What should I be telling my patients about sugars?

Dr Rivkeh Haryono, Nutrition Scientist, Dairy Australia

Sugars get a lot of attention in the media, and there’s a big push for a sugars tax in Australia from public health organisations and individuals. But do sugars deserve bad press and scrutiny and what should you be telling your patients when it comes to consuming sugars?

What do we mean when we talk about sugars?

In answering this question, we firstly need to define what we mean when we talk about sugars. A breakdown of sugars is shown here below.

Total sugars is the value we see on Nutrition Information Panels (NIP) – this value encompasses both intrinsic sugars (those naturally inherent to foods, including dairy, fruit and vegetables) and free sugars. Free sugars include both added sugars, and those naturally present in honey, fruit juices and syrups (i.e. maple syrup).

All sugars are equivalent when it comes to energy (all provide about 17kJ per gram), but the body can’t actually distinguish between the two types (nor can chemical analysis methods - which is why the NIP doesn’t distinguish between free or intrinsic sugars ). However, it’s excess intake of free sugars we should be concerned about. These sugars are typically found in energy dense, nutrient poor foods that offer little in the way of nutrition (for example, a soft drink).

Intrinsic sugars on the other hand tend to be accompanied by other nutrients in the food matrix. For example, the natural sugar in fruit (fructose) is accompanied by fibre, in addition to other vitamins and minerals. As a result, we shouldn’t be concerned about intrinsic sugars. 

Why is fruit juice included under free sugars?

Some might be surprised to see fruit juice (which is normally thought of as a healthy beverage) classified under free sugars (one to limit). Instead of eating the equivalent of a single fresh orange as a snack, 250mL glass of juice could contain the equivalent of five oranges. This also means consuming a more concentrated source of sugar, and therefore kilojoules. Juicing can also remove the fibre from whole fruit, making it a less nutritious option when compared to fresh fruit.  

How much free sugar is recommended?

Up-to-date recommendations for intake of free sugars come from the World Health Organisation (WHO) who suggest intake be limited to <10% energy, or even 5% if that can be managed.2 These Guidelines are based on meta-analyses of randomised controlled trials that show excessive intake of free sugars is associated with weight gain and development of dental caries.

What exactly does 10% of energy equate to? As an example, if your patient has an energy requirement of 8700 kJ (this will vary depending on the person), 10% of this is 870kJ. There are 17kJ per gram of sugar so this is about 51g of free sugars (or 13 teaspoons). 

The Australian Dietary Guidelines also advise limiting intake of foods and beverages containing added sugars including confectionary and sugar-sweetened beverages.3 

What are the main sources of free sugars in the diet? 

The Australian Health Survey (AHS) shows we’re over consumers of free sugar, in fact one in two exceed the WHO free sugar recommendations. On average, the population is consuming about 60g free sugars/day. Children and adolescents are most likely to exceed the guidelines, with around three quarters of 9-18 year olds exceeding the 10% recommendation.4

Most of the free sugars intake in our diet come from discretionary foods (which is not surprising given 35% of our energy intake comes from these foods). Sugar-sweetened beverages, fruit and vegetable juices, confectionary, muffins and cakes are some of the greatest contributors to free sugars in the diet.5  

Should we be as concerned as we are about sugars? What should health professionals be recommending?

The AHS shows we’re overconsuming free sugars, however more notably, we’re overconsuming discretionary foods – so we need to consider where the sugar is coming from in the diet, as well as frequency and amount of consumption. 

A small amount of sugars can still play a role in a healthy diet - take flavoured milk as an example. Flavoured milk contains about 23g total sugars/250mL serve6 - half of this is lactose (an intrinsic sugar) and half of this is added sugar (about 3 teaspoons). Compared to a soft drink which is energy dense and nutrient poor, flavoured milk is a better alternative as it contains the same nutrients as plain milk, such as calcium and protein.7 A small amount of sugar in foods can increase palatability of some foods and may actually help reach daily intake of five food group foods. It’s also crucial to remember that we eat whole foods and not individual nutrients, so we shouldn’t get too concerned about small amounts of sugar in five food group foods.
Development of chronic disease is also multifactorial – poor dietary patterns, physical inactivity, portion size and genetics are just a few of numerous other factors we need to consider. 

To summarise, there’s no need to think all sugar is dangerous or toxic. It’s not about eliminating all sugars, but making healthier choices, with a particular focus on reducing discretionary foods. This will not only help limit the amount of free sugars that’s consumed, but make room for more nutrient rich five food group foods in the diet Australians are under consuming.  


References

1. Louie JC et al. A systematic methodology to estimate added sugar content of foods. Eur J Clin Nutr. 2015 Feb;69(2):154-61.
2. World Health Organisation. Guideline: Sugars intake for adults and children. Geneva 2015. Available from: http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/.
3. National Health and Medical Research Council. Australian Dietary Guidelines, Canberra: Commonwealth of Australia; 2013.
4. Australian Bureau of Statistics. 4364.0.55.011. Australian Health Survey: Consumption of added sugars, 2011-12. Canberra: 2016.
5. Australian Bureau of Statistics. 4364.0.55.011. Australian Health Survey: Consumption of added sugars, 2011-12. Canberra: 2016.
6. NUTTAB data
7. Fayet-Moore F. Effect of flavored milk vs plain milk on total milk intake and nutrient provision in children. Nutr Rev. 2016 Jan;74(1):1-17.