December 2016 Issue

Curbing Children's Sugar Intake
By Christen C. Cooper, MS, RDN
Today's Dietitian
Vol. 18, No. 12, P. 28

Learn what the new American Heart Association guidelines say and the strategies for counseling patients.

A group of middle school students in a health class gasp with surprise as a teacher holds up an empty soda bottle nearly half filled with white granulated sugar. "That's how much sugar you're drinking when you drink a soda of this size—16 teaspoons!" It turns out that this 20 oz drink contains almost three times as much added sugar as kids should consume in an entire day, according to the American Heart Association's (AHA) first-ever recommendations for added sugar intake for children and adolescents.

The new guidelines were released in August 2016 with a position statement by Vos and colleagues, "Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association," published ahead of print online in the journal Circulation. The guidelines specify that children and adolescents aged 2 to 18 should consume no more than 6 teaspoons—100 kcal or 25 g—of added sugars per day, or less than one 8-oz serving of sugar-sweetened beverages per week. Those under age 2 should consume no added sugars at all. Currently, American kids get an average of 16% of their daily calories from added sugars, according to the National Health and Nutrition Examination Survey (NHANES) 2009–2012. NHANES suggests that the average child or adolescent aged 2 to 19 consumes an average of 80 g added sugar daily—55 g above the AHA's new recommendations. It appears that boys consume more added sugars (87 g/day) than girls (73 g/day), and intake increases with age.

Thus, for kids and their parents, reining in sugar likely will be a challenge at the dining table and grocery store.

What Are Added Sugars?
The USDA defines added sugars as "all sugars used as ingredients in processed and prepared foods, and sugars eaten separately or added to foods at the table." According to ChooseMyPlate.gov, names for added sugars on food labels include anhydrous dextrose, brown sugar, confectioner's powdered sugar, corn syrup, corn syrup solids, dextrose, fructose, high fructose corn syrup, honey, invert sugar, lactose, malt syrup, maltose, maple syrup, molasses, nectars (eg, peach nectar, pear nectar), pancake syrup, raw sugar, sucrose, sugar, and white granulated sugar.

NHANES data suggest that about 50% of the added sugars in children's diets comes from sugar-sweetened beverages (eg, soda, sports drinks, fruit juices), and 50% from foods such as cakes and cookies. According to ChooseMyPlate.gov, the top sources of added sugars in the American diet are regular soft drinks, energy drinks and sports drinks, candy, cakes, cookies, pies and cobblers, sweet rolls, pastries and donuts, fruit drinks, and dairy desserts such as ice cream. Even for the health-conscious consumer who tries to shun the obvious sweet culprits, added sugars can be hard to avoid. Added sugars can pop up as ingredients in many less conspicuous foods such as sauces, breads, crackers, and ketchup, to name just a few.

Elisa Bremner, MS, RDN, campus nutritionist at the Jewish Child Care Association Cottage School in Pleasantville, New York, which serves at-risk adolescents, advises parents to read food labels. "It's surprising that the foods that sugars show up in, and many foods which don't seem super sweet actually have more than you think." Currently, product labels list total sugar, but in 2018, the FDA will require food products to include total sugar as well as added sugar on labels.

Why New Recommendations?
With cardiovascular disease (CVD) being the number one killer of men and women in the United States, and overweight and obesity being a key underlying factor for heart disease, type 2 diabetes, and several cancers, emphasis on cutting empty calories from the American diet has grown. In 2005, the Dietary Guidelines for Americans recommended that children get 6% to 10% of their total energy from discretionary calories, defined as the added sugars and solid fats consumed above and beyond nutrient requirements. In 2010, the American Academy of Pediatrics recommended that children aged 1 to 6 consume only 4 to 6 oz of sugar-sweetened beverages and naturally sweetened beverages per day, and children aged 7 to 18, 8 to 12 oz per day. In 2015, the Dietary Guidelines Advisory Committee recommended keeping added sugars below 10% of total energy intake, and that individuals with lower energy needs (1,600 to 2,400 kcal per day) should stay in the range of 4% to 6%.

What spurred the need for the AHA to create child-specific guidelines were recent scientific findings that increased the urgency for new recommendations on added sugar intake. In 2014, a study on the risks of excess sugar in the diet and its association with death from heart disease rekindled discussions about added sugars. The study, performed by Yang and colleagues and published in JAMA in April 2014, found that people who consumed 17% to 21% of their calories from added sugars had a 38% higher risk of death from CVD compared with those who got just 8% of their calories from added sugars.

Another study raised eyebrows, particularly among pediatric experts. In the February 2016 issue of Obesity, Lustig and colleagues presented the results of a randomized controlled trial involving 43 children aged 9 to 18 who were obese and had at least one other metabolic disorder such as hypertension or hypertriglyceridemia. The participants were placed on a diet that matched their "regular" diets in terms of fat, protein, carbohydrate, and calorie levels but were reduced in sugar. The average sugar level in the participants' ordinary diet was 28% of calories, whereas in the study diet it was only 10%. Fructose in particular, which represented 12% of calories in the regular diet, was lowered to 4% of total calories in the study. The children's weight was monitored each day, and their weight began to drop; participants were given extra calories from reduced-sugar foods to maintain their weight. After just nine days on the lower-sugar diet, the researchers saw marked improvements in several participants' metabolic health measures: Blood pressure decreased 4.3% on average, LDL cholesterol was reduced by 12.5%, fasting triglycerides dropped 46%, and fasting insulin declined 53%. The authors stated that even putting aside the potential effect of added sugars on lowering weight, cutting sugar from the diet can improve several measures of children's cardiovascular health, thereby lowering their risk of CVD.

Melissa Halas-Liang, MA, RDN, CDE, founder of SuperKidsNutrition.com, a website that provides family-friendly nutrition and fitness information and that partners with AICR.org on the Healthy Kids Today, Prevent Cancer Tomorrow projects, says that it's key that parents and kids understand that reducing intake of added sugars isn't only about avoiding weight gain. "Avoiding added sugars leaves more room for fruits, vegetables, and whole grains in the diet, and those foods are low in calories and high in vitamins, minerals, and cancer-fighting antioxidants."

Science Behind the New Recommendations
In the 2016 AHA position paper mentioned previously, Vos and colleagues report on the added sugars' association among increased energy intake, adiposity, central adiposity, and dyslipidemia, all of which are CVD risk factors.

Overweight and Obesity
There have been several longitudinal school-based and randomized controlled trials that point to a relationship between dietary sugars, particularly sugar-sweetened beverages, and increased adiposity in children. The AHA position paper shows that there's strong evidence claiming that the introduction of added sugars during infancy carries particular health risks and should be avoided. A study by Pan and colleagues published in the September 2014 issue of Pediatrics suggested that the introduction of sugar-sweetened beverages in the first 12 months of life is associated with obesity at age 6. A study by Davis and colleagues in the April 2014 issue of Obesity showed that avoidance of sugar-sweetened beverages by toddlers is protective against obesity. The AHA's review of the scientific evidence, included in the position paper, found that children and adolescents who have high intakes of dietary sugars (especially sugar-sweetened beverages and added sugars) have higher daily energy intakes than children who have lower added sugar intakes. The review also concluded that "higher SSB [sugar-sweetened beverage] and added sugar intake is strongly linked to excess weight gain and increased risk of obesity." They believe that other factors, such as home environment, may contribute to adverse outcomes related to diet. However, in randomized controlled trials in which children drank noncaloric beverages rather than sugar-sweetened beverages, weight decreased, thereby suggesting that added sugars played a key, perhaps causal, role in such outcomes.

Blood Pressure
The authors concluded that there's both epidemiological and clinical trial evidence that fructose, when consumed in excess, results in increased blood pressure in children and adolescents. Jalal and colleagues analyzed NHANES 2000–2003 data to examine potential relationships between fructose intake and blood pressure in an article published in the September 2010 issue of the Journal of the American Society of Nephrology. They observed a strong relationship between fructose intake and elevated systolic blood pressure that was independent of obesity. Similarly, Nguyen and colleagues found an independent relationship between sugar-sweetened beverages and hypertension in young adults in a study published in the June 2009 issue of The Journal of Pediatrics. The AHA position statement suggests that clinical trials that directly examine the effects of glucose intake and hypertension seem to point to the same conclusions.

Dyslipidemia
In terms of dyslipidemia, the majority of cross-sectional and longitudinal studies examined found positive associations between larger amounts of added sugars and higher triglyceride and/or lower HDL levels. The previously mentioned 2016 study by Lustig was the only intervention the AHA committee reviewed, and it helped to demonstrate the effects of lowering added sugars on several CVD markers, including triglycerides, LDL cholesterol, blood pressure, and insulin sensitivity.

Nonalcoholic fatty liver disease (NAFLD) is a condition whereby excess triglycerides accumulate in the liver. This condition has been increasing rapidly among all Americans, particularly children. The cross-sectional data on added sugars and NAFLD seem to be conflictive, but a large longitudinal study on children shows a relationship between fructose consumption and hepatic fat. There's a lack of studies on this condition, especially those that look at the effects of lowering dietary added sugars on hepatic fat. In addition, NAFLD occurs in the presence of other conditions, such as visceral obesity, low HDL, and hypertriglyceridemia, which complicates researching a single aspect of the condition. However, Vos and colleagues concluded that the evidence to date seems to show a benefit in lowering added sugars in those with NAFLD.

Insulin Resistance and Diabetes
More research is required to understand added sugars' role in insulin resistance and diabetes mellitus. However, two notable studies suggest that added sugars may be linked to these conditions in children. One two-year longitudinal study by Wang and colleagues, published in the August 2013 issue of Pediatric Obesity, looked at the associations between sugar-sweetened beverages and glucose-insulin homeostasis in children aged 8 to 10 with at least one obese biological parent. The results suggest that a higher consumption of added sugars from liquid sources was associated with a higher fasting blood glucose, higher fasting insulin, and a lower insulin sensitivity index. However, the increases were statistically significant in overweight and obese children but not normal-weight children. A study by Heden and colleagues, published in the July 2014 issue of The American Journal of Clinical Nutrition, looked at the effects of glucose- and fructose-sweetened beverages in children over a two-week period, finding that metabolic health wasn't altered in male or female adolescents. A four-week study published in the August 2014 issue of Nutrients by Jin and colleagues that involved overweight Hispanic adolescents with NAFLD, however, found that the fructose beverage intake increased insulin resistance, whereas the glucose beverage was associated with lower insulin resistance.

Nutrient Insufficiency
Diet quality is a major concern in terms of the detriments of high added sugar intake. Ten-year follow up data from the National Heart, Lung, and Blood Institute Growth and Health Study, presented by Striegel-Moore and colleagues in the February 2006 issue of The Journal of Pediatrics, showed that girls aged 9 to 20 who consumed more than 40% of their total calories from solid fats and added sugars reported low intakes of vitamins A, D, and E, as well as calcium and potassium with increasing amounts of sugar intake. A 2012 Finnish longitudinal study published in Nutrition by Song and colleagues found that children from birth to age 9 with the highest sucrose intakes tended to receive less vitamin E, niacin, calcium, iron, zinc, and dietary fiber compared with those who had moderate and low consumption of sucrose. The low sucrose consumers also had higher intakes of nutrient-dense foods such as grains, vegetables, and dairy products.

NHANES data from 2005–2008 also suggest that dietary sodium intake is positively correlated with consumption of sugar-sweetened beverages, according to a May 2013 study by Grimes and colleagues in The American Journal of Clinical Nutrition. Another potential problem with added sugars, especially those in liquid form, is that they may provide children with excess calories, leading them to reduce energy intake from other foods. Briefel and colleagues used diet modeling in a study published in the February 2013 issue of the Journal of the Academy of Nutrition and Dietetics, suggesting that if children switched from sugar-sweetened beverages and flavored milks to unflavored low-fat milks at meals and water between meals, they would save an average of 205 kcal per day, or a 10% reduction in total calorie intake.

How Can Kids Limit Added Sugar?
Based on the research, "it's absolutely understandable for parents to be concerned about added sugars, as they're linked to some serious health concerns," Halas-Liang says. "Because there's so much confusion with advertisements regarding food, the more we can educate parents about added sugars in food, the more they can provide better choices for their children." Halas-Liang sees many potential benefits from the AHA's recommendation for added sugars. "Eating many foods that contain added sugars beginning at a young age creates poor eating habits that children will carry with them throughout their lives. Childhood should be a time when children are learning health-promoting habits that can help them in the long run."

Inga Voloshin, RDN, retail dietitian at ShopRite of White Plains, New York, has an optimistic outlook about helping customers in her supermarket to keep added sugars in check. She says she's "encouraged by the growing movement of both manufacturers and organizations that are working to raise awareness about the importance of nutrition, especially when it comes to empowering and educating parents who are deciding on foods to buy for their entire families."

Voloshin tries to "simplify this process by showing families how to read the Nutrition Facts label as well as ingredient list on the back of a packaged product." She says, "Identifying alternative names for sugar, like corn syrup or dextrose, may be a good way to gauge the presence of added sugars." She also recommends comparing nutrition facts of various products within the same category, since household staples like breakfast cereal, peanut butter, and even yogurt can vary tremendously in added sugar content, and encouraging children to drink water instead of sugar-sweetened beverages. Bremner believes that "the food supply needs to change to get most Americans within the recommendations for sugar, but the best defense is a good offense." For overall strategies, Bremner suggests sticking to a largely plant-based diet, which contains natural sugars.

Halas-Liang says, "Parents can focus on teaching children the difference between added sugar as opposed to natural sugars that come in whole foods, which also offer vitamins, minerals, and phytochemicals that keep us healthy." She adds: "It's important for parents not to create any fear or overly strict rules about specific food groups. Having candid conversations about how certain foods influence our bodies can help children understand healthful choices." By talking to children, she says, "parents are less likely to seem restrictive and more likely to help their kids gain an understanding why certain choices are more beneficial than others."

— Christen C. Cooper, MS, RDN, is a doctoral candidate in nutrition education at Teachers College, Columbia University.