72

ORIGINAL

Sugar Intake and Body Weight in Cambodian andJapanese Children
1

2

2,3

1

2,4

Saiko Shikanai , Ly Koung Ry , Hitomi Takeichi , Suzuki Emiko , Pann San ,2,52

Nobuko Sarukura , Sumiko Kamoshita , and Shigeru Yamamoto
1

2

Ochanomizu University Graduate School of Humanities and Sciences, Tokyo, Japan, 2Asian Nutrition

and Food Culture Research Center, Jumonji University, Saitama, Japan, 3Kobe Gakuin University,
Faculty of Nutrition, Hyogo, Japan, 4Asian Nutrition and Food Research Center, Phnom Penh,
Cambodia, 5National Institute of Health and Nutrition, Tokyo, Japan
Abstract : Because of the tastiness of sugars, it is easy to consume more than an adequate
amount. There are many research reports that excess sugar intake contributes to dental
decay, obesity, diabetes etc. Continuing economic development in Cambodia has made iteasier than before for people to consume sugars in their daily life. Currently, isomerizedsugar (a mixture of glucose and fructose) made from starches is commonly used in commercial beverages because of its low price. However, in Cambodia and Japan, sugar composition tables that include not only sucrose but also glucose, fructose, lactose and maltose
have not been available. Prior to the present nutrition surveys, we made sugar composition
tables for both countries. In this study we tried to estimate the intakes of various sugars bychildren in Cambodia and Japan and to determine the relationship between intake andbody weight. Nutrition surveys of children aged 7, 10 and 13 years old were conducted for3 nonconsecutive days by the 24 h recall method in 89 Cambodian children living in thecapital city of Cambodia, Phnom Penh, and 151 Japanese children living in 3 prefecturesfrom north to south. Height and weight of children in Cambodia and Japan were similar
until 10 years old but at 13 years old, the Cambodians were shorter and lighter than theJapanese. We could not observe any differences in BMI in either country. The sugar intakes from beverages and snacks were not different among the different gender and age.
Thus we combined the mean total sugar intake for Cambodian and Japanese, 28.42 25.28
g and 25.69 16.16 g respectively. These were within the range of WHO recommendations(less than 10%% of energy intakes). Cambodian children consumed about 46%% of sugars fromcommercial beverages and snacks and Japanese children 26%%. This means that for Cambodians half of the sugars came from isomerized sugar made from starches. Relationships
between sugar intake and body weight were not observed in both countries. In conclusion,
the Cambodian children consumed about 46%% of sugar from glucose and fructose (probably
in the form of isomerized sugar), while the Japanese children took 26%% ; however, the intakes in both countries met the WHO recommendation and there was no relationship tobody weight. J. Med. Invest. 61 : 72-78, February, 2014
Keywords : Cambodia, Japan, children, sugar intake, energy intake
Received for publication November 18, 2013 ; accepted November
25, 2013.

INTRODUCTION

Address correspondence and reprint requests to Saiko Shikanai,
Ochanomizu University Graduate School of Humanities and Scinences, 2 -1 -1 Ohtsuka, Bunkyo-ku, Tokyo 112-8610, Japan andFax : +81-48-260-7613.

Sugar is important as an easily absorbed energy
source, especially for rapidly growing children withhigh physical activity. This may account for why we
The Journal of Medical Investigation Vol. 61 2014

The Journal of Medical Investigation

find sugar tasty. However, the pleasing taste makes
it easy to consume more than an adequate amount.
There are many reports that excess sugar intake
contributes to dental decay, obesity, diabetes etc.
The rising prevalence of obesity in children in the
US has been reported to be linked in part to theconsumption of sugar-sweetened drinks (1). From1994 to 1996, Americans aged 2 years and older (n=15,010) consumed the equivalent of 82 g carbohydrate per day from added sweeteners, which accounted for 16% of total energy intake (2). The WHO
recommendation is less than 10% of energy fromsugars (3), which is about 40-50 g/d for children.
Continuing economic development in Asian countries, including Cambodia, has made it easier than
before for people to consume sugars in their daily
life. Childhood is important in establishing life-longfood habits ; therefore we must be concerned withsugar intakes and possible health problems in children.
Sugars are defined as mono- and di-saccharides.
They include glucose, fructose and sucrose, lactose
and maltose. Fructose is also called fruit sugar because it is found in fruits. It is a mono-saccharide,with the special characteristic that it has a 1.73 times
stronger taste than sucrose when it is cooled (4).
Since the 1970s, fructose has been a componentof isomerized sugar made from starches. Starch isdigested into glucose by enzymes and then about
half of it is converted into fructose by the isomerizeenzyme (5). The consumption of foods containingisomerized sugar (a mixture of glucose and fructose)
is increasing world-wide because it is cheap, and in
addition it is in a liquid form which is easy to use incommercial beverages and chilled or frozen snacks.
In the U.S, isomerized sugar is called High Fructose
Corn Syrup (HFCS), because it is produced fromhydrolyzed corn starch.
As mentioned above, at present not only is sucrose readily available, but other sugars are alsoavailable, making it necessary to devise a new sugarcomposition table to estimate sugar intakes. For thisreason, we have constructed sugar composition tables for Japan (6, 7) as well as for Vietnam and Cambodia (8). In this study we tried to estimate thesugar intakes in Cambodian and Japanese children
to determine the intakes and their relation to bodyweight.

Vol. 61 February 201473

METHODS
Subjects
The survey was conducted in children of 7, 10 and
13 years old in several schools in Phnom Penh, thecapital city of Cambodia, and finally the reliable datafrom 89 children were obtained. In Japan survey was
conducted in 3 prefectures from north to south andfinally 151 reliable samples were chosen. Despite
various limitations, we used random sampling as
much as possible in selecting areas, schools andclasses.

SurveyThe nutrition survey in each country was conducted on 3 days (2 weekdays and 1 weekend day),using the 24 hour-recall method. Height and weight
were measured.

Estimation of sugar and energy intakes
Calculations of energy intake in Cambodia weremade in accordance with the Standard Tables ofFood Composition in Vietnam in “Vietnam EIYOKUN” (10), and “ASEAN Food Composition Table”(11). Sucrose, glucose, fructose, lactose and maltose
intakes from foods other than meals were calculated
by using the sugar composition tables that was constructed by us previously for Japan (6, 7), Cambodia
and Vietnam constructed by us previously (8). We
analyzed commercial beverages and snacks whichsold in both Vietnam and Cambodia, because products are common to sell in both countries by easy
export and import. Calculations of energy intake inJapan were made in accordance with the data listed
in “Standard Tables of Food Composition in Japan,
5 revised and enlarged Version” (12) and the tableof processed foods data (13).

Degree of obesity
Degree of obesity was derived by the following
equation (14).
The degree of obesity=(Actual measured weightWeight for height standards)/Weight for heightstandards !100.

Ethical consideration
These studies were conducted with the approvalof the Ethics Committee in the Ministry of Healthin Cambodia and Ochanomizu University in accordance with the Declaration of Helsinki : Ethical principles for research involving human subjects withspecial attention paid to the following : to prevent

74

S. Shikanai, et al. Sugar Intake in Cambodian and Japanese

the identification of individuals each subject’s personal information was carefully coded and obtained
data were strictly managed. We obtained a statement that participation in the research was by free
will on the part of the participants and their guardians by providing explanations about the objectives
and details of the investigation and the intention to
use the results for oral and written presentations.
Even after commencement, explanations were provided whenever subjects dropped out of the study,
either of their own volition or at the guardian’s behest ; no subjects were penalized in any way.

while it was about 26% in Japan.
Fig. 2 shows the correlation between body weightand sugar intake in both genders at 7, 10 and 13
years old in Cambodia and Japan. No relationships
were observed.

Table 1 : Body Characteristics of Cambodian and Japanese subjects
Measurement Age Gender

Cambodia

Japanese

Height (cm)126.3!10.2

121.0!4.5

Statistical analysis
Statistical analysis of the data was carried out with
Microsoft Excel. Data were assessed by unpaired
Student t-test and p values less than 0.05 were considered statistically significant. Correlation between
body weight and sugar intake was also assessed.

Weight (kg)

7y

Boy
Girl

124.2!6.1

121.4!4.9

10y

Boy

135.7!4.0

140.9!6.9*

Girl

138.8!7.8

139.6!6.7*

13y

Boy

149.6!8.7

163.4!7.8

Girl

153.1!6.2

156.7!3.6*

Boy

22.26!5.01
24.28!4.04
34.76!10.86
30.34!4.54
40.24!7.50
43.44!8.50
14.1!3.4
15.7!2.3
18.7!4.7
15.7!2.3
17.9!2.1
18.4!2.5

22.18!2.37

7y

Girl
10y

Boy
Girl

13y

RESULT
Table 1 shows the body characteristics of Cambodian and Japanese children aged 7, 10 and 13
years old. Height and weight of children in bothcountries of the same age and gender were similar ;except Japanese children became much larger at theage of 13 years old in height (cm) : 149.6 vs 163.4
for boys and 153.1 vs 156.7 for girls and in bodyweight (kg) : 40.2 vs 52.6 for boys and 43.4 vs 45.7
for girls. BMI was not different between the twocountries.
Table 2 shows the energy intakes of children inboth countries. Energy intake of 13 years old children was higher in Japan than in Cambodia (p!
0.0001).
Table 3 shows the intakes of glucose, fructose,
sucrose, lactose, maltose and total sugars for children of different ages and gender in Cambodia andJapan. Intake of maltose in both countries was low.
Lactose intake of Japanese children was about 2times higher than that of Cambodian children, which
may suggest that milk consumption in Cambodia islower than in Japan. Intakes of glucose and fructose
were equal in each country, which may suggest thatthese two sugars came from isomerized sugars
made from starch.
Fig. 1 show percentages of each sugar against
total intake in Cambodian (upper) and Japanese(lower) children. The intake of glucose + fructose
was about 50% of total sugar intake in Cambodia,

Boy
Girl

BMI (kg)

7y

Boy
Girl

10y

Boy
Girl

13y

Boy
Girl

22.39!3.20
36.48!10.57
31.71!6.66
52.58!9.76
45.74!5.07
15.1!1.1
15.1!1.2
18.1!3.9
16.1!15.8
19.6!2.8*
18.6!2.1

Means!SD
Number of subjects in Cambodia and Japan were 23 (boy 10, girl13) and 43 (boy 19, girl 24) for 7 years old, 26 (boy 16, girl 10)
and 58 (boy 28, girl 30) for 10 years and 40 (boy 21, girl 19) and50 (boy 29, girl 21) for 13 years old, respectively.
Statistical analysis was conducted between Cambodian and Japanese groups by unpaired Student t-test. *p!0.05

Table 2 : Energy Intakes of Cambodian and Japanese subjects(kcal/d)Age

GenderCambodianJapanese7yBoy

1787!292

1727!237

Girl

1524!158

1617!210

10yBoy

1852!235

2060!364

Girl

1792!484

1816!235

13yBoy

1643!150

2424!454***

Girl

1557!243

1921!285***

Means!SD
Number of subjects in Cambodia and Japan were 23 (boy 10, girl13) and 43 (boy 19, girl 24) for 7 years old, 26 (boy 16, girl 10)
and 58 (boy 28, girl 30) for 10 years and 40 (boy 21, girl 19) and50 (boy 29, girl 21) for 13 years old, respectively.
Statistical analysis was conducted between Cambodian and Japanese groups by unpaired Student t-test. ***p!0.0001

The Journal of Medical Investigation75

Vol. 61 February 2014

Table 3 : Sugar intakes of Cambodian and Japanese subjects by age and gender(g/d)
GlucoseFructose

SucroseMaltoseTotal

Japanese

CambodianJapaneseJapanese

CambodianJapanese

CambodianJapaneseBoy

7.81!8.34

2.79!2.52*

8.68!8.44

2.86!2.59* 26.65!13.26 16.84!8.07*

1.24!1.24

2.76!2.22*

0.22!0.37

Tr

43.4!26.68 25.24!11.85*

Girl

3.67!5.95

3.68!3.44*

4.39!6.21

4.19!4.20* 16.92!19.01 16.58!9.51*

1.64!1.73

2.18!1.58*

Tr

Tr

24.12!20.38 26.63!15.23*

Boy

4.03!3.77

2.98!3.19*

4.42!4.13

3.11!3.50* 20.28!16.91 19.26!11.08* 0.93!1.23

Girl

6.27!10.60 3.23!2.49*

7.42!11.49 2.86!2.49* 12.15!8.08 17.45!9.34*

Boy

6.98!7.26

7.71!8.06

7y
10y
13y

CambodianLactoseAge Gender Cambodian

CambodianJapanese

2.63!1.09*

Tr

Tr

26.85!19.94 27.98!15.18*

1.10!1.40

2.72!2.25*

0.10!0.24

Tr

24.37!25.20 26.25!13.21*

6.45!5.46 16.59!13.96** 0.62!0.85

1.79!2.49*

Tr

Tr

20.00!18.51 27.41!22.81*

Girl 10.50!12.58 2.16!2.19** 11.58!13.66 2.19!2.70** 14.61!14.66 12.72!11.46* 0.51!0.07

1.70!1.94*

0.20!0.59

Tr

36.27!34.12 18.77!14.46*

2.30!2.14

0.10!0.32

Tr

28.42!25.28 25.69!16.16

Mean

6.73!8.73

4.30!4.52*
3.25!3.24

7.53!9.42

4.74!5.01*
3.38!3.65

15.12!14.54 16.75!10.87

0.93!1.20

Means!SD
Tr : trace amount
Number of subjects in Cambodia and Japan were 23 (boy 10, girl 13) and 43 (boy 19, girl 24) for 7 years old, 26 (boy 16, girl 10) and 58(boy 28, girl 30) for 10 years and 40 (boy 21, girl 19) and 50 (boy 29, girl 21) for 13 years old, respectively.
Statistical analysis was conducted between Cambodian and Japanese groups by unpaired Student t-test. *p!0.05, **p!0.01

Fig 1. Percentage of sugar against total intake in Cambodian (upper) and Japanese (lower) Children

76

S. Shikanai, et al. Sugar Intake in Cambodian and JapaneseFig. 2 Correlation between body weight and sugar intake was also assessed by Microsoft excel

DISCUSSION
We found in this study that Cambodian children
take about 46% of sugar from glucose and fructose
probably in the form of isomerized sugar, while
Japanese children take 26%. ; however, the intakes
in both countries met the WHO recommendation(3). Our present results were similar as our previous
study in different Japanese children (9).
As the primary cause of high sugar intake, thetropical climate could be considered crucial. People
drink more cold beverages in hot weather. However,
our survey was done in summer, which in Japan is
as hot as it is in Phnom Penh. Thus we can consider
climate not to be the primary factor in higher consumption in Cambodia than in Japan.
School lunch may be a major cause of the big difference in sugar intake. Japanese schools do not install soft-drink vending machines and soft drinks are
not available in schools. There is a nutrition teacher

The Journal of Medical Investigationor school dietitian basically in every school. Fromvarious information about the school lunch programin Japan, most children enjoy it and are satisfied.
On the other hand, in Cambodia, there is neither aschool lunch program nor school dietitians ; therefore, children become hungry at school and buy
food for themselves. The most available and favorite
energy source for children is fast food and beverages. In items of this sort, sugar and lipids are usually abundant and they are often called empty foods,
meaning that they contain energy but few nutrients.
Furthermore, an early and light breakfast which istypical in Cambodia makes children very hungry
while they are in school.
Although the average energy intake from sugar
was within the WHO recommendation level (3), thefact that about 50% of the intake was from isomerized sugar may lead to health problems. About halfof isomerized sugar is fructose. Fructose does not
require insulin, which is an advantage ; however,fructose easily becomes fatty acids, which may
cause other problems (15-18). In any case, the nutritional behavior of Cambodian children may need
to be changed. In Japanese schools, various types ofnutrition related laws and regulations help to improve the school meal programs. The school meal
law was established in 1954 (19), basically there isa licensed dietitian at each school and from 2007
they became a nutrition teacher by the new law andat present about half of them are the nutrition teachers (19). Basic Law of Nutrition Education was established in 2006 which supports the improvementof school lunch program (19). For example, schoolorder the products to specific reliable food producers including farmers, fish men etc. Most of theschool knows the producers and producers supply
foods with the responsibility, by this system there
are strong reliability between the school and foodproducers. If proper lunch is served at adequate
time for children in schools in Cambodia like Japan,
perhaps sugar intake could be reduced, especiallysugars from soft-drinks and sweetened beverages.
This could be confirmed on a small scale and if successful, a broader school meal program should beseriously considered.
In this study, we could not observe a relationshipbetween sugar intake and body weight. Average
BMI was also within the normal range. This also indicates that the energy balance was good. However,
if a high percentage of energy intake is from isomerized sugar in commercial beverages, children may
not form good dietary habits for their later life, sinceVol. 61 February 201477

such habits are usually established in childhood.
There are some limitations to this study. First,
there is the question of how much the present sample represents the larger communities. In both countries, studies in school children were quite difficultand many schools did not want to participate in the
study. As a result, it is not a fully random samplingof the communities and the data may be biased. We
need further studies.
In this study, we did not include sugars fromwhole fruits and fresh milk but only sugars fromsnacks and beverages, because this follows the definition by WHO (20). Fresh milk and fruits are usually rich in sugar ; however, if the definition is followed, sugar from them are not included in total
sugar intake. In Western countries, people usuallydrink large quantities of milk, while in ASEAN countries people consume large amounts of fresh fruit.
Sugars from these sources should be included in
total intake. We did not include the meal sugar in
the total intake. From the annual Japanese Nutrition
Survey, sugar used in the meal is about 6 g/day(21). For a fair comparison, this should be included,
too. However, even considering these sources, total
sugar intake would not exceed 50 g a day for Cambodian and Japanese, which is within the WHO recommendation (3).
In conclusion, Cambodian children take about 50%
of sugar from glucose and fructose, probably in theform of isomerized sugar, while Japanese children
take 26% ; however, the intakes in both countries
met the WHO recommendation.

ACKNOWLEDGEMENT
This study was supported by the fund of Student
Residential Experience Abroad Program, Center for
Leadership Education and Research in Ochanomizu
University and also by the US-Japan Science Program. The authors would like to thank all the staffof Asian Nutrition and Food Research Center inPhnom Penh, Cambodia for their hard work, kind
help and support. We are grateful to all the participants and teachers of all our survey. The authors
would like to thank Andrew R. Durkin, Professor
Emeritus of Indiana University, Bloomington, USA,for his careful editing of the English for this article.
None of the authors have any conflicts of interest
to declare.

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S. Shikanai, et al. Sugar Intake in Cambodian and Japanese

REFERENCES
1.

Ludwig DS, Peterson KE, Gortmaker SL : Relation between consumption of sugar-sweetened
drinks and childhood obesity : a prospective,
observational analysis. Lancet 357 : 505-8, 2001
2. Guthrie JF, Morton JF : Food sources of added
sweeteners in the diets of Americans. J Am
Diet Assoc 100 : 43-51, 2000
3. WHO Technical report Series 916 : Diet, Nutrition, and the prevention of chronic diseases,
WHO, Geneva, 2003
4. Hanover ML, White JS : Manufacturing, composition, and application of fructose. Am J Clin
Nutr 58 : 724s-732, 1993
5. Takasaki Y, Kosugi Y, Kanbayashi A : Studies
on sugar-isomerizing enzyme : purification,
crystallization, and some properties of glucose
isomerase from Streptomyces sp.. Agr Biol
Chem 33 : 1527-1534, 1969
6. Yamamoto S, Taniguchi H, Sarukura N, Tseng
AT, Wong UY, Takeichi H : Development of a
Food Composition Database of Monosaccharide
and Disaccharides in Sweet Snacks and Beverages. Journal Japan Dietetic Association 52 :22-25, 2009 (in Japanese)
7. Takeichi H, Wakikawa N, Taniguchi H,
Sarukura S, Tseng AT, Wong UY, Yamamoto
S : Concentrations of Monosaccharide and Disaccharides in Commercial Sweet Snacks. Journal Japan Dietetic Association 53 : 23-26, 2010
(in Japanese)
8. Shikanai S, Hien VTT, Tuyen LD, Hop LT,
Nhung BT, Thuan NT, Suzuki E, Yamamoto S :Concentration of glucose, fructose, sucrose, lactose and maltose in Vietnamese snacks/beverages, Vietnam Journal of Food and Nutrition
Science, 9, 2013 (in press)
9. Takeichi H, Taniguchi H, Fukinbara M, Tanaka
N, Shikanai S, Sarukura N, Hsu TF, Wong Y,
Yamamoto S : Sugar Intakes from Snacks andBeverages in Japanese Children. J Nutri Sci
Vitaminol 58 : 113-117, 2012
10. Eiyokun Software. : Nha xuat ban Y hoc Medical Publisher. HoChiMinh, Vietnam, 2004.

11. Puwastien P, Burlingame B, Raroengwichit M,
Sungpuag S : ASEAN Food Composition Tables
2000, Institute of Nutrition, Mahidol University,
Thailand. 2000
12. Ministry of education, culture, sports scienceand technology of Japan : Standard Tables ofFood Composition in Japan 5 revised and enlarged Edition, 2005 (in Japanese)
13. Kagawa Y: An ingredient list of processed
foods on the market, the 8th edition. Kagawa
Nutrition University, 2005 (in Japanese)
14. Japanese Society of School Health, Ministry of
Education, Culture, Sports, Science and Technology of Japan : Health Checkup Manual for
School Children (Revised) 2006 (in Japanese)
15. Stanhope KL : Role of Fructose-Containing
Sugars in the Epidemics of Obesity and Metabolic Syndrome. Annu Rev Med. 201116. Parrish LA : How does the consumption of fructose and high fructose corn syrup impact thehealth of children and adolescents? J Pediatr
Nurs 25 : 459-60, 2010
17. Rippe JM : The health implications of sucrose,high-fructose corn syrup, and fructose : what
do we really know? J Diabetes Sci Technol
Jul1 ; 4 : 1008-11, 2010.
18. Kimber L. Stanhope1, Peter J. Havel : Fructose
consumption : Recent results and their potentialimplications. Ann N Y Acad Sci 1190 : 1524, 2010
19. Tanaka N, Miyoshi M : School lunch programfor health promotion among children in Japan.
Asia Pac J Clin Nutr 21 : 155-8, 2012
20. Nishida C, Uauy R, Kumanyika S, Shetty P :The joint WHO/FAO Expert Consultation on
diet, nutrition and the prevention of chronic diseases : process, product and policy implications.
Public Health Nutrition 7 : 245-250, 2003
21. Ministry of Health, Labor and Welfare of Japan.
2011. The outline report of the National Healthand Nutrition Survey of Japan in 2009. Tokyo.
[online]. Available : http : //www.mhlw.go.jp/
stf/houdou/2r9852000000xtwq.html (in Japanese)