Reformulation without substitution as a strategy to reduce children's free sugar intake in Uruguay: A simulation study.

Background Policies to reduce free sugar intake in the population often suggest alternative low or no sugar products that may contain low-calorie sweeteners (LCS). However, the health effects of LCS are controversial and little is known about whether free sugar and energy intake differ between people with varying levels of LCS product consumption. This study examines the associations between LCS product consumption and free sugar and energy intake in UK adults from 2008 to 2019. Methods Repeat cross-sectional data from the UK’s National Diet and Nutrition Survey (2008/09 to 2018/19) involve 8304 adults aged ≥18 years (mean 48.7, SD 18.3) with 58.4% being women. Consumption of LCS products (grams/day) were obtained from 4-day diet diaries and participants were categorized into four groups (No-LCS, Low-LCS, Mid-LCS, High-LCS) based on LCS consumption tertiles in 2008/09. Linear regression analysed associations with LCS group, year, their interaction, and adjusted for sociodemographic factors. Results All four groups consumed free sugar (relative to total energy intake) above recommended levels (5% kcal/day) throughout the study period. In 2008/09, the mean free sugar intake for the No-LCS group was 58.1 grams/day, and the mean total energy intake was 1855.7 kcal/day, which were not significantly different from the High-LCS group. Over time, free sugar intake declined by -1.0 g/year (95%CI: -1.4, -0.6) whereas total energy intake declined by -6.0 kcal/year (95%CI: -11.4, -2.1) in the No-LCS group. The High-LCS group showed similar declines leading to no significant difference in mean free sugar and total energy intake between the No-LCS and High-LCS groups in 2018/19. Conclusions In this representative study of UK adults, similar levels of free sugars and total energy intake were observed among those with no LCS and those with the highest LCS product consumption from 2008 to 2019. Absence of LCS product consumption in diets were not associated with higher free sugar intake. Key messages • The high level of LCS product consumption was not associated with lower free sugar intake among UK adults. These finding challenges policies promoting LCS to reduce UK adults’ free sugar intake. • The finding that UK adults consistently consumed free sugar above recommended levels highlights the ongoing need for policy interventions.

Intake of free sugars is associated with a risk of non-communicable diseases including dental caries, and authoritative organisations recommend limiting intake to <5% energy intake (E) or lower (1, 2). National surveys of schoolchildren in India indicate the prevalence of obesity is rising >10%/year(3) and that 52.5% of young adolescents are affected with dental caries(4), yet, there is a dearth of data on dietary intake of sugars by this population. The objective of this research was to assess the intake of total and free sugars, and the contribution of food sources to free sugars intake, in a random sample of 11–13-year-old schoolchildren in Delhi, India. The study was approved by The University of Adelaide Human Research Ethics Committee and the Independent Ethics Committee of the Centre for Chronic Disease Control, New Delhi. The target sample size of 360 was based on a ± 5% margin of error in estimated sugars intake. A statistician external to the research team generated a random sample of 150 schools stratified by district (n = 11). Schools were recruited in turn from the list until 10 schools had consented. Teachers shared study information with parents who were invited to complete an online consent form. Child assent was obtained before data collection. Participants recorded all food and drink consumed over three consecutive days, including one weekend day, in a food diary. The information recorded was entered into an online dietary assessment tool, Intake24 (Southeast Asia version), during an interview with each participant during which portion size was ascertained with reference to the database of over 2400 food photographs of more than 100 foods. The Intake24 database converted food and drink reported into the intake of total and free sugars through integrated food compositional tables. Of 514 pupils providing consent, 393 participants (76.5%) (169 girls, 224 boys) completed the study. In girls, the median (IQR) daily intakes of total and free sugars were 95.0 (70.1-120.2) g/day and 43.0 (28.1-68.5) g/day respectively. The corresponding values in boys were significantly higher at 104.0 (80.2-138.7) g/day and 53.1 (34.1-76.5) g/day (p = 0.004). No between-gender difference was observed in the median percent contribution of sugars to E: total and free sugars contributed 14.9% (IQR 11.4-18.1%) and 7.1% (IQR 4.8-10.1%) respectively. The percent contribution of the main sources of sugars to free sugars intake were: (i) Sugars Preserves and Syrups (31.2% (IQR. 9.6-51.7%)); (ii) Cakes and Biscuits (13.7% (IQR 0-26.4%)); (iii) Desserts (5.4% (0-17.5%)) and (iv) Sugar-Sweetened Beverages and Juices (2.1% (IQR 0-15.7%)). In conclusion, in this sample of 11-13-year-old schoolchildren from Delhi, free sugars intake was above the WHO <5% E threshold. Forms of sugars that are added to foods by the consumer made the largest contribution to intake.

The study aimed to describe trajectories of free sugar (FS) intake, its main sources and the associations with socio-economic status (SES) in Portuguese children/adolescents evaluated at 4, 7, 10 and 13 years of age from Generation XXI birth-cohort. Dietary intake was assessed through 3-day food diaries (n 5268). Added sugar intake was estimated following a systematic methodology, and FS was based on the WHO definition. A mixed-effects model with linear and quadratic terms for time was used to estimate FS trajectories and its association with SES, adjusting for children's sex, age, BMI and SES. The FS mean intake (g/day) was 37, 47, 51 and 48 at 4, 7, 10 and 13 years, respectively. FS intake increased 4·6 g/year (CI 95 %: 4·20, 5·04), but velocity decreased by 0·3 g/year2 until 13 years. At all ages, the main food source was sweets. Some item's consumption declined (sweets 25-21 % and yoghurts 22-7 %) as children grew older. Inversely, soft drink intake increased (9-18 %). Boys and children from younger mothers had higher FS intake, whereas higher maternal-SES was associated with lower children's FS intake: occupational status (β = -3·5; 95 % CI: -4·97, -1·94), years of education (β = -3·7; 95 % CI: -4·93, -2·40) and household income (β = -4·9; 95 % CI: -6·50, -3·27). The FS trajectories were similar by SES categories but different by obesity status (interaction term β = -1·04; CI 95 % (-1·50, -0·59)). An increasing FS trajectory during childhood is mainly driven by an increasing intake of soft drinks and nectars. The FS trajectory pattern did not change according to SES categories, but children's FS intake was always higher when their mothers had a lower SES.

In the Netherlands, 4–8-year-old children consume proportionally the highest amounts of free sugars among all age groups, and in European countries, children’s sugar intake exceeds the World Health Organization’s recommendation. Restricting children’s access to sugary products could help reduce this consumption. However, it is unclear whether and how restriction is linked to children’s sugar intake and sweet taste preference. This study investigated the relationship between parental restriction of sugary products, children’s free sugar and fruit intake, as well as their sweet taste preference. Parents (N = 243) of 4–7-year-old children were asked to complete a survey that asked for their child’s consumption of fruits and free-sugar-containing products via a three-day food recall (three specified, non-consecutive days). Parental restriction was assessed via the Restricted Access Questionnaire. In a subset of children (N = 60), psycho-hedonic functions were mapped using the Monell two-series forced-choice paired comparison tracking test to estimate children’s optimal sweet taste preference. Regression analyses showed that more restricted children consumed less free sugars but more fruits than less restricted children as reported by the parents (p < 0.05). Parental restriction was unrelated to children’s sweet taste preference. In conclusion, our results imply that restriction is negatively linked to free sugar intake, positively linked to fruit consumption, and unrelated to sweet taste preference in 4–8-year-olds. Future research is needed to determine the causal and long-term effects of parental restrictions on children's sugar intake and sweet taste preference.

Background: Emerging studies suggest that focusing on the intake of specific types or sources of sugars may yield greater benefits in preventing chronic kidney disease (CKD). Objective: We aimed to investigate the associations between free and non-free sugar intakes and CKD risk as well as the potential sugar type-gut microbiome interactions. Methods: A total of 138 064 participants from the UK Biobank were included in this prospective study. The free and non-free sugar intakes were assessed using repeated web-based 24-hour dietary recalls. A cause-specific competing risk model was used to estimate hazard ratios (HRs) and the corresponding confidence intervals (CIs) of incident CKD, treating deaths before incident CKD as competing events. Results: During a median follow-up of 10.5 years, 2,923 participants (2.1%) developed CKD. The free sugar intake was positively associated with the risk of CKD (HRquartile 4 vs. quartile 1 = 1.32, 95% CI = 1.18, 1.47), with a nonlinear relationship (P for nonlinearity = 0.01, the risk increased rapidly after free sugars made up 10% of the total energy). The non-free sugar intake was inversely associated with CKD risk (HRquartile 4 vs. quartile 1 = 0.68, 95% CI = 0.60, 0.77), with an L-shaped nonlinear curve (p for nonlinearity = 0.01, the turning point was at 13.5% of the total energy). We found that the associations between free sugar and non-free sugar intakes and CKD risk were more pronounced in participants with high genetically predicted gut microbial abundance. Furthermore, a significant interaction was observed between the genetically predicted gut microbial abundance and non-free sugar intake (P for interaction = 0.04). Conclusion: A higher intake of free sugars was associated with an elevated risk of CKD, whereas a higher intake of non-free sugars was associated with a reduced risk of CKD. The impact of free sugar intake and non-free sugar intake may be modified by the gut microbial abundance.

Challenges and opportunities in the use of low‐energy sugar replacers

BackgroundThe lack of comprehensive food composition databases for sugar contents in Japanese foods has led to the lack of nutritional epidemiologic studies on sugar intake in Japanese population. This cross-sectional study aimed to investigate the association of free sugar intake estimated using a newly developed food composition database with the characteristics and lifestyles of Japanese children aged 3–6 years.MethodsThe food composition database contained information on sugars in 2,222 commonly consumed Japanese foods. Using this database, we estimated the sugar (total, added, and free sugars) intakes derived from a 3-day weighed dietary record of 166 boys and 166 girls aged 3–6 years living in 24 prefectures in Japan.ResultsThe mean free sugar intake was 26.8 g/d (standard deviation [SD], 12.3 g/d), while the mean value for energy intake was 7.8% (SD, 3.2%). The prevalence of excessive free sugar intake (≥10% of energy intake) was 21.7%. Among the characteristics and lifestyles examined, screen time was most strongly associated with the prevalence of excessive free sugar intake: multivariate adjusted odds ratios for screen time <0.5, ≥0.5 to <1, and ≥1 h/d were 1.0 (reference), 3.81 (95% confidence interval, 1.04–13.98), and 4.36 (95% confidence interval, 1.16–16.35), respectively. Additionally, younger age, shorter sleep, and mothers with office work and service and sales jobs (compared with those with professional and managerial jobs) were significantly associated with a higher prevalence of excessive free sugar intake.ConclusionsThis study showed the sugar intake of Japanese children aged 3–6 years is positively associated with screen time.

Identifying genetic variants associated with sugar intake and appraising the genetic correlations with cardiovascular outcomes.

Genetic and Environmental Influences on Free Sugar and Nonnutritive Sweetener Intake in Toddlerhood and Middle Childhood Using Data from the Gemini Twin Cohort: Findings from the SWEET Project.

To analyze the contribution of ultra-processed foods to the intake of free sugars among different age groups in Australia. Dietary intakes of 12,153 participants from the National Nutrition and Physical Activity Survey (2011-12) aged 2+ years were evaluated. Food items collected through two 24-h recalls were classified according to the NOVA system. The contribution of each NOVA food group and their subgroups to total energy intake was determined by age group. Mean free sugar content in diet fractions made up exclusively of ultra-processed foods, or of processed foods, or of a combination of un/minimally processed foods and culinary ingredients (which includes table sugar and honey) were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of free sugars, as well as in the prevalence of excessive free sugar intake (≥ 10% of total energy) were examined. Ultra-processed foods had the highest energy contribution among children, adolescents and adults in Australia, with older children and adolescents the highest consumers (53.1% and 54.3% of total energy, respectively). The diet fraction restricted to ultra-processed items contained significantly more free sugars than the two other diet fractions. Among all age groups, a positive and statistically significant linear association was found between quintiles of ultra-processed food consumption and both the average intake of free sugars and the prevalence of excessive free sugar intake. Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia.

Excessive consumption of free sugar increases the risk for non-communicable diseases where a proper assessment of this intake is necessary to correctly estimate its association with certain diseases. Urinary sugars have been suggested as objective biomarkers for total and free sugar intake in adults but less is known about this marker in children and adolescents. Therefore, the aim of this exploratory study is to evaluate the relative validity of self-reported intake using urinary sugars in children and adolescents. The study was conducted in a convenience subsample of 228 participants aged 5-18years of the I.Family study that investigates the determinants of food choices, lifestyle and health in European families. Total, free and intrinsic sugar intake (g/day) and sugar density (g/1000kcal) were assessed using 24-h dietary recalls (24HDRs). Urinary sucrose (USUC) and urinary fructose (UFRU) were measured in morning urine samples and corrected for creatinine excretion (USUC/Cr, UFRU/Cr). Correlation coefficients, the method of triads and linear regression models were used to investigate the relationship between intake of different types of sugar and urinary sugars. The correlation between usual sugar density calculated from multiple 24HDRs and the sum of USUC/Cr and UFRU/Cr (USUC/Cr + UFRU/Cr) was 0.38 (p < 0.001). The method of triads revealed validity coefficients for the 24HDR from 0.64 to 0.87. Linear regression models showed statistically significant positive associations between USUC/Cr + UFRU/Cr and the intake of total and free sugar. These findings support the relative validity of total and free sugar intake assessed by self-reported 24HDRs in children and adolescents.

To report dietary free sugars consumption and their different types and food sources in European children. The present study is based on the IDEFICS study, a European multicenter cohort study in children (2-9years old) from eight countries, comprising 8308 children (51.4% males). Dietary intake of the previous 24h was assessed using a computer-assisted 24-h dietary recalls (24-HDR) and the different types of sugars were assessed using the German food composition database. Mean total energy intake was 1720 (SD 477) kcal/d for boys and 1631 (SD 451) kcal/d for girls. Total sugars intake was 98 (SD 52) g/day for boys and 93 (SD 49) g/day for girls. Free sugars intake was 81 (SD 49) g/day for boys and 77 (SD 47) g/day for girls. Girls had significantly lower intakes of energy, total and free sugars compared with than boys but did not differ in terms of percent of energy from total (23%) or free sugars (18%). There were large variations between countries in average % energy from free sugars (ranging from 13% in Italy to 27% in Germany). Less than 20% of children were within the recommended intake of 10% of energy from free sugars. The food groups that contributed substantially to free sugars intakes were "Fruit juices", "Soft drinks", "Dairy" and "Sweets and candies". The contribution of free sugars to total energy intake in European children is higher than recommendations. The main food contributors to free sugars intake are sweetened beverages ("Fruit juices" and "Soft drinks"). It is especially important to reduce children's intake of free sugars, focusing in target population on certain foods and food groups.

PurposeOur recent analysis reported decreasing trends in intake of free sugar in children and adolescents in Germany. Here we set out to update this analysis with current dietary intake (until 2023) because of the strong public health nutrition interest in sugar intake.MethodsIn total, 4,218 dietary records kept between 2010 and 2023 by 751 participants (46.0% females, 3–18 years) from the German Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) cohort were examined. Age and time trends in free sugar intake (%E/d) were analysed using polynomial mixed-effects regression models.ResultsMedian intake data indicate a decline in the intake of free sugar between 2010/2011 (16.7%E) and 2022/2023 (11.7%E). Trend analyses confirmed, that intake of free sugars decreased continuously between 2017 and 2023 (Linear trend: β = -0.4126, p < 0.0001). In addition, free sugar intake changed significantly with age (Linear trend: β = 1.2922, p < 0.0001; quadratic trend: β = -0.08613, p = 0.0094; cubic trend: β = 0.001442, p = 0.1725), i.e. the intake of free sugars increases continuously up to early adolescence (9/10 years) and decreases again thereafter.ConclusionThe intake of free sugar among children and adolescents continued to decline, but still exceeded the WHO recommendations in 2023. Further measures to reduce free sugar intake would therefore be desirable, as well as continuous monitoring of sugar intake levels among this age groups.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00394-024-03456-1.

BACKGROUND The lack of comprehensive food composition databases for sugar contents in Japanese foods has led to the lack of nutritional epidemiologic studies on sugar intake in Japanese population. This cross-sectional study aimed to investigate the association of free sugar intake estimated using a newly developed food composition database with the characteristics and lifestyles of Japanese children aged 3-6 years. METHODS The food composition database contained information on sugars in 2,222 commonly consumed Japanese foods. Using this database, we estimated the sugar (total, added, and free sugars) intakes derived from a 3-day weighed dietary record of 166 boys and 166 girls aged 3-6 years living in 24 prefectures in Japan. RESULTS The mean free sugar intake was 26.8 g/d (standard deviation [SD], 12.3 g/d), while the mean value for energy intake was 7.8% (SD, 3.2%). The prevalence of excessive free sugar intake (≥10% of energy intake) was 21.7%. Among the characteristics and lifestyles examined, screen time was most strongly associated with the prevalence of excessive free sugar intake: multivariate adjusted odds ratios for screen time <0.5, ≥0.5 to <1, and ≥1 h/d were 1.0 (reference), 3.81 (95% confidence interval, 1.04-13.98), and 4.36 (95% confidence interval, 1.16-16.35), respectively. Additionally, younger age, shorter sleep, and mothers with office work and service and sales jobs (compared with those with professional and managerial jobs) were significantly associated with a higher prevalence of excessive free sugar intake. CONCLUSIONS This study showed the sugar intake of Japanese children aged 3-6 years is positively associated with screen time.

Excessive free sugars consumption has a possible role in health issues, diet quality and obesity development. The present cross-sectional study aimed to identify the major food sources of free sugars in Greek children's diet and investigate possible associations of dietary patterns with free sugars intake. Anthropometric measurements and information on dietary and physical activity habits were obtained. Energy and free sugars intake coming from foods were estimated and principal components analysis was applied to identify dietary patterns. The GRECO (Greek Childhood Obesity) study. Nationwide sample of 3089 children (aged 10-12 years). Adopting WHO criteria, 44·2 % of participants were categorized as having free sugars intake above 10 % of total energy intake. Mean contribution of free sugars to energy intake was 11·2 %, and the major food sources of free sugars differed from those of other childhood populations. Free sugars intake was not associated with overweight/obesity. Multiple linear regression analysis revealed that two lifestyle and dietary patterns, characterized by higher consumption of sweets, fast foods, fries, sugared drinks, frequently ordering/eating outside home and having meals in front of a screen (pattern 1) and higher consumption of whole fruits, 100 % fruit juices, vegetables, legumes and honey/jam (pattern 2), were positively associated with free sugars intake. A large proportion of children exceeded the recommended cut-off and free sugars intake was associated with lifestyle patterns rather than single foods. Public health programmes aiming to reduce free sugars consumption should be tailored on promoting the correct dietary habits of specific childhood populations.