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Added Sugars: Bittersweet

Sleuthing Out Added Sugars article

Culinary Medicine

sugar


 Sugar seduces our taste buds, whether you spoon it into coffee or sprinkle it onto cereal, it adds the sweetness that we crave. Sugar also provides a quick source of energy for our muscles and our brains. But adding too much sugar to your diet can contribute to the risk of obesity and other chronic disorders. Avoiding sugar, however; is not easy. For example, if you stop at Starbucks for a morning Frappuccino, snack on a granola bar, and then have a sugared soft drink with lunch you have consumed over 100 grams of what are called added sugars, more than double the maximum recommended for the entire day. How can we identify added sugars in our diets and why are health professionals trying to get us to eat less of them? 


Natural vs Added Sugars 

Many of the foods we enjoy are inherently sweet. Apples, pears, strawberries, watermelon, and even asparagus, and peas, contain the sugar fructose and milk contains lactose, also known as milk sugar. These sugars are natural components of fruits, vegetables, and milk so are not considered added sugars.  The sugar we consume in these foods comes along with the vitamins, minerals, protein, fiber, and phytochemicals found in the original source. In contrast, added sugars have been separated from their natural plant sources, often sugar beets or sugar cane, and then added to foods to increase sweetness as well to improve texture and extend shelf life. Americans consume about 60 pounds of added sugars per person per year.[1] Most of this is consumed in processed foods; 74% of processed packaged foods contain added sugars.[2]  Over half of the added sugars in the American diet come from sugar-sweetened beverages, such as soft drinks, sports drinks, fruit drinks, energy drinks, sweet tea, and sweetened coffee drinks.[3] Although added sugars are nutritionally and chemically identical to the sugars that occur naturally in foods, they do not come with other nutrients; they only contribute calories to the foods to which they are added. 


Added Sugars and Health

Diets high in added sugars have been implicated as a risk factor for some of the major chronic diseases in the United States, including obesity, diabetes, and cardiovascular disease (CVD) as well as fatty liver disease, dental caries, and some cancers.[4]  Because so much of the added sugars in our diet come from beverages, much of the research on added sugars and health has examined the relationship between sugar-sweetened beverage intake and disease. 


All added sugars add calories to our diets, which contribute to weight gain, but sugar-sweetened beverage consumption is a particular risk for obesity. This is because liquids are not as satiating as solid foods so the calories we consume in liquids are not compensated for by reductions in calorie intake from other foods. Also, the rapid absorption of the sugar in these beverages causes spikes in blood glucose and insulin that could increase hunger.[5] Meta-analyses find a positive correlation between sugar-sweetened beverage intake and obesity and when sugar-sweetened beverages are added to participants diets they gain weight.[6]  In contrast, replacing sugar-sweetened beverages with non-caloric beverages reduces body weight among study participants.[7]  


sugar identified in Nutrition Facts

Most sugar-sweetened beverages are sweetened with high-fructose corn syrup. This sweetener tastes sweeter than sucrose (table sugar) so manufacturers can use less to achieve the same degree of sweetness. A high intake of fructose is believed to be a particular risk for chronic disease. One reason is that fructose is broken down in the liver where it is used to synthesize fat, contributing to fat storage in the liver and the abdominal region.[8] Excess fat in the liver can lead to non-alcoholic fatty liver disease.[4] Greater amounts of abdominal fat increase the risk of diabetes and CVD. [6] The risk of diabetes is correlated with sugar-sweetened beverage intake. Part of this increased risk is due to weight gain, but factors independent of obesity also play a role. [9]   Sugar-sweetened beverage consumption is also associated with a higher risk of CVD.[10] Weight gain and diabetes increase the risk of CVD, but added sugars also impact other CVD risk factors; higher intakes increase serum triglycerides, total cholesterol, LDL cholesterol, and blood pressure. [11] 


Sleuthing Out Added Sugars

Reducing your intake of added sugars requires knowing where they are coming from in your diet. A teaspoon of sugar tipped into your coffee is an obvious source of added sugar. And sugar-sweetened beverages, cakes, candy, and cookies are foods we recognize as high in added sugars, but other sources are not so apparent. For example, low-fat fruit yogurt, which we think of as a healthy choice, often contains 13 grams of added sugars. Foods we don’t think of as sweet, such as pasta sauces, canned soups, and baked beans can also provide significant amounts; a serving of canned baked beans has more than 10 grams of added sugars. Even condiments like ketchup, salad dressing, and barbecue sauce add sugar to our diets. 


 To identify food products that are high in added sugars look at the Nutrition Facts panel on your food label. It lists the grams of total sugars in a serving, which is the sum of naturally occurring sugars and added sugars and includes a separate listing for added sugars, both in grams and as as a %Daily Value. The %Daily Value is the amount of added sugars in a serving of the food as a percentage of the amount recommended (less than 50 grams) for a 2000-Calorie diet. So, if a serving of a food has 20% of the Daily Value for added sugars it provides 20% of the 50-gram maximum recommended per day. Make sure to also check the serving size. If the serving size on the Nutrition Facts label on your box of cookies is 2 cookies and you eat four, you are eating twice the amount of added sugars listed on the label. 


The ingredient list can also help identify the added sugars in processed foods, but you may not see the word “sugar”. Only sucrose can be listed as sugar in ingredient lists and there are many other forms of sugar that are added to food products (See table). Since ingredients are listed in order of prominence by weight, the closer to the front of the list a sweetener appears, the more of it by weight is in the product. In a product that contains more than one sweetener, together they may account for a larger proportion of the products weight than you would judge from their place on the list. 


Reducing Added Sugars in Your Diet

The Dietary Guidelines for Americans recommend that people 2 years of age and older consume less than 10% of calories from added sugars. [12]  For a 2000-Calorie diet this is less than 200 Calories from added sugars (about 50 grams), which is the equivalent of about 12 teaspoons per day. Children younger than 2 years should not be given any foods or beverages with added sugars. Currently 60% of Americans exceed the 12 teaspoon per day limit, consuming an average of 17 teaspoons of added sugars per day. [13] 


For most of us, cutting down on added sugars should start by replacing sugar-sweetened beverages with water. A 12-ounce can of soda contains about 10 teaspoons of sugar; sweet teas, juice drinks, and coffee drinks have about the same amount. If you want more flavor than plain water offers, try adding lemon or lime juice to your water or choose a sugar-free commercial seltzer drink. Desserts are another major source of added sugars; replace some or all of your desserts with fruit. If you choose canned or frozen fruit, check the label to be sure it doesn’t contain added sugars. Reading labels can help you limit the added sugars from foods we don’t consider sweets such as sauces and condiments.  But you don’t have to skip the ketchup or make your own sugar-free spaghetti sauce, just keep track of how much added sugar you are consuming. You can still enjoy some sweet while avoiding the bitter consequences of added sugars by keeping your total below the 50-gram limit.


References


[1] US Department of Agriculture, Agricultural Research Service. Food Patterns Equivalents Intakes from Food: Mean Amounts Consumed per Individual, What We Eat in America, NHANES 2017–2018. https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/FPED/tables_1-4_FPED_1718.pdf 


[2] Ng SW, Slining MM, Popkin BM. Use of Caloric and Noncaloric Sweeteners in US Consumer Packaged Foods, 2005-2009. Journal of the Academy of Nutrition and Dietetics. 2012;112(11):1828-1834.e6. doi:https://doi.org/10.1016/j.jand.2012.07.009

[3] Lee SH, Zhao L, Park S, et al. High Added Sugars Intake among US Adults: Characteristics, Eating Occasions, and Top Sources, 2015–2018. Nutrients. 2023;15(2):265. doi:https://doi.org/10.3390/nu15020265

[4] Huang Y, Chen Z, Chen B, et al. Dietary sugar consumption and health: umbrella review. BMJ. 2023;381:e071609. doi:https://doi.org/10.1136/bmj-2022-071609

[5] Ludwig DS, Ebbeling CB. The Carbohydrate-Insulin Model of Obesity. JAMA Internal Medicine. 2018;178(8):1098. doi:https://doi.org/10.1001/jamainternmed.2018.2933

[6] Malik VS, Hu FB. The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases. Nature Reviews Endocrinology. 2022;18(4):205-218. doi:https://doi.org/10.1038/s41574-021-00627-6


[7] Ebbeling CB, Feldman HA, Steltz SK, Quinn NL, Robinson LM, Ludwig DS. Effects of Sugar‐Sweetened, Artificially Sweetened, and Unsweetened Beverages on Cardiometabolic Risk Factors, Body Composition, and Sweet Taste Preference: A Randomized Controlled Trial. Journal of the American Heart Association. 2020;9(15). doi:https://doi.org/10.1161/jaha.119.015668


[8]Hannou SA, Haslam DE, McKeown NM, Herman MA. Fructose metabolism and metabolic disease. J Clin Invest. 2018 Feb 1;128(2):545-555. doi: 10.1172/JCI96702. 


[9] Imamura F, O’Connor L, Ye Z, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;351:h3576. doi:https://doi.org/10.1136/bmj.h3576


[10] Yin J, Zhu Y, Malik V, Li X, Peng X, Zhang FF, Shan Z, Liu L. Intake of Sugar-Sweetened and Low-Calorie Sweetened Beverages and Risk of Cardiovascular Disease: A Meta-Analysis and Systematic Review. Adv Nutr. 2021 Feb 1;12(1):89-101. doi: 10.1093/advances/nmaa084. 


[11] Te Morenga, L. A., Howatson, A. J., Jones, R. M. Mann, J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am. J. Clin. Nutr. 100, 65–79 (2014). 


[12] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. https://www.dietaryguidelines.gov 

[13] CDC. Be Smart About Sugar. Healthy Weight and Growth. Published May 13, 2024. https://www.cdc.gov/healthy-weight-growth/be-sugar-smart/index.html

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