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The potential impact of sugars on health includes effects on diabetes, blood glucose, weight management, blood pressure, blood lipids, dental health.
European Union legislation (EU 2011) refers to sugars as 'all monosaccharides and disaccharides present in food, but excludes polyols', while foods with no added sugars are defined as foods without 'any added monosaccharides or disaccharides', or without 'any added food containing monosaccharides or disaccharides which is used for its sweetening purposes' (EC 2008, EU 2011)a.
The European Food Safety Authority (EFSA), in its scientific opinion on Dietary Reference Values for carbohydrates and dietary fibre ( EFSA 2010a ), refers to added sugars as 'sucrose, fructose, glucose, starch hydrolysates (glucose syrup, high-fructose syrup) and other isolated sugar preparations used as such or added during food preparation and manufacturing' (not including the sugars present in unsweetened fruit juice or honey as added sugars), and total sugars as the sum of added sugars and endogenous sugars present in fruits, vegetables, cereals, as well as lactose in milk products. The United States (US) Institute of Medicine (IoM) provides a similar definition for added sugars ( IOM 2006 ).
For the World Health Organization ( WHO 2015 ), the term sugars includes intrinsic sugars, which are those incorporated within the structure of intact fruit and vegetables; sugars naturally present in milk (lactose and galactose); and free sugars, which are 'monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates'. The main difference between the EFSA and WHO definitions is that the WHO 'free sugars' covers not only all sugars added to foods during manufacture or by the consumer, but also those present in fruit juice and honey or syrups.
In the US, the Food and Drug Administration ( FDA 2017 ), states that 'the definition of added sugars includes sugars that are either added during the processing of foods, or are packaged as such, and include sugars (free, mono- and disaccharides), sugars from syrups and honey, and sugars from concentrated fruit or vegetable juices that are in excess of what would be expected from the same volume of 100 percent fruit or vegetable juice of the same type. The definition excludes fruit or vegetable juice concentrated from 100 percent fruit juice that is sold to consumers (e.g. frozen 100 percent fruit juice concentrate) as well as some sugars found in fruit and vegetable juices, jellies, jams, preserves, and fruit spreads'.
For the purposes of this Brief, the term sugars, added sugars, total sugars, intrinsic sugars and free sugars will refer to the definitions provided above, while the term 'sugar' will refer to sucrose exclusivelyb.
Sugars belong to the family of carbohydrates. In the EU legislation (EU 2011), the term 'carbohydrates' refers to 'any carbohydrate which is metabolised by humans, and includes polyols' (see 1.2). Carbohydrates can be single unit molecules, but can also be made up of several units linked together by a variety of chemical bonds. Major dietary carbohydrates, including sugars, can be classified as described in Table 1.
Table 1: Main dietary carbohydrates
In the EU (EC 2008, EU 2011) sweeteners are referred to as food additive substances used to 'impart a sweet taste to foods or in table-top sweeteners'. Table-top sweeteners 'shall mean preparations of permitted sweeteners, which may contain other food additives and/or food ingredients and which are intended for sale to the final consumer as a substitute for sugars'.
In order to be included in the list of EU approved food additives, and in addition to the general requirements of food additives, sweeteners must serve one or more of these purposes: i) 'replacing sugars for the production of energy-reduced food, non-cariogenic food or food with no added sugars' or ii) 'replacing sugars where this permits an increase in the shelf life of the food'e. Following the above definition, for the purposes of this Brief, the term 'sweeteners' will refer to those non-nutritive (or low caloric) food additives that are approved for use as sugar replacers in the EU and are reported in Table 3.
Sweeteners can be of two categories: high-intensity sweeteners, which are substances with an intense sweet taste and with no energy value that are used to replace sugars in foods ( EFSA 2011 )f and polyolsd, defined as 'alcohols containing more than two hydroxyl groups', which are low calorie sugar replacers, but which can also exert other technological functions in food and can be used for purposes other than sweetening.
Common monosaccharides include glucose, fructose and galactose, while the main dietary disaccharides are sucrose (consisting of glucose and fructose) and lactose (consisting of glucose and galactose). The sources of these are described in Table 2 and include plants, especially fruits and vegetables where most mono- and disaccharides are intrinsically occurring. In addition, sugars are added to foods to impart a sweet taste, during cooking, table top use or in processed foods and beverages; this includes honey, molasses and various syrups such as isoglucose, or malt, corn or sugar beet syrups.
Table 2: Main dietary sugars and their sources
Major dietary sources of sweeteners (Table 3) include table-top use during cooking or beverage preparation, as well as through consumption of processed foods and beverages.
Table 3: Main sweeteners and their sources
In the EU, Regulation (EU) 1169/2011 (EU 2011) on food information to consumers requires mandatory nutrition declaration for sugars, under carbohydrates (stating amount of g per 100 g of product), in prepacked foods. For labelling purposes, the reference intake for sugars of an average adult (8400 kJ/2000 kcal) is 90 g/day. In addition, the same regulation states that, in conversion factors for the calculation of energy, carbohydrates (including sugars) have an energy value of 4 kcal/g.
Under Regulation (EU) 1924/2006 (EC 2006) for health and nutrition claims made on foods, the following sugars-related nutrition claims are permitted:
In the EU, in general, if a food additive belongs to the category/functional class 'sweetener' it must be designated by the name of that category (i.e., 'sweetener'), followed by its specific name or, if appropriate, E number on the food packaging (EC 2008, EU 2011).
Regulation (EU) 1169/2011 (EU 2011) on food information to consumers requires any food containing a sweetener(s) authorised pursuant to Regulation (EC) No 1333/2008 (EC 2008, EU 2011) (i.e. the sweeteners referred to in this Brief) to carry 'with sweetener(s)' as a statement that shall accompany the name of the food. Foods containing both an added sugar or sugars and a sweetener or sweeteners authorised pursuant to Regulation (EC) No 1333/2008 shall carry the statement 'with sugar(s) and sweetener(s)' as a statement that shall accompany the name of the food.
The sales description of a table-top sweetener shall include the term ‘…-based table-top sweetener', using the name(s) of the sweetener(s) used in its composition. The labelling of a table-top sweetener containing polyols and/or aspartame and/or aspartame-acesulfame salt shall bear the following warnings: for polyols: ‘excessive consumption may induce laxative effects’, and for aspartame/aspartame-acesulfame salt: ‘contains a source of phenylalanine’.Table-top sweeteners are exempted from mandatory nutrition declaration (EU 2011).
Foods containing aspartame/aspartame-acesulfame salt authorised pursuant to Regulation (EC) No 1333/2008 shall be accompanied by a statement 'contains aspartame (a source of phenylalanine)' on the label, if the substance is designated in the list of ingredients only by its E number; in cases where aspartame/aspartame-acesulfame salt is designated in the list of ingredients by its specific name, the statement appearing on the label shall be 'contains a source of phenylalanine'.
Foods containing more than 10% added polyols authorised pursuant to Regulation (EC) No 1333/2008 (EC 2008, EU 2011) shall be labelled with the particular 'excessive consumption may produce laxative effects'. In addition, Regulation (EU) 1169/2011 (EU 2011) states that the energy value to be declared in the nutrition declaration shall be calculated using the conversion factors of 10 kJ/g - 2,4 kcal/g for polyols and 0 kJ/g - 0 kcal/g for erythritol. The unit of measurement to be used in the nutrition declaration for mass of polyols is grams (g), and the order of presentation of the information, as appropriate, is indicated in Regulation (EU) 1169/2011.
As regards nutrition claims foreseen under Regulation (EU) 1924/2006 (EC 2006), some apply to table-top sweeteners, as is the case of food low in energy and energy-free food. Two sweetener related health claims have been approved for use under specific conditions (EU 2012), following EFSA opinions ( EFSA 2011 EFSA 2011 ); both relate to the use of intense sweeteners and polyols as sugar replacers (consumption of foods/drinks containing intense sweeteners and/or polyols instead of sugar contributes to the maintenance of tooth mineralisation and to reduction of post-prandial glycaemic responses compared to sugar- containing foods/drinks see also Table 5).
A number of national or international institutions have recently examined the potential impact of sugars consumption on health, focusing mainly on effects on body weight management, Type 2 Diabetes mellitus (T2DM), cardiovascular parameters such as blood glucose, pressure, lipids, cholesterol and dental health. The statements or opinions of these institutions, as well as the strength of the supporting evidence, are shown in Table 4. Sugar Sweetened Beverages (SSBs) consumption is high in many parts of the world and is considered to significantly contribute to added sugar intake ( WHO 2018 , CDC website , EC 2018 ). A considerable amount of evidence presented in this brief includes SSBs.
Table 4: Health effects by food- and health-related organisations.
The safety of sweeteners examined in this Brief has been extensively reviewed and (re)evaluated by a variety of competent authorities, including the European Food Safety Authority ( EFSA webpage ) and other national authorities such e.g. as the US Food and Drug Administration ( FDA webpage ). All sweeteners discussed here are approved and considered safe to use in the EU. The focus is therefore on nutrition and diet related health effects. For sweeteners, the main areas of focus refer to their use as sugars replacers and their effects on weight gain loss or maintenance, cardiovascular parameters, such as blood glucose and lipids, T2DM, dental health, and other categories such as appetite or gastrointestinal health (Table 5).
Table 5: Health effects related to intake by food- and health-related organisations
Seeing the potential health implications of sugars consumption, major nutrition and health-related organisations have issued nutritional recommendations on limiting sugars and sugar containing foods and beverages (Table 6). Most refer to added or free sugars intake and target specifically sugar-rich products such as SSBs. Some recommendations set an upper limit of daily energy (calorie) intake of (added/free) sugars, which is in most cases 10% and sometimes 5% of the total daily energy intake (E%). Similarly, food based dietary guidelines generally recommend limiting sugars and sweetened products.
Table 6: Dietary recommendations by food- and health-related organisations
Under EU law, sweeteners are food additives, and therefore their intake is considered under the scope of Acceptable Daily Intake (ADI) values. EFSA, and before that the Scientific Committee on Food, has set EU ADI values for both intense sweeteners and polyols, reported in Table 7.
Table 7: Acceptable daily of intense sweetener and polyols intake in the EU
In the EU, EFSA reported ( EFSA 2010a ) compiled data on carbohydrate intakes, drawn from national food consumption surveys, conducted from 1994 onwards, as well as from data in the ENHR report of 2009 ( ENHR 2009 ). Due to differences in the methodology used to assess individual intakes and the different time points analysed, EFSA notes that the quality and quantity of data varies making direct comparisons difficult.
In the dataset compiled by EFSA, most countries did not report intakes of mono- or disaccharides separately. In the few countries that didi, average intakes of mono- and disaccharides varied from 23 to 36 E% in children and adolescents, and from 17 to 26 E% in adults. Additionally, some countries specifically reportedj average sucrose intakes, which varied between 6 and 14 %E in adults. Average intakes below 11 E% were only observed in the age categories of 35-64 y (94% of the group) and over 65 y (79% of the group). As EFSA noted, added sugars intake in some EU MS exceeded the 10 E% threshold recommended by WHO as well as national EU authorities, especially in children.
Data from other surveys on sugar intake can be found in Table 8; as before, due to differences in methodology, year of study, age groups involved, and measurement taken (e.g. total sugars or added sugars) it is difficult to draw any conclusions on the intake of added sugars across the EU.
Table 8: Overview of intake across European countries
Acceptable Daily Intake (ADI) values have been already discussed in section 3.5 of the present Brief. In most cases, and as indicated in the relevant safety evaluations, even with high consumption scenarios, sweetener intake levels are expected to remain below the ADI threshold ( ANSES 2015 (pdf) ) .
As described in Table 4, high intake of added sugars can be a risk factor for ill health, especially in the case of intake of sugar sweetened beverages. For example, the Global Burden of Disease 2019 ( GBD study 2019 ) study estimated that diets high in SSBs, defined as consumption of any intake (in grams per day) of beverages with 50 or more kcal per a serving of one cupl, and including carbonated beverages, sodas, energy drinks, fruit drinks but excluding 100% fruit and vegetable juices, resulted in almost 25 000 avoidable deaths in 2019 in the EU, as well as in more than 575 000 Disability Adjusted Life years (DALYs). ( GBD tool 2019 ).
View visualisation: DALYs and data table
View visualisation: Mortality map and data table
A number of scientific associations, institutions and authorities have issued policy recommendations that ultimately aim to reduce intake of sugars, with a special focus on recommendations for children. These policy recommendations can be generally categorised in actions that i) tackle provision of information to the consumers, e.g. labelling of sugar content in foods, restrictions of marketing practices for foods high in sugars content, encouraging healthy behaviours such as drinking water, ii) making the healthy option available by improving the 'food environment', e.g. offering freely available water and limiting the availability of foods and beverages high in sugars content in schools or public environments, reformulating processed foods to reduce sugars content, and iii) implementing financial (dis)incentives such as taxes on products with high sugars content to dissuade consumers from purchasing or consuming them. A summary of such policy recommendations can be found in Table 9.
Table 9: Policy recommendations to sugars intake
The aim of this paragraph is to present examples of policies that are already in place to address sugars overconsumption. Similar to policy recommendations, most of these can be broadly categorised in policies that aim to provide information, make the healthy option available, or provide financial (dis)incentives to sugar consumption. Governments around the world have adopted different measures to reduce sugar consumption (Table 10), from the introduction of 'sugar taxes', to voluntary actions involving co-operation with relevant stakeholders, e.g. the voluntary reformulation pledges of the members of the EU Platform for Action on Diet, Physical Activity and Health. As in Table 10, many of the implemented policies target consumption of SSBs and limit the availability of sugary foods and beverages in schools.
Table 10: Implemented policies to sugars intake
There are few actions in place specific for sweeteners; most of these tackle the use of intense sweeteners in SSBs in school environments and are summarised in Table 11.
Table 11: Implemented policies to sweeteners intake
a. Not to be confused with the 'no added sugars' nutrient claim under Reg. (EU) 1924/2006 – see section 3.
b. An exception to this rule: when reporting directly from sources, e.g. in tables, the terminology used to describe sugars reflects the definition that each source is using.
c. The number of single units (monomers) that make up the substance
d. Although the Joint FAO/WHO Expert Consultation report (1998) includes polyols as sugars, this is due to a chemical classification; in this guide polyols are addressed separately from sugars, due to their different nutritional and functional properties following EFSA, the SACN report (2015) and the approach of Reg. (EC) 1333/2008 and Reg. (EU) 1169/2011
e. Reg. 1333/2008 also includes a third category: 'producing food intended for particular nutritional uses as defined in Article 1(2)(a) of Directive 89/398/EEC'. However, the 89/398/EEC directive has been repealed by Reg. (EU) 609/2013, which defines a list of substances that can be added to food intended for infants and young children, foods for special medical purposes, and foods for total diet replacement for weight control. Currently (Oct 2017), no sweetener is included in that list.
f. Some intense sweeteners contain calories. Even so, being much sweeter than sucrose, they are used in small amounts and therefore their overall energy contribution to the final product is very small.
g. Strong recommendations indicate that the desirable effects of adherence to the recommendation outweigh the undesirable consequences and can be adopted as policy in most situations. WHO handbook for guideline development (2014) 2
h. Conditional recommendations are made when there is less certainty about the balance between the benefits and harms or disadvantages of implementing a recommendation. This means that policy-making will require substantial debate and involvement of various stakeholders for translating them into action. WHO handbook for guideline development (2014) 2
i. For children and adolescents: NL, BE in the 1-3 y age group; BE, SE in the 4-6 y age group; NL, SE in the 7-9 y age group, BE, NL, SE for the 10-14 y age group; NL for the 15-18 y age group. For adults: BE, ES, SE for the 19-65 y age group; NL for the 19-34 y age group; DE for the 35-64 y age group
j. AT, DK, FI, HU, LT, NO, PL, SE in the 19-65 y age group; DK, SE in the 19-34 y age group; DE, DK, SE in the 35-64 y age group
k. As EFSA notes, given that EFSAs opinion on steviol glycosides indicated high consumers might exceed the established ADI value, the Commission may ask EFSA to perform a new exposure assessment, as data from the use of steviol glycosides become available.
l. There is no universal definition of a 'cup'. In the US Legislation, for the purposes of nutrition labelling, 1 cup equals 240 ml
m. For the scope of Annex II, the term added sugars goes beyond the EFSA definition of the term, and 'is additionally considered to include sugars present in honey, syrups, and fruit juices and fruit juice concentrates. This is the case because, for reformulation purposes, they can be described as providing energy while not significantly contributing other nutrients to foods.'
| Originally Published | Last Updated | 20 Oct 2020 | 26 Oct 2023 |
| Knowledge service | Metadata | Health Promotion Knowledge Gateway | Risk factors of non-communicable diseases | Sugars and sweeteners |
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