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First published: 04.
Feb.2025
Overview
There is mounting evidence that an excessive intake of sugar contributes to weight gain and cardiometabolic diseases. Added sugar, sugar that is added to processed foods plays an important role in the daily sugar intake of Americans. It is found in sweet sodas, cookies, candies, breakfast cereal, and savory foods like BBQ sauces, and catsup.
Sugars occur naturally in fruit, vegetables, milk, and honey. These sugars may be of different kinds (lactose, maltose, glucose, and fructose, to mention a few of them), but they are a natural ingredient that forms part of these foods. (2)
Plants convert sunlight and use its energy to combine water and atmospheric carbon dioxide to manufacture sugars (mainly glucose). This process, known as photosynthesis, is vital for all living creatures. The plants then break down the sugar in their cells converting it into oxygen and water, producing energy to keep them alive.
Sugars are relatively simple chemical compounds that belong to a group known as carbohydrates and are stored in the form of starches and simple sugars. They are also the building blocks of more complex molecules that form the plant's structure and tissue (stems, leaves, seeds, flowers).
Honey's sugar is glucose and fructose, obtained when the bees use enzymes to convert flower nectar (mainly sucrose) into honey.
Lactose, which gives milk its sweet taste, is synthesized by female mammals.
What are Added Sugars?
Added sugars, on the other hand, have been added as an ingredient when foods are processed.
Added sugars include table sugar or sucrose, sugars from syrups and honey, and sugars from concentrated fruit or vegetable juices.
Sugar and Added Sugar. A food may contain natural sugars. Think about a fruit preserve, the fruit naturally contains sugars; the same can be said about jam. Then, sugar is added to the recipe to make the preserve or the jam. So it contains both natural and added sugars. This answers the question "Is there a difference between sugar and added sugar?"
What does it mean when a label says added sugar?
The Nutrition Facts Label) specifically mentions sugar and added sugars (if they are present).
The label lists the nutrients, and Total Carbohydrate is one of them. The amount of Total Carbohydrate in grams is the sum of Total Sugar, starches, and Dietary Fiber. Starches aren't mentioned on the label; the list only mentions Dietary Fiber and Total Sugar (if they are present). Finally, if manufacturers add sugar to the food, it should be declared on the label as "added sugars". If they don't add sugar, it will not appear there. The "Sugar" mentioned on the label is the "Total Sugar" content and consists of the sugar that is naturally present in the food plus the added sugar. The label does not mention the "natural sugar", only the Total and added sugars.
If sugar is added it will appear as "Includes Xg Added Sugars."
Note that pure honey, pure maple syrup, and other pure sugars and syrups, are not required to bear the words "Includes Xg Added Sugars" on their containers, but must still include the percent Daily Value (DV) for added sugars on their labels.
Nutrition Facts Label Example
Total Carbohydrate Ag
Dietary Fiber Bg
Total Sugar Cg
includes Xg Added Sugars
Explanation
The maths is shown below; the two items that are underlined don't appear on the label S = starches, and N = natural sugars.
A = B + C + S. Where A is Total Carbohydrates, B is Dietary Fiber, C is Total Sugar, and S are starches which are not mentioned on the list, but make up the carbohydrate content of food.
Finally, C = X + N, where C is Total Sugar, X is Added Sugars, and N is the sugar naturally present in the food.
So, Total Sugar does include the Added Sugars. The image below is an example with numbers. In black letters, we show the information displayed on the label, in blue letters the nutrients that aren't shown on the label. The red box contains Total sugars as the sum of added and natural sugars. The blue box shows how total sugars, dietary fiber, and starch add up to Total Carbohydrate.
Understanding the Carbs and Sugars on a Nutrition Facts Label. A. Whittall.
Why is sugar added to processed foods?
Sugar serves many purposes as an ingredient in foods: It is a bulking agent, texturizer, preservative, processing lubricant, humectant, binder, flavor enhancer, colorant, viscosity agent. and thickener, it also improves the taste and palatability of different foods. (1)
Added sugar is found in sweet and savory processed foods, from tomato sauce, glazed ham, BBQ sauce, catsup, and chutneys, to jams, preserves, biscuits, breakfast cereal, cakes, yogurt, cereal bars, sodas, fruit juices, candies, nut and peanut butters. Sugar is an ingredient in almost all processed foods.
Dietary Guidelines Regarding Added Sugars
According to the 2020-2025 Dietary Guidelines for Americans, added sugars should account for less than 10% of the total daily calorie intake. The U.K. figure is lower, 5%.
Americans eat too much added sugars
However, most Americans consume far too much added sugars. The average calorie intake is 2,068 kcal/day, so the added sugar intake should be less than 207 Kcal⁄day. (3)
The 2015-16 National Health and Nutrition Examination Survey (NHANES) shows that 13% of total daily calories came from added sugars, down from 18% in the 1999-2000
NHANES.
A 2017-18 survey reported that men consume 19.2 teaspoons (tsp) of sugar per day, compared to 15.1 tsp/day in women; more than twice the levels recommended by the American Heart Association of 9 tsp/day for men and 6 tsp/day for women.
Most of these added sugars were eaten as snacks (sugar-sweetened sodas, cookies, sweets, desserts) and 1/3 of them were eaten on the couch in front of a TV, or at work. (3)
Ten Top Sources of Added Sugars in the American Diet
Below are the Top Ten Added Sugar Sources in the typical American Diet: (3)
Sweetened Beverages (41.7%)
Tea (12%)
Sweet Bakery products (11.5%)
Jams, syrups, sugars (7.2%)
Candy (5.3%)
Other Desserts (4.1%)
Alcoholic drinks (2.8%)
Mixed Dishes (2.7%)
Ready-to-eat-cereals (2.0%)
Fats and Oils (2.0%)
This represents a total sugar intake of 131 g or 4.65 oz. (almost 1/3 lb!) of table sugar equivalent per day.
Take-home point
Replacing sugary sodas and tea with water or unsweetened drinks would halve the added sugar intake of the average American.
What is high-fructose corn syrup?
High-fructose corn syrup or HFCS is an artificial, processed ingredient made from corn syrup. Corn syrup is touted as "natural", but it is a processed ingredient. First corn (maize) kernels are wet-milled in water with acid, ground, and sieved and the starch is separated, collected, and washed. The cornstarch is then hydrolyzed, a process that breaks the starch molecules into glucose, to make corn syrup. Hydrolyzing is done with heat and an acid or using enzymes.
Corn syrup is then processed again, with enzymes that turn part of the glucose into fructose. The end product contains 76% sugar and 24% water. The resulting high-fructose corn Syrup (HFCS) is sold in two grades:
55% fructose and 45% glucose. Used in mainly in sodas, sugary beverages, and ice creams.
42% fructose and 58% glucose. Used in bakery, cereals, processed foods, dairy products, and condiments.
Sucrose and High Fructose Corn Syrup aren't the same! A. Whittall
HFCS displaced sucrose (table sugar) in industrial uses because it is cheaper, and as it contains 24% water, it provides moisture with the same sweetening effect.
Sucrose
Table sugar (simple sugar) is obtained from sugar cane or beetroot and is 100% sucrose. The sucrose molecule is a disaccharide, formed by two different sugars bonded together with an oxygen chemical bond. One of these sugars is glucose, the other is fructose. Regular table sugar is 50% glucose and 50% fructose.
Note that the glucose and fructose in table sugar are bonded together, while HFCS is just a mixture of both molecules that are not bonded, they are free molecules.
Are All Sugars The Same?
The sugar industry and its lobby argue that HFCS contains the same sugar molecules found in "natural" foods, fructose and glucose. They state that the effect of HFCS and regular fructose from fruit is identical since both molecules are chemically identical. (6). This is partially true. Fructose in fruit and fructose in HFCS is the same molecule and has the same effect if taken alone, isolated from the other ingredients.
But fructose in fruit isn't isolated, it is part of a natural food, with
fiber, complex, unrefined carbohydrates, and plant-based bioactive chemicals. High Fructose Corn Syrup, on the other hand, is man-made and contains a mixture of glucose, and fructose in water.
Added sugars like HFCS are then used as ingredients in ultraprocessed foods, that are high in saturated fats, salt, refined carbohydrates, and low in fiber.
The body will treat both foods (fruit and processed food) in a different manner, and their impact on your health will not be the same.
The ingredient-centered view of nutrition, with its reductionist approach, focuses on the apparent benefits and health risks of individual ingredients instead of grasping the full picture (a "holistic view of nutrition"). We eat food, not nutrients. Fructose is a natural element within fruits, which in turn are a combination of other nutrients, and biochemical structures, which are not processed. When looking at this ingredient (fructose) in a biscuit, the context is different, a biscuit has been highly processed with many manmade ingredients and artificial synthetic additives (pigments, preservatives, acidulants, etc).
Fruit, despite its fructose content, is recommended as part of a healthy diet, and replacing high energy-dense foods with fruit is a healthy alternative (5) and helps improve weight loss programs.
The fiber in fruit pulp and edible skins improves satiety and also promotes a lower energy uptake from energy-dense foods as fat goes through the gut without being absorbed. High-fiber fruits allow for a better control of blood glucose levels. Eating whole fruit vs. consuming fruit juice has a positive effect on blood sugar levels, avoiding the immediate spike after consuming it, and the dip that follows. It has a regulating effect on insulin secretion.
Finally, fruits contain phytochemicals like polyphenols and carotenoids, plant-based products with antioxidant and anti-inflammatory effects. They also contain natural vitamins and high fiber-to-sugar ratios. These are absent in sugary processed foods and beverages, where vitamins and fiber are added as processed ingredients.
Take-home point
Fructose in fruit doesn't have the same effect on your health as added fructose in processed food.
What About Artificial Sweeteners and Healthy Sweet Foods?
Trying to avoid sugar and using
artificial sweeteners may have a negative health impact as consuming sweeteners from different sources (yogurt, beverages) may increase the intake beyond the recommended daily levels considered safe.
Rather than focusing on specific nutrients, the approach should be an holistic one, promoting a healthy diet (DASH, or Mediterranean), with a balanced intake of nutritive foods (fruit, vegetables, whole grain, dairy, fish, poultry, and legumes) with natural fiber, and healthy oils (nuts, seeds, avocados, olive oil).
In this context, a bar of chocolate or yogurt with some added sugar will still be a healthier choice than a sugar-laden soda because chocolate provides antioxidants, and yogurt is a probiotic, with calcium and protein. (6)
Health Risks from High Sugar Intake
A 2023 review (4) evaluated over 8,601 scientific articles and found a link between dietary sugar and harmful health outcomes.
It concluded that a high sugar consumption is harmful, and linked to weight gain, belly fat, metabolic, endocrine (hormonal), and cardiovascular disease.
"each serving/week increment of sugar sweetened beverage consumption was associated with a 4% higher risk of gout... and each 250 ml//day increment of sugar sweetened beverage consumption was associated with a 17% and 4% higher risk of coronary heart disease, and all cause mortality, respectively. In addition, low quality evidence suggested that every 25 g/day increment of fructose consumption was associated with a 22% higher risk of pancreatic cancer."
A 2022 study (7) suggests that a high intake of sugar promotes inflammation and may play a role in diseases like "rheumatoid arthritis (RA), multiple sclerosis (MS), psoriasis, inflammatory bowel disease (IBD), low-grade chronic inflammation... and even neuroinflammation."
High Sugar intake is linked to an unhealthy lifestyle
A 2023 review (4) reported that a high intake of sugars is associated to an unhealthy lifestyle and diet. Those who drink larger amounts of sugar-sweetened beverages are also more likely to consume more carbohydrates, saturated fat, and sodium, and less, fiber, fruit, whole grain, and dairy products. They are also more prone to smoking, drinking alcohol, and having sedentary lifestyles (less physical activity and more time on the couch watching television).
These unhealthy behaviors contribute to negative health outcomes and are confounding factors when studies attempt to explain the association between sugar intake and disease. How can a study isolate the negative effect of a poor diet, and lack of physical activity from the potentially harmful effects of a high sugar intake?
Conclusions: Less added sugar for a healthy life
The current guideline recommending less than 10% of daily calories should be added sugars is vague. People can't quantify it: This value is roughly 200 Kcal/day, equivalent to 12.5 teaspoons per day of table sugar or 1.8 oz (51 g).
A serving of breakfast cereal (12 to 14 g of added sugars), two Oreo cookies (9.4 g), and 39 grams of sugar in a 12 oz Coca‑Cola can will leave you more than 10 g over the mark (+20% above the guideline).
Some practical tips to help lower your added sugar intake would be to choose water over a sugary soda (or an artificially sweetened one), reduce the amount of sugar you put into your coffee or tea (sugar hides the flavor of these beverages), replace a processed snack for fruit, and shun the granola bars (packed with fats and sugars).
(7) Ma X, Nan F, Liang H, Shu P, Fan X, Song X, Hou Y, Zhang D., (2022). Excessive intake of sugar: An accomplice of inflammation. Front Immunol. 2022 Aug 31;13:988481. doi: 10.3389/fimmu.2022.988481. PMID: 36119103; PMCID: PMC9471313
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