Free sugar intake and dietary sources among adult population in Brunei: The national health and nutritional status survey

Nur Zakirah Hamdani; Haji Zakaria Haji Kamis; Hanif Abdul Rahman

doi:10.4103/WHO-SEAJPH.WHO_SEAJPH_275_20

ORIGINAL RESEARCH

Year : 2021 | Volume : 10 | Issue : 2 | Page : 90-94

Free sugar intake and dietary sources among adult population in Brunei: The national health and nutritional status survey

Nur Zakirah Hamdani¹, Haji Zakaria Haji Kamis², Hanif Abdul Rahman³
¹ PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam
² Health Promotion Centre, Ministry of Health, Brunei Darussalam
³ PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam; School of Nursing, University of Michigan, USA

Date of Submission	15-Oct-2020
Date of Decision	29-Jan-2022
Date of Acceptance	28-Feb-2022
Date of Web Publication	30-Apr-2022

Correspondence Address:
Dr. Nur Zakirah Hamdani
Universiti Brunei Darussalam, Gadong
Brunei Darussalam

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/WHO-SEAJPH.WHO_SEAJPH_275_20

Abstract

High sugar consumption is associated with increased risk of noncommunicable diseases. This study identifies the dietary sources of free sugars and explores association of sugar intake with related factors among adult population in Brunei. Data from the National Health and Nutritional Status Survey 2010, of 1559 adult residents of Brunei, aged 18–75 years, were extracted and analyzed. The results revealed that mean daily free sugar intake was 55.5 g/day (standard deviation [SD] -51.4), contributing to 14.5% of total energy intake. The prevalence of free sugar intake of <10% and 5% among the adult population was 60.1% (95% confidence interval [CI]: 57.6, 62.5) and 82.6% (95% CI: 80.6, 84.4), respectively. Free sugar from sugar-sweetened beverages was sourced from beverages prepared with sugar (17.9%), cordial and syrup (15.1%), and carbonated drinks (14.6%). Free sugar consumption was significantly higher in men (66.6 g/day, SD – 61.2) than women (46.2 g/day, SD – 39.1) (P < 0.001). Younger participants had significantly higher free sugar intake and percentage of energy from free sugar compared to older participants. This study provides justification for addressing sugar intake as a component of strengthening nutrition policy in Brunei.

Keywords: Adults, dietary sources, free sugars, national health nutritional status survey

How to cite this article:
Hamdani NZ, Haji Kamis HZ, Rahman HA. Free sugar intake and dietary sources among adult population in Brunei: The national health and nutritional status survey. WHO South-East Asia J Public Health 2021;10:90-4

How to cite this URL:
Hamdani NZ, Haji Kamis HZ, Rahman HA. Free sugar intake and dietary sources among adult population in Brunei: The national health and nutritional status survey. WHO South-East Asia J Public Health [serial online] 2021 [cited 2023 Feb 5];10:90-4. Available from: http://www.who-seajph.org/text.asp?2021/10/2/90/344473

Introduction

Free sugars refer to the monosaccharides and disaccharides added to foods and drinks by the manufacturer, cook, or consumer, and not the sugars naturally present in honey, syrups, fruit juices, and nectar juices.^[1] The high consumption of free sugars is of concern as it is associated with an increased risk of dental caries, obesity, and risk of noncommunicable diseases (NCDs).^[2],[3] A systematic review and meta-analysis of 39 clinical trials concluded that higher intake of sugar raised triglyceride levels, resulted in weight changes and raised blood pressure.^[4]

The World Health Organization (WHO) strongly recommended reducing the intake of free sugars to <10% of total energy intake for additional health benefits.^[1] Many countries worldwide exceed this recommended limit. For example, in Australia, more than half (55·7%) of the study population (8202 participants) had higher free sugar intake than the WHO's recommendation.^[5]

Increased intake of food high in sugar content is often seen as a major factor contributing to the rise of obesity. In Brunei, the prevalence of obesity in adults has increased more than double, from 12% in 1997 to 27.2% in 2011.^[6] According to Global Nutrition report 2016, Brunei has the highest prevalence of obesity in adults among South-east Asian countries.^[7] The Sugar Sweetened Beverages (SSB) tax was introduced in 2017 in an attempt to curb the epidemic.^[8] Despite that, there is a lack of published information on the free sugar intake and dietary sources of free sugar in Brunei to evaluate effectiveness of current risk reduction measures. Therefore, the primary objective of the study was to analyze the National Health and Nutritional Status Survey (NHNSS) data to identify the dietary sources of free sugars and explore the association with related factors among adult population in Brunei.

Methods

Study design, population, and sample

The study involved the analysis of dataset extracted from The NHNSS 2010.^[9] This was the first nationwide, cross-sectional survey, to explore health and nutritional status of Brunei citizens or permanent residents aged 18–75 years. A total of 1559 participants agreed and joined the study. The data collected included following information:

Sociodemographic (Self-reported): Gender, district, age, marital status, ethnicity, education level, employment status, and income level
Measurements: Waist circumference, waist-height ratio, body mass index, triglyceride, systolic blood pressure, diastolic blood pressure, and full blood sugar (not fasting)
Food and nutrient intake based on 24-h dietary recall.

Statistical analysis

All analyses were computed using RStudio v. 4.3.3. Free sugar (g) intake and the percentage of energy from free sugars were compared using the independent t-test and one-way ANOVA. Simple logistic regression was used to explore the possible factors that significantly affect the study outcomes of free sugar (>10 g/day) and free sugar (>5 g/day), and additional outcomes, including waist-height ratio (≥0.5 unit), body mass index (≥25), body mass index (≥30), systolic blood pressure (≥130 mmHg), diastolic blood pressure (≥90 mmHg), blood sugar (≥7 mmol/l), and triglyceride (≥1.7 mmol/l). Multiple logistic regression was done with the variables that were significant with free intake of sugar >10% of total energy as the outcome variable.

Ethical considerations

The institutional review board from the Ministry of Health and Universiti Brunei Darussalam approved this study.

Results

A total of 1,599 participants of age 18 years and older were extracted from the NHNSS 2010 dataset. The prevalence of the adult participants exceeding WHO recommendation of free sugar <10% and 5% of total energy intake was calculated. It was observed that the prevalence of free sugar intake >10% among the adult participants was 60.1% (95% confidence interval [CI]: 57.6, 62.5). The prevalence of free sugar >5% was 82.6% (95% CI: 80.6, 84.4).

[Table 1] illustrates the intake of free sugar in adults, in terms of grams/day and as a percentage of the daily energy. Estimated mean daily intake of free sugars was 55.5 g/day, contributing 14.5% of the total daily energy intake. Men (66.6 g/day) had significantly higher mean free sugar intake as compared to women (46.2 g/day) (P < 0·001). Those with diastolic pressure ≥90 mmHg (48.7 g/day) and systolic pressure ≥130 mmHg (49.2 g/day) had a lower free sugar intake than those with lower diastolic (56.6 g/day) and systolic pressure (59.9 g/day).

Table 1: Free sugar (g/day) and percentage energy from free sugar (n=1559)

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[Table 2] shows the dietary sources of free sugar among the adult population. All the foods and beverages were categorized into 28 groups, where they were further classified into solid and liquid foods. Sugar sweetened beverages (SSBs) contributed the largest proportion of free sugar intake (78%) among the adult population in Brunei. The highest sources of free sugar from beverages were prepared with free sugar (17.9%), cordial and syrup (15.1%), and carbonated drinks (14.6%).

Table 2: Dietary sources of free sugar among adult population in Brunei (n=1559)

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[Table 3] represents the factors associated with intake of free sugar >10% and free sugar >5%. The results showed that the participants aged 41–50 years and 51 and above were 0.59 times and 0.44 times less likely to have free sugar >10% as compared to those aged 18–30 years old, respectively. The result also showed that the odds of having free sugar >5% decreased by 0.64 times when diastolic pressure was >90.

Table 3: Factors associated with free sugar >10% and free sugar >5% using simple and multiple logistic regression (n=1559)

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Discussion

The present study indicated several important findings. The adherence of the adult participants to the WHO recommendation for free sugar intake <10% and <5% of total energy was overall low. More than half (60.1%) of the adult participants in the present study consumed more than the WHO recommendation for free sugar. Only 17.4% of the participants met the recommendation for free sugar <5% of total energy. Approximately 51.1% of Brunei population consumed SSB daily. This is very alarming because high intake SSB has been strongly linked with weight gain and obesity in children and adults.^[10] High intake of free sugar has been associated with unsatisfactory quality of diet and reduced micronutrients intakes due to micronutrients dilution.^{[11],[12],[13]} Therefore, it is critical to address this issue and promote dietary patterns in accordance with the recommendations of free sugar consumption.

The free sugar intake was higher in men, which was consistent with the findings in several studies.^{[14],[15],[16]} However, both men and women still had similar percentage of energy from free sugar intake. Furthermore, this study also found that those in older age group had lower free sugar intake and percentage of energy from free sugar compared to the younger participants, even after significant confounding factors were adjusted. This result follows the trend observed in other studies.^{[15],[17],[18]} This could be because of the reduced appetite in elderly population and the presence of existing comorbidities.

The strengths of the study are national representativeness, large number and detailed food intake assessment. The main limitation is that it is a cross-sectional study and associations should not be treated as causal. There is a possibility of recall and reporting bias from the NHNSS survey. It may not be representative of the usual dietary intake of the participant as dietary intake usually varies each day, which might result in under-reporting. Various population-level interventions and policies are currently in place in Brunei to control and reduce SSB intake, for example, mass-media campaign, regulation, and guidelines of foods and beverages sold in the school canteens and more recently fiscal policy on SSB. The fiscal measure to control the demand and consumption of SSB by taxation of SSB has been implemented in Brunei, effective April 1, 2017.^[8] Future studies should explore the trends of free sugar intake in Brunei over the years and look into the associations between free sugar intake and the health outcomes and chronic diseases to provide a more robust evidence for nutritional policy.

Conclusion

In conclusion, the study reveals that the majority of the Bruneian adults exceeded the WHO's free sugar intake recommendation, and the main sources of free sugar come from SSBs. The present study analysis provides crucial evidence needed to strengethen nutrition policy and actions for the pevention and control of NCDs in Brunei.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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