Effect of sugar intake on cardiovascular health

Coronary Heart Disease

• Based on moderate evidence, no significant association observed between sugars consumption and coronary event incidence.

• 'the evidence regarding the association between the intake of mono- and disaccharides or the consumption of sugar-sweetened beverages respectively, and the risk of CHD is judged as insufficient'.

• Moderate evidence indicates that 'higher intake of added sugars, especially in the form of sugar sweetened beverages, is consistently associated with increased risk of […] CHD in adults'.

Stroke

• Moderate evidence indicates that 'higher intake of added sugars, especially in the form of sugar sweetened beverages, is consistently associated with increased risk of […] stroke […] in adults'.

Blood pressure

• 'Concerning…blood pressure, in the short- and medium-term intervention studies, deleterious metabolic effects of sugars were observed, in the case of very high consumption and/or consumption associated with an excess energy intake. However, the long-term impact of these changes on the occurrence of pathologies remains unknown'.

• Based on limited evidence, no significant effect is demonstrated for diets differing in the proportion of sugars on systolic blood pressure or diastolic blood pressure.

• Suggestive evidence that frequent con­sumption of SSBs has an unfavourable effect on blood pressure.

• 'There is possible evidence that there is no association between long-term intake of fructose or sucrose and blood pressure increase'.
• 'There is possible evidence that there is no association between the intake of sugar-sweetened beverages and the risk of hypertension. This judgement is based on 1 cohort study only, but is confirmed by the judgement of the individual components of sweetened beverages like fructose and sucrose'.

• '…evidence suggests that excessive fructose intake results in increased blood pressure in children and young adult'.
• '…evidence suggests that added sugars are a source of excess fructose and that reduction of fructose from added sugars is likely to decrease uric acid, possibly improving blood pressure in children. However, further research on this topic is needed to test whether a reduction in added sugars results in improved blood pressure in children'.

• Moderate evidence indicates that 'higher intake of added sugars, especially in the form of sugar sweetened beverages, is consistently associated with increased risk of […] hypertension in adults'.
• 'Observational and intervention studies indicate a consistent relationship between higher added sugars intake and higher blood pressure…' (moderate evidence).

Blood lipids

• Although some evidence exists that high intakes (>20 E%) of sugars may increase serum triglyceride and cholesterol concentrations, the available data are not sufficient to set an upper limit for (added) sugar intake.

• 'epidemiological studies indicate a hypertriglyceridemia effect of sugars provided in the form of sugar-sweetened beverages, but these data do not show a specific effect, independent of total energy intake'.
• 'The effect of sugars containing fructose (sucrose, HFCS), the respective roles of excess energy or sugar intake per se, and the effect of co-ingestion of glucose and fructose, are still poorly understood. But in the intervention studies, daily intakes of fructose above 50 g/d can lead to an increase in fasting and/or post-prandial blood triglycerides'.

• Based on limited evidence, no significant effect is demonstrated for diets differing in the proportion of sugars on fasting total cholesterol, fasting low density lipoprotein (LDL) or high density lipoprotein (HDL) cholesterol concentration, or fasting triacylglycerol concentration.

• Insufficient evidence to draw conclusions on ef­fects on plasma lipids with respect to fructose or sucrose.
• Limited-suggestive evidence that high intake of SSBs might be associated with dys­lipidaemia indicating that the specific food source of sugar might influence metabolic response.

• 'Current evidence supports the associations of added sugars with […] and increased dyslipidaemia, all of  which are demonstrated CVD risk factors'.
•  'The preponderance of evidence […] weighs in favour of improved triglycerides and HDL in children with low consumption of added sugars'.

• 'there is insufficient evidence regarding the influence of increased intake of mono- or disaccharides on the plasma levels of total and/or LDL cholesterol'.
• 'there is insufficient evidence regarding the influence of increased intake on mono- or disaccharides on the plasma levels of HDL cholesterol'.
• 'the evidence is judged as probable that there is no association between a fructose intake of < 100 g/day and the fasting plasma triglyceride concentration as well as between a fructose intake of < 50 g/day and the postprandial plasma triglyceride concentration, respectively'.
• 'There is convincing evidence that with higher fructose intake of up to 350 g/day, the fasting plasma triglyceride concentration increases'.
• 'The evidence regarding the effects of other mono- and disaccharides on plasma triglycerides is insufficient'.

• 'Observational and intervention studies indicate a consistent relationship between higher added sugars intake and higher […] serum triglycerides'. (moderate evidence).

General

• 'A higher than recommended intake of added sugars among adolescents may be positively associated with multiple measures known to increase cardiovascular disease risk'.
• 'Data in adolescents reflect interventional studies in adults suggesting that higher fructose consumption (from added sugars) is also associated with multiple factors that increase risk for cardiovascular disease…'.

• 'Concerning glucose homeostasis and insulin sensitivity, the studies indicate that only a very large increase in fructose intake, of around 80 g/d, leads to a decrease in hepatic sensitivity to insulin. This effect, however, is modest and is not accompanied by a clinically significant increase in fasting blood glucose'.
•  'A limited number of epidemiological cohort studies indicate an increase in the incidence of diabetes in high consumers of sugar-sweetened beverages; however this is in part linked to the weight status'.
• For those pathologies where weight gain and obesity are established risk factors, in particular for T2DM, the contribution of sugars to excess energy intake must not be overlooked.

• Based on limited evidence, there is no effect of sugars consumption on fasting blood glucose concentration and blood insulin concentrations.
• Based on limited evidence, there is 'no consistent evidence of an association between diets differing in the proportion of sugars in relation to incidence of type 2 diabetes mellitus'. Sucrose and fructose were also individually examined with same findings.
• Based on moderate evidence, an association was found between greater sugars-sweetened beverage (SSB) soft-drink consumption and higher incidence of type 2 diabetes mellitus, while there was insufficient that included fruit juices. The association direction indicates that 'greater consumption of SSBs is detrimental to health'.

• 'the evidence regarding an association between the total intake of mono- and disaccharides and the risk of type 2 diabetes mellitus is judged as insufficient'.
• 'The evidence regarding an association between the intake of glucose and fructose and the risk of diabetes is insufficient'.
• 'the evidence regarding a lack of an association between sucrose intake and the risk of type 2 diabetes mellitus is judged as probable'.
• 'the evidence regarding a lack of an association between lactose intake and the risk of diabetes is judged as possible'.
• Majority of studies indicate 'an increased risk of type 2 diabetes mellitus due to regular consumption of sugar-sweetened beverages. The evidence regarding this association is judged as probable'.

• Evidence for effects of sugars intake on glucose and insulin responses is limited.
• Probable evidence that high con­sumption of SSBs increases T2DM risk.

• Studies related to added sugars intake and insulin resistance and diabetes mellitus  in children are inconclusive.
• 'To date, added sugars appear to have a relationship with insulin resistance in children who are overweight, but this finding was not demonstrated in normal-weight children'.

• 'Strong evidence shows that higher consumption of added sugars, especially sugar-sweetened beverages, increases the risk of type 2 diabetes among adults and this relationship is not fully explained by body weight'.

• For those pathologies where weight gain and obesity are established risk factors, in particular for endometrial cancer and breast cancer, the contribution of sugars to excess energy intake must not be overlooked.

• Based on adequate evidence, no association was found between consumption of SSBs and colon cancer incidence.

• Insufficient evidence regarding an association between intake of monosaccharides and oesophagus, colorectum and breast cancer risk.
• 'There is possible evidence of a positive association between the intake of monosaccharides and malignant tumours of the pancreas'
• Insufficient evidence regarding an association between intake of disaccharides and risk of cancer of oesophagus and endometrium.
• 'There is possible evidence of a lack of a risk relation between the intake of disaccharides and the development of malignant tumours in the colorectum, breast and pancreas'
• 'There is also possible evidence regarding a lack of an association between the intake of sugar-sweetened beverages and cancer of the colorectum and pancreas'.

• 'a cause and effect relationship has not been established between total sugar intake and body weight gain'.
•  'the evidence relating high intake of sugars (mainly as added sugars), compared to high intakes of starch, to weight gain is inconsistent for solid foods'.
• 'However, there is some evidence that high intakes of sugars in the form of sugar-sweetened beverages might contribute to weight gain. 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'.

• 'A higher than recommended intake of free sugars, particularly SSBs in children and adolescents, is associated with increased incidence of […] adiposity'.
• 'Sugars-containing beverages do not promote satiety compared the equivalent amount of sugars in solid form and therefore induce excessive energy intakes'.
• 'Reducing the intake of SSBs by replacing them with water in children and adolescents is associated with reduced weight and adiposity'.

• 'Weight gain is related to an excess energy intake. Sugars and particularly sugar-sweetened beverages contribute to this excess energy intake'.
• 'Concerning the effect of sugars on adiposity and the distribution of body fat, the data are too limited to reach any conclusion'.
• 'sugars, and more particularly in liquid form (sodas, nectars, fruit juices produced from concentrates, fresh fruit juices, smoothies, etc.) contribute to weight gain, with a convincing level of evidence'.

• Based on adequate evidence, sugars consumption has an effect on energy intake; the direction of the effect demonstrates that greater consumption of sugars is detrimental to health (relevant in free living individuals not subject to energy restriction).
• In cohort studies, there is limited and conflicting evidence on the relationship between SSBs consumption and Body Mass Index (BMI).
• In cohort studies, 'overall there is no consistent evidence of a significant change in body fat amount or distribution with sugars-sweetened beverage consumption assessed in childhood or adolescence' (limited evidence).
• In randomised control trials (RCTs), and based on limited evidence, SSBs consumption has an effect on BMI; 'the direction of the effect demonstrates that greater consumption of SSBs is detrimental to health.'

• 'The evidence regarding the relevance of monosaccharides for the risk of obesity is insufficient'
• The evidence regarding the relevance of sucrose or added sugar, respectively, for the risk of obesity in children, adolescents and adults is insufficient.
• 'The available cohort and intervention studies regarding adults mainly show that a higher consumption of sugar-sweetened beverages is accompanied by an increased risk of obesity. Therefore, the respective evidence is judged as probable'.
• 'The overall evidence regarding an increased risk of obesity due to higher consumption of sugar-sweetened beverages in children and adolescents is […]only judged as possible'.  
• 'The evidence regarding an increased risk of obesity especially in children and adolescents with initially already increased BMI or already existing overweight is also judged as possible'.

• In children, 'current evidence supports the associations of added sugars with increased energy intake, increased adiposity, increased central adiposity […] , all which are demonstrated CVD risk factors'.
• 'children and adolescents who have high intakes of dietary sugars (specifically from SSBs and added sugars) tend to have higher daily energy intakes compared with similar populations with lower intakes of dietary sugars'.
• In children, 'higher SSB and added sugars intake has been strongly linked to excess weight gain and an increased risk of obesity'.

• 'Strong and consistent evidence shows that intake of added sugars from food and/or sugar sweetened beverages are associated with excess body weight in children and adults'; reduction of added sugars and/or SSBs in the diet reduces body mass index in both children and adults.

• 'a cause and effect relationship has been established between the consumption of sugar-containing foods/drinks at an exposure frequency of four times daily or more and an increased tooth demineralisation'
• 'frequent consumption of sugar-containing foods can increase risk of dental caries, especially when prophylactic measures, e.g. oral hygiene and fluoride prophylaxis, are insufficient'.
• available data do not allow the setting of an upper limit for sugars on the basis of a risk reduction for dental caries,  'as caries development related to consumption of sucrose and other cariogenic carbohydrates does not depend only on the amount of sugar consumed, but it is also influenced by various other lifestyle factors…'.

• Moderate quality evidence from cohort studies suggests a positive association between levels of free sugars intake and dental caries; higher rates of caries when free sugars intake exceeds 10% of total energy. In three population studies with very low quality of evidence, lower levels of caries development were observed with approx. free sugars intake of 5%.

• 'A higher than recommended intake of free sugars, particularly SSBs in children and adolescents, is associated with increased incidence of dental caries…'.

• Based on moderate evidence, there is an association between amount of sugars consumed and dental caries in mixed and permanent dentition; 'The direction of the association indicates that greater consumption of sugars is detrimental to oral health'. No significant association reported between the frequency of sugars consumption and the risk of developing dental caries in mixed and permanent dentition.
• Adequate evidence for an association between the amount and frequency of SSBs and detriment to deciduous dentition. 'The direction of the association indicates that greater consumption of sugars sweetened beverages is detrimental to oral health'.
• Amount and frequency of consumption of sugar containing foods and/or confectionary is associated with dental caries. 'The direction of the association indicates that greater consumption of sugars containing foods and/or sugars confectionery is detrimental to oral health'. For deciduous dentition there is limited evidence, while for mixed and permanent dentition the evidence is moderate.

• 'The DGAC concurs with the World Health Organization's commissioned systematic review that moderate consistent evidence supports a relationship between the amount of free sugars intake and the development of dental caries among children and adults. Moderate evidence also indicates that caries are lower when free sugars intake is less than 10 percent of energy intake'.

• 'Observed negative associations between added sugar intake and micronutrient density of the diet are mainly related to patterns of intake of the foods from which added sugars in the diet are derived rather than to intake of added sugars'.

• Higher sucrose intake (>10 E%) is associated with lower intake of many micronutrients and dietary fibre and a higher intake of saturated fatty acids in Nordic countries.

• 'The evidence regarding an association between the consumption of sugar-sweetened beverages and the occurrence of the metabolic syndrome is judged as possible'.

• 'Observational studies, show that SSB intake during infancy and early childhood is associated with SSB intake in childhood and adolescence', but cannot demonstrate causality.

• 'For the risk of non-alcoholic fatty liver disease, a small number of intervention studies show that an excess energy intake, in particular in the form of fructose, increases the concentration of intrahepatic lipids in healthy subjects. The epidemiological data are, however, insufficient to assess the role of sugars in the occurrence of this pathology'.

• 'the introduction of added sugars during infancy appears to be particularly harmful and should be avoided'.