The article, "A Closer Look at Sugars," authored by Schorin et al is the first in a 4-part series entitled, "The Science of Sugars," to be published over the next several issues of Nutrition Today. The good news in this article is that consumption of added sugars fell over the past decade. Using dietary data from the National Health and Nutrition Examination Survey, Welsh and colleagues found that from 1999 to 2008 Americans' intake of added sugars dropped from 18.1% to 14.6% of total energy intake-a 19% drop.1 Most of this drop was due to a reduction in the consumption of soft drinks,1 the No. 1 source of added sugars in Americans' diets.2 Welsh et al1 posit that early work done by advocacy groups to raise awareness of the increase in sugar-sweetened beverage (SSB) consumption may have had an impact by the mid-2000s.1,3 The bad news is Americans' added sugar intakes still far exceed dietary recommendations made by respected nutrition authorities.4,5

In 2009, the American Heart Association (AHA) Nutrition Committee published a scientific statement on dietary sugars and cardiovascular health.5 One of the driving forces behind this statement was the committee's belief that Americans needed a specific number defining how much added sugars can fit into a healthy diet. Prior to 2009, the Dietary Guidelines for Americans (DGA) made no firm quantifiable recommendations. In 2000, the DGA said "choose beverages and foods to moderate your intake of sugars,"6 and in 2005, the DGA said, "choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as amounts suggested by the US Department of Agriculture (USDA) Food Guide and the DASH Eating Plan."7 The AHA writing group conducted a comprehensive review of the literature and made the recommendation that a prudent upper intake for added sugars is no more than 100 calories (6 teaspoons) per day for most American women and 150 calories (9 teaspoons) per day for most American men. These numbers were based on half the discretionary calorie allowance in the food guide patterns developed for MyPyramid. Discretionary calories are now referred to as empty calories or SoFAAS (solid fats, alcohol, and added sugars) in more recent MyPlate consumer education materials.8

The foundation of the AHA added sugars recommendations was a literature base demonstrating that high added sugar intakes were associated with known risk factors for cardiovascular disease. Since 2009, the literature base has expanded with recent articles strengthening the links between SSBs and hypertension,9 dyslipidemia in adolescents10 and adults,11 and adverse changes in lipids, inflammatory markers, and leptin in male health professionals,12 among many others. Obesity is a major risk factor for cardiovascular disease (as well as asthma, diabetes, and high blood pressure). Woodward-Lopez and colleagues13 concluded in 2010 that "all lines of evidence support the conclusion that the consumption of sweetened beverages has contributed to the obesity epidemic. It is estimated that sweetened beverages accounted for at least one-fifth of the weight gained between 1977 and 2007 in the US population. Actions that are successful in reducing sweetened beverage consumption are likely to have a measurable impact on obesity."13

Because of the evidence linking SSBs with obesity and other poor health indices, there has been a proliferation of public health campaigns designed to limit Americans' SSB consumption. The USDA and Department of Health and Human Services issued their strongest consumer message to date when the 2010 DGA advised consumers to "drink water instead of sugary drinks."4 The AHA recently announced an aggressive goal to improve the cardiovascular health of all Americans by 20% by 2020. A healthy diet is critical to achieving the goal, and thus, AHA identified 5 key components to a heart-healthy diet; one of the 5 is limiting SSBs to no more than 450 calories (36 oz) a week.14

On a municipal level, in 2011 the New York City Health Department launched a media campaign asking "Are You Pouring on the Pounds?" encouraging New Yorkers to cut back on soda, juice, and other sugary drinks.15 The Boston Public Health Commission, Blue Cross and Blue Shield of Massachusetts, and Boston Medical Center advise consumers to "Stop. Rethink Your Drink. Go on Green" indicating that cutting back on red drinks (SSBs) and substituting them with green drinks (water, seltzer water, 1% or skim milk, and unsweetened soymilk) helps prevent weight gain.16 The Mayor of Boston recently issued an order to end the sale of SSBs on city property joining the efforts of 10 Boston hospital campuses.17

The concept of taxing SSBs as a tool to limit consumption and raise revenue for obesity-prevention programs has been around for some time but is recently gaining more traction.18-20 Lustig and colleagues21 argued in the high-profile journal Nature that added sugars should be regulated and suggested that this might include taxation, limiting sales during school hours, and placing age limits on its purchase. Last year, New York State petitioned USDA to conduct a pilot project in New York City to eliminate Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) benefits for SSBs. Many other states have either requested the same permission or urged Congress to allow states more flexibility to set standards for what can and cannot be purchased with SNAP benefits.22 To date, the USDA has not granted any of these requests.

It is important to point out that the AHA recommendation recognizes there is room for some added sugars in a healthy diet. The best use of the added sugars allowance is to sweeten and enhance the flavor of otherwise nutritious foods such as whole grains and low or nonfat dairy that deliver nutrients of public health concern. The AHA addressed this recently when it revised and enhanced its popular Heart Check Food Certification Program. Shoppers instantly know that any food with a Heart Check has been certified to meet the AHA's science-based guidelines for a heart-healthy food. In 2011, AHA established dietary fiber, total sugars, and calorie screening guidelines to promote the consumption of foods that deliver important shortfall nutrients without contributing excess calories from added sugars. Screening guidelines limiting calories for milk and juices were implemented specifically to limit calories from added sugars. As added sugars are not currently disclosed as part of the nutrition facts label, there was not a transparent way to establish specific added sugars criterion for the program. Compliance is required by January 2014, giving the food industry time to reformulate products to meet AHA's new criteria (Table).

Table American Heart Association Heart-Check Food Certification Program Nutritional Guidelines

Segments of the food industry have stepped up to meet the demand for products with less added sugars. During 2011 to 2012, on average the flavored milk available in US schools was 134 calories per 8-oz carton; down from 166 calories/8 oz in 2006 to 2007. Added sugars in flavored milk in schools declined an average of 38% (from 16.7 to 10.4 g/8 oz) over this period.23 In 2010, AHA held a conference with more than 100 multinational participants to discuss ways to translate the AHA 2009 added sugars recommendations into actions. Participants learned that General Mills was committed to reducing sugar levels in their cereals, from 13 g per serving in 2007 to 11 g in 2009, to the goal of 9 g or less in the future.24

In summary, public health messages to reduce added sugar intake abound. There are bright lights in the food industry where popular products are being reformulated to reduce added sugars and calories. Americans' added sugar intakes appear to have dropped. But, most importantly, although the numbers of Americans who are overweight or obese remain alarmingly high, the prevalence of childhood obesity has begun to stabilize in some segments of the population,25 and the rapid rate of increase among US adults seems to be slowing, particularly for women.26 Perhaps this multifaceted proliferation of efforts across many sectors to lower Americans' added sugars consumption by removing added sugars from the food supply, decreasing SSB availability, and increasing consumer awareness is making up what Katz27 describes as sandbags in a levee to hold the flood waters of obesity and chronic disease at bay.

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