The relationship between sugar and health is affected by energy balance, macronutrient substitutions, and diet and lifestyle patterns. Several authoritative organizations have issued public health guidelines addressing dietary sugars.
To systematically review guidelines on sugar intake and assess consistency of recommendations, methodological quality of guidelines, and the quality of evidence supporting each recommendation.
MEDLINE, EMBASE, and Web of Science (1995 to September 2016); guideline registries; and gray literature (bibliographies, Google, and experts).
Guidelines addressing sugar intake that reported their methods of development and were published in English between 1995 and 2016.
Three reviewers independently assessed guideline quality using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II), instrument. To assess evidence quality, articles supporting recommendations were independently reviewed and their quality was determined by using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods.
The search identified 9 guidelines that offered 12 recommendations. Each of the reviewed guidelines indicated a suggested decrease in the consumption of foods containing nonintrinsic sugars. The guidelines scored poorly on AGREE II criteria, specifically in rigor of development, applicability, and editorial independence. Seven recommendations provided nonquantitative guidance; 5 recommended less than 25% to less than 5% of total calories from nonintrinsic sugars. The recommendations were based on various health concerns, including nutrient displacement, dental caries, and weight gain. Quality of evidence supporting recommendations was low to very low.
The authors conducted the study independent of the funding source, which is primarily supported by the food and agriculture industry.
Guidelines on dietary sugar do not meet criteria for trustworthy recommendations and are based on low-quality evidence. Public health officials (when promulgating these recommendations) and their public audience (when considering dietary behavior) should be aware of these limitations.
Primary Funding Source:
Technical Committee on Dietary Carbohydrates of the North American branch of the International Life Sciences Institute. (PROSPERO: CRD42015029182)
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Author, Article, and Disclosure Information
From University of Minnesota, St. Paul, Minnesota; McMaster University, Hamilton, Ontario, Canada; Kerman University of Medical Sciences, Kerman, Iran; and The Hospital for Sick Children Research Institute and University of Toronto, Toronto, Ontario, Canada.
Note: As the guarantors of the study, Drs. Johnston and Slavin take full responsibility for the work as a whole, including the study design, access to data, and the decision to submit and publish the manuscript.
Acknowledgment: The authors thank Tamsin Adams-Webber, clinical librarian, for helping to develop our search strategy and Gordon Guyatt, GRADE Working Group Co-Chair, for advice on applying the GRADE methods and for reviewing the manuscript.
Financial Support: This project was funded by the Technical Committee on Dietary Carbohydrates of ILSI North America. The authors wrote the protocol, the scope of which was reviewed and approved by ILSI; and conducted the study independently from ILSI.
Disclosures: Dr. Slavin served on the 2010 Dietary Guidelines for Americans Advisory Committee (DGAC) where she chaired the carbohydrate committee that reviewed the relationships between added sugar intake and health outcomes. The results of that review were published in the 2010 DGACs, in Nutrition Reviews (Slavin J. Beverages and body weight: challenges in the evidence-based review process of the Carbohydrate Subcommittee from the 2010 Dietary Guidelines Advisory Committee. Nutr Rev. 2012;70 Suppl 2:S111-20.). She has presented widely on her work as chair of the carbohydrate and protein committees for the 2010 DGAC. Most of her research is in the areas of dietary fiber and gut health. As a dietitian, she is interested in dietary patterns and whole foods. Her research funding in the area of dietary sugars is summarized below. She received a grant from ILSI-NA Carbohydrate Committee in 2010 to examine sugar recommendations. That work was published in 2012 (Hess J, Latulippe ME, Ayoob K, Slavin J. The confusing world of dietary sugars: definitions, intakes, food sources and international dietary recommendations. Food Funct. 2012;3:477-86.). One of the co-authors of that paper was an employee of ILSI-NA at the time. That information is disclosed in the paper. Dr. Slavin and the University of Minnesota received the grant from ILSI-NA to support the current project. Besides ILSI-NA, Dr. Slavin thanks the following organizations for providing research funds for her laboratory the past 3 years: Minnesota Beef Council (satiety), Minnesota Cultivated Wild Rice Council (literature review), Barilla (snacking), Novartis Consumer Health (GSK) (fiber), American Pulse Association (satiety), MNDrive Global Food Ventures (nutrients in spinach), United States Department of Agriculture (fiber), The Mushroom Council (gut health), Pepsico (oatmeal), Welch’s (FODMAPs), Nestle Health Sciences (FODMAPs), and DSM (fiber). Her laboratory also has received contracts for services for analytical services in the areas of dietary fiber, whole grains, legumes, FODMAPS, digestive health, protein needs, carbohydrate needs, and snacking: Besides the companies listed, the laboratory has received funds in the past 3 years from Danone (snacking) and Coca-Cola (fiber). When the work is published, the funding source for all work in the laboratory will be disclosed as outlined by the journal. Dr. Slavin speaks widely on a range of human nutrition topics. Some talks on the topic of interest in this paper: "Fluid Consumption: Caloric Contribution to Weight Gain/Loss and Health: Factors That Influence Satiety" (Second International Conference on hydration and Health, sponsored by the ILSI North America Committee on Hydration, November 2011); "The Confusing World of Dietary Sugars: Views From the 2010 Dietary Guidelines Scientific Advisory Committee" (2012 Nutrition News Forecast, Academy of Nutrition and Dietetics, April 2012); "Food Is Not a Talisman: Reflections on the Science and Practice of Nutrition" (WO Atwater Lecture at Experimental Biology, April 2015). For full financial disclosure: ILSI meetings do not pay speakers; other scientific meetings also typically do not pay speakers if you are a member of that society. Dr. Slavin serves on the scientific advisory board for Tate and Lyle, Kerry Ingredients, Atkins Nutritionals, and Midwest Dairy Association. She also owns one-third share of the Slavin Sisters Farm LLC, a 119-acre farm in Walworth, Wisconsin, that is currently rented. Crops in 2016 included corn, soybeans, and pumpkins. Dr. Johnston is a member of GRADE, a working group that has developed a common, sensible, and transparent approach to grading quality of evidence and strength of recommendations. In addition to being a methods consultant to ILSI for this project, over the last 5 years, he has held investigator-initiated grants unrelated to the topic of sugar from BioK+ (a probiotic manufacturer), Genzyme (a manufacturer of enzyme replacement therapy for patients with rare lysosomal storage diseases), and a joint grant funded by Nestle and MITACS Accelerate (a provincially and federally supported not-for-profit organization that works with Canadian universities and companies to build partnerships that support industrial and social innovation in Canada) to assess probiotics for preventing necrotizing enterocolitis. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2020.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015029182. Statistical code: Not applicable. Data set: See tables and appendices for all relevant data.
Corresponding Author: Bradley C. Johnston, PhD, Prevention Lab, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Room 11.9859 West, Toronto, Ontario M5G 0A4, Canada; e-mail, bradley.
Current Author Addresses: Ms. Erickson and Dr. Slavin: Department of Food Science and Nutrition, University of Minnesota, 1334 Eckles Avenue, St. Paul, MN 55108.
Dr. Sadeghirad: Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
Ms. Lytvyn and Dr. Johnston: Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Room 11.9859 West, Toronto, Ontario M5G 0A4, Canada.
Author Contributions: Conception and design: L. Lytvyn, J. Slavin, B.C. Johnston.
Analysis and interpretation of the data: J. Erickson, B. Sadeghirad, L. Lytvyn, J. Slavin, B.C. Johnston.
Drafting of the article: J. Erickson, B. Sadeghirad, L. Lytvyn, B.C. Johnston.
Critical revision of the article for important intellectual content: J. Erickson, B. Sadeghirad, L. Lytvyn, J. Slavin, B.C. Johnston.
Final approval of the article: J. Erickson, B. Sadeghirad, L. Lytvyn, J. Slavin, B.C. Johnston.
Provision of study materials or patients: J. Slavin, B.C. Johnston.
Statistical expertise: B. Sadeghirad.
Obtaining of funding: J. Slavin, B.C. Johnston.
Administrative, technical, or logistic support: L. Lytvyn, J. Slavin, B.C. Johnston.
Collection and assembly of data: J. Erickson, B. Sadeghirad, L. Lytvyn, B.C. Johnston.
This article was published at Annals.org on 20 December 2016.
* Ms. Erickson and Dr. Sadeghirad contributed equally to this work.