Sugar sweeteners in the food supply

Sugar-containing sweeteners have been used to improve the taste of foods and beverages for thousands of years, but only natural-occurring sweeteners such as honey and only very small amounts of high-priced refined sugar or “white gold” from cane, were available until the 1800s, so consumption was low. In the United States after the Civil War, with improved methods for extracting sugar from beets as well as cane, the price began to decline, and consumption of refined sugars began to increase dramatically. Since then, sugars added to foods and beverages to improve their taste as well their texture, appearance, and shelf life have become ubiquitous in the food supply.

While chemically and physiologically there appears to be little difference between sugars that occur naturally and those that are added to foods, in 2000, the US Dietary Guidelines began to use the term “added sugars” to increase awareness that some foods provide energy but generally contribute few vitamins or nutrients. “Added sugars”, as defined in the 2005 US Dietary Guidelines, include all sugars and syrups used as ingredients in processed and prepared food as well as those added at the table. Sugars that occur naturally in foods, such as fructose in fruits and lactose in milk, are not included in this definition unless they are used as a food additive.

As fructose is the sweetest of all naturally occurring sugars, it and the sugars and syrups that contain it are commonly used in the processing and preparation of foods. Sucrose (fructose bonded to glucose, obtained primarily from beets and cane) and high-fructose corn syrup (HFCS, a solution of free fructose and glucose made from processed corn starch) are the most commonly consumed sweeteners in the United States. As food manufacturers are not required by the US Food and Drug Administration (FDA) to provide information on the amount of added sugar in processed foods, consumers will not find this information on a product’s Nutrition Facts Panel on the food label (where information on the caloric, total sugar, and other important nutrient content appear). To determine if a processed food contains added sugars, consumers must read the ingredients list on the food label, where all forms of sugar and other additives will be listed, in order by weight. The names of several different sugar sweeteners that might be found on food labels 1, are listed in Table 1 .

Naturally occurring sugars, which are those that are intrinsic to foods, are found in fruits and vegetables and in milk and other dairy products. These sources of naturally occurring sugars also contain beneficial nutrients such as fiber, protein, and calcium. In contrast, added sugars are consumed primarily in foods and beverages that are high in energy and low in essential nutrients, such as sugar-sweetened beverages (SSBs) and desserts. A comparison of the sugar and other nutrient content of commonly consumed foods and beverages high in naturally occurring and added sugars is presented in Table 2 .

Consumption patterns and trends

National survey data indicate that, from 1977 to 1978 to 1994 to 1996, the consumption of added sugars among Americans ages 2 years and older increased from 13.1% to 16.0% of total energy intake. More recently, consumption has decreased. Between 1999 to 2000 and 2007 to 2008, the mean consumption of total added sugar in the United States is estimated to have decreased by almost one-fifth, from 18.1% to 14.6% of total energy intake, with decreases observed among all race/ethnic, income, and age groups. During this period, the percent of total energy intake from added sugar consumption decreased among adolescents (ages 12–17 years) from 22.3% to 17.3%; among elementary school children (ages 6–11 years) from 20.6% to 17.0%; and among preschool children (ages 2–5 years) from 17.0% to 13.4%. These trends are also reflected in USDA loss-adjusted food disappearance data, which, although known to overestimate intake, are useful for measuring trends. Estimates obtained using disappearance data indicate that consumption of added sugars increased by 6.5% between 1995 and 2000 and decreased by 6.3% between 2000 and 2003.

As SSBs are the largest source of added sugars in the American diet, trends in total added sugar consumption closely track trends in SSB consumption. Between the 1960s and 2000, the consumption of soft drinks and other SSBs increased dramatically. Adults in 1965 consumed only an estimated 50 kcal/d (2.5% of total energy) as SSBs, while by 2002 this consumption had increased to 230 kcal/d (9.3% of total energy). Then, between 1999 to 2000 and 2007 to 2008, SSB consumption decreased from 9.3% to 6.6% of total energy intake among Americans 2 years of age and older. This decrease in sugar intake from SSBs represents two-thirds of the absolute decrease in total added sugars intake observed over this time period.

Although added sugar consumption has decreased significantly, the relative importance of soft drinks and other large contributors of added sugar in the American diet have remained the same over the past decade. From 2007 to 2008, as from 1994 to 1996, soft drinks contributed the most added sugars, followed by sugars and candies, cakes and cookies, fruit drinks (including sports drinks), and dairy desserts. Consumption of added sugars begins early, well before the age of 2 years. In 2002, almost 30% of 12- to 14-month-old children, 37% of 15- to 18-month-old children, and 44% of 19- to 24-month-old children consumed fruit drinks and/or carbonated soft drinks at least once in a day. Among preschool and elementary school children, added sugars are a substantial component of calories consumed; from 2007 to 2008, 13.4% of total calories consumed by 2 to 5-year-olds and 17.0% of total calories consumed by 6 to 11-year-olds came from sugars added to the foods and beverages they consumed.

Consumption patterns and trends

National survey data indicate that, from 1977 to 1978 to 1994 to 1996, the consumption of added sugars among Americans ages 2 years and older increased from 13.1% to 16.0% of total energy intake. More recently, consumption has decreased. Between 1999 to 2000 and 2007 to 2008, the mean consumption of total added sugar in the United States is estimated to have decreased by almost one-fifth, from 18.1% to 14.6% of total energy intake, with decreases observed among all race/ethnic, income, and age groups. During this period, the percent of total energy intake from added sugar consumption decreased among adolescents (ages 12–17 years) from 22.3% to 17.3%; among elementary school children (ages 6–11 years) from 20.6% to 17.0%; and among preschool children (ages 2–5 years) from 17.0% to 13.4%. These trends are also reflected in USDA loss-adjusted food disappearance data, which, although known to overestimate intake, are useful for measuring trends. Estimates obtained using disappearance data indicate that consumption of added sugars increased by 6.5% between 1995 and 2000 and decreased by 6.3% between 2000 and 2003.

As SSBs are the largest source of added sugars in the American diet, trends in total added sugar consumption closely track trends in SSB consumption. Between the 1960s and 2000, the consumption of soft drinks and other SSBs increased dramatically. Adults in 1965 consumed only an estimated 50 kcal/d (2.5% of total energy) as SSBs, while by 2002 this consumption had increased to 230 kcal/d (9.3% of total energy). Then, between 1999 to 2000 and 2007 to 2008, SSB consumption decreased from 9.3% to 6.6% of total energy intake among Americans 2 years of age and older. This decrease in sugar intake from SSBs represents two-thirds of the absolute decrease in total added sugars intake observed over this time period.

Although added sugar consumption has decreased significantly, the relative importance of soft drinks and other large contributors of added sugar in the American diet have remained the same over the past decade. From 2007 to 2008, as from 1994 to 1996, soft drinks contributed the most added sugars, followed by sugars and candies, cakes and cookies, fruit drinks (including sports drinks), and dairy desserts. Consumption of added sugars begins early, well before the age of 2 years. In 2002, almost 30% of 12- to 14-month-old children, 37% of 15- to 18-month-old children, and 44% of 19- to 24-month-old children consumed fruit drinks and/or carbonated soft drinks at least once in a day. Among preschool and elementary school children, added sugars are a substantial component of calories consumed; from 2007 to 2008, 13.4% of total calories consumed by 2 to 5-year-olds and 17.0% of total calories consumed by 6 to 11-year-olds came from sugars added to the foods and beverages they consumed.

Possible role of added sugars in child obesity

Several studies have shown an association between the consumption of added sugars and higher calorie intake, weight gain, or obesity in adults as well as children, but others have not. Early findings, based primarily on the results of cross-sectional studies, were inconsistent, but multiple studies, including meta-analyses, randomized controlled trials, and long-term prospective studies published in recent years strengthen the evidence of this association.

While there has been little study of the health effects of total added sugar intake, the results of a meta-analysis and a systematic review published in 2006 report that the consumption of SSBs is associated with increased risk of weight gain and obesity among adults as well as children. The meta-analysis done by Vartanian and colleagues included cross-sectional, short-term, and long-term experimental studies and found that consumption of SSBs was associated with an increase in total calorie consumption and a small but significant increase in body weight among adults and children. Similar findings were reported in a review done by Malik and colleagues. A third meta-analysis published in 2008 analyzed the results from studies in children and adolescents and found no significant association between the consumption of SSBs and weight status, although a follow-up reanalysis of the same data reported a positive association.

Several other studies in children have been published recently. A prospective study of 2.5- to 4.5-year-olds (n = 1944) demonstrated that those who consumed more SSBs between meals (4–6 times/wk or more) were more likely to be overweight at 4.5 years of age. A longitudinal study following children from preschool to school ages reported that high consumption of SSBs (>2 servings/d) at age 5 years was associated with a higher percentage of body fat and higher waist circumference and body weight through age 15 years. A longitudinal study of low-income African American children aged 3 to 5 years (n = 365) showed that the intake of SSBs predicted development of overweight and obesity. A randomized controlled pilot study among teens showed the home delivery of no-calorie beverages for 25 weeks decreased SSB intake among high consumers and reduced obesity risk among children in the highest body mass index (BMI) tertile at baseline. BMI change differed significantly between the intervention (-0.63 ± 0.23 kg/m ² ) and control (+0.12 ± 0.26 kg/m ² ) groups, a net effect of -0.75 plus or minus 0.34 kg/m ² . Another large prospective study among preschool-aged children (n = 10,904) determined that low-income overweight children who consumed at least 1 sweet drink daily (sodas, fruit drinks, and fruit juice) were twice as likely to become obese at follow-up 1 year later as those who consumed less.