Methodology for the assessment of added/free sugar intake in epidemiological studies

Added Sugar, Sugar-Sweetened Beverages, and Artificially Sweetened Beverages and Risk of Cardiovascular Disease: Findings from the Women’s Health Initiative and a Network Meta-Analysis of Prospective Studies

Much remains unknown about the role of added sugar in relation to cardiovascular disease (CVD) and the relative contributions of sugar-sweetened beverages (SSB) or artificially sweetened beverages (ASB) to CVD risk. Among the 109,034 women who participated in Women’s Health Initiative, we assessed average intakes of added sugar, SSB and ASB, and conducted Cox regression to estimate the hazard ratios (HRs) and their 95% confidence intervals for CVD risk. The consistency of findings was compared to a network meta-analysis of all available cohorts. During an average of 17.4 years of follow-up, 11,597 cases of total CVD (nonfatal myocardial infarction, coronary heart disease (CHD) death, stroke, coronary revascularization, and/or incident heart failure) were confirmed. Added sugar as % energy intake daily (%EAS) at ≥15.0% was positively associated with total CVD (HR = 1.08 [1.01, 1.15]) and CHD (HR = 1.20 [1.09, 1.32]). There was also a higher risk of total CVD associated with ≥1 serving of SSB intake per day (HR = 1.29 [1.17, 1.42]), CHD (1.35 [1.16, 1.57]), and total stroke (1.30 [1.10, 1.53]). Similarly, ASB intake was associated with an increased risk of CVD (1.14 [1.03, 1.26]) and stroke (1.24 [1.04, 1.48]). According to the network meta-analysis, there was a large amount of heterogeneity across studies, showing no consistent pattern implicating added sugar, ASB, or SSB in CVD outcomes. A diet containing %EAS ≥15.0% and consuming ≥1 serving of SSB or ASB may be associated with a higher CVD incidence. The relative contribution of added sugar, SSB, and ASB to CVD risk warrants further investigation.

A Scoping Review of Epidemiological Studies on Intake of Sugars in Geographically Dispersed Asian Countries: Comparison of Dietary Assessment Methodology

Previous systematic reviews, which focused on sugar intake and its relation with health issues, were mainly conducted in Western countries, not Asian countries characterized by differences in dietary habits and disease prevalence. The scarcity of Asian studies may be attributed to the lack of assessment tools for estimating sugar intake. To provide an overview of the epidemiological studies on sugar intake in Asian countries, with a primary focus on dietary assessment methodology for estimating sugar intake, we conducted a scoping review of the epidemiological studies estimating sugar intake in Asian countries (the United Nations' definition) and Taiwan using PubMed and Web of Science. Study quality was evaluated based on its assessment of sugar intake in the whole diet, dietary assessment methods, and data sources used for estimating sugar content. We identified 143 studies from 136 publications from Eastern (n = 63), Southern (n = 30), South-Eastern (n = 26), and Western (n = 24) Asia. Total sugars were investigated in 95 studies, while 23-30 studies investigated sucrose, fructose, added sugars, and free sugars. The main aim of the selected studies was assessment of diet-disease relations (n = 85) and estimation of dietary intake (n = 40), and 62 studies assessed sugars as the primary exposure/outcome. A total of 120 studies assessed sugar intake in the whole diet, and 62 studies used validated FFQs or multiple-day dietary assessment methods. Only 41 studies used country-specific comprehensive food-composition databases or directly measured sugar content. Only 17 studies reported high-quality data. This review elucidated a sufficient number of epidemiological studies estimating sugar intake across Asian countries; however, most studies reported low-quality data. The results from our review showed that both feasible and validated dietary assessment methods, as well as comprehensive country-specific sugar-composition databases, are essential for producing high-quality studies with accurate sugar intake to examine its association with health outcomes.

Nutritional status and adequacy of feeding Practices in Infants and Toddlers 0-23.9 months living in the United Arab Emirates (UAE): findings from the feeding Infants and Toddlers Study (FITS) 2020

BACKGROUND

Infant and young child feeding practices (IYCF) impact the early and later health status of the population. Limited data is available regarding IYCF in the United Arab Emirates (UAE). This study aimed to evaluate the nutritional status and adequacy of feeding practices, energy, food, and nutrient intakes of UAE infants and toddlers ages 0-23.9 months.

METHODS

This study is a population-based cross-sectional survey of 276 infants and toddlers aged 0-23.9 months of which 180 were nationals and 96 were Arab non-nationals living in the UAE. Data were collected from the three major emirates: Abu Dhabi, Dubai, and Sharjah. Anthropometry was collected and assessed using WHO Anthro-Survey Analyzer, and a multicomponent age-specific questionnaire was used to evaluate IYCF and sociodemographic characteristics. Usual intake of energy, micronutrients, and macronutrients, including supplements, were collected using multiple-pass 24-h dietary recall and analyzed using the PC-side software. IYCF practices were assessed using the WHO indicators.

RESULTS

Overall, 4% of children were malnourished, 8% wasted, 15% stunted, 18% at risk of overweight, and 7% overweight and obese. 95% of infants were ever breastfed and 37% exclusively breastfed at 6 months. Around 98% of infants had a timely introduction of complementary food. Macronutrient intake exceeded AMDR for fat, carbohydrates, and protein for 27%, 8% and 2% of toddlers respectively. As for the percentage of those exceeding the ESPGHAN cut-off for free sugars set at 5% of energy intake, 28.6% had excessive intakes overall, 10% in 0-5.9, 21.9% in 6-11.9 and 56.7% in 12-23.9 month. Usual iron intake was below the Estimated Average Requirement (EAR) in 47% of infants 6-11.9 months. Above 12 months, the usual intake of iron and vitamin D were below EAR in 11% and 49% of toddlers respectively. Usual intake exceeded the tolerable upper intake levels (UL) for vitamin A (14 to 18%) and zinc (11 to 22%) across all ages. Approximately 93% of toddlers ages 12-23.9 months did not meet food groups' recommendations for vegetables, 87% for fruits, 48% for milk/dairy, 54% for lean meat and beans, and 33% for grains.

CONCLUSIONS

This study revealed that a high percentage of infants and toddlers aged 0-23.9 m suffer from a double burden of malnutrition, which is the coexistence of both undernutrition, and overweight and obesity in the same population. In addition to suboptimal feeding practices and inadequate/overconsumption of various nutrients. The findings highlight the need for the development of culturally specific programs aiming to improve the nutritional status of infants and toddlers in the UAE.

Tolerable upper intake level for dietary sugars

Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50-75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15-50% probability) and very low for hypertension (0-15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

A Machine Learning Approach to Predict the Added-Sugar Content of Packaged Foods

BACKGROUND

Dietary guidelines recommend limiting the intake of added sugars. However, despite the public health importance, most countries have not mandated the labeling of added-sugar content on packaged foods and beverages, making it difficult for consumers to avoid products with added sugar, and limiting the ability of policymakers to identify priority products for intervention.

OBJECTIVE

The aim was to develop a machine learning approach for the prediction of added-sugar content in packaged products using available nutrient, ingredient, and food category information.

METHODS

The added-sugar prediction algorithm was developed using k-nearest neighbors (KNN) and packaged food information from the US Label Insight dataset (n = 70,522). A synthetic dataset of Australian packaged products (n = 500) was used to assess validity and generalization. Performance metrics included the coefficient of determination (R2), mean absolute error (MAE), and Spearman rank correlation (ρ). To benchmark the KNN approach, the KNN approach was compared with an existing added-sugar prediction approach that relies on a series of manual steps.

RESULTS

Compared with the existing added-sugar prediction approach, the KNN approach was similarly apt at explaining variation in added-sugar content (R2 = 0.96 vs. 0.97, respectively) and ranking products from highest to lowest in added-sugar content (ρ = 0.91 vs. 0.93, respectively), while less apt at minimizing absolute deviations between predicted and true values (MAE = 1.68 g vs. 1.26 g per 100 g or 100 mL, respectively).

CONCLUSIONS

KNN can be used to predict added-sugar content in packaged products with a high degree of validity. Being automated, KNN can easily be applied to large datasets. Such predicted added-sugar levels can be used to monitor the food supply and inform interventions aimed at reducing added-sugar intake.

High Fructose Intake Contributes to Elevated Diastolic Blood Pressure in Adolescent Girls: Results from The HELENA Study

BACKGROUND

The association between high fructose consumption and elevated blood pressure continues to be controversial, especially in adolescence. The aim of this study was to assess the association between fructose consumption and elevated blood pressure in an European adolescent population.

METHODS

A total of 1733 adolescents (mean ± SD age: 14.7 ± 1.2; percentage of girls: 52.8%) were analysed from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study in eight European countries. Blood pressure was measured using validated devices and methods for measuring systolic blood pressure (SBP) and diastolic blood pressure (DBP). Dietary data were recorded via repeated 24 h recalls (using specifically developed HELENA-DIAT software) and converted into pure fructose (monosaccharide form) and total fructose exposure (pure fructose + fructose from sucrose) intake using a specific fructose composition database. Food categories were separated at posteriori in natural vs. were non-natural foods. Elevated BP was defined according to the 90th percentile cut-off values and was compared according to tertiles of fructose intake using univariable and multivariable mixed logistic regression models taking into account confounding factors: centre, sex, age and z-score-BMI, MVPA (Moderate to Vigorous Physical Activity) duration, tobacco consumption, salt intake and energy intake.

RESULTS

Pure fructose from non-natural foods was only associated with elevated DBP (DBP above the 10th percentile in the highest consuming girls (OR = 2.27 (1.17-4.40); p = 0.015) after adjustment for cofounding factors.

CONCLUSIONS

Consuming high quantities of non-natural foods was associated with elevated DBP in adolescent girls, which was in part due to high fructose levels in these foods categories. The consumption of natural foods containing fructose, such as whole fruits, does not impact blood pressure and should continue to remain a healthy dietary habit.

Total and Free Sugar Levels and Main Types of Sugars Used in 18,784 Local and Imported Pre-Packaged Foods and Beverages Sold in Hong Kong

There is limited information regarding the free sugar content of pre-packaged foods in Hong Kong. This study aims to assess the free sugar content and identify the most frequently used free sugar ingredients (FSI) in pre-packaged foods in Hong Kong. Data from 18,784 products from the 2019 FoodSwitch Hong Kong database were used in this analysis. Ingredient lists were screened to identify FSI. Total sugar content was derived from nutrition labels on packaging. Free sugar content was estimated based on adaptation of a previously established systematic methodology. Descriptive statistics of the total sugar and free sugar content, as well as the mean ± SD contribution of free sugar to total sugar of the audited products were calculated, stratified by food groups. Almost two-thirds (64.5%) of the pre-packaged foods contained at least one FSI. 'Sugar (sucrose)' was the most popular FSI that was found in more than half (54.7%) of the products. 'Fruit and vegetable juices' (median 10.0; IQR 8.3-11.5 g/100 mL) were found to have a higher median free sugar content than 'Soft drinks' (8.0; 6.0-10.6 g/100 mL). Mean ± SD contribution of free sugar to the total sugar content was 65.8 ± 43.4%, with 8 out of 14 food groups having >70% total sugar as free sugar. To conclude, free sugar, especially sucrose, was extensively used in a wide variety of pre-packaged products sold in Hong Kong. Further studies are needed to assess the population intake of free sugar in Hong Kong to inform public health policy on free sugar reduction.

A Systematic Review of Metabolomic Biomarkers for the Intake of Sugar-Sweetened and Low-Calorie Sweetened Beverages

Intake of added sugars (AS) is challenging to assess compared with total dietary sugar because of the lack of reliable assessment methods. The reliance on self-reported dietary data in observational studies is often cited as biased, with evidence of AS intake in relation to health outcomes rated as low to moderate quality. Sugar-sweetened beverages (SSBs) are a major source of AS. A regular and high intake of SSBs is associated with an overall poor diet, weight gain, and cardiometabolic risks. An elevated intake of low-calorie sweetened beverages (LCSBs), often regarded as healthier alternatives to SSBs, is also increasingly associated with increased risk for metabolic dysfunction. In this review, we systematically collate evidence and provide perspectives on the use of metabolomics for the discovery of candidate biomarkers associated with the intake of SSBs and LCSBs. We searched the Medline, Embase, Scopus, and Web of Science databases until the end of December 2020. Seventeen articles fulfilled our inclusion criteria. We evaluated specificity and validity of the identified biomarkers following Guidelines for Biomarker of Food Intake Reviews (BFIRev). We report that the ¹³C:¹²C carbon isotope ratio (δ¹³C), particularly, the δ¹³C of alanine is the most robust, sensitive, and specific biomarker of SSBs intake. Acesulfame-K, saccharin, sucralose, cyclamate, and steviol glucuronide showed moderate validity for predicting the short-term intake of LCSBs. More evidence is required to evaluate the validity of other panels of metabolites associated with the intake of SSBs.

Dietary intakes, sources, and determinants of free sugars amongst Lebanese children and adolescents: findings from two national surveys

PURPOSE

To determine the intake levels, dietary sources, and determinants of free sugars (FS) consumption amongst Lebanese children and adolescents.

METHODS

This study is based on data collected by two national cross-sectional surveys conducted on representative samples of Lebanese children: survey 1 (under-five years (U5) children) (n = 899) and survey 2 (5-18 years-old children) (n = 1133). Multi-component questionnaires were used for data collection. Dietary intakes were assessed using one 24 h dietary recall. Median daily intakes of FS, and percent contribution of various food groups to FS intake were compared between sex and age groups. Logistic regressions were conducted to explore the determinants of high FS intake (> 10% energy intake/d), as per the WHO recommendations.

RESULTS

Median contribution of FS to daily energy intake was 8.5% in U5 children and 11.9% amongst those aged 5-18 years old. The top contributors to FS in both surveys were sugar-sweetened beverages and biscuits and chocolates. The proportion of children and adolescents exceeding WHO upper limits for FS was estimated at 43 and 62% in survey 1 and survey 2, respectively. Regression models showed females, higher household monthly incomes and higher parental educational levels were associated with significantly lower odds of exceeding the WHO upper limit for FS.

CONCLUSION

The study showed that a high proportion of Lebanese children and adolescents exceeded the WHO upper limit for FS intake, while also documenting a socioeconomic gradient in FS intake. Findings call for devising food system-based interventions to help reduce FS intake in this nutritionally vulnerable age group.

The adaptation, validation, and application of a methodology for estimating the added sugar content of packaged food products when total and added sugar labels are not mandatory

Nutrition policies recommend limiting the intake of added sugars. Information about added sugar content is not provided on packaged foods in Brazil, and even total sugar content information is often absent. This study aimed to (i) adapt a systematic methodology for estimating added sugar content in packaged foods when information on total and added sugar contents is not mandatory on labels, (ii) apply the adapted methodology to a Brazilian food composition database to estimate the extent of added sugar content in the national food supply, and (iii) assess the validity of the adapted methodology. We developed an 8-step protocol to estimate added sugar content using information provided on food labels. These steps included objective and subjective estimation procedures. Mean, median, and quartiles of the added sugar content of 4,805 Brazilian foods were determined and presented by food categories. Validity was assessed using a US database containing values of added sugar as displayed on the product labels. Objective estimation of added sugar content could be conducted for 3,119 products (64.9%), with the remainder 1,686 (35.1%) being assessed using subjective estimation. We found that 3,093 (64.4%) foods contained added sugar ingredients and the overall estimated median added sugar content was 4.7 g (interquartile range 0-29.3) per 100 g or 100 ml. The validity testing on US data for products with known added sugar values showed excellent agreement between estimated and reported added sugar values (ICC = 0.98). This new methodology is a useful approach for estimating the added sugar content of products in countries where both added and total sugar information are not mandated on food labels. The method can be used to monitor added sugar levels and support interventions aimed at limiting added sugar intake.

Nutritional Interventions and Considerations for the Development of Low Calorie or Sugar Free Foods

Diabetes is a globally prevalent chronic metabolic disease characterized by blood glucose levels higher than the normal levels. Sugar, a common constituent of diet, is also a major factor often responsible for elevating the glucose level in diabetic patients. However, diabetic patients are more prone to eat sweets amongst the human population. Therefore, we find a popular consumption of zero or low-calorie sweeteners, both natural and artificial. But, the uses of these sweeteners have proved to be controversial. Thus, the purpose of this review was to critically analyze and highlight the considerations needed for the development of sugar-free or low-calorie products for diabetic patients. For this purpose, various measures are taken such as avoiding sugary foods, using natural nectar, artificial sweeteners, etc. It cannot be ignored that many health hazards are associated with the overconsumption of artificial sweeteners only. These sweeteners are high-risk compounds and a properly balanced consideration needs to be given while making a diet plan for diabetic patients.

Intakes of Total, Free, and Naturally Occurring Sugars in the French-Speaking Adult Population of the Province of Québec, Canada: The PREDISE Study

The objective of this study was to characterize the intakes of different types of sugars in an age- and sex-representative sample of French-speaking adults from five regions of the Province of Québec, Canada, enrolled in the cross-sectional PREDISE (PRÉDicteurs Individuels, Sociaux et Environnementaux) study (n = 1147, 18-65 years old; 50.2% women). Because only total sugar content of foods and beverages is available in the Canadian Nutrient File (CNF) 2015, the initial step of this study was thus to build a database of free and naturally occurring sugars content of each food item and recipe included in the R24W, which is an automated, self-administered, web-based, 24-h dietary recall validated to estimate nutrient intakes in French-speaking adults of the Province of Québec. Total sugars were manually differentiated into free and naturally occurring sugars using a systematic algorithm based on previously published systematic algorithms. The World Health Organization (WHO)'s free sugar definition was used to differentiate total sugars into free and naturally occurring sugars. Dietary intake estimates were assessed using three 24-h dietary recalls completed with the R24W. Mean total, free, and naturally occurring sugar intakes were 116.4 g (19.3% of daily energy intake (%E)), 72.5 g (11.7%E), and 44.0 g (7.5%E), respectively. Over half (57.3%) of the overall sample did not meet the WHO's recommendation to consume less than 10%E from free sugars. Women had a higher %E from naturally occurring sugars than men and being younger was associated with a greater %E from free sugars. Sugar intakes among French-speaking adults from the Province of Québec were mainly in the form of free sugars, with the majority of the population exceeding the WHO recommendation regarding free sugar intake. This suggests that public health efforts towards reducing free sugar intake in this population are relevant and necessary, considering that overconsumption of free sugars negatively influences health outcomes.