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New review on dietary sugar guidelines spark debate
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Research findings suggest that the current guideline recommendations for sugar intake are not based on high-quality evidence and thus are not trustworthy. As a result, researchers urge public health officials and their public audience to consider such limitations.
However, due to industry funding as well as other factors, several experts dispute the credibility of this systematic review.
“The relationship between sugar and health is complex due to multiple interrelated variables, including state of energy balance, macronutrient substitutions, and underlying diet and lifestyle patterns,” Jennifer Erickson, RD, from the University of Minnesota, and colleagues wrote. “Existing evidence of a link between sugar intake and adverse health outcomes has been translated into dietary guidance and recommendations for the general public by authoritative health organizations.”
Erickson and colleagues identified and reviewed nine eligible public health guidelines consisting of 12 specific recommendations for dietary sugar intake that were published between 1995 and 2016. They evaluated the consistency of recommendations, methodological quality of guidelines using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) instrument, and the quality of evidence supporting each guideline using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.
All nine of the guidelines suggested that consumption of foods containing nonintrinsic sugars should be limited. Qualitative guidance was presented in seven recommendations, while quantitative guidance was presented in five recommendations, ranging from less than 5% to less than 25% of daily caloric intake from nonintrinsic sugars. Various health concerns such as nutrient displacement, dental caries and weight gain served as the basis of the recommendations.
Based on AGREE II criteria, the guidelines scored poorly, particularly in rigor of development, applicability and editorial independence. Overall, results indicated that the recommendations were supported by low to very low quality of evidence.
“The prevailing concerns with high sugar are directed toward excessive calorie consumption and nutrient displacement,” Erickson and colleagues concluded. “At present, there seems to be no reliable evidence indicating that any of the recommended daily caloric thresholds for sugar intake are strongly associated with negative health effects. The results from this review should be used to promote improvement in the development of trustworthy guidelines on sugar intake.”
In a related editorial, Dean Schillinger, MD, of USCF division of general internal medicine at Zuckerberg San Francisco General Hospital, and Cristin Kearns, DDS, MBA, of UCSF Institute for Health Policy Studies, argued that the review by Erickson and colleagues contained several limitations and shortcomings, including funding from the International Life Sciences Institute, and use of AGREE II and GRADE to evaluate quality of evidence.
“Our concerns about the funding source and methods of the current review preclude us from accepting its conclusion that recommendations to limit added sugar consumption to less than 10% of calories are not trustworthy,” they concluded. “Policymakers, when confronted with claims that sugar guidelines are based on ‘junk science,’ should consider whether ‘junk food’ was the source.” – by Alaina Tedesco
Disclosure: Erickson and colleagues report primary funding by the Technical Committee on Dietary Carbohydrates of the North American branch of the International Life Sciences Institute. Schillinger reports no relevant financial disclosures. Kearns reports receiving grants from National Institute of Dental and Craniofacial Research.
Perspective
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Marion Nestle, PhD, MPH
This is a classic example of industry-funded research aimed at one purpose and one purpose only: To cast doubt on the science linking diets high in sugars to poor health. What are dietary guidelines supposed to say about sugars? That we are supposed to eat more of them? Give me a break. Sugars provide calories and nothing else of nutritional value. They are not dietary essentials and an enormous body of research suggests that people who consume high-sugar diets are at higher risk for obesity, type 2 diabetes, heart disease, and other chronic conditions than those who do not. I use the word “suggests” advisedly. Because we can’t lock people up in cages for decades to do nutrition experiments on them, and people consume diets of great complexity, it is scientifically impossible to prove that sugars alone are responsible for poor health. Really, this paper is shameful and I cannot understand why the journal agreed to publish it.
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