Added sugars are sugars and syrups that are added to foods or beverages during processing or preparation. These include ingredients such as refined sugar, high-fructose corn syrup, honey and fruit juice concentrate, among others. The term ‘added sugars’ does not include naturally occurring sugars in foods, such as lactose in milk and sucrose and/or fructose in fruits and vegetables( 1 – Reference Scapin, Fernandes and Proença 3 ).
Systematic reviews and meta-analyses provide substantial evidence that a high intake of added sugars is associated with an increased risk of several diseases, specifically dental caries( Reference Moynihan and Kelly 4 ), obesity( Reference Te Morenga, Mallard and Mann 5 ) and CVD( Reference Te Morenga, Howatson and Jones 6 ). Consequently, the WHO recommends a low intake of added sugars throughout the life course as well as limiting consumption to less than 5–10 % of total daily energy intake( 7 ).
As packaged foods seem to be the main source of added sugars in many countries( Reference Powell, Smith-Taillie and Popkin 8 – Reference Pereira, Duffey and Sichieri 13 ), food labelling is a tool for consumers to make informed choices regarding the intake of added sugars( 14 ). Although some places such as Chile( Reference Salud and Pública 15 ), Australia and New Zealand( 16 ) and the European Union( 17 ) require a declaration of total sugars on nutrition labels, only the USA( 2 ) and Canada( 18 ) require that the amount of added sugars be specified. On the other hand, in places where the quantitative declaration of sugars on food labels is not mandatory (e.g. Brazil), the identification of added sugars is possible only through the ingredients list. Thus, it can be presumed that individuals find it difficult to adhere to the WHO recommendation of limiting added sugars intake using food labels, because consumers in most countries can identify the presence of added sugars only through the ingredients list, without having access to detailed information on the amount of added sugars in packaged foods.
Few studies have investigated the presence of added sugars in packaged foods sold in supermarkets considering a large number of products from several food groups( Reference Bernstein, Schermel and Mills 19 – Reference Ng, Slining and Popkin 22 ) or the variety of terms used to refer to added sugars on food labels( Reference Bernstein, Schermel and Mills 19 , Reference Ng, Bricker and Li 21 ). Brazilian data on these topics are not available. In the light of the above, the present study aimed to investigate the presence and types of added sugars in the ingredients lists of packaged food products sold in Brazil.
Methods
Study design
The present cross-sectional study investigated all retail packaged food products available in a large Brazilian supermarket. The supermarket was chosen purposely and belongs to one of the ten largest Brazilian chain stores, according to the Brazilian Supermarket Association, with twenty-seven stores throughout the country( 23 ). Most of the products sold in this supermarket are of well-known food and beverage brands and represent products sold in other large supermarket chain stores throughout the country. This same study design and data gathering method have been used in previous studies( Reference Martins, de Sousa and Veiros 24 – Reference Figueiredo, Scapin and Fernandes 27 ).
A survey was performed by mapping all aisles in the supermarket; data collectors were responsible for mapping every product in assigned aisles. All packaged food products available in the supermarket that met criteria established by the Brazilian and Mercosur regulation on food labelling (no. 360/2003) were included in the audit( 28 ).
Data collection
Data were gathered over a 3-month period (October to December 2013) in the city of Florianópolis, Santa Catarina, southern Brazil. Information on product name and type, nutritional values (energy, carbohydrates, protein, total fat, saturated fat, trans fat, fibre and sodium contents per serving) and serving sizes were obtained in-store from labels of all available products. These data were then fed into an electronic version of the data collection form developed by Kliemann et al. ( Reference Kliemann, Veiros and González-Chica 29 ). The electronic form was created using Epi Collect Plus software and was installed on tablet computers. All food labels were photographed in-store to record the ingredients lists, which were later transcribed to the electronic form outside the supermarket. This procedure was adopted so as not to disturb shoppers, as transcribing requires a long time to be executed.
To improve quality control of data, as in a previous study( Reference Rodrigues, Rayner and Fernandes 25 ), the inter-rater agreement between the photographs and data transcribed to the electronic forms was evaluated for 5 % of the products. Kappa test results showed a high degree of inter-rater agreement between the two databases (>99 %; P<0·05).
All data collectors (n 12) received training and participated, one month before data collection, in a field test in a different supermarket.
Data management
Collected data were transferred directly from the tablet computers to an online database at the end of each collection day. The database was exported to a Microsoft Excel® 2010 spreadsheet. Each food product was coded with a number and, later, each image in the database was renamed to the corresponding food product number.
Identification of added sugars in packaged foods
All ingredients listed on the label of each product were transcribed from the photographic records to the Microsoft Excel® 2010 spreadsheet. For quality control purposes, transcribed data were checked by three researchers.
For the identification of added sugars in packaged foods, it was first necessary to identify the terms that refer to these components in the ingredients list. For this, all ingredients that appeared in the database were listed and those that referred to added sugars were identified with the aid of scientific literature and food regulations.
Packaged foods were classified into eight food groups according to similarities in nutritional composition, as defined by a Brazilian and Mercosur resolution( 30 ). To identify the frequency of foods that contained added sugars in each food group, a cluster analysis was performed using a text mining technique in R statistical environment.
Data were organised and analysed using descriptive statistics, with absolute and relative frequencies of added sugars according to food group, to investigate the use of added sugars in packaged foods sold in Brazil. The χ 2 test (P<0·05) was used to compare the presence of added sugars among the groups defined by legislation. The statistical software package Stata version 11.0 was employed.
Results
Ingredients lists of 4539 packaged foods available for sale during the data collection period were analysed, of which 70·8 % (n 3214) had at least one type of added sugar. Characteristics and distribution of products with added sugars according to food group are shown in Table 1.
Characterisation of packaged foods and the presence of added sugars, according to food group, on the ingredients lists of 4539 packaged food products available in a large supermarket in Florianópolis, Santa Catarina, Brazil, October–December 2013
* There was a significant difference between the frequencies of each group (P<0·01) according to the χ 2 test of heterogeneity.
A significant difference was observed between groups regarding the frequency of foods with added sugars (P<0·01). The group ‘products in which carbohydrates and fats are the main energy sources’ had a frequency of added sugars 2·4 times (145 %) higher than the group ‘oils, fats and nuts’, which had the lowest frequency.
In seven of the eight food groups, added sugars were present in more than 50 % of the products. Even in the group with the lowest frequency of added sugars (‘oils, fats and nuts’), 38 % of the products had at least one type of these components.
In total, 179 different terms for added sugars were identified in the packaged foods. When analysing the terms, variations in types of sweet spreads and juices were included (e.g. ‘apple juice’ was identified as a term and ‘grape juice’ as another term)( Reference Scapin, Fernandes and Proença 3 ) and variations in terms referring to ingredients’ quality and/or purity were not considered (e.g. ‘organic’ in ‘organic sugar’; Table 2).
Terms for added sugars, classified into major groups, identified from the ingredients lists of 4539 packaged food products available in a large supermarket in Florianópolis, Santa Catarina, Brazil, October–December 2013
* In total, 179 different terms for added sugars were identified, excluding quality and/or purity variations (e.g. ‘organic sugar’ or ‘100 % fruit juice from concentrate’).
† Different fruit flavours not specified here were included (e.g. ‘orange juice’, ‘watermelon juice’, etc.). Therefore, there are fewer examples in the table than the total number of terms identified.
These terms appeared 7093 times in the 3214 food products containing added sugars, representing an average of 2·2 types of added sugars per product. The most common types of added sugars in ingredients lists were sugar, maltodextrin and glucose syrup.
Discussion
To the authors’ best knowledge, the present study is the first one that systematically analysed the presence and types of added sugars in packaged foods available for sale in South America. In our study, more than 70 % of the analysed foods had at least one type of added sugar in their composition. Such proportion was similar to those identified in studies in the USA (68·0 %)( Reference Ng, Bricker and Li 21 , Reference Ng, Slining and Popkin 22 ), Canada (63·5 %)( Reference Bernstein, Schermel and Mills 19 ) and China (72·0 %)( Reference Lv, Chen and Wang 20 ), indicating that added sugars are largely used in packaged foods throughout the world.
In total, 179 different terms for added sugars were identified in the present study. It should be noted that consumers may have trouble in identifying some denominations, such as maltodextrin, dextrose, corn glucose and fructose. In Canada( Reference Bernstein, Schermel and Mills 19 ), 152 different types of free sugars were identified in packaged foods marketed in supermarkets under names that might be difficult to understand by the population.
In the scientific literature, there are few studies that evaluate the understanding of terms referring to added sugars and/or free sugars by consumers. In a study with 445 adults in the UK, only 4 % of participants correctly classified ten or more ingredients from a list of thirteen items as added sugars or artificial sweeteners. Half of the participants failed to classify terms difficult to understand, such as isoglucose or invert sugar( Reference Tierney, Gallagher and Giotis 31 ).
Contrary to what has been observed in studies in the USA, where corn syrup is the main type of added sugar in processed foods( Reference Ng, Bricker and Li 21 , Reference Ng, Slining and Popkin 22 ), the present study identified refined sugar as the most frequent ingredient, accounting for 40 % of the total number observed. Brazil is the world’s largest sugar producer and the third largest consumer( 32 ), which may explain the extensive use of this ingredient in the evaluated packaged foods sold in the Brazilian supermarket.
Maltodextrin was the second most prevalent added sugar (8·3 %) in the analysed Brazilian products. Chemically, maltodextrin is classified as an oligosaccharide( 33 ). Its use in packaged foods is indicated as a substitute for sugars and fats, acting mainly as a bulking agent( Reference Goldfein and Slavin 34 ).
The analysis per food group showed that the group ‘products in which carbohydrates and fats are the main energy sources’ had the highest frequency of products with added sugars. As expected, almost all products in this group (93 %), which includes sweet biscuits, cakes, jams, and chocolate, had added sugars. Noteworthy, this group also had the largest number of packaged foods available for sale, 38 % of the total number of products, characterising the high availability of foods with added sugars for the population.
In addition, there was a high frequency of packaged foods with added sugars in groups of predominantly salty foods: ‘gravies, sauces, ready-made seasonings, broths, soups and ready-to-eat dishes’ (61 %); ‘meats and eggs’ (60 %); and ‘canned vegetables’ (58 %). In these products, sugars may have been used as a preservative, acid stabiliser, colorant or flavour enhancer( Reference Goldfein and Slavin 34 , Reference Clemens, Jones and Kern 35 ). The use of sugars in salty products may lead consumers to eat added sugars without knowing. As these products do not have a characteristic sweet taste, the presence of sugar probably would not be expected or perceived.
In Brazil, as well as in other countries where the declaration of sugar content is not mandatory, the ingredients list remains the only means of estimating the presence, but not the quantity, of added sugars in packaged foods. However, according to the present study results, the diversity of terms used for added sugars may hamper their identification and consequently the adoption of the WHO recommendation to limit sugar consumption.
These issues could be minimised with a quantitative statement of added sugars on the nutrition information label of packaged foods, which is especially important because the WHO provides quantitative recommendations for the intake of added sugars( 7 ). In the USA and Canada, declaration of added sugars on packaged food labels in grams and percentage of daily value (%DV) is mandatory( 2 , 18 ). In Canada, a footnote must be included in nutrition labels to indicate whether the food has ‘a lot’ or ‘a little’ of sugar according to the %DV and ingredients defined as added sugars are grouped into a single category in the ingredients list under the term ‘sugars’( 18 ). Such information may assist consumers in identifying the presence and types of added sugars in packaged foods.
Considering the results of the present study, we suggest that Brazilian legislation on nutrition labelling should be revised. Specifically, quantitative declaration of added sugars in packaged foods must be mandatory, as already occurs in other countries. We also suggest that regulations concerning the presentation of added sugars in the ingredients list should be modified to ensure that (i) the terms used to refer to added sugars are standardised and (ii) added sugars are grouped in the ingredients list, as proposed and implemented in Canada( 18 ).
Regarding our recommendation for a quantitative declaration of added sugars on food labels, we acknowledge the challenge of quantifying sugars according to their origin, either naturally occurring or added, as no analytical methods are currently available for this measurement( Reference Louie, Moshtaghian and Boylan 36 ). However, manufacturers know the amounts of sugar-based ingredients added to their products( Reference Pomeranz 37 ) and could easily state this information on nutrition information labels. Such initiative could promote a reduction in the consumption of added sugars by consumers and perhaps encourage manufacturers to modify product formulations.
Studies have shown that reformulation of products by manufacturers may involve the use of low-calorie sweeteners as substitutes for added sugars( 1 , 33 , Reference Pomeranz 37 ). However, frequent consumption of low-calorie sweeteners has been associated with adverse health effects( Reference Qurrat-ul-Ain & Khan 38 – Reference Swithers 41 ). Therefore, from a health perspective, the substitution of sugars with low-calorie sweeteners may not be advantageous. For this reason, the Pan-American Health Organization’s Nutrient Profile Model declares that the use of low-calorie sweeteners should be limited to promote the development of products with better nutritional profiles( 42 ).
To summarise, the present study contributes to the literature by showing the magnitude of the presence of added sugars in packaged foods commercialised in Brazil. We highlight the major importance of food labelling in allowing consumers to make informed food choices and the lack of studies on added sugars in Brazil. As future directions, we believe that data gathered during our study can be used for monitoring the nutritional quality of packaged foods marketed in the country.
Study limitations and strengths
As limitations of the present study, we highlight the difficulty in classifying certain packaged foods not covered by Regulation No. 359/2003, such as hydroponic and lyophilised vegetables, which were not common in Brazil when this regulation was implemented( 30 ). In addition, the limitations that arise from gathering data from only one supermarket must be considered. As the study was conducted in a large supermarket in southern Brazil, data may not reflect the profiles of products sold throughout the country. As frequently occurs, our data may underestimate the frequency of foods containing added sugars in low-income regions of the country, as markets in low-income areas tend to offer foods with worse nutritional profiles. Nevertheless, we state that care was taken during the selection of the supermarket to ensure that our database consisted of products of well-known brands that are found in other parts of the country.
To the best of our knowledge, our survey is the fifth in Brazil investigating all food product labels in a single supermarket; the other studies were conducted in the same supermarket chain as that of the present study( Reference Martins, de Sousa and Veiros 24 – Reference Figueiredo, Scapin and Fernandes 27 , Reference Kliemann, Veiros and González-Chica 43 – Reference Silveira, Kliemann and Silva 49 ).
Conclusion
Most of the analysed packaged foods (71 %) had added sugars in their composition, of which refined sugar was the most prevalent ingredient. Although added sugars were more frequent in sweet foods, they were also observed with a high frequency in salty foods, which could lead consumers to increase added sugars consumption without knowing.
There were 179 different terms for added sugars in ingredients lists, which may hamper their identification on food labels by consumers. For this reason, the amount of added sugars should be stated on nutrition information labels. Moreover, we recommend that laws should be established to standardise the classification of ingredients that contain added sugars and to group sugar-based ingredients under a category with the generic name of ‘sugar’ to facilitate identification. In addition, the promotion of knowledge on terms that refer to added sugars by organisations such as councils and associations of health professionals could be a strategy to assist consumers in identifying these sugars in packaged foods.
Thus, considering the recommendations of limiting the intake of added sugars by government agencies, data on the presence and types of these sugars in packaged foods should be available to researchers, health professionals and consumers. These results may also serve as a basis for future comparisons of trends in the use and types of added sugars in packaged foods.
Acknowledgements
Financial support: The authors thank the Federal Agency for Support and Evaluation of Graduate Education in Brazil (CAPES) for its financial support in the form of scholarships to T.S. This analysis was conducted as part of a wider study about the comprehension and use of food labelling in Brazil, which was funded by the National Council for Scientific and Technological Development (CNPq) of the Ministry of Science and Technology in Brazil and by the Brazilian Health Surveillance Agency (ANVISA) (grant number 440040/2014-0), with the aim of filling gaps related to the policies, management and organisation of the Brazilian National Health Surveillance System. The funders had no role in the design, analysis or writing of this article. Conflicts of interest: None. Authorship: T.S. was responsible for planning the research, collecting, analysing and interpreting data, and drafting the manuscript. A.C.F. was responsible for collecting, analysing and interpreting data, and revising the manuscript. A.A. was responsible for statistical analyses and for revising the manuscript. R.P.C.P. was responsible for the design of the original study, planning the research and analysis, research coordination, and supervising and revising the final manuscript. All authors approved the version submitted for publication. Ethics of human subject participation: Not applicable.
