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Sugars: Improving information and messages to consumers
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Sugars: Improving information and messages to consumers October 2010
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Contents
Executive Summary
1
Purpose of This Report
2
1. Introduction
3
2. Current Intake of Sugars in the UK
4
2.1 Recommendations for Dietary Intake of Sugars 2.2 Consumption of Sugars in the UK 2.3 Changes in Intakes of Sugars in the UK 3. Sugars in Food Labelling and Nutrition Information 3.1 Food Labelling 3.1.1 Terms used to describe sugars in published literature 3.2 Nutrition Information 3.3 Front of Pack Nutrition Information 3.3.1 Guideline Daily Amount (GDA) for Sugars 3.3.2 Traffic Light Labelling Criteria for Sugars 3.4 Nutrition and Health Claims
4 6 8 9 9 10 12 13 13 14 15
4. Existing Consumer Messages About Sugars
16
5. Consumer Understanding of Sugars
20
5.1 Retail Customer Feedback 5.2 IGD Research on Consumer Understanding of Sugars
20 22
6. Testing Consumer Responses to Messages About Sugars
23
6.1 Qualitative Research to Test Consumer Messages About Sugars 23 6.1.1 Results of Qualitiative Research 23 7. Scientific Evidence for a Relationship Between Sugars and Health
27
8. Recommended Information and Messages About Sugars 32 8.1 Consumer Messages About Sugars 8.2 Information for Food Businesses About Sugars
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Appendices
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Appendix Appendix Appendix Appendix Appendix
35 41 46 64 72
I II III IV V
Sugars: Improving information and messages to consumers
Executive Summary Sugars occur naturally in many foods including fruit, vegetables, dairy products and cereals. They are also a common ingredient of processed foods. In addition to providing energy, they perform a variety of functions such as enhancing palatability, giving texture and colour, and acting as a preservative. Sugars are an important source of energy in the diet, but as such are viewed by some as a leading cause of obesity. Confusion about their nutritional value has led to the perception amongst consumers that certain sugars may be ‘better for you’ depending on their source. This may be exacerbated by poor definition and understanding of the term ‘added sugar’. This report by IGD’s Industry Nutrition Strategy Group aims to help food businesses provide consumers with clarity on aspects of sugars such as where they occur and their role in the diet. It is also a resource for food businesses, drawing together information on terminology, labelling, and the relationship between sugars and health outcomes. Consumer Messages Current public health messages are about reduction of sugars in the diet, and focus particularly on calorie consumption and dental health. Retail customer insight data indicated that consumers are interested in reducing their sugars intake, but may require clarification on certain product claims related to sugars. Qualitative research, carried out by IGD, revealed the current state of consumer understanding of sugars and terms associated with sugars and sugar processing. In particular there was confusion around processing of sugars; respondents were unclear of the nutritional value of different sugars, their impact on health and how they might fit in a healthy balanced diet. Consumer messages were developed to address the areas highlighted by the IGD research. After testing in further qualitative research, a set of messages was identified that provided information for consumers on: • Sugars in a healthy balanced diet • Sources of sugars • Nutritional value of sugars • Sugars and weight management • Sugars and dental health Information for Food Businesses In addition to the consumer messages, this report provides information for food businesses on terms used to describe sugars, labelling and nutrition information, and a summary of the scientific evidence for the relationship between sugars and health.
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Sugars: Improving information and messages to consumers
Purpose of This Report Consumers need clarity on the role of sugars in the diet, and on the meaning of terms used to describe sugars in food and drinks. This report by IGD’s Industry Nutrition Strategy Group sugars working group aims to help improve consumer understanding by providing food businesses with relevant information and consumer messages about sugars. The report contains: • Evidence-based consumer messages for use by food businesses • Information about labelling of sugars on food and drink products • A review of terms used to describe sugars in the diet • Scientific evidence for the relationship between sugars and health The messages and recommendations made by the working group are based on current science and the results of new consumer research detailed in this report. The report refers frequently to information provided by the FSA. At the time of writing the nutrition programme within the FSA has recently moved to the Department of Health. Information in this report is correct at publication and will be revised to reflect any changes brought about by reorganisation of the FSA that are of relevance to this report.
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Sugars: Improving information and messages to consumers
1. Introduction Sugars occur naturally in many foods, including fruit, vegetables, dairy products and cereals. They are also a common ingredient of processed foods. In addition to providing energy and carbohydrate, they perform a variety of technological functions such as enhancing palatability, giving texture and colour, and acting as a preservative. Sugars are an important source of energy in the diet, but as such are viewed by some as a leading cause of obesity. As part of its Saturated Fat and Energy Intake programme the Food Standards Agency (FSA) has published recommendations on the reduction of sugars in drinks1. Current public health messages are about reducing consumption in the context of managing energy intake, and the impact of sugars on dental health. Confusion exists amongst consumers about the nutritional value of sugars. There is a perception that sugars found naturally occurring within foods are different to refined sugars in terms of their nutritional value, their effect on health, and the way they are utilised by the body. This may be exacerbated by poor definition and understanding of the term ‘added sugar’. The Scientific Advisory Committee on Nutrition is currently reviewing dietary carbohydrates to provide clarification of the relationship between dietary carbohydrate and health and make public health recommendations. SACN is scheduled to publish its findings in 2012.
1. http://www.food.gov.uk/multimedia/pdfs/satfatrecommendations
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Sugars: Improving information and messages to consumers
2. Current Intake of Sugars in the UK 2.1 Recommendations for Dietary Intake of Sugars In the UK a Dietary Reference Value (DRV) of 11% of food energy was set for non-milk extrinsic sugars (NMES) by the Department of Health’s Committee on the Medical Aspects of Food Policy (COMA)2. This recommendation was based on dental health outcomes. NMES is defined as total sugars excluding lactose in milk and milk products and sugars present within the cellular structures of fruits and vegetables2 (see section 3). This equates to approximately 50g for women and 65g for men based on estimated average energy requirements for adults of 19 to 50 years old. There is no DRV for intake of total sugars. The European Food Safety Authority (EFSA) panel on Dietetic Products, Nutrition and Allergies recently delivered a scientific opinion on DRVs for carbohydrates and dietary fibre3. EFSA noted that the available data do not allow the setting of an upper limit for intake of total or added sugars. The USA Institute of Medicine also noted that there was insufficient evidence to set an upper limit for intake of total or added sugars in the 2005 report on Dietary Reference Intakes4. However, a maximal intake level of 25% of energy from added sugars was suggested based on limited evidence of decreased intake of some micronutrients in American sub-populations exceeding this level. EFSA was requested by the European Commission (EC) to provide an opinion on labelling reference intake values for nutrients, including sugars, that form part of a proposed EC Food Information Regulation5. The Authority agreed with a proposed labelling reference intake of 90g for total sugars, corresponding to 18 % energy for a 2000 kcal diet. They noted the absence of recommended intakes for total sugars, and that estimated intake of indigenous sugars provided by recommended daily intakes of fruits, vegetables, cereals and dairy products would amount to approximately 45 g in adults.
4
2
Department of Health (1991) Dietary reference values for food energy and nutrients for the United Kingdom: Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. Reports of Health and Social Subjects 41. TSO, London
3
EFSA (2010) Dietary Reference Values for carbohydrates and dietary fibre. EFSA J. 8; 1462
4
Institute of Medicine (2005) Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids (macronutrients). National Academy Press, Washington DC
5
EFSA (2009) Scientific opinion of the panel on Dietetic Products, Nutrition and Allergies on a request from the Commission related to the review of labelling reference intake values for selected nutritional elements. EFSA J 1008; 1-14
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Sugars: Improving information and messages to consumers
Only one country has a nutrition recommendation referring to ‘total sugars’. In its 2003 nutrition recommendations for both adults and children, the Australian National Health and Medical Research Council6, 7, indicates that: ‘There is no evidence that, for most Australians, consumption of up to 15-20% energy as sugars is incompatible with a healthy diet.’ This provides the basis on which Australia has set a population target level for total sugars of 90g for labelling purposes.
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6
National Health & Medical Research Council (2003) Dietary guidelines for Australian adults. Commonwealth of Australia, Canberra
7
National Health and Medical Research Council (2003) Dietary guidelines for children and adolescents in Australia. Commonwealth of Australia, Canberra
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Sugars: Improving information and messages to consumers
2.2 Consumption of Sugars in the UK Data on average intake of sugars in the UK are available from the National Diet and Nutrition Survey (NDNS)8. According to the data from year 1 of the survey, 2008/2009, highest total sugars consumption was by those in the 11 to 18 years age group (Figure 1).
Sugars intake (g/d)
Figure 1. Intakes of sugars in the UK
Age group (years) Source: Bates et al (2010)8
The Department of Health and Food Standards Agency recommend that population average intakes of NMES make up no more than 11% of food energy per day. Consumption of NMES currently exceeds this level in all age groups except 1.5 to 3 years (Figure 2).
8
6
Bates B, Lennox A, Swan G (2010) National diet and nutrition survey: headline results from year 1 of the rolling programme (2009/2009). London: Food Standards Agency/ Department of Health
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Sugars: Improving information and messages to consumers
MMES (as % food energy
Figure 2. Intake of non-milk extrinsic sugars as a percentage of food energy
Age group (years) Source: Bates et al (2010)8, COMA (1991)2
Some of the main sources of NMES in the diets of different age groups are shown in Table 1. Non-alcoholic beverages contributed most to NMES intake making up 31, 30, 40 and 25% of NMES across the youngest to oldest age groups respectively. Cereals and cereal products contributed between 20 and 28% of NMES, while sugar, preserves and confectionery contributed between 18 and 25%8. Table 1. Contribution of food types to NMES intake (%) Age group (years) 1.5 to 3
4 to 10
11 to 18 19 to 64
Breakfast cereals
6
8
7
5
Biscuits, buns, cakes, pies
14
17
12
12
Milk and milk products
17
12
7
6
Sugars, preserves & sweet spreads
6
7
6
15
Chocolate confectionery
8
8
8
8
Sugar confectionery
4
8
7
1
Fruit juices
17
12
9
8
Other sweetened soft drinks
12
18
31
16
Source: Bates et al (2010)8
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Sugars: Improving information and messages to consumers
2.3 Changes in Intakes of Sugars in the UK Comparison of the recent NDNS data with past surveys indicates that there has been very little change in intake of total sugars or NMES in the last decade or more. For both males and females, for all age groups, little change has been seen, and the small changes seen are in a downward direction, as shown in Figure 3. Other recent studies of trends in intake of sugars have shown similar results, as in the studies of 11-12 year olds in Northumberland.9 Figure 3. Intake of total and non-milk extrinsic sugars as a percentage of food energy intake in 2008/09 NDNS and past NDNS (1997 or 2000/01)8,9
Sugars % food energy
30 25
Total Sugars 24.4
23.1
22 22
NMES 20.9 20.6
20
17.1 14.5
15
16 15.7 12.7 12.5
1997/2000/01 2008/09
10 5 0 4-10y
11-18y
9
8
19-64y
4-10y
11-18y
19-64y
Rugg-Gunn et al (2007) Changes in consumption of sugars by English adolescents over 20 years. Public Health Nutr.10:354-63
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Sugars: Improving information and messages to consumers
3. Sugars in Food Labelling and Nutrition Information 3.1 Food Labelling Sugars are one of the few food ingredients that have specific legislation relating to their product names and definitions. In the UK, the Specified Sugar Products (England) Regulations 2003 (SI No 1563)10, and similar regulations for Scotland, Northern Ireland and Wales, implement EC Directive2001/111 relating to certain sugars intended for human consumption. The Regulations lay down reserved descriptions for the sugar products they cover and provide additional labelling requirements for these sugar products. The reserved descriptions may only be used where a product matches the compositional criteria in the Regulations. The most commonly used reserved descriptions for sugar products are: Sugar, sugar solution, invert sugar solution, invert sugar syrup, glucose syrup, dried glucose syrup, dextrose and fructose. Where a glucose syrup (or dried glucose syrup) contains above 5% fructose (on a dry basis) the reserved description is (dried) glucosefructose syrup or (dried) fructose-glucose syrup depending on which component (i.e glucose or fructose) is the higher. Additional qualifying terms can be used in addition to the reserved description providing this labelling is not misleading e.g. “granulated sugar”, “fructose: fruit sugar”. Names of sugars and sweetening substances commonly used for sweetening foods and drinks are listed in Table 2. Table 2. Sugars used to sweeten foods and drinks Corn syrup
Lactose
Dextrin
Maltose
Dextrose
Starch hydrolysates (e.g glucose syrup, high fructose corn syrup)
Fructose (“fruit sugar”)
Sugar
Fruit juice/de-ionised fruit juice
Syrups (e.g golden syrup, agave syrup, glucose/fructose syrup)
Glucose
Treacle
Honey Invert sugar/syrup
10 OPSI (2003) The Specified Sugar Products (England). Statutory Instrument No 1563. London HMSO
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Sugars: Improving information and messages to consumers
3.1.1 Terms used to describe sugars in published literature The number of terms used to describe sugars has resulted in a literature on sugars intakes where data from study to study are not comparable. This limits comparisons between countries and analysis of trends over time. It also impacts ability to compare intakes to recommendations, risk factors or disease endpoints, and to results of intervention studies. In order to advance knowledge in these fields of research, and to provide a useful terminology on which to base public health messages, it would be valuable to have uniformity in approach. Clarity about what is meant by the various terms used would allow some of the confusion around sugars intakes to be eliminated; the recent FAO/WHO update on terminology concluded that the frequently used terms ‘added sugars’, ‘free sugars’, and ‘NMES’ are misleading and recommended they should not be used . The authors suggest ‘total sugars’ as the most useful term for labelling purposes. Their overall conclusion was: ‘Many terms exist to describe sugars in the diet. The most useful are total sugars and their division into mono- and disaccharides. The use of other terms creates difficulties for the analyst, confusion for the consumer and suggests properties of foods that are not related to sugars themselves, but to the food matrix’11. Terms used to describe sugars are listed in Table 3. A detailed discussion of the meanings of each of these terms is provided in Appendix I. Table 3. Terms used to describe sugars in the diet Sugar
Refined sugars
Sugars
Refined sugar
Simple sugars
Discretionary sugar
Total sugars
Intrinsic sugars
Free sugars
Extrinsic sugars
Total available sugars
Non-milk extrinsic sugars
Added sugars
Caloric sweeteners
11 Cummings JH, Stephen AM (2007) Carbohydrate terminology and classification. Eur. J. Clin. Nutr. 61 (Suppl.); S5-S18
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Sugars: Improving information and messages to consumers
Based on the findings of the research carried out for this report (sections 5.0 and 6.0), it is recommended that the terms shown in Box 1 are used in consumer communications: Box 1 - Use of sugar and sugars in consumer communications Sugar= table sugar = sucrose Consumers are less familiar with sucrose than the names of other sugars such as glucose. ‘Sugar’ or ‘table sugar’ should be used in preference to sucrose in consumer communications. Sugars=total sugars=any mono- or di-saccharides in foods These include glucose, fructose, sucrose, maltose, lactose, whether naturally occurring or added to foods.
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Sugars: Improving information and messages to consumers
3.2 Nutrition Information The quantity of total sugars in a product may be shown in the nutrition panel on the back of food packs as ‘Carbohydrate (g)......of which sugars (g)’ (Table 4). The quantity is shown per 100g, a value per portion is sometimes also given. Information on sugars content must be given in compliance with the Food Labelling Regulations12 in the UK. At present nutrition information is only legally required where a nutrition or health claim is made on the food, although it is often provided by manufacturers on a voluntary basis even when not required . However, the proposal for a Food Information Regulation that is under consideration by the European Parliament will require nutrition information on all products, and this is currently recommended as good practice. Table 4. Information contained in the nutrition panel on the back of a food pack Per 100g energy
kJ and kcal
protein
g
carbohydrate
g
of which: - sugars
g
fat
g
of which: - saturates
g
fibre
g
sodium
g
Source: OPSI (1996) The Food Labelling Regulations. London, HMSO
12 OPSI (1996) The Food Labelling Regulations. Statutory Instrument 1996 London HMSO
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No. 1499.
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Sugars: Improving information and messages to consumers
3.3 Front of Pack Nutrition Information Voluntary front of pack nutrition labelling systems show total sugars either as a guideline daily amount (GDA) or with red, amber or green traffic light signposting, or a combination of both. 3.3.1 Guideline Daily Amount (GDA) for Sugars GDAs were initially developed to help consumers understand the nutrition information on the back of food packs in the context of their overall daily diet13. They have since been extended to provide nutrition information on the front of food packs14. GDAs are based on Dietary Reference Values (DRVs). However, no DRV has been set in the UK for total sugars, only non-milk extrinsic sugars (NMES, see section 2.0), at 11% food energy. There is currently no agreed definition for NMES and they cannot be measured analytically. Furthermore, EU labelling law requires that total sugars be calculated for labelling purposes. Therefore a GDA for total sugars was developed, rather than using a value based on NMES alone. The GDA for total sugars is based on work by Rayner et al (2003)15, and includes intake of sugars from fruit and vegetables ( 7% food energy) and milk (2% food energy). Total sugars therefore account for 19% of food energy, which results in a GDA of 90g for women and 120g for men. The European Food Safety Authority agreed this figure in an opinion on labelling reference intake values for the proposed EU Food Information regulation16. A value of 90g is also used by Food Standards Australia New Zealand (FSANZ)17 for their GDA equivalent, the ‘Daily Intake’, which accompanies nutrition labelling for sugars. The rationale for the 90g value is quite different to that used to determine the GDA, although the figure is identical. Australia has a recommended total sugars intake of 15-20% of energy intake (section 2.1). FSANZ used the midpoint of this range (17.5%) to calculate the energy from sugars for the reference value for energy17,18.
13 IGD (2005) Report of the IGD/PIC Industry Nutrition Strategy Group Technical Working Group on Guideline Daily Amounts (GDAs). IGD Letchmore Heath, Watford, UK 14 http://www.whatsinsideguide.com/Home.aspx 15 Rayner M, Scarborough P &Williams C (2003). The origin of Guideline Daily Amounts and the Food Standards Agency’s guidance on what counts as .a lot. and .a little. Public Health Nutrition 7 (4) 549 - 556. 16 http://ec.europa.eu/food/food/labellingnutrition/foodlabelling/proposed_legislation_ en.htm 17 FSANZ (2005) Nutrition information requirements, standard 1.2.8. Issue 84, Canberra 18 FSANZ (2002) Proposal P254: Minor Amendments Omnibus to Volume 2 of the Food Standards Code. Canberra
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3.3.2 Traffic Light Labelling Criteria for Sugars The Food Standards Agency developed criteria for a voluntary labelling scheme to indicate on the front of food packs using red, amber and green colouring whether a product is high, medium or low respectively in terms of sugars content19. The green/amber boundaries were determined by the European Regulation EC No 1924/2006 on Nutrition and Health Claims20. The amber/red boundary for sugars was based on the value for NMES set by COMA21, using 25% of the recommended intake level per 100g. In its technical guidance19, the FSA refers to ‘added sugars’ rather than NMES. The definition of ‘added sugars’ used by the FSA is given in Appendix 1. The colour code per 100g of product is shown as: • Green if total sugars are less than or equal to 5g/100g • Amber if total sugars exceed 5g/100g and added sugars are less than 12.5g/100g • Red if added sugars are more than 12.5g/100g Since no advice on intake of total sugars was available, the FSA set up an expert group to recommend suitable criteria for a high (‘red’) level based on total sugars. Using data from the National Diet and Nutrition Survey22, the group calculated an average intake of intrinsic sugars from fruit, vegetables and milk of 10g per day. This was added to the intake of NMES recommended by COMA (50g per day for a 2000kcal diet) to give an intake of total sugars of 60g per day. Applying the FSA criteria of 25% of the reference value, this translated to 15g/100g as the total sugars level for a red traffic light23. Further work was also undertaken to develop suitable sugars criteria for breakfast cereals. Consumer research confirmed that consumers expect the colour code and the nutritional information per portion for breakfast cereals to be based on the dry weight of cereal. Consumers also wanted to be able to distinguish at a glance between breakfast cereals which are high in added sugars and those high in sugars due to high fruit content. A technical working group recommended that the sugars colour code for cereals should be based on added sugars and that additional on pack text, discrete from the traffic light signpost, should be provided to highlight the presence of sugars from fruit and/or milk not included in the colour code24.
19 http://www.food.gov.uk/multimedia/pdfs/frontofpackguidance2.pdf 20 http://ec.europa.eu/food/food/labellingnutrition/claims/index_en.htm 21 Department of Health (1991) Dietary reference values for food energy and nutrients for the United Kingdom: Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. Reports of Health and Social Subjects 41. TSO, London 22 Henderson L et al (2003) The National Diet and Nutrition Survey Volume 2. Energy, protein, carbohydrate, fat and alcohol intake. London, HMSO 23 http://www.food.gov.uk/foodlabelling/signposting/devfop/signposttimeline/ rationalesugars/ 24 http://www.food.gov.uk/multimedia/pdfs/breakfastcerealpaper.pdf
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3.4 Nutrition and Health Claims Food businesses wishing to make claims about the sugars in a food product must comply with regulation EC 1924/2006 on nutrition and health claims made on foods. The annex to the regulation lists the only nutrition claims which are permitted to be used, and the conditions applying to them. They include a number relating specifically to sugars – “low sugars”, “sugars-free”, “with no added sugars” – and “Reduced [name of nutrient]” which may be applied to sugars. Claims about reductions in energy content as a result of reduced sugars are also included in the annex to the regulation25. Health claims about sugars are also subject to the conditions of regulation EC 1924/2006. Health claims may only be made which have been preapproved by the European Commission and which have received a favourable scientific opinion by the European Food Safety Authority (EFSA)25.
25 http://ec.europa.eu/food/food/labellingnutrition/claims/index_en.htm
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Sugars: Improving information and messages to consumers
4. Existing Consumer Messages About Sugars A number of government and non-governmental organisations use messages to communicate to consumers about sugars and health. The focus is on reduction of intake or frequency of intake. Table 5 summarises current consumer messages about sugars. Consumer messages about sugars use a number of different terms including ‘sugar’, ‘sugars’, ‘sugary’, ‘high sugar’, ‘added sugar’, ‘milk sugar’ and ‘cariogenic sugars’. The messages generally address health outcomes including healthy weight maintenance, dental health and micronutrient dilution. Diabetes UK gives advice specifically on management of diabetes. These areas have been the subject of scientific investigations and evidence for association of sugars with the various health outcomes is reviewed in section 7. The current messages do not focus on consumer awareness of other aspects of sugars such as their non-sweetening functions. Messages and campaigns aimed at helping individuals to manage their sugars intake may benefit from increased clarity on the terms and function of sugars in the diet. Table 5. Current consumer messages about sugars
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• Many foods that contain added sugar can also contain lots of calories so eating less of these foods may help with weight control
• The sugars found naturally in whole fruit are less likely to cause tooth decay ...
• Sugary foods and drinks can cause tooth decay, particularly if you have them between meals. This includes fruit juice and honey
• Food and drinks containing lots of added sugars contain calories but often have few other nutrients, so we should try to eat these types of foods only occasionally
http://www.eatwell.gov.uk/healthydiet/fss/sugars/
Eatwell
Food Standards Agency
• The frequency and amount of sugary food and drinks should be reduced and, when consumed, limited to mealtimes. Sugars should not be consumed more than four times per day • Sugars (excluding those naturally present in whole fruit) should provide less than 10% of total energy in the diet or less than 60 g per person per day. Note that for young children this will be around 33 g per day • Most sugars in the diet are contained in processed and manufactured foods and drinks • It is important to recognise that honey, fresh fruit juice and dried fruit all contain cariogenic sugars • Reducing the amount and frequency of sugary food intake can reduce dental caries and could help control weight
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102331
Delivering better oral health. An evidence-based toolkit for prevention
Department of Health/British Association for the Study of Community Dentistry
• Sugar swaps: Low sugar healthy snacks for kids • Excess sugar can mean excess energy which in turn can lead to stored fat in the body and diseases like type 2 diabetes and heart disease • Fill your diet with fruit and veg instead of food that's high in fat or sugar • Look out for these words on the ingredients labels: sucrose, glucose, fructose, maltose, hydrolysed starch, invert sugar, corn syrup, honey • Swap sugary fizzy drinks for sparkling water with a slice of lemon or a dash of fruit juice, or even 'diet' versions
http://www.nhs.uk/change4life/Pages/change-for-life.aspx
Change4life
Department of Health
Government
Sugars: Improving information and messages to consumers
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• Limit your intake of foods containing fat and sugar, choosing low fat or reduced sugar foods where possible
http://www.bda.uk.com/foodfacts/BalanceRight.pdf
Getting the Balance Right
British Dietetic Association
Non-government organisations
Nutrient-based standards have strict controls on non-milk extrinsic sugar (added sugar) content at lunchtime.
Note: there is a voluntary code on drinks - see the School Food Trust website for more information
• Confectionery such as chocolate and cereal bars
• Snacks with added sugar
School Food Regulations prevent the provision of:
http://www.schoolfoodtrust.org.uk/the-standards/the-nutrient-based-standards/guides-and-reports/guide-to-the-nutrientbased-standards
School Food Trust
• Try swapping your fatty, sugary snacks for fruit and vegetables
http://www.nhs.uk/Livewell/loseweight/Pages/Healthyfoodswaps.aspx
A balanced diet: Healthy food swaps
NHS Choices
• Don’t have sugary foods and drinks too often
• It is the amount you eat that is important, so don’t eat too many foods high in fat and sugar too often
http://www.food.gov.uk/multimedia/pdfs/finaltrainerguide.pdf
Get cooking (Trainer’s guide)
Food Standards Agency Wales
Government
Sugars: Improving information and messages to consumers
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This does not mean you need to eat a sugar-free diet. Sugar can be used in foods and in baking as part of a healthy diet. Using sugar-free, no added sugar or diet fizzy drinks/squashes, instead of sugary versions can be an easy way to reduce the sugar in your diet
• Limit sugar and sugary foods
http://www.diabetes.org.uk/Guide-to-diabetes/Healthy_lifestyle/Eating_Well/
A healthy lifestyle – Eating well
Diabetes UK
• It is important that teeth are brushed twice a day and foods high in sugar should be eaten with main meals, rather than in between snacks to prevent dental caries
http://www.foodafactoflife.org.uk/Sheet.aspx?siteId=19§ionId=75&contentId=240
Food a fact of life: 11-16 years
• Sugar adds flavour and sweetness to foods, but frequent consumption of sugar-containing foods and drinks is associated with an increased tendency towards tooth decay especially in those with poor dental hygiene
• Foods in this group should be used sparingly if they are eaten every day (such as butter and spreads) or not eaten too often (such as sweets and some crisps)
• Most of us should eat less!
http://www.nutrition.org.uk/healthyliving/healthyeating/a-healthy-varied-diet?start=6
A healthy varied diet: Foods high in fat and/or sugar
British Nutrition Foundation
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5. Consumer Understanding of Sugars Consumers’ ability to implement healthy eating messages about sugars requires an understanding of sugars and accurate interpretation of the messages themselves. Evidence of consumer understanding of sugars and messages about sugars was obtained from two sources: 1. Enquiries and feedback from retail customers 2. IGD research on consumer understanding of sugars
5.1 Retail Customer Feedback The amount of fat, saturated fat, salt and sugars in foods are the top issues of concern among consumers and the quantity of fat and salt are the most commonly checked nutrition information on labels. However, the latest consumer attitudes survey published by the FSA suggests that the percentage of people who are concerned about these is slightly down since 2006 – fat to 40% from 46%, saturated fat to 37% from 44%, salt to 50% from 54%, and sugar to 39% from 43% in 200626. When out shopping, consumers see a number of messages about sugars, in addition to any front of pack nutrition labelling and the nutritional listings on the back of pack. Typically, products can claim to be: • Unsweetened • No added sugars* (this must be accompanied by the statement 'contains naturally occurring sugars' if sugars are naturally present) • Sugars free* • Reduced sugars* • Low sugars* *See section 3.4 on nutrition and health claims. In most cases, consumers either understand or disregard such messages and can complete their shopping mission with no problems. However, for some these messages can confuse or are misinterpreted and further clarification is requested from Customer Service. Table 6 summarises the types of queries that customers have relating to sugars in their diets, with an estimation of their relative frequency, based on figures provided by two retailers.
26 http://www.food.gov.uk/news/pressreleases/2008/feb/cas2007ukpr
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Table 6. Retailer customer queries relating to sugars Query type
Relative Frequency (split of sugar-related queries)
Request for a list of products that are low in sugar
Roughly a third of all customer list requests
Of these: Tips for reducing sugar for health (e.g. candida, acne, diabetes, for a healthier diet)
50%
Comments on high sugar levels in products (e.g. ready meals, breakfast cereals, sandwiches, yogurts)
30%
Role of sugar in children’s diets
6%
Explanation of high sugar content of fruit juices, prepared fruit
3%
Source: Waitrose Nutrition Advice Service http://www.waitrose.com/nutrition and Marks and Spencer
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5.2 IGD Research on Consumer Understanding of Sugars Qualitative consumer research was carried out by IGD to understand the current state of knowledge of sugars and terms associated with sugars and sugar processing (Phase 1). This information was used to develop messages about sugars, which were also tested with consumers (Phase 2, Section 6). Phase 1 of the research was carried out in February 2010. Eight focus groups with a maximum of eight participants per group took part, details of the recruitment criteria, group profiles, method and detailed results are available in Appendix 3. The research highlighted areas of consumer misunderstanding about sugars or where consumer perspective is inconsistent with the available scientific evidence. These areas are highlighted in Table 7. Table 7. Consumer perspective of areas related to sugars. Subject
Consumer perspective
Sugars in a healthy balanced diet
Confusion about the best ways to consume sugars in a healthy balanced diet
Nutritional value of sugars
Sugars have no nutritional value
Intrinsic and extrinsic sugars
Food containing natural sugars are ‘better for you’ than those with added sugars ( ‘bad for you’) Foods containing sugar are a proxy for unhealthy foods Glucose, fructose, sucrose ‘sound scientific’ and therefore are ‘less natural/healthy’ Certain foods such as fruit and milk are rarely considered sources of sugars
‘Natural’ and processed sugars
Some sugars are more natural than others (‘natural’ vs ‘processed’ sugars) White granulated sugar is ‘manufactured’, with bleach and chemicals added Brown sugar and honey are better for you than white sugar
Sugars and weight management
Sugars and fat are linked (= sugar is fattening)
Sugars and dental health
Sugars content of fruit juice less of a concern than soft drinks
Sugars and diabetes
People with diabetes should avoid sugar
Sugars and behaviour
Linked with hyperactivity in children Source: IGD, 2010
Consumer messages were subsequently developed to address areas of confusion or misunderstanding highlighted by the research and retail customer intake data, or to address gaps in current consumer messages (section 6).
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6. Testing Consumer Responses to Messages About Sugars IGD consumer research together with retail customer insight data helped to identify areas of confusion where appropriate messages may aid consumer understanding of sugars and their place in a healthy balanced diet (Table 7). Existing or new messages were identified that could help to address each area. These were tested directly with consumers in a second phase of qualitative research. Testing allowed messages to be identified that were likely to be most effective at helping consumers understand the role of sugars in the diet. In addition, information useful to food businesses in developing information for consumers was highlighted.
6.1 Qualitative Research to Test Consumer Messages About Sugars The messages in Table 8 were tested in qualitative research between 5th and 18th May 2010 in eight focus groups of eight participants each. Focus group recruitment criteria were the same as for Phase 1 of the consumer research and are detailed in Appendix 3. 6.1.1 Results of Qualitative Research Methodology and detailed finding of the research are available in Appendix 4. General findings indicated that: Top level findings of qualitative research • Sugars are not as big a concern to consumers as fat, salt and calories in general • The most important message is the need for a healthy balanced diet • Care is needed in messages that attempt to compare added sugars with sugars naturally present in fruit and vegetables • Messages improve understanding, but it is not clear whether behaviour will change • Information needs to be substantiated independently Key findings for each specific area are summarised in Table 8. The results were used to identify the set of consumer messages and information recommended for use by businesses described in section 8.
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•
•
•
•
• Respondents viewed intrinsic sugars as having a different nutritional value to extrinsic sugars
• ‘Sucrose’ was not understood by respondents, while participants Sucrose (table sugar) normally comes from sugar beet recognised that ‘glucose’ and ‘fructose’ and cane, which are rich sources of this natural sugar are sugars Sucrose (table sugar) can also be found naturally in • Messages that attempted to demonstrate most fruits and vegetables that intrinsic and extrinsic sugars have Once absorbed the human body makes no distinction the same nutritional value, and are between added sugars and naturally occurring sugars treated in the same way by the body, Sugars can be found in many foods such as fruit and caused confusion vegetables and dairy products, and some processed foods including savoury products such as sauces and condiments. Read the label to find out more
• There are no ‘good’ or ‘bad’ foods: All foods can play an important role in the diet
3. Intrinsic and • All sugars have the same calories (energy), whether extrinsic sugars naturally occurring in fruit and vegetables or added
• Sugars (sources of glucose)* are the essential energy • There was little understanding that the body, and in particular the brain, requires source for the brain and the body sugar for energy * Tested with and without text in brackets
• Sugars are a source of energy
• All sugars are carbohydrate; carbohydrate provides us with energy
• Use the nutrition panel to determine how much sugars are in a product. The nutrition panel shows the carbohydrate and total sugars
• Concentrate on a healthy balanced diet. Base your diet on grains and eat 5 fruit and vegetables per day. If you get the basics right your sugars intake will be ok
• Carbohydrate is associated with energy, but many respondents did not realise that sugars are carbohydrate
• Respondents felt that overall calorie intake was more important than sugars
• The GDA for sugars is 90g per day
2. Nutritional value of sugars
• Those messages which included information about quantities of sugars were regarded as less helpful
• Some foods containing sugars provide other important nutrients
• Know your GDA for sugars
• Messages about a healthy balanced diet were well received
• Sugars can form a useful part of a healthy balanced diet
1. Sugars in a healthy balanced diet
Findings
Messages tested in consumer research
Subject
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Table 8. Messages tested in qualitative consumer research (Phase 2).
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6. Sugars and dental health
5. Sugars and weight management
4. ‘Natural’ and processed sugars
Subject
• Carbohydrate was widely understood to mean starch in foods such as pasta and bread, but not sugar
• White sugar was perceived by respondents as 'less natural' than brown sugar or honey
Findings
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• It is important to recognise that honey, fresh fruit juice and dried fruit all contain sugars that can cause tooth decay
• Limit consumption of foods and drinks with added sugars to a maximum of four times a day
Sub- message. Expert committees have noted that the balance of available evidence does not implicate sugars in any of the ‘lifestyle diseases’ obesity, diabetes, coronary heart disease, or cancer
• Sugar is a carbohydrate, it provides 4 calories per gramme. If you are concerned about your weight, monitor your calorie intake
that count. All excess calories contribute to weight gain, know your GDA and try to stick to it
• Information about the dental health impact of foods perceived as healthy caused concern but was considered very useful
• Respondents felt that messages about the frequency of sugars consumption should be realistic and achievable
• Focus group participants had little knowledge of the energy value of sugars, but messages that included this information were not perceived as helpful
• Sugars provide 4 calories/g; less than half the calories • Respondents preferred messages that of fat (9 cals/g) focused on total calories rather than specific nutrients • If you are watching your weight, it is total calories
• There is no nutritional difference between brown and white sugar
• White sugar is no better or worse for you than brown sugars or honey - replacing one for another won't make any difference to your calorie intake and dental health
• Sugar crystallises naturally white - it is not bleached. Brown colours and flavours come from raw sugars or are added back
• All sugars are natural carbohydrates
• Sugar is a natural food
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8. Sugars and behaviour
• Sugar (sucrose)* does not cause diabetes. Sugars can be eaten as part of a healthy balanced diet
7. Sugars and diabetes
• Supporting information relating to scientific evidence received a mixed reaction; it was welcomed by many but there was some cynicism concerning the source of the evidence
• Information relating to a healthy balanced diet was particularly welcomed
• Messages that addressed the perception amongst participants that sugar causes diabetes were seen as useful
Findings
• There was a commonly held belief amongst participants that sugars cause hyperactivity in children Sub-message: This is supported by a wealth of scientific evidence • The language used in the message caused confusion, and the meaning of “behavioural problems” was not well understood
• Sugars, including table sugar, do not cause behavioural problems in children
Sub-message: This is supported by a wealth of scientific evidence
*Also test with text in brackets as table sugar
Messages tested in consumer research
Subject
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7. Scientific Evidence for a Relationship Between Sugars and Health Sugars are commonly associated with a number of areas related to health including weight management, dental health, diet quality, type 2 diabetes and behaviour. A significant body of scientific literature exists about the relationship between sugars and each of these health issues. Table 9 provides a summary of the scientific evidence for an impact of sugars on specific health outcomes derived from the recent systematic reviews and meta analyses listed. Table 9. Scientific evidence for a relationship between sugars and health outcomes
WEIGHT MANAGEMENT Commonly held belief: Sugars are implicated in obesity due to their possible role in encouraging over-consumption of energy Scientific evidence • Recent reviews have failed to find a positive association between sugars consumption and obesity • The recent EFSA opinion stated that the available evidence is insufficient to set an upper limit for sugars based on their effects on body weight. Evidence on the relationship of sugar-sweetened beverages and body weight should be considered when developing food-based dietary guidelines References Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. (2002). Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids. National Academic Press. USA. van Baak MA, Astrup A (2009) Consumption of sugars and body weight. Obes Rev. 10 Suppl 1; 9-23 EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA)(2010) Scientific Opinion on Dietary Reference Values for carbohydrates and dietary fibre. EFSA Journal 8(3);1462 Gibson S (2010) Trends in energy and sugar intakes and body mass index between 1983 and 1997 among children in Great Britain. J Hum Nutr Diet 23; 371 - 381 Ruxton CHS, Gardner EJ, McNulty HM (2010) Is Sugar Consumption Detrimental to Health? A Review of the Evidence 1995—2006 Crit Rev Food Sci and Nutrition 50; 1 – 19
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DENTAL HEALTH Commonly held belief: Too much sugar in the diet leads to dental decay (caries) Scientific evidence • Few reviews have demonstrated clear strong associations between amounts of sugars in the diet and caries; associations between the frequency of sugars consumed and caries risk are more significant • The association of dietary intakes of sugars and the risk of dental caries has changed significantly with exposure of the population to fluoride from drinking water and/or in toothpaste • Reduction of sugars intake has not been shown to be a reliable means of reducing dental caries risk. In contrast, use of fluoride, especially in toothpaste, has been extremely successful References Kay EJ (1998) Caries Prevention: based on evidence? Or an act of Faith? British Dental Journal 185: 432-3 Burt BA & Pai S (2001) Sugar Consumption and Caries Risk: A Systematic Review. Journal of Dental Education 65(10); 1017-1023 Harris R, Nicoll AD, Adair PM, Pine CM (2004) Risk factors for dental caries in young children: a systematic review of the literature. Community Dental Health 21 (suppl); 71-85 Moynihan P & Petersen PE (2004) Diet, nutrition and the prevention of dental diseases. Public Health Nutrition 7(1A); 201-26 Anderson CA , Curzon MEJ, Van Loveren C, Tatsi C, Duggal MS (2009) Sucrose and dental caries: a review of the evidence. Obesity Reviews 10 (Supplement 1); 41-54
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MICRONUTRIENT DILUTION/DIET QUALITY Commonly held belief: Since sugar-containing foods contain little vitamins or minerals, eating more of these foods means you will have lower intakes of micronutrients Scientific evidence • Systematic reviews of the literature have shown no clear evidence of micronutrient dilution with increasing sugars intake • Although the majority of the population has a more than adequate intake of all micronutrients, dietary estimates suggest that a proportion of the population fails to consume the minimum recommended amount of one or more micronutrients • Encouraging a wide variety of foods in the diet is likely to be most effective as a method of maintaining adequate micronutrient intake References Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. (2002). Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids. National Academic Press. USA. Gibson SA (2007) Dietary sugars intake and micronutrient adequacy: a systematic review of the evidence Nutrition Research Reviews 20; 121-131. Rennie KL & Livingstone MBE (2007) Associations between dietary added sugar intake and micronutrient intake: a systematic review British Journal of Nutrition 97; 832-841 EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA)(2010) Scientific opinion on Sugars Scientific Opinion on Dietary Reference Values for carbohydrates and dietary fibre. EFSA Journal 2010 8(3);1462 Ruxton CHS, Gardner, EJ, McNulty HM (2010) Is Sugar Consumption Detrimental to Health? A Review of the Evidence 1995—2006 Crit Rev Food Sci and Nutrition 50; 1–19
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TYPE 2 DIABETES Commonly held belief: Sugar causes diabetes, and people with diabetes should not eat sugars Scientific evidence • Overall, the literature indicates that excess weight plays a more fundamental role in insulin resistance and the development of type 2 diabetes, than the effect of the macronutrient composition of the diet • A direct causal link between sugars consumption and type 2 diabetes has not been demonstrated • Current dietetic practice allows for inclusion of modest amounts of sugars in a diabetic diet provided that most of it is consumed as part of a meal and not in isolation References Hu FB, van Dam RM, Liu S (2001) Diet and risk of Type II diabetes: the role of types of fat and carbohydrate. Diabetologia 44; 805-817 McClenaghan NH (2005) Determining the relationship between dietary carbohydrate intake and insulin resistance. Nutrition Res. Reviews 18; 222-240 McAuley K & Mann J (2006) Nutritional determinants of insulin resistance. J Lipid Res 47; 1668-1676 Thomas, B. & Bishop, J. Eds. (2007) Manual of dietetic practice. Oxford, Blackwell Publishing. Nield L, Summerbell CD, Hooper L & Whittaker V, Moore H (2008) Dietary advice for the prevention of type 2 diabetes mellitus in adults. The Cochrane Collection, J Wiley & Sons LTD Spence M, McKinley MC & Hunter SJ (2010) Diet, insulin resistance and diabetes: the right (pro) portions. Proce. Nutr. Soc; 61-69
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BEHAVIOUR/HYPERACTIVITY/ATTENTION DEFICIT HYPERACTIVITY DISORDER Commonly held belief: Sugars cause changes in behaviour in children, for example hyperactivity after eating sugars Scientific evidence • The evidence does not support a significant impact of sucrose on the behaviour of children • A report by the FAO concluded that restricting a child’s sugar intake to try and control their behaviour was not appropriate References FAO (1997) Food and Nutrition Paper 66 . Carbohydrates in human nutrition. Report of a Joint FAO/WHO Expert Consultation (Reprinted 1998, up-dated 2007) Rome, 14-18 April 1997 http://www.fao.org/docrep/w8079e/w8079e00.htm#Contents accessed on 19th May 2010 Ells LJ, Hillier FC, Shucksmith J, Crawley H, Harbige L, Shield J, Wiggins A, Summerbell CD (2006). A systematic review of the effect of dietary exposure that could be achieved through normal dietary intake on learning and performance of school-aged children of relevance to UK schools. http://www.food.gov.uk/multimedia/pdfs/systemreview.pdf Accessed on 18th May 2010 Benton D (2008) Sucrose and behavioural problems. Crit. Rev. Food Sci. Nutr. 48; 385-401 A number of reviews have addressed whether sugars have a role in development of heart disease. The Department of Health (1989)27 found no evidence for a role, and while the impact of dietary sugars on heart disease remains an area of active research, recent reviews have supported this view28,29.
27 Department of Health (1989)Dietary sugars and human disease. Report on the Panel on Dietary Sugars of the Committee on Medical Aspects of Food Policy (COMA). Report No. 37. HMSO, London 28 Ruxton CHS, Gardner EJ, McNulty HM (2010) Is sugar consumption detrimental to health? A review of the evidence 1995-2006. Crit Rev Food Sci and Nutrition 50: 1-19 29 EFSA Panel on dietetic Products, Nutrition and Allergies (NDA) (2010) Scientific opinion on dietary reference values for carbohydrates and dietary fibre. EFSA J 2010 8: 1462
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8. Recommended Information and Messages About Sugars The aim of this report is to help food businesses improve information and messages to consumers about sugars. The Industry Nutrition Strategy Group sugars working group identified a set of messages to help consumers better understand sugars and their role in the diet. Consumer messages were selected based on the need to address specific aspects of sugars, and on the outcomes of testing in focus groups. In some cases, messages were adjusted to take into account feedback from focus groups in terms of the length of messages and the amount of information. Since only length and not overall meaning was changed, messages were not re-tested following adjustment.
8.1 Consumer Messages About Sugars General messages to help consumers understand the sources of sugars and their role in the diet are shown in Box 2. Specific messages about sugars and weight management, and sugars and dental health are provided in Box 3.
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BOX 2 - General consumer messages about sugars Sugars in a healthy balanced diet • Use the label to check the sugars in a product • Sugars can form a useful part of a healthy balanced diet • Sugar-containing foods can provide other important nutrients • Try to get the balance of foods and drinks in your diet right – if you do this your sugars intake will be okay Nutritional value of sugars • All sugars have the same calories (energy) • There are no nutritional differences between brown and white sugar • All sugars are carbohydrate; carbohydrate provides us with energy* • Sugars, as sources of glucose, are the energy source for the brain* *NB These are claims and must only be used in compliance with regulation EC 1924/2006 on nutrition and health claims made on foods30 (see section 3.4) Sources of sugars • Sugars can be either naturally occurring in fruit and vegetables and milk, or added to foods during cooking or processing • Sugar is naturally white, it is not bleached • Sugars can be found in many different types of foods including savoury. Read the label to find out more
Box 3 - Specific consumer messages about sugars and health Sugars and weight management • If you are watching your weight it is the total calories that count. All excess calories contribute to weight gain Sugars and dental health • Many foods containing sugars, including honey, fruit juice, fresh fruit, and dried fruit, can cause tooth decay • Foods and drinks containing sugars should not be consumed too frequently throughout the day Given the importance of oral hygiene in preventing tooth decay, where appropriate, consider adding the advice to 'Always clean your teeth twice daily with floride toothpaste'
30 http://ec.europa.eu/food/food/labellingnutrition/claims/index_en.htm
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8.2 Information for Food Businesses About Sugars A number of the messages tested in focus groups were not found to be appropriate for consumers. However, food businesses may find the information in these messages (Box 4) useful to consider when developing products or resources: BOX 4 - Information for businesses Sugar processing • Brown colours and flavours come from raw sugars or are added back • Sugar is naturally white, it is not bleached Nutritional value of sugars • Sugars provide 4 calories per gram. This is less than half the calories of fat (9 calories/gram). The GDA for sugars is 90g Sugars and diabetes • Sugar (sucrose) does not cause diabetes. Sugars can be eaten as part of a healthy balanced diet** Sugars and behaviour • Sugars (including table sugar) do not cause behavioural problems in children** **Consumer messages addressing health outcomes are based on current scientific evidence. Expert committees have noted that the balance of available evidence does not implicate sugars in any of the 'lifestyle diseases' including obesity and diabetes. Food businesses will find the key scientific papers listed in section 7.0 of this report helpful for further information on sugars and health.
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Appendices Appendix I - Meanings and use of the terms used to describe sugars in the diet Total sugars In those countries which have traditionally determined carbohydrate components directly for food composition databases, the term used for the content of sugars is “total sugars” comprising all mono and disaccharides in the food, from whatever source, whether naturally occurring or added to the food during processing or cooking31,32. In foods, total sugars is the sum of fructose, glucose, sucrose, lactose, maltose and galactose. Sugars The term "sugars" is used to refer to a variety of components. Often it is a short form of “total sugars” and used to refer to the same components: any free mono- or disaccharide present in foods, such as glucose, fructose, sucrose, maltose or lactose, whether naturally-occurring or added to foods33. This definition is consistent with that used by the Food and Drug Administration (FDA) for nutrition labelling purposes34. Simple sugars This term is not used often in dietary intake reports, but is used commonly when sugars are discussed. It is generally assumed to mean the same thing as “sugars” and “total sugars”.35
31 Paul AA, Southgate DAT. McCance and Widdowson's The Composition of Foods. 4th ed. 1978, London: Her Majesty's Stationery Office 32 Food Standards Agency. McCance and Widdowson's The Composition of Foods. Sixth summary edition. 2002. Cambridge: Royal Society of Medicine 33 International Food Information Council Foundation, IFIC Review - Sweet Facts About Sugars and Health, I.F.I.C. Foundation, Editor: Washington, DC 34 U. S. Food and Drug Administration, The Food Label. 2003, Washington, DC: Department of Health and Human Services 35 Sigman-Grant M, Morita J. Defining and interpreting intakes of sugars. Am J Clin Nutr, 2003. 78: 815S-826S
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Free sugars Traditionally “ free sugars” referred to any sugars in a food that were free and not bound31. This term was used to describe what was being analysed when the carbohydrate in a food was hydrolysed and components detected by chromatography or colorimetric methods, and therefore includes all types of sugars, including lactose and those released by the hydrolysis of starch. In recent years, the term free sugars has changed its meaning in some instances to refer to all “monosaccharides and disaccharides added to foods by the manufacturer, cook and consumer, plus sugars naturally present in honey, syrups and fruit juices”36. While this seems the most common usage currently, it is quite different from what the term “free sugars” meant in earlier times, which may lead to confusion in some circumstances. Total available sugars This term is used in some food composition databases, such as in New Zealand37,38. It is described as being the sum of individual mono and disaccharides, but it is not clear why the term ‘available’ is included, since none of the sugars terms include unavailable sugars, such as the disaccharide lactulose, within their definition. Sugars, not including lactose Some studies report total sugars, but without lactose. Milk sugar is excluded from the description of “sugars” in some databases, as this sugar is not considered to be of concern for health.39 It often takes detailed reading of a publication to notice that lactose has been omitted from the results. Added sugars The UK Food Standards Agency defines ‘added sugars’ as “any mono- or disaccharide or any other food used for its sweetening properties. This would include, but is not exclusively limited to: sucrose, fructose, glucose, glucose syrups, fructose-glucose syrups, corn syrups, invert sugar, honey, maple syrup, malt extract, dextrose, fruit juices, deionised fruit juices, lactose, maltose, high maltose syrups, Agave syrup, dextrin and maltodextrin”.40
36 WHO (2003) Diet, nutrition and the prevention of chronic diseases. WHO Technical Report series 916. Geneva 37 Athar N, McLaughlin J, Taylor G, Mishra S. The Concise New Zealand Food Composition Tables. 7th ed. 2006, Christchurch: New Zealand Institute for Crop and Food Research 38 Sugar Research Advisory Board, Sugar and Our Diet. 2004, Sugar Research Advisory Board: Auckland 39 Gibney M, Sigman-Grant M, Stanton JL, Jr., Keast DR. Consumption of sugars. Am J Clin Nutr, 1995. 62: 178S-193S; discussion 194S 40 http://www.food.gov.uk/foodlabelling/signposting/technicalguide/
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In the United States ‘added sugars’ comprises sugars and syrups that are “added to foods during processing or preparation”41. In the food composition table of the United States Department of Agriculture (USDA), added sugars are defined as those sugars “added to foods and beverages during processing or home preparation”.42 Whereas the FDA uses this term to mean only mono and disaccharides for labelling purposes, the Economic Research Service in the United States includes oligosaccharides derived from corn syrups in its definition . Fruit juices are not currently included in the FDA definition.43 Others have used the definition for ‘added sugars’ as “all refined sugars (e.g. sucrose, maltose, lactose, glucose, dextrin) eaten separately at the table or used as ingredients in processed foods”,44 which differs from other definitions in including lactose. ‘Added sugar’ has in some cases been used interchangeably with ‘added sugars,45,46,47 but in other cases is defined as “sugar added to tea, coffee, cereals etc.” in which case it appears to be limited to table sugar.48 Sugar There is a general belief that this term, i.e. without the “s” at the end, is understood by the public to mean sucrose, and is commonly used in the published literature. However, it appears to have a number of meanings. In some cases, it refers to sucrose only, while elsewhere it includes “all monosaccharides and disaccharides”, or “any free monosaccharide or disaccharide in a food”.49 At a Sugars and Health workshop in 2002, where terminology was discussed, the consensus was that this term should refer only to sucrose.43 In many publications the term is used without an indication of what it refers to, and in some cases is used interchangeably with the term ‘sugars’, which can cause confusion for the reader.
41 Institute of Medicine of the National Academies, Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Proteins and Amino Acids. 2002:, The National Academies Press, Washington DC 42 United States Department of Agriculture and Agriculture Research Service, USDA National Nutrient Database for Standard Reference, Release 19. 2006, Nutrient Data Laboratory Home Page. http://www.ars.usda.gov/main/ 43 Sigman-Grant M, Morita J. Defining and interpreting intakes of sugars. Am J Clin Nutr, 2003. 78: 815S-826S 44 Alexy U, Sichert-Hellert W, Kersting M. Associations between intake of added sugars and intakes of nutrients and food groups in the diets of German children and adolescents. Br J Nutr, 2003. 90: 441-7 45 Knol LL, Haughton B, Fitzhugh EC. Dietary patterns of young, low-income US children. J Am Diet Assoc, 2005. 105: 1765-73. 46 Kranz S, Smiciklas-Wright H, Siega-Riz AM, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr, 2005. 146: 105-11 47 Overby NC, Lillegaard IT, Johansson L, Andersen LF. High intake of added sugar among Norwegian children and adolescents. Public Health Nutr, 2004. 7: 285-93 48 Larsson SC, Bergkvist L, Wolk A. Consumption of sugar and sugar-sweetened foods and the risk of pancreatic cancer in a prospective study. Am J Clin Nutr, 2006. 84: 1171-6 49 Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr, 2004. 79: 537-43
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Refined sugars Refined sugars is a term commonly used in many European countries, and generally comprises sucrose, fructose, glucose, starch hydrolysates (glucose syrup, high-fructose corn syrup) and other isolated components added during food preparation and manufacturing.50 Refined sugar Refined sugar, without the “s”, is also used in some publications, such as studies that use the National Coding Center at the University of Minnesota. In these cases, it refers to refined sucrose only and dietary items are included only if sucrose is the only sweetener in a recipe. If more than one sweetener is used in the preparation of a food, all the sweeteners, including the sucrose are coded as “other carbohydrates”51. Sucrose is underestimated in studies using this system. Recent assessment of refined sugar intake in Australia indicates that this term refers to ‘discretionary sugars’ and ‘added refined sugars’ during manufacture52, and is therefore not the same as the refined sugar in the American publications. Discretionary sugar Discretionary sugar, a term which is also used in some publications, generally without definition, has been described as a subset of refined sugar and includes refined sugars that people choose to add to beverages, breakfast cereals and other foods at the table, and is considered to be mostly sucrose53. Intrinsic sugars Intrinsic sugars are those naturally incorporated into the cellular structure of food54.
50 The Nordic Council, Nordic Nutrition Recommendations 2004: Intergrating Nutrition and Physical Activity. 2004, The Nordic Council of Ministers, The Nordic Food Policy Co-Operation: Copenhagen 51 Kaufmann NA, Dennis BH, Heiss G, Friedlander Y, Kark JD, Stein Y. Comparison of nutrient intakes of selected populations in the United States and Israel: the Lipid Research Clinics Prevalence Study. Am J Clin Nutr, 1986. 43: 604-20. 52 Somerset SM. Refined sugar intake in Australian children. Public Health Nutr, 2003. 6: 809-13 53 Sugar Research Advisory Board, Sugar and Our Diet. 2004, Sugar Research Advisory Board: Auckland 54 Kelly SA, Summerbell C, Rugg-Gunn AJ, Adamson A, Fletcher E, Moynihan PJ. Comparison of methods to estimate non-milk extrinsic sugars and their application to sugars in the diet of young adolescents. Br J Nutr, 2005. 94: 114-24
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Extrinsic sugars These sugars can be described as all sugars not encapsulated within the cellular architecture of the food. Several methods have been proposed to define and estimate extrinsic sugars. Non-milk extrinsic sugars (NMES) This term was introduced in the United Kingdom in 1989 by COMA (Committee on Medical Aspects of Food Policy) during the production of a report on Dietary Sugars and Human Disease55 to help researchers and others in the nutrition field describe intakes of those types of sugars about which they had concerns. These include total sugars excluding lactose in milk and milk products and those present within the cellular structures of fruits and vegetables. There are currently five different methods for estimating NMES: a. By subtracting values for sugars from liquid cow’s milk, fruit and fruit products (excluding fruit juice) from the values for total sugars56,57 b. From sucrose added to foods during manufacturing, preparation and at the table, and all sugars in fruit juices, squashes and drinks58. Sugars in unsweetened fruit purees are considered intrinsic. c. All sugars in fruit juices, as well as table sugar, honey and the sucrose, glucose and glucose syrups added to food sugars naturally present in fruit that have been canned, stewed, dried or used in preserves are considered to be half extrinsic and half intrinsic59,60 d. Sugars not naturally occurring within the intracellular structure of foods, plus 50% of the sugars in refined or processed fruits, vegetables and grains61,62
55 Department of Health (1989) Dietary Sugars and Human Disease. Report on the Panel on Dietary Sugars of the Committee on Medical Aspects of Food Policy (COMA). Report No. 37. HMSO, London 56 Gregory J, Foster K, Tyler H, Wiseman M. The Dietary and Nutritional Survey of British adults. 1990, London: Her Majesty's Stationery Office 57 Ministry of Agriculture, Fisheries and Food, The Dietary and Nutritional Survey of British Adults - Further Analysis. 1994, London: HMSO 58 Mills A and Tyler H, Food and Nutrient Intakes of British Infants Aged 6-12 Months. 1992, London: H. M. Stationery Office 59 Gregory J, Lowe S, Bates, CJ, Prentice A, Jackson LV, Smithers G, Wenlock R, Farron M. National Diet and Nutrition Survey: Young People Aged 4 to 18 Years. Volume 1: Report of the Diet and Nutrition Survey. 2000, London: The Stationery Office 60 Gregory JR, Collins DL, Davies PSW, Hughes JM, and Clarke PC, National Diet and Nutrition Survey: Children aged 1½ to 4½ years. Volume 1: Report of the Diet and Nutrition Survey. 1995, HMSO: London 61 Bolton-Smith C and Woodward M, Dietary composition and fat to sugar ratios in relation to obesity. Int J Obes Relat Metab Disord, 1994. 18: 820-8. 62 Drummond S and Kirk T, The effect of different types of dietary advice on body compostition in a group of Scottish men. J Hum Nutr Diet, 1998. 11: 473-485
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e. Added sugars plus sugars from fruit in fruit juices and other soft drinks. Sugars from fruit in jams and yoghurts are intrinsic. Lactose from milk in chocolate is included. Dried fruit is intrinsic63,64 Estimates using these methods shows some differences65. Three of these methods have been used for the National Diet and Nutrition Surveys58,59,66. The most recent of these method, category c above, is that currently used for national surveys in the United Kingdom66. The term non-milk extrinsic sugars or “NME sugars” is used by nutritionists, researchers and government agencies in the United Kingdom, but is not well understood by the public and is not usually referred to in public communications about sugars. Its use is focused on dietary surveys and other reports where intakes are described. Caloric sweeteners Caloric sweeteners is the term used in Food Balance data produced by the Food and Agriculture Organization67. The term refers to “sweeteners consumed directly and as food ingredients, such as sucrose, from refined cane and beet sugars, honey, dextrose, edible sugars and corn sweeteners”. This term may also include some oligosaccharides68. This term is rarely used in the literature about individual intakes.
63 Rugg-Gunn AJ, Adamson AJ, Appleton DR, Butler TJ, and Hackett AF, Sugars consumption by 379 11-12 year-old English children in 1990 compared with results in 1980. J Hum Nutr Diet, 1993. 6: 419-431 64 Adamson AJ ,Rugg-Gunn AJ, Butler TJ, Appleton DR. The contribution of foods from outside the home to the nutrient intake of young adolescents. J Hum Nutr Diet, 1996. 9: 55-68. 65 Kelly SA, Summerbell C, Rugg-Gunn AJ, Adamson A, Fletcher E, Moynihan PJ. Comparison of methods to estimate non-milk extrinsic sugars and their application to sugars in the diet of young adolescents. Br J Nutr, 2005. 94: 114-24 66 Henderson L, Gregory J, Swan G. The National Diet & Nutrition Survey: Adults Aged 19 to 64 Years, Volume 1: Types and Quantities of Foods Consumed. 2002, London: The Stationery Office 67 Food and Agriculture Organisation of the United Nations (1991) Food balance sheets 1984-86. Food and Agriculture Organisation, Rome 68 Sigman-Grant M, Morita J. Defining and interpreting intakes of sugars. Am J Clin Nutr, 2003. 78: 815S-826S
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Appendix II - Scientific evidence supporting consumer messages about sugars Sugars have been linked to a number of health concerns including obesity, dental caries, micronutrient dilution, type 2 diabetes and hyperactivity behaviour. The status of scientific evidence for an impact of sugars on each of these was collected from systematic reviews and metaanalyses, and is summarised below. Weight management Obesity affects around 50% of adults and a third of children in developed countries. Sugars are implicated in obesity due to their possible role in encouraging over-consumption of energy, increasing energy density and making high-fat foods more palatable69. Recent reviews of the evidence have failed to find a positive association between sugars consumption and obesity. Ruxton et al69 concluded that results from high quality obesity studies did not suggest a positive association between body mass index and sugar intake. Van Baak and Astrup70 found insufficient evidence that an exchange of sugar for nonsugar carbohydrates in the context of a reduced-fat ad libitum diet or energy-restricted diet results in lower body weights. Analysis of trends in energy and sugar intakes and body mass index among children in Great Britain found that it was unlikely that the rise in BMI observed over the period 1983 to 1997 (on average 0.7 – 1 kg m-2), could be attributed to increased consumption of sugars in any form. The author noted that this epidemiological perspective did not deny that individuals who are overweight or at risk of becoming overweight should avoid excess calorie consumption71. The European Food Safety Authority (EFSA) opinion on dietary reference values for carbohydrates and fibre stated that “the available evidence is insufficient to set an upper limit for sugars based on their effects on body weight. Evidence on the relationship of sugar-sweetened beverages and body weight should be considered when developing food-based dietary guidelines”72.
69 Ruxton CHS, Gardner, EJ, McNulty HM (2010) Is Sugar Consumption Detrimental to Health? A Review of the Evidence 1995-2006 Crit Rev Food Sci and Nutrition, 50, 1 – 19. 70 Van Baak MA, Astrup A (2009) Consumption of sugars and body weight. Obes Rev 10 Suppl 1; 9-23 71 Gibson S (2010) Trends in energy and sugar intakes and body mass index between 1983 and 1997 among children in Great Britain. J Hum Nutr Diet 23; 371 - 381 72 EFSA Panel on Dietetic Products, Nutrition and Allergies (2010) Scientific opinion on Dietary reference values for carbohydrates and dietary fibre. EFSA J. 8; 1462
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Dental health Caries is the end outcome of the loss of enamel on the tooth surface. This is caused mainly by periods of increased acidity (reduced pH levels) on the tooth surface, as a result of acid by-products. These arise when particular bacteria present in dental plaque on the tooth, come into contact with sugars from foods and drinks consumed in meals or between meals. The surface of the tooth is exposed to constant ‘tides’ of demineralisation and remineralisation of the tooth enamel related to factors in foods consumed and other factors that affect the oral environment. The degree of caries (carious lesions) is the accumulation of these caries-promoting and inhibiting factors over a period of time. For example, dairy products have been found to inhibit caries formation78. Various reviews have looked at the associations between intakes of sugars and caries risk. Few have demonstrated clear strong associations between amounts of sugars in the diet and caries; associations between the frequency of sugars consumed and caries risk are more often reported as significant. A review by Anderson et al found associations between amount of sugars consumed and caries risk in only 9 of the 31 studies that met approved quality criteria, but the association between the frequency of sugars consumed and caries risk was found to be significant in 19 of the 31 studies assessed73. The direct association between intakes of sugars in the diet and the prevalence and severity of caries, is more strongly linked to the frequency of intakes of sugars, than to the total amounts of sugars consumed (although amounts of sugars and frequency of sugars are correlated). Guidelines now advise reducing the frequency and amount of sugary foods and drinks, and limiting consumption to meal times. They further recommend that sugars should not be consumed more than four times per day74. Significant modification of the association of dietary intakes of sugars and the risk of dental caries has occurred with exposure of the population to fluoride (from that added to drinking water and/or in toothpaste). In the UK most water supplies do not have any added fluoride, but the advice of dental professionals is that everyone, regardless of diet or caries risk, should brush teeth with a fluoride-containing toothpaste at least twice daily. Although a fluoride-containing environment weakens the observed associations between diets containing free sugars and the development of caries, controlling the amounts and especially the frequency of sugars consumed remains a justifiable part of public health caries prevention advice.
73 Anderson CA et al (2009) Sucrose and dental caries: a review of the evidence. Obesity Reviews 10,S1: 41-54 74 Department of Health/British Association for the Study of Community Dentistry (2007) Delivering Better Oral Health: An evidence-based toolkit for prevention. London, The Stationery Office
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Micronutrient dilution/diet quality The theory that increased sugars in the diet would result in reduced intake of essential micronutrients arose from the lack of vitamins and minerals in table sugar. It appeared that the higher the proportion of sugar in the diet the lower the vitamin and mineral content must be. Subsequent research has shown this assumption to be incorrect, except perhaps, in the most extreme cases75. A number of analyses have been carried out to investigate the variation in intake of vitamins and minerals with sugar consumption in the diets of individuals of various ages. Systematic reviews of the literature on studies involving both adults and children have shown that there is no clear evidence of micronutrient dilution or a threshold for a quantitative amount of added sugar intake for any of the micronutrients investigated69,75,76. There are also inconsistencies between studies. Similar conclusions were also drawn by the Institute of Medicine following a review of NHANES III data77. More recently, the European Food Safety Authority noted the available data on nutrient density is not sufficient to set an upper limit for (added) sugar intake72. The data do not suggest an appreciable impact of sugar intake, or that modifying sugar intake is likely to be an effective means of altering micronutrient consumption. This is not to state that all individuals consume sufficient amounts of micronutrients. While the majority of the population has a more than adequate intake of all micronutrients, dietary estimates suggest that an appreciable proportion of the population fails to consume the minimum recommended amount of one or more micronutrients. The evidence clearly shows that sugar consumption has little, if any influence on micronutrient intakes. Energy intake has been established as the prime predictor of micronutrient adequacy75. When sugar consumption levels are higher than the recommendations, Ruxton et al69 reported that dietary adequacy was achieved. These authors noted that key sources of sugar in the diet are often fortified, eg breakfast cereals, yogurts and drinks. One study in which separate sources of sugars in the diets of US children and adolescents were analysed found that consumption of sweetened dairy foods and beverages and presweetened cereals had a positive impact on children and adolescents' diet quality, whereas sugar-sweetened beverages, sugars and sweets, and sweetened grains had a negative impact on their diet quality75.
75 Gibson (2007) Dietary sugars intake and micronutrient adequacy: A systematic review of the evidence. Nutr. Res. Revs 20; 121-131 76 Rennie KL, Livingstone MBE (2007) Associations between dietary added sugar intake and micronutrient intake: A systematic review. British J. Nutr. 97; 832-841 77 Food and Nutrition Board, Institute of Medicine, National Academy of Sciences (2002). Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids. National Academic Press. USA
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Encouraging a wide variety of foods in the diet, while avoiding overconsumption of individual foods, is therefore likely to be most effective as a method of improving micronutrient intake, given that sugar is used to enhance the flavour and palatability of many nutrient dense foods. Type 2 diabetes and insulin resistance Type 2 diabetes occurs when the body produces insufficient insulin or is insensitive to the insulin it does produce. It is characterized by high blood glucose levels. There is no cure for diabetes, and research has focused on determining the best means of prevention. The World Health Organization78 concluded that a direct causal association between free sugar consumption and Type 2 diabetes is not clearly demonstrated, although there is an indirect link through weight gain. A review of the literature produced since the publication of this report confirms that the question of a direct link still remains. Reviews of the literature indicate that existing research is lacking and far from conclusive in this area79,80,81. A recent Cochrane review concludes there is a need for “more well-designed, long term studies, providing well-reported, high-quality data”80. Furthermore, there is also some emerging interest in investigating the impact that the type of carbohydrate has rather than the just the amount, looking at factors such as glycaemic index79,82,83. Overall, the literature is consistent in agreeing that excess weight plays a more fundamental role in insulin resistance and the development of Type 2 diabetes, than the effect of the macronutrient composition of the diet79,81,82,83.
78 WHO (2003) Diet, nutrition and the prevention of chronic diseases. WHO Technical Report series 916. Geneva 2003 79 McClenaghan NH (2005) Determining the relationship between dietary carbohydrate intake and insulin resistance. Nutrition Res. Reviews 18; 222-240 80 Nield L, Summerbell CD, Hooper L & Whittaker V, Moore H (2008) Dietary advice for the prevention of type 2 diabetes mellitus in adults. The Cochrane Collection, J Wiley & Sons LTD 81 Spence M, McKinley MC & Hunter SJ (2010) Diet, insulin resistance and diabetes: the right (pro) portions. Proce. Nutr. Soc (2010); 61-69 82 Hu FB, van Dam RM, Liu S (2001) Diet and risk of Type II diabetes: the role of types of fat and carbohydrate. Diabetologia 44; 805-817 83 McAuley K & Mann J (2006) Nutritional determinants of insulin resistance. J Lipid Res 47; 1668-1676
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Behaviour Sugars are implicated in changes in behaviour in children through reports of hyperactivity following sugars consumption. However, the evidence does not support the assertion that sucrose has a significant influence on the behaviour of children84. A report by the Food and Agriculture Organisation (FAO) of the United Nations concluded that restricting a child’s sugar intake to try and control their behaviour was not appropriate85. Advice for the management of Attention Deficit Hyperactivity Disorder (ADHD) focuses on encouraging a balanced and nutritional diet, and regular exercise. Although the influence of sugar in ADHD has attracted much public attention, it is not always covered specifically in guidance to health care professionals. Generally, the advice is not to routinely restrict or eliminate foods from the diet. There may be a small proportion of children with ADHD with reactions to some foods or ingredients where referral to a dietitian and a careful investigation of their diet may be required.
84 Ells LJ et al (2006). A systematic review of the effect of dietary exposure that could be achieved through normal dietary intake on learning and performance of school-aged children of relevance to UK schools. http://www.food.gov.uk/multimedia/pdfs/systemreview.pdf Accessed 18th May 2010 85 FAO (1997) Food and Nutrition Paper 66 . Carbohydrates in human nutrition. Report of a Joint FAO/WHO Expert Consultation (Reprinted 1998, up-dated 2007) Rome, 14-18 April 1997 http://www.fao.org/docrep/w8079e/w8079e00.htm#Contents accessed on 19th May 2010
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Appendix III - IGD qualitative research on consumer knowledge of sugars and terms associated with sugars and sugar processing: Recruitment criteria, Method/Discussion Guide and Results Recruitment criteria for sugars qualitative research Eight groups of eight participants were recruited with the composition shown in Table 9. Table 9. Recruitment criteria for qualitative research on sugars Group No.
Gender
Social grade
Location Employment Life stage
Inclusion criteria Attitude to health (Q1)
Attitude to sugars/ sweeteners (Q2)
1
Women
BC1
London
Full/PT
Children 0-5 years
Balancers
No sugar or sweeteners
2
Women
BC1
Leicester
PT/No
Children 0-5 years
Balancers
Sugar
3
Women
BC1
Cardiff
Full/PT/No
Children 6-15 years
Avoiders
No sugar
4
Women
C2D
London
Full/PT
Pre-family
Strugglers
Sugar
5
Women
C2D
Sheffield
Full
Children 6-15 years
Balancers
Sweeteners
6
Men
BC1
Sheffield
Full/PT
Pre-family
Balancers
No sugar or sweetener
7
Men
C1C2
Cardiff
Full/PT
Children 0-15 years**
Strugglers
Sugar
8
Mixed*
BC1
Leicester
PT/No
Post-family
Avoiders
No sugar or sweeteners
*Aim for at least 5 women **Aim for 4 with 0-5 year olds and 4 with 6-15 year olds At least two participants in groups 1, 2, 3, 4, 6, and 7 who have been on a weight loss diet in the last year. Exclude diabetics and those who are on a medical diet (codes 1-3 at Q3) Exclude those not interested in eating a healthy diet (code 4 at Q1)
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Q1 Please indicate which of the following statements most closely reflects your attitude to eating 1. I eat a very healthy diet, and avoid certain foods even if I fancy them (Avoiders 19%) 2. My diet is mostly healthy, but I do have treats now and again (Balancers 55%) 3. I find it difficult to eat a healthy diet most of the time, but I do try (Strugglers 14%) 4. I’m not really interested in eating a healthy diet (Don’t cares 8%) Q2 Do you sometimes add any of the following to hot drinks (e.g tea or coffee) or to food (e.g cereals)? 1. Sugar (white or brown) 2. Sweetener (e.g Candarell, Sweetex) 3. No – I don’t add sugar or sweetener Q3 Does any of the following apply to you? 1. I am diabetic 2. I have a close relative who is diabetic 3. I have a medical condition that means I am on a diet 4. None of the above Method Each focus group was 1.5 hours duration in the form of a guided discussion. The discussion guide and stimulus materials are shown below. Research was conducted between 1st and 8th February 2010. Focus groups were recorded and subsequently transcribed. Transcripts were analysed and themes identified. Discussion guide Time allocated: 90 minutes Introduction Purpose of the evening/afternoon: explain to the group that the purpose is to discuss sugars – sweet ingredients used in foods. Warm up Ask participants to introduce themselves, give their first name, where they shop for groceries and their favourite food. Ask participants to write down on post-it notes the first thing that comes to mind when thinking about sugars. Share these with the group.
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1. Use of sugars Objective: Begin the discussion. Start to look at basic attitudes to sugars. Adapt questions according to group profile (based on Question 2 in recruitment criteria) Sugars users Do you use sugars ? Which foods or drinks do you add sugars to? Why? Have you ever tried to stop adding sugar or reduce the amount? • If so, why, when (recently, sometime ago etc), how etc? How successful were you? • [If applicable] Do you allow your children to add sugars to their foods? Sweeteners users Do you prefer to use sweeteners or sugars? Why? Are there any foods or drinks you do use sugars in? Why? Are there any foods or drinks that you buy or would add sweeteners too? All Why don’t you use [sugars and/or sweeteners] in foods? Which foods or drinks do you associate with containing the most sugars and sweeteners? When you use sugars, what types do you use? [If not covered already] Do you use sugars in cooking? • Which foods? • Other than sweets and desserts, when do you add sugars to food?
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2. Knowledge of sugars Objective: Determine whether participants recognise that sugars occur in many different types of foods and their attitudes to added and intrinsic sugars. Think about your most recent meal [exclude breakfast]. Do you think there were any sugars in it? [Pick on two or three examples] • Which foods were the sugars in? What do the rest of you think? How do you know the amount of sugars a food or drink contains? • Can the labelling help you do this? • Which parts of the labelling? • Any others? What does the body use sugars for? Are there any recommendations on the amount of sugars you should eat? What foods or drinks do you associate with sugars? • How often do you eat or drink these? • What do you think about these foods in terms of nutritional value? Group exercise Participants were shown cards with paired or grouped examples of foods and drinks. For each card, participants were asked which food or drink contains the most sugars (per portion shown). Participants used voting cards (L, R or M) to indicate their choice and revealed simultaneously. Mini-pack confectionery and mini-pack raisins
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Fruit yoghurt and natural yoghurt
Carbonated drink and fruit smoothie
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Cereal bar, chocolate biscuit and ripe banana
Fruit loaf and plain sponge cake
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Sugar contents revealed to the group Confectionery (14g)
9.5g sugars
Raisins (14g)
10g sugars
Natural yoghurt (125g)
9.5g sugars
Fruit yoghurt (125g)
14g sugars
Cola (250ml)
27g sugars
Fruit smoothie (250ml) 30.5g sugars
Plain sponge cake (38g) 10.5g sugars Fruit loaf (34.5g)
Cereal bar (25g)
9g sugars Chocolate biscuit bar (25g)
12g sugars
7g sugars
Banana (120g)
25g sugars
Participants were asked • Is this what you would expect? • What do you feel/think about this? 3. Types of sugars and sweeteners Objective: Explore attitudes to different types of sweetening substances. What are sugars? • Where do they come from? • Do you know what type of nutrient they are? [Are they protein, fat or carbohydrate?] What are sweeteners? • Where do they come from? • How do they differ from sugars in terms of nutrients? Group exercise Participants were shown cards with groups of sweetening substances Group 1 Granulated sugar Icing sugar Fruit sugar Soft brown sugar Dried fruit pieces
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Group 2 Golden syrup Honey Black treacle Fruit juice Glucose/fructose syrup Agave syrup Group 3 Sucrose Fructose Isomaltose Glucose Xylitol Canderel (Aspartame) Splenda (Sucralose) For each group of sweetening substances: • Are there any that you don’t recognise? • Have you come across foods or drinks containing these substances? • What have you found them in? • Are they foods or drinks you consumer regularly? • Perceptions of each [+ve/-ve]. Would you eat foods with these in? After all 3 groups have been discussed • Which would you prefer to sweeten your foods and drinks with? Why? 4. Functions of sugars Objective: Determine level of understanding of the functions of sugars other than sweetening What other reasons are sugars added to foods other than for sweetening? [Unprompted]
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Here are some examples of ways in which sugars are used in foods other than for sweetening Participants were shown list of functions of sugars: Energy Texture Preservative Flavour Colour Glazing Fermentation Were you aware that sugars could be used in these ways? • Any examples you can think of? If no examples were given, respondents were prompted with the following: Energy – in energy drinks e.g. sports drinks Texture – using granulated, caster or icing sugar in baking gives different properties to cakes, biscuits and pastry Preservative – jam Flavour – caramel Colour – dark colours using dark brown or muscovado sugar for fruit cakes Glazing – honey roast ham, Fermentation – beer, wine What do you think about sugars being used in these ways? [+ve/-ve attitudes, not aware, never thought about it, surprise, interest, already aware etc] 5. Re-cap Objective: Test whether participants give the same responses as they gave at the start of the session. Respondents were asked about sugars even if the group contained sweeteners users. Revisit question 1 to find out whether responses remain the same. Knowing what you know now, has this affected your perception of how much you use sugars and what you use them for?
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How have your perceptions of sugars and sweeteners changed, if at all? Revisit the word associations from the warm-up exercise. Have these changed? How? Results of Phase 1 research Warm-up exercise. Top of mind perceptions about sugars Overall, top-of-mind perceptions about sugars were quite negative. In one way or another many respondents tended to think of sugars as being unhealthy or bad for you. Sugars were associated with: • Tooth decay • Obesity/over weight • Poor nutritional value and ‘empty calories’ • Hyperactivity in children in association with certain food additives • A proxy for identifying unhealthy foods and drinks. • Guilty pleasure - ’naughty but nice’ This perception was not universal – some respondents only regarded sugars as a health concern if consumed to excess. Some recognised that the body needs a certain amount of sugar; others thought that in moderation sugars are neutral. 1. Uses of sugars Three ways were identified in which respondents added sugars to foods and drinks themselves: 1. Sugars sprinkled/spread on or into food and drinks just before they’re consumed: • Particularly addition of table sugars to hot drinks e.g. Tea , coffee, hot chocolate, horlicks, hot milk (childhood memories). Honey added to hot lemon • Breakfast cereals – table sugars added to a range of cereals. One respondent added fruit juice to their breakfast cereal. A range of sugars was added to porridge
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• Toast – honey used • Pancakes - granulated, caster, syrup, honey, treacle • Fruit – e.g. strawberries, cherries 2. During cooking • Vegetables – honey to carrots, fruit juice to red cabbage • Fruit e.g cooking apples • Tomato based sauces/meals - bolognaise, chilli, curry, pasta sauces • Other meals - sweet and sour, honey glaze • Jams, pickles, chutney 3. When baking • Sugars, including brown, caster, icing, syrup and treacle, were added to cakes, puddings and biscuits • Some respondents expressed surprise at how much sugar had to be added to bread recipes Reasons for adding sugars to foods and drinks included: • To make them sweeter • To provide flavour – e.g. honey or syrup in porridge • To manage the taste - Offset/balance the tartness/bitterness e.g. tomato based dishes/fruits - Provide contrast e.g. sweet and sour • Many respondents reported trying to restrict the addition of sugars to foods/drinks consumed by their children • It was commonly felt that the habit of adding sugar to tea/coffee starts when young and that children could easily get used to drinks without sugar • Some parents added the sugar for their child • Some parents avoided having sugars on the table at breakfast by having sweetened cereals. The reason given for this was that it was then easier to control and regulate the amount of sugar consumed by the child Use of sweeteners A narrower range of uses was reported for sweeteners than for sugars: • Hot drinks • Breakfast cereals • Baking – some prompted by advertisements • Strawberries
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Triggers to use of sweeteners included weight loss and a general aim to reduce sugar intake. Barriers included: 1) Health concerns • Sweeteners suffer from perceived ‘bad press’ –cancer and eczema were cited as conditions associated with their use • Warnings on products – laxative effect of sugar free mints/gum • Personal experience – stomach ache, sleep deprivation 2) Poor after-taste • Most agree sweeteners don’t taste as good - even those who use them • Some say they have got used to it/tolerate it but would rather have sugar • Others find the taste poor Foods associated with sugars When asked which foods they associated with sugars, respondents mentioned the categories listed below, and in some cases, specific foods. Food categories are listed in descending order of strongest association (highest frequency of mention by respondents) at the top, to less common association with sugar content: • Drinks: cola, energy drinks, fizzy, fruit, alcoholic • Convenience foods: fast foods, ready meals • Biscuits, cakes • Confectionery • Sauces: ketchup, brown sauce, gravy/stock, mayo, dressing • Baked beans • Cooking sauces: tomato based, creamy, curry • Breakfast cereals and cereal bars • Fruit • Bread: white bread, long life, bagels • Vegetables: peas, tinned sweetcorn, sweet potato • Milk 2. Knowledge of sugars Knowledge of sugars appears to be driven by personal interest in things such as: • Home baking – the different types of sugars, the functions they perform, and the amount of sugars used in certain products • Sport – providing energy, the different types of energy (slow vs. quick release were mentioned) and certain foods (e.g. bananas) with high sugar content.
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Some respondents would look at the ingredient list to find out how much sugar is in a product. There was some awareness that the order of ingredients relates to the relative amount of each ingredient, and various names of different sugars to look for. Other respondents mentioned looking at the nutritional information on either the front- or back-of-pack. Some noted the % Guideline Daily Amount (GDA), others the grammes of sugar per 100 grammes of product, or traffic light colour coding. Only one respondent spontaneously referred to the ‘carbohydrates of which sugars’ reference on pack. Most respondents assumed there was a recommended maximum amount of sugars but admitted they didn’t know or hadn’t heard what the recommendation was. Sugar was generally associated with providing energy particularly instant energy/boost. There were vague notions of what happens to sugar in the body including it converting, breaking down or breaking other things down, e.g: • Converts to carbohydrate/starch • Converts to or is stored as fat – if not used up • Makes insulin, • Releases endorphins Group exercise Participants were shown the cards of paired or grouped examples of foods and drinks (see above), and asked which food or drink in each grouping contains the most sugars. Fruit yoghurt (14g sugars per 125g) v natural yoghurt (9.6g sugars per 125g) Most respondents identified the fruit yoghurt as containing the most sugars. The fruit yogurt tastes discernibly sweeter, but some respondents were surprised how much sugars were in natural yogurt. Confectionery (9.5g sugars per 14g) v raisins (10g sugars per 14g) Quite a few respondents correctly predicted that raisins had more sugar than the confectionery as they had already heard something to this effect or they realised that this was why children liked the raisins so much. Many were unaware of the amount of sugars in raisins, and some mothers amongst the respondents began to be concerned at the number of boxes of raisins they let their young children consume. Plain sponge (10.5g sugars per 38g slice) v fruit loaf (7g sugars per 34.5g slice) Many respondents were confused by a lack of familiarity with fruit loaf as opposed to fruit cake, and incorrectly assumed that fruit loaf would be higher in sugars due to the fruit content.
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Cereal bar ( 9g sugars per 25g) v chocolate biscuit bar (12g sugars per 25g) v banana (25g sugars per 120g) Bananas had a stronger association with sugars than other fruits for some respondents due to their link with sports as an energy food. The browning on ripening was also associated with sugars content. Respondents recognised the higher weight of the banana compared to the cereal and chocolate biscuit bar. Those who chose the cereal bar as higher in sugars noted that sugars were used to ‘stick’ the ingredients together. Chocolate was also strongly associated with sugars. Cola (27g per 250ml) v fruit smoothie (30.5g sugars per 250ml) Cola is very strongly associated with sugars and caused most respondents to select this over the smoothie. This caused confusion for many respondents who believed that the smoothie must have other added ingredients and not just fruit. Some post-rationalised the sugars content by suggesting that the smoothie might contain bananas , and recognising that smoothies do taste sweet. Overall many respondents were surprised by the sugars content of some of the foods shown to them. Even those who appreciated that fruit contained some sugars were surprised by just how much. Some respondents struggled to rationalise the quantity of sugars in fruit alongside the general perception that sugar was bad for you and fruit was good. As a result some genuinely began to question what they should be eating. They were able to square this apparent contradiction by assuming that there were different types of sugar (as per fats): • Natural sugars - Perceived to be much better for you i.e. fruit sugar - Providing slow release energy – so don’t crave more sugar so soon after - Easier to breakdown in the body • Added sugar, which was refined and viewed as the ‘bad’ variety - At times described as: ‘artificial’, ‘man-made’, ‘messed about with’ - Providing a ‘sugar rush’ and then a ‘crash’, leaving a craving for more A few respondents felt that sugar was sugar – that there was no essential difference between different types. 3. Types of sugars and sweeteners Sugars When asked where sugars come from, respondents most frequently answered sugar cane, followed by sugar beet . Both of these were generally understood to be plants, some knew that sugar cane grew above the ground and beet is a root crop, but most were lacking in this or any other knowledge. A few respondents mentioned other sources of sugars including fruit, and lactose in milk. Some were not sure of where sugars came from, referring to the manufacturing process and mentioning crystals, molasses, glucose etc, but not where the sugar originated.
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Some respondents recognised that sugars are carbohydrates, this knowledge was linked to interest in the Atkins diet, sport or from school science lessons. There was some awareness of simple and complex carbohydrates, but respondents were generally unclear about which one described sugars, although they were regarded as providing quick release energy. Other responses were that sugars have no nutritional value, they form a nutrient group of their own, or that they are linked to fat. Sweeteners Sweeteners were viewed as artificial, and man made in a laboratory, with some reference to chemicals. Respondents felt that sweeteners have no nutritional value, they were seen as containing no calories and for taste only. Awareness and perceptions of groups of sweetening substances (see discussion guide) were explored. Awareness for the different substances was ranked high, medium or low according to overall responses of focus group participants: High awareness Granulated sugar, icing sugar, soft brown sugar, honey, golden syrup, black treacle, fruit juice, glucose, Canderel, Splenda Medium awareness Dried fruit pieces, fruit sugar, glucose/fructose syrup, fructose, Aspartame Low awareness Agave syrup, sucrose, xylitol, isomaltose, sucralose Perceptions of sweetening substances in each group are shown in Table 10. There was a strong preference amongst participants for group 1 sweetening substances. These felt familiar and provided the consumer with control over how a food was sweetened. Honey was the most preferred, additional taste, health and texture benefits were mentioned. Sweetening substances in Group 3 were generally perceived as sounding scientific, less natural and less healthy. These were regarded as out of the control of consumers as they were added by food manufacturers. There was a suspicion that manufacturers hid added sugar by using a different name e.g sucrose instead of sugar. Artificial sweeteners drew very polarising opinions. Non-users tended to be negative about taste and/or health. Users preferred sweeteners as a means of reducing sugar intakes, and were broadly split by preference for Canderel or Splenda.
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Table 10. Summary of perceptions of sweetening substances presented to focus group participants. Group
Sweetening substance
Awareness
1
Granulated sugar
High
2
Icing sugar
High
Soft brown sugar
High
Dried fruit pieces
Medium
Fruit sugar
Medium
Honey
High
Perceptions •
Viewed as the basic, proper, or ‘normal’ sugar
•
Available in most participant’s kitchen supboards
•
Commonly perceived as the most refined sugar – chemicals and bleach mentioned
•
Some participants preferred brown over white sugar
•
Perceived as less processed/unrefined
•
Colour association with health – brown is best (e.g whole grain bread, rice)
•
More moist
•
Rarely considered as a type of sweetening agent
•
Viewed as sweeter and therefore better
•
Some participants had used as a substitute for granulated sugar e.g in baking
•
Some assumed it came from fruit but hadn’t heard of it
•
Strong preference for honey amongst participants
•
Viewed as very natural
•
Pleasant taste as well as sweetness
•
Believed to have additional health properties – vitamins, antibiotics, helps hayfever
•
Texture – very smooth, less thick and sticky than syrups or treacle
Golden syrup
High
•
Considered less healthy
Black treacle
High
•
Considered less healthy
Fruit juice
High
•
Preferred by some
•
Added benefit of providing one of 5-a-day
•
Some concerns over association with dental health in children
Glucose/fructose syrup
Medium
•
Seen as a specialist ingredient by some who had used it in recipes, and had purchased it from chemists
Agave syrup
Very low
•
Few aware of this – viewed as something that would be purchased from a health food shop for use in specific recipes
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Group
Sweetening substance
Awareness
Perceptions
3
Glucose
High
•
Positive image - very useful in certain instances
•
Associated with providing high energy in drinks
•
Some medical association
Fructose
Medium
•
Some linked it to fruit sugars or thought it sounded of fruit origin
Sucrose
Low
•
Even if participants were aware of this they didn’t know what it was
•
Some participants thought it was a sugar substitute of some type
•
Some participants associated this with sugar free products including confectionery (e.g. mints, gum) and oral care (e.g. toothpaste, mouthwash).
•
A few participants noted laxative warnings on products containing xylitol
•
Many assumed this to be an artificial sweetener
Xylitol
Low
Isomaltose
Very low
•
Some assumed this was linked to energy drinks, but little knowledge amongst participants
Canderel (Aspartame)
High (medium)
•
Most participants did not link Canderel with aspartame
•
Associated with fizzy drinks
•
Some were particularly negative about aspartame from a health perspective
•
Some recalled TV adverts for Splenda
•
Very few participants had heard of sucralose or knew what it was
Splenda (Sucralose)
High (low)
4. Functions of sugars In general respondents were aware that sugars had different functions in food products, once reminded. Certain functions were more top-of-mind than others: High spontaneous awareness • Energy –quick to mention energy drinks • Preservative – quick also to mention jams, plus marmalade, chutneys etc and some mention of ready meals Medium awareness • Fermentation – general awareness that sugars are needed to make alcohol • Flavour – participants tended to think more about sugars providing or enhancing taste rather than specific flavours such as caramel. It was regarded as necessary to mask bad tastes such as medicines, bland foods e.g. baked beans, or to offset bitterness/tartness e.g. tomatoes
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Low awareness until prompted • Texture – referred more to toppings (e.g. crunchiness) rather than internal • Glazing – once prompted (e.g. ham, chicken wings, marinades, crispy doughnuts) • Colour – once prompted (e.g. fruit cake) • Between them respondents also identified some other functions that they attributed to sugar including binding ingredients together, making food more palatable, providing decoration and assisting yeast fermentation in bread making In general respondents were amenable to the use of sugars in these ways. Some were suspicious of the use of sugars to make foods ‘addictive’ to children. 5. Re-cap Focus group participants were questioned about whether/how their understanding, attitudes and behaviour concerning sugars had changed during the discussion. Many participants said they were now more aware of sugar content in food and drink and that they were probably consuming more than they realised. There was surprise (shock for some) at the level of naturally occurring sugars in fruit and some other foods e.g. Baked beans. Participants expressed a desire to know more, including: • Safe/recommended limit of sugars intake • Best ways to consume sugars • Distinction between ‘good’ and ‘bad’ (viewed as natural vs. processed) sugars • Concentration of sugars rather than the absolute amount Some participants expressed feeling more positive about sugar, having moved from a perspective of “sugar is unhealthy” to recognising some positives, such as the body’s need for energy which can be provided by sugars. They also saw a difference in value between sugars naturally present in foods and those that are added. However, some focus group participants felt confused; sugar could no longer be used as a proxy for unhealthy food and their understanding of what is healthy in terms of sugars was not clear. Fat and salt tended to remain the priorities in terms of healthy eating for many. Few participants anticipated any change in their behaviour. Some suggested that they may be more diligent in looking for ‘hidden’ sugars by looking for different types/names of sugar on labels. While some had initially been confused by the discussion about sugars content of fruit, this had largely dissipated although some parents questioned how many raisins they should give to their children. Those who didn’t add sugar to foods and drinks were least likely to change their behaviour as they felt as if they’d done all they could and had less to worry about.
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Appendix IV - IGD qualitative research on consumer messages about sugars. Recruitment criteria, Method and Results. Recruitment criteria The same recruitment criteria were used for this second phase of consumer research as for Phase 1. Criteria are shown in Table 9 in Appendix III. Method The messages shown in Table 8 were presented to focus group participants on cards. Each message was presented separately or with a related submessage. Participants were probed on their general response to the message, their understanding of it and how helpful/useful they found the information. Messages were either existing messages used by government or non-government organisations, or new messages developed by the working group. They aimed to address the areas of consumer misunderstanding about sugars listed in Table 7. Focus group sessions were recorded, transcribed and analysed to provide the responses recorded in the results for each message. Results A summary of the responses to each message is provided under the subject areas identified in Table 7. ‘Natural’ and processed sugars Sugar is a natural food Participants were generally aware of this fact, although they continued to talk about some sugars as ‘natural’ suggesting a distinction between these and others that were not natural. The belief emerged that brown sugars are ‘more natural’ than white. All sugars are natural carbohydrate Participants tended to separate sugars and carbohydrate; carbohydrate was generally thought of as pasta, bread and rice, and not associated with sugars. There was mention also of fast and slow release energy. The message suggested to participants that they should treat sugars in the same way as starchy carbohydrate. This also resonated with some understanding within focus groups that carbohydrate is needed for energy.
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Sugar crystallises naturally white – it is not bleached. Brown colours and flavours come from raw sugars or are added back There was some surprise about this. Many participants believed that brown sugar was ‘more natural’. The use of terms such as ‘unrefined’ and ‘raw’ on some packaging had led to this view. The message was perceived as interesting but not important and unlikely to have any impact on consumer behaviour. White sugar is no better or worse for you than brown sugars or honey – replacing one for another won’t make any difference to your calorie intake and dental health Surprise over the information in the first part of the message meant that the second part was generally ignored. Participants were particularly surprised that honey was no better that white or brown sugars. There was a commonly held belief that honey contained additional elements which made it healthier. Participants tended to describe sugars as ‘good’ or ‘bad’. Emphasising ‘better’ or ’worse’ as used in the message made no difference. There are no nutritional differences between brown and white sugars This was viewed as a useful message by participants, many of whom believed that brown sugar was ‘better for you’. There was a further perception that brown sugars were not as sweet as white and this led to excessive intake with one spoonful of white sugar replaced by two of brown. The message caused confusion amongst some participants who attempted to apply the information to other foods, rationalising that there were no nutritional differences between whole grain and white rice and bread. Many participants appeared to ignore the word ‘nutritional’ in the message, and only heard ‘there are no differences between brown and white sugars’. Summary In the context of some of the messages that appear later in the discussion, some of the information about ‘natural’ and processed sugars in the above messages is contradictory from a consumer perspective. Particular care is needed to avoid disrupting the association of brown starchy carbohydrate such as rice and pasta with health as this might lead some to decrease their intake of whole grains. Participant responses in the focus groups indicated that communicating to consumers about the absence of nutritional differences between brown and white sugars would lead some to transfer this to other foodstuffs.
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Intrinsic and extrinsic sugars All sugars have the same calories (energy), whether naturally occurring in fruit and vegetables or added This message caused confusion amongst participants who focused on the information about calories alone. For example, the message prompted participants to talk about replacing fruit with sweets since the calorie value of the sugars they contain is the same. There are no ‘good’ or ‘bad’ foods – all foods can play an important role in the diet The first part of the message was not seen as credible; few agreed with this assertion. There was consensus that everything should be eaten in moderation, and the importance of a balanced diet was discussed. Participants’ responses indicated that they have views on what they should eat more of and less of. The message risks disrupting these ideas. Sucrose (table sugar) normally comes from sugar beet and cane, which are rich sources of this natural sugar Participants were generally aware of the sources of sugars. The reference to a ‘rich source’ was either very good or very bad depending on the respondent’s perception of sugar. Few were aware that sucrose is table sugar. Some thought sucrose was a sweetener, and felt that the name could mislead consumers. Other sugars including fructose and glucose were mentioned and were apparently more familiar. Sucrose (table sugar) can also be found naturally in most fruits and vegetables Most respondents knew that fruits contain sugars but there was less awareness that sugars could also be found in vegetables. Most associated fructose with fruit and struggled to understand that table sugar was also present in fruit and vegetables. The message was perceived negatively by many who thought that it might reduce intake of fruit and vegetables. Once absorbed, the human body makes no distinction between added sugars and naturally occurring sugars The message prompted some initial surprise amongst participants, although most found that it made sense on reflection. However, the focus on sugar as a nutrient again led many to the conclusion that there were no nutritional differences between foods containing sugars such as fruit and confectionery. Some confusion also arose amongst participants as the information appeared to conflict with an earlier message stating that sugar is a natural food. Respondents questioned why the message therefore distinguished between ‘added ’ and ‘naturally occurring’ sugars.
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Sugars can be found in many foods such as fruit and vegetables and dairy products, and some processed foods including savoury products such as sauces and condiments. Read the label to find out more. In general participants were aware that sugars were present in some savoury products. Claims such as ‘reduced sugar’ on some products had raised awareness of the sugars content. There was some surprise that dairy foods contained sugars. Summary Discussion of the messages on intrinsic and extrinsic sugars highlighted the extent to which participants used sugar as a proxy for ‘unhealthy’ or ‘bad for you’. In this context, reference was made to the claim ‘no added sugar’ on food labels. Participants’ responses to the messages emphasised the difficulty in communicating about sugar as a nutrient contained in a food. Many questioned why fruit and vegetables are good for you when the sugars they contain are the same as those added to food that they regarded as ‘unhealthy’. Terminology is important; participants were comfortable with glucose and fructose as names of sugars, but were less familiar with sucrose and regarded use of this term in place of ‘table sugar’ as suspicious. Nutritional value of sugars All sugars are carbohydrate; carbohydrate provides us with energy Respondents involved in sport or exercise were particularly aware of the importance of carbohydrate as a source of energy. ’Slow release’ and ‘quick release’ energy was mentioned. Participants discussed pasta as an energy source when playing sport, although there was also some mention of energy drinks and consuming oranges at half time. Sugars are a source of energy Participants were aware of this. The impact of sugars on children’s behaviour was raised with the effect of making them ‘hyper’ given as a demonstration of the fact that sugar provides energy. Sugars (sources of glucose) are the essential energy source for the brain and the body There was low awareness amongst participants that sugars are the ‘essential’ energy source for the brain and body, and it was regarded as important information for consumers. The message was seen as permissive, providing a rationale for inclusion of a lot of sugars in the diet.
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Summary Phase 1 of the research indicated that consumers viewed sugars as having no nutritional value. Focus group responses to the messages presented indicate that they could potentially change the perception of sugars amongst consumers, and their role in the diet. Sugars and weight management Sugars provide 4 calories/g; less than half the calories of fat (9cals/g) There was some surprise at the calorie content of sugars, which respondents perceived as being low. It was suggested that the information would be more useful if provided in a portion size that consumers could relate to such as a teaspoon. However, some viewed this as problematic (e.g level vs. heaped teaspoon). The benefit of comparing the calories in sugar and fat was questioned; some reference was made to substitution of fat with sugar in weight loss foods. If you are watching your weight it is the total calories that count. All excess calories contribute to weight gain, know your GDA and try to stick to it This was considered common sense, but good advice. There was a preference for focus on total calories rather than specific nutrients. Some participants were unaware of GDAs. Sugar is a carbohydrate, it provides 4 calories per gramme. If you are concerned about your weight, monitor your calorie intake Participants found there was too much information in this message, and suggested that it was difficult to picture a gramme of sugar in foods such as fruit and vegetables. However, monitoring overall calorie intake was regarded as sensible. Expert committees have noted that the balance of available evidence does not implicate sugars in any of the ‘lifestyle diseases’ obesity, diabetes, coronary heart disease or cancer This information was provided as a sub-message to support those about sugars and weight/obesity. Participants found the language used was unhelpful and generally asked for the moderator to interpret the message. Participants were unsurprised by the message even though reduction of sugars intake in order to lose weight had been discussed. There was acknowledgement that excess calories rather than sugar per se was the cause for concern. Sugars were not linked to all of the health conditions listed by most participants and therefore served to prompt new (unnecessary) concerns.
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Summary The focus on calories was well-received amongst participants, however some questioned the need to monitor sugars intake if there are no direct health implications. Sugars and diabetes Sugar (sucrose/table sugar) does not cause diabetes. Sugars can be eaten as part of a health balanced diet Participants agreed that this message could be important to help dispel the commonly held belief that sugar causes diabetes. The emphasis on a healthy balanced diet in the second half of the message was considered good. This is supported by a wealth of scientific evidence (sub-message) The addition of this sub-message received a mixed reaction from focus group participants. Generally evidence from scientific experts was welcomed, however there was some cynicism and an expectation that the message would change depending on who carried out the research. The need for independent research was highlighted in the discussion, some questioned the credibility of the information. Participants mentioned conflicting messages and agreed that information needed to be consistent. Sugars and dental caries Limit consumption of foods and drinks with added sugars to a maximum of four times a day Most felt that this advice was unachievable and therefore not useful to communicate. Some interpreted the message as meaning it is better to eat a pack of sweets in one go than over time. The message caused some confusion as it again drew a distinction between added sugars and those naturally occurring in foods. Participants found this at odds with information in earlier messages. It is important to recognise that honey, fresh fruit juice and dried fruit contain sugars that cause tooth decay This was considered very useful information, particularly for parents who often gave dried fruit to children as a ‘healthy’ snack. The need for dental hygiene messages from dental professionals was highlighted. The message was seen to conflict with the recommendation to eat more fruit and vegetables, and there was a concern that it could lead some to reduce their children’s fruit consumption.
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Sugars and behaviour Sugars, including table sugar, do not cause behavioural problems in children This message prompted many anecdotes amongst participants about children being hyperactive after eating sugary foods. Other respondents suggested that ‘E numbers’ caused behavioural issues. However, participants also indicated that the activity they observed could be due to other factors, such as overall energy and response to the environment, rather than a response to sugar per se. The message was seen as important in terms of managing children’s energy levels and understanding behaviour. The language used in the message caused confusion, as it was not clear to participants what was meant by ‘behavioural problems’. Sugars in a healthy balanced diet Sugars can form a useful part of a healthy balanced diet This was regarded as a good, simple message with straightforward advice. However only one respondent noted that ‘sugars’ and not ‘sugar’ were mentioned. Most participants perceived the message as indicating table sugar. Some foods containing sugars provide other important nutrients This was viewed as particularly important in light of earlier messages about the nutritional value of sugars. This message helped participants to focus on the other nutritional attributes of the food as well as the sugars content. Know your GDA for sugars Some participants felt it was important to know how much sugar they should consume. However, despite the availability of Guideline Daily Amounts for sugars, few had noticed it on food packaging. Awareness was greater for calories, fat and salt. The GDA for sugars is 90g per day Participants were not sure what 90g would look like, and questioned the usefulness of the GDA as they couldn’t assess the sugars present in fruit and vegetables. Concentrate on a healthy balanced diet. Base your diet on grains and eat 5 fruit and vegetables per day. If you get the basics right your sugars intake will be ok This message was generally considered good advice, although too wordy for most participants. Participants felt that messages about a healthy balanced diet rather than specific nutrient would be easier for consumers to follow. Some questioned why meat was not mentioned as part of a balanced diet.
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Use the nutrition panel to determine how much sugars are in a product. The nutrition panel shows the carbohydrate and total sugars This message received a mixed response from participants. Some felt that it might encourage consumers to check the nutrition information on products more frequently, while others felt that information about the total calories in a product was more helpful. Participants questioned how useful it is to watch sugars intake, given that there are no health implications of consuming too much sugars, rather than too many calories.
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Appendix V - Working Group Members Cereal Partners UK (Chair) British Sugar plc Coca-Cola GB and Ireland Innocent Kellogg Europe Marks & Spencer plc The British Dietetic Association The Dairy Council United Biscuits (UK) LTD Waitrose LTD Dr Alison Lennox, Independent IGD’s Policy Issues Council (PIC) is a forum of industry leaders, broadly representative of IGD’s membership. It brings together Chairmen and Chief Executives of the UK’s leading retailers, manufacturers, wholesalers, foodservice businesses and producers to address strategic challenges for the food and grocery industry. Nutrition is a key priority for the PIC. The IGD Industry Nutrition Strategy Group was therefore established in 2003 to examine how the industry can play its part in encouraging healthy eating as part of a healthy lifestyle throughout the UK. The sugars working group is a sub-group of the Industry Nutrition Strategy Group.
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