Strong evidence links children's consumption of added sugars with increased cardiovascular disease (CVD) risk, according to a recent Scientific Statement from the American Heart Association (AHA).¹ Based on a review of relevant research, the statement recommends limits on consumption of sugar-sweetened beverages (SSBs) by children and adolescents, and identifies limits on total added sugar intake deemed reasonable. In considering this statement's conclusions, health care providers may have several relevant questions:

• How can these guidelines be positioned as part of promoting an overall healthy eating pattern, without simply shifting focus from one group of foods identified as "bad" to another, and without fueling attitudes that promote overly restrictive patterns of eating?
• What are the key message points to convey in discussing steps to reduce children's and adolescents' consumption of added sugars?

Research Overview

The AHA statement reviews and grades current evidence regarding cardiometabolic effects of children's intake of added sugars. Longitudinal studies and randomized controlled trials link added sugars, and particularly SSBs, with increased daily calorie intake, excess weight gain, and increased risk of obesity.^1,2

Intervention trials of added sugars and other CVD risk factors in youth are limited, but longitudinal and cross-sectional studies support an association of high intake with abnormal serum triglyceride and HDL levels. More research is needed to evaluate the potential for sugar intake to affect nonalcoholic fatty liver disease in children. Despite the strength of evidence in adults,^2,3 studies are likewise inconclusive on whether added sugars are related to insulin resistance and diabetes or blood pressure in children.¹ It's possible, but not yet shown, that children who are overweight or with particular genetic polymorphisms may be more strongly affected than others.

The AHA statement concludes that it is reasonable to recommend that children consume ≤25 g (100 calories, equivalent to about six teaspoons) of added sugars per day, and to avoid added sugars for children less than two years of age.¹

Prevalence of Risk-Relevant Intake

Overall, 2- to 18- year olds consumed 17% of total calories from added sugars in 2011-2012, according to the National Health and Nutrition Examination Survey.⁴ That's far above the 10% maximum recommended for overall health by the 2015 Dietary Guidelines Advisory Committee (DGAC).²

In comparison with the AHA's suggested target of ≤100 calories of added sugars daily for children, consumption ranged from 53 calories/day in the lowest quintile to 620 calories/day in the highest.⁴ Average intake expressed as grams of added sugar exceeds the AHA target across all ages in youth.¹

Added sugars most likely can be safely consumed in low amounts as part of a healthy diet, but few children consume such levels. Intake beyond AHA's advised levels is the norm, rather than the exception, and warrants attention in discussing healthy eating choices for youth.

Focus on Eating Pattern

Foods high in added sugars contribute to a diet rich in calories but poor in nutrients. Aside from added sugars' effects on cardiometabolic risk factors directly, and through excess calorie intake that leads to unhealthy adiposity, they may also increase risk by crowding out healthful, cardioprotective foods.²

The goal of an overall eating pattern that promotes health needs to be the focus in discussions of limiting added sugars. Recommended eating patterns in another recent AHA Scientific Statement increase unsaturated oils beyond amounts in patterns developed by the DGAC, reducing added sugar intake to ≤25 g/day at all calorie levels of 2400 calories/day or less.⁵ At higher calorie levels appropriate for adolescents who are larger and physically active, these patterns include added sugars beyond 25 g/day. However, in these higher-calorie eating patterns, added sugars represent about 5% of total calories, fitting well within an overall healthy diet.

Another vital message about reducing added sugars as part of overall healthy eating involves considering what, if anything, replaces those sugars. Reducing dietary saturated fat reduces heart disease risk when it is replaced by unsaturated fat or carbohydrate from whole grains, but not when replaced by refined grains and added sugars.^5,6 Similarly, in conveying the message to reduce added sugar consumption, it is important to emphasize that reducing sweets does not mean "butter and bacon are back."

Regardless of whether aiming for the AHA-advised limit of 25 g/day added sugars or the DGAC goal of <10% of total calories, creating a nutrient-rich eating pattern within an appropriate calorie level means limiting added sugars primarily to those that improve the palatability, enjoyment, and consumption of nutrient-dense foods. For example, small amounts of added sugars may enhance intake of whole-grain breakfast cereal or low-fat/fat-free yogurt, providing net improvement in a child's nutrient intake without excessive sugar or calories.

Key Talking Points

Despite the high level of added sugars in diets of US children and adolescents, both parents and youth are exposed to diverse messages about dietary sugar. In discussing ways to reduce added sugars, it's helpful to address common points of confusion.

Added sugars or total sugars? Added sugars, as defined by the US Department of Agriculture (USDA), include all sugars used as ingredients in processed and prepared foods, and sugars eaten separately or added to foods at the table. It does not include sugars naturally occurring in a food, such as fructose in fruit or lactose in milk. Total sugars include both added sugars and sugars naturally found in a food.

For a healthful eating pattern, aim to reduce added sugars. Fruit, for example, naturally contains sugar, yet also offers viscous fiber, as well as nutrients and phytochemicals that may offer antioxidant, anti-inflammatory benefits. Fruit in amounts beyond typical US consumption is part of eating patterns associated with lower risk of CVD.^5,7

Seem overwhelming? A wide range of foods, including pasta sauce, soup, and bread, contain small amounts of added sugar. However, for the average US child or adolescent, over 70% of added sugar intake comes from drinks (soda, fruit drinks, sports drinks) and sweet desserts or snacks (cake, cookies, candy, ice cream, and other dairy desserts).¹ Changing those major choices to occasional use only brings average intake of added sugars to under the AHA's suggested cap of 25 g/day.

Personal food choices vary, so it is helpful to inquire how large portions or multiple daily servings of lightly sweetened foods or unique food preferences might contribute to added sugars for a given individual. Moderate amounts of added sugar in foods throughout the day can add up, and it has been suggested that repeated exposure to foods with added sugars may promote preference for sweet taste.

Beverage choice is recommended as the first focus in reducing added sugars, and the AHA statement recommends no more than 8 ounces per week for youth.¹ On average, SSBs account for about half of children's and adolescents' added sugar intake. Research linking SSB intake to obesity and CVD risk factors is stronger than research on total added sugars. In part, that likely reflects methodological issues. However, longitudinal and cross-sectional studies suggest that SSB intake may especially promote weight gain as a source of liquid calories that do not promote satiety, with incomplete compensatory reduction in energy intake at subsequent meals.^1,3 Cardiovascular risk factors could also be particularly affected by SSBs independently through noncalorically-related metabolic effects of sugar consumed without fiber and other food components.³

Unsweetened 100% fruit juice is not a source of added sugars, but large amounts should not be encouraged as a replacement for SSBs. Although juice is nutrient-rich, based on current research regarding satiety and weight, for most children, it's best to limit fruit juice to one small glass daily, with solid fruit providing remaining fruit servings.^3,7

Confused by labels? The Nutrition Facts panel on food labels currently does not specifically identify added sugars, but new rules were published in May 2016.⁸ Under Total Carbohydrate, labels will list Dietary Fiber and Total Sugars, followed by an extra line identifying "Includes X g Added Sugars."

As for most other nutrients, the label will also list % Daily Value (DV) for added sugars. However, this is based on 10% of calories in a typical 2000-calorie adult diet, and thus DV equals 50 g added sugars. Since this is double the AHA recommended maximum for youth, use % DV only as a quick scan for foods that are relatively high (>20% DV) or low (<5% DV) in added sugars. Encourage people instead to focus on the grams of added sugars per serving, noting how the listed serving size compares to what they will consume.

Bottom Line

The AHA Scientific Statement concludes that strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia. Since intake of SSBs and added sugars are considerably beyond recommended limits in a large proportion of youth, talking about how to reduce intake makes sense as part of encouraging a heart-healthy lifestyle. Center discussions around identifying choices that can reduce added sugars not as a singular focus or overly restrictive approach to eating, but instead as part of improving overall healthfulness of eating habits while maintaining food as an enjoyable part of life.

References

1. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and cardiovascular disease risk in children: a scientific statement from the American Heart Association. Circulation 2016. [Epub ahead of print]
2. US Department of Health and Human Services. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Washington, DC: US Government Printing Office; 2015. http://www.health.gov/dietaryguidelines/2015-scientific-advisory-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf (Accessed November 2, 2016).
3. Malik VS, Hu FB. Fructose and cardiometabolic health: what the evidence from sugar-sweetened beverages tells us. J Am Coll Cardiol 2015;66:1615-24.
4. Powell ES, Smith-Taillie LP, Popkin BM. Added sugars intake across the distribution of US children and adult consumers: 1977-2012. J Acad Nutr Diet 2016 Oct;116:1543-50.
5. Van Horn L, Carson JA, Appel LJ, et al. Recommended dietary pattern to achieve adherence to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines: a scientific statement from the American Heart Association. Circulation 2016. [Epub ahead of print]
6. Li Y, Hruby A, Bernstein AM, et al. Saturated fats compared with unsaturated fats and sources of carbohydrates in relation to risk of coronary heart dsease: a prospective cohort study. J Am Coll Cardiol 2015;66:1538-48.
7. Mozaffarian M, Appel LJ, Van Horn L. Components of a cardioprotective diet. Circulation 2011;123:2870-91.
8. U.S. Food and Drug Administration. Changes to the Nutrition Facts Label. Updated November 1, 2016. http://www.fda.gov/Food/GuidanceRegulation/ GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm385663.htm (Accessed November 2, 2016).

Keywords: Adiposity, Adolescent, American Heart Association, Blood Pressure, Body Weight, Cardiovascular Diseases, Child, Diabetes Mellitus, Dyslipidemias, Energy Intake, Heart Diseases, Insulin Resistance, Life Style, Nutrition Policy, Pediatric Obesity, Obesity, Phytochemicals, Risk Factors, Sweetening Agents, Triglycerides, Weight Gain

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