Scientific Report of the 2015 Dietary Guidelines Advisory Committee

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Part D. Chapter 6: Cross-Cutting Topics of Public Health Importance - Continued

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Added Sugars and Low-Calorie Sweeteners

Introduction

Added sugars are sugars that are either added during the processing of foods, or are packaged as such, and include sugars (free, mono- and disaccharides), syrups, naturally occurring sugars that are isolated from a whole food and concentrated so that sugar is the primary component (e.g., fruit juice concentrates), and other caloric sweeteners.28 Added sugars have been discussed in previous iterations of the Dietary Guidelines, including a key recommendation in the 2010 Dietary Guidelines to “Reduce the intake of calories from solid fats and added sugars.” The 2010 Dietary Guidelines also included guidance stating that, for most people, no more than about 5 to 15 percent of calories from solid fats and added sugars (combined) can be reasonably accommodated in a healthy eating pattern. However, as discussed in Part D. Chapter 1: Food and Nutrient Intakes, and Health: Current Status and Trends, the current intake of added sugars still remains high at 268 calories, or 13.4 percent of total calories per day among the total population ages 1 year and older.

Similar to the healthy eating patterns modeled for the 2010 DGAC, in the three healthy eating patterns modeled for the 2015 DGAC (Healthy U.S.-style Pattern, Healthy Mediterranean-style Pattern, and Healthy Vegetarian Pattern), a limited number of calories are available to be consumed as added sugars (see Part D. Chapter 1: Food and Nutrient Intakes, and Health: Current Status and Trends). As shown in Table D.6.1, the full range of these three patterns at all calorie levels allow for 3 to 9 percent of calories from added sugars, after meeting food group and nutrient recommendations. For the patterns appropriate for most people (1600 to 2400 calories), the range is 4 to 6 percent of calories from added sugars (or 4.5 to 9.4 teaspoons). The total empty calorie allowance in these patterns is 8 to 19 percent of calories, and based on current consumption patterns, 45 percent of empty calories are allocated to limits for added sugars, with the remainder (55 percent) allocated to solid fats.

Table D6.1. Added sugars available in the USDA Food Patterns (Healthy U.S.-Style, Healthy Mediterranean-Style, and Healthy Vegetarian Patterns) in calories, teaspoons, and percent of total calories per day*

CALORIE LEVEL

1000

1200

1400

1600

1800

2000

2200

2400

2600

2800

3000

3200

Empty calorie limits available for added sugars

(assuming 45% empty calories from added sugars and 55% from solid fat)

Healthy U.S.-style

68

50

50

54

77

122

126

158

171

180

212

275

Healthy Med-style

63

50

50

81

72

117

126

135

149

158

194

257

Healthy Vegetarian

77

77

81

81

81

131

131

158

158

158

185

234

Average

69

59

60

72

77

123

128

150

159

165

197

255

Average (tsp)

4.3

3.7

3.8

4.5

4.8

7.7

8.0

9.4

9.9

10.3

12.3

15.9

Healthy U.S.-style

7%

4%

4%

3%

4%

6%

6%

7%

7%

6%

7%

9%

Healthy Med-style

6%

4%

4%

5%

4%

6%

6%

6%

6%

6%

6%

8%

Healthy Vegetarian

8%

6%

6%

5%

5%

7%

6%

7%

6%

6%

6%

7%

Average

7%

5%

4%

5%

4%

6%

6%

6%

6%

6%

7%

8%

* See Part D. Chapter 1: Food and Nutrient Intakes, and Health: Current Status and Trends and Appendix E-3.7 for a full discussion of the food pattern modeling.

Although food pattern modeling evaluates the amount of added sugars that can be consumed while meeting food group and nutrient needs, the DGAC also reviewed scientific literature examining the relationship between the intake of added sugars and health to inform recommendations. The Committee focused on the health outcomes most commonly researched related to added sugars, specifically, body weight and risk of type 2 diabetes, CVD, and dental caries.

As noted above, the Committee acknowledged that a potential unintended consequence of a recommendation on added sugars might be that consumers and manufacturers replace added sugars with low-calorie sweeteners. As a result, the Committee also examined evidence on low-calorie sweeteners to inform statements on this topic. The Committee approached this topic broadly, including sweeteners labeled as low-calorie sweeteners, non-caloric sweeteners, non-nutritive sweeteners, artificial sweeteners, and diet beverages. This work is complemented by a food safety evidence review on aspartame (see Part D. Chapter 5: Food Sustainability and Safety). As the evidence on added sugars was considered collectively, the added sugars conclusions are presented together below, and a similar approach was taken for low-calorie sweeteners.

Question 6: What is the relationship between the intake of added sugars and cardiovascular disease, body weight/obesity, type 2 diabetes, and dental caries?

Source of evidence: CVD: NEL systematic review; Body weight/obesity, type 2 diabetes, and dental caries: Existing reports

Conclusions

Strong and consistent evidence shows that intake of added sugars from food and/or sugar-sweetened beverages are associated with excess body weight in children and adults. The reduction of added sugars and sugar-sweetened beverages in the diet reduces body mass index (BMI) in both children and adults. Comparison groups with the highest versus the lowest intakes of added sugars in cohort studies were compatible with a recommendation to keep added sugars intake below 10 percent of total energy intake. DGAC Grade: Strong

Strong evidence shows that higher consumption of added sugars, especially sugar-sweetened beverages, increases the risk of type 2 diabetes among adults and this relationship is not fully explained by body weight. DGAC Grade: Strong

Moderate evidence from prospective cohort studies indicates that higher intake of added sugars, especially in the form of sugar-sweetened beverages, is consistently associated with increased risk of hypertension, stroke, and CHD in adults. Observational and intervention studies indicate a consistent relationship between higher added sugars intake and higher blood pressure and serum triglycerides. DGAC Grade: Moderate

The DGAC concurs with the World Health Organization’s commissioned systematic review that moderate consistent evidence supports a relationship between the amount of free sugars intake and the development of dental caries among children and adults. Moderate evidence also indicates that caries are lower when free sugars intake is less than 10 percent of energy intake. DGAC Grade: Moderate

Review of the Evidence

Added Sugars and Body Weight/Obesity

These findings come from three recent reports, all using SRs and MA that examined the relationship between the intake of added sugars and measures of body weight.6, 29, 30 Te Morenga et al.6 considered “free sugarsix, 32, while Malik29 and Kaiser et al.30 focused on sugar-sweetened beverages. All reviews reported on body weight. The Te Morenga report also reported on body fatness. In the Te Morenga et al. study, 30 trials and 38 cohort studies were included in the analyses. In the Malik et al. study, 10 trials and 22 cohort studies were included in the analyses. Kaiser et al. provided an updated meta-analysis to a previous publication (Mattes31) and included a total of 18 trials. In total, 92 articles were considered in these reviews, of which 21 were included in two or more reviews. Children and adults were included in the analyses as were females and males. Diverse demographics (race/ethnicity and geographic location) also were represented by the participants in the respective research studies. All three reviews were high-quality, with ratings of 11 out of 11 using the AMSTAR tool, and they specifically addressed the Committee’s question of interest.

The reviews by Malik et al. and Te Morenga et al. were very consistent. The findings from both reports provide strong evidence that among free-living people consuming ad libitum diets, the intake of added sugars or sugar-sweetened beverages is associated with unfavorable weight status in children and adults. Increased added sugars intake is associated with weight gain; decreased added sugars intake is associated with decreased body weight. Although a dose response cannot be determined at this time, the data analyzed by Te Morenga et al. support limiting added sugars to no more than 10 percent of daily total energy intake based on lowest versus highest intakes from prospective cohort studies. Te Morenga et al. state that, “despite significant heterogeneity in one meta-analysis and potential bias in some trials, sensitivity analyses showed that the trends were consistent and associations remained after these studies were excluded.” Despite these limitations the DGAC gave this evidence a grade of Strong, as the limitations are those inherent to the primary research on which they are based, notably inadequacy of dietary intake data and variations in the nature and quality of the dietary interventions.

The Kaiser et al. review concluded that the currently available randomized evidence for the effects of reducing sugar-sweetened beverage intake on obesity is equivocal. However, the DGAC noted methodological issues with this review, particularly the inclusion of both efficacy studies (in more controlled settings) and effectiveness studies (in real world). The outcomes from the effectiveness trials vary substantially, depending how effective the interventions are. As a result, the Committee viewed the reviews by Te Morenga et al. and Malik et al. to be stronger than the Kaiser et al. review.

Added Sugars and Type 2 Diabetes

Evidence for this question and conclusion came from five SRs and MA published between January 2010 and August 2014.33-37 Four of the reviews focused on sugar-sweetened beverages33-35, 37 and one review examined sugar intake.36 Combined, a total of 17 articles were considered in these reviews, of which nine were included in two or more reviews. Increased consumption of sugar-sweetened beverages was consistently associated with increased risk of type 2 diabetes. Pooled estimated relative risks ranged from 1.20 to 1.28, and included 1.20 (95% CI = 1.12 to 1.29)/330 ml/day of sugar-sweetened soft drinks;331.26 (95% CI = 1.12 to 1.41) for sugar-sweetened beverages,35 and 1.28 (95% CI = 1.04 to 1.59) for sugar-sweetened fruit juices.37 Comparably, a hazard ratio of 1.29 (1.02, 1.63) was identified for sugar-sweetened beverages.34 These consistently positive associations between sugar-sweetened beverages and type 2 diabetes were attenuated, but still existed, after adjustment for BMI, suggesting that body weight only partly explains the deleterious effects of sugar-sweetened beverages on type 2 diabetes. Although the studies were highly heterogeneous, findings from the MA by Malik et al. tentatively showed that consumption of more than one 12-ounce serving per day of sugar-sweetened beverage increased the risk of developing type 2 diabetes by 26 percent, compared to consuming less than one serving per month. Insufficient high-quality data are available to determine a dose-response line or curve between sugar-sweetened beverage consumption and type 2 diabetes risk.

The issue of generalizability, whether the participants included in this body of evidence are representative of the general U.S. population, was not specifically addressed in the literature reviewed, but the large sample sizes of the pooled data (several hundred thousand subjects from different populations) are noteworthy.

Added Sugars and Cardiovascular Disease

This NEL systematic review included 23 articles published since 2000 that examined the relationship between added sugars and risk of CVD or CVD risk factors such as blood lipids and blood pressure.38-60 This literature included 11 intervention studies and 12 prospective cohort studies.

The majority of intervention and observational studies included in this SR provide some evidence among adults in support of an association between higher intake of added sugars, especially in the form of sugar-sweetened beverages, and higher risk of CVD or increased CVD risk factors. More consistent associations were seen between added sugars and elevated serum triglycerides, blood pressure, and increased risk of hypertension, stroke, or CHD. Evidence for associations between added sugars and dyslipidemia (i.e., low HDL, high LDL, and high total cholesterol) was not as consistent, especially among intervention studies.

The body of evidence examined in this SR had a number of limitations. For example, the intervention studies had extensive heterogeneity in terms of the types and forms of sugars used (i.e., fructose, glucose, sucrose, sugar-sweetened beverages, sweetened milk) and the type of control and/or isocaloric condition used. In addition, most intervention studies had a short duration of the intervention and a small sample size. Most of the observational studies assessed dietary intake only at baseline, and did not take assessments during follow-up. Residual confounding by other dietary and lifestyle factors in observational analyses could not be completely ruled out.

Added Sugars and Dental Caries

These findings were extracted from a World Health Organization (WHO)-commissioned SR by Moynihan et al. published in 2014 examining the association between the amount of sugars intake and dental caries.7 The search for SRs/MA published since completion of the WHO review did not yield any additional reviews that met the DGAC’s inclusion criteria.

Moynihan et al. examined total sugars, free sugars, added sugars, sucrose, and non-milk extrinsic (NME) sugars. In the review, eligible studies reported the absolute amount of sugars. Dental caries outcomes included caries prevalence, incidence and/or severity.

Several databases were searched from 1950 through 2011. From 5,990 papers identified, 55 studies (from 65 papers) were eligible, including 3 interventions, 8 cohort studies, 20 population studies, and 24 cross-sectional studies. No RCTs were included. Data variability limited the ability to conduct meta-analysis. Of the 55 studies included in the review, the majority were in children and only four studies were conducted in adults. The terminology used for reporting sugars varied, but most were described as pertaining to free sugars or added sugars.

The findings indicated consistent evidence of moderate quality supporting a relationship between the amount of sugars consumed and dental caries development across age groups. Of the studies, 42 out of 50 studies in children and five out of five in adults reported at least one result for an association between sugars intake with increased caries. Moderate evidence also showed that caries incidence is lower when free sugars intake is less than 10 percent of energy intake. When a less than 5 percent energy intake cutoff was used, a significant relationship between sugars and caries was observed, but the evidence was judged to be of very low quality. Although meta-analysis was limited, analysis of existing data indicated a large effect size (e.g., Standardized Mean Difference for Decayed/Missing/Filled Teeth [DMFT] = 0.82 [CI = 0.67-0.97]) for the relationship of sugars intake and risk of dental caries. A strength of the in-depth SR was the consistency of data, despite methodological weaknesses in many studies, which included unclear definitions of endpoints, questions about outcomes ascertainment, and lack of clarity about the generalizability of individual study results given the study populations used.

For additional details on this body of evidence, visit: References 6, 7, 29, 30, and 38-60 and Appendices E-2.44 (body weight), E-2.45 (type 2 diabetes), E-2.46 (dental caries), and http://NEL.gov/topic.cfm?cat=3376 (CVD)

Question 7: What is the relationship between the intake of low-calorie sweeteners and body weight/obesity and type 2 diabetes?

Source of evidence: Existing reports

Conclusions

Moderate and generally consistent evidence from short-term RCTs conducted in adults and children supports that replacing sugar-containing sweeteners with low-calorie sweeteners reduces calorie intake, body weight, and adiposity. DGAC Grade: Moderate

Long-term observational studies conducted in children and adults provide inconsistent evidence of an association between low-calorie sweeteners and body weight as compared to sugar-containing sweeteners. DGAC Grade: Limited

Long-term observational studies conducted in adults provide inconsistent evidence of an association between low-calorie sweeteners and risk of type 2 diabetes. DGAC Grade: Limited

Review of the Evidence

Low-Calorie Sweeteners and Body Weight/Obesity

The evidence to support these conclusions comes from three SRs/MA published between January 2010 and August 2014.61-63 In total, 39 articles were considered in these reviews, of which six were included in two or more reviews. Experimentally, the protocols described in the 39 articles included RCTs and prospective cohort studies. Although results from both experimental designs were carefully assessed, the DCAC deemed evidence from RCTs to be scientifically stronger and used it as the foundation for conclusions pertaining to body weight.

Among prospective cohort studies, low-calorie sweetener intake was not associated with body weight or fat mass, but was significantly associated with slightly higher BMI (0.03; 95% CI = 0.01 to 0.06).62 These findings should be viewed with caution, however, because of the high risk of reverse causality and the possibility that people with higher body weights would consume more low-calorie sweetener-containing foods and beverages as a weight-control strategy.

Evidence from short-term RCTs consistently indicated that low-calorie sweeteners (vs. sugar-containing foods and beverages) modestly reduce body weight in adults. When evidence from adults and children were combined, low-calorie sweeteners modestly reduced BMI, fat mass, and waist circumference. The primary research articles used by Miller and Perez for the MA contained findings from both adults (n=5 cohorts) and children (n=4 cohorts).62 The results of interventions lasting 3 to 78 weeks indicated that low-calorie sweeteners reduced body weight in adults (-0.72 kg; 95% CI = -1.15 to -0.30) and children (-1.06 kg; 95% CI = -1.17 to -0.56). Age-specific results were not provided for BMI, fat mass, or waist circumference, but data from both age groups were pooled to show the impact of low-calorie sweeteners vs. sugar-containing foods/beverages on these outcomes.

In contrast, Brown et al. summarized that very limited evidence from three short-term (12 to 25 week) RCTs, which suggested that consumption of low-calorie sweeteners does not influence body weight or BMI in predominantly pre-teenage and teenage youth (ages 10 to 21 years), compared to sugar-sweetened beverage or placebo.61 The authors cautioned that insufficient data exist to assess causality of low-calorie sweeteners on body weight. The evidence reported in this 2010 publication was obtained from very heterogeneous experimental designs and interventions. One study tested the effects of encapsulated aspartame vs. placebo during weight loss; another allowed subjects to exchange sugar-sweetened beverages with either low-calorie sweetener beverages or water (precluding assessment of low-calorie sweetener beverages specifically); and a third was described as a “pilot study.”

Collectively, evidence is mixed on the impact of low-calorie sweeteners vs. sugar-containing foods/beverages on body weight in children. However, the DGAC deemed evidence presented by Miller and Perez62 to be stronger than from Brown et al.61 because it culminated from a larger, more recent research base and include both systematic review and meta-analysis assessment and evaluation techniques.

Low-Calorie Sweeteners and Type 2 Diabetes

Evidence to address the impact of low-calorie sweeteners (specifically artificially sweetened soft drinks, ASSD) on risk of type 2 diabetes comes from two SRs/MA published between January 2010 and August 2014.33, 34 The data from one of the reviews also is represented in the second review.

Greenwood et al. reported that higher consumption of ASSD predicts increased risk of type 2 diabetes.33 The summary RR for ASSD on type 2 diabetes risk was 1.13 (95% CI = 1.02 to 1.25, p<0.02) per 330 ml/day, based on four analyses from three prospective observational studies. Although the finding indicates a positive association between ASSD and type 2 diabetes risk, the trend was not consistent and may indicate an alternative explanation, such as confounding by lifestyle factors or reverse causality (e.g., individuals with higher BMI at baseline may use ASSD as a means to control weight).

Romaguera et al. also reported that higher consumption of ASSD was associated with increased risk of type 2 diabetes.34 In adjusted models, one 336 g (12 oz) daily increment in ASSD consumption was associated with a hazard ratio for type 2 diabetes of 1.52 (95% CI = 1.26 to 1.83). High consumers of ASSD showed almost twice the hazard ratio of developing type 2 diabetes compared with low consumers (adjusted HR = 1.93; 95% CI = 1.47 to 2.54; p for trend <0.0001). However, the association was attenuated and became statistically not significant when BMI was included in the model (HR = 1.13, 95% CI = 0.85 to 1.52; p for trend = 0.24). The authors offered these interpretations of the findings: “In light of these findings, we have two possible explanations of the association between artificially sweetened soft drinks and diabetes: (1) the observed association is driven by reverse causality and residual confounding, given that the underlying health of people consuming artificially sweetened soft drinks may be compromised and their risk of type 2 diabetes increased; or (2) the association between artificially sweetened soft drinks and type 2 diabetes is mediated through increased BMI.” The authors argued that explanation 1 is more likely correct based on reverse causality, but new research would be needed to clarify the issue.

Collectively, both studies report a positive association between ASSD and type 2 diabetes risk that was confounded by baseline BMI. The experimental designs of the studies included in these reviews analyzed associations, but precluded the assessment of cause and effect relationships, and future experimental studies should examine the relationship between ASSD and biomarkers of insulin resistance and other diabetes biomarkers.

For additional details on this body of evidence, visit: References 33, 61-63 and Appendices E-2.47 (body weight) and E-2.48 (type 2 diabetes)

Implications

Obesity, type 2 diabetes, CVD, and dental caries are major public health concerns. Added sugars intake negatively impacts all of these conditions, and strong evidence supports reducing added sugars intake to reduce health risks. Added sugars are frequently used in food/beverage processing and provide calories but no other nutrients. Since 39 percent of added sugars are from sugar-sweetened beverages, efforts are needed to reduce these beverages (see Figure D1.36. Food Sources of Added Sugars). Currently, the mean intake of added sugars in the U.S. population is 13%, and from 15% to 17% in children 9 and older, adolescents, and young adults.

The DGAC recommends limiting added sugars to a maximum of 10% of total daily caloric intake. This recommendation is supported by: 1) the food pattern modeling analysis conducted by the 2015 DGAC and 2) the scientific evidence review on added sugars and chronic disease risk conducted by the Committee. The food pattern analysis, based on the Healthy U.S.-Style Pattern, the Healthy Vegetarian Pattern, and the Healthy Mediterranean-Style Pattern (see Part D. Chapter 1: Food and Nutrient Intakes, and Health: Current Status and Trends and Appendix E-3.7), demonstrates that when added sugars in foods and beverages exceeds 3% to 9% of total calories, depending on calorie level, a healthful food pattern may be difficult to achieve and nutrient density may be adversely affected (Table D6.1). The scientific evidence on added sugars and chronic disease risk also supports this limit.

The recommendation to limit added sugars, especially sugar-sweetened beverages, is consistent with recommendations from national and international organizations including the American Academy of Pediatrics, World Health Organization, American Heart Association, Centers for Disease Control and Prevention, and the American Diabetes Association (Table D6.2).

When low-calorie sweeteners are used to replace sugar, the resulting reduction in calories can help to achieve short-term weight loss. However, there is insufficient evidence (due to a paucity of data) to recommend the use of low-calorie sweeteners as a strategy for long-term weight loss and weight maintenance. Since the long-term effects of low-calorie sweeteners are still uncertain, those sweeteners should not be recommended for use as a primary replacement/substitute for added sugars in foods and beverages.

Policies and programs at local, state, and national levels in both the private sector and public sector are necessary to support efforts to lower added sugars in beverages and foods and to limit availability of sugar-sweetened beverages and snacks. Suggested specific approaches for reducing added sugars intake include:

  • Water is the preferred beverage choice. Strategies are needed to encourage the US population, especially children and adolescents, to drink water when they are thirsty. Water provides a healthy, low-cost, zero-calorie beverage option. Free, readily accessible, safe water should be available in public settings, as well as child care facilities, schools, worksites and other community places and promoted in all settings where beverages are offered.
  • The Nutrition Facts Panel (NFP) should include added sugars (in grams and teaspoons) and include a percent daily value, to assist consumers in making informed dietary decisions by identifying the amount of added sugars in foods and beverages.
  • Consumers would benefit from a standardized, easily understood front-of-package (FOP) label on all food and beverage products to give clear guidance about a food’s healthfulness. An example is the FOP label recommended by the IOM,18 which included calories, and 0 to 3 “nutritional” points for added sugars, saturated fat, and sodium. This would be integrated with the NFP, allowing consumers to quickly and easily identify nutrients of concern for over-consumption, in order to make healthier choices.
  • Economic and pricing approaches, using incentives and disincentives should be explored to promote the purchase of healthier foods and beverages. For example, higher sugar-sweetened beverage taxes may encourage consumers to reduce sugar-sweetened beverage consumption. Using the revenues from the higher sugar-sweetened beverage taxes for nutrition health promotion efforts or to subsidize fruits and vegetables could have public health benefits.
  • Efforts to reduce added sugars in foods and sugar-sweetened beverages in school meals and through the new smart snacks in schools should continue and also be expanded to other settings, including early child care (through the Child and Adult Care Food Program- CACFP), parks, recreation centers, sports leagues, after school programs, work sites and other community settings.
  • Policies that limit exposure and marketing of foods and beverages high in added sugars to young children, youth and adolescents are needed as dietary preferences are established early in life.
  • Young adults (ages 20-29 years) are among the greatest consumers of sugar-sweetened beverages and are directly targeted in sugar-sweetened beverage marketing campaigns. Health promotion efforts and policies are needed to reduce sugar-sweetened beverages in settings, such as postsecondary institutions and worksites.
  • Policy changes within the federal Supplemental Nutrition Assistance Program (SNAP), similar to policies in place for the WIC program, should be considered to encourage purchase of healthier options, including foods and beverages low in added sugars. Pilot studies using incentives and restrictions should be tested and evaluated.
  • Public education campaigns are needed to increase the public’s awareness of the health effects of added sugars and help consumers reduce added sugars intake and reduce intake of sugar-sweetened beverages through policy, food environment and education initiatives.

Table D6.2. Recommendations or statements related to added sugars or sugar-sweetened beverages from international and national organizations

Organization

Recommendation/Statement Related to Added Sugars and/or Sugar-Sweetened Beverages

World Health Organization (WHO)64

  • WHO recommends reduced intake of free sugars throughout the life-course (strong recommendation).
  • In both adults and children, WHO recommends that intake of free sugars not to exceed 10% of total energy (strong recommendation).
  • WHO suggests further reduction to below 5% of total energy (conditional recommendation).

American Heart Association (AHA)65

The AHA recommends reductions in added sugars with an upper limit of half of the discretionary calorie allowance that can be accommodated within the appropriate energy intake level needed for a person to achieve or maintain a healthy weight based on the USDA food intake patterns. Most American women should eat or drink no more than 100 calories per day from added sugars (about 6 teaspoons), and most American men should eat or drink no more than 150 calories per day from added sugars (about 9 teaspoons).

HealthyPeople 202066

Objective NWS-17.2: Reduce consumption of calories from added sugars (Target: 10.8%)

American Academy of Pediatrics (AAP)67-69

Limit consumption of sugar-sweetened beverages (consistent evidence)

Pediatricians should work to eliminate sweetened drinks in schools

Note: Due to limited studies in children, the American Academy of Pediatrics (AAP) has no official recommendations regarding the use of non-caloric sweeteners.

American Diabetes Association (ADA)70, 71

Prevention
Research has shown that drinking sugary drinks is linked to type 2 diabetes, and the American Diabetes Association recommends that people limit their intake of sugar-sweetened beverages to help prevent diabetes.

Diabetes Management
People with diabetes should limit or avoid intake of sugar-sweetened beverages (from any caloric sweetener including high fructose corn syrup and sucrose) to reduce risk for weight gain and worsening of cardiometabolic risk profile. (Evidence rating B)

NHLBI Expert Panel Guidelines for Cardiovascular Health and Risk Reduction in Childhood72

Reduced intake of sugar-sweetened beverages is associated with decreased obesity measures (Grade B).

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