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Research Article *Corresponding author Omar Obeid, Professor in Human , Department of Nutrition and Sciences, Faculty of Agricultural Regional Policies on and Food Sciences, American University of Beirut, Beirut, Lebanon. P.O. Box 11-0236, Lebanon, Fax: Intake Reduction at Population 00961-1-744460; Tel: 00961-1-350000; Ext 4440, Email: Submitted: 10 May 2018 Levels to Address in Accepted: 18 May 2018 Published: 19 May 2018 Copyright the Eastern Mediterranean © 2018 Obeid al. Ayoub Al Jawaldeh1, Carla El Mallah2, and Omar Obeid2* OPEN ACCESS 1Department of Non-Communicable Diseases and Mental Health, World Health Organization (WHO), Egypt Keywords 2Department of Nutrition and Food Science, American University of Beirut, Lebanon • Sugar; Refined Carbohydrates; Supply; Availability; Intake

Abstract Sugar intake was reported to be associated with the increase in body weight and adiposity as well as several non-communicable diseases (NCDs). This relationship has highlighted the importance of reducing sugar consumption among all populations, especially those who experience nutrition and dietary transitions. The Eastern Mediterranean Region (EMR) was described to have the highest increment of sugar intake over the past few decades, and this paralleled increased rates of obesity, dental and oral health problems, and others NCDs. The WHO – EMRO developed a very strict regional policy to reduce sugar intake, which requires a major change in food intake patterns. In brief, sugar supply (kg/year or energy %) in EMR seems to be relatively close to that of Europeans and Americans and this is further compounded by a massive intake of refined carbohydrates that mainly consist of milled cereals, specifically rice and wheat (double that of EU and America). Thus, recommendations should address both sugar and refined carbohydrate for fruitful results. This review discusses sugar recommendations, availability and intake as well as other sugar-related topics in countries of the EMR. It is always believed that life becomes sweeter without adding sugar!

INTRODUCTION in nutrients and highly caloric was correlated to high intake of Sugar intake has increased over the past few decades and has become an important contributor to the daily total energy refined carbohydrates, defined as free and refined starchy intake. Although sugar per se does not cause direct harm to the namely refined cereals [10], which raises the energy density human body, it is known to increase daily energy intake and however,and decreases the loss nutrient of nutritious density compounds[11]. The refinement was described process to goof thus contribute to increased body weight and fatness [1-4], an cereals is known to decrease the fiber content by more than 50%; underlying condition of several health problems such as [5] and hyperlipidemia [6]. B6)beyond that theare onesbelieved of fibers to support [12]. carbohydrateA milled grain metabolism. retains less Thus, than Additionally, sugar intake is the fundamental cause of tooth 70% of the initial micronutrients (like phosphorus and vitamin on inducing serious dental erosion and decay throughout life, increasedietary patterns the risk of that the heavily onset of depend obesity on[13] refined and other carbohydrate metabolic i.e.decay into that the affects eighth children decade with of life.their In first fact, set sugar of teeth is and considered carries (sugars and refined cereals) and other low nutrient foods cariogenic as its fermentation creates acidic conditions which increase risks of dental decays [7]. Caries is not only one of energyabnormalities intake, especially such as non-communicable in heavy cereal-consuming diseases communities (NCDs). In the most costly diseases affecting countries, but it also induces [14-16],fact, refined like cereals ours. Therefore, constitute they a larger form proportion stronger determinants of our daily infections in children leading to emergency hospital admissions. It also impairs their physical growth and their attendance and accused to cause more cardiovascular harm than saturated learning ability at school [8]. [17].of health problems. For instance, refined carbohydrates were Further correlations between sugar intake and different diseases have been studied and yielded different outcomes. Multiple correlations and regression analyses showed that higher cerealsNevertheless, and sugar-sweetened high sugary foods beverages are reported like sodas to andsubstitute fruit- sugar consumption worsens schizophrenia and is associated with nutritious foods; whole grain cereals are replaced by milled greater prevalence of depression [9]. Hence, high , phosphorus and B-vitamins products are exchangedflavored juices for highreplace sugar milk and and zero dairies nutrient specially products. among children. Several authors described nutrient inadequacy when sugar intake increases, yet the data are controversial. A poor diet, low Consuming too many foods and drinks rich in sugar increases

Cite this article: Al Jawaldeh A, El Mallah C, Obeid O (2018) Regional Policies on Sugar Intake Reduction at Population Levels to Address Obesity in the Eastern Mediterranean. JSM Nutr Disord 2(1): 1006. Obeid et al. (2018) Email:

Central Bringing Excellence in Open Access the concentration of energy per unit weight in foods, which Data extraction means that, given the less effective brain regulatory systems for preventing weight gain rather than weight loss, children and Irrelevant papers are excluded and all related ones are entirely adults, particularly if they are genetically sensitive, will gain readRelevance and data wasare decidedretrieved upon as needed. reading Although the title and our the target abstract. was weight [18]. A high level of free sugars intake increases energy to collect national studies that are representative, small scale studies were also included because the national ones were rare with a poor quality diet, which is often short in important nutrients.intake without children and adults realizing; it is also associated andDEFINITION very hard to ANDfind. SOURCES OF SUGAR Sugar in many forms of drinks, i.e. soft drinks, etc. on the basis of clinical trials and some longitudinal studies leads to a greater Definition of sugar and seem to evade the normal brain regulatory processes to an evenlikelihood greater of extentweight than gain energy-rich [19,20]. These foods. products So, energy-rich are energy-rich drinks Varied terminologies around the world are used to define are particularly conducive to weight gain. Attempts to replace references.“sugars”. The In general, supplementary the terms table“sugar” (Table or “free S1) sugar” lists or different “added sugar”definitions are found and categories in studies of that sugars assess according sugar intake to several among populations and they mainly mean the amount of sucrose added sucrose with low-calorie artificial sweeteners did not show increase the risk of diabetes but mainly by promoting weight gain to food and beverages during processing or preparation. impressive results. Artificially sweetened drinks also seem to report also assessed these drinks in relation to the development Sources of sugar ofand diabetes obesity. and The found UK Government’s a clear link to theScientific development Expert Committeeof diabetes

productionGlobally, decreased 86% of sugar in the supply past fourcomes years from despite sugar thecane, increase which independent of weight gain [21]. inis consumption produced by and few raised counties its withprice. tropical climates [23]. Sugar and sugar supply and consumption emphasizes the importance of reducingThis association sugar intake, between especially the worldwide in areas increase where nutrition of NCDs transition was highlighted. Policy-makers and program of sugars. Their main “food providers” of sugars are soft drinks, tableAmericans sugar, candies, are known cakes, to cookies, consume pies, a significantly and fruit drinks high followed amount levels and their sources in both foods and drinks. They should by milk based desserts such as ice cream, sweetened yogurt, and alsomanagers consider in EMR the are development advised to assess of nationwide current free measures sugar intake that othersSUGAR [24]. PRODUCTION, IMPORT, EXPORT AND aim at transforming the food chain in their country [22]. The SUBSIDIES IN THE REGION thefact adoption that, refined of policies carbohydrates and measures (sugars that andtarget refined all for cereals)optimal Sugar is considered an important low cost contributor of outcomes,constitute moresince thanfree sugars60% of aloneour daily solve energy a small intake, fragment necessitate of the energy intake. Almost all countries have high import dependency problem. (Table 1), which makes sugar relatively costly. Several EMR countries depend (Egypt, on Iran, import. Pakistan In addition, and Sudan,) several are countries known are to The objective of this review is to provide an updated summary that help countries decrease their intakes, abiding by the new knownproduce to significantsubsidize sugar amount prices, of keeping their need, it an affordable while remaining source on sugar consumption in the EMR and to suggest strategies recommendations. This report sheds a light on the importance of of energy especially among poor populations. Below is a list of interest to promote health-conscious populations. sugar metabolism rather than just intake; which would be of high countriesRECOMMENDATIONS that have policies to support sugar subsidies (Table 2). METHODS Literature search recommendations for sugar consumption. Strong evidence The WHO report, issued in 2015, suggested new

supports reducing free sugar (that is monosaccharide’s and Online database on sugar intake in the EMR (a total of 22 libraries, and Good Scholar. The terms used to search data were disaccharides added to foods and beverages, as defined by FAO/ countries) were accessed on July 2015 using Pub Med, AUB daily total energy intake, in both adults and children. A further WHO, 2015, refer to Table S1) intake to less than 10% of the [37]. Individuals who consume less than the recommendations “Sugar” OR “Sweet” OR “Dessert” OR “Sweetened Beverages” reduction to less than 5% is advised yet considered conditional OR “Dietary Pattern” AND/OR “Intake” OR “Consumption” AND “EMRO” OR “EMR” OR the name of the country e.g. “Lebanon”. shouldThese not percentages increase their do intakes not provide to reach a clear the 10%.picture if the total energy intake exceeds the acceptable ones. In this framework, Additional data are retrieved from the WHO Regional Office of the Eastern Mediterranean (http://applications.emro.who.int/ accordance with the WHO recommendations, calculated a library/Databases/wxis.exe/Library/Databases/iah/). Books, associations e.g. AHA, are also visited. recommendedthe World Cancer amount Research of sugar Fund intake. International A person should(WCRFI), have in national/regional reports, guidelines, and website of scientific

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Figure 1

Trend of the sugar consumption in the six WHO regions from 2000 to 2007, retrieved from Khan, 2011 [25].

Figure 2

Sugar supply (g/capita/d) in the Eastern Mediterrnean countries in 2013, data from FAO stat, 2017. JSM Nutr Disord 2(1): 1007 (2018) 3/16 Obeid et al. (2018) Email:

Central Bringing Excellence in Open Access which are equivalent to 6 teaspoons of sugar. A further decrease no more than 50 grams daily (10% based on a 2000 kcal diet), that exceeded that of Western Europe (109.5 g/day). According allowanceto the WCRFI for recommendations wastage was factored, (50 g/day), which only is known Afghanistan to better and of fewer than 25 grams (5% based on a 2000 kcal diet) is of Iraq had appropriate sugar intake (Figure 2). However, if 20% additional health benefits, suggested the WCRFI [23]. reflect intake, Yemen, Sudan and Pakistan would have been very Lower recommendations were advised by the American close to the WCRFI recommendation. Heart Association [24] that blames sugar for contributing to the obesity endemic in the ; no more than 100 kcal/d The percentage energy intake from sugar of all EMR counties for women and 150 kcal/d for men are suggested. was lower than that of North America (15%), while few countries like Djibouti, Jordan, Lebanon, and Sudan had similar values to recommendEuropean anguidelines, average European intake of Food added, Safety non-milk Authority extrinsic (EFSA) Western Europe (13%). Six countries (Kuwait, Morocco, Oman, and Committee on Medical Aspects of Food Policy (COMA), Pakistan, Tunisia, and Emirates Arab United) had a value close to 10%, while five countries (Afghanistan, Egypt, Iraq, Iran and sugars, that does not exceed 10%. SaudiIn Arabia)order to were build below an idea the WHOon the cutoffs trend (Figureof sugar 3). availability, we looked at sugar supply of four countries with different levels Different percentages were also suggested; added sugars sugars of total food energy according to the UK Food Standards of income. In brief, the trend of sugar supply doesn’t seem to be Agencyshould be [38] no and more the than dietary 5% of guidelines free sugars for and10% Americans of added [39], respectively. associated with the economic status and country income (Figure 4). The average sugar consumption in the Region is lower while WHO – EMRO developed a policy statement and action plan the prevalence of obesity, reflecting also the prevalence of NCDs, in sugar reduction [22], based on the WHO guidelines, taking pooris higher nutrient than support the ones of incarbohydrate Europe and metabolism American. Thisand thus further to in consideration energy intake per person a day exceeds 2000 confirms the suggested hypothesis that sheds the light on the kcals in all countries of the Region, with almost half the countries reaching or almost reaching 3000 kcals a day [21]; therefore, Kuwait,refined carbohydratethe region with intake the highest rather prevalence than sugar of intake. obesity Figure is not 3 average sugar intakes should fall by more than 50% for both thealso one proves with that the obesityhighest issugar not onlyconsumption. dependent In on parallel, sugar intake;Sudan, children and adults, or to less than 5% of food energy , equivalent with a low obesity rate is amongst the countries that have the to less than 35 grams per day for men and less than 25 grams per highest intake. daySUGAR for women SUPPLY and children AND INTAKE [22]. IN THE REGION Sugar intake in the Region which have affected the quality of the diet of the Middle the same geographical location but also have similar cuisine, The EMR has been witnessing several nutrition transitions traditionalThe Eastern foods, and Mediterranean dietary habits. countries do not only share consumption globally and this dietary transition has markedly Eastern population. The Region has the fastest growth in sugar These changes in dietary patterns have favored higher sugar reduced the quality of the diet among the population [21,25]. Data that show major sources of sugars, whether added or naturally occurring, were not available for the EMR. Some papers intakes and the increment of sugar consumption between 2000 and reports describe the main sources of sugars in the EMR as and 2007 was classified the largest amongst all WHO regions the following: soft drinks, sweetened tea, canned juice and fruit rapid country-base evaluation. However, some country-related dietary and cultural habits as (Figure 1). This alarming situation highlights the importance of a flavored drinks, chocolate, candies, and Arabic sweets. well as some small-scale studies have helped in drawing a clear picture. AFRO: Africa Regional Office Tea is considered the main traditional beverage in almost all AMRO: Americas Regional Office several countries [48,49]. Black tea is usually consumed hot with EMRO: Eastern Mediterranean Regional Office acountries considerable of EMR amount [40-47], of andtable the sugar main that source usually of cane exceeds sugar two in EURO: Europe Regional Office teaspoons per serving. Tea consumption is common at all times, with breakfast, dinner, between meals, and at night. It is well SEARO: South East Asia Regional Office SugarWPRO: supply: Western amounts, Pacific Regional percentages Office and trends in the region known that some dietary habits target specific age range (e.g. soft drinks are mostly consumed by children and adolescents); however, tea in the EMR does not spare any age category even young children [50,51]. Palestine,Based on Qatar, the FAO Somalia, stat 2017, and Syria data whichon sugar were supply missing, per capita were of all the Eastern Mediterranean countries, except Bahrain, Libya, Data are missing for the following countries of the EMR: Bahrain, Libya, Palestine, Qatar, Somalia, and Syria. A subtraction drawn in Figures 2 and 3. of 20% of the present numbers (due to wastage) is a better reflection of intake. The red diet. and green lines show equivalent The sugar supply (g/day) of all EMR countries was lower than amounts of the recommended 10% and 5% of a daily energy that of North America (145.8 g/day) and only Jordan had a supply intake based on a 2000 kcal JSM Nutr Disord 2(1): 1007 (2018) 4/16 Obeid et al. (2018) Email:

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Figure 3

Percentage energy intake from sugar (blue) in the Eastern Mediterrnean countries in 2013, data from FAO stat, 2017and pervalence of obesity among adults (red). Data in FAO are missing for the following countries: Bahrain, Libya, Palestine, Qatar, Somalia, and Syria. The red and green lines show equivalent amounts of the recommended 10% and 5% of a daily energy intake based on a 2000 kcal diet.

Figure 4

Sugar supply (kcal/capita/d), rate of obesity, and gross national product Egypt, Lebanon, Morocco, and Saudi Arabia between 2013 and 2015, data from FAO stat 2017 Gross domestic product per capita, PPP (constant 2011 international $) Prevalence of obesity in the adult population (18 years and older) The relatively high temperatures that reign the region favors These items, sold in schools, are mainly highly consumed by the intake of cold sweetened beverages such as soft drinks and preservation, they have low risk of contamination and food witnessed by the region has dramatically increased the intake of poisoning,students because and they they are dousually not requireaffordable specific and easily conditions unpacked for thesefruit-flavored beverages drinks which [40,48,52-60].are not part of the The dietary food westernizationheritage of the by young children. These facts have made these options highly region. preferred by both schools and children. The traditional dietary patterns, the cultural and social habits, and the nutritional transitions, have all contributed to this high routineSocializing daily situations over sweets such is as a lunch tradition or dinner among invitations Eastern intake of sugar among all age groups of this region. includeMediterranean the consumption populations of sweets.especially Thus, Arabs. daily Even high the intake most of sugar is expected to be part of the cultural habits of the region. Refined carbohydrate intake Other sources of sugar are chocolate, biscuits, and candies. Recent dietary recommendations focus on having low intake JSM Nutr Disord 2(1): 1007 (2018) 5/16 Obeid et al. (2018) Email:

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Figure 5

Percentage energy intake from cereals (excluding beer) (light blue) and sugar (dark blue) in the Eastern Mediterranean countries in 2013, data from FAO stat, 2017. of refined carbohydrates including sugar [39]. The dietary habits unlike thateals. of refined cereals. In brief, the high intake of refined in the EMR (Figure 5) are characterized by a high intake of refined carbohydrates in the EMR is highly attributable to the intake of cereals (mainly wheat, rice and their products) that overcomes EFFECTIVErefined cer POLICIES AND STRATEGIES TO (almost double) the intake among Northern Americans and REDUCE SUGAR INTAKE Western Europeans. Thus, the average supply of sugars in EMR seems to be close to that of North America and Western Europe, A multidisciplinary approach involving policymakers, media, Table 1: social partnerships, academics, etc. is mandatory in order

Sugar production, import, and export of countries of EMR in Production Import Export metabolism among populations. Policies should include building Country2013, data from FAO stat, 2017[26]. to reduce refined carbohydrate consumption or support its 1000 metric tons marketing strategies to counter the exaggerated intake of sugar, Afghanistan 4 conducting awareness and providing reliable information, Bahrain controlling promotions on unhealthy high sugary foods and 288 0 Djibouti beverages and milled cereals, improving access to alternative NA NA NA Egypt 0 217 109 Iran 1455 54 in kindergartens, schools, universities, and workplaces where 2187 1068 322 peoplehealthy spend food (wholemost of grains), their time. etc. As Implementations part of monitoring, should studies start Iraq 1 676 990 Jordan 384 47 0 continuously performed in order to evaluate the effectiveness of Kuwait 13 0 thethat strategies. assess large-scale refine carbohydrate intakes must be Lebanon 315 NA 172 Libya 2 62 SUGGESTED MEASURES TO MINIMIZE SUGAR Morocco 964 54 NA NA NA INTAKE IN EMR Oman 119 402 Pakistan a- Reformulate sugar-rich foods and drinks to lower 0 10 Palestine sugar intakes 5283 30 1211 Qatar This measure is recognized to be highly effective and requires NA NA NA Saudi Arabia 437 the government to set appropriate food and drink standards. NA NA NA Somalia NA 1840 Sudan 617 47 measures to reduce sugar in food and drinks they become very NA NA NA Syria concernedExperience if alsoother shows competitor that when companies responsible do not do companies the same takeand 1525 Tunisia 19 NA NA NA UAE set by the government allows all companies to operate on the 10 400 gain a commercial advantage. Establishing common standards Yemen 8 4 same basis. NA 2554 932 701 NA: Data not available JSM Nutr Disord 2(1): 1007 (2018) 6/16 Obeid et al. (2018) Email:

Central Bringing Excellence in Open Access b- Set standards for all food and drink served by government-sponsored institutions In adults, table biscuits, buns, cakes, pastries and puddings, fruit cereals, confectionery and fruit juice may be the major sources. Progressive policies should specify that no sugar sweetened easier to formulate priority changes once a country knows the drinks should be offered for sale and the amount of sugar used by sugarjuices contentand soft of drinks the principal may be itemsthe main in its sources. diet, but It sugarywill be drinks much all caterers and food manufacturers supplying the government should be limited as much as possible and ideally be eliminated facilities should be progressively reduced. as a source of caloric intake. c- Restrict promotion of sugar-enriched products, d- Impose restrictions on marketing, advertising and especially drinks sponsorship of all sugar-enriched foods and drinks across all Price promotions are used for increasing sales and this is media platforms The marketing of inappropriate sugar-enriched foods sales of sugar-enriched soft drinks have been increasing rapidly and drinks is becoming increasingly aggressive as the region overparticularly the last evident two decades in the [61].Eastern Price Mediterranean promotions like Region, presenting where represents an ideal marketing opportunity due to limited two items for the price of one, price reductions or increasing the regulatory restrictions. Special measures are needed to address portion size for the same price are known to be highly effective the unopposed marketing on satellite television channels and in encouraging consumers to purchase and consume more of a product. andacross drinks all digital and these media. restrictions Several European are sometimes countries accompanied now have source of sugar for adolescents, but there is a need to establish bymajor taxes restrictions and health on warnings sales promotions associated of with inappropriate each advertising foods Soft drinks (excluding fruit juice) may be the largest single slot and advertisement. Sponsorship of sporting events is a notorious avenue for promoting the consumption of sugary and the major sources of sugar in the diet. Table sugar, confectionery, fatty products and this form of advertising is increasingly seen as softand drinks,fruit juice biscuits, are often buns, large cakes, contributors pastries and to puddings, the sugar breakfast intake of detrimental to public health. adolescents in the Region. For younger primary school children,

Table 2:

Countries of EMR that have sugar subsidies policy. thatshows helps that reducing almost all sugar countries intake. of the EMR have policies that support sugar subsidies. Eliminating food subsidies for sugar used in industries (pastries, candies, chocolate, sweets, etc.) will raise the price of the industrial products that are high in sugar and this can be a potential strategy Country Sugar Subsidies Law Reference Afghanistan

Bahrain NA NA No NASdarlevichet al. Djibouti Yes Sdarlevichet al., 2014[27] IranEgypt Yes , 2014[27] Iraq Yes Iqbal, 2006[28] Jordan Yes FAO,Sdarlevich 2014 et[29] al. Kuwait Yes , 2014[27] Yes Albawaba, 2012 [30] Lebanon Yes Ministry of Finance Thematic Reports, 2012[31] LibyaMorocco Yes SubsidiesSdarlevich inet Libya,al. 2013[32] Oman Yes , 2014[27] Pakistan NA NA Palestine Yes State Bank of Pakistan, 2015[33] Qatar NA NA Saudi Arabia NA NA Somalia NA NA Sudan NA NASdarlevichet al. Syria Yes , 2014[27] Tunisia Yes FAO, 2003[34] Yes Iqbal, 2006[28] UAE Yes Trade Arabia, 2008 [35] Yemen Yes Republic of Yemen: Selected Issues, 2001[36] NA: Data not available JSM Nutr Disord 2(1): 1007 (2018) 7/16 Obeid et al. (2018) Email:

Central Bringing Excellence in Open Access e- Use nutritional profiling to establish clear roadmap in nutrition for the member states to implement the definitions of foods and drinks high in sugar

WHO-developed methods for assessing the appropriate levels Global Targets and ICN-2 recommendations [63]. National of nutrients, including sugar and a method has been established strategies and/or national action plans developed in most countries of the Region. Promoting healthy diet is a key strategic setting the criteria for developing clear, understandable methods and a cost effective intervention identified by the Regional for use in marketing in the Region [62]. There are also methods of theCommittee International within Code the Regional of Marketing Framework of Breast-milk for Action Substitutes, to address being used internationally and for which there is extensive NCDs, including: Promoting breastfeeding and implementing of food labeling, e.g. traffic light labeling, which is increasingly reducing salt intake at population levels, replacing trans-fats with polyunsaturated fats at population level and obesity control evidencef- Eliminateof its usefulness sugar for subsidiesinterested consumers. provided by national and prevention, including sugar reduction [64]. governments and introduce progressive taxes initially on sugary drinks and then on all foods and drinks with added sugar The WHO Regional office developed a “Proposed policy priorities for preventing obesity and diabetes in the Eastern often used but economic analyses suggest that a minimum of Mediterranean Region” where sugar imported in most countries An initial retail price increase of 10% on sugary drinks is of the Region, except in Egypt where there is some home pervadesproduction the and food in system Pakistan and whichis abundantly is the used fifth in largest all catering sugar ofa 20%the impact increase of insuch retail measures price is in needed several to countries induce appreciable and in the outletsproducer including and exporter those in in the the world. public Throughout sector such the as Region government sugar Unitedchanges Kingdom in intake where(10 included the Government already). There has proposed is new evidence a price amount used in these outlets as well as reducing sugar subsidies anddepartments, then progressively the military taxing and the sugar police containing [65]. Reducing soft drinks the increaseg- greaterImprove than accredited 20% on sugary training soft on drinks. diet and health for involves initiatives by many government departments. Many individuals with opportunities to influence population food countries commend with the implementation of the “Policy choices statement and recommended actions for lowering sugar intake Those eating in facilities provided in schools, hospitals, government departments and other national groups, e.g. and reducing prevalence of type 2 diabetes and obesity in the the military or police are totally dependent on the choice of Eastern Mediterranean Region” [66]; including opposed Sin Taxes ingredients made by the caterers. In many countries, these on Soft drinks; . KSA is the first Country at GCC to implement the caterers have little understanding of nutrition but in providing Taxes on soft drinks and fizzy drinks -The GCC Member States an appreciable part of the daily intake of those attending they have agreed to impose excise tax rates of 50% on soft drinks, and 100% on energy drinks [67-69]. Few countries removed subsidy substantial number of people. So, if the governments target these on sugarBesides such pricing as Jordan strategies, and Egypt. guiding consumers to buy healthier caterershave, in with practice, skilled a majorpractical influence advice to on reduce the dietary sugar qualityuse, as well of a as salt and content of the foods that they serve, then these changes would automatically impact an appreciable proportion food products is an important food policy for preventing NCDs. labelingDue to the as critical an essential role of food approach labeling of on its health regional and and control global of depends on a cross-government initiative. NCDs, the world health organization (WHO) introduces nutrition of the population in the Region. This approach, therefore, h- Provide routine health education to populations the purchasing behavior of consumers, is being implemented in strategies to address NCDs(1). Food labeling as a means to change Given that unhealthy diets are one of the main causes of Iran, using traffic light labeling for content of fat, sugar, salt and health education about the importance of a varied diet low in trans-fattyRESEARCH acids GAPS of food AND products LIMITATIONS [70]. disease and disability in the Eastern Mediterranean Region, fats, sugar and salt should become part of the routine information The aim of this review was to present a brief overview of the provided both by doctors and the government in schools and in public information systems. a list of research limitations encountered the process. actual sugar consumption in countries of the EMR; nevertheless, Providing health education should be seen as a background We used the FAO database as a main source of information policy – it has to be combined with other measures, such as those since the same criteria are applied to all countries. However, 5 listed above. countries were missing in this database which has affected the whole picture of the region. PROGRESS IN EMR TO PROMOTE HEALTHY DIET INCLUDING SUGAR REDUCTION STRATEGIES consumption were rare. Although, when found, national studies Sustainable food systems are key to promoting healthy diets. providedFurthermore, better description national studiesof the whole on refinedstatus of carbohydrate the country, Governments are called upon to promote nutrition-enhancing small scale studies were used as indicator. and implementation of agricultural programs, ensure food Additionally, most of the surveys targeted schoolchildren as securityagriculture, and byenable integrating healthy diets nutrition [63]. objectivesWHO developed into the a regional design adults, if performed, was on small scales. they are more prone to oral/dental problems. Assessment on

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14. epidemic in india be explained, at least in part, Last but not least, a major problem was the lack of clear Mohan V, Radhika G, Vijayalakshmi P, Sudha V. Can the diabetes/ definition of “sugar” in the papers. In some cases, sugar as table by excess refined grain (rice) intake? Indian J Med Res. 2010; 131: hassugar made and honeythe comparison was studied; between in others, countries sugar wasvague the and group hard that to 15. 369-372. interpret.combined sweets and desserts as well. The varied classification Song S, Lee JE, Song WO, Paik H-Y, Song Y. Carbohydrate intake and CONCLUSIONS refined-grain consumption are associated with metabolic syndrome 16. in the korean adult population. J Acad Nutr Diet. 2014; 114: 54-62. The consumption of sugar has taken lots of attention when consumption and the metabolic syndrome in urban asian indians Radhika G, Van Dam RM, Sudha V, Ganesan A, Mohan V. Refined grain both obesity and diseases are tackled. Most updated dietary 675-681. guidelines and nutrition recommendations tend to only focus on (chennai urban rural epidemiology study 57). Metabolism. 2009; 58: white sugar that is added to food and drinks, while new research 17.

Hu FB. Are refined carbohydrates worse than saturated fat? Am J Clin that are quantitatively consumed in big amounts and need more 18. Nutr. 2010; 91:1541-1542. nutrientsattempts shed to be the metabolized. lights on reducing This report all refined suggests carbohydrates to cut down Amine E, Baba N, Belhadj M, Deurenberg-Yap M, Djazayery A, Forrestre T, et al. Diet, nutrition and the prevention of chronic diseases. World and nutrients intake for an enhanced sugar metabolism and a 19. Health Organ Tech Rep Ser. 2003; 916: 1-149.ó ítez- healthieron refined community. carbohydrates and to balance between their amounts Arciniega AA, et al. Soft drink consumption is positively associated Funtikova AN, Subirana I, Gomez SF, Fit M, Elosua R, Ben AUTHOR CONTRIBUTIONS with increased waist circumference and 10-year incidence of abdominal obesity in spanish adults–3. J Nutr. 2015; 145: 328-334. Contributed to the interpretation and writing of the manuscript. sports drinks with weight gain among adolescents and young adults. O.O.: Conceived, developed and drafted the work. C. E-M: 20. Field AE, Sonneville KR, Falbe J, Flint A, Haines J, et al. Association of

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52. Tayel DI, El-Sayed NA, El-Sayed NA. Dietary pattern and blood 72. Ervin RB, Ogden CL. Consumption of added sugars among us adults, pressure levels of adolescents in sohag, egypt. J Egypt Public Health 73. 2005-2010. NCHS Data Brief. 2013; 1-8. 53. Assoc. 2013; 88: 97-103. Dietary reference values for food energy and nutrients for the United Bazhan M, Kalantari N, Houhiar-Rad A, Alavi-Majd H, Kalantari S. 74. Kingdom. HM Stationery Office: C.o.M.A.o.F.P.P.o.D. 1991. Dietary habits and nutrient intake in adolescent girls living in northern Bresson J-L, Flynn A, Heinonen M, Hulshof K, Korhonen H, Lagiou P, et 54. iran. Journal of Paramedical Sciences. 2013; 4: 2008-4978. panel on dietetic products, nutrition and allergies on a request from theal. Review commission of labelling related reference to the intake review values of labelling scientific reference opinion intakeof the inKhosravi-Boroujeni relation to the metabolic H, Sarrafzadegan syndrome N, amongMohammadifard iranian adults. N, Alikhasi Obes H, Sajjadi F, Asgari S, et al. Consumption of sugar-sweetened beverages 75. values for selected nutritional elements. 2009. 55. Facts. 2012; 5: 527-537. Survey of sugar intake among children in scotland. Food Standards Sheehy C, McNeill G, Masson L, Craig L, Macdiarmid J, Holmes B, et al. 733.Hejazi N, Mazloom Z. Socioeconomic status, youth’s eating patterns and meals consumed away from home. Pak J Biol Sci. 2009; 12: 730- 76. Agency Scotland, Aberdeen, UK. 2008. 56. drinks and foods as a behavioral risk for health of adolescents in The national risk and vulnerability assessment 2011-2012 Honkala S, Behbehani JM, Honkala E. Daily consumption of sugary (afghanistan living conditions survey); Central Statistics Organization: 2014. kuwait. Oral Health Prev Dent. 2012; 10: 113-122. JSM Nutr Disord 2(1): 1007 (2018) 10/16 Obeid et al. (2018) Email:

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Gharib N, Rasheed P. Energy and macronutrient intake and dietary pattern among school children in bahrain: A cross-sectional study. 89. Oman. Nutr Health. 1996; 11: 29-48. 78. Nutr J. 2011; 10: 62. Gilani G. 30 years of polling on eating habits of Pakistanis (1980– Musaiger A, Bader Z, Al-Roomi K, D’Souza R. Dietary and lifestyle 2010); perceptions and preferences of pakistani public. 2011. 79. habits amongst adolescents in bahrain. Food Nutr Res. 2011; 55: 7122. 90. Hakeem R, Thomas J, Badruddin SH. Rural-urban differences in food Programme, U.N.W.F. Urban in-depth efsa djibouti; 2011. and nutrient intake of pakistani children. J Pak Med Assoc. 1999; 49: 91. 288-294.Alzain B. Anemia and nutritional status of pre-school children in 80. Programme, U.N.W.F. Comprehensive food security & vulnerability 81. analysis in Iraq. 2008. north gaza, palestine. International Journal of Scientific & Technology Bawadi H, Abu-Jamous D, Tayyem RF. Evaluation of the dietary pattern Research. 2012; 1: 86-91. of patients with type 2 diabetes in northern jordan: An inconvenient truth! International Journal of Diabetes in Developing Countries. 92. Project AZ. Determining the dietary pattern and biochemical markers 2014; 34: 134-138. 93. among women and children in hebron and gaza city. 2010. sociodemographic factors and dental caries in 4–5-year-old children Mohanna FA. Sugar-sweetened carbonated beverage consumption 82. Sayegh A, Dini E, Holt R, Bedi R. Food and drink consumption, correlatesCollison KS, with Zaidi bmi, MZ, waist Subhani circumference, SN, Al-Rubeaan and poor K, dietary Shoukri choices M, Al- in

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Table S1: Reference Term Definition Different definition of sugar. Monosaccharides and disaccharides added to foods and beverages by the Free sugars manufacturer, cook or consumer, and sugars naturally present in honey, syrups,

FAO/WHO Free sugars + intrinsic sugars + milk sugars. (WHO, 2015) [37] Total sugars fruit juices and fruit juice concentrates. They include syrups and other caloric sweeteners that are added to foods and Added sugars

Dietary Guidelines for Americans, 2015- Sugars and syrups that are added to foods during processing and preparation. 2020[39] beverages to sweeten them; they add calories without contributing essential. Added sugars corn-syrup solids, high-fructose corn syrup, malt syrup, maple syrup, pancake syrup,Specifically, fructose added sweetener, sugars include anhydrous white dextrose, sugar, brown and crystal sugar, dextrose. raw sugar, They corn do syrup, not Institute of Medicine, 2005 [71] include naturally occurring sugars such as lactose in milk or fructose in fruits. All sugars used as ingredients in processed and prepared

Added sugars whitefoods suchsugar, as brown breads, sugar, cakes, raw soft sugar, drinks, corn jams, syrup, chocolates, corn syrup and solids, ice cream, high andfructose sugars corneaten syrup, separately malt syrup,or added maple to foods syrup, at pancakethe table. syrup, Examples fructose of added sweetener, sugars liquid include NCHS, 2013 [72] fructose, honey, molasses, anhydrous dextrose, crystal dextrose, and dextrin Committee on Medical Aspects of Food Policy, 1991 Added sugars [73] Non-milk extrinsic sugars e.g. sucrose, glucose and fructose, and sugars naturally present in fruit juices, e.g. glucose and fructose Total sugars cereals and lactose in milk products) and added sugars. [74] Include both indigenous (sugars naturally present in foods such as fruit, vegetables, European Authority, 2009 Added sugars fructose syrup, isoglucose) and other isolated sugar preparations used as such, or addedRefer to during sucrose, food fructose, preparation glucose, and starch manufacturing. hydrolysates (glucose syrup, high-

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i.e. enclosed in the cell, the most important being whole fruits and vegetables) and Committee on Medical Aspects of Food Sugars Policy, 1989 Intrinsic sugars (sugars forming an integral part of certain unprocessed foodstuffs,

[75] Compriseextrinsic sugars both recipe (milk sugars and tableNon-milk sugars. extrinsic sugars, which includes fruit ( Scotland, 2008) Added sugars juices, honey, and added sugars).

Free sugars Non-milk extrinsic sugars which includes fruit juices, honey, and added sugars.

Table S2: Sample Age Country SugarReference intake in Eastern YearMediterranean countries. Type-Design Method Findings Comment Size Group - The average quantity of sugar available for This is Central consumption ranged 7 day food according Statistics Two-stage Afghanistan consumption to the food Organization years cluster design 2011- 0-85+ recall between 16 and 50 g/ commodity 21,000 - Sugar contributed to 2012 person/d status (2014) [76] energy consumption - Theonly intake5% of theof sugar total daily was Cross-sectional descriptive Intrinsic and 1999- 6-18 study using extrinsic sugars - The101.3±37.3 study also g for showed boys years A multi-stage recall are accounted [77]Gharib & thatand 89.1±36.1milk sugar for girls sampling 24-h dietary in this study Rasheed, 2011 2,562 decreased with age 2001 design Bahrain while sucrose increased Cross-sectional - High frequency of study self- Musaiger et al., 15-18 consumption of soft 735 multi-stage administered - years drinks, sweets, and questionnaire 2006 chocolate 2011 [78] sampling stratifiedTwo-stage random - Sugar is consumed at a Household Djibouti house- All random frequent of 6 days per - questionnaire holds1,251 sampling week WFP, 2011 [79] 2011 - This study Comparative normotensive students Tayel et al., which 175 food frequency included only cross-sectional had63.4% high of consumptionthe are300 nor of - years questionnaire students living 12-18 study of sweetened tea and 2010 motensive in Sohag 2013 [52] soft drinks Egypt - excess consumption of This study self- Abdel-Hady et Cross-sectional 54% of the students had included only administered al years study - high intake of students living 15-20 questionnaire sugar/sweet 2010 927 sweetened tea and soft in Mansoura ., 2014 [41] drinks This study - included only dietary recall, consumed sweets such Bazhan et al., 14-17 Cross sectional students from Iran - food24-hour habits and as87% confectionary, of the subjects sugar, years study public and food frequency 400 girls private schools 2013 [53] questionnaires daily basis jam and soft drinks on a - The average consumption of soft Thisin Lahijan study diets recalls included only 84 - Three 24 h years this is equivalent to a adolescents [55]Hejazi & and two week 12-16 minimumdrinks was 36g 360 of ml sugar and living in Shiraz Mazloom, 2009 2007 days)(one weekend

- High consumption of soft Khosravi- people lived 1999- 19+ Cross-sectional Food frequency et al., inRecruited Isfahan, years study questionnaire - drinks and artificially sweetened fruit juices Boroujeni 1,752 drinks, sweetened coffee, 2006 Usual intake of flavored Arak 2012 [54] and sports drinks Najafabad and

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- Food consumption scores increased sugar contribution increased. - Sugar and honey, pastry Food Security Survey zalabia) and sweets Iraq house- - Questionnaire (biscuits, baklavas, - holds25,875 WFP, 2008 [80] 2007 sampling and soft drinks were Random cluster consumed(chocolate, 7, candy…..), 3 and 3 times per week, respectively

cross-sectional Retrieved from: Nationwide Income and population - Sugar, confect, and DoS, Household survey was honey consumption Kharabsheh, - - - Survey, Jordan, Alwan & conducted using Expenditure 2002 multistage the total energy intake cluster sampling accounted for 14.4% of 2006 [42] not(1992-1997- found design 2002), source Semi- This study Jordan quantitative - Sugar accounted for Bawadi et al., Cross-sectional only included - food frequency years study 22-84 questionnaire energy consumption 750 around 20% of the total 2014 [81] type 2 diabetic - Confectionary was subjects reported to be regularly

of the 4–5-year-old childrenconsumed and by biscuits 76%

- This study Two-stage Sayegh et al., 4 and 5 reportedand/or cakes to drink by 71% only included sampling Questionnaire years More than 50% were kindergartens procedure 1,140 carbonated drinks in Amman. 2002 [82] regularlycanned fruit between juice and meals - Forty two percent were reported to consume teas with sugar

- did not prefer any ofOnly the 1% carbonated of the sample

- Tea and coffee are Martinez, 1984 - Adults Systematic study popularbeverages drinks or fruit and juice are [83]Kamel & consumed sweetened 500 24-hour recall with a considerable

Kuwait amount of sugar (3-4 - tsp/cup or more) snacks alone was 193.8 Sugar from identified The selection - Carbonated beverages, 8, 13 and was made in a 588 Questionnaire g/d [84] 17 years Al-Ansari, 2006 cakes are part of the jellies, ice cream, and in Kuwait daily schoolchildren specific region diet

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Quantitative The sample - Free sugars formed et Across-sectional food-frequency only included 444 al years dietary survey questionnaire people living in Nasreddine 25–54 energy intake 2001 11.4% of the daily Beirut ., 2006 [57] - Sugar and desserts Lebanon contributed between Baba, 1998 [85] - - - - - Cowan et al., energy intake in urban Data from 12.95% of the daily 1964 women men and 17.4% in rural The study - Total sugars involved Huew et al., students living Libya - 3 d food diary selected sample the daily energy intake, in Benghazi, the Randomly contributed 20.4% of 180 12 years second largest 2014 [86] and free sugars 12.6% - The intake of sugar per 1984- city in Libya - capita per year was 1985 years laRetrieved Statistique, from Benjelloun, 20+ Direction de 41,526 National survey 2002 [43] Morocco 27 kg The data - The supply of sugar and excluded1992 sugars la statistique, Questionnaire and honey in La direction de years 2000- 10+ desserts and 14,243 National survey honey exceeded 24 kg/ 2001 sweets 2001 [87] - Highcapita/year consumption of These This is based on Questionnaire Children sugars such as studies were Musaiger, 1996 1988- several rapid A qualitative Oman - and chocolatesfood rich in and refined sweets, performed on [88] 1991 assessment mothers biscuits, canned drinks people living in surveys recall 24 hour dietary and ice-cream among Muscat Omani The results presented here are from These multiple surveys nationwide range - house hold from 18+ Multi-stage - Questionnaire consumed sweets on a surveys years areaNational probability survey dailyOnly 2%basis of Pakistanis carried out Gallup & Gilani, sampling Pakistan by Gallup and 2011 [89] men1000- and Gilani over women2500 the last three

Three-day decades (1980- Hakeem et al., - Very frequent 1995 estimated diet 2010) years consumption of sugary 10-12 records 180 1999 [90] - Sweetened tea is often consumed between The results meals Short food- describe the - Sugar is a main Community- frequency patterns of Stene et al., 1996- contributor of energy Palestine based cross- questionnaire Palestinian 1999 [44] 1997 years sectional survey West Bank 30 - 65 - The mean household 500 without village consumption(13-14%) of sugar 24-h recall population

is 37.8 kg/consumption unit/year

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The study consumptionDietary was carried frequencysurvey: food and - The whole sample out three daily dietary had a daily sugar [91] months Alzain, 2012 24-62 recall for three consumption Beit hanon , 150 consecutive Jabaliacommunities( and Beit days lahia

-

Between 43 and 88% of Cross-sectional Children athe daily children sugar and and 27 sweet and population study Questionnaire The sample was 3-7 years intake79% of the women had 366 following a multiple pass recruited from Women - Sugars and sweets 345 multi-cluster Hebron and A2Z project, random Gaza City 2009 years 2010 [92] sampling 24-hour recall 18-50 intake informed children 8% andand women,4% of the respectively total energy

- had sweetened milk Questionnaire and51. 7% tea ofat thebreakfast sample Cross-sectional on food Visited schools Qatar survey on a frequency, years [45]Hassan & Al- random sample food habits and city 9-10 drinksand 98.8% and andcandy 41.7% and Dosari (2008) 2004 259 types of foods were in Doha chocolatehad fruit flavored as snacks at school, respectively - Soft drinks, milk with sugar, biscuits, The study was 6 years chocolate, and caramel Petersen, 1998 1995 - Questionnaire carried out in are consumed at least [58]Al-Tamimi & Madina City 240 once per day by the 240 12 years - A student consumed Saudi Arabia majority of the children The recruitment of total sugar per day Food was done Collison et al., Cross-sectional whichon average accounted 172.5 forg 9,433 Frequency in different years study more than 7 servings 10-19 Questionnaire regions of the 2007 per week and formed 2010 [93] capital city of total energy around 26.3% of the Somalia ------Riyadh - School-based survey 80.6%, 80.0%, 69.3%, Students two-stage consumed65.3%, 61.4%, respectively, 48.7%, attended public Food et al probability soft3.3% drinks, of the chocolates,children and private Sudan Frequency [59] proportional dessert, biscuits, schools in 7 Nazik . 2013 2007- Questionnaire 1109 12 years to size cluster popsicles, sweets, and main localities 2008 sampling sugar-sweetened hot in Khartoum technique beverages on a daily basis - consumed sweets Cross-sectional 35.3% of the subjects The sample was 15-18 multi-stage Syria 365 Questionnaire canned sugary selected from years [94]Musaiger & beveragesand 22.2% more consumed than Kalam, 2014 2012 sampling stratified four times per week Damascus

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- had sugar more than 3 The students times74% of a theday children were selected - Sweetened tea was from 4 the source of sugar geographical the mostly consumed Jaghasi et al., Food frequency areas with - years questionnaire diverse population, followed by 2010- 6–12 socioeconomic 504 plain(80 %) biscuits, by the samplebiscuits 2012 [47] 2011 characteristics with chocolate, and city in Damascus children,chocolates respectively by 52%, - Sugar44% and and 33% of confectionary are one of the main constituents of the diet with an Adolescents Semi- Aounallah- were chosen 15-19 Cross-sectional quantitative Tunisia Skhiri et al., from three years survey frequency - average intake of 34.8 ± regions of questionnaire 2005 1,019 1.2 g/1000 kcal Tunisia 2011 [95] theFree recommended sugar intake (26.8 level g/1000 kcal) exceeded

(10%) The study was performed - Jacob et al., 3-15+ Cross-sectional on University - Questionnaire years study students in drinksAmong on 125 health students, drinks 125 92% preferred energy 2003 [96] United Arab TheAjman, sample UAE was Emirates - Students who consume selected chocolate, sweets, and from between et al. Cross-sectional soft drinks more than - 661 Questionnaire different years study 4 times a week were geographical Bin Zaal 12-17 more prevalent than (2009) [60] those who consume less

- Sugar and honey are areas of Dubai house- consumed on average 6 Two-stage holds10,500 times per week This is a food Yemen - - - They are one of the sampling security survey women three main constituent techniquestratified WFP, 2014 [97] 2014 15,800 of energy children 13,400

Cite this article Al Jawaldeh A, El Mallah C, Obeid O (2018) Regional Policies on Sugar Intake Reduction at Population Levels to Address Obesity in the Eastern Mediterranean. JSM Nutr Disord 2(1): 1006.

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