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Supplement

Choose Beverages and Foods to Moderate Your Intake of Sugars: The 2000 Dietary Guidelines for Americans—What’s All the Fuss About?¹

University of Vermont, Burlington, VT and ^* Department of Nutrition and Food Sciences, University of Vermont, Burlington, VT

²To whom correspondence should be addressed. E-mail: rachel.johnson{at}uvm.edu.

	ABSTRACT

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
As part of the 2000 Dietary Guidelines for Americans, the public is advised to choose beverages and foods to moderate their intake of sugars. The term sugars is conventionally used to describe the mono- and disaccharides. However, the Dietary Guidelines for Americans distinguish between added sugars and other sources of carbohydrates. The concept of added sugars provides consumers with useful information, especially if they are trying to limit excessive use of caloric sweeteners. Added sugars are defined as sugars that are eaten separately at the table or used as ingredients in processed or prepared foods. Consumption of added sugars has increased steadily as documented by both food supply data and nationwide food consumption survey data. The largest source of added sugars in the U.S. diet is nondiet soft drinks, accounting for one third of total intake. Diets high in sugars have been associated with various health problems, including dental caries, dyslipidemias, obesity, bone loss and fractures, and poor diet quality. Research gaps are identified.

KEY WORDS: • added sugars • soft drinks • dietary guidelines

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
The Dietary Guidelines for Americans form the foundation of U.S. federal nutrition policy. Every day, the guidelines directly affect millions of Americans who participate in government food and nutrition programs such as Food Stamps, USDA school breakfast and lunch programs and the Special Supplemental Program for Women, Infants, and Children (1) . President Clinton released the 2000 edition of the Dietary Guidelines in May 2000. Ten guidelines help Americans answer the question: what should I eat to be healthy? As part of the guidelines, Americans are advised to choose beverages and foods to moderate their intake of sugars. The aim of this paper is to put the sugar guideline into context by presenting a framework for the classification of sugars, providing data on U.S. trends in sugar consumption, discussing some of the health concerns related to sugar consumption and outlining areas of needed research on sugars and carbohydrates.

	Classification of sugars

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
The term "sugars" is conventionally used to describe the mono- and disaccharides (2) . The monosaccharides include glucose, galactose and fructose, whereas the disaccharides include sucrose, lactose and trehalose. Many commonly used sweeteners also contain trisaccharides and higher saccharides, such as corn-derived sweeteners. For example, only 33% or less of the carbohydrates in some corn syrups are mono- and disaccharides; the remaining 67% or more are trisaccharides and higher saccharides (3) .

The text of the 2000 dietary guideline for sugars distinguishes between added sugars and other sources of carbohydrates (4) . Added sugars are defined as sugars that are eaten separately at the table or used as ingredients in processed or prepared foods, such as cakes and cookies, soft drinks and ice cream. Specifically, added sugars include white sugar, brown sugar, raw sugar, corn syrup, corn syrup solids, high fructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, liquid fructose, honey, molasses, anhydrous dextrose and crystal dextrose. Added sugars do not include naturally occurring sugars such as lactose in milk or fructose in fruits (5) . The sugar guideline clarifies that physiologically the body cannot tell the difference between added and naturally occurring sugars. However, the term added sugars helps consumers identify food and beverages that, for the most part, provide energy but are poor sources of micronutrients and phytochemicals.

	Consumption of added sugars in the United States

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
Consumption of added sugars in the United States has increased steadily as documented by both food supply data and nationwide food consumption survey data. According to U.S. Food Supply Data, per capita consumption of added sugars by Americans went from 27 tsp/(person · d) in 1970 to 32 tsp/(person · d) in 1996, an increase of 23% (6) . These data are adjusted for spoilage, other losses accumulated throughout the marketing system and home waste losses. From 1970 to 1996, the supply of honey and edible syrups remained fairly constant, cane and beet sugar supplies declined and supplies of corn sweeteners rose dramatically (Fig. 1 ).

View larger version (17K): [in this window] [in a new window]   Figure 1. Food supply data: food supply intake of added sugars, 1970–1996. The recommended upper limit for a 2200-kcal diet is 12 tsp/d.

	Quantification of intake of added sugars

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
Unlike the dietary guidelines for total and saturated fat, sodium and alcohol, the guideline for sugar does not quantify how much added sugar constitutes moderation. However, the Food Guide Pyramid (the most widely distributed and best-recognized nutrition education device ever produced in the United States) offers some direction. The pyramid advises consumers to use added sugars sparingly (8) . Amounts of added sugars that could be included in a diet for three different energy levels are determined after the number of servings of each of the food groups that are required to meet nutrient adequacy goals are set (Table 1 ). If choices in each food category are restricted to their lowest fat forms with no added sugars (for example skim milk in the dairy category), the major food groups alone would provide 1200–2000 kcal (8) . The difference between these energy levels and a person’s energy requirements formed the foundation for quantifying the amounts of fats and sugars that could be added to the diet with the level of total fat held at 30% of energy. Added sugars account for 6% of total energy at 1600 kcal, 8.7% at 2200 kcal and 10.3% at 2800 kcal (Table 1) . Because it is more difficult to achieve micronutrient adequacy at lower energy intakes and because the amount of fat was constrained, the lower energy level (1600 kcal) has a proportionately lower recommendation for added sugars (7) . With the most currently available U.S. consumption data putting mean added intake of sugars at 20.5 tsp (accounting for 15.8% of total energy intake), it is clear that the intake of sugars is substantially higher than the Food Guide Pyramid recommendations.

	Sources of added sugars in the U.S. diet

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

View larger version (21K): [in this window] [in a new window]   Figure 2. Sources of added sugars in the U.S. diet. From Guthrie and Morton (10) .

	Sugars and health

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
Diets high in sugars have been associated with various health problems, such as dental caries, dyslipidemias, obesity, bone loss and fractures, and poor diet quality.

Dental caries.

Sugars play a significant role in the development of dental caries (11) . Caries affect 3–6% of the general pediatric population and are associated with frequent, long-term use of baby bottles containing fermentable sugars and at-will breast-feeding (12) . Mean decayed, missing, filled scores of 5- and 8-y-old children who consumed sweet snacks between meals >5 times/d were significantly higher than scores of children with a lower reported sweet snack consumption (13) . Root caries in middle-aged and elderly adults have been shown to be associated with sucrose consumption (14) .

Dental caries are a disease of multifactorial causation. Thus, it is difficult to rationalize the role of sugar and dental caries as simple cause and effect. Caries occurrence is confounded by frequency of meals and snacks, oral hygiene, fluoride supplementation, and fluoride toothpaste (11) . Caries have declined in many industrialized countries and in areas with water fluoridation despite relatively high sugar consumption (15) . However, in recognition that not all people have fluoridated water or access to fluoride supplements and toothpastes, the WHO recommended in 1989 that for optimal dental health intake of extrinsic (added) sugars should be <10% of total energy intake (16) .

Dyslipidemias.

The 2000 Dietary Guidelines recommend that Americans choose a diet that is low in saturated fat and cholesterol and moderate in total fat (4) . This recommendation was based on strong scientific evidence that high intakes of saturated fat and cholesterol contribute to the development of coronary heart disease. The change from recommending a diet low in total fat in the 1995 guidelines to a diet moderate in total fat in 2000 was not accompanied by a change in the numerical recommendation (30%) for the maximum percentage of energy provided by fat (1) . In part, the change represented a growing view that recommendations for diets low in total fat (defined as 20% of energy from fat) and high in carbohydrate precipitate metabolic changes in the lipoprotein profile that result in atherogenic dyslipidemia. The profile is characterized by elevated triacylglycerides, small, dense LDL and low concentrations of HDL (17 ,18) .

High carbohydrate diets, especially diets high in sugars (19) , have been associated with cardiovascular disease (20) . Parks and Hellerstein (19) published an exhaustive review of carbohydrate-induced hypertriglyceridemia (HPTG) and concluded that if the carbohydrate content of a high carbohydrate diet is made up primarily of monosaccharides, particularly fructose, the ensuing HPTG is more extreme than if oligo- and polysaccharides are consumed. Purified diets, whether based on starch or monosaccharides, induce HPTG more readily than do diets higher in fiber in which most of the carbohydrate is derived from unprocessed whole foods (19) .

Kant (21) used the Third National Health and Nutrition Examination Survey (NHANES III) to examine the effect of consumption of energy-dense, nutrient-poor (EDNP) foods on lipid profiles. EDNP foods included visible fats, nutritive sweeteners and sweetened beverages, desserts and snacks. HDL cholesterol concentration was inversely related and serum homocysteine concentration was positively related to EDNP food intake. Both serum homocysteine and HDL cholesterol concentration are independent risk factors for cardiovascular disease.

	Obesity

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
The increasing prevalence of obesity has been referred to as a pandemic or a worldwide disease (22) . According to NHANES III data (1988–1994), over half of American adults are overweight or obese. The latest findings from the 1999 NHANES showed that more and more children and teens are overweight, continuing the pattern the survey documented over the past two decades when the number of overweight children and adolescents nearly doubled (Fig. 3 ) (23) . Thirteen percent of children aged 6–11 y are overweight, up from 11% in the NHANES III survey. The number of overweight teenagers aged 12–19 y increased from 11 to 14% in the same period.

View larger version (16K): [in this window] [in a new window]   Figure 3. Prevalence of overweight among children and adolescents ages 6–19 y from 1963 to 1999. Data exclude pregnant women beginning with 1971–1974. Preganacy status not available for 1963–1965 and 1966–1970. Data for 1963–1965 are for children 6–11 y old; data for 1966–1970 are for adolescents 12–17 y old, not 12–19 y old. Source: National Center for Health Statistics: National Health Examination Survey and National Health and Nutrition Examination Survey.

Cavadini and colleagues (26) examined U.S. adolescent food intake trends from 1965 to 1996 and found notable changes in beverage consumption patterns. Soft drink intake increased by 187% for boys and 123% for girls, fruit drink (<10% fruit juice) intake increased by 112% for boys and 65% for girls, and milk intake declined by 37% for boys and 43% for girls. Energy intake has been shown to be positively associated with children’s and adolescents’ consumption of nondiet soft drinks. Mean adjusted energy intake was 1830 kcal/d for school-aged children (ages 6–12 y) who did not consume soft drinks compared with 2018 kcal/d for children in this age group who consumed an average of 9 oz/d (270 mL/d) or more of soft drinks. For adolescents (ages 13–18 y), nonconsumers of soft drinks consumed 1984 kcal/d in contrast to 2604 kcal/d for those who consumed 26 oz/d (770 mL/d) or more of soft drinks (27) . Troiano and colleagues (28) found that soft drinks contributed a significantly higher proportion of daily energy intake for overweight than nonoverweight children and adolescents. Obesity prevalence in adults has been shown to differ between those who did and did not consume soft drinks. Among those drinking soft drinks, 16% of men and 24% of women were obese, whereas 12% of men and 18% of women who did not drink soft drinks were obese (29) . Kant (21) demonstrated a positive association between EDNP food and beverages and energy intakes.

Ludwig and colleagues (30) examined the relationship between consumption of sugar-sweetened drinks and childhood obesity. They followed 548 ethnically diverse Massachusetts children (aged 11–17 y) for 19 mo. They concluded that for each additional serving of sugars-sweetened drink consumed, the odds of becoming obese increased by 60%. Sugar-sweetened drinks, such as soft drinks, have been suggested to promote obesity because compensation at subsequent meals for energy consumed in the form of a liquid could be less complete than for energy consumed in the form of solid food (31) .

Published reports disagree about whether a direct link exists between the trend toward higher intake of sugars and increased rates of obesity. The lack of association in some studies may be due in part to the pervasive problem of underreporting of food intake, which is known to occur with dietary surveys (32) . Underreporting is more prevalent and severe by obese adolescents and adults than by their lean counterparts (32) . In addition, foods high in added sugars are selectively underreported (33) . Thus, it can be difficult to make conclusions about associations between sugars intake and body mass index by using self-reported dietary data.

	Bone health

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
Calcium intake is critical throughout life to promote optimal bone health. Failure to meet calcium requirements during childhood and early adulthood can impede a person’s ability to achieve maximal skeletal growth and bone mineralization, which can increase the risk of developing osteoporosis later in life (34) . Maximizing peak bone mass is especially important during adolescence, when the rate of calcium accretion is the highest (35) . Jackman and colleagues (36) studied adolescent females and concluded that daily calcium intake should not be < 1300 mg/d to achieve maximal calcium retention. Beginning at age 11 y, median dietary calcium intakes in the United States are considerably less than the Adequate Intakes suggested by the Dietary Reference Intakes (Fig. 4 ) (37) .

View larger version (19K): [in this window] [in a new window]   Figure 4. Daily calcium intakes for females as a percentage of the Dietary Reference Intakes. Source: 1994–1996 Continuing Survey of Food Intakes of Individuals. From Anderson (37) .

View larger version (14K): [in this window] [in a new window]   Figure 5. Trends in milk and soft drink consumption. From Gerrior et al. (39) .

	Diet quality

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
Bowman (43) examined data from the USDA’s 1994–1996 CSFII, a nationally representative food consumption survey, to assess the effect of added sugars on essential nutrients in the U.S. diet. The sample (14,709 subjects) was divided into three groups on the basis of the percentage of energy consumed from added sugars: group 1 (5058 subjects) consumed <10% of total energy from added sugars; group 2 (4488 subjects), between 10 and 18%; and group 3 (5158 subjects), >18%. Group 3 (mean percentage of energy from added sugars 26.7%) had the lowest mean absolute intakes of all the micronutrients, especially vitamins A, C, and B-12, folate, calcium, phosphorus, magnesium and iron. A lower percentage of people in group 3 met their Recommended Dietary Allowances (RDA) for many micronutrients. Of the people in group 3, 60% did not meet their 1989 RDA for vitamins A, B-6, and E, calcium, magnesium and zinc. In addition, group 3 had lower intakes of grains, fruits, vegetables, and meat, poultry and fish than did groups 1 and 2. Group 3 also consumed more soft drinks, fruit drinks, punches and sugar-sweetened drinks, cakes, cookies, and grain-based pastries, milk desserts and candies than did the other groups.

Forshee and Storey (44) used the same data set as Bowman (1994–1996 CSFII) to examine the role of added sugars in the diet quality of children and adolescents (ages 6–19 y). A multivariate regression model was used to predict the effect of added sugars on the consumption of servings of the major food groups and the percentage of the RDA for selected vitamins and minerals. The independent variables (added sugars, carbohydrates minus added sugars, protein, fat, alcohol, age and sex) were selected to represent all sources of total energy intake as well as to control for the effect of age and sex on the dependent variables. Added sugars were positively associated with servings of grains and lean meat as well as the percentage of the RDA of vitamin C, iron and folate. Added sugars were negatively associated with servings of vegetables, fruit and dairy as well as the percentage of the RDA of vitamin A and calcium.

Sugar-sweetened beverages account for 47% of the total added sugars in the U.S. diet (10) . Beverage choices can have a meaningful effect on nutrient intakes. Ballew and colleagues (45) examined beverage choices of children and adolescents by using the 1994–1996 CSFII. They found that juice (100% fruit juice) was positively associated with achieving recommended intakes of vitamin C and folate. In addition, milk consumption was positively associated with the likelihood of achieving recommended intakes of vitamins A and B-12, folate, calcium and magnesium. Johnson and colleagues (46) demonstrated in an analysis of the CSFII survey that only children who consumed milk at the noon meal met their calcium requirements. On the other hand, soft drink consumption has been shown to have a negative effect on children’s micronutrient intake. Harnack and colleagues (27) determined that children who were high consumers of soft drinks had lower intakes of riboflavin, folate, vitamins A and C, calcium and phosphorus. Ballew and colleagues (45) found that soft drinks were negatively associated with vitamin A, calcium and magnesium intakes. Using 1990–1991 cross-sectional data, Guthrie (47) found that women whose diets met their RDA for calcium consumed significantly more milk products, fruit and grains but fewer nondiet soft drinks than did women who did not meet their calcium recommendations.

The literature cited in this paper demonstrates that at high intake levels of added sugars, especially of sugar-sweetened beverages, a significant deterioration in nutrient adequacy and overall diet quality occurs. At high levels of intake, it becomes very difficult to meet micronutrient requirements from food alone and also meet recommendations to consume a variety of foods from the major food groups while remaining in energy balance.

	Research needs

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 
There are a number of information gaps identified in this review. Many of these were identified by the 2000 Dietary Guidelines Advisory Committee (48) . The discussion below identifies these gaps.

Improved nutrient databases are needed for added sugars. To date, only the USDA Pyramid Servings Database (PSDB) includes a variable for added sugars (using the USDA definition mentioned earlier) (7) . Currently, any nutrient database that uses the CSFII food codes can be linked to the PSDB. For example, the NHANES III survey can now be linked to the PSDB and the added-sugar variable calculated for NHANES analyses (7) .

Consensus is needed on the best statistical methods for analyzing food consumption data to identify nutrient displacement. The consumption of most nutrients, including added sugars, is positively correlated with total energy intake. This correlation may be a source of error in many analyses (49) . Thus, it is essential to adjust for total energy intake when analyzing the effect of added sugars on overall diet quality. Different researchers analyzing the same nationwide food intake surveys have used different adjustment techniques (43 ,44) , which has led to differing results regarding nutrient displacement. These differing results add to the confusion and controversy concerning whether high intakes of added sugars are affecting overall diet quality in the United States.

Substantial debate is occurring over the usefulness of the concept of added sugars. Some nutrition scientists feel that added sugars should not be differentiated from total sugars because they all belong to the same biochemical class of nutrients and do not behave any differently physiologically. Other scientists feel that the concept provides consumers with useful information especially if they are trying to limit excessive use of caloric sweeteners. In light of this, a number of health groups have petitioned the Food and Drug Administration to require that added sugars be added to the food label.

The associations between added and total sugars intake and body fatness must be tested more effectively. The pervasive problem of underreporting of self-reported food intakes must be accounted for in these analyses especially because underreporting is more prevalent by obese people and foods high in added sugars are differentially underreported.

It is widely agreed that milk and soft drink intakes are inversely related. However, research is required to determine whether this is a cause and effect. If children drink fewer soft drinks, will that necessarily result in higher milk intakes?

Some evidence exists that cola-type drinks are associated with reduced bone mineral density and bone fractures. These findings should be confirmed in longitudinal cohort studies. In addition, research is warranted to elucidate the biological mechanism by which cola drinks may lead to bone fractures.

	FOOTNOTES

 
¹ Presented as part of the symposium entitled Carbohydrates—Friend or Foe given at the Experimental Biology 2001 Meeting held March 31–April 4, 2001 in Orlando, FL.. The symposium was sponsored the American Society for Nutritional Sciences and the International Life Sciences Institute Research Foundation’s Human Nutrition Institute. The proceedings of this symposium are published as a supplement to The Journal of Nutrition. The views expressed herein are those of the authors and do not necessarily reflect those of the ILSI Research Foundation. Guest editor for the symposium publication was Suzanne Harris, ILSI Research Foundation, Human Nutrition Institute, Washington, DC.

³ Abbreviations used: CSFII, Continuing Survey of Food Intakes of Individuals; EDNP, energy-dense, nutrient-poor; HPTG, hypertriglyceridemia; NHANES III, Third National Health and Nutrition Examination Survey; PSDB, Pyramid Servings Database; RDA, Recommended Dietary Allowance.

	LITERATURE CITED

TOP ABSTRACT INTRODUCTION Classification of sugars Consumption of added sugars... Quantification of intake of... Sources of added sugars... Sugars and health Obesity Bone health Diet quality Research needs LITERATURE CITED

 

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