Total and Free Sugar Content of Pre-Packaged Foods and Non-Alcoholic Beverages in Slovenia

Dietary Intake of Adolescents and Alignment with Recommendations for Healthy and Sustainable Diets: Results of the SI.Menu Study

BACKGROUND

The SI.Menu study offers the latest data on the dietary intake of Slovenian adolescents aged 10 to 17. The purpose of this study is to comprehensively assess their dietary intake (energy and nutrients) and compare their food intakes with dietary recommendations for healthy and sustainable diets.

METHODS

The cross-sectional epidemiological dietary study SI.Menu (March 2017-April 2018) was conducted on a representative sample of Slovenian adolescents aged 10 to 17 years (n = 468) (230 males and 238 females). Data on dietary intake were gathered through two non-consecutive 24 h recalls, in line with the European Food Safety Authority (EFSA) EU Menu methodology. The repeated 24 h Dietary Recall (HDR) and Food Propensity Questionnaire (FPQ) data were combined to determine the usual intakes of nutrients and food groups, using the Multiple Source Method (MSM) program.

RESULTS

Adolescents' diets significantly deviate from dietary recommendations, lacking vegetables, milk and dairy products, nuts and seeds, legumes, and water, while containing excessive meat (especially red meat) and high-sugar foods. This results in insufficient intake of dietary fibre, and nutrients such as vitamin D, folate, and calcium.

CONCLUSIONS

The dietary intake of Slovenian adolescents does not meet healthy and sustainable diet recommendations. This study provides an important insight into the dietary habits of Slovenian adolescents that could be useful for future public health strategies.

Use of Branded Food Composition Databases for the Exploitation of Food Fortification Practices: A Case Study on Vitamin D in the Slovenian Food Supply

Vitamin D deficiency is a worldwide public health concern, which can be addressed with voluntary or mandatory food fortification. The aim of this study was to determine if branded food composition databases can be used to investigate voluntary fortification practices. A case study was conducted using two nationally representative cross-sectional datasets of branded foods in Slovenia, collected in 2017 and 2020, and yearly sales data. Using food labeling data we investigated prevalence of fortification and average vitamin D content, while nutrient profiling was used to investigate overall nutritional quality of the foods. In both datasets, the highest prevalence of vitamin D fortification was observed in meal replacements (78% in 2017; 100% in 2020) and in margarine, corresponding to high market share. Other food categories commonly fortified with vitamin D are breakfast cereals (5% in 2017; 6% in 2020), yogurts and their imitates (5% in 2017; 4% in 2020), and baby foods (18% in both years). The highest declared average content of vitamin D was observed in margarine and foods for specific dietary use (7-8 μg/100g), followed by breakfast cereals (4 μg/100g), while the average content in other foods was below 2 μg/100g. Only minor differences were observed between 2017 and 2020. Major food-category differences were also observed in comparison of the overall nutritional quality of the fortified foods; higher overall nutritional quality was only observed in fortified margarine. Our study showed that branded food composition databases are extremely useful resources for the investigation and monitoring of fortification practices, particularly if sales data can also be used. In the absence of mandatory or recommended fortification in Slovenia, very few manufacturers decide to add vitamin D, and even when this is the case, such products are commonly niche foods with lower market shares. We observed exceptions in imported foods, which can be subject to fortification policies introduced in other countries.

Branded Foods Databases as a Tool to Support Nutrition Research and Monitoring of the Food Supply: Insights From the Slovenian Composition and Labeling Information System

Branded foods databases are becoming very valuable not only in nutrition research but also for clinical practice, policymakers, businesses, and general population. In contrast to generic foods, branded foods are marked by rapid changes in the food supply because of reformulations, the introduction of new foods, and the removal of existing ones from the market. Also, different branded foods are available in different countries. This not only complicates the compilation of branded foods datasets but also causes such datasets to become out of date quickly. In this review, we present different approaches to the compilation of branded foods datasets, describe the history and progress of building and updating such datasets in Slovenia, and present data to support nutrition research and monitoring of the food supply. Manufacturers are key sources of information for the compilation of branded foods databases, most commonly through food labels. In Slovenia, the branded food dataset is compiled using standard food monitoring studies conducted at all major retailers. Cross-sectional studies are conducted every few years, in which the food labels of all available branded foods are photographed. Studies are conducted using the Composition and Labeling Information System (CLAS) infrastructure, composed of a smartphone application for data collection and online data extraction and management tool. We reviewed various uses of branded foods datasets. Datasets can be used to assess the nutritional composition of food in the food supply (i.e., salt, sugar content), the use of specific ingredients, for example, food additives, for nutrient profiling, and assessment of marketing techniques on food labels. Such datasets are also valuable for other studies, for example, assessing nutrient intakes in dietary surveys. Additional approaches are also being tested to keep datasets updated between food monitoring studies. A promising approach is the exploitation of crowdsourcing through the mobile application VešKajJeš, which was launched in Slovenia to support consumers in making healthier dietary choices.

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.

Effect of the Addition of Different Vegetal Mixtures on the Nutritional, Functional, and Sensorial Properties of Snacks Based on Pseudocereals

Quick meals available in markets are popular among consumers. Generally, these products are not recognized as functional foods owing to nutrient-poor composition. In this study, energy snack bars were developed with different formulations, using puffed quinoa, amaranth, cacao liquor, and coconut oil, and the effects of the addition of commercial vegetal mixtures (VM) on nutritional and functional properties were assessed. VM addition showed significant effects on the protein, lipid, and fiber contents, phenolic compounds (PHC) content, and antioxidant activity of the snacks. The control snack showed higher levels of free and bound PHC. The oxygen radical absorbance capacity (ORAC) analyses recorded highest values of free PHC (9392.7 μmol TE/100 g dry weight) in PC65 (concentrate based on a combination of vegetal proteins), whereas the highest bound PHC levels of 47,087 and 46,531 μmol TE/100 g dry weight were observed in PC65 and the control snacks, respectively. Sensorial attributes assessment provided a high score on the hedonic scale, wherein panelists detected no differences among the samples. Altogether, the selection of non-conventional ingredients with high antioxidant activities emerged as a successful strategy to produce sensory acceptable meals.

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.

Trends in the Use of Low and No-Calorie Sweeteners in Non-Alcoholic Beverages in Slovenia

Excessive sugar intake and the associated increased obesity risk indicate that food reformulation is needed. Non-alcoholic beverages are often high in free sugars, making reformulation with low and no-calorie sweeteners (LNCS) a common choice. Our knowledge of the use of LNCS in the European food supply is, however, very limited. This study aimed to evaluate the trends in the use of LNCS in different non-alcoholic beverages in the Slovenian food supply over the course of two years. We assessed which LNCS are most used and how the use of LNCS affects energy and sugar content. We analyzed labeling information of non-alcoholic beverages in selected grocery stores, covering the majority of the Slovenian food supply. Selected grocery stores were located in the capital city (Ljubljana). LNCS were present in 13.2% and 15.5% of non-alcoholic beverages in the years 2017 and 2019, respectively. The use of LNCS has significantly increased only in energy drinks (p < 0.01). The most used LNCS in 2017 were acesulfame K, aspartame, and cyclamates. In 2019 the use of sucralose increased significantly (p < 0.01) to become the second most used LNCS. Energy and sugar content varied between subcategories, which depended on the presence of added sugar and LNCS. Comparison between the energy value and the presence of the LNCS showed an almost 50% lower energy content of beverages containing both added sugar and LNCS (E₂₀₁₇ = 92.8 kJ; E₂₀₁₉ = 96.2 kJ per 100 mL), compared with beverages with only added sugar (E₂₀₁₇ = 161.8 kJ; E₂₀₁₉ = 159.0 kJ per 100 mL). In beverages sweetened only with LNCS, the difference was even more noticeable (E₂₀₁₇ = 22.3 kJ; E₂₀₁₉ = 14.3 kJ per 100 mL). Results show that the use of LNCS can help producers reduce the energy value of non-alcoholic beverages. Still, compared to other countries, the offer of such products in the Slovenian food supply is relatively low. However, due to possible public health risks of excessive use of LNCS, producers should be further encouraged for reformulation and production of less sweet products without LNCS, enabling consumers to adapt to less sweet taste of beverages. Further monitoring of LNCS in the food supply is therefore recommended, preferably also with consideration of sales data.

Influence of sugar label formats on consumer understanding and amount of sugar in food choices: a systematic review and meta-analyses

CONTEXT

Reducing population intakes of sugar has become a focus of many national and international public health policies. Packaged foods and beverages are key contributors to sugar intakes, and food labels can be an effective tool to reduce sugar consumption.

OBJECTIVE

The aim of this systematic review was to examine the influence of sugar label formats on 2 outcomes: consumers' understanding of sugar information, and the amount of sugar in consumers' food choices.

DATA SOURCES

Scopus, Web of Science, PubMed, CAB Abstracts, SciELO, and the Cochrane Library databases were searched up until February 4, 2020.

STUDY SELECTION

Randomized experiments or quasi-experiments were included if they investigated the influence of sugar label formats on consumers' understanding of sugar information or on the amount of sugar in consumers' food choices.

DATA EXTRACTION

Data were extracted independently by 2 authors. Mean differences (MDs), standardized mean differences (SMDs), and odds ratios (ORs) plus 95%CIs were used to describe between-group differences for intervention label formats using random-effects models.

RESULTS

Twenty-three studies, which examined 39 comparisons, were included. Label formats using "high in sugar" interpretative texts (traffic light labels [MD 41.6; 95%CI 37.9-45.4] and warning signs [OR 1.33; 95%CI 1.0-1.78]) were most effective in increasing consumers' understanding of the sugar content in packaged foods. Health warning messages (SMD -0.32; 95%CI -0.43 to -0.22), graphical depictions of sugar content in teaspoons (SMD -0.32; 95%CI -0.48 to -0.17), and warning signs (SMD -0.24; 95%CI -0.35 to -0.13) were most effective for influencing consumers to choose products with lower sugar content.

CONCLUSIONS

Formats that provide an interpretation of sugar information, particularly those indicating if a product is high in sugar, were more helpful than only numerical information for improving consumer understanding and promoting food choices with less sugar.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42018081222.

Nutrient and Food Intake of Participants in a Whole-Food Plant-Based Lifestyle Program

OBJECTIVE

We evaluated the nutrient adequacy of a well-planned supplemented whole-food plant-based (WFPB) diet as a component of an ongoing community lifestyle optimization program. We investigated the contributions of nutrients from foods and supplements and plant-based meal replacement (SMR) separately (foods, SMR) and combined (vs recommendations) as well as food group intake, both according to sex.

METHOD

Our cross-sectional study included 151 healthy, active participants (aged 39.6 years) who were on a Western-type diet when they voluntarily joined our WFPB lifestyle program (0.5-10 years ago). We assessed diet using 3-day weighed dietary records (foods, S, and MR). After we standardized nutrient intake to 2000 kcal/d, we calculated the contribution of macro- and micronutrients from foods and SMR separately and combined (foods + SMR) (vs central European Recommendations), as well as food group intake, both according to sex.

RESULTS

All macro- and micronutrient intake (total: from foods plus SMR) exceeded the reference values, except for calcium (95% and 82% in females and males) and vitamin D (both sexes, in summertime). Compared with male participants, female participants consumed (i.e., from foods and SMR together) significantly larger amounts of 23 (/25) micronutrients (8 [/25] from foods and 22 [/25] from SMR). The diet was primarily composed of the following (by mass in descending order): unprocessed vegetables/fruits, whole grains, legumes, potatoes, nuts/seeds, MR, and spices/herbs.

CONCLUSIONS

Participants in our WFPB lifestyle program ingested a nutrient-rich WFPB diet and targeted supplementation. The presented ongoing community WFPB lifestyle program ensures a healthy, balanced, and environment-friendly dietary pattern for participants who are compliant.

Total and Free Sugars Consumption in a Slovenian Population Representative Sample

Excessive free sugars consumption is associated with poor health outcomes. Thus, the World Health Organization (WHO) recommends limiting free sugars intake to no more than 10% of total energy intake. To evaluate current intakes of dietary sugars and monitor the adherence to the guidelines, the objective of this study was to comprehensively assess total and free sugars consumption of different age groups within the Slovenian population. The Slovenian national food consumption survey SI.Menu 2017/18 was conducted on representative samples of adolescents (10–17 years), adults (18–64 years), and the elderly (65–74 years) using two non-consecutive 24-h dietary recalls. The analyses were carried out on a sample of 1248 study participants. Free sugars content in food was estimated based on previously established databases. The population weighted median free sugars intake accounted for 10.1% of total energy intake (TEI) among adolescents, 6.4% among adults, and 6.5% in the elderly population. Both total and free sugars consumption in the percentage of TEI were higher among women than men, in participants with lower education, and those with higher family net income. The main sources of free sugars in adolescents were beverages, cakes, muffins, pastry, and dairy products; for adults and the elderly, the key sources of free sugars were beverages, cakes, muffins, pastry, and sugars, honey, and related products. A total of 56% of adolescents, 84% of adults, and 81% of the elderly population adhered to the WHO free sugars guidelines. Additional measures will be required to further decrease free sugars consumption among the teenage population, in which dietary patterns are still of greatest concern.

Free Sugar Content in Pre-Packaged Products: Does Voluntary Product Reformulation Work in Practice?

Ultra-processed, pre-packaged foods are becoming a growing part of our diet, while displacing whole and minimally processed foods. This results in an increased intake of free sugar, salt, and saturated fats, that have a profoundly negative effect on health. We aimed to assess the trend in free sugar content in pre-packaged foods in Slovenia and evaluate the efficacy of industry self-regulations designed to combat the excess consumption of free sugar. A nation-wide data collection of the Slovenian food supply was performed in 2015 and repeated in 2017. In 2017, 54.5% of all products (n = 21,115) contained free sugars (median: 0.26 g free sugar/100 g). Soft drinks became the main free sugar source among pre-packaged goods (28% of all free sugar sold on the market) in place of chocolates and sweets, of which relative share decreased by 4.4%. In the categories with the highest free sugar share, market-leading brands were often sweeter than the average free sugar value of the category. This indicates that changes in on-shelf availability towards a greater number of healthier, less sweet products are not necessarily reflected in healthier consumers’ choices. Relying solely on voluntary industrial commitments to reduce free sugar consumption will likely not be sufficient to considerably improve public health. While some further improvements might be expected over the longer term, voluntarily commitments are more successful in increasing the availability of healthier alternatives, rather than improving the nutritional composition of the market-leading products. Additional activities are, therefore, needed to stimulate reformulation of the existing market-leading foods and drinks, and to stimulate the consumption of healthier alternatives.

Variations in Sugar Content of Flavored Milks and Yogurts: A Cross-Sectional Study across 3 Countries

BACKGROUND

The consumption of dairy products is encouraged at all life stages as a nutrient-rich component of the diet. However, many milk and yogurt products, particularly flavored varieties, may contain large amounts of free sugar.

OBJECTIVES

The aim of this paper was to evaluate the availability and sugar content of flavored milks and yogurts in supermarkets across 3 countries: Australia, England, and South.

METHODS

Nutrition information for flavored milks and yogurts was collected by trained researchers and supplemented by crowd-sourced data from a smartphone application. Data were extracted in April 2018 and 3724 milk and yogurt products were available for analysis. Mean sugar concentrations were compared across countries with the use of ANOVA followed by Tukey's post-hoc pairwise comparisons. Sugar concentrations were compared with the UK's "green" traffic-light classifications.

RESULTS

Approximately 74% (n = 2753) of all products were flavored. Flavored products contained nearly twice the average total sugar content of unflavored products, with substantial variability: mean total sugar was 9.1 g/100 mL (range: 4.3-15.0 g/100 mL) and 11.5 g/100 g (range: 0.1-22.6 g/100 g) for flavored milks and yogurts, respectively. Free sugars contributed an estimated 41% and 42% of total sugar in milks and yogurts, respectively. Flavored milks in England had ∼0.7 g/100 mL higher total sugar on average compared with Australia and South Africa (P ≤ 0.04), whereas flavored yogurts in South Africa had the lowest average total sugar (∼2 g/100 g lower than England and Australia; P < 0.001). Less than 4% of flavored products would receive a "green" rating under the UK traffic-light labeling scheme.

CONCLUSIONS

In Australia, England, and South Africa, flavored milks and yogurts are highly prevalent in the food supply and contain significantly higher concentrations of total and added sugars than unflavored products.

Nutrient Profiling Is Needed to Improve the Nutritional Quality of the Foods Labelled with Health-Related Claims

Health-related claims on food products influence consumers and their food preferences. None of the European countries have restricted the use of health claims to foods of high nutritional quality despite the regulatory background provided by the European Union in 2006. We evaluated the nutritional quality of foods labelled with claims available in the Slovenian market using two nutrient profile models—Food Standards Australia New Zealand (FSANZ) and European World Health Organization Regional office for Europe model (WHOE)—and compared the results to the nutritional quality of all available foods. Data for prepacked foods in the Slovenian food supply were collected in 2015 on a representative sample (n = 6619) and supplemented with 12-month product sales data for more accurate assessments of the food supply. A considerable proportion of foods labelled with any type of health-related claim was found to have poor nutritional quality. About 68% of the foods labelled with health-related claims passed FSANZ criterion (75% when considering sales data) and 33% passed the WHOE model (56% when considering sales data). Our results highlight the need for stricter regulations for the use of health-related claims and to build upon available nutrient profiling knowledge to improve nutrition quality of foods labeled with health-related claims.

Trends in marketing foods to children in Slovenian magazines: a content analysis

OBJECTIVE

Food marketing is an important factor influencing children's food preferences. In Slovenia the use of magazines is widespread among children. We investigated food advertising in children's and teens' magazines (CTM) in 2013 and 2017. The penetration of food advertising was compared with magazines targeting the adult population.

DESIGN

A repeated cross-sectional study. Magazines were searched for branded food references (BFR). All BFR were categorised and evaluated using the WHO Europe nutrient profile model.

SETTING

Slovenia.

SUBJECTS

All issues of CTM and a selected sample of issues of adult-targeting magazines and newspapers published in Slovenia in 2013 and 2017.

RESULTS

One hundred and seventy-five issues of CTM (ninety-two in 2013, eighty-three in 2017) and 675 issues of adult-targeted magazines and newspapers were analysed (345 in 2013, 330 in 2017). In 2017, food advertising in CTM dropped notably but the opposite was found for adult-targeted magazines. Regular advertisements dominated in 2017 in CTM, while in 2013, 83 % of BFR types were games/puzzles, competitions and product placements. Chocolate and confectionery were the most advertised in CTM and food supplements in adults' magazines. Most foods in CTM were classed as 'not permitted' in both years (98 % in 2013 and 100 % in 2017).

CONCLUSIONS

The advertisements in CTM still mostly refer to unhealthy foods. The extent of food advertising has dropped considerably since 2013. On the contrary, food advertising in printed media targeting adults has increased, chiefly referring to food supplements and foods that do not pass the WHO Europe nutrient profile model criteria.

Added Sugars and Low- and No-Calorie Sweeteners in a Representative Sample of Food Products Consumed by the Spanish ANIBES Study Population

Low- and no-calorie sweeteners (LNCS), intensely sweet compounds that virtually contain no calories, are used to replace added sugars in food and drinks. Knowledge about different LNCS data in Spanish foods and added sugar sources in Spain is limited, therefore our aim was to identify and compare their presence across main food groups consumed. Food and beverage products (n = 434) were obtained from the ANIBES Study (anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles), a cross-sectional study of a representative sample of the Spanish population (9⁻75 years old; n = 2009) carried out in 2013. Food records were obtained from a three-day dietary record using a tablet device. Label data from 1,164 products of different brands were collected and reviewed for content of added sugars and LNCS. LNCS were present in diet soft drinks (100%), "other sweets" (89%), soya drinks (45%), and yogurt and fermented milks (18%). Added sugars were present mainly in sugar soft drinks (100%), energy drinks (96%), sports drinks (96%), bakery and pastry (100%), chocolates (100%), ice cream (100%), breakfast cereals/bars (96%) and jams (89%). Main LNCS were acesulfame K, aspartame, cyclamate and sucralose. Sucrose, dextrose, glucose-fructose syrup, caramel and honey were the main added sugars. Our results show the diversity of foods groups including these ingredients. These data are not compiled in food composition databases, which should be periodically updated to include LNCS and added sugars to facilitate their assessment and monitoring in nutritional surveys.