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WHO sugar recommendations for adult and children 2015

07 / 01 / 15

The World Health Organisation (WHO) recently revised Sugar Intake Recommendations state:

 WHO recommends a reduced intake of free sugars throughout the lifecourse (strong recommendation).

  • In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake (strong recommendation).
  • WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake (conditional recommendation).

 To summarise the evidence and detail behind the recommendations Australian and New Zealand experts have helped answer the questions below.

________________________________

Q&A 

1.    What are the differences between the newly revised 2015 and the previous 2003 WHO recommendations?

The recommendation to reduce free sugars to less than 10% of total energy has not changed. The 10% limit was first recommended in 1989 and maintained by a WHO/FAO Consultation in 2002. According to the WHO evidence-based guidance system, the recommendation to limit free sugar intake to less than 10% of total energy is based on moderate quality evidence from observational studies of dental caries.

What is new in the 2015 WHO guidelines is the addition of a “conditional” recommendation to reduce free sugars to less than 5% of total energy, in order to provide additional dental health benefits. A “conditional” recommendation is one that is based on lower quality evidence. There are only three studies to support reducing free sugars to less than 5%, and these are population ecological studies conducted during periods of war in which the availability of free sugar was limited. The quality of this evidence is considered by WHO as ‘very low’.

2.    The guidelines are based on “free sugars”. What does this mean? Are ‘free sugars’ the same as the sugar you see on a packaged food label like breakfast cereal?

Free sugars are those added to foods by the manufacturer, cook or consumer. Examples include sucrose (table sugar), glucose, fructose, honey or syrups, and the WHO also include fruit juices and fruit juice concentrates. The nutrition information panel on food products does not provide free sugars content but instead lists “total sugars” which include naturally occurring sugars such as those from fruit and milk. To roughly estimate the amount of free sugars in a packaged food, refer to the ingredients list. Free sugars may also be estimated by calculation based on nutrient composition databases that provide sucrose and glucose content.

3.    What is the health rationale for reducing intake of free sugars throughout the lifecourse? 

“Increasing or decreasing free sugars is associated with parallel changes in body weight, and the relationship is present regardless of the level of intake of free sugars. The excess body weight associated with free sugars intake results from excess energy intake. This recommendation is classified by the WHO as ‘strong’ and is based on moderate and low quality studies” [1].

4.    What is the health rationale for limiting free sugars intake to 10% of total energy intake (total kilojoules or calories)?  

“The WHO’s recommendation to limit intake of free sugars to less than 10% of total energy is based on positive associations between sugar intake and dental caries seen in observational studies. The overall quality of the evidence was considered moderate though positive associations were observed in developed and developing countries and in both children and adults”[1].

5.    What is the health rationale for reducing free sugars to less than 5% of total energy? 

“The recommendation to further limit free sugars intake to less than 5% of total energy intake is based on very low quality evidence from ecological studies in which a positive dose-response relationship between free sugars intake and dental caries was observed at free sugars intake less than 5% of total energy intake.” [1].

WHO is making recommendations at a population level given the options available and based the evidence for an effect on dental caries. In effect if consumers attempt to meet the target, they will automatically reduce frequency of free sugars consumption which at an individual level is most effective to prevent caries. This is especially important in childhood where if caries establishment can be avoided or reduced, the risks are lower in adulthood. The document also notes that dental caries can occur throughout life and attempts to reduce risk throughout the life course are important. 

6.    Reducing free sugars to 5% of total energy is a conditional recommendation. What does this mean?

According to the WHO evidence-based guideline system, a “conditional” guideline is one that has a weaker evidence base. In the case of reducing free sugars to less than 5% of energy, there are only three studies to support it and these are population ecological studies conducted during periods of war in which the availability of free sugar was limited. The WHO issues conditional recommendations where the desirable effects of adhering to the recommendation probably outweigh the undesirable effects but the trade-offs need to be clarified, and dialogue and consultation with stakeholders is needed before it is implemented as policy in individual countries.

7.    Are Australians and New Zealanders currently meeting the WHO target of 10% energy intake coming from free sugars?

The mean intake of total sugars by Australians is about 20% of dietary energy [2]. About half comes from naturally occurring sugars in dairy foods and fruit; the other half comes from free sugars (or added sugars). This suggests that about half of the population is adhering to the WHO free sugar target of 10% of energy, however this is likely an underestimate because sugar intakes in the Australian population are skewed i.e. there are some people with very high intakes which tends to inflate the mean figure. In reality more than half of Australians are meeting the WHO 10% target.

According to the last national nutrition survey in New Zealand mean added sugar intakes were about 9-10% of energy – very similar to intakes in Australia [3].

8.    What does 10% and 5% of free sugars look like for an adults or children’s diet?

Adult:

Based on an average adult energy requirement of 8000 kJ or 2000 calories 10% of total energy equates to 800 kJ’s (200 calories). As there is 17 kJ in every gram of sugar (sugar is pure carbohydrate), 800 kJ ÷ 17 kJ = 47 g of sugar. There is approximately 4 g sugar in a level metric teaspoon, therefore 47 g ÷ 4 g = 11.8 g (12 teaspoons)

            10% of energy in an adult is 47g, or 12 teaspoons of free sugars

Following the same calculations above

            5% of energy in and adult is 23.5g of sugar, or 6 teaspoons

Children:

There is no sanctioned average daily energy requirement for children to use in food labelling in Australia and New Zealand, and energy requirements vary depending on age and size. As an example, we can use the estimated average energy requirement for an 8 year old child (the median age of children 2-18 years) and assume a moderate activity level (1.6 PAL). The Nutrient Reference Values for Australia and New Zealand gives this as 7550 kJ (average of boys and girls). Using the same calculations as above, 10% of energy is 44g or 11 teaspoons sugar and 5% of energy is 22g or 5.5 teaspoons.

10% of energy in an eight year-old child is 44 g, or 11 teaspoons of free sugars

5% of energy in and eight year old child is 22 g, or 5.5 teaspoons of free sugars

What does 10% and 5% added sugars look like in an overall healthy 8,000 kilojoule (2,000 calorie) diet? [4]

 

 10% added sugar adult food plan (based on 8000 kJ and 2000 calories)

5% added sugar adult food plan (based on 8000 kJ and 2000 calories)

Breakfast

 

2/3 cup rolled oats

1 cup reduced fat (1-2%) milk

3 tsps. honey

2/3 cup rolled oats

1 cup reduced fat (1-2%) milk

2 tsps. honey

Morning snack

 

½ grapefruit

½ grapefruit

Lunch

 

2 slices of wholegrain bread

2 tsps. margarine

100g canned salmon

½ cup mixed salad

2 slices of wholegrain bread

2 tsps. margarine

100g canned salmon

½ cup mixed salad

Afternoon tea

 

200g plain yoghurt

½ banana

200g plain yoghurt

½ banana

Dinner

 

60g beef strips

1 ½ cups stir-fry noodles

2 cups stir-fry vegetables

1 tsp. oil

¼ cup stir-fry sauce

 

60g beef strips

1 ½ cups stir-fry noodles

2 cups stir-fry vegetables

1 tsp. oil

¼ cup stir-fry sauce

Small glass (100ml) white wine

Dessert

 

½ cup reduced-fat vanilla ice-cream

½ cup strawberries

1 piece (8g) milk chocolate

½ cup reduced-fat vanilla ice-cream

½ cup strawberries

 

Nutritional information

8570 kJ (2,040 calories), 105g protein, 62g fat, 16g saturated fat, 250g total carbohydrates, 104g total sugars, 50g added sugars, 25g fibre, 1742mg sodium

8400 kJ (2000 calories); 106g protein; 60g fat; 228g total carbohydrates; 82g sugars; 25g added sugars; 25g fibre; 1,765 mg sodium)


*Table taken from directly from [4].

9.    How do I know how much “free sugars” I am consuming?

Free sugars are contained in sweet tasting processed, packaged as well as home cooked foods. If you are consuming a lot of sugar-sweetened drinks, sweet snacks (e.g. biscuits, cakes) and confectionery, you are consuming a lot of free sugars.

The ingredients list of food products will tell you if free sugars have been added but calculating free sugar content is complex as this information is not available on the nutrition information panel. Free sugars, as defined by the WHO, must be calculated from nutrient databases by subtracting the naturally occurring sugars (not part of fruit syrups, juice or concentrates) from the total sugars content.

It is perhaps most helpful to look at whole foods and the whole diet rather than grams of free sugars to determine whether a food or a diet is healthy, and to follow the National guidelines:

For Australians, the Dietary Guidelines state to “Limit intake of foods and drinks containing added sugars such as confectionery, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters and sports drinks” and for New Zealanders The Food and Nutrition Guidelines state to “Prepare foods or choose pre-prepared foods, drinks and snacks, with little added sugar; limit your intake of high-sugar foods” [5, 6].

Summary:

  • Recommendations 1 and 2, to reduce free sugars intake throughout the lifecourse and to reduce free sugars intake to less than 10% of total energy intake has not changed from since 1989 WHO recommendations.
  • Australians and New Zealanders are currently consuming on average about 10% energy as free sugars
  • The ‘strong’ recommendation to reduce free sugars throughout the lifecourse is based on the relationship between free sugars and body weight (low and moderate quality evidence) and dental caries (moderate quality evidence).
  • The ‘strong’ recommendation to limit free sugars intake to less than 10% of total energy is based on moderate quality evidence from observational studies of dental caries.
  • A “conditional” recommendation to further limit free sugars intake to less than 5% of energy intake for additional health benefits is based on very low quality evidence from ecological studies of dental caries.
  • Free sugars refer to those added to foods by the manufacturer, cook or consumer. Examples include sucrose (table sugar), glucose, fructose, honey or syrups, and also include fruit juices and fruit juice concentrates.

If you have any further questions on the above information please contact info@srasanz.org

NEXT: That Sugar Film

References:

  1. Guideline: Sugars intake for adults and children. Geneva: World Health Organization; 2015.
  2. Australian Bureau of Statistics, 4364.0.55.007 Australian Health Survey: Nutrition First Results- Foods and Nutrients [internet], 2011-12 [cited 2015 Feb 17], Table 1: Mean daily energy and nutrient intake. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0072011-12?OpenDocument
  3. 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
  4. Barclay, A, Sandall, P & Shwide-Slavin, C (2014) The Ultimate Guide to Sugars & Sweeteners, The Experiment, New York, USA
  5. Australian Government NHMRC, The Australian Dietary Guidelines [internet], 2013 [cited 2015 Jan 19] Available from: http://www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55_australian_dietary_guidelines.pdf
  6. New Zealand Government, Ministry of Health, NZ Food and Nutrition Guideline statements for healthy adults [internet], 2012[cited 13/3/15] http://www.health.govt.nz/our-work/preventative-health-wellness/nutrition/food-and-nutrition-guidelines/nz-food-and-nutrition-guideline-statements-healthy-adults

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