Charting the Chronology of Research on Added Sugars: A Scoping Review and Evidence Map.

The objective of this study was to conduct a scoping review and produce a publicly available database characterizing the design and reporting elements of the literature on dietary added sugars and select health outcomes. Relevant studies published from 1990 to 2021 were identified to create a database containing information on study and population characteristics, reported added sugars source and concentrations, dietary energy balance, total energy intake, and outcome measures related to body composition, obesity, cardiovascular disease, and diabetes mellitus. There were 245 publications identified, 22% of which describe interventions, and 78% describe observational studies. Publications pertaining to added sugars have risen dramatically since 2010, led by studies primarily assessing body composition (36%) or cardiovascular health (32%), including adults (65%), measuring liquid-only sources of added sugars (56%). Over 65% of studies reported total energy intake, 61% controlled for total energy intake in the design and analysis, and fewer than 5% of studies reported the energy balance of subjects. There has been a significant increase in research on added sugars since 2010, with substantial heterogeneity across all facets of methodology-study designs, exposures and outcomes of interest, terminology, and reporting of dietary intake data-thus limiting the ability to synthesize evidence in this scope of the literature. This evidence map highlights gaps and important areas for improvement to strengthen the state of research and better inform future policies and dietary recommendations on added sugars.

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.

Intakes of Added Sugars, with a Focus on Beverages and the Associations with Micronutrient Adequacy in US Children, Adolescents, and Teens (NHANES 2003-2018).

Added sugars intake from sweetened beverages among children, adolescents, and teens is a public health concern. This study examined the relationships between added sugars intake from specific types of beverages with added sugars and from the rest of the diet (excluding beverages with added sugars) and micronutrient adequacy among US children, adolescents, and teens. Data from eight consecutive 2 y cycles of NHANES were combined (2003-04 through 2017-18), and regression analysis was conducted to test for trends in quantiles of added sugars intake from each beverage source (soft drinks, fruit drinks, sport and energy drinks, coffee and tea, and flavored milk) and the rest of the diet (excluding those beverages) and micronutrient adequacy among children (2-8 y) and adolescents and teens (9-18 y). Among those aged 2-8 y, higher added sugars from flavored milk were associated with lower percentages below the estimated average requirement (EAR) for calcium. Among those aged 9-18 y, higher added sugars from soft drinks or coffee and tea were associated with higher percentages below the EAR for magnesium and vitamins A and C. In contrast, higher added sugars from fruit drinks or flavored milk were associated with lower percentages below the EAR (higher percentages above the adequate intake (AI)) for vitamin C (fruit drinks) and calcium, magnesium, phosphorus, vitamin A, and potassium (flavored milk). Regarding the rest of the diet, higher added sugars were associated with lower percentages below the EAR (higher percentages above the AI) for most micronutrients examined. The results suggest that the relationship between added sugars intake and micronutrient adequacy depends on the added sugar sources and their nutrient composition. Continued monitoring of sweetened beverage consumption, including beverage type, and the association with added sugars intake, micronutrient adequacy, and diet quality is warranted, given the changes in consumption and product development over time.

Trends in added sugars intake and sources among U.S. adults using the National Health and Nutrition Examination Survey (NHANES) 2001-2018.

Research on trends over time in added sugars intake is important to help gain insights into how population intakes change with evolving dietary guidelines and policies on reducing added sugars. The purpose of this study was to provide an analysis of dietary trends in added sugars intakes and sources among U.S. adults from 2001 to 2018, with a focus on variations according to the sociodemographic factors, age, sex, race and ethnicity and income, and the health-related factors, physical activity and body weight. Data from nine consecutive 2 year cycles of the National Health and Nutrition Examination Survey (NHANES) were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001 to 2018. Trends were examined in the whole sample (19+ years) and in subsamples stratified by age (19-50, 51+ years), sex, race and ethnicity (Asian, Black, Hispanic, White), household income (poverty income ratio low, medium, high), physical activity level (sedentary, moderate, vigorous) and body weight status (normal, overweight, obese). From 2001 to 2018, added sugars intake (% kcal) decreased significantly (P < 0.01), from 16.2 to 12.7% among younger adults (19-50 years), mainly due to declines in added sugars from sweetened beverages, which remained the top source. There were no changes in intake among older adults, and by 2018, the 23% difference in intake between younger and older adults that existed in 2001 almost disappeared. Declines in added sugars intake were similar among Black and White individuals, and all income, physical activity and body weight groups. Population-wide reductions in added sugars intake among younger adults over an 18 year time span coincide with the increasing public health focus on reducing added sugars intake. With the updated Nutrition Facts label now displaying added sugars content, it remains to be seen how added sugars intake trends carry forward in the future.

Trends in Added Sugars Intake and Sources Among US Children, Adolescents, and Teens Using NHANES 2001-2018.

BACKGROUND: Over the past 2 decades, there has been an increased emphasis on added sugars intake in the Dietary Guidelines for Americans (DGA), which has been accompanied by policies and interventions aimed at reducing intake, particularly among children, adolescents, and teens. OBJECTIVES: The present study provides a comprehensive time-trends analysis of added sugars intakes and contributing sources in the diets of US children, adolescents, and teens (2-18 years) from 2001-2018, focusing on variations according to sociodemographic factors (age, sex, race and ethnicity, income), food assistance, and health-related factors (physical activity level, body weight status). METHODS: Data from 9 consecutive 2-year cycles of the NHANES were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001-2018 for the overall age group (2-18 years) and for 2 age subgroups (2-8 and 9-18 years). Trends were also examined on subsamples stratified by sex, race and ethnicity (Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White), income (household poverty income ratio), food assistance, physical activity level, and body weight status. RESULTS: From 2001-2018, added sugars intakes decreased significantly (P < 0.01), from 15.6% to 12.6% kcal among children (2-8 years) and from 18.4% to 14.3% kcal among adolescents and teens (9-18 years), mainly due to significant declines in added sugars from sweetened beverages, which remained the top source. Declines in added sugars intakes were observed for all strata, albeit to varying degrees. CONCLUSIONS: Declines in added sugars intakes were observed among children, adolescents, and teens from 2001-2018, regardless of sociodemographic factors, food assistance, physical activity level, or body weight status, but variations in the magnitudes of decline suggest persistent disparities related to race and ethnicity and to income. Despite these declines, intakes remain above the DGA recommendation; thus, continued monitoring is warranted.

Sources of Added Sugars Intake Among the U.S. Population: Analysis by Selected Sociodemographic Factors Using the National Health and Nutrition Examination Survey 2011-18.

Recent estimates of added sugars intake among the U.S. population show intakes are above recommended levels. Knowledge about the sources of added sugars contributing to intakes is required to inform dietary guidance, and understanding how those sources vary across sociodemographic subgroups could also help to target guidance. The purpose of this study was to provide a comprehensive update on sources of added sugars among the U.S. population, and to examine variations in sources according to sociodemographic factors. Regression analyses on intake data from NHANES 2011-18 were used to examine sources of added sugars intake among the full sample (N = 30,678) and among subsamples stratified by age, gender, ethnicity, and income. Results showed the majority of added sugars in the diet (61-66%) came from a few sources, and the top two sources were sweetened beverages and sweet bakery products, regardless of age, ethnicity, or income. Sweetened beverages, including soft drinks and fruit drinks, as well as tea, were the largest contributors to added sugars intake. There were some age-, ethnic-, and income-related differences in the relative contributions of added sugars sources, highlighting the need to consider sociodemographic contexts when developing dietary guidance or other supports for healthy eating.

Comparison of Various Methods to Determine Added Sugars Intake to Assess the Association of Added Sugars Intake and Micronutrient Adequacy.

Different methods for determining the effect of added sugars intake among children and adults on meeting recommended nutrient intakes were compared using 24 h dietary recall data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Four methods were used to determine deciles of added sugars intake (as the percentage of total calories): 1 day intake, 2 day average intake, and individual usual intake (UI) determined with the National Cancer Institute (NCI) and the multivariate Markov Chain Monte Carlo methods. Percentages of the population below the Estimated Average Requirement (EAR) for calcium and vitamin D/above the Adequate Intake (AI) for potassium and dietary fiber for each decile of added sugars intake were assessed with the NCI method. Using regression analyses, added sugars intake deciles (by any method) in children were inversely associated (p < 0.001) with percentages below the EAR/above the AI of vitamin D, calcium, potassium, and fiber. In adults, added sugars intake deciles were inversely associated with meeting recommendations for vitamin D, potassium, and fiber. There were no significant between-method differences for regression coefficients for any nutrients investigated. Overall, these methods showed a similar association of added sugars intake with nutrient inadequacy/adequacy; therefore, method preference may depend more on practical reasons.

Micronutrient Dilution and Added Sugars Intake in U.S. Adults: Examining This Association Using NHANES 2009-2014.

There is inconsistent evidence regarding the impact of added sugars consumption on micronutrient dilution of the diet. We examined the associations between added sugars intake deciles and nutrient adequacy for 17 micronutrients in U.S. adults 19+ (n = 13,949), 19-50 (n = 7424), and 51+ y (n = 6525) using two days of 24 hour dietary recall data from the National Health and Nutrition Examination Survey (NHANES) 2009-2014 and regression analysis. Added sugars intake deciles ranged from <3.8 to >23.3% of calories among adults 19+ y, with a median intake of 11.0% of calories. Significant associations (p ≤ 0.01) between added sugars intake deciles and percentage of the population below the Estimated Average Requirement (EAR) were found for magnesium, vitamin C, vitamin D, and vitamin E; only the association with magnesium remained significant after dropping the two highest and lowest deciles of intake, suggesting a threshold effect. Intakes below approximately 18% of calories from added sugars were generally not associated with micronutrient inadequacy. However, even at the lower deciles of added sugars, large percentages of the population were below the EAR for these four micronutrients, suggesting that adequate intakes are difficult to achieve regardless of added sugars intake.

Association of Added Sugars Intake with Micronutrient Adequacy in US Children and Adolescents: NHANES 2009-2014.

BACKGROUND: A concern about the excessive consumption of added sugars is the potential for micronutrient dilution, particularly in children and adolescents; however, the evidence is inconsistent. OBJECTIVE: We examined the associations between added sugars intake and micronutrient adequacy in US children and adolescents using data from NHANES 2009-2014. METHODS: Children and adolescents aged 2-18 (n = 7754), 2-8 (n = 3423), and 9-18 y (n = 4331) were assigned to deciles of added sugars intake based on the average of 2 d of dietary recall. Usual intake of micronutrients was determined using 2 dietary recalls and the National Cancer Institute method. Within each age group, regression analyses were used to assess the relationship between added sugars intake decile and percentage of the population below the estimated average requirements (EARs) for 17 micronutrients. RESULTS: Deciles of added sugars intake (percentage of calories) ranged from <6.4 to >22.8 among children and adolescents aged 2-18 y, with a median intake of 13.3% of calories. Significant positive associations (P < 0.01) between added sugars intake and percentage of the population (aged 2-18 y) below the EAR were found only for calcium, magnesium, and vitamin D. These associations virtually disappeared after dropping the 2 highest and lowest deciles of intake, suggesting a threshold effect; intakes below approximately 19% of calories from added sugars were generally not associated with micronutrient inadequacy. CONCLUSIONS: As added sugars intake increased, there was a threshold above which an increase in the prevalence of inadequate intakes for calcium, magnesium, and vitamin D among US children and adolescents was observed. However, even at the lower deciles of added sugars, large percentages of the population were below the EAR for these nutrients, suggesting that adequate intakes of these nutrients are difficult to achieve independent of added sugars intake.

Dietary approaches to treat MS-related fatigue: comparing the modified Paleolithic (Wahls Elimination) and low saturated fat (Swank) diets on perceived fatigue in persons with relapsing-remitting multiple sclerosis: study protocol for a randomized controlled trial.

BACKGROUND: Fatigue is one of the most disabling symptoms of multiple sclerosis (MS) and contributes to diminishing quality of life. Although currently available interventions have had limited success in relieving MS-related fatigue, clinically significant reductions in perceived fatigue severity have been reported in a multimodal intervention pilot study that included a Paleolithic diet in addition to stress reduction, exercise, and electrical muscle stimulation. An optimal dietary approach to reducing MS-related fatigue has not been identified. To establish the specific effects of diet on MS symptoms, this study focuses on diet only instead of the previously tested multimodal intervention by comparing the effectiveness of two dietary patterns for the treatment of MS-related fatigue. The purpose of this study is to determine the impact of a modified Paleolithic and low saturated fat diet on perceived fatigue (primary outcome), cognitive and motor symptoms, and quality of life in persons with relapsing-remitting multiple sclerosis (RRMS). METHODS/DESIGN: This 36-week randomized clinical trial consists of three 12-week periods during which assessments of perceived fatigue, quality of life, motor and cognitive function, physical activity and sleep, diet quality, and social support for eating will be collected. The three 12-week periods will consist of the following: 1. OBSERVATION: Participants continue eating their usual diet. 2. INTERVENTION: Participants will be randomized to a modified Paleolithic or low saturated fat diet for the intervention period. Participants will receive support from a registered dietitian (RD) through in-person coaching, telephone calls, and emails. 3. FOLLOW-UP: Participants will continue the study diet for an additional 12 weeks with minimal RD support to assess the ability of the participants to sustain the study diet on their own. DISCUSSION: Because fatigue is one of the most common and disabling symptoms of MS, effective management and reduction of MS-related fatigue has the potential to increase quality of life in this population. The results of this study will add to the evidence base for providing dietary recommendations to treat MS-related fatigue and other symptoms associated with this disease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02914964 . Registered on 24 August 2016.