Are restrictive guidelines for added sugars science based?

Charting the Chronology of Research on Added Sugars: A Scoping Review and Evidence Map

The objective of this study was to conduct a scoping review and produce a publicly available database characterizing the design and reporting elements of the literature on dietary added sugars and select health outcomes. Relevant studies published from 1990 to 2021 were identified to create a database containing information on study and population characteristics, reported added sugars source and concentrations, dietary energy balance, total energy intake, and outcome measures related to body composition, obesity, cardiovascular disease, and diabetes mellitus. There were 245 publications identified, 22% of which describe interventions, and 78% describe observational studies. Publications pertaining to added sugars have risen dramatically since 2010, led by studies primarily assessing body composition (36%) or cardiovascular health (32%), including adults (65%), measuring liquid-only sources of added sugars (56%). Over 65% of studies reported total energy intake, 61% controlled for total energy intake in the design and analysis, and fewer than 5% of studies reported the energy balance of subjects. There has been a significant increase in research on added sugars since 2010, with substantial heterogeneity across all facets of methodology-study designs, exposures and outcomes of interest, terminology, and reporting of dietary intake data-thus limiting the ability to synthesize evidence in this scope of the literature. This evidence map highlights gaps and important areas for improvement to strengthen the state of research and better inform future policies and dietary recommendations on added sugars.

Current WHO recommendation to reduce free sugar intake from all sources to below 10% of daily energy intake for supporting overall health is not well supported by available evidence

Sugar is widely consumed over the world. Although the mainstream view is that high added or free sugar consumption leads to obesity and related metabolic diseases, controversies exist. This narrative review aims to highlight important findings and identify major limitations and gaps in the current body of evidence in relation to the effect of high sugar intakes on health. Previous animal studies have shown that high sucrose or fructose consumption causes insulin resistance in the liver and skeletal muscle and consequent hyperglycemia, mainly because of fructose-induced de novo hepatic lipogenesis. However, evidence from human observational studies and clinical trials has been inconsistent, where most if not all studies linking high sugar intake to obesity focused on sugar-sweetened beverages (SSBs), and studies focusing on sugars from solid foods yielded null findings. In our opinion, the substantial limitations in the current body of evidence, such as short study durations, use of supraphysiological doses of sugar or fructose alone in animal studies, and a lack of direct comparisons of the effects of solid compared with liquid sugars on health outcomes, as well as the lack of appropriate controls, seriously curtail the translatability of the findings to real-world situations. It is quite possible that "high" sugar consumption at normal dietary doses (e.g., 25% daily energy intake) per se-that is, the unique effect of sugar, especially in the solid form-may indeed not pose a health risk for individuals apart from the potential to reduce the overall dietary nutrient density, although newer evidence suggests "low" sugar intake (<5% daily energy intake) is just as likely to be associated with nutrient dilution. We argue the current public health recommendations to encourage the reduction of both solid and liquid forms of free sugar intake (e.g., sugar reformulation programs) should be revised due to the overextrapolation of results from SSBs studies.

Directions of Changes in the Health Values of Dairy Products in the Opinion of Consumers

The aim of our research was to assess whether and to what extent the perceived change in the content of selected ingredients in dairy products is important for Polish consumers in accepting the enhancement of the health benefits of dairy products, including yogurt. The data were collected using a CAPI (Computer Assisted Personal Interview) survey on a sample of 983 consumers. The logistic regression model was used to predict the behavior of consumers associated with their willingness to accept the health aspects of improving dairy products. The results indicated that changes in the level of selected ingredients enhanced the willingness to accept increasing the health value of the product. The socio-demographic characteristics of the participants were not associated with the degree of their willingness to accept the improvement of the perceived health attributes. Practitioners in the dairy industry and policy makers can benefit from these results. When designing food products, it is worth focusing on increasing the nutritional value and enhancing the health value of food that is perceived by consumers as generally possessing positive health benefits, rather than on food that is perceived by them as possessing negative qualities.

To Raise or Not to Raise the Level of Ingredients in Yoghurts: Polish Consumer Preferences Regarding Dairy Products

Modern consumers are becoming increasingly aware of the perceived health benefits of food. As a result, they are in search of various types of information, for example, information on the packaging of food products that could confirm to what extent the purchased product will meet their expectations regarding the proper composition, that is, nutritional value, or perceived health values earlier mentioned. Furthermore, consumers increasingly seek new dairy products with additional health benefits and, therefore, it is essential to explore which attributes are important drivers of food choices and how producers can better respond to shifting consumer values and needs in each dairy product category. Therefore, the aims of our research was twofold: (1) To determine different segments of consumers based on their preferences towards food and nutrition, including opinion on new food products with a particular emphasis on a dairy market as well as (2) to study the importance of some statements related to nutrition presented on the yoghurt label with a precise focus on aspects of the increased and decreased content of some ingredients. The data were collected using a CAPI (Computer Assisted Personal Interview) survey on a sample of 489 adult Polish consumers. Respondents provided answers to questions and took part in a discrete choice-based experiment. The obtained data were analysed using the clustering method. The segmentation was performed using a hierarchical Ward's method. As a result, four segments were identified: Quality-oriented, Involved, Quality Enthusiasts, and Neutral. The results indicated that in relation to the features that are important in the case of yoghurts, the following were indicated above all: Beneficial effects on health, its sensory values, as well as its availability on the market and production by traditional methods. Consumers belonging to Quality Enthusiasts seemed to be the most promising segment due to their openness to new products, as well as positive feedback on yoghurt. From the perspective of taking action on the food market, Involved may also be interesting, as it showed their openness to new products available on the food market. However, due to the relatively lower, compared to other segments, assessment on the beneficial effect of yoghurt on health, their taste, aroma, availability, as well as the importance of information on care for the proper method of breeding animals, this segment can pose a special challenge to entrepreneurs. Moreover, Involved seemed to be more demanding and critical towards some projects undertaken on the market by policy makers and marketing practitioners.

Usual Nutrient Intakes from the Diets of US Children by WIC Participation and Income: Findings from the Feeding Infants and Toddlers Study (FITS) 2016

Background

A recent report of the National Academies of Sciences, Engineering, and Medicine (NASEM) outlined priority nutrients for infants and children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Objective

The objective of this study was to assess usual nutrient intakes from foods and beverages (not supplements) among US children aged <4 y by WIC participation status.

Methods

A national random sample of children aged <4 y (n = 3,235) from the Feeding Infants and Toddlers Study (FITS) 2016 was categorized by WIC participation status (participants, lower-income nonparticipants, or higher-income nonparticipants) and age (younger infants aged 0-5.9 mo, older infants aged 6-11.9 mo, toddlers aged 12-23.9 mo, or preschoolers aged 24-47.9 mo). All participants contributed one 24-h dietary recall, with a second recall from a representative subsample (n = 799). Usual intakes and compliance with federal dietary recommendations were estimated by using the National Cancer Institute method. Differences between WIC participants and either lower-income nonparticipants or higher-income nonparticipants were tested using t tests.

Results

The diets of infants (aged <12 mo) were nutritionally adequate in general. Older infants participating in WIC had higher compliance with iron and vitamin D guidelines than either group of nonparticipants and greater compliance with calcium, zinc, and potassium guidelines than higher-income nonparticipants. WIC toddlers had a higher risk of inadequate calcium and excessive sodium intakes than higher-income nonparticipants. Eight percent of WIC toddlers exceeded added sugar guidelines compared with either nonparticipant group (∼2%). WIC toddlers and preschoolers had a lower risk of inadequate vitamin D intake than lower-income nonparticipants, but inadequacy was >75% across all subgroups. WIC preschoolers had higher compliance with saturated fat guidelines but lower compliance with sodium and added sugar guidelines than higher-income nonparticipants.

Conclusions

WIC participants had better intakes of iron (ages 6-23.9 mo), zinc and potassium (ages 6-11.9 mo), saturated fat (ages 24-47.9 mo), and vitamin D (all ages). Regardless of WIC participation status, most infants and children met the calcium and zinc guidelines, but large proportions had intakes not meeting the recommendations for iron (ages 6-11.9 mo), vitamin D, potassium, fiber, saturated fat, and sodium.

Adolescents perceive a low added sugar adequate fiber diet to be more satiating and equally palatable compared to a high added sugar low fiber diet in a randomized-crossover design controlled feeding pilot trial

BACKGROUND

High added sugar (AS) intake is associated with obesity and poor diet quality. Guidelines recommended limiting AS to 5-10% of total energy intake, but palatability and feasibility of this AS intake level is uncertain.

OBJECTIVE

To compare adolescents' perceptions of hunger, fullness, and palatability in response to a low AS adequate fiber (LASAF; 5% total energy from AS and 13.5 g fiber/1000 kcal) and a high AS low fiber (HASLF; 25% total energy form AS and 8.2 g/1000 kcal) diet.

DESIGN

Adolescents (n = 32, age: 15.3 ± 1.6 yrs., BMI percentile: 47 ± 4, 15 male) completed a randomized, crossover, controlled feeding study. Participants consumed calorie-matched LASAF and HASLF diets for 7 days, separated by a 4 week washout. Body weight was monitored daily on each diet. Hunger, fullness, and palatability were assessed via 100 mm visual analogue scales at the end of each feeding period. Differences were assessed with paired sample t-tests. Data are expressed as mean ± SD.

RESULTS

Participants remained weight stable, and no difference in weight change between diet conditions was detected (LASAF: -0.06 ± 0.7 vs. HASLF: -0.02 ± 0.6 kg, p = 0.751). Less hunger (LASAF: 24.1 ± 14.6 vs. HASLF: 32.1 ± 17.6 mm, p = 0.024) and greater fullness (LASAF: 70.2 ± 12.3 vs. HASLF: 61.3 ± 18.1 mm, p = 0.006) were reported on the LASAF compared to the HASLF. Participants reported the diets to be equally palatable (LASAF: 39.6 ± 12.9 vs. HASLF: 37.2 ± 17.8 mm, p = 0.440).

CONCLUSIONS

Adolescents perceive a LASAF diet to be as palatable as a HASLF diet, but more satiating. LASAF diets should be investigated as a strategy for weight control in adolescents.

Total and Added Sugar Intake: Assessment in Eight Latin American Countries

Non-communicable diseases are growing at an alarming rate in Latin America. We assessed total and added sugar intake in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela, to verify the adequacy of the World Health Organization’s recommendations, considering gender, socioeconomic level (SEL) and age. A total of 9218 non-institutionalized individuals living in urban areas (age range 15–65 years) were assessed in the Latin American Study of Nutrition and Health (ELANS), a multicenter household population-based cross-sectional survey. Socio-demographic data were collected. Total and added sugar intakes were measured using two non-consecutive 24-h dietary recalls. The prevalence of excessive sugar intake was estimated. A large proportion of individuals showed high consumption of total and added sugar intake, which reflected in the high prevalence of excessive sugar intake. With minimal differences across countries, in general, women, individuals with high SEL, and younger people had higher percentages of total energy intake from total and added sugar intake, and of contribution of carbohydrates from total and added sugars. Thus, there is high consumption of total and added sugar intake in the Latin American countries with some peculiarities considering socio-demographic variables, which should be considered in each country’s health intervention proposals.

Gastrointestinal Tolerance and Glycemic Response of Isomaltooligosaccharides in Healthy Adults

Ingredients delivering functional and nutritional benefits are of interest to food manufacturers. Isomaltooligosaccharides (IMOs) which serve as alternate sweeteners fit into this category. IMOs are a mixture of α-(1 → 6) and α-(1 → 4)-linked glucose oligomers, synthesized by an enzymatic reaction from starch (corn, tapioca). The aim of this study was to evaluate the fermentability and glycemic response of IMO in a healthy population. Two randomized, double-blind, placebo-controlled, cross-over human studies were conducted. In the first study (n = 26), participants’ breath hydrogen over 24 h, gastrointestinal tolerance, and glycemic and insulinemic response to BIOLIGO^TM IL5040 isomaltooligosaccharide were measured. In another study (n = 10), participants’ two-hour post-prandial glycemic response to BIOLIGO^TM IL5040 isomaltooligosaccharide and BIOLIGO^TM IL7010 isomaltooligosaccharide was measured compared to dextrose (control). The IMOs differed in the composition of mono and di-saccharide sugars. IMO syrup dose was matched for 50 g of total carbohydrates and was consumed by mixing in water (237 mL/8 oz.). Mean composite gastrointestinal score was not significantly different (p = 0.322) between the control (1.42) and IMO (1.38). Lack of difference in glycemic response (p = 0.662), with no impact on breath hydrogen (24 h; p = 0.319) and intestinal tolerance, demonstrates that IMO is digestible and can be used to replace sugars in product formulations.

Intake of free sugars and micronutrient dilution in Australian adults

Background

The negative health effect of excessive intake of free sugars has been gaining increasing public awareness.

Objective

This secondary analysis aimed to evaluate the impact of free-sugar intake on micronutrient dilution, and estimate a threshold level of free-sugar intake at which a decrease in micronutrient intake becomes evident, based on data from the Australian Health Survey 2011-2012.

Design

Dietary data from adult respondents (weighted n = 6150) who had completed two 24-h recalls were analyzed. A published 10-step methodology was adopted and used to estimate the free-sugar intake of the respondents. Six modified cut-offs for percentage of energy of free sugars (%EFS) were created based on recommendations from the WHO and the Institute of Medicine to examine the association between %EFS on micronutrient intakes. Estimated marginal means and SEs were calculated using ANCOVA. Logistic regression was used to calculate the ORs of not meeting the nutrient reference values for Australia and New Zealand for each micronutrient with an increase in free-sugar intake. Analyses were adjusted for age, sex, socioeconomic status, country of birth, whether dieting, smoking status, and remoteness of living area.

Results

Peak intake for most micronutrients was observed at %EFS between 5% and <15%. A significant reduction in most micronutrient intakes was observed at >25%EFS. At <5%EFS, some micronutrient intakes were reduced. Only small variations in micronutrient consumptions were observed when %EFS was between 5% and 25%. Core food intake decreased and discretionary food increased with an increase in free-sugar intake.

Conclusion

A high free-sugar intake, particularly >25%EFS, was found to have a significant diluting effect on most nutrients. However, a free-sugar intake <5%EFS may increase the risk of undesirably low micronutrient consumption related to inadequate total energy intake. This secondary analysis was registered at anzctr.org.au as ACTRN12617000917336.

A review of total & added sugar intakes and dietary sources in Europe

Public health policies, including in Europe, are considering measures and recommendations to limit the intake of added or free sugars. For such policies to be efficient and monitored, a precise knowledge of the current situation regarding sugar intake in Europe is needed. This review summarizes published or re-analyzed data from 11 representative surveys in Belgium, France, Denmark, Hungary, Ireland, Italy, Norway, The Netherlands, Spain and the UK. Relative intakes were higher in children than in adults: total sugars ranged between 15 and 21% of energy intake in adults and between 16 and 26% in children. Added sugars (or non-milk extrinsic sugars (NMES), in the UK) contributed 7 to 11% of total energy intake in adults and represented a higher proportion of children's energy intake (11 to 17%). Educational level did not significantly affect intakes of total or added sugars in France and the Netherlands. Sweet products (e.g. confectionery, chocolates, cakes and biscuits, sugar, and jam) were major contributors to total sugars intake in all countries, genders and age groups, followed by fruits, beverages and dairy products. Fruits contributed more and beverages contributed less to adults' total sugars intakes than to children's. Added sugars were provided mostly by sweet products (36 to 61% in adults and 40 to 50% in children), followed by beverages (12 to 31% in adults and 20 to 34% in children, fruit juices excluded), then by dairy products (4 to 15% in adults and 6 to 18% in children). Caution is needed, however, as survey methodologies differ on important items such as dietary data collection, food composition tables or estimation of added sugars. Cross-country comparisons are thus not meaningful and overall information might thus not be robust enough to provide a solid basis for implementation of policy measures. Data nevertheless confirm that intakes of total and added sugars are high in the European countries considered, especially in children, and point to sweet products and beverages as the major contributors to added sugar intakes.