per capita.
Estimates of per capita availability do not represent actual food consumption. Also, the quality of
the data reported by countries to FAO is not consistent. These factors must be considered when
attempting to interpret the per capita data and raise caution when trying to make diet-related
policy decisions.
Sugars and sweeteners data for the years 1961 to 2002 are available from Food Balance Sheets for
several countries in Southeast Asia and Oceania.5 When expressed as kilograms per person per
year, there has been an increase over time for New Zealand, Malaysia, Thailand, Philippines, Indonesia,
and Vietnam; a decrease for Australia; and fluctuations for Samoa and Cambodia. Countries differ
widely in the amount of sugars and sweeteners available for consumption, e.g., in 2002, from a low
of 11kg per person in Cambodia to 59kg per person in New Zealand, which is equivalent to 30g and
162g per day, respectively.
Because total energy available for consumption has also increased over time in these countries,
the amount of sugars and sweeteners available for consumption as kilograms per year needs to
be examined as a percentage contribution to total energy. This allows an assessment in trends of
the relative contribution of sugars and sweeteners versus other major sources of energy. Expressed
this way, the contribution of sugars and sweeteners to total energy increased for Malaysia (from
12% of Kcal in 1961 to 14% in 2000), the Philippines (from 8% to 12%), and Thailand (from 2% to 12%).
The contribution to total energy available for consumption actually decreased for Australia (from
18% to 13%) and Samoa (from 10% to 8.5%), and remained somewhat stable for New Zealand (16-
17%), Indonesia (5%), Vietnam (2% to 4%), and Cambodia (3%). The relative contribution of sugars
and sweeteners to total energy availability varies greatly across countries, e.g., from 5% to 6% for
Indonesia, Cambodia, and Vietnam to 18% for New Zealand in 2002.
The WHO6 has published statistics on the prevalence of preobesity (BMI ≥ 25 but < 30kg/m2) and
obesity (BMI ≥ 30kg/m2) in the adult population of several Western Pacific countries. These data
allow for a comparison of prevalence rates with sugars and sweeteners availability. However, a clear
pattern of relation between sugars availability (either as kilograms per year or percentage of total
energy availability) and the rate of preobesity plus obesity is not evident. For example, New Zealand
had 59kg per year of sugars and sweeteners available for consumption (18% of Kcal) and a prevalence
rate for preobesity plus obesity of 41% for males and 30% for females, whereas Samoa had 28kg
per year of sugars and sweeteners available for consumption (9% of Kcal) and preobesity plus
obesity prevalence rates of 47% for males and 66% for females (Figure 1). Clearly, factors others
than sugars and sweeteners are contributing to obesity.
Figure 1. Sugars and sweeteners availability5 and prevalence rates of preobesity plus obesity
in adult Males and females6 by country
Sugars (kg/year) Sugars (% Kcal) Males (%) Females (%)
80
70 67 66
59
60 52
50 48 47
41 44
40
30 29 28
30 24 28
23
20 18 17
14 15 12 9
10
0
New Zealand Australia Malaysia Philippines Samoa
Dietary Surveys
Actual consumption of sugars by individuals within a country is needed to obtain a clearer picture
of associations, if any, with nutrition and health parameters. But, even dietary intake data have
limitations.2 Firstly, good food composition tables are needed. Ideally, data for the individual mono-
and disaccharide contents of foods should be made available, but that is not always the case.
Furthermore, there are the issues of whether to include oligosaccharides as sugars or as other
carbohydrates, the inability to differentiate analytically the naturally occurring and added sugars
in a prepared food, and the uncertainty of the exact sugars content in food recipes of unknown
composition. Secondly, food intakes in general tend to be underreported due to problems with
remembering foods consumed, estimating portion sizes, and literacy barriers. Certain foods may,
also, be selectively underreported - especially by overweight and obese individuals - based on what
is perceived to be a socially desirable intake. Also, it is useful to have an estimate of an individual's
usual dietary intake, which requires collection of more than one day's food intake. If reasonably
accurate dietary intakes are obtained, the data should be examined by mean and percentiles of
intake, population subgroups (e.g., based on age, gender, race, ethnicity, urbanicity, socioeconomic
status, and body weight status), and food sources. These various ways of analyzing sugars intake
data are helpful in identifying specific issues and potential problems.
Nutrition and Health Impact

Reviews of the literature on the relation between sugars intake and nutrition and health variably
focus on (1) dental caries, (2) dietary quality and nutrient intakes, (3) energy balance and body
weight management, (4) glycemic response, insulin sensitivity and diabetes mellitus, (5) lipoprotein
metabolism, kinetics and blood levels, and cardiovascular disease, (6) hyperactive behavior in children,
(7) cognitive and physical performance, and (8) cancer. Some reviews address topics directly for
the effect of sugars intakes, whereas other topics are addressed indirectly, e.g., through sugars'
putative impact on energy balance or through general effects of carbohydrates. Expert groups have
drawn different conclusions about the strength of the evidence linking sugars intake with these
conditions or parameters. However, certain observations appear to be consistent. Some examples
will follow.
Dental Caries
Sugars play a significant role in dental caries, but dental caries is a disorder of multifactorial
causation and the role of sugars cannot be rationalized as a single cause and effect relationship.7
Sugars and all other fermentable carbohydrates are acidogenic in dental plaque and exert a caries
risk. The risk is related to form, retentiveness, exposure duration, frequency of consumption, and
nutrient composition, and is significantly reduced with the use of fluoride vehicles.1,3,4,7,8
Dietary Quality
Diets that are higher in added sugars (e.g., > 25% of energy) may contain more calories and smaller
amounts of micronutrients than diets with lower amounts of added sugars.4,7,8,10 Not all foods that
contain added sugars, however, are poor sources of nutrients (e.g., pre-sweetened cereals and
flavored yogurts and milk) and the intakes of certain nutrients are at risk of inadequacy at very
low levels of added sweeteners intake (e.g., < 5% of energy).7, 9, 10 Excessive intakes of sugars which
compromise micronutrient density should be avoided. However, dietary guidance may be more
effective if language conveys the desirability of choosing foods with a higher nutrient density rather
than avoiding/limiting sugars per se.1, 10
Energy Balance
No clear and consistent association between increased intake of added sugars and BMI has been
found,7 and no data suggest that different types of carbohydrates differentially affect total energy
intake.3 Additionally, evidence is conflicting on whether or not liquid and solid foods differ in their
effect on calorie compensation.9 Overall, many questions about sugars, appetite control, and energy
balance have not yet been resolved.1, 11,12,13
Glycemic Response
The evidence is convincing that overweight, obesity, and abdominal obesity decrease insulin sensitivity
and increase the risk for Type 2 diabetes.4,7 While animal studies have shown a decrease in insulin
sensitivity with high sucrose and high fructose diets, there is no conclusive evidence that humans
respond similarly to high sucrose diets or that sucrose and other sugars are directly implicated in
the etiology of diabetes.3,14 Some research has shown associations between high dietary glycemic
load and Type 2 diabetes, but sugars per se are not the largest contributor to dietary glycemic
load.1,14 With respect to diabetes management, a moderate amount of sugars may be consumed
as part of mixed meal within energy allowance and nutritionally adequate diet.2, 3
Blood Lipids
Convincing evidence exists that overweight contributes to the risk for cardiovascular disease.4
Fructose is more lipogenic than glucose or starches7 and high intakes (>~20% of energy) of sucrose
and fructose over the short term can raise blood triglycerides.14,15 However, a link between sugars-
induced hypertriglyceridemia and cardiovascular disease risk over the long term is not evident.
Other dietary factors need to be considered, e.g., the amount of total carbohydrates and fiber and
type of dietary fat. Sedentary and obese individuals with metabolic syndrome appear to be most
sensitive to effects of dietary sugars.
Summary
Research and dietary guidance on sugars would benefit by clear definitions and consistency in the
use of sugars-related terms and expressions of intake. Caution is needed in how data on sugars
availability from Food Balance Sheets are used. Per capita availability does not represent actual
intakes by individuals or even groups of individuals, and can under- or overestimate actual intake.
It is more desirable to estimate actual sugars intakes from dietary survey data. Good dietary intake
data require good food composition data and rigorous methods to ensure accurate reporting and
validating of food intake. The relation between sugars intake and many nutritional and health
parameters has been examined. The general consensus appears to be that sugars intake is only
one component of a complex mix of factors associated with diet-related performance, health, and
chronic disease.
References
1. Jones JM, Elam K. Sugars and health: is there an issue? J Am Diet Assoc 2003; 103:1058-1060.
2. Sigman-Grant M, Morita J. Defining and interpreting intakes of sugars. Am J Clin Nutr 2003;78
(4S):815S-826S.
3. FAO/WHO. Carbohydrates in Human Nutrition. Report of a Joint FAO/WHO Expert Consultation,
FAO Food and Nutrition Paper 66, Rome: FAO. 1998.
4. WHO/FAO. Diet, Nutrition and the Prevention of Chronic Disease. Report of a Joint WHO/FAO
Expert Consultation. WHO Technical Series Report, No. 916, Geneva Switzerland) 2003, at
http://www.who (accessed 10 May 2005).
5. FAOSTAT data. Food Balance Sheets, last updated 27 August 2004, at http://faostat.fao.org/faostat/
collections?subset=nutrition (accessed 9 June 2005).
6. WHO Regional Office for the Western Pacific. Basic Health Information on Nutrition (revised as
of 31 May 2005), at http://www/wpro.who.int/information_sources/dayatabases/regional_statistics/
rstat_nutrition.htm (accessed 23 June 2005).
7. Institute of Medicine. Dietary Reference Intakes: Energy, Carbohydrates, Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids. Washington, DC: National Academy Press, 2002.
8. Touger-Decker R, van Loveren C. Sugars and dental caries. Am J Clin Nutr 2003;78 (4S):881S-
8927S.
9. 2005 Dietary Guidelines Advisory Committee Report at http://www.health.gov/dayietary guidelines
(accessed 8 August 2004).
10. Murphy SP, Johnson RK. The scientific basis of recent guidance on sugars intake. Am J Clin Nutr
2003;78 (4S):827S-833S.
11. Levine AS, Kotz CM, Gosnell BL. Sugars: hedonic aspects, neuroregulation, and energy balance.
Am J Clin Nutr 2003;78 (4S):834S-842S.
12. Anderson GH, Woodend D. Consumption of sugars and the regulations of short-term satiety and
food intake. Am J Clin Nutr 2003;78 (4S):843S-849S.
13. Saris WHM. Sugars, energy metabolism, and body weight control. Am J Clin Nutr 2003;78 (4S):843S-
849S.
14. Kelley DE. Sugars and starch in the nutritional management of diabetes mellitus. Am J Clin Nutr
2003;78 (4S):843S-849S.
15. Fried SK, Rao SP. Sugars, hypertriglyceridemia, and cardiovascular disease. Am J Clin Nutr 2003;78
(4S):873S-8807S.
Carbohydrate Dietary Guidelines from Around

the World
E-Siong Tee
President
Nutrition Society of Malaysia
Kuala Lumpur
Malaysia
Introduction
One of the identified strategies of the World Declaration and Plan of Action for Nutrition, adopted
at the International Conference on Nutrition (ICN) in 1992, was the promotion of appropriate diets
and healthy lifestyles. Member countries were urged to provide dietary guidelines to the public,
relevant for different age groups and lifestyles and appropriate for the country’s population.1
Following up on the ICN, the FAO/WHO jointly held an expert consultation on the preparation
and use of food-based dietary guidelines in 1995.2 Dietary guidelines (DGs) are sets of advisory
statements that give dietary advice for the population to promote overall nutritional well-being.
DGs relate to all diet-related conditions. The FAO/WHO Consultation emphasized that DGs should
be clearly differentiated from dietary goals and recommended nutrient intakes (RNI, RDA or RDI).
DGs are broad targets for which people can aim, while RNI indicate what should be consumed on
the average every day. Hence, dietary guidelines need to reflect food patterns rather than numerical
goals. It is preferable that the messages to the public be in terms of foods, i.e., food-based dietary
guidelines (FBDGs).
FBDGs are developed in a specific socio-cultural context, and need to reflect relevant social,
economic, agricultural and environmental factors affecting food availability and eating patterns.
Public health issues should determine the direction and relevance of dietary guidelines. These
guidelines need to be positive and encourage enjoyment of appropriate dietary intakes. Countries
around the world have developed and been using dietary guidelines for many years. The purpose
of the above mentioned FAO/WHO Consultation was to establish the scientific basis and recommended
process for the development and evaluation of FBDGs in various regions of the world.
This paper aims to highlight those aspects of dietary guidelines that are related to carbohydrate
nutrition. Several sections of the FAO/WHO Consultation on Carbohydrates in Human Nutrition,
1997 are first highlighted.3 The recommendations of the Consultation on the role of carbohydrates
(including dietary fiber) in human nutrition and its role in the maintenance of health and disease
are summarized. The relevant parts of the WHO Monograph on Diet, Nutrition & Prevention of
Chronic Diseases pertaining to carbohydrates and dietary fiber are also briefly mentioned.4 The
main part of the paper examines the dietary guidelines of 18 selected countries around the world,
including Asian countries, Australia, New Zealand, Canada, USA, South Africa and some European
countries. The references used are mostly official dietary guidelines from the Ministries of Health
or equivalent authorities and also include guidelines by professional bodies, e.g., nutrition, dietetics
and medical associations. Only guidelines for adults are considered in the paper although it is
recognized that several countries have developed guidelines for specific population groups such
as children and pregnant mothers. The focus shall be on carbohydrates and dietary fiber
recommendations in these guidelines. The interesting array of pictorial presentations of dietary
recommendations from these countries shall also be discussed.
FAO and WHO Carbohydrate Dietary Guidelines

FAO/WHO Joint Expert Consultation on Carbohydrates in Human Nutrition
The report of the FAO/WHO Joint Expert Consultation on Carbohydrates in Human Nutrition, 19973
(1997 Report) touched on several aspects of the subject, including the basic description and
physiology of carbohydrates, their role in maintenance of health and causation of diseases, the
role of glycemic index in food choice as well as goals and guidelines for carbohydrate food choices.
Some of the recommendations that the Consultation made in the context of the role of carbohydrates
in nutrition are summarized as follows:
• The many health benefits of dietary carbohydrates should be recognized and promoted.
• Carbohydrate foods provide more than energy alone.
• Energy balance should be maintained by consuming a diet containing at least 55% total energy
from carbohydrate from various sources and engaging in regular physical activity.
• Carbohydrates, including carbohydrate-containing beverages, should not be consumed above
optimum levels for recreational physical activity purposes. Higher carbohydrate intakes are only
needed for long-term extreme endurance physical activities.
• A wide range of carbohydrate-containing foods should be consumed so that the diet is sufficient
in essential nutrients as well as total energy, especially when carbohydrate intake is high. The
bulk of carbohydrate-containing foods consumed should be those rich in non-starch
polysaccharides and with a low glycemic index. Processed cereals, vegetables, legumes, and fruits
are particularly good food choices.
* A nutrient-dense, high carbohydrate diet may be considered optimal for the elderly, but
individualization is recommended because their specific nutritional needs are complex.
The 1997 Report also noted that excess energy intake in any form will cause body fat accumulation.
Excessive intakes of sugars which compromise micronutrient density should be avoided. There is,
however, no evidence of a direct involvement of sucrose, other sugars and starch in the etiology
of lifestyle-related diseases.
WHO Monograph on Diet, Nutrition & Prevention of Chronic Diseases

The WHO Monograph on Diet, Nutrition & Prevention of Chronic Diseases also makes several
references to the importance of carbohydrates and dietary fiber in human health.4 In the ranges
of population nutrient intake goals tabulated in Table 1, references have also been made to total
carbohydrates, free sugar and dietary fiber. Population nutrient intake goals represent the population
average intake that is judged to be consistent with the maintenance of health in a population. For
carbohydrates, this goal has been recommended to be from 55% to 75% of the total energy intake,
whereas free sugars intake is to be less than 10%. A high daily intake of more than 400g of fruits
and vegetables has been recommended. Total dietary fiber has been recommended to be more than
25 gram per day, of which more than 20 gram should be from non-starch polysaccharides (NSP).
Whole grain cereals, fruit and vegetables are the preferred sources of NSP, of which the major
components are the polysaccharides of the plant cell wall such as cellulose, hemicellulose and pectin.
Table 1. Ranges of population nutrient intake goals4

Dietary factor Goal (% of total energy)
Total fat 15-30%
Saturated fatty acids <10%
Polyunsaturated fatty acids (PUFAs) 6-10%
n-6 Polyunsaturated fatty acids (PUFAs) 5-8%
n-3 Polyunsaturated fatty acids (PUFAs) 1-2%
Trans fatty acids <1%
Monounsaturated fatty acids (MUFAs) 9-13%
Total carbohydrate 55-75%
Free sugars <10%
Protein 10-15%
Cholesterol <300 mg per day
Sodium chloride (sodium) <5 g per day
Fruits and vegetables ≥400 g per day
Total dietary fiber > 25 g per day
Non-starch polysaccharides (NSP) > 20 g per day
The WHO Monograph also presents the strength of evidence on factors that might promote or
protect against various chronic diseases.4 Those factors that are related to carbohydrates are
extracted and presented in Table 2. Dietary fiber has been specified to have “convincing” evidence
for being protective against obesity and “probably” beneficial for Type 2 diabetes and cardiovascular
diseases (CVD). Wholegrain cereals are also probably protective against CVD. With regard to dental
disease, the consumption of free sugars has been convincingly shown to promote the condition,
whereas sugar-free chewing gum may have protective effect. There is no relationship between the
consumption of starch and dental disease.
Table 2. Strength of evidence on carbohydrate factors that might promote or protect against
chronic diseases4
Obesity Type 2 CVD Cancer Dental Osteo-
diabetes disease porosis
High intake of NSP (dietary fiber) C↓ P↓ P↓
Free sugars (frequency and amount) C
Sugar-free chewing gum P↓
Starch C-NR
Whole grain cereals P↓
Notes:
C : convincing
P : probable
NR: no relationship
Carbohydrate Dietary Guidelines in Southeast Asia

Malaysian Dietary Guidelines (1999)
The Malaysian dietary guidelines developed by the Ministry of Health Malaysia, with the collaboration
of an inter-sectoral, multi-agency committee,5 include the following three messages that are relevant
to this paper:
• Enjoy a variety of foods;

• Eat more rice and other cereal products, legumes, fruit and vegetables; and
• Reduce sugar intake and choose foods low in sugar.
The aims of these messages are to ensure that an individual meets all of his nutrient needs by
eating a wide variety of foods; to encourage balanced meals with emphasis on consumption of
grain products, legumes, vegetables and fruits; and to highlight that sugars are devoid of other
nutrients and tend to displace more nutritious foods from the diet.
In an elaboration of the first of the 3 listed main messages, the Guidelines explain the reason for
eating a variety of foods. Obtaining the nutrients the body needs depends on the amount and
variety of foods that an individual eats daily. All foods can be enjoyed as part of a nutritious diet.
The best way to ensure that an individual meets all of his nutrient needs is to eat a variety of foods.
In an elaboration of the second message above, the Guidelines encourage a balanced meal with
emphasis on consumption of grain products for example rice, corn, wheat, wheat products, oats,
barley, legumes, vegetables and fruits. Cereal products, legumes, vegetables and fruits provide
complex carbohydrates, vitamins, minerals, fibers and other components that are important for
good health. It is further explained that complex carbohydrates, also known as polysaccharides
include starch and fiber. The Guidelines also provide some brief notes on dietary fiber, its sources
and importance to human health. The recommended intake for fiber is 20g to 30g per day. It is
also pointed out that the approach should ensure that the diet is not only rich in fiber but also
balanced in the other nutrients that the body needs.
The third message above highlights that sugars are devoid of other nutrients and tend to displace
other more nutritious foods from the diet. The Guidelines also emphasize on the importance of
looking out for “hidden sugars” in a variety of foods including desserts, ice cream, candies, pastries,
cookies, soft and sweetened drinks, kuih and syrups.
While emphasizing the importance of looking out for "hidden sugars" in a variety of foods, the
Guidelines further explain that complex carbohydrates, also known as polysaccharides, include
starch and fiber. Brief notes on dietary fiber, its sources and importance to human health are also
provided, with the recommended intake of 20g to 30g fiber per day.
Singapore Dietary Guidelines (2003)

The 2003 Singapore Dietary Guidelines by the Singapore Health Promotion Board6 include four
messages that are related to carbohydrates:
• Enjoy a variety of foods using the healthy diet pyramid as a guide;

• Eat sufficient amounts of grains, especially whole grains;
• Eat more fruit and vegetables every day; and
• Choose beverages and food with less sugar.
The Singapore Food Pyramid places grains and grain products at the base of the pyramid as they
are a major component of the diet. The Guidelines also encourage the consumption of whole grains
or unpolished grains as they contain more vitamins, minerals, dietary fiber and phytochemicals
than refined grains.
In addition to encouraging increased consumption of fruit and vegetables, the explanatory notes
proceed to explain the beneficial health effects of soluble fiber and insoluble fibers found in fruit
and vegetables, including lowering blood cholesterol, promoting healthy bowel function as well as
lowering risk to diseases such as heart disease, stroke and certain types of cancers.
The Guidelines also highlight that sugars are found naturally in many foods such as milk, fruit and
vegetables. Sugars are also added during food processing or preparation, and frequent consumption
of sweet foods and drinks between meals promotes dental caries, especially if oral hygiene is
neglected. The Guidelines recommend reduction in the intake of added sugar, to no more than 10%
of dietary energy.
Dietary Guidelines of Thailand (2001)

The Thai National Dietary Guidelines are jointly developed by the Institute of Nutrition, Mahidol University
and the Ministry of Public Health.7 Four of these messages are relevant to carbohydrate nutrition:
• Eat a variety of foods from each of the 5 food groups and maintain proper weight;
• Eat adequate amount of rice or alternative carbohydrate sources;
• Eat plenty of vegetables and fruit regularly; and
• Avoid sweet and salty foods.
To provide a pictorial guide to the consumer in choosing the correct “portion”, “quantity” and
“variety” of foods required daily, Thailand has adopted the “Nutrition Flag” (See Table 3) which is
conceptually similar to the food pyramid. The Guidelines note that fiber in vegetables and fruit
helps the body to remove waste as well as eliminate cholesterol and some carcinogenic compounds.
It is also highlighted that unpolished rice or home-pounded rice is more nutritious than milled rice
as it contains substantial amounts of important nutrients such as protein, fat, dietary fiber, minerals
and vitamins. The Guidelines further recommend that not more than 10% of a person's total food
energy should be from sugar.
Dietary Guidelines of the Philippines (2000)

The official Dietary Guidelines of the Philippines, developed by the Food and Nutrition Research
Institute (FNRI),8 has two messages that are relevant to carbohydrates:
• Eat a variety of foods everyday; and

• Eat more vegetables, fruit and root crops.
The Guidelines provide information on each of the major nutrients required, food groups and the concepts
of a balanced diet. Consumers are encouraged to consume more vegetables, fruit and root crops, such
as potato, sweet potato, yam, cassava and taro, in order to tackle the micronutrient deficiencies that
are prevalent amongst some segments of the population. Eating root crops will also add dietary energy
to the meal. In addition, these foods also provide dietary fiber in the diet. The supporting notes in the
Guidelines provide details of the nutritional value of vegetables, fruits and root crops.
The Dietary Guidelines booklet of FNRI8 (2000) does not have a food guide pyramid. The Institute
had, however, published a pyramid guide separately. The Philippines Association for the Study of
Obesity (PASOO) also published a pictorial guide for healthy eating (See Table 3).
Dietary Guidelines of Indonesia (2003)

The Dietary Guidelines of Indonesia are developed by the Department of Health.9 Two of these
messages are relevant to carbohydrate nutrition:
• Eat a variety of foods; and

• Consume carbohydrate foods to meet half of energy needs.
The Indonesian Dietary Guidelines have adopted the cone as a pictorial guide, which is in principle
similar to the food pyramids used by several other countries. The Guidelines recommend that
approximately 50% to 60% of the energy needs of an individual should be derived from complex
carbohydrates such as rice, maize, tubers and sago. Consumption of sugars or simple carbohydrates
should not exceed 5% of the total energy requirement of an individual.
The Guidelines do not include specific messages about dietary fiber. However, they emphasize the importance
of having a balanced diet and sufficient dietary fiber intake (25 gram per day) to prevent or reduce risk
of degenerative diseases such as coronary heart disease, hypertension and diabetes mellitus.
Dietary Guidelines of Brunei Darulssalam (2000)

The Brunei Ministry of Health Dietary Guidelines10 include four messages that are related to
carbohydrate nutrition:
• Eat a variety of foods from each of the groups according to the amounts recommended;
• Eat 2 to 3 servings of vegetables and 2 to 3 servings of fruit everyday;
• Prepare dishes that are less salty and less sweet; and
• Enjoy more legumes and cereal foods.
As a pictorial guide to the consumer, Brunei Darulssalam has adopted the food trays, with four layers
of different sizes. Conceptually, it is similar to the food pyramid and the largest tray is at the bottom,
containing complex carbohydrate foods such as rice and rice products, wheat and wheat products
and tubers. The smallest tray, at the top, contains fats and oils, sugars and salt.
Dietary Guidelines of Vietnam (1997)

The Vietnamese Guidelines for appropriate food intake, jointly developed by the National Institute of Nutrition
and the Vietnam Woman's Union,11 has two key messages that are related to carbohydrate nutrition:
• Consume a small amount of sugar; and

• Increase the intake of vegetables, tubers and fruit.
Sugar has been specifically mentioned in the Guidelines, and it is recommended that a person
should only consume an average of 500g of sugar per month. The Guidelines also provide
recommended amounts of the other food groups that should be consumed per month.
Table 3. Carbohydrate (and dietary fiber) related key messages in the dietary guidelines of
Southeast Asian countries
Country Food Guide Variety Cereals and Grains, Fruit and Vegetables Sugar
Root Crops (Legumes)
Malaysia Enjoy a variety of foods. Eat more rice and other Eat more fruit and Reduce sugar intake
(1999) cereal products, vegetables. and choose foods low
legumes. in sugar.
Singapore Enjoy a variety of foods Eat sufficient amounts Eat more fruit and Choose beverages and
(2003) using the healthy diets of grains, especially vegetables every day. food with less sugar.
pyramid as a guide. whole grains.
Thailand Eat a variety of foods Eat adequate amount Eat plenty of vegetables Avoid sweet and salty
(2001) from each of the 5 food of rice or alternative and fruit regularly. foods.
groups and maintain carbohydrate sources.
proper weight.
Philippines Eat a variety of foods Eat more fruit, Consume milk, milk –
(2000) everyday. vegetables and root products or other
crops. calcium rich foods such
as small fish and dark-
green leafy vegetables
everyday.
Indonesia Eat a variety of foods. Obtain about half of – –

(2003) total energy from
complex carbohydrate-
rich food.
Southeast Asian countries (continued)
Brunei Eat a variety of foods Enjoy more legumes Take 2-3 servings of Take foods that are less
Darulssalam from each of the and cereals. vegetables, ulam and 2- salty and less sweet.
(2000) groups, according to 3 servings of fruit every
the amounts day.
recommended.
Vietnam Increase intake of Increase intake of Consume a small

(1997) vegetables, fruit and vegetable and fruit. amount of sugar.
tubers.
Dietary Guidelines of China (1997)

Guidelines for the general population of the People's Republic of China has two messages which
are related to carbohydrate nutrition:12
• Eat a variety of foods, with cereals as the staple; and

• Consume plenty of vegetables, fruit and tubers.
The Dietary Guidelines released by the Chinese Nutrition Society emphasize the importance of
maintaining the favorable traditional Chinese diet which comprises primarily of cereals. Additionally,
the cereals in the diet should include a certain amount of coarse grains such as millet and corn,
other than refined or milled rice and wheat flour. The Guidelines also emphasize the importance
of consuming plenty of vegetables, fruits and tubers for the prevention of cardiovascular diseases,
enhancement of immunity, reduction of risk of blindness and increased mortality in young children
and even prevention of some cancers. Vegetables and fruit are rich in a variety of vitamins, minerals
and dietary fiber. Besides vitamins and minerals, tubers are also rich in starch and dietary fiber.
To help consumers put the dietary guidelines into practice, the Food Guide Pagoda provides a visual
guide to the types and amounts of foods to be consumed in order to achieve a balanced diet.
Culturally more familiar to the Chinese people, the pagoda is nevertheless based on the same
principles as the food pyramid, with the foods to be consumed most at the base of the pagoda
and decreasing at the higher levels of the structure. Carbohydrate-rich and fiber-containing cereals
and cereal products are at the base of the pagoda, whereas fats and oils are placed at the tip. The
amount to be consumed are given in weight (grams).
Dietary Guidelines of Japan (2000)

In the dietary guidelines for Japanese, proposed by the Ministry of Health, Labour and Welfare,13
four messages relate to carbohydrate nutrition:
• Eat well-balanced meals with staple food, as well as main and side dishes;
• Eat enough grains such as rice and other cereals;
• Combine vegetables, fruit, milk products, beans and fish in your diet; and
• Take advantage of your dietary culture and local food products, while incorporating new and
different dishes.
The Guidelines emphasize the importance of eating a variety of foods cooked in various ways. They
also encourage individuals to combine home-made meals wisely with processed and prepared foods
eaten out. Intake of sufficient grains such as rice and other cereals is encouraged to maintain adequate
intake of energy from carbohydrates. The importance of consuming sufficient amounts of vegetables
and fruit everyday to obtain enough vitamins, minerals and dietary fiber is further highlighted.
Dietary Guidelines of Republic of Korea (2002)

The Dietary Guidelines of Korea14 have two messages that are related to carbohydrate intake and
emphasizes on rice consumption:
• Eat a variety of grains, vegetables and fruits, fish, meat, poultry and dairy products; and
• Enjoy a rice-based diet.
The Guidelines include action guides for adults and the elderly. A food pagoda is also used as a
pictorial guide on food choices to the consumer.
Dietary Guidelines of India (1998)

The Indian Dietary Guidelines were developed by the National Institute of Nutrition in Hyderabad,
India.15 Five of the key messages deemed relevant to carbohydrate nutrition, are listed below:
• A nutritionally adequate diet should be consumed through a wise choice from a variety of foods;
• Plenty of green leafy vegetables, other vegetables and fruit should be consumed; and
• Processed and ready-to-eat foods should be used judiciously. Sugar should be used sparingly.
The supporting notes for message 1 above, highlight the importance of consuming nutritionally
adequate diet, providing all essential nutrients in the required amounts, at any age throughout
life. Daily intakes lower or higher than the body requirements can lead to under-nutrition (deficiency
diseases) or over-nutrition (diseases of affluence), respectively. In a balanced diet, carbohydrates,
preferably starch, should provide around 60% to 70% of total calories, proteins should provide
about 10% to 12%, and fat should provide about 20% to 25%. In addition, a balanced diet should
provide other non-nutrients such as dietary fiber, antioxidants and phytochemicals which provide
positive health benefits. The required nutrients must be obtained through judicious choices and
combination of a variety of foods.
Dietary Guidelines of Australia (2002)

The key messages in the official Australian Dietary Guidelines, developed by the National Health
and Medical Research Council, include four messages that are related to carbohydrates nutrition:16
• Enjoy a wide variety of nutritious foods;

• Eat plenty of vegetables, legumes and fruit;
• Eat plenty of cereals, preferably whole grains; and
• Consume only moderate amounts of sugars and foods containing added sugars.
The food plate is used as a guide to the choice of types of food and the amounts of each to be
consumed daily. Consumers are encouraged to consume plenty of vegetables, legumes (lentils,
beans and peas) and fruit. Together with nuts and seeds, these foods provide the body with many
of the essential nutrients needed daily. In addition, they also protect against the ageing process
and common diseases such as high blood cholesterol, diabetes, cataracts in the eyes and even
some forms of cancers. Cereals (including wheat, maize, rice, barley, sorghum, oats, rye and millet)
form the foundation of the daily meals and are highlighted in the third key message above. These
foods are eaten in relatively large amounts and provide half the energy and half the protein needs
of communities. They are also excellent sources of B-group vitamins and contain useful amounts
of vitamin E, essential fatty acids, minerals and dietary fiber. The Guidelines also recognize that
sugar does provide extra calories in the diet without adding any other beneficial nutrients, and
plays a significant role in tooth decay. Hence, the Guidelines recommend consuming only moderate
amounts of sugars and foods containing added sugars.
other Asian countries and Australia
China Enjoy a variety of foods. Use cereals as the Consume plenty of -
(1997) staple food. Consume vegetables, fruit and
beans or bean products tubers.
everyday.
Japan Eat well-balanced meals Eat enough grains such Eat enough of -
(2000) with staple food, as well as rice and other vegetables and fruit
as main and side dishes; cereals. everyday to get
Combine vegetables, vitamins, minerals and
fruit, milk products, fiber.
beans and fish in your
diet.
other Asian countries and Australia (continued)
Republic of – Eat a variety of grains; Eat a variety of -
Korea enjoy your rice-based vegetables and fruit.
(2002) diet.
India Nutritionally adequate – Green leafy vegetables, Processed and ready-

(1998) diet should be other vegetables and to-eat foods should be
consumed through fruit should be used in used judiciously. Sugars
wise choices from a plenty. should be used
variety of foods. sparingly.
Australia Enjoy a variety of Eat plenty of cereals, Eat plenty of vegetables Consume only
(2002) nutritious foods. preferably whole grain; and fruit. moderate amounts of
eat plenty of legumes. sugars and foods
containing added
sugars.
Dietary Guidelines of the USA (2005)

The US Department of Health and Human Services and the US Department of Agriculture jointly
released the new Dietary Guidelines for Americans in 2005. Three of the 10 chapters contain
messages that are related to carbohydrate nutrition:17
• Adequate nutrients within calorie needs (Chapter 2);

• Food groups to encourage (Chapter 5); and
• Carbohydrates (Chapter 7).
In Chapter 2, the Guidelines point out that many Americans consume more calories than they
need without meeting recommended intakes for a number of nutrients. Hence, the Dietary Guidelines
recommend that most people need to choose meals and snacks that are high in nutrients but low
to moderate in energy content; that is, meeting nutrient recommendations must go hand in hand
with keeping calories under control. Doing so offers important benefits - normal growth and
development of children, health promotion for people of all ages, and reduction of risk for a number
of chronic diseases that are major public health problems. The emphasis was to consume a variety
of nutrient-dense foods and beverages within and among the basic food groups while choosing
foods that limit intake of saturated and trans fats, cholesterol, added sugars, salt and alcohol.
The dietary guidelines also emphasize that intake levels of the following nutrients may be of concern
for adults: calcium, potassium, fiber, magnesium, and vitamins A (as carotenoids), C, and E. For
children and adolescents, the following nutrients are important: calcium, potassium, fiber, magnesium,
and vitamin E. For specific population groups (e.g., pregnant women and the elderly), vitamin B12,
iron, folic acid, and vitamins E and D are important.
Chapter 5 of the Dietary Guidelines emphasizes the important health effects of increased intakes
of fruit, vegetables, whole grains, and fat-free or low-fat milk and milk products. The consumer
is encouraged to choose a variety of fruits and vegetables each day, particularly, dark green, orange,
legumes, starchy vegetables, and other vegetables. An array of evidence points to beneficial health
effects of increased intake of fruit and vegetables and reduced risk of chronic diseases including
stroke and perhaps other cardiovascular diseases, Type 2 diabetes, and cancers in certain sites (oral
cavity and pharynx, larynx, lung, esophagus, stomach, and colon-rectum). Diets rich in foods
containing fiber, such as fruit, vegetables, and whole grains, may reduce the risk of coronary heart
disease. Diets rich in milk and milk products can reduce the risk of low bone mass throughout the
life cycle. The consumption of milk products is especially important for children and adolescents
who are building their peak bone mass and developing lifelong habits. Although each of these food
groups may have a different relationship with disease outcomes, the adequate consumption of all
food groups contributes to overall health.
Chapter 7 emphasizes that carbohydrates are part of a healthful diet, contributing 45% to 65% of
total calories. Dietary fiber is composed of nondigestible carbohydrates and lignin, intrinsic and
intact in plants. Diets rich in dietary fiber have been shown to have a number of beneficial effects,
including decreased risk of coronary heart disease and improvement in laxation. There is also
interest in the potential relationship between diets containing fiber-rich foods and lower risk of
Type 2 diabetes. Sugars and starches supply energy to the body in the form of glucose, which is
the only energy source for red blood cells and is the preferred energy source for the brain, central
nervous system, placenta, and fetus. Sugars can be naturally present in foods (such as the fructose
in fruit or the lactose in milk) or added to the food. Added sugars, also known as caloric sweeteners,
are sugars and syrups that are added to foods at the table or during processing or preparation
(such as high fructose corn syrup in sweetened beverages and baked products). Although the
body's response to sugars does not depend on whether they are naturally present in a food or
added to the food, added sugars supply calories but few or no nutrients.
Consequently, it is important to choose carbohydrates wisely. Foods in the basic food groups that
provide carbohydrates - fruit, vegetables, grains, and milk - are important sources of many nutrients.
Choosing plenty of these foods, within the context of a calorie-controlled diet, can promote health
and reduce chronic disease risk. However, the greater the consumption of foods containing large
amounts of added sugars, the more difficult it is to consume enough nutrients without gaining weight.
Consumption of added sugars provides calories while providing little, if any, of the essential nutrients.
In 2005, the United States Department of Agriculture18 released a new food pyramid to help
consumers choose the appropriate types and amounts of foods. An online version of MyPyramid
(www.mypyramid.gov) has been made available. MyPyramid makes recommendations for the amounts
(given in cups and ounces) of each of the main food groups, namely grains, vegetables, fruits, milk
and meat and beans to be consumed daily, taking into consideration the activity level of the
individual. For each food group, the Guidelines provide brief notes on the types of foods and the
nutritional properties.
Dietary Guidelines of Canada (1997)

Canadian Dietary Guidelines were released by Health Canada, the Federal department responsible
for helping Canadians maintain and improve their health a few years ago.19 Two of them relates
to carbohydrates nutrition:
• Enjoy a variety of foods; and

• Emphasize cereals, breads and other grain products, vegetables and fruit.
The Guidelines recommend that the Canadian diet should provide 55% of energy as carbohydrate
from a variety of sources. Eating patterns that are high in complex carbohydrate and fiber are
associated with a lower incidence of heart disease and certain types of cancer. Canada's Food Guide
to Healthy Eating promotes carbohydrates in a rainbow design that places grain products, vegetables
and fruit in the outermost arcs and shows a wide range of foods in both groups. A larger number
of servings are recommended for both grain products and vegetables and fruit. Consumers are also
encouraged to choose dried peas, beans and lentils more often, as alternatives to meat.
The Food Guide also discusses the consumption of simple carbohydrates and sugars. Sugars occur
naturally in foods like milk, fruit and vegetables, as well as fructose, dextrose, liquid invert sugar,
molasses, honey and corn syrup. Examples of foods that are mostly sugars are soft drinks, candy
and jams. All added sugars, including honey and molasses, contribute primarily energy and taste
and have no other significant nutritional advantages. With the exception of dental caries, there
is no conclusive evidence that sugars, when consumed at current levels, are hazardous to the
health of the general public. However, people with lower energy needs may need to be more careful
with their intake of foods that are high in sugar in addition to foods that are high in fat because
they may not need to consume this extra energy.
Dietary Guidelines of the UK (2004)

The Dietary Guidelines of the Department of Health, UK has the following four key messages that
relate to carbohydrate nutrition:20
• Eat a variety of different foods;

• Eat plenty of foods rich in starch and fiber;
• Eat plenty of fruit and vegetables; and
• Don't have sugary foods and drinks too often.
The Balance of Good Health (BGH), a pictorial representation of the recommended balance of foods
in the diet, is in the shape of a plate. It shows the types of foods and the proportion in which they
should be eaten to have a well-balanced, healthy diet. BGH is based on five food groups. Choosing
a variety of foods from the first four groups every day will provide the body with the wide range
of nutrients needed. Foods in the fifth group - foods containing fat and foods containing sugar
- are not essential to a healthy diet but add extra variety, choice and palatability to meals. This
group of foods should form the smallest part of the diet.
Dietary Guidelines for Adults in Greece (2000)

The Greek Dietary Guidelines, issued by the Hellenic Ministry of Health, also emphasize eating a
variety of foods.21 As with the other guidelines reviewed so far, the emphasis is for the consumer
to consume carbohydrate and dietary fiber-rich cereals and products, particularly non-refined
ones. These foods, such as wholegrain bread, whole grain pasta and brown rice, etc., are placed
at the base of the pictorial presentation of the food-based dietary guidelines, in the shape of a
pyramid. Sweets are close to the top of the pyramid and are to be consumed weekly. The Guidelines
encourage the consumption of fruits and nuts as snacks, instead of sweets or candy bars and
water instead of soft drinks.
South African Food-Based Dietary Guidelines (2001)

There are 10 prime messages in the South African Dietary Guidelines,22 four of which are related
to carbohydrates and elaborated below:
• Enjoy a variety of foods;

• Make starchy foods the basis of most meals;
• Eat plenty of fruit and vegetables; and
• Eat dry beans, split peas, lentils and soya regularly.
The key message of making starchy foods the basis of most meals is directly relevant to this paper.
Starchy or high carbohydrate foods such as cereals, grains and some root vegetables, the main
sources of dietary energy and valuable sources of micronutrients and dietary fiber when they are
eaten in minimally processed forms. These foods also contribute protein to the diet. Foods rich
in carbohydrates in the form of starch, resistant starch, sugars and non-starch polysaccharides
or dietary fiber, influence health and prevent chronic diseases by various effects and mechanisms.
The recommendation to eat dry beans, peas, lentils and soy regularly is one of the key messages
in the South African dietary guidelines. Also known as legumes, these foods are rich and economical
dietary sources of good quality protein, carbohydrates, soluble and insoluble dietary fiber components
and a variety of minerals and vitamins. In addition, soya beans also contribute significantly to
polyunsaturated fatty acid intake, including α-linolenic acid, an n-3 fatty acid not commonly found
in plant foods. Legumes are excellent foods to increase dietary fiber consumption and most
individuals can incorporate legumes into their diet without difficulty. Including legumes in a health-
promoting diet is important to meet the major dietary recommendations to improve the nutritional
status of undernourished as well as to reduce risk for chronic diseases such as cardiovascular
disease, diabetes mellitus, cancer and osteoporosis.
Dietary Guidelines of Argentina (2000)

The dietary guidelines developed by the Argentine Dietitian and Nutritionist Association has 10 key
recommendations for healthy living; three of them refer to carbohydrates (and fiber) consumption:23
• Consume a variety of breads, grains and cereals, pasta, flour, starches and legumes (dry beans);
• Reduce the consumption of sugar and salt; and
• Consume a variety of vegetables and fruit each day.
Grains in these Dietary Guidelines include rice, maize, wheat, oat, barley and rye, whereas legumes
include lentils, peas and soya bean. The Guidelines also encourage the consumption of whole grain
products. Calories from carbohydrate is recommended to contribute 50% to 60% of total daily
energy requirement. An intake of 25g to 30g of dietary fiber a day is recommended.
The Guidelines also recommend reducing consumption of sugar and limiting food and beverages
with added sugar for occasional situations. With regards to fruit and vegetables, five portions of
these are recommended each day. It is also encouraged to consume raw vegetables and fruit at
least once a day. For cooking, large pieces of vegetables with their skin are recommended to be
steamed or boiled in a small amount of water.
Instead of a pyramid, the Argentine Dietary Guidelines have adopted the use of an oval pictorial
with the graphics of six food groups, starting with water.
other countries
United Consume a variety of Choose fiber-rich fruits, Choose a variety of Choose and prepare
States of nutrient-dense foods vegetables, and whole fruit and vegetables foods and beverages
America and beverages within grains often. each day. In particular, with little added sugars
(2005) and among the basic select from all five or caloric sweeteners.
food groups. vegetable subgroups
(dark green, orange,
legumes, starchy
vegetables, and other
vegetables) several
times a week.
Canada Enjoy a variety of foods. Emphasize cereals, Emphasize vegetables –

(1997) bread, other grain and fruit
products.
United Eat a variety of different Eat plenty of foods rich Eat plenty of fruit and Do not have sugar-
Kingdom foods. in starch and fiber. vegetables. containing foods and
(2004) drinks too often.
other countries (continued)
Greece Food variability (variety Cereals, potatoes, Vegetables and fruit. Sugars.
(2000) of foods). pulses.
South Enjoy a variety of foods. Make starchy foods the Eat plenty of fruit and –
Africa basis of most meals; eat vegetables.
(2001) dry beans, peas, lentils
and soya often.
Argentina – Consume a variety of Consume a variety of Reduce the

(2000) breads, grains (rice, vegetables and fruit consumption of sugar.
maize, wheat, oat, each day.
barley, rye, etc)
especially whole grains
and cereals, pasta,
flours, starches and
legumes (dry beans).
Discussions and Conclusions

The dietary guidelines of 18 countries across seven regions of the world have been reviewed in this
paper. Two key expert consultation reports of the FAO and WHO have also been reviewed and the
relevant information discussed.3,4 The key messages of each of the country guidelines were examined
and those messages related to carbohydrates (including dietary fiber) were listed out and discussed.
It is evident that there is a great deal of similarity across the countries surveyed.
Guidelines of some of the countries also emphasized nutrient-dense foods and beverages. All but
one of the countries (India) support the consumption of cereals, grains and root crops to provide
carbohydrate (starch) as the main source of energy for daily activities, as well as dietary fiber,
vitamins, minerals and phytochemicals that are important for health. Several countries, namely
Malaysia, Thailand, Korea, Japan and Argentina, focus specifically on rice as one of the recommended
cereals. A few countries - Singapore, Australia, USA and Argentina - further encourage consumption
of whole grains for their dietary fiber content.
Although not specifically mentioned in the key messages, all guidelines reviewed stated the importance
of dietary fiber to human health in their supporting notes. This mention of dietary fiber can be in
conjunction with consuming cereals and grains and legumes, as well as with increasing intake of
fruits and vegetables. Several countries specifically mentioned the association of fiber consumption
and lowering risk of chronic diseases. The amount of dietary fiber recommended for daily consumption
is not specifically mentioned in most of the dietary guidelines with the exception of 2 countries -
Malaysia (20g to 30g per day) and Indonesia (25g per day). In the WHO (2003) nutrient intake
goals,4 the recommended total dietary fiber per day is more than 25g, of which more than 20g
should be from non-starch polysaccharides. WHO (2003) has indicated dietary fiber as having
“convincing” evidence for being protective against obesity and “probably” beneficial for Type 2 diabetes
and cardiovascular diseases (CVD). Whole grain cereals are also probably protective against CVD.
The message on sugar is less consistent for all the countries surveyed. Eleven of the 18 countries
(Malaysia, Singapore, Thailand, Brunei, Vietnam, India, Australia, USA, UK, Greece and Argentina)
have a key message recommending consuming less sugar or less sweet foods. These foods are
generally placed at the tip of the pyramid or comprise the smallest portion of the food plate. Even
for those countries with key a message on sugar or sweet foods, the supporting information on
this message is not consistent. The message is generally to reduce intake of sugars, and the amount
is not stipulated. A few countries do recommend reduced intake of added sugar to no more than
5% (Indonesia) or 10% (Singapore and Thailand) of dietary energy. The WHO (2003) population
nutrient intake goals4 have recommended daily free sugars intake to be not more than 10% of total
energy intake.
Dietary guidelines should remain as important educational tools in promoting healthy eating
amongst the community. There should be greater efforts amongst all relevant parties to make these
truly effective tools. FAO and WHO should continue to play leadership roles in making dietary
guidelines as one of the effective strategies for the promotion of appropriate diets and healthy
lifestyles.
References
1. FAO/WHO (1992). World Declaration and Plan of Action for Nutrition. Food and Agriculture
Organization, Rome.
2. FAO/WHO (1998a). Preparation and Use of Food-Based Dietary Guidelines. Report of a Joint
FAO/WHO Consultation. WHO Technical Report Series 880. World Health Organization, Geneva.
3. FAO/WHO (1998b). Carbohydrates in Human Nutrition. FAO Food and Nutrition Paper 66. Report
of a Joint FAO/WHO Expert Consultation, Rome, 14-18 April, 1997. Rome.
4. WHO (2003). Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint FAO/WHO
Expert Consultation, WHO Technical Report Series 916, World Health Organization, Geneva.
5. NCCFN (1999). Malaysian Dietary Guidelines. National Coordinating Committee on Food and
Nutrition, Ministry of Health Malaysia, Kuala Lumpur.
6. HPB (2003). Dietary Guidelines 2003 For Adult Singaporeans (18-65 years). Health Promotion
Board, Singapore.
7. MU & MPH (2001). Food Based Dietary Guidelines for Thai. Institute of Nutrition, Mahidol University
and Nutrition Division, Department of Health, Ministry of Public Health, Thailand.
8. FNRI (2000). Nutritional Guidelines for Filipinos. Food and Nutrition Research Institute, Department
of Science and Technology, Manila, Philippines.
9. DHRI (2003). Pedoman Umum Gizi Seimbang (Panduan Untuk Petugas) (General Guide for Balanced
Diet). Community Health Development Directorate-General, Community Nutrition Directorate,
Department of Health, Republic of Indonesia.
10. MOHBD (2002). Panduan Pemakanan Kebangsaan (National Dietary Guidelines). Ministry of
Health, Brunei Darulssalam.
11. NIN & VWU (1997). Ten recommendations for appropriate food intake. National Institute of
Nutrition and the Vietnam Woman's Union, Vietnam.
12. CNS (1999). Dietary guidelines and the food guide pagoda for Chinese residents: balanced diet,
rational nutrition and health promotion. Adopted by the Standing Board of the Chinese Nutrition
Society, April 10, 1997. The Chinese Nutrition Society. Nutrition Today 34(3): 106-115.
13. MHLWJ (2000). Dietary Guidelines for Japanese. Ministry of Health, Lahour & Welfare, Japan.
14. MHLWRK (2002). Revision of Dietary Guidelines for Koreas (2002: with action guides for adults and
the elderly). Korea Health Industry Development Institute, Ministry of Health and Welfare,
Republic of Korea.
15. NIN (1998). Dietary Guidelines for Indians - A Manual. National Institute of Nutrition, Indian
Council of Medical Research, Hyderabad, India.
16. NHMRC (2002). Food for Health. Dietary Guidelines for Australians. A Guide to Healthy Eating.
National Health & Medical Research Council, Canberra, Australia. Accessed from: www.nhmrc.gov.au/
publications/_files/n31.pdf
17. USDHHS & USDA (2005). Dietary Guidelines for Americans 2005. U.S. Department of Health and
Human Services and U.S. Department of Agriculture. Washington, DC. Accessed from:
www.health.gov/dayietaryguidelines/dayga2005/dayocument/pdf/dayGA2005.pdf
18. USDA (2005). My Pyramid, Steps to a Healthier You. United States Department of Agriculture.
Accessed from: www.mypyramid.gov
19. HC (1997). Canada's Food Guide to Healthy Eating. Health Canada. Accessed from: www.hc-
sc.gc.ca/fn-an/nutrition/index_e.html
20. DHUK (2004). Wired for Health - Guidelines for Healthy Diet. Department of Health, United
Kingdom. Accessed from: www.wiredforhealth.gov.uk
21. HMOH (2000). Dietary Guidelines for Adults in Greece. Hellenic Ministry of Health. Accessed from:
www.nut.uoa.gr/english/Greekguid.htm
22. SAWG (2001). South African Food-based Dietary Guidelines. South African Working Group. SA J
Clin Nutr 14(3): S2-S77. Accessed from: www.sahealthinfo.org/publications/publ.htm
23. ADNA (2000). The Argentine Dietary Guidelines. Argentine Dietitian and Nutritionist Association.
Accessed from www.aadynd.org.ar
Panel Discussion I
Carbohydrates and Nutrition Labeling Issues
The first Panel Discussion, which dealt with nutrition labeling issues with respect to carbohydrates,
was chaired by Dr. David Lineback who steered the discussion towards a number of important issues:
What do we like to see in the label concerning carbohydrates? What do the consumers want? Will
they use the information? How are they going to use it? Related to these issues is the problem of
defining qualitative terms such as “sugar free”, “low carbohydrates”, “reduced sugar”, “no added
sugar”, “unsweetened”, etc. Despite the fact that there are a number of health claims approved by
regulatory bodies, the health claims stated on the label may be unclear, confusing and misleading.
While there was a general agreement on the need for nutrition labeling as an instrument of
consumer education as well as consumer and professional guidance, the participants expressed
the need not only for stating the amounts of carbohydrates, dietary fiber and sugar, but voiced
the question of how the values should be expressed, whether by weight per serving or per 100g
of food, or per cent of Daily Value. It was suggested that the Codex recommendation of expressing
the amounts in terms of NRV for comparison purposes should be followed for uniformity.
The issue of the need to include classes of carbohydrates and dietary fiber, such as soluble and
insoluble dietary fiber, psyllium, β-glucan, etc, or functional properties such as glycemic index,
glycemic load, GGE, etc, or added components such as pre- and probiotics, was more contentious
on account of the absence of clear definitions and guidelines on their use such as on how much
is enough. There is still a need for clear definitions of such terms as “low carbohydrate food”, “low
carbohydrate diet”, “whole grains”, “high fiber”, etc. The need for a virtual food component to
represent food effects separate from food composition label was suggested. More scientific studies
will be required to clarify all these issues, but ultimately, the question boils down to what information
would be useful to consumers and how the consumers are going to use the information in the
label. On the matter of what is useful to consumers, it was suggested to consider the priority public
health problems in the country.
On the issue of health claims that may be included in the label, it is clear that they could only
apply to the reduction of risk and not the cure of any disease. Approval of health claims is subject
to strict regulations by the country’s regulatory bodies. Only a limited number of health claims
are permitted based on scientific studies, and any question of permissibility is subject to deliberation
and approval by the regulatory body.
Consumer research has shown some of the information consumers want. Consumers, particularly
those who are health conscious, do read labels, but they want to know if the product is “good”
or “better”. Most consumers understand basic nutrition information, but could not compare foods,
such as which processed food is a healthier choice compared to another. They need guidance on
what food to choose through a simple system of indicating a healthy food as pronounced by a
reputable body. Thus, there is a need to move from the scientific area to the area of effective
communication to consumers, in a way that is simple and positive. The challenge is how to effectively
educate consumers on how to apply the nutrition information in food labels, and therefore the
need for a continuing consumer education program.
Panel Discussion II
Dietary Guidance - Forecasting the Future
The second Panel Discussion, focusing on dietary guidance on carbohydrates and its future, was
chaired by Dr. E-Siong Tee. Dr. Tee guided the discussion along the relevance of current dietary
guidelines with respect to carbohydrates, their utilization by professionals and the community, and
the new directions that the guidelines should take in the face of new scientific information and
changing public health problems.
The participants agreed that the purpose of dietary guidelines is to encourage the general public
to consume the proper amount and balance of foods in order to live healthy lives. Hence, there
should, first, be a clear definition of what is needed for a healthy diet, or what the “gold standard”
for the population is. While this should be based on science, we should understand the dietary
patterns of the consumers, and what behaviors or behavior changes are encouraged. When changes
in dietary pattern are advised, the question of whether the public is ready for such change should
be considered, and whether there may be a need for transitional messages. The bottom line is
whether the current dietary guidelines are understood, utilized and followed by the consumers.
With respect to the relevance of current messages, the guidelines should not only be culturally
specific for the country but population specific as well. There may be urban-rural differences that
need to be considered. The participants agreed that the messages should reflect the changing
public health problems of the population, such as the increasing incidence of obesity and chronic
diseases like diabetes and heart disease in relation to the trend in carbohydrate intake. While
agreeing with the FAO/WHO recommendations of 55% to 70% of total calories as carbohydrates,
the participants felt that consideration should be given to the caloric intake of the population, the
effect of changing the level of carbohydrate intake on the other macronutrients especially fat, and
on the intake of micronutrients and other functional food components that are present in
carbohydrate-rich foods. Consideration should also be given to the different physical activity levels
in the population. Moreover, it is not enough to express carbohydrate recommendations in terms
of total amounts and proportion to total calories, but there is a need to be more specific as to
the type of carbohydrates such as starch and complex or unrefined carbohydrates, simple sugars,
dietary fiber, under-milled grains, etc. The effect of carbohydrates on performance, as well as the
role of carbohydrates in obesity, diabetes, metabolic syndrome, and other metabolic abnormalities
should be taken into account. However, any recommendations on these matters should be based
on science.
The current dietary guidelines in the Southeast Asian region appear to be simple enough and stated
in layman’s terms to be understandable. However, there is a need for a supporting framework to
help the public apply the messages. Accompanying explanatory text in the form of brochures and
other informational strategies would be useful. The use of a pictorial guide such as the Food Guide
Pyramid may be helpful, but again this should be culturally appropriate. Care should be taken with
regards to the amounts and portion sizes recommended as these may be unrealistic and difficult
to follow. The wording of the guidelines should be carefully examined for clarity. For example,
“unrefined grains” may be better understood than “whole grains”. Descriptive terms such as “high”
or “low” need to be defined. Apart from the guideline for the general population, there may be a
need for guidelines for specific groups such as the elderly, pregnant and nursing women, adolescents,
and those suffering from chronic diseases like diabetes, heart disease, etc., where the recommendations
could be more specific and focused. Likewise, distinction may be made between guidelines for
professionals and guidelines for the general public.
The issue of whether current guidelines are being utilized by the public and their impact on the
population was extensively discussed. There is a dearth of information on how the current guidelines
are being understood and used by the public. There is thus a need for monitoring and evaluating
the effectiveness of the guidelines in improving the diet of the population. Monitoring the efficiency
by which the guidelines are being delivered and disseminated in addition to evaluating their
effectiveness was also suggested. It is important to know if the guidelines are reaching the people
who need to know, and not only the individuals who are already health-conscious. All this information
is essential in formulating effective strategies to convey the messages of the guidelines. Ultimately,
the challenge is how best to inform and educate the public together with the media on the
recommended dietary guidelines.
The participants also recognized the important role of the guidelines in industry. Industry is in fact
looking at the guidelines as an expression of policy with regards to the recommended dietary
pattern for the population. Based on this, industry may take certain directions in terms of product
development. As such, there is a need to consider the contribution of processed foods and fast
foods to achieving the objective of the guidelines.
Finally, the issue of harmonizing the different country guidelines currently being used in the region
was discussed. ILSI SEA Region has in fact taken steps towards this direction. In 1996, ILSI SEA Region
organized the Regional Workshop on Food-Based Dietary Guidelines (FBDG) for Asian Countries
held in Singapore, and in 1998, ILSI SEA Region together with FAO followed this up with the
Seminar/Workshop on FBDG and Nutrition Education held in Kuala Lumpur, Malaysia. The recent
review of Dr. Tee on the dietary guidelines in the region and around the world focusing on
carbohydrates has again shown the similarities and differences of the guidelines used in the region.
Nevertheless, it was apparent that there were striking similarities among them, particularly on
carbohydrates.
The Panel Discussion ended with a summary by Dr. Tee of the major points taken up, such as the
need to consider the changing trends in public health problems in the region, the importance of
monitoring and evaluating dietary patterns not only for evaluating the effectiveness of the
recommended dietary guidelines but to point to future directions that the guidelines should take,
and the need for guidelines directed to specific population groups and targets.
Editor
Dr. Rodolfo F. Florentino is currently the Chairman-President of the Nutrition Foundation of the
Philippines, and a Scientific Director of the International Life Sciences Institute, Southeast Asia
Region. He is a Fellow of the International Union of Nutrition Science, and a Fellow of the Philippine
Association for the Advancement of Science. He is a member of the WHO Expert Advisory Panel
on Nutrition, the National Research Council of the Philippines, the Board of Directors of the Philippine
Association for the Study of Overweight, Obesity (PASOO), and the Osteoporosis Society of the
Philippines (OSPFI). Dr. Florentino has been in the nutrition field since 1958. From 1983 to 1997, he
served as Director of the Food and Nutrition Research Institute (FNRI) of the Philippines.
For more information on ILSI Southeast Asia Region, its activities
and a listing of its publications, contact:
ILSI SOUTHEAST ASIA REGION

Regional Office
One Newton Road, Goldhill Plaza, Podium Block #03-45, Singapore 308899
Tel: (65) 6352 5220 Fax: (65) 6352 5536 Email: ilsisea@singnet.com.sg
website: www.ilsi.org
MONOGRAPH SERIES ROLE OF CARBOHYDRATES IN HEALTH & DISEASE: EVALUATING SCIENTIFIC EVIDENCE FOR DIETARY GUIDANCE

ILSI SEAR Monograph Carbohydrates

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MONOGRAPH SERIES

INTERNATIONAL LIFE SCIENCES INSTITUTE

Copyright © 2006 International Life Sciences Institute (ILSI)

International Life Sciences Institute (ILSI)

Yeong Boon Yee

Carbohydrate Definitions: Are They Important?

Available and Non-Available Carbohydrates:

Understanding Carbohydrates and Health

Glycemic Indexes, Glycemic Impact and Virtual Food Components:

Carbohydrates and Obesity

Carbohydrates and Oral Health – Dental Caries:

Carbohydrates in the Prevention and Treatment of Diabetes

Carbohydrates and Gut Health: Probiotics and Prebiotics

Grains in the Diet: A Historical Perspective of Grain Nutrition

Sweeteners in Life and Health

Carbohydrate Dietary Guidelines from Around the World

Carbohydrate Definitions: Are They Important?

Dietary fiber consists either of:

Available and Non-Available Carbohydrates:

Health Effects of Fiber in the Colon

Fiber and Colorectal cancer

Colorectal Cancer and Stool Characteristics

Colorectal Cancer in Southeast Asia

Fiber Interventions in Preventing Recurrence of Adenomas

Resistant Starch and Colorectal Cancer

A case-control study. Ann Intern Med. 1993 Jan 15;118(2):91-5.

Understanding Carbohydrates and Health

Carbohydrate Intake and Glycemic Control

Sugars and Short-term Satiety

Sugars and Health

Glycemic Indexes, Glycemic Impact and Virtual

Studies on Links to Health Support GIcarb and GL also Support GGE

GIcarb, GL, RGP and RGI Are All Expressions of GGE

Communications of Glycemic Potency Are All Based On Relative Response To Food

Glycemic Glucose Equivalent (GGE) is the Basic Datum Describing Glycemic

IAUCfood Wt glucose used for IAUCglucose

Figure 1. The relationship between carbohydrate (CHO)-referenced and food-referenced

Glycemic Index of Carbohydrate (Food-based, Carbohydrate-Weighted)

IAUC/g food (50/Pac)

Glycemic Load (Food Based, Calculated From GIcarb)

IAUC/g food (50/Pac)

GL Contains an Intrinsic Error

A more correct calculation of GL is therefore:

GL = GIcarb x Pac x Food wt. x Q

Q is the factor required for dose-transformation of GI so that GL = GGE.

RGP and RGI (Food-based, Determined directly) Adjusted for Non-Linearity

IAUC/g food Wt glucose used

Meeting the Needs of Consumers

Criteria for Assessing Measures of Glycemic Potency and Glycemic Impact

• make sense to the users;

Criterion GIcarb RGI Comment

The Nutritional Context of Glycemia Management

Figure 2. Multidimensional representation of nutrients, virtual food components including

The Future: Food Effects, Individual Responsiveness, Personalized

Carbohydrates and Obesity

Fructose and Lipids

Resistant Starch and Obesity

Fiber and Obesity

Carbohydrates and Oral Health - Dental Caries:

Figure 1. Social determinants of oral health

Source: Oral Health Promotion, Evaluation Toolkit12

Risk factors/ Personal Group Population

Figure 2. Changing severity of dental decay in New Zealand children

Reconstructing Appropriate Population Models of Oral Health