Intakes of added and free sugars should be ‘as low as possible as part of a nutritionally adequate diet’: EFSA

By Oliver Morrison contact

- Last updated on GMT

Image: Getty/Anouk de Maar
Image: Getty/Anouk de Maar

Related tags: Efsa, Sugar

EFSA’s scientists have completed their comprehensive safety assessment of sugars in the diet and their potential links to health problems.

After evaluating over 30,000 publications they concluded that added and free sugars ‘should be as low as possible’. Prof. Dominique Turck, the Chair of EFSA’s panel of nutrition experts who carried out the assessment, stated: “We concluded that intakes of added and free sugars should be as low as possible as part of a nutritionally adequate diet; this is in line with current recommendations. However, the scientific evidence did not allow us to set a tolerable upper intake level for dietary sugars, which was the original goal of this assessment.”

Our diet includes different categories and sources of sugars, which can be naturally occurring or added. ‘Added sugars’ are refined sugars used in food preparation and as table sugar. ‘Free sugars’ includes ‘added sugars’ plus those naturally present in honey and syrups, as well as in fruit and vegetable juices and juice concentrates. ‘Total sugars’ are all sugars present in the diet, including those naturally present in fruit, vegetables, and milk.

EFSA added that the ‘valuable input’ received during last year’s public consultation on a draft version of the opinion allowed the scientists to refine and clarify important aspects of their work.

Prof. Turck said: “We underlined there are uncertainties about chronic disease risk for people whose consumption of added and free sugars is below 10% of their total energy intake. This is due to the scarcity of studies at doses in this range.

“Data limitations also meant it was not possible to compare the effects of sugars classified as added or free, overall.”

Sources of sugars and health problems

Sugar consumption is a known cause of dental caries. Evidence also links―to varying degrees of certainty―consumption of sugar-sweetened beverages, juices and nectars with various chronic metabolic diseases including obesity, non-alcoholic fatty liver disease, and type 2 diabetes.

"Although we could not assess their contributions, the impact of other important contributors to sugar intake should be considered by national authorities when setting food-based dietary guidelines,”​ stated Prof Turck. These foods could not be assessed because of limited data. They include sweets, cakes and desserts, other sweetened beverages such as sweetened milk and milkshakes, and yogurts.

The assessment stated there is evidence for a positive and causal relationship between the intake of fructose (as monosaccharide and bound to glucose in sucrose) and risk of some chronic metabolic diseases. The EFSA panel noted that limiting the intake of added and free sugars in mixed diets would also limit the intake of fructose.

It also concluded there is evidence for a positive and causal relationship between the intake of sugar-sweetened beverages and fruit juices and risk of some chronic metabolic diseases.

The proportion of consumers of sugar-sweetened soft drinks and sugar-sweetened fruit drinks in Europe meanwhile varied widely across population groups and countries, ranging from 0% to 97% of the dietary survey’s sample. In consumers, the contribution of added and free sugars in SSBs to total energy intake ranged from 1 to 8 E%, depending on the survey. With few exceptions, the contribution of SSBs to the intake of added and free sugars ranged from 15% to about 50%.

Free sugars and health risks

Serum lipids:​ although there is some evidence that high intakes (> 20 E%) of sugars may increase serum triglycerides and cholesterol concentrations, the available data are not sufficient to set an upper limit for (added) sugars intake.

Body weight:​ the evidence relating high intake of sugars (mainly as added sugars), compared to high intakes of starch, to weight gain is inconsistent for solid foods. However, there is some evidence that high intakes of sugars in the form of sugar-sweetened beverages (SSBs) might contribute to weight gain. The available evidence is insufficient to set an upper limit for sugars based on their effects on body weight.

Type 2 diabetes:​ controversial findings on the association between total sugars and/or specific types of sugars and diabetes risk were reported in large prospective cohort studies. However positive associations were found between SSBs and increased type 2 diabetes risk. The available evidence was found insufficient to set a Tolerable Upper Level of Intake (UL) for sugars based on their effects on type 2 diabetes risk.

Dental caries:​ available data do not allow the setting of a UL for (added) sugars on the basis of a risk reduction for dental caries, as caries development related to consumption of sucrose and other cariogenic carbohydrates does not depend only on the amount of sugars consumed, but it is also influenced by oral hygiene, exposure to fluoride, frequency of consumption and various other factors.

The review came after five countries - Denmark, Finland, Iceland, Norway and Sweden -- made the original request to EFSA in 2017 to assess the potential health risks for consumers from excess intake of dietary sugars. The scientists said that their findings will now support national public health authorities in Europe update future advice for their consumers.

“This safety assessment of dietary sugars provides us with important knowledge,”​ said Anna Karin Lindroos, nutritionist and PhD at the Swedish Food Agency. "It will, together with other relevant science-based reports, be a useful source when reviewing recommendations for sugar intake and food-based dietary guidelines in the Nordic countries.”

Future research on dietary sugars

The fact that EFSA’s review was so wide-ranging allowed its scientists to prioritise the data gaps and research needed to set a tolerable upper intake level for dietary sugars in the future.

Prof Turck said: “We screened over 30,000 publications so we have identified several areas to target for researchers and technicians. The pooling and reuse of individual human data from research studies would be a valuable source of information. Research should focus both on the health effects of dietary sugars and on the impact of clinical and community interventions designed to reduce sugar intakes. Finally, we need validated methods for assessing intakes and the standardisation of reporting guidelines and definitions for dietary sugars and their sources.”

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