The estimated reading time for this post is 13 Minutes

Introduction:

Free sugars, added sugars, simple sugars, and refined sugars are some of the negatively perceived labels assigned to this renowned commodity we call sugar. But before we can delve into why these particular sugar categories receive heavy criticism we must first understand where this unfavourable outlook stems from. In common colloquial speech ‘sugar’ is your everyday table sugar, added for the most part mindlessly to our teas, coffees, and breakfast cereals. Sugar is a class of the most abundant sources of food energy in the human diet- carbohydrates. Carbohydrates are classified by their molecular size into sugars, oligosaccharides, and polysaccharides (Mathers and Wolever, 2009). Sugars are the simplest form of carbohydrates that describe the monosaccharides and disaccharides present in food. Monosaccharides are the building blocks of all the other carbohydrate classes and include glucose, fructose, and galactose (Hummings and Stephen, 2007).  Grant and Morita (2003) say that we are born with an innate preference for sweet things. During pregnancy, the fetus is surrounded by sweet amniotic fluid and once born, babies consume either breast milk or formula milk both containing the milk sugar lactose. The continued lean towards sweetness in adulthood is, therefore no surprise. Throughout history, sugars have been added to enhance the sweetness of foods to appeal to our sweet tooth cravings.

How do we fair in comparison to our ancestor’s free sugar intake? Is free sugar consumption increasing or decreasing across the globe? Is this another media publicity stunt or is their unwavering attention on the nutrient needed? Are we victims of misleading and confusing sugar advertising? And is our health suffering as a consequence of free sugar consumption? These are just some of the questions I wish to address and dissect throughout this paper.  

Free Falling

What are free sugars and why are we so concerned with them? The explanation is in the name. Free sugars aren’t naturally bound within the cellular structure of whole foods like fruit, vegetables, and dairy products. They are all the monosaccharides and disaccharides free or available to be added to foods by the manufacturer, cook , or consumer. They differ from added sugar in that they also include sugars naturally present in honey, syrups , and unsweetened fruit juices (Butriss, 2016). Free from the enclosure of the cell wall free sugars enter the bloodstream quicker than intrinsic sugars whose sugars are released after the cell wall is broken down. The relationship as established by the World Health Organisation (2019) between free sugar consumption, tooth decay, and unhealthy weight is the grounds for attracting adverse publicity to the nutrient. With the current global obesity epidemic, this correlation has spurred the World Health Organisation to review their recommended free sugar intake and reduce the number from 10% to 5% of total energy intake. Their reasoning comes as a result of high levels of free sugar intake being linked with parallel changes in body weight. WHO also states that higher intakes of free sugars are a threat to the overall nutrient quality of diets, as they are high in calories and low in nutrients. This is why they are often deemed empty calories. The empty part comes from their ability to contribute little nutritionally. Sugar-sweetened drinks like soda contain lots of empty calories and children who consume these regularly are more likely to be overweight or obese. This makes sense are they are providing ample calories without the satiation that comes after eating a meal of equal calorie content. If drank alongside food, as opposed to lower-calorie drinks like water or tea, extra calories are ingested very easily (WHO, 2015). 

What is interesting to note is that this 5% reduction is a conditional recommendation. The quality of evidence is not as strong, but the desired effects of complying with the recommendations outweigh the undesirable effects. This is unlike the previous recommendation of reducing our free sugar intake to less than 10% of total energy which was deemed strong based on the quality of the evidence supporting it. WHO’s decision to further drop the percentage intake runs along with their desire to prevent NCDs (Non-Communicable Diseases). This low figure highlights their urgency to tackle the rise in diabetes and obesity while reducing the burden of premature deaths due to NCDs. (WHO, 2015).

How achievable is this 5% of total energy? The World Health Organisation, the UK, and Ireland have a consensus on the term free sugars, however, The US implements the term added sugar. Even then, the FDA and the USDA cannot agree on a suitable definition. The former considers fruit juice added sugar while the latter does not consider any type of fruit juice as added sugar. Without an accepted universal definition, nutritional databases may use different equations to calculate added/free sugar resulting in a range of conflicting values that could be very confusing and misleading for the consumer. It may also be hard for the average person to consume less than this amount of free sugar when food labeling has yet to distinguish between free and total sugar content. This confusion has a danger of leading to reduced intakes of nutrient-rich foods, like yogurt, whole grains, and dried fruits such as raisins, cranberries, and grapefruit. (Erickson and Slavin, 2015).

Sweet Memories

In his article ‘In Defence of Sugar’ Edward Archer explains the key role sugars played in the diets of our ancestors, he also examines historical intakes of sugar and argues for their benefit in society. He points out that modern hunter-gatherers consumed 20–80% of their total energy intake from added sugar, honey (a disaccharide of glucose and fructose) being the main source. This is 5-8 times larger than the current recommendations. Their glycaemic loads (how high blood sugar rises and how long it stays high after eating carbohydrates) (Glycaemic Index Foundation, 2017) were elevated by intrinsic sugars in fruits and tuber vegetables. Despite the elevated consumption of sugar and high glycaemic loads, these populations recorded having some of the lowest risks of Non-Communicable Diseases (Archer, 2018).

More recently, the greatest increases in sugar availability in the US occurred from the late 19th century right up until World War II. Sugar availability increased from less than 10 lbs. per capita to more than 100 lbs. per capita each year. At the same time, the US population experienced improvements in every health metric examined over the period 1880 to 1980. In 1979, the availability of sugar in the American food supply had never been higher and the US Surgeon General’s Report on Health Promotion and Disease Prevention declared that the health of the American people had never been better. Similarly, the United Kingdom also experienced rises in health and well-being corresponding with increases in sugar availability which was linked to better, not worse health.

After the fall of the Soviet Union in the 1980s, Cuba was forced to rely on domestic crops such as sugar cane. Domestic sugar use increased from 530 metric tons in 1980 to 637 in 1995. The level of physical activity also increased considerably in addition to the increase in sugar use. Significant declines in obesity, Type 2 Diabetes mellitus, and NCDs were observed. Results such as these suggest that increments in both physical activity and dietary sugar lead to improvements in metabolic health (Archer, 2018). What Archer failed to mention was other possible improvements in medicine such as antibiotics, vaccinations, and sanitation which may also have contributed to this transition in the health scale.

Surprise – free sugar not on the rise

With all the hype surrounding our current sugar intakes, one would assume it must have increased dramatically over the years. However, evidence tells a different story. A descriptive study that used 6 cross-sectional nationally representative surveys of food intake in the US to examine trends in added sugar intake between 1977 and 2012 found, for both children and adults, there was a significant increase in calories from added sugars from 1977 to 2003. From 14% to 18% of total energy for children and 12% to 15% of total energy for adults. More interesting is the decline that followed from 2003 to 2012. Children’s percentage dropped from 18% to 17% and adults from 15% to 14% of total energy intake (Powell et al., 2016). Despite this decrease intakes still, exceed the recommended level.

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Australia has seen a substantial decrease in refined sugar consumption (declined by 20%) over the past 30 years along with a 10% decline in the amount of sugar-sweetened beverages (SSBs) consumed. Over this same period, obesity in the country has increased by 300%. This has become known as the Australian Paradox and puts a question on whether global efforts to reduce sugar consumption will reduce obesity levels (Barclay and Brand-Miller, 2011).

Sweet tooth- children most at risk

Free Sugar consumption varies globally. A common theme is that these countries exceed the recommended 5% free sugar guidelines. In Europe, adult consumption ranges from 7-8% of total energy in countries like Hungary and Norway to higher levels of 16-17% in Spain and the UK. Children are found to have a much higher intake, ranging from 12% in countries Denmark, Slovenia, and Sweden, to approximately 25% in Portugal (World Health Organisation, 2015). Age is a factor in consumption levels as added sugar contributes 30% more to total energy intake in children as opposed to adults. Ranging from 32% in

Ireland and up to 50% in the Netherlands (Azaïs-Braesco et al., 2017). In the UK SSBs are the largest contributor of free sugars in children (Evans, 2016).

Reducing free sugar consumption in children should be of utmost importance as they are vulnerable in society with little control over their food intake and the least knowledge of dietary effects.

Adolescents also face challenges when trying to adhere to free sugar recommendations. After sampling 2587 adolescents aged 11-18, in The UK National Diet and Nutrition Survey, it was discovered that the adolescents who consumed 10–15% of energy from

Non-milk extrinsic sugars (NMES) were less deficient in numerous micronutrients than the 4% of adolescents reported consuming 5% or less. This emphasizes the care that needs to be taken to ensure restrictions in diet do not lead to deficiencies in other nutrients (Lai et al., 2019).

The need to question what you read

The bold article ‘The Toxic Truth about Sugar’ presents strong biased opinions on current sugar consumption. The idea that nature made sugar difficult to get (honey guarded by bees) while man made it easy, along with man’s addition of sugar to processed foods limiting the consumer’s choice, can provoke strong feelings in the average reader who may feel they are being wronged. The authors say sugar is the cause of all the diseases associated with metabolic syndrome and puts sugar in the same category as tobacco and alcohol (Lustig et al., 2012) Frightening statements will naturally draw media attention to the nutrient. They can be easily read and understood with little scientific knowledge or background. On further investigation, the Scientific Advisory Committee on Nutrition (SACN) in the UK did not find a link between intake of sugars (total or individual) and cardiovascular risk factors, risk of coronary events, incidence of or risk factors for type 2 diabetes, inflammatory markers or cancer (SACN 2015).

Conclusion:

Research shows that high intakes of free sugars are linked to overweight and obesity, as excess body weight results from excess energy intake. High levels of free sugars can threaten a balanced diet as they lack other nutrients. However, care needs to be taken to ensure low levels (≤5% of total energy) do not compromise or restrict the micronutrient composition of diets, particularly in adolescents. Reducing free sugar intake to below 5% of total energy will be difficult to achieve unless a universal definition of free sugars is accepted.

Data is showing a decline in free sugar consumption in recent years, though levels still exceed current recommendations. Children consume significantly more of their total energy from free sugar than adults and so should be the prime target when devising sugar reduction strategies. WHO’s recent recommendation to reduce free sugar to ≤5% of total energy intake is a conditional recommendation and given the decline in free sugar consumption, the unattractive picture the media paints of sugar is unwarranted. Care needs to be taken to avoid scaremongering amongst the general population on the nutrient by equipping them with an evidence-based base, which does not pin free sugar as the sole cause of NCDs but rather as a contributor when consumed at high levels.

References: 

    1.  Archer, E. (2018). In Defence of Sugar: A Critique of Diet-Centrism. Progress in Cardiovascular Diseases, [online] 61(1), 10-19. Available from: doi: 10.1016/j.pcad.2018.04.007. [Accessed 4th November 2019].Available from: doi: 10.3390/nu3040491. [Accessed 2nd November 2109]. 
    2. Azaïs-Braesco, V., Sluik, D., Maillot, M., Kok, F. and Moreno, L. (2017). A review of total & added sugar intakes and dietary sources in Europe. Nutrition Journal, [online] 16(6), 5. Available from: doi: 10.1186/s12937-016-0225-2. [Accessed 26 October 2019]. 
    3. Barclay, A. and Brand-Miller, J. (2011). The Australian Paradox: A Substantial Decline in Sugars Intake over the Same Timeframe that Overweight and Obesity Have Increased. Nutrients, [online] 3 (4), 491-504.
    4. Buttriss, J. (2016). Sugars – part of a bigger picture? Nutrition Bulletin, [online] 41(1), 79. Available from: doi:10.1111/nbu.12192. [Accessed 26th October 2019]. 
    5. Cummings, J. and Stephen, A. (2007). Carbohydrate terminology and classification. European Journal of Clinical Nutrition, [online] 61 (1), S7. Available from: doi:10.1038/sj.ejcn.1602936. [Accessed 25th October 2019]. 
    6. Erickson, J. and Slavin, J. (2015). Total, Added, and Free Sugars: Are Restrictive Guidelines Science-Based or Achievable? Nutrients, [online] 7(4), 2866-2868. Available from: doi: 10.3390/nu7042866. [Accessed 28th October 2019]. 
    7. Evans, C. (2016). Sugars and health: a review of current evidence and future policy. Proceedings of the Nutrition Society, [online] 76(3), 402. Available from: doi: 10.1017/s0029665116002846. [Accessed 2nd November 2019]. 
    8. Glycemic Index Foundation. (2019). What about Glycemic Load? – Glycemic Index Foundation. [online] Available from: https://www.gisymbol.com/what-about-glycemic-load/. [Accessed 2nd November 2019]. 
    9. Lai, H., Hutchinson, J., and Evans, C. (2019). Non-Milk Extrinsic Sugars Intake and Food and Nutrient Consumption Patterns among Adolescents in the UK National Diet and Nutrition Survey, Years 2008–16. Nutrients, [online] 11 (7), 1-14. Available from: doi: 10.3390/nu11071621. [Accessed 3rd November 2019].
    10. Lustig, R., Schmidt, L. and Brindis, C. (2012). The toxic truth about sugar. Nature, [online] 482 (1), 27-29. Available from: doi: 10.1038/482027a. [Accessed 3rd November 2019].
    11. Matthews, J. and Wolever, T. (2009). Digestion and Metabolism of Carbohydrate. In:  Gibney, M., Lamham-New, s., Cassidy, A. and Vorster, H. (ed.), The Nutrition Society Textbook Series- Introduction to Human Nutrition 2nd edition. UK: Wiley- Blackwell, 74.
    12. Powell, E., Smith-Taillie, L. and Popkin, B. (2016). Added Sugars Intake Across the Distribution of US Children and Adult Consumers: 1977-2012. Journal of the Academy of Nutrition and Dietetics, [online] 116 (10), 1543-1550. Available from: doi:10.1016/j.jand.2016.06.003. [Accessed 2nd November 2019]. 
    13. SACN (2015). SACN Carbohydrates and Health Report. Scientific Advisory Committee on Nutrition.
    14. Sigman-Grant, M. and Morita, J. (2003). Defining and interpreting intakes of sugars. The American Journal of Clinical Nutrition, [Online] 78 (4), 815S. Available from: https://doi.org/10.1093/ajcn/78.4.815S. [Accessed 25th October 2019]. 
    15. World Health Organization. (2015). WHO guideline: sugar consumption recommendation. [online] Available from: https://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/ [Accessed 4th November 2019].
    16. World Health Organization. (2019). Reducing free sugar intake in children and adults. [online] Available from: https://www.who.int/elena/titles/guidance_summaries/sugars_intake/en/. [Accessed 4th November 2019].

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