- Email: [email protected]
Weighing in on Added Sugars and Health
RESEARCH Commentary
Weighing in on Added Sugars and Health RACHEL K. JOHNSON, PhD, MPH, RD; BETHANY A. YON, MS
I
n this issue of the Journal, Lustig contends that a reduction in fructose consumption is necessary to combat the obesity epidemic (1). His review is one of many recently that is focused on the adverse health effects of increased intakes of sugars, especially added sugars and those coming from sugar-sweetened beverages. Although registered dietitians have for years focused on fat as the macronutrient most associated with chronic disease, it has become increasingly clear that the amount and quality of carbohydrates in the diet may be equally as important as fats to reduce diet-related chronic disease. Registered dietitians, nutrition scientists, nutrition policy makers, and advocacy groups are increasingly focusing on added sugars. The US Department of Agriculture (USDA) defines added sugars as all sugars used as ingredients in processed and prepared foods (such as breads, cakes, soft drinks, jam, and ice cream), and sugars eaten separately or added to foods at the table (2). Specifically, added sugars include white sugar, brown sugar, raw sugar, corn syrup, corn-syrup solids, highfructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, liquid fructose, honey molasses, anhydrous dextrose, and crystal dextrose (2). Added sugars do not include the naturally occurring sugars lactose (in milk and dairy products) or fructose (in fruit). Americans’ consumption of added sugars has been estimated using national food consumption survey data and USDA Economic Research Service food availability data. Although in recent years there has been a slight decrease in the availability of energy-containing sweeteners in the US food supply (3), intakes remain substantially higher than they were 4 decades ago (4). In addition, intakes remain considerably higher than current recommendations across all age and sex groups (5). A recent analysis of 1999-2006 National Health and Nutrition Examination Survey data estimated added sugars intake from a representative sample of 6,113 US adults at 21.4 tsp/day (359 kcal), which represented 15.8% of total daily energy intake (6). This represents a substantial increase from 1977-78, when added sugars contributed only 10.6% of R. K. Johnson is associate provost and a professor of nutrition, and B. A. Yon is a research specialist, Nutrition and Food Sciences, The University of Vermont, Burlington. Address correspondence to: Rachel K. Johnson, PhD, MPH, RD, University of Vermont, 347A Waterman Bldg, Burlington, VT 05405. E-mail: rachel.johnson@ uvm.edu Manuscript accepted: June 4, 2010. Copyright © 2010 by the American Dietetic Association. 0002-8223/$36.00 doi: 10.1016/j.jada.2010.06.013
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the energy consumed by adults (7). Sugar-sweetened carbonated beverages and energy and sports drinks along with fruit drinks continue to be the primary source (46%) of added sugars in Americans’ diets (5). Along with these beverages, grain-based desserts (13%), dairy desserts (7%), candy (6%), and ready-to-eat cereals (4%) make up the top five sources of added sugars. Until recently there was no quantifiable recommendation for added sugars. The 2000 Dietary Guidelines for Americans (DGA) advised consumers to “choose beverages and foods to moderate your intake of sugars” (8) and the 2005 DGA advised them to “choose prepared food and beverages with little added sugars or caloric sweeteners” (9). In 2006, the American Heart Association (AHA) Dietary and Lifestyle Recommendations advised consumers to “minimize intake of foods and beverages with added sugars” (10). In 2009, a writing group for the AHA, which included Lustig, published a scientific statement that for the first time made specific recommendations for added sugars intakes based on people’s energy needs (11). The AHA statement concluded that most women should limit their daily added sugars intake to 100 kcal, or about 6 tsp; for men, the recommendation is 150 kcal, or 9 tsp. The statement generated unprecedented interest from the popular press and the AHA estimated that it received more than 60 million media impressions. THE AHA RECOMMENDATION Why did the AHA make a recommendation that calls for a dramatic decrease in the amount of added sugars consumed by most Americans? Because the scientific evidence base is becoming increasingly robust and demonstrates that added sugars, especially those coming from sugar-sweetened beverages, increase the risk of overweight and obesity as well as other risk factors for cardiovascular disease, including dyslipidemia and high blood pressure. In addition, with the exception of the extremely physically active, very few Americans are able to meet their nutrient needs with room in their diet for many extra kilocalories from added sugars. The AHA statement did not address the use of non-nutritive sweeteners, however the Food and Drug Administration has approved their use and they are considered safe (12). OBESITY A meta-analysis examined 88 cross-sectional and prospective studies exploring the relationship between soft drink intake and health outcomes and found that higher intakes were associated with greater energy intake, higher body weight, lower intake of other nutrients, and worse health indexes (13). Subsequent analyses from a large trial confirmed these findings; namely, greater weight loss as sugar-sweetened beverage intake de-
© 2010 by the American Dietetic Association
creased (14). In addition, data from two large cohort studies have been published since the AHA statement was released. Consumption of sweetened beverages was positively associated with body mass index as well as an increased risk of coronary heart disease (CHD) in the 24-year follow-up study in the Nurses Health Study (15). Soft drink consumption was also highly associated with increased body weight, after adjusting for overall dietary quality, in the Singapore Chinese Health Study (16). Weight gain may occur with greater energy intake from fluids than from solid foods due to the weak satiety signals evoked from energy-containing beverages; therefore, total energy intake may be greater with fluid energy intake than from solid foods (17-19). Recently the 2010 DGA Advisory Committee stated that among several strategies to reduce the incidence and prevalence of overweight and obesity, Americans should avoid sugar-sweetened beverages (20). The use of the word avoid is the strongest recommendation to date for a policy document of this nature, indicative of the strength of the association between sugar-sweetened beverages and obesity. The American Dietetic Association’s Evidence Analysis Library (12) concluded that using non-nutritive sweeteners will affect overall energy balance only if they are substituted for higher-energy food or beverages. Studies show that the use of non-nutritive sweeteners does not cause weight gain among children and adolescents. If non-energy beverages, including those with non-nutritive sweeteners, are substituted for sugar-sweetened beverages, a potential for energy savings has been found in adolescents. DYSLIPEDEMIA The AHA statement summarized the links between added sugars and dyslipidemia as follows: “Although the mechanisms are unclear, relative to other carbohydrate sources, sugar intake appears to be associated with increased triglyceride levels, a known CHD risk factor; however, relative to other sources of carbohydrate, the effects of sugar intake on HDL and LDL levels remain unclear” (11). Since the AHA publication, new evidence indicated that consuming a higher amount of added sugars in processed or prepared foods was associated with lower levels of high-density lipoprotein cholesterol and higher levels of triglycerides in a large sample of US adults (6). This study strengthens the evidence that there is an association between added sugars intakes and these important risk factors for CHD. BLOOD PRESSURE The AHA statement also concluded that “an emerging but inconclusive body of evidence suggests that increased intake of added sugars might raise blood pressure” (11). In the Framingham Heart Study, consumption of one or more soft drinks per day significantly increased the odds of developing high blood pressure (21). New evidence from the PREMIER study, a randomized intervention trial, adds strength to the evidence in this area. Reducing sugar-sweetened beverage intake by one serving a day was significantly associated with a reduction in blood pressure (22).
NUTRIENT ADEQUACY There is evidence that diets containing a high proportion of added sugars are lower in micronutrients than diets containing a moderate proportion of added sugars (23). One review found that studies examining the percentage of people achieving the Recommended Dietary Allowances or reference nutrient intake for micronutrients across categories of sugar intake often found nonlinear relationships, such that higher levels of micronutrient intake were observed in the moderate added sugar intake categories compared with low and high categories of intakes. As acknowledged in the AHA statement, the form in which added sugars are consumed seems to be an important modifier of the effects of dilution (23). Sugarsweetened carbonated beverages, sugar, and sweets are more likely to have a negative influence on diet quality, whereas dairy foods, milk drinks, and pre-sweetened cereals may have a positive influence (24). Recently, the 2010 DGA Advisory Committee recommended reducing intakes of foods containing added sugars, solid fats, refined grains, and sodium because they contain few, if any, nutrients (20). This statement highlights the committee’s concern about the effects of excess intakes of added sugars on nutrient adequacy. DISCRETIONARY CALORIES AND SOLID FATS, ALCOHOL, AND ADDED SUGARS (SoFAAS) How did the AHA writing group set a quantifiable recommendation? The AHA recommendation for added sugars is based on the discretionary calorie concept developed by the 2005 DGA Advisory Committee. A person’s discretionary calorie allowance is determined by estimating the energy needed to meet his or her daily energy requirements and then subtracting the energy needed to meet nutrient requirements from food. Any energy remaining are discretionary calories. These obviously vary according to energy needs; an active teenage boy will have a substantially higher discretionary calorie allowance than a sedentary elderly woman (Table). The allowance for discretionary calories includes not only added sugars, but also solid fats and alcohol, often referred to as SoFAAS. The AHA writing group for the scientific statement on added sugars determined that a prudent upper limit of intake for added sugars would be half of the discretionary calorie allowance. If a person chooses to consume alcohol, then added sugars and solid fats intakes should be further reduced to accommodate the additional energy from alcohol. Depending on the energy level, the AHA added sugars recommendations vary from a low of 3 tsp/day (48 kcal) for an energy requirement of 1,600 kcal to a high of 18 tsp/day (288 kcal) for an energy requirement of 3,000 kcal. Because most American women require about 1,800 kcal/day and most American men require about 2,200 kcal/day, the AHA’s take home message is “aim for 100 calories (6 tsp) of added sugars per day if you’re a woman and 150 calories (9 tsp) if you’re a man.” These recommendations are consistent with the new 2010 DGA Advisory Committee recommendations to significantly reduce the number of calories consumed from SoFAAS, as there typically is not room for the excess energy in most Americans’ diets. The AHA recently published a novel, exciting roadmap
September 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
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Table. Discretionary calories and added energy allowances based on a variety of age, sex, and physical activity levelsa Men
Women
Variable
21-25 y
46-50 y
51-55 y
71-75 y
Physical activity levelb Energy needs (kcal)c Discretionary calories (kcal)d Added sugars (tsp)e Added sugars energy (kcal)
Active 3,000 512 18 288
Sedentary 2,200 290 9 144
Moderately active 1,800 195 5 80
Sedentary 1,600 132 3 48
a
Based on references (9), (28), and (29). Sedentary means a lifestyle that includes only the physical activity of independent living; moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles/day at 3 to 4 miles/hour, in addition to the activities of independent living; active means a lifestyle that includes physical activity. c Energy needs to maintain current weight, this will not promote weight loss in overweight/obese people. d Recommended limit for discretionary calories, per Dietary Guidelines for Americans, 2005 (9). e Recommended limit for added sugars, per Dietary Guidelines for Americans, 2005 (9). b
● Search the ingredient list for the word syrup, such as corn syrup, high-fructose corn syrup, maple syrup, and agave syrup. ● Look for words ending in “ose,” such as fructose, glucose, sucrose, and dextrose. ● Compare the unsweetened version of a product (plain, unsweetened yogurt or plain shredded wheat cereal) with the sweetened version (fruit-flavored yogurt or frosted shredded wheat) to estimate the amount of added sugars. ● Beware of a health halo effect. Some added sugars, such as brown rice syrup, may sound healthful but are just another added sweetener. Figure 1. Identifying added sugars in processed and prepared foods.
to achieve the goal of a 20% improvement in Americans’ cardiovascular health by 2020 (25). The AHA acknowledged that to achieve ideal cardiovascular health, a healthy eating pattern is essential. Thus, the roadmap includes five measureable eating behaviors as a part of their health and lifestyle recommendations. One of the five behaviors states that, in the context of an energybalanced diet, sugar-sweetened beverages should not exceed 450 kcal or 36 oz/week. How can dietetics practitioners help consumers implement the AHA recommendation? Currently, food labels in the United States contain information on total sugars per serving but do not distinguish between added sugars and those sugars naturally present in foods and beverages. Thus, it is difficult for consumers to determine the amount of added sugars in the foods and beverages they select. Figure 1 lists some practical tips to help consumers identify added sugars. In 2006 the USDA published a database for the added sugars content of selected foods that dietetics practitioners can use to help educate consumers (26). The Food and Drug Administration has been petitioned by a number of organizations, including the AHA, to include added sugars on the Nutrition Facts panel. However, until a methodology that can distinguish added sugars from naturally occurring sugars in food and beverage products is developed, the Food and Drug Administration would be unable to enforce a regulation re-
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● Avoid sugar-sweetened beverages. ● Don’t worry about the naturally occurring sugars like fructose in fruit and lactose in milk and dairy products. ● Use your added sugars allowance to sweeten already nutrientdense foods (a little maple syrup on oatmeal, some added sweeteners in yogurt and flavored milk) rather than in nutrientvoid foods and beverages like soft drinks and candy. ● If a food contains little or no milk or fruit, the sugars number on the package’s Nutrition Facts panel will be a good estimate of how much added sugar is in each serving (30). Figure 2. Consumer messages for choosing healthful foods, based on reference (30).
quiring listing added sugars on the label, making such a regulation unlikely in the near future. CONCLUSIONS Undoubtedly there will be continued debate among registered dietitians, nutrition scientists, policy makers, and advocacy groups about the deleterious health effects of added sugars. However, in the context of an American population that is predominantly overweight and obese and thus unhealthy, it is time for change. No one, except those who are extremely physically active, has room in his or her everyday diet for hundreds of kilocalories’ worth of empty calories from added sugars. In May 2010, a conference sponsored by the AHA, brought together stakeholders to focus on issues surrounding added sugars. Lawrence Appel, MD, MPH, past chair of the AHA Nutrition Committee and member of the 2005 and 2010 DGA Advisory Committees, eloquently stated that “the enemy of good is pursuit of the perfect, and expectation of the impossible” (personal communication, May 10, 2010). The science around added sugars and health will never be perfect. Nevertheless, strong scientific evidence is building and dietetics practitioners need to be aware of the negative health consequences related to excess added sugars. It is also time to advocate for fewer added sugars in the food supply. Industry is responding to First Lady Michelle Obama’s Let’s Move campaign with its own
pledge to reduce 1.5 trillion kcal in the food supply by the end of 2015 (27). The dairy industry is working to reduce the amount of added sugars in flavored milks offered to schools. Although it will take time for the food supply to change, dietetics practitioners can continue to help clients make changes (see Figure 2) to lower the amount of added sugars in their diets to the levels recommended by the AHA to achieve and maintain healthy weights, meet their essential nutrient needs, and lower risk for cardiovascular disease. STATEMENT OF POTENTIAL CONFLICT OF INTEREST: Dr Johnson serves on the American Heart Association Nutrition Committee and the Medical Advisory Board for the Milk Processors Education Program. Dr Johnson and Ms Yon have research grant funding from Dairy Management Incorporated.
12. 13.
14.
15.
16.
17.
18.
References 1. Lustig RH. Fructose: Metabolic, hedonic, and societal parallels with ethanol. J Am Diet Assoc. 2010;110:1307-1321. 2. Otten JJ, Hellwig JP, Meyers LD eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: Institute of Medicine of the National Academies; 2006. 3. Sugar and sweeteners yearbook table 50, US per capita caloric sweeteners estimated deliveries for domestic food and beverage use, by calendar year. US Department of Agriculture, Economic Research Service Web site. http:// www.ers.usda.gov/briefing/sugar/data.htm#yearbook. Accessed May 24, 2010. 4. Wells HF, Buzby J. Dietary assessment of major trends in US food consumption, 1970-2005. Economic Information Bulletin No. 33. March 2008. US Department of Agriculture, Economic Research Service Web site. http://www.ers.usda.gov/Publications/EIB33. Accessed May 23, 2010. 5. Sources of calories from added sugars among the US population, 2005-06. Risk Factor Monitoring and Methods Branch Web site. http://riskfactor.cancer.gov/diet/foodsources/added_sugars/. Accessed May 24, 2010. 6. Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults. JAMA. 2010;303:1490-1497. 7. Glinsmann WH, Irauquin H, Park YK. Evaluation of health aspects of sugars contained in carbohydrate sweeteners: Report of Sugars Task Force, 1986. J Nutr. 1986;116(suppl):S1-S216. 8. US Departments of Agriculture and Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 2000. 5th ed. Washington, DC: US Government Printing Office; 2000. Home and Garden Bulletin No. 232. 9. US Departments of Health and Human Services and Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: US Government Printing Office; 2005. 10. Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, WylieRosett J. Diet and lifestyle recommendations revision 2006, A scientific statement From the American Heart Association Nutrition Committee [published corrections appear in Circulation. 2006;114:e629 and 2006;114:e27]. Circulation. 2006;114:82-96. 11. Johnson RK, Appel LJ, Brands M, Howard B, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J. Dietary sugars intake and
19. 20.
21.
22.
23. 24.
25.
26.
27. 28. 29.
30.
cardiovascular health. A scientific statement from the American Heart Association. Circulation. 2009;120:1011-1020. American Dietetic Association’s Evidence Analysis Library. http:// www.adaevidencelibrary.com. Accessed June 3, 2010. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: A systematic review and metaanalysis. Am J Public Health. 2007;97:667-675. Chen L, Appel LJ, Loria C, Lin PH, Champagne CM, Elmer PJ, Ard JD, Mitchell D, Batch BC, Svetkey LP, Caballero B. Reduction in consumption of sugar-sweetened beverages is associated with weight loss: The PREMIER trial. Am J Clin Nutr. 2009;89:1-8. Fung TT, Malik V, Rexrode KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89:1037-1042. Odegaard AO, Koh WP, Arakawa K, Yu MC, Pereira MA. Soft drink and juice consumption and risk of physician-diagnosed incident type 2 diabetes: The Singapore Chinese Health Study. Am J Epidemiol. 2010;171:701-708. Mourao DM, Bressan J, Campbell WW, Mattes RD. Effects of food form on appetite and energy intake in lean and obese young adults. Int J Obes. 2007;31:1688-1695. Mattes R. Fluid calories and energy balance: The good, the bad, and the uncertain. Physiol Behav. 2006;89:66-70. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: Effects on food intake and body weight. Int J Obesity. 2000;24:794-800. US Departments of Health and Human Services and Agriculture. Dietary guidelines for Americans, 7th ed. http://www.cnpp.usda.gov/ dietaryguidelines.htm. Accessed May 24, 2010. Dhingra R, Sullivan L, Jacques PF, Wang TJ, Fox CS, Meigs JB, D’Agostino RB, Gaziano JM, Vasan RS. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation. 2007; 116:480-488. Chen L, Caballero B, Mitchell DC, Loria C, Lin P, Champagne CM, Elmer PJ, Ard JD, Batch BC, Anderson CAM, Appel LJ. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure: A prospective study among US adults. Circulation. 2010;121:2398-2406. Gibson SA. Dietary sugars intake and micronutrient adequacy: A systematic review of the evidence. Nutr Res Rev. 2007;20:121-131. Frary CD, Johnson RK, Wang MQ. Children’s choices of food and beverages high in added sugars impact their diet quality. J Adol Health. 2004;34:56-63. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow Gc, Ho PM, Lauer MS, Masoudi FA, Robertson RM, Roger V, Schwamm LH, Sorlie P, Yancy CW, Schwamm LE, Sorlie P, Yancy CW, Rosamond WD. Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association’s strategic impact goals through 2020 and beyond. Circulation. 2010;121:586-613. Nutrient Data Laboratory. USDA Database for the added sugars content of selected foods. February 2006. US Department of Agriculture, Agricultural Research Service Web site. http://www.nal.usda. gov/fnic/foodcomp/Data/add_sug/addsug01.pdf. Accessed May 23, 2010. Healthy Weight Commitment Foundation homepage. http://www. healthyweightcommit.org/. Accessed May 23, 2010. US Department of Agriculture. MyPyramid. http://mypyramid.gov. Published 2005. Accessed May 23, 2010. Britten P, Marcoe K, Yamini S, Davis C. Development of food intake patterns for the MyPyramid food guidance system. J Nutr Educ Behav. 2006;38(suppl):S78-S92. Liebman B. Sugar overload: Curbing America’s sweet tooth. Nutrition Action Health Letter. 2010;January/February:1-8.
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Weighing in on Added Sugars and Health RACHEL K. JOHNSON, PhD, MPH, RD; BETHANY A. YON, MS
I
n this issue of the Journal, Lustig contends that a reduction in fructose consumption is necessary to combat the obesity epidemic (1). His review is one of many recently that is focused on the adverse health effects of increased intakes of sugars, especially added sugars and those coming from sugar-sweetened beverages. Although registered dietitians have for years focused on fat as the macronutrient most associated with chronic disease, it has become increasingly clear that the amount and quality of carbohydrates in the diet may be equally as important as fats to reduce diet-related chronic disease. Registered dietitians, nutrition scientists, nutrition policy makers, and advocacy groups are increasingly focusing on added sugars. The US Department of Agriculture (USDA) defines added sugars as all sugars used as ingredients in processed and prepared foods (such as breads, cakes, soft drinks, jam, and ice cream), and sugars eaten separately or added to foods at the table (2). Specifically, added sugars include white sugar, brown sugar, raw sugar, corn syrup, corn-syrup solids, highfructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, liquid fructose, honey molasses, anhydrous dextrose, and crystal dextrose (2). Added sugars do not include the naturally occurring sugars lactose (in milk and dairy products) or fructose (in fruit). Americans’ consumption of added sugars has been estimated using national food consumption survey data and USDA Economic Research Service food availability data. Although in recent years there has been a slight decrease in the availability of energy-containing sweeteners in the US food supply (3), intakes remain substantially higher than they were 4 decades ago (4). In addition, intakes remain considerably higher than current recommendations across all age and sex groups (5). A recent analysis of 1999-2006 National Health and Nutrition Examination Survey data estimated added sugars intake from a representative sample of 6,113 US adults at 21.4 tsp/day (359 kcal), which represented 15.8% of total daily energy intake (6). This represents a substantial increase from 1977-78, when added sugars contributed only 10.6% of R. K. Johnson is associate provost and a professor of nutrition, and B. A. Yon is a research specialist, Nutrition and Food Sciences, The University of Vermont, Burlington. Address correspondence to: Rachel K. Johnson, PhD, MPH, RD, University of Vermont, 347A Waterman Bldg, Burlington, VT 05405. E-mail: rachel.johnson@ uvm.edu Manuscript accepted: June 4, 2010. Copyright © 2010 by the American Dietetic Association. 0002-8223/$36.00 doi: 10.1016/j.jada.2010.06.013
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Journal of the AMERICAN DIETETIC ASSOCIATION
the energy consumed by adults (7). Sugar-sweetened carbonated beverages and energy and sports drinks along with fruit drinks continue to be the primary source (46%) of added sugars in Americans’ diets (5). Along with these beverages, grain-based desserts (13%), dairy desserts (7%), candy (6%), and ready-to-eat cereals (4%) make up the top five sources of added sugars. Until recently there was no quantifiable recommendation for added sugars. The 2000 Dietary Guidelines for Americans (DGA) advised consumers to “choose beverages and foods to moderate your intake of sugars” (8) and the 2005 DGA advised them to “choose prepared food and beverages with little added sugars or caloric sweeteners” (9). In 2006, the American Heart Association (AHA) Dietary and Lifestyle Recommendations advised consumers to “minimize intake of foods and beverages with added sugars” (10). In 2009, a writing group for the AHA, which included Lustig, published a scientific statement that for the first time made specific recommendations for added sugars intakes based on people’s energy needs (11). The AHA statement concluded that most women should limit their daily added sugars intake to 100 kcal, or about 6 tsp; for men, the recommendation is 150 kcal, or 9 tsp. The statement generated unprecedented interest from the popular press and the AHA estimated that it received more than 60 million media impressions. THE AHA RECOMMENDATION Why did the AHA make a recommendation that calls for a dramatic decrease in the amount of added sugars consumed by most Americans? Because the scientific evidence base is becoming increasingly robust and demonstrates that added sugars, especially those coming from sugar-sweetened beverages, increase the risk of overweight and obesity as well as other risk factors for cardiovascular disease, including dyslipidemia and high blood pressure. In addition, with the exception of the extremely physically active, very few Americans are able to meet their nutrient needs with room in their diet for many extra kilocalories from added sugars. The AHA statement did not address the use of non-nutritive sweeteners, however the Food and Drug Administration has approved their use and they are considered safe (12). OBESITY A meta-analysis examined 88 cross-sectional and prospective studies exploring the relationship between soft drink intake and health outcomes and found that higher intakes were associated with greater energy intake, higher body weight, lower intake of other nutrients, and worse health indexes (13). Subsequent analyses from a large trial confirmed these findings; namely, greater weight loss as sugar-sweetened beverage intake de-
© 2010 by the American Dietetic Association
creased (14). In addition, data from two large cohort studies have been published since the AHA statement was released. Consumption of sweetened beverages was positively associated with body mass index as well as an increased risk of coronary heart disease (CHD) in the 24-year follow-up study in the Nurses Health Study (15). Soft drink consumption was also highly associated with increased body weight, after adjusting for overall dietary quality, in the Singapore Chinese Health Study (16). Weight gain may occur with greater energy intake from fluids than from solid foods due to the weak satiety signals evoked from energy-containing beverages; therefore, total energy intake may be greater with fluid energy intake than from solid foods (17-19). Recently the 2010 DGA Advisory Committee stated that among several strategies to reduce the incidence and prevalence of overweight and obesity, Americans should avoid sugar-sweetened beverages (20). The use of the word avoid is the strongest recommendation to date for a policy document of this nature, indicative of the strength of the association between sugar-sweetened beverages and obesity. The American Dietetic Association’s Evidence Analysis Library (12) concluded that using non-nutritive sweeteners will affect overall energy balance only if they are substituted for higher-energy food or beverages. Studies show that the use of non-nutritive sweeteners does not cause weight gain among children and adolescents. If non-energy beverages, including those with non-nutritive sweeteners, are substituted for sugar-sweetened beverages, a potential for energy savings has been found in adolescents. DYSLIPEDEMIA The AHA statement summarized the links between added sugars and dyslipidemia as follows: “Although the mechanisms are unclear, relative to other carbohydrate sources, sugar intake appears to be associated with increased triglyceride levels, a known CHD risk factor; however, relative to other sources of carbohydrate, the effects of sugar intake on HDL and LDL levels remain unclear” (11). Since the AHA publication, new evidence indicated that consuming a higher amount of added sugars in processed or prepared foods was associated with lower levels of high-density lipoprotein cholesterol and higher levels of triglycerides in a large sample of US adults (6). This study strengthens the evidence that there is an association between added sugars intakes and these important risk factors for CHD. BLOOD PRESSURE The AHA statement also concluded that “an emerging but inconclusive body of evidence suggests that increased intake of added sugars might raise blood pressure” (11). In the Framingham Heart Study, consumption of one or more soft drinks per day significantly increased the odds of developing high blood pressure (21). New evidence from the PREMIER study, a randomized intervention trial, adds strength to the evidence in this area. Reducing sugar-sweetened beverage intake by one serving a day was significantly associated with a reduction in blood pressure (22).
NUTRIENT ADEQUACY There is evidence that diets containing a high proportion of added sugars are lower in micronutrients than diets containing a moderate proportion of added sugars (23). One review found that studies examining the percentage of people achieving the Recommended Dietary Allowances or reference nutrient intake for micronutrients across categories of sugar intake often found nonlinear relationships, such that higher levels of micronutrient intake were observed in the moderate added sugar intake categories compared with low and high categories of intakes. As acknowledged in the AHA statement, the form in which added sugars are consumed seems to be an important modifier of the effects of dilution (23). Sugarsweetened carbonated beverages, sugar, and sweets are more likely to have a negative influence on diet quality, whereas dairy foods, milk drinks, and pre-sweetened cereals may have a positive influence (24). Recently, the 2010 DGA Advisory Committee recommended reducing intakes of foods containing added sugars, solid fats, refined grains, and sodium because they contain few, if any, nutrients (20). This statement highlights the committee’s concern about the effects of excess intakes of added sugars on nutrient adequacy. DISCRETIONARY CALORIES AND SOLID FATS, ALCOHOL, AND ADDED SUGARS (SoFAAS) How did the AHA writing group set a quantifiable recommendation? The AHA recommendation for added sugars is based on the discretionary calorie concept developed by the 2005 DGA Advisory Committee. A person’s discretionary calorie allowance is determined by estimating the energy needed to meet his or her daily energy requirements and then subtracting the energy needed to meet nutrient requirements from food. Any energy remaining are discretionary calories. These obviously vary according to energy needs; an active teenage boy will have a substantially higher discretionary calorie allowance than a sedentary elderly woman (Table). The allowance for discretionary calories includes not only added sugars, but also solid fats and alcohol, often referred to as SoFAAS. The AHA writing group for the scientific statement on added sugars determined that a prudent upper limit of intake for added sugars would be half of the discretionary calorie allowance. If a person chooses to consume alcohol, then added sugars and solid fats intakes should be further reduced to accommodate the additional energy from alcohol. Depending on the energy level, the AHA added sugars recommendations vary from a low of 3 tsp/day (48 kcal) for an energy requirement of 1,600 kcal to a high of 18 tsp/day (288 kcal) for an energy requirement of 3,000 kcal. Because most American women require about 1,800 kcal/day and most American men require about 2,200 kcal/day, the AHA’s take home message is “aim for 100 calories (6 tsp) of added sugars per day if you’re a woman and 150 calories (9 tsp) if you’re a man.” These recommendations are consistent with the new 2010 DGA Advisory Committee recommendations to significantly reduce the number of calories consumed from SoFAAS, as there typically is not room for the excess energy in most Americans’ diets. The AHA recently published a novel, exciting roadmap
September 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1297
Table. Discretionary calories and added energy allowances based on a variety of age, sex, and physical activity levelsa Men
Women
Variable
21-25 y
46-50 y
51-55 y
71-75 y
Physical activity levelb Energy needs (kcal)c Discretionary calories (kcal)d Added sugars (tsp)e Added sugars energy (kcal)
Active 3,000 512 18 288
Sedentary 2,200 290 9 144
Moderately active 1,800 195 5 80
Sedentary 1,600 132 3 48
a
Based on references (9), (28), and (29). Sedentary means a lifestyle that includes only the physical activity of independent living; moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles/day at 3 to 4 miles/hour, in addition to the activities of independent living; active means a lifestyle that includes physical activity. c Energy needs to maintain current weight, this will not promote weight loss in overweight/obese people. d Recommended limit for discretionary calories, per Dietary Guidelines for Americans, 2005 (9). e Recommended limit for added sugars, per Dietary Guidelines for Americans, 2005 (9). b
● Search the ingredient list for the word syrup, such as corn syrup, high-fructose corn syrup, maple syrup, and agave syrup. ● Look for words ending in “ose,” such as fructose, glucose, sucrose, and dextrose. ● Compare the unsweetened version of a product (plain, unsweetened yogurt or plain shredded wheat cereal) with the sweetened version (fruit-flavored yogurt or frosted shredded wheat) to estimate the amount of added sugars. ● Beware of a health halo effect. Some added sugars, such as brown rice syrup, may sound healthful but are just another added sweetener. Figure 1. Identifying added sugars in processed and prepared foods.
to achieve the goal of a 20% improvement in Americans’ cardiovascular health by 2020 (25). The AHA acknowledged that to achieve ideal cardiovascular health, a healthy eating pattern is essential. Thus, the roadmap includes five measureable eating behaviors as a part of their health and lifestyle recommendations. One of the five behaviors states that, in the context of an energybalanced diet, sugar-sweetened beverages should not exceed 450 kcal or 36 oz/week. How can dietetics practitioners help consumers implement the AHA recommendation? Currently, food labels in the United States contain information on total sugars per serving but do not distinguish between added sugars and those sugars naturally present in foods and beverages. Thus, it is difficult for consumers to determine the amount of added sugars in the foods and beverages they select. Figure 1 lists some practical tips to help consumers identify added sugars. In 2006 the USDA published a database for the added sugars content of selected foods that dietetics practitioners can use to help educate consumers (26). The Food and Drug Administration has been petitioned by a number of organizations, including the AHA, to include added sugars on the Nutrition Facts panel. However, until a methodology that can distinguish added sugars from naturally occurring sugars in food and beverage products is developed, the Food and Drug Administration would be unable to enforce a regulation re-
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● Avoid sugar-sweetened beverages. ● Don’t worry about the naturally occurring sugars like fructose in fruit and lactose in milk and dairy products. ● Use your added sugars allowance to sweeten already nutrientdense foods (a little maple syrup on oatmeal, some added sweeteners in yogurt and flavored milk) rather than in nutrientvoid foods and beverages like soft drinks and candy. ● If a food contains little or no milk or fruit, the sugars number on the package’s Nutrition Facts panel will be a good estimate of how much added sugar is in each serving (30). Figure 2. Consumer messages for choosing healthful foods, based on reference (30).
quiring listing added sugars on the label, making such a regulation unlikely in the near future. CONCLUSIONS Undoubtedly there will be continued debate among registered dietitians, nutrition scientists, policy makers, and advocacy groups about the deleterious health effects of added sugars. However, in the context of an American population that is predominantly overweight and obese and thus unhealthy, it is time for change. No one, except those who are extremely physically active, has room in his or her everyday diet for hundreds of kilocalories’ worth of empty calories from added sugars. In May 2010, a conference sponsored by the AHA, brought together stakeholders to focus on issues surrounding added sugars. Lawrence Appel, MD, MPH, past chair of the AHA Nutrition Committee and member of the 2005 and 2010 DGA Advisory Committees, eloquently stated that “the enemy of good is pursuit of the perfect, and expectation of the impossible” (personal communication, May 10, 2010). The science around added sugars and health will never be perfect. Nevertheless, strong scientific evidence is building and dietetics practitioners need to be aware of the negative health consequences related to excess added sugars. It is also time to advocate for fewer added sugars in the food supply. Industry is responding to First Lady Michelle Obama’s Let’s Move campaign with its own
pledge to reduce 1.5 trillion kcal in the food supply by the end of 2015 (27). The dairy industry is working to reduce the amount of added sugars in flavored milks offered to schools. Although it will take time for the food supply to change, dietetics practitioners can continue to help clients make changes (see Figure 2) to lower the amount of added sugars in their diets to the levels recommended by the AHA to achieve and maintain healthy weights, meet their essential nutrient needs, and lower risk for cardiovascular disease. STATEMENT OF POTENTIAL CONFLICT OF INTEREST: Dr Johnson serves on the American Heart Association Nutrition Committee and the Medical Advisory Board for the Milk Processors Education Program. Dr Johnson and Ms Yon have research grant funding from Dairy Management Incorporated.
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References 1. Lustig RH. Fructose: Metabolic, hedonic, and societal parallels with ethanol. J Am Diet Assoc. 2010;110:1307-1321. 2. Otten JJ, Hellwig JP, Meyers LD eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: Institute of Medicine of the National Academies; 2006. 3. Sugar and sweeteners yearbook table 50, US per capita caloric sweeteners estimated deliveries for domestic food and beverage use, by calendar year. US Department of Agriculture, Economic Research Service Web site. http:// www.ers.usda.gov/briefing/sugar/data.htm#yearbook. Accessed May 24, 2010. 4. Wells HF, Buzby J. Dietary assessment of major trends in US food consumption, 1970-2005. Economic Information Bulletin No. 33. March 2008. US Department of Agriculture, Economic Research Service Web site. http://www.ers.usda.gov/Publications/EIB33. Accessed May 23, 2010. 5. Sources of calories from added sugars among the US population, 2005-06. Risk Factor Monitoring and Methods Branch Web site. http://riskfactor.cancer.gov/diet/foodsources/added_sugars/. Accessed May 24, 2010. 6. Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults. JAMA. 2010;303:1490-1497. 7. Glinsmann WH, Irauquin H, Park YK. Evaluation of health aspects of sugars contained in carbohydrate sweeteners: Report of Sugars Task Force, 1986. J Nutr. 1986;116(suppl):S1-S216. 8. US Departments of Agriculture and Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 2000. 5th ed. Washington, DC: US Government Printing Office; 2000. Home and Garden Bulletin No. 232. 9. US Departments of Health and Human Services and Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: US Government Printing Office; 2005. 10. Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, WylieRosett J. Diet and lifestyle recommendations revision 2006, A scientific statement From the American Heart Association Nutrition Committee [published corrections appear in Circulation. 2006;114:e629 and 2006;114:e27]. Circulation. 2006;114:82-96. 11. Johnson RK, Appel LJ, Brands M, Howard B, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J. Dietary sugars intake and
19. 20.
21.
22.
23. 24.
25.
26.
27. 28. 29.
30.
cardiovascular health. A scientific statement from the American Heart Association. Circulation. 2009;120:1011-1020. American Dietetic Association’s Evidence Analysis Library. http:// www.adaevidencelibrary.com. Accessed June 3, 2010. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: A systematic review and metaanalysis. Am J Public Health. 2007;97:667-675. Chen L, Appel LJ, Loria C, Lin PH, Champagne CM, Elmer PJ, Ard JD, Mitchell D, Batch BC, Svetkey LP, Caballero B. Reduction in consumption of sugar-sweetened beverages is associated with weight loss: The PREMIER trial. Am J Clin Nutr. 2009;89:1-8. Fung TT, Malik V, Rexrode KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89:1037-1042. Odegaard AO, Koh WP, Arakawa K, Yu MC, Pereira MA. Soft drink and juice consumption and risk of physician-diagnosed incident type 2 diabetes: The Singapore Chinese Health Study. Am J Epidemiol. 2010;171:701-708. Mourao DM, Bressan J, Campbell WW, Mattes RD. Effects of food form on appetite and energy intake in lean and obese young adults. Int J Obes. 2007;31:1688-1695. Mattes R. Fluid calories and energy balance: The good, the bad, and the uncertain. Physiol Behav. 2006;89:66-70. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: Effects on food intake and body weight. Int J Obesity. 2000;24:794-800. US Departments of Health and Human Services and Agriculture. Dietary guidelines for Americans, 7th ed. http://www.cnpp.usda.gov/ dietaryguidelines.htm. Accessed May 24, 2010. Dhingra R, Sullivan L, Jacques PF, Wang TJ, Fox CS, Meigs JB, D’Agostino RB, Gaziano JM, Vasan RS. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation. 2007; 116:480-488. Chen L, Caballero B, Mitchell DC, Loria C, Lin P, Champagne CM, Elmer PJ, Ard JD, Batch BC, Anderson CAM, Appel LJ. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure: A prospective study among US adults. Circulation. 2010;121:2398-2406. Gibson SA. Dietary sugars intake and micronutrient adequacy: A systematic review of the evidence. Nutr Res Rev. 2007;20:121-131. Frary CD, Johnson RK, Wang MQ. Children’s choices of food and beverages high in added sugars impact their diet quality. J Adol Health. 2004;34:56-63. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow Gc, Ho PM, Lauer MS, Masoudi FA, Robertson RM, Roger V, Schwamm LH, Sorlie P, Yancy CW, Schwamm LE, Sorlie P, Yancy CW, Rosamond WD. Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association’s strategic impact goals through 2020 and beyond. Circulation. 2010;121:586-613. Nutrient Data Laboratory. USDA Database for the added sugars content of selected foods. February 2006. US Department of Agriculture, Agricultural Research Service Web site. http://www.nal.usda. gov/fnic/foodcomp/Data/add_sug/addsug01.pdf. Accessed May 23, 2010. Healthy Weight Commitment Foundation homepage. http://www. healthyweightcommit.org/. Accessed May 23, 2010. US Department of Agriculture. MyPyramid. http://mypyramid.gov. Published 2005. Accessed May 23, 2010. Britten P, Marcoe K, Yamini S, Davis C. Development of food intake patterns for the MyPyramid food guidance system. J Nutr Educ Behav. 2006;38(suppl):S78-S92. Liebman B. Sugar overload: Curbing America’s sweet tooth. Nutrition Action Health Letter. 2010;January/February:1-8.
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