Canadian Adults with Moderate Intakes of Total Sugars have Greater Intakes of Fibre and Key Micronutrients: Results from the Canadian Community Health Survey 2015 Public Use Microdata File

Intakes of Added Sugars, with a Focus on Beverages and the Associations with Nutrient Adequacy in US Adults (NHANES 2003-2018)

The Dietary Guidelines for Americans recommend adults increase their intake of nutrients that are under-consumed while limiting their intake of added sugars, sodium, and saturated fats. The purpose of this study was to examine the relationship between added sugars intake from specific types of beverages with added sugars (soft drinks, fruit drinks, sports and energy drinks, coffee and tea, and flavored milk) and nutrient adequacy among US adults (19+ y). Data from eight consecutive 2-y cycles of NHANES were combined (2003-2004 through 2017-2018), and regression analysis was conducted to test for trends in quantiles of added sugars intake from each beverage source and the rest of the diet (excluding those beverages) and nutrient adequacy. Results revealed significant associations that varied in direction according to the added sugars source, negative for some (i.e., soft drinks) in terms of greater percentages of adults not meeting a defined threshold of nutrient adequacy with higher added sugars intakes, and positive for others (i.e., fruit drinks, flavored milk, the rest of the diet) in terms of lower percentages of adults not meeting nutrient thresholds. In conclusion, the contribution of different added sugars sources to nutrient intakes is a critical consideration in developing population-based dietary recommendations.

Trends in Loss-Adjusted Availability of Added Sugars and Energy Contribution from Macronutrients and Major Food Groups in Canada and the United States

A clear understanding of changes in the consumption of sugars and other sugars-containing foods has become essential for dietary recommendations and nutrition policy considerations. This study aimed to estimate the consumption trends of added sugars, energy, macronutrients, and food categories using food supply data.

Annual food availability data were obtained from Statistics Canada "Food Available in Canada" database and compared to the equivalent data from Canadian Community Health Survey 2004/2015 and USDA "Food Availability (Per Capita) Data System".

There was a 17% decline in the loss-adjusted per capita consumption of added sugars (%energy) in Canada over the past two decades, largely attributed to reduced intakes of refined sugar and sugars from soft drinks. Added sugars consumption was generally 30% less than that in the US. There was also a consistent decline in total energy intake and %energy from carbohydrates, accompanied by increased %energy derived from fats particularly during the most recent 10 years.

The observed trends in added sugars availability are similar to findings from the Canadian Community Health Surveys, demonstrating the potential application of annual loss-adjusted food availability data in monitoring trends in food and macronutrient intakes over time to complement dietary survey data in informing public policy development.

Nutrient intakes and top food categories contributing to intakes of energy and nutrients-of-concern consumed by Canadian adults that would require a 'high-in' front-of-pack symbol according to Canadian labelling regulations

Canada recently mandated front-of-pack (FOP) labelling regulations, where foods meeting and/or exceeding recommended thresholds for nutrients-of-concern (i.e., saturated fat, sodium, and sugars) must display a 'high-in' FOP nutrition symbol. However, there is limited research on the amounts and sources of foods consumed by Canadians that would require a FOP symbol. The objective was to examine the intakes of nutrients-of-concern from foods that would display a FOP symbol and to identify the top food categories contributing to intakes for each nutrient-of-concern. Using the first day 24-hour dietary recall from the nationally representative 2015 Canadian Community Health Survey-Nutrition (CCHS), Canadian adults' intakes of nutrients-of-concern from foods that would display a FOP symbol was examined. Foods were assigned to 1 of 62 categories to identify the top food categories contributing to intakes of energy and nutrient-of-concern that would display a FOP symbol for each nutrient-of-concern. Canadian adults (n = 13,495) consumed approximately 24% of total calories from foods that would display a FOP symbol. Foods that would display a FOP symbol for exceeding thresholds for nutrients-of-concern accounted for 16% of saturated fat, 30% of sodium, 25% of total sugar, and 39% of free sugar intakes among Canadian adults. The top food category contributing intakes of each nutrient-of-concern that would display a FOP symbol were nutrient-specific: Processed meat and meat substitutes for saturated fat; Breads for sodium; and Fruit juices & drinks for total and free sugars. Our findings show that Canadian FOP labelling regulations have the potential to influence the intakes of nutrients-of-concern for Canadian adults. Using the findings as baseline data, future studies are warranted to evaluate the impact of FOP labelling regulations.

Important Food Sources of Fructose-Containing Sugars and Non-Alcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of Controlled Trials

Background: Fructose providing excess calories in the form of sugar sweetened beverages (SSBs) increases markers of non-alcoholic fatty liver disease (NAFLD). Whether this effect holds for other important food sources of fructose-containing sugars is unclear. To investigate the role of food source and energy, we conducted a systematic review and meta-analysis of controlled trials of the effect of fructose-containing sugars by food source at different levels of energy control on non-alcoholic fatty liver disease (NAFLD) markers. Methods and Findings: MEDLINE, Embase, and the Cochrane Library were searched through 7 January 2022 for controlled trials ≥7-days. Four trial designs were prespecified: substitution (energy-matched substitution of sugars for other macronutrients); addition (excess energy from sugars added to diets); subtraction (excess energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced by other macronutrients). The primary outcome was intrahepatocellular lipid (IHCL). Secondary outcomes were alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Independent reviewers extracted data and assessed risk of bias. The certainty of evidence was assessed using GRADE. We included 51 trials (75 trial comparisons, n = 2059) of 10 food sources (sugar-sweetened beverages (SSBs); sweetened dairy alternative; 100% fruit juice; fruit; dried fruit; mixed fruit sources; sweets and desserts; added nutritive sweetener; honey; and mixed sources (with SSBs)) in predominantly healthy mixed weight or overweight/obese younger adults. Total fructose-containing sugars increased IHCL (standardized mean difference = 1.72 [95% CI, 1.08 to 2.36], p < 0.001) in addition trials and decreased AST in subtraction trials with no effect on any outcome in substitution or ad libitum trials. There was evidence of influence by food source with SSBs increasing IHCL and ALT in addition trials and mixed sources (with SSBs) decreasing AST in subtraction trials. The certainty of evidence was high for the effect on IHCL and moderate for the effect on ALT for SSBs in addition trials, low for the effect on AST for the removal of energy from mixed sources (with SSBs) in subtraction trials, and generally low to moderate for all other comparisons. Conclusions: Energy control and food source appear to mediate the effect of fructose-containing sugars on NAFLD markers. The evidence provides a good indication that the addition of excess energy from SSBs leads to large increases in liver fat and small important increases in ALT while there is less of an indication that the removal of energy from mixed sources (with SSBs) leads to moderate reductions in AST. Varying uncertainty remains for the lack of effect of other important food sources of fructose-containing sugars at different levels of energy control.

The economic burden of excessive sugar consumption in Canada: should the scope of preventive action be broadened?

Objective

Excessive sugar consumption is an established risk factor for various chronic diseases (CDs). No earlier study has quantified its economic burden in terms of health care costs for treatment and management of CDs, and costs associated with lost productivity and premature mortality. This information, however, is essential to public health decision-makers when planning and prioritizing interventions. The present study aimed to estimate the economic burden of excessive free sugar consumption in Canada.

Methods

Free sugars refer to all monosaccharides and disaccharides added to foods plus sugars naturally present in honey, syrups, and fruit juice. Based on free sugar consumption reported in the 2015 Canadian Community Health Survey–Nutrition and established risk estimates for 16 main CDs, we calculated the avoidable direct health care costs and indirect costs.

Results

If Canadians were to comply with the free sugar recommendation (consumption below 10% of total energy intake (TEI)), an estimated $2.5 billion (95% CI: 1.5, 3.6) in direct health care and indirect costs could have been avoided in 2019. For the stricter recommendation (consumption below 5% of TEI), this was $5.0 billion (95% CI: 3.1, 6.9).

Conclusion

Excessive free sugar in our diet has an enormous economic burden that is larger than that of any food group and 3 to 6 times that of sugar-sweetened beverages (SSBs). Public health interventions to reduce sugar consumption should therefore consider going beyond taxation of SSBs to target a broader set of products, in order to more effectively reduce the public health and economic burden of CDs.

Intakes of nutrients and food categories in Canadian children and adolescents across levels of sugars intake: cross-sectional analyses of the Canadian Community Health Survey 2015 Public Use Microdata File

Dietary recommendations to reduce sugars consumption may influence choices of sugars-containing foods and affect the intake of key micronutrients. We compared intakes of nutrients and food sources stratified by quintiles of total sugars in Canadian children (2-8 y) and adolescents (9-13 y, 14-18 y) using 24-hour dietary recalls from the 2015 Canadian Community Health Survey-Nutrition. Energy intakes did not differ across quintiles of sugars intake. Those with lower sugars intakes (Q1/Q3) generally had higher protein, fat, sodium, niacin, folate, and zinc and lower vitamin C compared with those with the highest sugars intakes (Q5). Q1 also had lower potassium but higher saturated fat compared with Q5. Further, Q1 generally had higher protein, fats, and niacin compared with Q3, while children in Q3 had higher potassium and riboflavin and older adolescents had higher calcium and fibre. Q5 had highest intakes of multiple sugar-containing food categories (e.g., fruit, confectionary, milks, cakes/pies/pastries), with higher sugars-sweetened beverages in adolescents. Q3 had higher fruit, milks, and fruit juice compared with Q1 and lower sugars/syrups/preserves, confectionary, and fruit juices compared with Q5. Certain nutrient-dense food sources of sugars (fruit, milks) may help increase key nutrients (potassium, calcium, fibre) in older adolescents with low sugars intakes. However, in those with the highest sugars intakes, nutrient-poor foods may displace nutrient-dense foods. Novelty: Canadian children and adolescents with lower sugars intake have better intakes of some nutrients. Energy intakes did not differ across sugars intake. Older adolescents with mean intakes of total sugars had better intakes of some key nutrients (potassium, calcium, fibre).

Free Sugars Consumption in Canada

Free sugars (FS) are associated with a higher risk of dental decay in children and an increased risk of weight gain, overweight and obesity and type 2 diabetes. For this reason, Canada’s Food Guide recommends limiting foods and beverages that contribute to excess free sugars consumption. Estimating FS intakes is needed to inform policies and interventions aimed at reducing Canadians’ consumption of FS. The objective of this study was to estimate FS intake of Canadians using a new method that estimated the free sugars content of foods in the Canadian Nutrient File, the database used in national nutrition surveys. We define FS as sugars present in food products in which the structure has been broken down. We found that 12% of total energy (about 56 g) comes from FS in the diet of Canadians 1 year of age and older (≥1 year). The top four sources were: (1) sugars, syrups, preserves, confectionary, desserts; (2) soft drinks; (3) baked products and (4) juice (without added sugars), and accounted for 60% of total free sugars intake. The results show that efforts need to be sustained to help Canadians, particularly children and adolescents, to reduce their FS intake.

An examination of contributions of animal- and plant-based dietary patterns on the nutrient quality of diets of adult Canadians

Dietary guidance and Canada's 2019 Food Guide encourage increased consumption of plant-based foods as a source of dietary protein. However, there is an absence of recent data on protein and nutrient intakes and quality of Canadian dietary patterns that might occur with increased plant protein intakes. This study compared food sources and nutrient intakes of Canadian adults within groups of increasing plant protein-containing diets. The CCHS 2015 Public-Use Microdata File of single 24-hour dietary recalls of males and females ≥19 years (n = 6498) or ≥70 years (n = 1482) were examined. Respondents were allocated into 4 groups defined by their protein intake percentage coming from plant-based foods (i.e., group 1: 0-24.9%, group 2: 25-49.9%, group 3: 50-74.9%, group 4: 75-100%). Protein intake in adults averaged 63.3% animal and 36.7% plant protein. Where plant protein contributed >50% protein, higher intakes of carbohydrate, dietary fibre, folate, dietary folate equivalents, iron and magnesium (p < 0.001) but lower intakes of total and saturated fat, protein, vitamin D, vitamin B12, riboflavin and niacin (p < 0.0001) were reported. In contrast, group 1 had higher total and saturated fat, protein, vitamin B12, thiamin, niacin, and zinc, but lower carbohydrate, dietary fibre, and magnesium. Balancing plant- with animal-based protein foods leads to healthier dietary patterns with more favourable nutritional properties when compared with diets based on either high animal or high plant protein content. Novelty: Combinations of animal- and plant-based proteins improve nutrient quality of Canadian diets. The source of protein influences diet quality.

Destigmatizing Carbohydrate with Food Labeling: The Use of Non-Mandatory Labelling to Highlight Quality Carbohydrate Foods

Dietary carbohydrates are components of healthy foods, but many carbohydrate foods have recently been stigmatized as primary causes of diet-related risk factors for chronic disease. There is an opportunity to enhance efforts within the food landscape to encourage the consumption of higher quality carbohydrate foods. The use of labelling is one strategy that permits consumers to identify healthy carbohydrate foods at the point-of-purchase. This review discusses the regulatory frameworks and examples of associated non-mandatory food labelling claims that are currently employed to highlight healthy carbohydrate foods to consumers. The existing labelling frameworks discussed here align with established measures of carbohydrate quality, such as 1. dietary fibre nutrient content claims and associated dietary fibre-based health claims; 2. the presence of whole carbohydrate foods and ingredients that are intact or reconstituted, such as whole grains; and 3. low glycemic index and glycemic response claims. Standards from Codex Alimentarius, and regulations from Australia and New Zealand, Canada, Europe, and the United States will be used to illustrate the means by which food labelling can be used by consumers to identify quality carbohydrate foods.