Hostname: page-component-78c5997874-s2hrs Total loading time: 0 Render date: 2024-10-30T09:17:29.737Z Has data issue: false hasContentIssue false

Current perspectives on global sugar consumption: definitions, recommendations, population intakes, challenges and future direction

Published online by Cambridge University Press:  09 August 2021

Janette Walton*
Affiliation:
Department of Biological Sciences, Munster Technological University, Cork, Republic of Ireland
Haley Bell
Affiliation:
Cambridge Food Science, Cambridge, UK
Roberta Re
Affiliation:
Cambridge Food Science, Cambridge, UK
Anne P Nugent
Affiliation:
Institute for Global Food Security, School of Biological Sciences, Queens University Belfast, Belfast, Northern Ireland Institute of Food and Health, School of Agriculture and Food Sciences, University College Dublin, Belfield, Dublin 4, Ireland
*
*Corresponding author: Janette Walton, email janette.walton@mtu.ie
Rights & Permissions [Opens in a new window]

Abstract

Currently, there is considerable emphasis on the relationship between dietary sugar consumption and various health outcomes, with some countries and regions implementing national sugar reduction campaigns. This has resulted in significant efforts to quantify dietary sugar intakes, to agree on terms to describe dietary sugars and to establish associated recommendations. However, this information is infrequently collated on a global basis and in a regularised manner. The present review provides context regarding sugar definitions and recommendations. It provides a global review of the available data regarding dietary sugar intake, considering forms such as total, free and added sugars. A comprehensive breakdown of intakes is provided by age group, country and sugar form. This analysis shows that free sugar intakes as a percentage of total energy (%E) are the highest for children and adolescents (12–14%E) and the lowest for older adults (8%E). This trend across lifecycle stages has also been observed for added sugars. The available data also suggest that, while some reductions in sugar intake are observed in a few individual studies, overall intakes of free/added sugars remain above recommendations. However, any wider conclusions are hampered by a lack of detailed high-quality data on sugar intake, especially in developing countries. Furthermore, there is a need for harmonisation of terms describing sugars (ideally driven by public health objectives) and for collaborative efforts to ensure that the most up-to-date food composition data are used to underpin recommendations and any estimates of intake or modelling scenarios.

Type
Review Article
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Nutrition Society

Introduction

Sugar has been described as a ‘ubiquitous term’, difficult to both define and measure, which may be in part due to its dual function as both a nutrient and as an ingredient(Reference Fidler Mis, Braegger and Bronsky1). A form of carbohydrate, chemically, the term ‘sugars’ usually describes mono- and disaccharides, with examples of monosaccharides being glucose, galactose and fructose and examples of disaccharides being sucrose, lactose and maltose. Examples of some natural contributing food sources include fruits (fructose, glucose, sucrose), honey (fructose, glucose, sucrose), milk and milk products (galactose, lactose), and table sugar (sucrose). Such ‘-ose’ sugars can also form the building blocks of other carbohydrate types, such as oligosaccharides and polysaccharides. In addition, sugars in many of the above forms may be added as an ingredient to foods during processing or preparation to preserve food and/or to confer functional properties, such as viscosity, texture, body and colour, or at the table by consumers to add sweetness(Reference Fidler Mis, Braegger and Bronsky1,Reference Clemens, Jones and Kern2) . As a result, there is a broad range of foods containing sugars with varying quantities depending on the desired function, individual preference and food form. As a carbohydrate form, sugars, regardless of type, contribute 3·75 kcal/g, which is equivalent to the contribution from starch.

Whilst the relationship between the frequency of consumption of foods containing sugars (particularly sucrose) and dental caries is well established(35), there is debate concerning the relationship between dietary sugar intake and other health outcomes such as obesity, type 2 diabetes and cardiovascular disease. The evidence has been critiqued and systematically reviewed both in scientific publications(Reference Prinz6,Reference Johnson, Appel and Brands7) and by advisory bodies and competent authorities(35,Reference Tappy, Morio and Azzout-Marniche8,9) with no firm conclusion that dietary sugars are directly related to diet-related diseases other than as a source of dietary energy particularly implicated as a contributor towards positive energy balance. As an individual dietary sugar, fructose has been identified of note, particularly with respect to metabolic health and hyperuricemia; however, as yet, no agreed conclusion has been reached regarding fructose(Reference Jamnik, Rehman and Blanco Mejia10,Reference Dornas, de Lima and Pedrosa11) . The strongest available evidence of any link between dietary sugars and health is for body weight, and following the consumption of sugar-sweetened beverages rather than sugars or a single sugar per se (5,Reference Lobstein12,Reference Te Morenga, Mallard and Mann13) . At the request of a number of countries in the wider Nordic region, the European Food Safety Authority (EFSA) is currently (2020) undertaking a renewed review of the evidence to provide scientific advice on dietary sugars and to derive a tolerable upper intake level (UL) for total/added/free dietary sugars(14). A draft for public consultation is expected in mid-2021.

In light of this continuing focus on sugars and their role in health, it is important to review current estimates of intake globally and to place these in context against recommendations. This allows generation of a benchmark for ongoing surveillance. Previously, there have been three reviews covering dietary sugars intakes, one with a global perspective(Reference Newens and Walton15) a second focused on European countries(Reference Azaïs-Braesco, Sluik and Maillot16) and a third focusing on Latin American countries(Reference Fisberg, Kovalskys and Gómez17). However, there exists a need to capture more recent data on a global basis and in a consistent balanced manner. The current review provides an up-to date critique of sugars in terms of their classification and dietary recommendations. A secondary analysis of the available data on dietary sugar intakes worldwide is described, followed by a perspective on the role of sugars in the diet globally.

Classification and definitions of dietary sugars

The term ‘sugars’ is conventionally used to define the mono- and disaccharides in foods (also known as total sugars). This includes naturally occurring sugars as well as those added to a food or drink (such as sucrose, fructose, maltose, lactose, honey, syrup, corn syrup, high-fructose corn syrup, molasses and fruit juice concentrate) but does not include polyols. Other definitions of dietary sugars are typically either linked to function in terms of establishing dietary recommendations, or they inform regulations and food labelling. With respect to definitions used to underpin dietary recommendations, the key terms are ‘total sugars’ (as defined above), ‘free sugars’, ‘added sugars’ and, historically, ‘non-milk extrinsic sugars’ (UK only). Table 1 provides a brief description of these definitions and issuing guidance body. Of note, the term ‘total sugars’ provides the most encompassing measure of dietary sugars intake, used widely in food labelling and for informing consumers about the total sugars content of foods and drinks. The use of the term ‘total sugars’ in food labelling is mainly due to there currently being no accepted method for empirically measuring free sugars or non-milk extrinsic sugars in a food/drink. However, it is less frequently used in dietary recommendations(Reference Mela and Elizabeth18). Terms that are used more frequently in dietary recommendations include ‘free’ or ‘added’ sugars(Reference Buyken, Mela and Dussort19). Both EFSA (Europe) and the Institute of Medicine (United States) define added sugars as all sugars that are added to foods and beverages by the manufacturer, cook and consumer, but do not include natural sources of sugars such as those included in unsweetened fruit juices(3,20) . On the other hand, free sugars, as defined by WHO and EFSA, include all added sugars but also those sugars naturally present in honey, syrups and fruit juices(4,21) . Such divergence in definitions for sugars is reflected in varying descriptions when reporting on dietary intake, in varying use of the terms in food regulations and even in defining the composition of formulae and foods for infants and young children(Reference Fidler Mis, Braegger and Bronsky1).

Table 1. Definitions of sugars as used in dietary recommendations

FAO/WHO (Food and Agriculture Organization and the World Health Organization), 1998. Carbohydrates in human nutrition. Report of a Joint FAO/WHO Expert Consultation, Rome, Italy, 14–18 April 1997. EFSA NDA Panel (EFSA Panel on Dietetic Products, Nutrition and Allergies), 2010. Scientific Opinion on Dietary Reference Values for carbohydrates and dietary fibre.

EFSA Journal 2010;8(3): 1462, 77 pp. https://doi.org/10.2903/j.efsa.2010.1462.

IoM (Institute of Medicine), 2002. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids.

Dietary guidelines for sugars consumption

Universally, most food-based dietary guidelines make the sensible and pragmatic suggestion for populations to limit the consumption of foods of low nutrient density, such as foods of low dietary quality that are high in calories, sugar, salt and/or fat, especially saturated fat. In recent years, many government and health organisations worldwide have revisited their guidance for dietary sugar intake, particularly in relation to maximum recommended intakes for added or free sugars. Some of these goals are average population maximum targets, and some are recommendations for intakes at the individual level. Examples of current recommendations relating to quantitative guidelines for dietary sugars are included in Table 2 and are summarised briefly below.

Table 2. Examples of dietary reference values for sugars globally

For free sugars, the World Health Organisation (WHO) recommends that all individuals, both adults and children, reduce their intake of free sugars to <10% energy (E) intake and suggest a further conditional recommendation of reduction to <5% E for further health benefits(4). This <5%E value is also proposed by both the UK Scientific Advisory Committee on Nutrition (SACN) (as an average population maximum target) and by the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) (as individual guidance). Of note, there is a differing body of evidence underpinning these recommendations. Whilst SACN focus on intervention and prospective cohort studies relating to the intake of sugars to energy intake and to an increased risk of dental caries and type 2 diabetes mellitus(5), the ESPGHAN recommendation(Reference Fidler Mis, Braegger and Bronsky1) is informed by the conclusions of both WHO and SACN(4,5) rather than by independent analyses. Of note also, ESPGHAN suggest children under 2 years of age should have even lower intakes than the <5%E(Reference Fidler Mis, Braegger and Bronsky1).

For added sugars, both the Nordic countries and the United States recommend limiting the intake of added sugars to <10%E(23,25) . In both cases, these recommendations were in the context of healthy dietary patterns rather than any link with disease risk, a major difference to recommendations for free sugars. Whilst the American Heart Association (AHA) in the United States have listed a UL for children(Reference Vos, Kaar and Welsh29), this was not reflected in US national guidelines, which were unable to establish this guidance value owing to lack of evidence. In the absence of such scientific evidence, the IoM suggested that intakes above 25%E from added sugars may be associated with displacement of foods that are major sources of essential micronutrients, but they were unable to set a UL at that time (2002) and have not set one since(9). Of note, the French Agency for Food, Environmental and Occupational Health & Safety (ANSES) have set an upper limit for total sugars of 100 g/d for adults, but this excludes lactose and galactose naturally present in milk and dairy products(Reference Tappy, Morio and Azzout-Marniche8). As mentioned previously, the EFSA is currently mandated to provide scientific advice on dietary sugars and to establish a UL if the available data allow it, having previously being unable to set such a benchmark in 2010(3). It is unknown yet how an establishment of such a UL may influence national dietary guidelines within Europe: currently, whilst some European countries have quantitative limits established, such as the Nordic countries, the UK and France, others such as Germany have adopted the WHO recommendations(Reference Ernst, Arens-Azevêdo and Bitzer28). What is currently known regarding the EFSA scientific evaluation is that the exposure assessment will focus on intake of free sugars and that the disease endpoints of interest will include incidence/severity of dental caries and incidence of metabolic diseases. Other less direct endpoints will include measures of body fatness, ectopic fat distribution, glucose homeostasis and blood lipids among others(14). As we await the findings of this EFSA scientific opinion, recent reviews suggest that, for numerical dietary sugar recommendations, more explicit quantification, justifications and communication of uncertainty factors, together with greater international harmonisation for both exposures and outcomes, would help to minimise any variation in recommendations(Reference Fisberg, Kovalskys and Gómez17,Reference Buyken, Mela and Dussort19,Reference Erickson, Sadeghirad and Lytvyn30) . An update of these reviews is included below.

Sugar intake data

Selection of data

Recent reviews of dietary surveys (published between 2014 and 2018) were used to identify a list of countries that have undertaken dietary surveys and the dates that these surveys were performed(Reference Rippin, Hutchinson and Evans31Reference Song and Song34). These were then supplemented with searches of databases such as Science Direct, PubMed and Google Scholar using terms such as ‘national dietary survey’ and ‘sugar(s) consumption’. As nutrient and food intakes derived from national food consumption survey data are typically published in reports, rather than peer-reviewed papers, the data presented in the present review were primarily collected from various reports and publications of national dietary surveys. Surveys and reports known to the authors of the present study were also included. Peer review publications were used to obtain additional data, for countries including New Zealand, Mexico, Spain, Brazil, the United States and Ireland. Studies were included if the data were (i) nationally representative, (ii) available in the public domain, (iii) summarised (no raw data were analysed) and (iv) collected at the individual level, and if (v) sugar intake was reported as a nutrient rather than a food group. There was no limit to the study size, and data from all available direct dietary assessment methodology were included, including food diaries, diet recalls or food frequency questionnaires.

Presentation of data

In an attempt to assess the available evidence which quantifies dietary sugar intake, a secondary analysis of published intake data for all sugar forms has been completed, and the findings (as reported in their original form) are reported in Tables 37 and summarised below. Energy values have been included to allow others to make crude estimates of sugars intakes as a percentage of energy where these data were not in the original reports.

Table 3. Energy and sugar intake of infants and young children (<4 years)

M: male; F: female.

BF: breastfed; FF: formula fed.

* Energy values per 10 MJ.

United States reports SEM.

Table 4. Energy and sugar intake of children (4–12 years)

M: male; F: female.

* Chile and Germany report median intakes.

China, Mexico (4–13) and United States report SEM.

Spain energy intake from ANIBES (2014). Sugar intake reported from Ruiz et al. (2017).

Table 5. Energy and sugar intake of adolescents (˜13–18 years)

M: male; F: female.

Total sugars for Andorra reported as digestible sugars.

Germany and New Zealand report median values.

§ United States reports SEM.

Table 6. Energy and sugar intake of adults (19–64 years)

M: male; F: female.

Total sugars for Andorra reported as digestible sugars.

Canada variance reported as standard error (SE), not SD. Intakes for adults not split by sex, based on the first day recall, not usual intake.

§ Chile, Germany and New Zealand report median values.

|| Greece n-values include older adults, but data are for age groups as reported.

Hungary mono- and disaccharides added to foods, foodstuffs during production or preparation, and natural sugars in honey.

** United States reports SEM.

Table 7. Energy and sugar intake of older adults (65+ years)

* M: male; F: female.

Total sugars for Andorra reported as digestible sugars.

Chile, Mexico and New Zealand report median.

§ n-Values combined for 19–59 and 65–74 years for Greece.

|| United States reports SEM.

Values are reported for estimated intakes of energy, total sugars, added sugars, free sugars or sucrose as available. Where energy was provided in kcal, it was converted to MJ using a factor of 238·85. Data are presented as provided in the reports and publications, and where possible, data have been divided by age range and not subdivided by sex. No statistical analysis has been performed on these data sets, and the results are purely descriptive. Under-reporting of food consumption can influence the accuracy of dietary intake data, resulting in an underestimate of energy and nutrients. The data presented in the tables do not account for under-reporting as under-reporters are not typically excluded from data presented in reports of food and nutrient consumption. Additionally, the data are usually presented as a percentage of energy intake, which partially accounts for this but will still result in an underestimate of sugar intake if foods/drinks that are high in sugar are selectively under-reported. It should also be noted that there are significant limitations in comparing sugar intakes across countries (from different time points) since the composition of individual foods and beverages may have changed drastically over that time and may not be reflective of current consumption.

Children (<4 years)

For infants and very young children (<4 years), sugar intake data are available for 16 countries: Australia, Belgium, Chile, Denmark, Estonia, Finland, France, Iceland, Ireland, Israel, Italy, Mexico, the Netherlands, Norway, the UK and the United States (Table 3). These include intakes of total sugars (nine countries), added sugars (seven countries), free sugars (four countries) and sucrose (two countries).

Total sugar intake expressed as a percentage of total energy (%E) ranged from 18·8 % for 2–5-year-old girls in Israel to 31·4 % for 1–3-year-old girls in the Netherlands. Intake of added sugars (%E) ranged from 1·5 % in 6–11-month-old girls in the United States to 14·1 % in 1–3-year-old girls in the Netherlands. Intake of free sugars (%E) ranged from 9 % in 1-year-olds in Ireland to 17·4 % in 1–3-year-old girls in the Netherlands.

Children (4–12 years)

For children aged 4–12 years, sugar intake data are available for 25 countries: Australia, Austria, Belgium, Brazil, Canada, Chile, China, Denmark, Estonia, Finland, France, Germany, Iceland, India, Ireland, Israel, Italy, Mexico, the Netherlands, New Zealand, Norway, Portugal, Spain, the UK and the United States (Table 4). These include intakes of total sugars (eighteen countries), added sugars (eleven countries), free sugars (six countries), sucrose (four countries) and intrinsic sugars (Spain only).

Total sugar intake (%E) ranged from 8 % in 4–13-year-olds in China to 28·6 % in 4–8-year-old girls in the Netherlands. Intakes of added sugars (%E) ranged from 3 % in 4–13-year-old children in China to 17·0 % in 4–8-year-old girls in the Netherlands. Intakes of free sugars (%E) ranged from 9·1 % in 3-month-old-to-10-year-old boys in Portugal to 19·5 % for 4–8-year-old girls in the Netherlands.

Adolescents (13–18 years)

For older children (13–18 years), sugar intake data were available for 24 countries: Andorra, Australia, Austria, Belgium, Brazil, Canada, Chile, Denmark, Estonia, France, Germany, Iceland, India, Ireland, Israel, Italy, Mexico, the Netherlands, New Zealand, Portugal, Slovenia, Spain, the UK and the United States (Table 5). These include intakes of total sugars (sixteen countries), added sugars (twelve countries), free sugars (eight countries), sucrose (four countries) and intrinsic sugars (Spain only).

Total sugar intake (%E) ranged from 15·4 % in 10–18-year-old boys in Italy to 30 % in 15–16-year-old girls in Slovenia. Intakes of added sugars (%E) ranged from 9·1 % in 10–17-year-old girls in Portugal to 16·2 % in 9–18-year-old children in the United States. Intakes of free sugars (%E) ranged from 9·1 % in 10–17-year-old boys in Portugal to 17·9 % for 9–13-year-old boys in the Netherlands.

Adults (19–64 years)

For adults, sugar intake data are available for 29 countries: Andorra, Australia, Austria, Belgium, Brazil, Canada, Chile, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, India, Ireland, Israel, Italy, Lithuania, Mexico, the Netherlands, New Zealand, Norway, Portugal, Spain, Switzerland, the UK and the United States (Table 6). These include intakes of total sugars (eighteen countries), added sugars (fifteen countries), free sugars (eleven countries), sucrose (four countries) and intrinsic sugars (Spain only).

Total sugars intake (%E) ranged from 12·7 % in 35–49-year-old men and women in Lithuania to 26 % in 19–30-year-old women in the Netherlands. Intakes of added sugars (%E) ranged from 6·3 % in 50–59-year-old men in Norway to 14 % in 19–59-year-old women in Brazil. Intakes of free sugars (%E) ranged from 6·9 % in 18–64-year-old men in Portugal to 18·1 % in 51–64-year-old women in Austria.

Adults (>65 years)

For older adults, sugar intake data are available for 26 countries: Andorra, Australia, Austria, Brazil, Chile, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, India, Ireland, Israel, Italy, Lithuania, Mexico, the Netherlands, New Zealand, Norway, Portugal, Spain, the UK and the United States (Table 7). These include intakes of total sugars (fifteen countries), added sugars (eleven countries), free sugars (seven countries), sucrose (five countries) and intrinsic sugars (Spain only).

Total sugar intake (%E) ranged from 13·2 % in 65–75-year-old adults in Lithuania to 23·3 % in women ≥71 years old in New Zealand. Intakes of added sugars (%E) ranged from 4 % in men aged 65–84 years in Portugal to 12 % in women ≥60 years old in Brazil. Intakes of free sugars (%E) ranged from 4·4 % in 65–84-year-old men in Portugal to 12·5 % for men aged >75 years old in the UK.

Patterns of dietary sugars intake

Our analysis shows that intakes (expressed as %E) of both free and added sugars are highest in children and adolescents and are lowest for older adults.

Based on data as reported and one data point per age category per country, crude global estimates of mean intakes of free sugars (%E) were 12 % for 1–4-year-olds, 12 % for 4–12-year-olds, 14 % for 13–18-year-olds, 11 % for 19–64-year-olds and 8 % for >65-year-olds. For added sugars, crude global estimates of mean intakes were 8 % for 1–4-year-olds, 11 % for 4–12-year-olds, 13 % for 13–18-year-olds, 10 % for 19–64-year-olds and 8 % for >65-year-olds. These findings indicate that, where quantified, intakes of both added and free sugars are generally higher than recommended dietary guidelines at all life stages.

Such patterns of added sugars intake across the lifecycle are similar to previous findings, with the highest intakes in school-aged children and adolescents and the lower intakes observed in young children and adults (particularly older adults)(Reference Newens and Walton15,Reference Azaïs-Braesco, Sluik and Maillot97) . Findings from individual countries such as Australia, Canada, the UK and Ireland have shown some reduction in intakes of added/free sugars in children and adolescents over the last ∼15–20 years(35,Reference Roberts, Steer and Maplethorpe73,Reference Langlois, Garriguet and Gonzalez75,98) . For example, free sugar intake in Ireland has decreased from 16%TE (2003–2004) to 9%TE (2017–2018)(98). These studies have suggested that this reduction is largely due to reformulation, particularly in the sweetened beverage categories which are commonly consumed by children and adolescents. It is difficult to draw stronger conclusions beyond this due to differing terminology and methodologies used between countries and over time.

In brief, two observations are apparent from this analysis of published dietary sugars intake data globally. The first is the high intake of added/free sugars compared with recommendations at all life stages but particularly in school-aged children and adolescents. The second outcome is that more data (both in terms of quantity and harmonisation) are required to give a complete picture of sugars intake globally. Caution is needed when interpreting these dietary intake data across sugar types and making inter-country comparisons, due to differences in the dietary assessment methodologies, differences in the time periods in which dietary intake was assessed and differences in national clustering of age groups. Future studies could examine the feasibility of identifying and compensating for selected under-reporting (which may be worse for sugar-sweetened foods and beverages) by using biomarkers in a subset of the population.

Interpretation and application of dietary sugar data

Challenges of data availability and quality

Whilst this review serves to update data on sugar intake from two previous reviews, for some countries there have been no updates since the time of the previous reviews, and hence these earlier data are included here also. New data are, however, available and included for countries such as Andorra, Australia, Chile, China, Estonia, Germany, Greece, India, Lithuania, Mexico, New Zealand, Portugal, Slovenia and Switzerland, and updated data are available for some age groups, including for Belgium, Canada, Denmark, Finland, France, Germany, Ireland, Israel, Netherlands, Norway, the UK and the United States.

Notwithstanding the addition of new data, the findings suggest that relatively few countries globally provide any kind of dietary data on sugar intake. The greatest amount of intake data was available for adults, but even then, data were only available for 29 countries; mostly in the European Union (EU) and greater European region, Australia and New Zealand, the United States and some of the Americas. Of note, there are 194 countries in the world today(Reference Hayes99) and 100 countries which have food-based dietary guidelines(26). Significant gaps remain in examining sugars intakes globally, mirroring gaps in dietary surveillance in general(Reference Micha, Coates and Leclercq100).

A notable difference between this 2020 review and previous reviews(Reference Newens and Walton15,Reference Azaïs-Braesco, Sluik and Maillot16) is the inclusion of available data for dietary free sugar intake. This is in part due to newly available methods and definitions to estimate free sugars in databases of food consumption(Reference Louie, Moshtaghian and Boylan101,Reference Swan, Powell and Knowles102) . These new data allow comparisons against nutrient goals for dietary sugars, which are typically based on free sugars intake. In particular, the inclusion of these data highlights the challenges of meeting dietary recommendations for free sugars, particularly at 5%E. For example, of the twenty-seven surveys that provided an estimate for free sugars, only one survey reported an estimate of mean intake below that value (Spain, where older male adults reported sugars intakes of 4·8%E). Understanding which food groups are the key contributors to free sugars at each lifecycle stage will help to inform strategies to reduce these intakes(Reference Amoutzopoulos, Page and Steer103).

Nevertheless, there remain considerable challenges in estimating dietary sugar intake data. Standard challenges exist relating to population sampling, selection bias and the assumptions and uncertainties inherent to the dietary collection methods used (24 h recall, food records and food frequency questionnaires)(Reference Newens and Walton15,Reference Micha, Coates and Leclercq100) . Further, for sugars, obtaining reliable estimates of added and free sugar consumption continues to be a challenge for researchers. Despite the development of protocols to estimate added/free sugar composition(Reference Louie, Moshtaghian and Boylan101,Reference Amoutzopoulos, Steer and Roberts104) , detailed food and composition data at brand level are necessary for these purposes(Reference Newens and Walton15,Reference Swan, Powell and Knowles102) . As part of EFSA’s ongoing assessment to provide scientific advice on an tolerable upper intake level for sugars, harmonised data on dietary sugars intake will be compared for countries in the European region; however, challenges remain for assuring valid comparisons in other global regions(14).

Application of dietary sugar data

For dietary intake researchers, data managers and risk assessors, the need to survey and accurately quantify dietary sugars intake remains a priority. However, it also remains problematic, given the lack of global harmonisation of definitions, classifications and recommendations and the lack of biomarkers to differentiate between the dietary intake of different sugars types. Future situations that could overcome this lack of harmony, but that could also offer objective biomarkers of intake and quantitative measures of the amounts of the various sugar forms present within foods, would be welcome. However, where available, these are currently only in their infancy and, indeed for biomarkers at least, may be a futile effort(Reference Davy and Jahren105Reference Louie108).

For policy makers, current dietary sugar intake patterns are needed for consistent longitudinal monitoring and may enforce concerns and underline the importance of policy initiatives to reduce population sugar and energy (calorie) intakes. To date, there have been a variety of approaches undertaken by different countries, ranging from education strategies, taxation policies on single food types (e.g. taxes on sugar-sweetened beverages) to more comprehensive initiatives affecting multiple food types (e.g. UK initiatives targeting reformulation, portion size and altering consumer purchasing behaviour(Reference Capacci, Allais and Bonnet109), or indeed a mix of all three(110,111) ). Although there is some information to suggest that such efforts may reduce purchase and, in some cases, intake, any impact on outcomes other than absolute dietary intakes (e.g. health outcomes such as obesity risk) remain unknown, despite numerous modelling exercises(Reference Wright, Smith and Hellowell112Reference Amies-Cull, Briggs and Scarborough117). A challenge remains in balancing the need to have regular robust population dietary assessments to underpin and evaluate policy with the costs and logistics that accompany such surveillance programmes(Reference Micha, Coates and Leclercq100).

Food compositional data for sugars are also used on food labels as applied by the food industry. The values on such labels can be used to underpin estimates of dietary sugars intake by researchers. For most countries, there is no mandatory labelling of added or free sugars, and only total sugars is required to be declared on the label, mainly due the current lack of a an accepted analytical method for manufacturers to assess added/free sugar content in foods/drinks. Exceptions include the United States, where added sugars (g, % daily value) will be included on the food label from 2021(118), and Mexico, who have recently (2020) also updated their labelling guidelines to include added sugars(119). Notwithstanding this, challenges remain: for example, in the United States, single-ingredient sugars such as syrups are treated differently with respect to labelling requirements and are not labelled as added sugars unless added as an ingredient in other foods. Given such disparities, continued challenges will remain when sourcing and applying food composition data to underpin estimates or modelling of dietary sugars intake, particularly for foods which are either new to market or have been recently reformulated for sugars. It is promising to see a recently proposed method to quantify free sugars in foods and beverages which, if workable, will be a valuable addition for assessment of free sugars and will be useful in product development and for public health bodies, industry and regulatory agencies(Reference Mela107).

A further challenge relates to consumer awareness and understanding of the meaning of the terms ‘added’ or ‘free’ sugars in the context of dietary guidance. As mentioned, globally, food labels mostly only provide the interested consumer with information on quantitative amounts of total sugars present. Recent studies have suggested confusion in recognising dietary sources of added or free sugars, with results reiterating the need to have a readily understood term for sugars relating to label information and to educate and inform consumers of such(Reference Tierney, Gallagher and Giotis120,Reference Tang, Lin and Yang121) . With disconnection between dietary guidance and food labelling regulations with respect to total/free/added sugars, it will be a challenge for consumers to understand the relevant sugar content of foods from the nutrition label.

Future directions and conclusion

With the role of dietary sugars under scrutiny, this review aimed to provide a current picture of dietary guidance and actual sugar intake worldwide. It shows that, globally, a minority of countries provide any estimate of sugar intake. Further, intakes of the sugar forms upon which the greatest emphasis is placed (free and added sugars) generally exceed existing dietary guidelines across all population groups and are highest in children and adolescents and lowest for older adults Whilst individual studies suggest some reductions in intakes of added sugars (%E) in children and adolescents, this review suggests that there is a need for more data to understand the complete picture. Furthermore, this review suggests a greater need for harmonisation of terms and for collaborative efforts to ensure that the most up-to-date food composition data are used to underpin any estimates of intake or modelling scenarios. Development and consensus on robust, valid biomarkers which provide accurate measures of dietary sugars intake, and preferably in a manner which is cost-effective, non-invasive and quick, would be welcome. In the interim, continued focus on monitoring of both dietary intakes and the efficacy of any public health initiatives remains paramount.

Acknowledgements

We wish to thank the authors of the dietary survey reports in different countries who assisted us with data related queries.

Financial support

This work was supported by the World Sugar Research Organisation (WSRO). WSRO had no role in the analysis or writing of this review.

J.W. received financial support from the WSRO for the initial draft of the manuscript. No funding was received for later drafts or for final manuscript. R.R. and H.B. are previous employees of WSRO and were employees at the time that the data were collected.

R.R. and J.W. conceived the idea of this review paper. H.B. collated the data. J.W. and A.N. interpreted the data and drafted the manuscript. All authors read and approved the final version of the manuscript.

References

Fidler Mis, N, Braegger, C, Bronsky, J, et al. (2017) Sugar in infants, children and adolescents: a position paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 65, 681696.CrossRefGoogle ScholarPubMed
Clemens, RA, Jones, JM, Kern, M, et al. (2016) Functionality of sugars in foods and health. Comprehensive Reviews in Food Science and Food Safety. Blackwell Publishing Inc.; 15, 433470.Google Scholar
European Food Safety Authority (2010) Scientific opinion on dietary reference values for carbohydrates and dietary fibre. EFSA J [Internet] 8, 1462. Available from: http://www.efsa.europa.eu/sites/default/files/scientific_output/files/main_documents/1462.pdf.Google Scholar
World Health Organization (2015) WHO Guideline: sugars intake for adults and children. Geneva: WHO.Google Scholar
Scientific Advisory Committee on Nutrition (2015) Carbohydrates and Health. http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf (accessed January 2020).Google Scholar
Prinz, P (2019) The role of dietary sugars in health: molecular composition or just calories? Eur J Clin Nutr 73, 12161223.10.1038/s41430-019-0407-zCrossRefGoogle ScholarPubMed
Johnson, RK, Appel, LJ, Brands, M, et al. (2009) Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 10111120.10.1161/CIRCULATIONAHA.109.192627CrossRefGoogle Scholar
Tappy, L, Morio, B, Azzout-Marniche, D, et al. (2018) French recommendations for sugar intake in adults: a novel approach chosen by ANSES. Nutrients 10, 989.10.3390/nu10080989CrossRefGoogle ScholarPubMed
Institute of Medicine (2005) Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington, DC: The National Academies Press.Google Scholar
Jamnik, J, Rehman, S, Blanco Mejia, S, et al. (2016) Fructose intake and risk of gout and hyperuricemia: a systematic review and meta-analysis of prospective cohort studies. BMJ Open 6, e013191.10.1136/bmjopen-2016-013191CrossRefGoogle ScholarPubMed
Dornas, WC, de Lima, WG, Pedrosa, ML, et al. (2015) Health implications of high-fructose intake and current research. Adv Nutr 6, 729737.10.3945/an.114.008144CrossRefGoogle ScholarPubMed
Lobstein, T (2014) WHO | Reducing consumption of sugar-sweetened beverages to reduce the risk of childhood overweight and obesity [Internet]. World Health Organization [cited 2020 Jun 14]. Available from: https://www.who.int/elena/titles/ssbs_childhood_obesity/en/ Google Scholar
Te Morenga, L, Mallard, S & Mann, J (2013) Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 346, e7492.10.1136/bmj.e7492CrossRefGoogle Scholar
European Food Safety Authority (2018) Protocol for the scientific opinion on the Tolerable Upper Intake Level of dietary sugars. EFSA J 16, 53935440.Google Scholar
Newens, KJ & Walton, J (2016) A review of sugar consumption from nationally representative dietary surveys across the world. J Hum Nutr Diet 29, 225–40.10.1111/jhn.12338CrossRefGoogle Scholar
Azaïs-Braesco, V, Sluik, D, Maillot, M, et al. (2017) A review of total & added sugar intakes and dietary sources in Europe. Nutr J 16, 6.CrossRefGoogle ScholarPubMed
Fisberg, M, Kovalskys, I, Gómez, G, et al. (2018) Total and added sugar intake: assessment in eight Latin American countries. Nutrients 10, 389.10.3390/nu10040389CrossRefGoogle ScholarPubMed
Mela, DJ & Elizabeth, MW (2018) Perspective: total, added, or free? What kind of sugars should we be talking about? Adv Nutr 9, 6369.10.1093/advances/nmx020CrossRefGoogle ScholarPubMed
Buyken, AE, Mela, DJ, Dussort, P, et al. (2018) Dietary carbohydrates: a review of international recommendations and the methods used to derive them. Eur J Clin Nutr 72, 16251643.CrossRefGoogle Scholar
DRI (2005) Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington DC: The National Acadamies Press.Google Scholar
European Food Safety Authority (2018) Protocol for the scientific opinion on the Tolerable Upper Intake Level of dietary sugars. EFSA J 16, 5393.Google Scholar
WHO/FAO (1998) Carbohydrates in human nutrition. Report of a Joint FAO/WHO Expert Consultation. FAO Food Nutr. Pap 66, 1140.Google Scholar
U.S. Department of Agriculture and U.S. Department of Health and Human Services (2020) Dietary Guidelines for Americans, 2020–2025, 9th Edn. [Internet]. Available from: DietaryGuidelines.gov.Google Scholar
Institute of Medicine (2005) Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academies Press, 11331.Google Scholar
Nordic Council of Ministers (2012) Nordic nutrition recommendations 2012: integrating nutrition and physical activity. Copenhagen: Nordic Council of Ministers, Narayna PressGoogle Scholar
FAO (2003) Food based dietary guidelines in the WHO European Region Nutrition and Food Security Programme. WHO Regional Office for Europe [Internet]. Available from: http://www.euro.who.int.Google Scholar
Committee on Medical Aspects of Food Policy (COMA) (1991) Dietary reference values for food energy and nutrients for the United Kingdom. London: HMSO.Google Scholar
Ernst, JB, Arens-Azevêdo, U, Bitzer, B, et al. (2019) Quantitative Empfehlung zur Zuckerzufuhr in Deutschland Kurzfassung des Konsensuspapiers der Deutschen Adipositas-Gesellschaft e. V. (DAG), der Deutschen Diabetes Gesellschaft e. V. (DDG) und der Deutschen Gesellschaft für Ernährung e. V. (DGE). Ernahrungs Umschau [Internet], [cited 2020 Jun 16] 66, 2634. Available from: www.dge.de/fileadmin/public/ Google Scholar
Vos, MB, Kaar, JL, Welsh, JA, et al. (2017) Added sugars and cardiovascular disease risk in children: a scientific statement from the American Heart Association. Circulation 135, e1017e1034.CrossRefGoogle ScholarPubMed
Erickson, J, Sadeghirad, B, Lytvyn, L, et al. (2017) The scientific basis of guideline recommendations on sugar intake: a systematic review. Ann Intern Med 166, 257267.CrossRefGoogle ScholarPubMed
Rippin, HL, Hutchinson, J, Evans, CEL, et al. (2018) National nutrition surveys in Europe: a review on the current status in the 53 countries of the WHO European region. Food Nutr Res 62, 10.2919.CrossRefGoogle ScholarPubMed
Newens, KJ & Walton, J (2016) A review of sugar consumption from nationally representative dietary surveys across the world. J Hum Nutr Diet 29, 225240.CrossRefGoogle Scholar
Huybrechts, I, Aglago, EK, Mullee, A, et al. (2017) Global comparison of national individual food consumption surveys as a basis for health research and integration in national health surveillance programmes. Proc Nutr Soc 76, 549567.CrossRefGoogle Scholar
Song, SJ & Song, WO (2014) National nutrition surveys in Asian countries: surveillance and monitoring efforts to improve global health. Asia Pac J Clin Nutr 23, 514523.Google ScholarPubMed
Australian Bureau of Statistics (2016) Australian Health Survey: Consumption of Added Sugars Australia. Australian Bureau of Statistics [Internet]. Available from: http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/58042B7FE6A65821CA2581F4000D1020/$File/4364.0.55.011 - australian health survey - consumption of added sugars.pdf.Google Scholar
Australian Bureau of Statistics (2014) Australian health survey: nutrition first results – food and nutrients, 2011–12 [Internet]. 4364.0.55.007, 178. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0072011-12?OpenDocument.Google Scholar
Ridder, K, Bel, S, Brocatus, L, Cuypers, K, Lebacq, T, Moyersoen, I, Ost, C, & Teppers, E Enquête de Consommation Alimentaire 2014–2015 Rapport 4: La Consommation Alimentaire. [Internet]. 2016. Available from: https://fcs.wiv-isp.be/nl/Gedeelde-documenten/FRANS/Rapport4/Resume_rapport_4_finaal_finaal.pdf.Google Scholar
Ministry of Health Chile (2021) Chile National Food Consumption Survey 2010–2011. Santiago, Chile: Ministry of Health Chile.Google Scholar
Trolle, E, Gondolf, UH, Ege, M, Kørup, K, Ygil, KH & Christensen, T (2013) Danskernes kostvaner Spæd- og småbørn 2006–2007 [Internet]. Available from: http://orbit.dtu.dk/files/84054319/Rapport_Danskernes_kostvaner_sp_d_og_sm_b_rn_rev_12_12_13_1_.pdf.CrossRefGoogle Scholar
Pitsi, T, Zilmer, M, Vaask, S, et al. (2015) Eesti toitumis- ja liikumissoovitused [Internet]. Available from: https://intra.tai.ee/images/prints/documents/149019033869_eesti toitumis- ja liikumissoovitused.pdf.Google Scholar
Kyttälä, P, Ovaskainen, M, Kronberg-Kippilä, C, et al. (2008) The diet of Finnish preschoolers (in Finnish, abstract in English) [Internet]. Available from: http://www.julkari.fi/bitstream/handle/10024/78163/2008b32.pdf.Google Scholar
Agence nationale de sécurité sanitaire de l’alimentation de, travail l’environnement et du (2017) Étude Individuelle Nationale des Consommations Alimentaires 3 (INCA3) (2014–2015) Rapport [Internet]. Available from: https://www.anses.fr/fr/system/files/NUT2014SA0234Ra.pdf.Google Scholar
Þórsdóttir, I, Þórisdóttir, ÁV & Pálsson, GI (2008) The diet of Icelandic infants: results from a research on infants’ diet, growth and iron status 2005–2007 [Internet]. Available from: http://www.landlaeknir.is/servlet/file/store93/item11592/Ungbarnaskyrsla.pdf.Google Scholar
Gunnarsdóttir, I, Eysteinsdóttir, T, Þórsdóttir, T (2008) Hvað borða íslensk börn á leikskólaaldri? Könnun _a mataræði 3ja og 5 á ra barna [Internet]. Available from: http://www.landlaeknir.is/servlet/file/store93/item14897/3ja_og_5_ara_skyrsla_181208.pdf.Google Scholar
Irish Universities Nutrition Alliance (2012) National Pre-School Nutrition Survey 2010–11 [Internet]. Available from: https://irp-cdn.multiscreensite.com/46a7ad27/files/uploaded/The National Pre-School Nutrition Survey Summary Report June 2012.pdf.Google Scholar
Israel Ministry of Health (2017) MABAT Kids – The National Survey on the Health and Nutrition Status of Children Ages 2–11 in Israel: 2015–2016, 79. Available from: https://www.health.gov.il/publicationsfiles/mabat_kids2_11_2015-2016.pdf.Google Scholar
Sette, S, Le Donne, C, Piccinelli, R, et al. (2011) The third Italian National Food Consumption Survey, INRAN-SCAI 2005-06 – Part 1: nutrient intakes in Italy. Nutr Metab Cardiovasc Dis 21, 922932.CrossRefGoogle ScholarPubMed
Sánchez-Pimienta, TG, Batis, C, Lutter, CK, et al. (2016) Sugar-sweetened beverages are the main sources of added sugar intake in the Mexican population. J Nutr 146, 1888S1896S.CrossRefGoogle ScholarPubMed
National Institute for Public Health and the Environment Ministry of Health Welfare and Sport (2019) Food consumption survey 2012–2016 [Internet]. Available from: https://www.rivm.nl/bibliotheek/rapporten/2020-0083.pdf.Google Scholar
Helsedirektoratet (2009) Spedkost – 12 måneder 2006–2007 [Internet]. Available from: https://www.helsedirektoratet.no/rapporter/spedkost-og-smabarnskost-landsomfattende-kostholdsundersokelser/Spedkost 12 måneder – landsomfattende kostholdundersøkelse 2007-2008.pdf/_/attachment/inline/1544ff4a-db55-4db1-b24b-f3efa19dd26b:20d97036e4aa5f5c92.Google Scholar
Helsedirektoratet (2009) Småbarnskost – 2 år Landsomfattende kostholdsundersøkelse blant 2 år gamle barn. Available from: åhttps://www.helsedirektoratet.no/rapporter/spedkost-og-smabarnskost-landsomfattende-kostholdsundersokelser/Småbarnskost 2007 – landsomfattende kostholdsundersøkelse blant 2 år gamle barn.pdf/_/attachment/inline/54fa23d7-f5cc-4ce8-bc21-41418c21a126:5dee89c.Google Scholar
Public Health England, Food Standards Agency (2018) National Diet and Nutrition Survey: results from Years 1–4 (combined) of the Rolling Programme [Internet]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/699241/NDNS_results_years_7_and_8.pdf.Google Scholar
Bailey, RL, Fulgoni, VL, Cowan, AE, et al. (2018) Sources of added sugars in young children, adolescents, and adults with low and high intakes of added sugars. Nutrients 10, 102.CrossRefGoogle ScholarPubMed
Herrick, KA, Fryar, CD, Hamner, HC, et al. (2020) Added sugars intake among US infants and toddlers. J Acad Nutr Diet 120, 2332.CrossRefGoogle ScholarPubMed
US Department of Agriculture (2020) Nutrient intakes from food: mean amounts consumed per individual, by gender and age, what we eat in America, NHANES 2017–2018. Available from: www.ars.usda.gov/nea/bhnrc/fsrg.Google Scholar
Souza, RAG, Yokoo, EM, Sichieri, R, et al. (2015) Energy and macronutrient intakes in Brazil: results of the first nationwide individual dietary survey. Public Health Nutr 18, 30863095.CrossRefGoogle ScholarPubMed
Statistics Canada (2018) Canadian community health survey – nutrition. Ottawa: Health Canada.Google Scholar
Afeiche, MC, Koyratty, BNS, Wang, D, et al. (2018) Intakes and sources of total and added sugars among 4 to 13-year-old children in China, Mexico and the United States. Pediatr Obes 13, 204212.CrossRefGoogle ScholarPubMed
Pedersen, AN, Christensen, T, Matthiessen, J, Knudsen, VK, Sørensen, MR, Biltoft-Jensen, AP, Fagt, S (2015) Danskernes kostvaner 2011–2013 [Internet]. Available from: http://www.food.dtu.dk/-/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2015/Rapport_Danskernes-Kostvaner-2011-2013.ashx?la=da.Google Scholar
Mensink, GBM, Helmut, H, Stahl, A, Richer, A & Vohmann, C (2007) Die aktuelle Nährstoffzufuhr von Kindern und Jugendlichen in Deutschland – Ergebnisse aus EsKiMo, Ernährungs Umschau [Internet]. Available from: https://www.ernaehrungs-umschau.de/fileadmin/Ernaehrungs-Umschau/pdfs/pdf_2007/11_07/EU11_636_646.qxd.pdf.Google Scholar
Gunnarsdottir, I, Helgadottir, H, Thorisdottir, B, et al. (2013) Diet of six-year-old Icelandic children – National dietary survey 2011–2012. Laeknabladid Laeknafelag Islands; 99, 1723.Google ScholarPubMed
Unit for Nutrition Research (2006) Iceland dietary survey of 9 and 15 year old children and adolescents 2003–2004 [Internet]. Available from: http://www.landlaeknir.is/servlet/file/store93/item11594/hvad_borda_isl_born_og_ungl.pdf.Google Scholar
International Life Sciences Institute India (2019) Consumption levels of sugar among rural and urban population in India [Internet]. Available from: http://www.ilsi-india.org/ (Accessed December 2020).Google Scholar
Irish Universities Nutrition Alliance (2019) National Children’s Food Consumption Survey II (NCFS II) 2017–2018 [Internet]. Available from: rp-cdn.multiscreensite.com/46a7ad27/files/uploaded/The National Children%27s Food Survey II Summary Report - September 2019.pdf.Google Scholar
National Center for Disease Control Israel National Survey on the Subject of Health and Nutrition Status in children aged 2–11 in Israel [Internet]. Available from: https://www.health.gov.il/publicationsfiles/mabat_kids2_11_2015-2016.pdf.Google Scholar
Ministry of Health (2003) 2002 National Children’s Nutrition Survey (CNS02) [Internet]. Wellington. Available from: https://www.health.govt.nz/system/files/documents/publications/nzfoodnzchildren.pdf.Google Scholar
FHI (2017) UNGKOST 3 Landsomfattende kostholdsundersøkelse blant 4-åringer i Norge, 2016 [Internet]. Available from: https://www.fhi.no/globalassets/dokumenterfiler/rapporter/2016/rapport-ungkost-3-landsomfattende-kostholdsundersokelse-blant-4-aringer-i-norge-2016.pdf.Google Scholar
FHI (2016) UNGKOST 3 Landsomfattende kostholdsundersøkelse blant elever i 4. -og 8. klasse i Norge, 2015 [Internet]. Available from: https://www.fhi.no/globalassets/dokumenterfiler/rapporter/2016/ungkost-rapport-24.06.16.pdf.Google Scholar
IAN-AF (2017) National Food and Physical Activity Survey (IAN-AF) 2015–2016. ANEXO 2 – INGESTÃO NUTRICIONAL [Internet]. Available from: https://ian-af.up.pt/en/consulta-de-dados?shs_term_node_tid_depth=All&field_indicador_tid=All&field_estratificacao_tid=All%0A (accessed December 2020).Google Scholar
FEN (2014) Ingesta, perfil y fuentes de energía en la población española: Resultados obtenidos del estudio científico ANIBES. Available from: http://www.fen.org.es/anibes/archivos/documentos/ANIBES_numero_3.pdf.Google Scholar
Ruiz, E, Rodriguez, P, Valero, T, et al. (2017) Dietary intake of individual (free and intrinsic) sugars and food sources in the Spanish population: findings from the ANIBES study. Nutrients 9, 275.CrossRefGoogle ScholarPubMed
Roberts, C, Steer, T, Maplethorpe, N, et al. (2018) National diet and nutrition survey: results from Years 7 and 8 (combined) of the Rolling Programme (2014/2015–2015/2016). London: Public Health England.Google Scholar
d’Andorra, G, de Salut, M & i Família, BS (2007) Evaluation of the nutritional status of the Andorran population [Internet]. Available from: http://www.salut.ad/images/microsites/AvaluacioNutricional_04-05/index.html (accessed December 2020).Google Scholar
Langlois, K, Garriguet, D, Gonzalez, A, et al. (2019) Change in total sugars consumption among Canadian children and adults. Health Rep 30, 1019.Google ScholarPubMed
Perrar, I, Schadow, AM, Schmitting, S, et al. (2020) Time and age trends in free sugar intake from food groups among children and adolescents between 1985 and 2016. Nutrients 12, 20.CrossRefGoogle Scholar
Irish Universities Nutrition Alliance (IUNA) (2007) National Teens’ Food Survey 2005–2006. [Internet]. Available from: https://irp-cdn.multiscreensite.com/46a7ad27/files/uploaded/The National Teens%27 Food Survey %282005-2006%29.pdf.Google Scholar
Joyce, T, Mccarthy, SN & Gibney, MJ (2008) Relationship between energy from added sugars and frequency of added sugars intake in Irish children, teenagers and adults. Br J Nutr 99, 11171126.CrossRefGoogle ScholarPubMed
Israel Center for Disease Control (2017) Mabat Youth Second National Health and Nutrition Survey of 7th-12th grade students 2015–2016. Publication 373 [Internet]. Available from: https://health.gov.il/publicationsfiles/mabat_kids2_11_2015-2016-eng.pdf%0A%0A.Google Scholar
Kibblewhite, R, Nettleton, A, McLean, R, et al. (2017) Estimating free and added sugar intakes in New Zealand. Nutrients 9, 1292.CrossRefGoogle ScholarPubMed
University of Otago and Ministry of Health (2011) A focus on nutrition: key findings of the 2008/09 New Zealand Adult Nutrition Survey. Wellington: Ministry of Health.Google Scholar
Mis, NF, Kobe, H, Štimec, M. (2012) Dietary intake of macro- and micronutrients in Slovenian adolescents: comparison with reference values. Ann Nutr Metab 61, 305313.Google Scholar
Rust, P, Hasenegger, V & König, J (2017) Österreichischer Ernährungsbericht [Internet]. Available from: https://broschuerenservice.sozialministerium.at/Home/Download?publicationId=528%0A%0A (accessed December 2020).Google Scholar
Valsta, L, Kaartinen, N, Tapanainen, H, Männistö, S & Sääksjärvi, K (2018) Ravitsemus Suomessa – FinRavinto 2017 -tutkimus. Terveyden ja hyvinvoinnin laitos (THL). Raportti 12/2018, 239 sivua [Internet]. Available from: https://www.julkari.fi/bitstream/handle/10024/137433/URN_ISBN_978-952-343-238-3.pdf?sequence=1&isAllowed=y%0A%0A%0A (accessed December 2020).Google Scholar
Max Rubner-Institut (2008) Nationale Verzehrsstudie II – Ergebnisbericht Teil 1; Max Rubner-Institut Karlsruhe: Karlsruhe [Internet]. Available from: https://www.bmel.de/SharedDocs/Downloads/Ernaehrung/NVS_ErgebnisberichtTeil2.pdf?__blob=publicationFile%0A%0A (accessed December 2020).Google Scholar
Cust, AE, Skilton, MR, van Bakel, MME, et al. (2009) Total dietary carbohydrate, sugar, starch and fibre intakes in the European prospective investigation into cancer and nutrition. Eur J Clin Nutr 63, S37S60.CrossRefGoogle ScholarPubMed
Eszter, SN, Márta, B, Éva, I, et al. (2017) Országos táplálkozás és tápláltsági állapot vizsgálat – OTÁP2014. II. A magyar lakosság energia-és makrotápanyag-bevitele. Orv Hetil 158, 587597.Google Scholar
Directorate of Health (2011) Hvað borða Íslendingar? Könnun á mataræði Íslendinga 2010–2011 Helstu niðurstöður 2010–2011. Helstu niðurstöður [Internet]. Available from: ðhttp://www.landlaeknir.is/servlet/file/store93/item14901/Hvað borða Íslendingar_april 2012.pdf.Google Scholar
Irish Universities Nutrition Alliance (IUNA) (2011) National adult nutrition survey: food and nutrient intakes, physical measurements, physical activity patterns and food choice motives. Summary Report. [Internet]. Available from: https://irp-cdn.multiscreensite.com/46a7ad27/files/uploaded/The%20National%20Adult%20Nutri.Google Scholar
Walton, J, Kehoe, L, McNulty, BA, et al. (2017) Intakes and sources of dietary sugars in a representative sample of Irish adults (18–90y). Proc Nutr Soc [Internet]. Cambridge University Press; [cited 2021 Jan 4]; 76, E65. Available from: https://www.cambridge.org/core/product/identifier/S0029665117001380/type/journal_article.CrossRefGoogle Scholar
Israel Center for Disease Control (2019) Rav Mabat Adult Second National Health and Nutrition Survey 2014–2016. Publication 383 [Internet]. Available from: https://health.gov.il/publicationsfiles/mabat_adults_2014_2016_383_en.pdf.Google Scholar
Barzda, A, Bartkeviciute, R, Baltusyte, I, Stukas, R & Bartkeviciute, S (2016) Suaugusiu˛ ir pagyvenusiu˛ Lietuvos gyventoju˛ faktin ˙ es mitybos ir mitybos ı˛proˇciu˛ tyrimas. Visuom. Sveik 72, 8594. [Internet]. Available from: http://www.hi.lt/uploads/pdf/visuomenes sveikata/2016.01.72/VS 2016 1(72) ORIG Mitybos iprociai.pdf %0A%0A.Google Scholar
Helsedirektoratet (2012) Norkost 3 En landsomfattende kostholdsundersøkelse blant menn og kvinner i Norge I alderen 18-70ar, 2010–11 [Internet]. Available from: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/301/Norkost-3-en-landsomfattende-kostholdsundersokelse-blant-menn-og-kvinner-i-norge-i-alderen-18-70-ar-2010-11-IS-2000.pdf.Google Scholar
Chatelan, A, Gaillard, P, Kruseman, M, et al. (2019) Total, added, and free sugar consumption and adherence to guidelines in Switzerland: results from the First National Nutrition Survey menuCH. Nutrients [Internet]. MDPI AG; [cited 2020 Jun 10]; 11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/31109151.CrossRefGoogle Scholar
Heuer, T (2017) Estimation of “free” sugar intake in Germany based on the data of the German National Nutrition Survey II. Available from: https://www.openagrar.de/receive/openagrar_mods_00030594.Google Scholar
De la Cruz-Góngora, V, Martínez-Tapia, B, Cuevas-Nasu, L, et al. (2017) Dietary intake and adequacy of energy and nutrients in Mexican older adults: Results from two National Health and Nutrition Surveys. Salud Publica Mex 59, 285298.CrossRefGoogle Scholar
Azaïs-Braesco, V, Sluik, D, Maillot, M, et al. (2017) A review of total & added sugar intakes and dietary sources in Europe. Nutr J BioMed Central Ltd. 16, 6.Google ScholarPubMed
IUNA (2019) National Children’s Food Survey II: summary report [Internet], 144. Available from: www.iuna.net.Google Scholar
Hayes, M (2019) How many countries are there in the world? [Internet]. WorldAtlas, [cited 2020 Jun 15]. Available from: https://www.worldatlas.com/articles/how-many-countries-are-in-the-world.html.Google Scholar
Micha, R, Coates, J, Leclercq, C, et al. (2018) Global dietary surveillance: data gaps and challenges. Food Nutr Bull 39, 175205.CrossRefGoogle ScholarPubMed
Louie, JCY, Moshtaghian, H, Boylan, S, et al. (2015) A systematic methodology to estimate added sugar content of foods. Eur J Clin Nutr 69, 154161.CrossRefGoogle ScholarPubMed
Swan, GE, Powell, NA, Knowles, BL, et al. (2018) A definition of free sugars for the UK. Public Health Nutr 21, 16361638.CrossRefGoogle ScholarPubMed
Amoutzopoulos, B, Page, P, Steer, T, et al. (2020) Free and added sugar consumption and adherence to guidelines: the UK national diet and nutrition survey (2014/15–2015/16). Nutrients MDPI AG, 12, 393.CrossRefGoogle ScholarPubMed
Amoutzopoulos, B, Steer, T, Roberts, C, et al. (2018) A disaggregation methodology to estimate intake of added sugars and free sugars: an illustration from the UK national diet and nutrition survey. Nutrients MDPI AG; 10, 1177.CrossRefGoogle ScholarPubMed
Davy, B & Jahren, H (2016) New markers of dietary added sugar intake. Curr Opin Clin Nutr Metab Care 19, 282288.CrossRefGoogle ScholarPubMed
Abreu, TC, Hulshof, PJM, Boshuizen, HC, et al. (2020) Validity coefficient of repeated measurements of urinary marker of sugar intake is comparable to urinary nitrogen as marker of protein intake in free-living subjects. Cancer Epidemiol Biomarkers Prev 30, 193202.CrossRefGoogle ScholarPubMed
Mela, DJ (2020) A proposed simple method for objectively quantifying free sugars in foods and beverages. Eur J Clin Nutr [Internet] 74, 13661368. doi: 10.1038/s41430-020-0575-x CrossRefGoogle ScholarPubMed
Louie, JCY (2020) Objective biomarkers for total added sugar intake – are we on a wild goose chase? Adv Nutr 11, 14291436.CrossRefGoogle ScholarPubMed
Capacci, S, Allais, O, Bonnet, C, et al. (2019) The impact of the French soda tax on prices and purchases. An ex post evaluation. PLoS One 14, e0223196.CrossRefGoogle ScholarPubMed
World Health Organisation (2017) Reformulation measures for foods and beverages – European Health Information Gateway [Internet], [cited 2020 Jun 15]. Available from: https://gateway.euro.who.int/en/indicators/gnpr_survey_17-reformulation-measures-for-foods-and-beverages/.Google Scholar
Public Health England (2018) Sugar reduction and wider reformulation programme: report on progress towards the first 5 % reduction and next steps May 2018 About Public Heath England [Internet]. Available from: www.facebook.com/PublicHealthEngland.Google Scholar
Wright, A, Smith, KE & Hellowell, M (2017) Policy lessons from health taxes: a systematic review of empirical studies. BMC Public Health 17, 583.CrossRefGoogle ScholarPubMed
Redondo, M, Hernández-Aguado, I & Lumbreras, B (2018) The impact of the tax on sweetened beverages: a systematic review. Am J Clin Nutr 108, 548563.CrossRefGoogle ScholarPubMed
Briggs, ADM, Mytton, OT, Kehlbacher, A, et al. (2013) Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ 347, f6189.CrossRefGoogle ScholarPubMed
Blakely, T, Nghiem, N, Genc, M, et al. (2020) Modelling the health impact of food taxes and subsidies with price elasticities: the case for additional scaling of food consumption using the total food expenditure elasticity. PLoS One 15, e0230506.CrossRefGoogle ScholarPubMed
Ma, Y, He, FJ, Yin, Y, et al. (2016) Gradual reduction of sugar in soft drinks without substitution as a strategy to reduce overweight, obesity, and type 2 diabetes: a modelling study. Lancet Diabetes Endocrinol 4, 105114.CrossRefGoogle ScholarPubMed
Amies-Cull, B, Briggs, ADM & Scarborough, P (2019) Estimating the potential impact of the UK government’s sugar reduction programme on child and adult health: modelling study. BMJ 365.Google ScholarPubMed
Center for Food Safety and Applied Nutrition (2018) Labeling & nutrition – changes to the nutrition facts label. Washington DC: United States Department of Health & Human Services.Google Scholar
U.S. Department of Agriculture & Global Agricultural Information Network (2020) Implementation of the New Mexican Regulation for front-of-package nutrition label.Google Scholar
Tierney, M, Gallagher, AM, Giotis, ES, et al. (2017) An online survey on consumer knowledge and understanding of added sugars. Nutrients 9, 37.CrossRefGoogle ScholarPubMed
Tang, Q, Lin, Q, Yang, Q, et al. (2020) Knowledge, attitude, and practice of adolescent parents on free sugar and influencing factors about recognition. Int J Environ Res Public Health 17, 4003.CrossRefGoogle ScholarPubMed
Figure 0

Table 1. Definitions of sugars as used in dietary recommendations

Figure 1

Table 2. Examples of dietary reference values for sugars globally

Figure 2

Table 3. Energy and sugar intake of infants and young children (<4 years)

Figure 3

Table 4. Energy and sugar intake of children (4–12 years)

Figure 4

Table 5. Energy and sugar intake of adolescents (˜13–18 years)

Figure 5

Table 6. Energy and sugar intake of adults (19–64 years)

Figure 6

Table 7. Energy and sugar intake of older adults (65+ years)