Few topics in nutrition get more attention these days than added sugars. As much or more than any other dietary component or lifestyle factor, sugars have been studied for their role in health. The latest comes from the American Heart Association (AHA) in their recently published Scientific Statement: Added Sugars and Cardiovascular Disease Risk in Children. You may have noticed it in media headlines or shared within your social networks. Let’s go beyond the headlines and learn more about the findings, methodology and recommendations to see how the report aligns with 2015-2020 Dietary Guidelines (DGA).
First things first, what is an added sugar?
The U.S. Food and Drug Administration (FDA) defines added sugars as “sugars that are either added during the processing of foods, or are packaged as such, and include sugars (free, mono- and disaccharides), sugars from syrups and honey, and sugars from concentrated fruit or vegetable juices that are in excess of what would be expected from the same volume of 100 percent fruit or vegetable juice of the same type.”
Whole foods and 100 percent juices have naturally occurring sugars, like fructose found in fruit or lactose in milk. These are not considered added sugars. Sugar alcohols (e.g., erythritol and xylitol) and low-calorie sweeteners (e.g., aspartame, sucralose and stevia leaf extract) are also not considered added sugars.
Now that we know what added sugars are, what did the AHA report determine about their role in the health of children?
The report concludes that “strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia.”
Did they issue recommendations based on the report’s findings and methods?
The AHA did issue recommendations in their report. In fact, many global groups have offered different recommendation levels (Institute of Medicine, World Health Organization and US Dietary Guidelines) of sugars intake. Based on the report’s findings, the AHA recommend that children “consume ≤ 25 g (100 cal or ≈ 6 teaspoons) of added sugars per day and to avoid added sugars for children < 2 years of age” which is essentially half of what the DGA recommend for all Americans more than 2 years of age.
Do the AHA recommendations align with 2015-2020 Dietary Guidelines (DGA) recommendations?
Added sugars have been at the forefront of the nutrition dialogue during the development of the past three DGA. In 2010, the DGA recommended Americans to limit their intake of solid fats and added sugars to “no more than about 5 to 15 percent of calories.” Most recently, the 2015-2020 DGA recommend limiting intake of added sugars to less than 10 percent of total calories to assist in establishing healthy eating patterns, which the DGA define as meeting “nutrient and food group needs through nutrient-dense food and beverage choices and staying within calorie limits.” The recommendations from the DGA (<10% of total calories for Americans ages 2 and over) offer more flexibility (from a much stronger evidence base, btw) than those from AHA (~<4% of total calories for moderately active 14-18 year olds).
What methods were used to determine the evidence is strong?
Despite the rise in strength and broad use of systematic reviews and meta-analyses, the AHA report did not rely on reviews of this nature that consolidate large bodies of evidence. If you’re not familiar with these methods, here’s an intro.The AHA uses various levels of evidence to inform their report. A more objective approach, however, would exclude the use of “group consensus to develop recommendations.” Group consensus is not a standardized, objective or validated evidence analysis/grading method.
What do these recommendations look like in practice?
This is where the broad recommendation on limiting added sugars per day can get a bit dicey. For example, the calorie recommendation for a somewhat active 14-18 year old boy is about 2,600 calories. Restricting daily added sugars intake to six teaspoons equates to less than 3 percent of his calories. Similarly for a somewhat active 14-18 girl, following the AHA recommendation, added sugars intake equates to 5 percent of her total calories.
Does the AHA report tell the whole story about added sugars?
This is another example of where the added sugars debate is more nuanced. Important nutrients can come from foods and beverages that contain added sugars. For example, nutrient-rich foods that are naturally low in sugars but high in acid (e.g., cranberries and rhubard) must have sugars added to them to make their products more palatable. In the case of cranberry products (dried fruit and juice cocktail), even after the added sugars have been added, the total caloric and nutrient values are still equal to other dried fruits (e.g., raisins) and 100 percent juices.
In addition, the 2015-2020 DGA have identified calcium, fiber, iron, potassium and vitamin D as nutrients of public health concern for under consumption, or “shortfall nutrients.” To increase intake of these shortfall nutrients, the DGA recommend consuming more dairy, fruits, vegetables and whole grains. While whole fruits and vegetables and plain dairy products contain only naturally-occurring sugars, some dairy, fruit, and whole grain products contain added sugars to improve taste. While added sugar may mean more calories than whole or unsweetened versions, sweetened versions don’t always mean fewer nutrients. Recall the cranberry example above.
The last few words…
While the overall message of the AHA report on the importance of a nutrient-rich and balanced diet for children is one that we can (and should) get behind, their recommendation levels and how these recommendations levels were established is a bit of a different story. Yes, our food choices could all use a bit of improvement by seeking more nutrients in fewer calories. However, the AHA added sugars intake recommendation for children may be more restrictive than the totality of evidence (and the 2015-2020 DGA) recommends for good health.