Jin-Xin Guo,Hong-Fang Zhang,Yu Lu,Hong-Mei Xue

1College of public health,Hebei University,Baoding 071002,China.2Tianjin Beichen District Center for Disease Control and Prevention,TianJin 300400,China.3Department of Clinical Nutrition,The First Hospital of Hebei Medical University,Shijiazhuang 050031,China.

Abstract Objective: The aim of this study was to explore the relationship between total dietary sugar and overweight and obesity in North China.Methods: A total of 1,074 permanent residents of Baoding,China aged 18-65 were selected by cluster random sampling method.Relevant information was collected by questionnaires.A multiple logistics regression model was used to analyze the relationship between total dietary sugar intake and obesity-related indicators.Results: The average dietary sugar intake of residents aged between 18 and 65 in Baoding was 34.6 g per day.The average dietary total sugar intake of men was lower than that of women (28.5 g vs.37.4 g).The combined detection rate of overweight and obesity was 68.1%.After adjusting variables such as age,gender,education level,smoking,and energy intake,it was found that excessive dietary sugar intake may be a risk factor for overweight[OR (95% CI)=1.382 (1.014,1.889)] and obesity [OR (95% CI):1.490 (1.112,2.002)] in men.In women,only dietary sugar intake was found to be a risk factor for overweight [OR(95% CI):1.616 (1.001,2.625)].Conclusion: The intake level of dietary sugar of adults in the Baoding area is high,and the problem of overweight and obesity is serious.The level of dietary total sugar intake may be a risk factor for overweight and obesity,but there are gender differences.

Keywords: dietary sugar;physical indicators;overweight and obesity;adult cross-sectional study

Background

According to the WHO (2021),the age-standardized prevalence of obesity among adults aged 18 and older (defined as body mass index(BMI) ＞30 kg/m2) has been rising globally over the past few decades with 650 million obese adults in 2016 [1].Obesity is a leading cause of various non-communicable diseases (NCDs),including life-threatening and nonfatal diseases [2].Overweight and obesity contributed to 11.1% of deaths associated with noncommunicable diseases (NCDs) in 2019,an increase from 5.7% in 1990 [3].The prevalence of obesity was increased 50% from 8.7% in 2000 to 13.1%(UI 12.4 to 13.9) in 2016 [1].The worldwide obesity prevalence has increased to almost tripled since the year 1975 [4].Based on Chinese criteria,the most recent national data (2015-19) showed that 16.4%of Chinese adults had obesity (BMI 28.0 kg/m2 or higher) and another 34.3% were overweight (24.0-27.9 kg/m2) [5].Nowadays,China has the highest number of people with overweight and obesity [6],and the prevalence and problem of overweight and obesity are increasing.Thus,it can be seen that it is extremely important to prevent the occurrence and development of overweight and obesity in our country.

Sugar intake plays a role in the aetiology of obesity.Many studies have been conducted worldwide that show a direct link between obesity and sugar intake.Dietary sugar is a simple carbohydrate in food intake.Which is easily absorbed and is an important source of energy [7-8].The high intake of food items containing sugars often leads to an excess energy intake,which,if not compensated by energy expenditure will increase of body fat [9].Besides,with further research,many reports show that the excessive intake of sugar increases the risk of lifestyle-related diseases,such as obesity and type 2 diabetes (2,3) [10-15].However,in China,few studies have evaluated the association between dietary sugar intake and obesity,most of which are studies on sugar-sweetened beverage intake [16],intervention measures,and related policies [17-20].These studies reported that dietary sugar intake was one of the risk factors for overweight and obesity.

The objective of this study was to investigate sugar intake from collecting physique,eating habits,and diet of 1,074 permanent residents in a community of Baoding.We also tried to determine the relationship between total dietary sugar and obesity-related indexes.

Material and Methods

Ethics approval and consent to participate

This study was approved by the Ethics Committees of Hebei University(HDFY-LL-2020-039) and adhered to the Helsinki Declaration in course of implementation.All children and their parents gave written informed consent.

Study sample

A total of 1074 permanent residents of Dongguan,Jiuhua,and Xiyuan communities aged 18-65 were selected by cluster random sampling method,363 boys and 711 girls,were included in this study.Firstly,three communities in baoding urban area were selected,namely Dongguan Community,Jiuhua community and Xiyuan community.Then with the help of the local health service,about 70 households were randomly selected.In each household,persons aged 18-65 years.The inclusion criteria were participants that are permanent residents who have no diabetes,no hyperlipidemia,no serious physical disability and can communicate normally.The study was approved by the Medical Ethics Committees of Hebei University and adhered to the Helsinki Declaration in the course of implementation.We obtained informed consent that the participation in the research was by free will from the participants by providing explanations about the objectives and details of the survey.

Baseline survey

In this study,a unified survey method was adopted,and the investigators were interviewed by uniformly trained investigators.The contents of the questionnaire included basic information questionnaire,24-hour dietary review questionnaire,physical exercise,and physical questionnaire.Waist circumference (WC) and hip circumference (HC) were measured to calculate waist to hip ratio(WHR).Height and weight were measured by ultrasonic electronic weight meter,and waist to height ratio (WHtR),body mass index(BMI),and percentage of body fat (%BF) was calculated.BMI was calculated as the subjects’ weight in kilograms divided by the square of their height in meters (kg/m2).Calculate the percentage of body fat(%BF) according to the formula developed by Liu et al [21].

Assessment of weight status

Given that Chinese sex-age-specific BMI references recommended by Working Group on Obesity in China (WGOC) are similar to World Health Organization BMI references,and can reflect better the body composition of Chinese [22].Obese using the WGOC BMI cutoffs.Overweight:BMI ≥24 kg/m2and Obese:BMI ≥30 kg/m2.

Estimation of sugar intakes

The food consumption of the respondents was obtained according to the 24-H dietary review and used a nutrition calculator to record the food intake of the respondents.We refer to the 2015 version of the American Food composition Table and the 2015 version of Japan's Food composition Nutrition Table to calculate the content of sugar per 100 g of food and total dietary sugar intake was aggregated [23-25].

Statistical analysis

Data were arranged by Epidata3.1 and statistical analyses were carried out using SAS version 9.4.The normal distribution data are expressed by (),the non-normal continuous variables are represented by the median and inter-quartile range,and counting data are expressed by frequency (%).The continuous variables of a normal distribution are compared between groups by t-test,or by one-way ANOVA.Nonparametric rank-sum test and Spearman rank correlation were used for non-normal distribution data,and the chi-square test was used to compare the constituent ratio or rate.With aP＜0.05 representing statistical significance for all tests.

To investigate the association between dietary sugar intake and overweight and obesity,multivariate regression models were used.Since the initial analyses revealed gender interactions of BMI with the relations of total dietary sugar intake (P=0.001),two-way interaction between dietary sugar intake and BMI was included to consider the differential effects of obesity.In the basic models,BMI as the dependent variable is put into the basic model,and the relationship between them is observed.The following variables potentially affecting these associations were considered:age,gender,income (family income/personal income),smoking,stress,energy intake.Each variable was initially considered separately,those variables that modified the coefficient of dietary sugar in the initial models or were significantly associated with the outcome variables were included in the series of subsequent multivariate models.In the final model,factors such as age,sex,education level,smoking,and energy intake are included in the model.

Results

General characteristics of study sample

Sample descriptive characteristics and sugar intake levels are presented in Table 1 by gender.1,074 aged 18-65 years took part in this study,711 were females (66.00%),363 were males (34.0%).Males had significantly higher percentages of obesity (34.7%) than females (24.3%) (P=0.002),and higher percentages of overweight(44.6%) (P=0.01) than females.BMI,%BF,WHR,and WHtR were higher in males than in females.The level of income is not high.The average dietary sugar intake of residents aged between 18-65 in Baoding was 34.6 g.There was a statistical difference in dietary sugar intake energy intake between males and females (P=0.044).The average level of dietary sugar intake in males was lower than in females (28.5 g vs.37.4 g).According to WGOC standards,54.2% of residents aged 18-65 in Baoding are overweight and 13.9% were obese,and 68.1% for both (Table 2).

According to the level of total dietary sugar intake,1,074 subjects were divided into five groups:low dietary sugar intake group (Q1),medium dietary sugar intake group (Q3),and high dietary sugar intake group (Q5).Table 2 shows that among the social behavior factors,there was a statistical difference in age (P＜0.05).The average age of the high sugar intake group was 54.6 years,which was higher than that of the other two groups.There were statistically significant differences in energy intake among groups,and the energy intake of the high sugar intake group was also the highest,which was 1,934.5 kcal/d.There were statistically significant differences in overweight and obesity among different sugar intake groups(Table 3).

Table 4 shows the relationship between dietary total sugar intake and overweight and obesity,it was found that there was gender interaction (paired 0.001).Therefore,there is a need for gender stratification.In men only,a significant association was found between dietary sugar intake and BMI after adjustment for age,smoking status,income level,and energy intake level (P=0.04).In women,dietary sugar intake was associated with BMI before adjustment for confounding factors,but not after adjustment for confounding factors.There was no statistical difference in other physique-related indexes.

Multi-regression analysis of factors of logistics

Logistics using multivariate regression model analysis of dietary sugar intake and the relationship between overweight obesity.Model 1 is the basic model,including only independent variables and dependent variables.Model 2 included age,sex,education,smoking,and energy intake.After adjusting for age,gender,educational level,smoking,and physical activity and found that dietary intake of sugar after energy intake and other variables may be a risk factor for males in overweight (OR (95% CI):1.4 (1.0,1.9)),and is a risk factor for being obese (OR (95% CI):1.5 (1.1,2.0)).In women,only dietary sugar intake was found to be a risk factor for overweight (OR (95% CI):1.6(1.0,2.6)) (Table 5).Excess dietary sugar intake in men may increase the risk of overweight by 0.4 times and obesity by 0.5 times.However,among women,only dietary sugar intake has a certain risk of overweight,which may increase the risk of overweight by 0.6 times.

Table 1 Characteristics of the study sample and sugar intake level

Table 2 Overweight obesity rate of Baoding residents1(n=1074)

Table 3 Data analysis of different dietary sugar intake groups among residents aged 18-65 in Baoding city

Table 4 The relationship between dietary sugar intake and overweight and obesity

Table 5 Logistics regression analysis of sugar intake among residents aged 18-65 in Baoding city

Discussion

Granting to the results of this survey,the rates of overweight and obesity in males were both higher than those in females(P=0.0003).The rate of overweight and obesity in the sample population is at a high level,generally higher than other regions.Compared with the large-scale survey data from 2003-2010 in southwest China,the overweight rate in this study is much higher than that in southwest China (54.2% vs.35.9%) [29].The study is still far higher than a nationwide survey conducted in 2014 about the national average for overweight (54.2% vs.34.3%) [29].Compared with other provinces and cities with a higher overweight rate,the prevalence of overweight in Baoding city is still relatively severe.After grouping by gender and age,it was found that the overweight rate was lower in the group of 36-45 and 46-55 years old,but higher in the group of 18-35 and 56-65 years old.The trend of the incidence of overweight in the group of 18-35 years old and 56-65 years old was "decreasing first and then rising".The obesity rate decreased gradually with age,and the obesity rate was the lowest in the 56-65 age group.The rate of overweight in women increased with age,while the rate of obesity had no obvious relationship with the trend of the age.Therefore,young men are at high risk of overweight and obesity and should be given high attention.

Dietary sugar intake was divided into five groups using SAS 9.4.There was no significant difference among the other variables.Given this study is a cross-sectional study,and the sample size is limited,survey bias and other factors,the relationship between dietary total sugar intake and obesity-related indicators needs to be confirmed by further research.

In general data,there were statistically significant differences in average personal income and smoking between males and females.BMI,%BF,overweight,and obesity were all Body fat indicators among females and males had statistical significant differences (P＜0.05).Dietary sugar intake and energy intake were significant statistically differences between females and males.

Dietary sugar intake and energy intake were significant statistical differences between females and males.Multivariate logistics analysis among groups showed that age,income,education level,stress,and other variables affected the relationship between total dietary sugar intake and overweight and obesity to varying degrees.After gender stratification,adjusting for age,gender,educational level,smoking,and found that the excessive intake of total dietary sugar may be a risk factor for males in overweight and is a risk factor for being obese.In women,only dietary sugar intake was found to be a risk factor for overweight.Some of the relevant epidemiological studies have also found that there are different results in the relationship between overweight,obesity and investigated factors between men and women and the causes of gender differences remain to be verified.In this study,total dietary sugars refer to monosaccharides and disaccharides in the diet,which can be directly absorbed by the body to provide energy,possibly is a major cause of overweight and obesity.Previous studies have shown that high-fructose corn syrup and sucrose may directly promote the occurrence of overweight and obesity,which is consistent with the conclusion of this study.

The prevalence of obesity has risen rapidly.Some foreign studies have found that the intake of total dietary sugar affects the occurrence of overweight and obesity.While overweight and obesity were strong adverse associations between overweight and obesity and major non-communicable diseases (NCDs) such as cardiovascular disease,diabetes,and certain cancers.At present,there are few studies on the relationship between sugar intake and overweight and obesity in China.In addition,the relationship between sugar intake and overweight and obesity is not clear.In this study,the sugar content in the daily food intake of the survey subjects was calculated concerning the calculation standards of dietary sugar content in the food composition tables of the United States and Japan.We analyzed the differences in physical indexes among different groups and further analyzed the relationship between dietary total sugar intake and obesity-related indicators.

To sum up,overweight and obesity can be biologically depicted as the result of energy surplus due to individual factors such as diet,physical activity,and genetic predisposition.The results of this study are consistent with those of relevant foreign studies,which verify the relationship between dietary total sugar intake and body weight.It provides an epidemiological basis for the design of experimental research in the future.

Conclusion and implications

There were significant differences in energy intake between different dietary sugar intake groups in Baoding.Both the average dietary total sugar intake and the lowest dietary total sugar intake of different ages and genders exceeded the recommended dietary sugar intake in the Dietary Guidelines for American residents (2020-2025).Multiple logistics regressions showed that excessive sugar intake in men increased the risk of being overweight by 0.382 times and the risk of obesity by 0.490 times.Among women,only sugar intake was found to have a certain risk of being overweight,and sugar intake increased women's risk of being overweight by 0.616 times.

The intake level of dietary sugar of adults in the Baoding area is high,overweight and obesity are closely related to metabolic disorder,the problem of it is serious.The excessive intake of dietary sugar can contribute to cardiovascular disease,hypertension,hyperlipidemia,diabetes,and other health problems.We should attach great importance to this.It is expected that the results of our study will promote healthy lifestyles and community-based education about the dangers of obesity in China,maintain an appropriate body weight and monitor regularly to reduce the rate of obesity and prevent overweight people from developing into obesity.