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Sugary foods and drinks

This HEART UK Nutrition Academy webpage has been funded by Novartis Pharmaceuticals UK Ltd who have had no input into the content or development of this material.
 

Excess sugar intakes are unfortunately the norm in the UK1 and have been demonstrated to negatively impact numerous health outcomes, including cardiovascular health, through direct or indirect mechanisms.

Take home messages

  • Free sugars and foods rich in these sugars are high in calories and provide little to no healthy nutrients.
  • Free sugars include table sugar, all types of honey, all types of syrups, and natural fruit juices and smoothies.
  • Higher intakes of free sugars and especially sugar sweetened beverages have been extensively investigated and found to be associated with:
    • excess energy intakes
    • higher body weight and risk of obesity
    • higher risk of type 2 diabetes
    • higher blood triglycerides
    • an 8-20% higher risk of CVD, linked to the excess energy intake and weight gain.
  • Current adult recommendations are to not exceed 30g (7 tsp) of free sugars daily.
  • All age groups in the UK exceed this recommendation by 50%-150%.
  • Key sources of free sugars are: sweetened cereal products (buns, pastries, cakes, biscuits), preserves, sugar sweetened beverages and fruit juice.



About sugar 

Which sugars are harmful to health?


The main cause of concern is excess intakes of ‘added sugars’ and ‘free sugars’

  • 'Added sugars' refers to sugars actively added to foods and drinks to enhance sweetness. This term is used in the United States2 and Europe3.
  • 'Free sugars'. As well as added sugars, free sugars also include sugars naturally produced during the food production process, for example in some plant-based drinks, and sugars naturally present in juices and smoothies made from fruit and vegetables. This term is used by the World Health Organization (WHO)4 and in the UK5.

What counts as ‘free sugars’ in the UK?


Free sugars are simple carbohydrates – monosaccharides and disaccharides. They include the following6:

  • Sugars added to foods and drinks by manufacturers or whilst cooking, whether at home or in catering establishments. They include all types of honey, syrups, malt extract, fructose, and fruit juice concentrates.
  • Lactose and galactose that are added as ingredients to manufactured foods and drinks to enhance sweetness (this does not include lactose and galactose naturally present in milk and dairy).
  • All sugars naturally present in fruit and vegetable juices, concentrates, smoothies, purees, pastes, and powders. This includes the sugars found naturally in unsweetened juices and smoothies, alcoholic drinks, and those that occur naturally in the production of plant-based drinks such as oat and rice.
    • Even though these sugars occur naturally, they are not in their natural state. Breaking down the cell structure of a food results in the release of sugars (‘free sugars’) which are then absorbed and metabolised at a similar rate to other free sugars such as table sugar and honey.

What is NOT a free sugar?

  • The sugars naturally present in milk and dairy products – lactose and galactose.
  • Whole fruit and vegetables, where all the natural sugars remain within the cell structure. This includes fresh, dried, canned and frozen varieties. 
  • All sugars that are naturally present and intact within the cell structure of starchy foods such as flour, rice and pasta, and the small quantities found in nuts, seeds, beans and pulses.
  • Maltodextrins, oligofructose and sugar substitutes such as polyols (sorbitol).

Metabolic and cardiovascular health 

In the past decade, several systematic reviews and meta-analyses of randomised controlled trials (RCTs) and prospective cohort studies have investigated the effects of free sugars on cardiometabolic risk factors and cardiovascular health outcomes4,5,7–13. Much of the research has focussed on the effects of sugar-sweetened beverages (SSBs).

  • The most robust evidence shows an association between free sugars, excessive calorie intake and a higher risk of overweight and obesity, particularly among adults4,5,14.
  • There is substantial evidence linking SSBs to a greater risk of type 2 diabetes5,15.
  • It is well-documented that higher body weight and type 2 diabetes are significant risk factors for CVD4,5,16.

Sugar intakes result in higher daily calorie intakes

  • A 2015 systematic review and meta-analysis of RCTs conducted by the Scientific Advisory Committee on Nutrition (SACN) showed that higher sugar intakes were associated with an additional energy intake of up to 346 calories per day compared to lower sugar intakes5. The association was most pronounced with SSBs where individuals failed to moderate their food intake at subsequent meals to compensate for the extra SSB calories consumed.
  • Also in 2015, the WHO conducted a comprehensive review of the evidence and updated their recommendations for free sugars for adults and children4. The results showed a link between free sugars and weight gain where sugar intakes exceeded energy needs. 
  • A 2022 analysis of two cohort studies with over 29,000 participants also showed a link between SSBs and excess energy intake9. ; Those who drank the most SSBs had significantly higher energy intakes than those who drank the least. 

Sugars, especially sugary drinks, are linked to overweight and obesity

  • Excess body weight and fat tissue are widely acknowledged risk factors for CVD and dyslipidaemias16–18. The SACN 2015 meta-analysis of cohort studies with children and adolescents demonstrated a clear link between high SSB intakes and increased risk of weight gain, overweight and obesity5.
  • The link between free sugars (mainly as SSBs) and weight gain in all age groups was confirmed by the 2015 WHO systematic review and meta-analysis of 30 RCTs and 38 cohort studies4. The analysis established a direct link between higher free sugar intakes and greater weight gain as well as higher risk of overweight and obesity, both in children and adults.
  • A 2020 systematic review of data from seven cohort studies with over 56,000 participants found a 12% increased risk of obesity with every 250ml serving of SSB consumed per day15.

Sugars and other refined carbohydrates increase blood triglycerides

 

Diets rich in refined carbohydrates including sugars have been linked to dyslipidaemias, particularly raised plasma triglycerides (TGs)9,19. It is well established that16,19,20

  • raised plasma levels of TG-rich lipoproteins such as Very Low Density Lipoprotein (VLDL) contribute to atherosclerosis 
  • fasting plasma TG levels over 1.7 mmol/L increase CVD risk.

Sugar sweetened beverages increase the risk of type 2 diabetes

 

Extensive systematic reviews and meta-analyses have provided strong evidence linking high intakes of SSBs to a higher risk of type 2 diabetes. 

  • The 2015 SACN analysis of nine cohort studies found a 23% higher risk of type 2 diabetes for every 330ml of SSBs consumed. This association is not always seen in RCTs comparing isocaloric diets, but in real-life scenarios where individuals are free to eat and drink what they choose, drinking SSBs consistently leads to excess energy intake4,5,21. More recently, two meta-analyses, one with 445,040 participants and one with over a million, found a 27% and 19% increased risk of type 2 diabetes for every serving of SSB consumed, respectively14,15.

Higher sugar intakes increase CVD risk

 

Multiple systematic reviews and meta-analyses of prospective cohort studies comparing SSBs or total sugar consumption with CVD outcomes have found a substantial increased risk of CVD with higher sugar intakes8,12,14,17. For example:

  • Huang and colleagues conducted a meta-analysis of data from seven large cohort studies of nearly 330,000 participants and found an 8% increase in CVD risk for every daily serving of SSB14
  • A 2023 systematic review, based on data from the Nurses’ Health Study which included 65,730 nurses and the Health Professionals’ Follow-Up study of 39,418 subjects, revealed a 21% higher CVD risk for those consuming at least two SSBs daily, compared to those who didn’t drink SSBs8. In addition, this review looked at those who met US physical activity recommendations and found that being physically active does not negate the impact of SSBs. In people who met physical activity recommendations, those who drank at least two servings of SSBs daily had a 15% higher risk of CVD compared to non-consumers.

In their discussions, all these studies suggest that long term excess calorie intake and subsequent weight gain, linked to excessive sugar consumption, are potential mechanisms that contribute to the higher risk of CVD.

Summary of the evidence 

Overall, the evidence demonstrates that free sugars, especially when consumed in the form of SSBs including fruit juice, have a detrimental effect on cardiovascular health. This is mainly due to higher energy consumption and heightened risk of obesity, type 2 diabetes and dyslipidaemias.

What are the recommendations for sugar?

Free sugars are not an essential nutrient and foods with a high sugar content are typically high in calories while lacking beneficial nutrients. Therefore, it’s advisable to keep sugar intakes to a minimum for overall health.

UK recommendations for the maximum intake of free sugars


Free sugars should not exceed 5% of total energy intake – the lower the intake the better5. This translates as no more than 30g free sugars daily22.

The sugar guidelines in the UK are in line with the more ambitious recommendation from the WHO of less than 5% of total energy intake4.  Most countries advocate for the more moderate WHO recommendations of a sugar intake of less than 10% of total energy intake.

Sugar recommendations for primary and secondary CVD prevention and lipid management
Guidelines Amount of free/added sugars recommended Note
NICE guidelines20

No more than 5% energy intake

30g (7 tsp) daily for adults

No specific sugar recommendations are stipulated; however, NICE recommend following the national healthy eating guidelines with a link to the NHS website which supports the ≤5% energy of free sugars daily
2019 ESC/EAS Guidelines for the management of dyslipidaemias16

No more than 10% energy intake – approx. 60g (14 tsp) daily

and discourage SSBs

Potentially lower levels (not specified) for individuals with raised serum triglycerides (TGs), visceral adiposity, metabolic syndrome or diabetes
2021 ESC Guidelines on cardiovascular disease prevention in clinical practice17

No more than 10% energy intake – approx. 60g (14 tsp) daily

and discourage SSBs & fruit juice

The recommendations are based on the WHO 2015 guidelines where they also highlight that fruit juice should also be considered as a free sugar

UK intakes compared to recommendations

Across all age groups, the consumption of free sugars exceeds recommended intakes. Adults aged 19-64 exceed these recommendations by an average of 66%, resulting in an additional 80 kcal daily. This accumulated excess intake amounts to 2,400 kcal over the course of a month23

These are conservative estimates, as the UK Government's sugar reduction strategy has identified a potential underreporting of calorie intake in the national diet and nutrition survey which could be as high as 34%24. Actual free sugars intake and the associated excess calorie intake could be significantly higher.

Key sources of free sugars in the UK diet

  • The main sources of free sugars are sugars added to cereal products including pastries, buns, puddings and biscuits, followed by sugars, preserves and confectionery. 
  • SSBs and fruit juice are equal contributors to sugar intakes. 
    Key sugar sources for teenagers are similar to adults. Pastries, buns, puddings and biscuits are the main sources of cereal sugars. But for this age group, breakfast cereals also contribute a quarter of cereal sugars.
  • In young people, beverages play a more significant role in the overall sugar intake, comprising 29% of total free sugars.
    For over 64-year-olds, there is a greater contribution from fruit juice and table sugar.

Sugar swaps for lower sugar intakes

High sugar options Lower sugar option
Food/Drink Free sugars Free sugars Food/Drink
Cola – 330ml can 35g – 8 tsp 0g Diet cola - 330ml
Orange juice – 200ml carton 17g – 4 tsp 0g Sugar free flavoured water - 200ml
2 Chocolate digestives 7.4g – 1¾ tsp 3g – ¾ tsp 2 Rich tea biscuits
1 Danish pastry (~87g) 15g – 3.6 tsp 5.4g – 2¼ tsp Malt loaf – 2 slices
1 Chocolate muffin (~75g) 22g – 5¼ tsp 3.3g – ¾ tsp Thick sliced bread with peanut butter and sliced banana
Chocolate or fruit mousse-style dessert (~55g) 8.4g – 2 tsp 0g 125g pot sugar-free fruit yogurt
Mars-style bar (51g) 31g – 7 1/3 tsp 0g Handful nuts with spoonful dried fruit
Bowl honey-nut cornflakes (small serving – 30g) 8.3g – 2 tsp 0g Unsweetened muesli

Source: Nutritics Sept 2023

Visit our e-learning Diet and Lipids Module 4: Beyond fats

Find out more

References

  1. NDNS: results from years 9 to 11 (2016 to 2017 and 2018 to 2019). GOV.UK. Accessed January 3, 2024. https://www.gov.uk/government/statistics/ndns-results-from-years-9-to-11-2016-to-2017-and-2018-to-2019
  2. FDA. Added Sugars on the Nutrition Facts Label. US FDA. Published September 27, 2023. Accessed September 29, 2023. https://www.fda.gov/food/nutrition-facts-label/added-sugars-nutrition-facts-label
  3. EFSA. Nutrition claims. European Commisssion. Accessed September 29, 2023. https://food.ec.europa.eu/safety/labelling-and-nutrition/nutrition-and-health-claims/nutrition-claims_en
  4. World Health Organization. Guideline: Sugars Intake for Adults and Children. World Health Organization; 2015. Accessed September 28, 2023. https://iris.who.int/handle/10665/149782
  5. Public Health England. SACN Carbohydrates and Health Report. GOV.UK. Published 2015. Accessed December 15, 2023. https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report
  6. Swan GE, Powell NA, Knowles BL, Bush MT, Levy LB. A definition of free sugars for the UK. Public Health Nutrition. 2018;21(9):1636-1638. doi:10.1017/S136898001800085X
  7. Schwingshackl L, Neuenschwander M, Hoffmann G, Buyken AE, Schlesinger S. Dietary sugars and cardiometabolic risk factors: a network meta-analysis on isocaloric substitution interventions. The American Journal of Clinical Nutrition. 2020;111(1):187-196. doi:10.1093/ajcn/nqz273
  8. Pacheco LS, Tobias DK, Li Y, et al. Sugar- or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in US adults. medRxiv. Published online April 24, 2023:2023.04.17.23288711. doi:10.1101/2023.04.17.23288711
  9. Haslam DE, Chasman DI, Peloso GM, et al. Sugar-Sweetened Beverage Consumption and Plasma Lipoprotein Cholesterol, Apolipoprotein, and Lipoprotein Particle Size Concentrations in US Adults. The Journal of Nutrition. 2022;152(11):2534-2545. doi:10.1093/jn/nxac166
  10. Malik VS, Hu FB. Sugar-Sweetened Beverages and Cardiometabolic Health: An Update of the Evidence. Nutrients. 2019;11(8):1840. doi:10.3390/nu11081840
  11. Shi D, Tao Y, Wei L, et al. The Burden of Cardiovascular Diseases Attributed to Diet High in Sugar-Sweetened Beverages in 204 Countries and Territories From 1990 to 2019. Current Problems in Cardiology. 2024;49(1, Part A):102043. doi:10.1016/j.cpcardiol.2023.102043
  12. Pietrantoni D, Mayrovitz HN. The Impacts of Sugar-Sweetened Beverages (SSB) on Cardiovascular Health. Cureus. 2022;14(7):e26908. doi:10.7759/cureus.26908
  13. Huang C, Liang Z, Ma J, Hu D, Yao F, Qin P. Total sugar, added sugar, fructose, and sucrose intake and all-cause, cardiovascular, and cancer mortality: A systematic review and dose-response meta-analysis of prospective cohort studies. Nutrition. 2023;111:112032. doi:10.1016/j.nut.2023.112032
  14. Huang Y, Chen Z, Chen B, et al. Dietary sugar consumption and health: umbrella review. BMJ. 2023;381:e071609. doi:10.1136/bmj-2022-071609
  15. Qin P, Li Q, Zhao Y, et al. Sugar and artificially sweetened beverages and risk of obesity, type 2 diabetes mellitus, hypertension, and all-cause mortality: a dose–response meta-analysis of prospective cohort studies. Eur J Epidemiol. 2020;35(7):655-671. doi:10.1007/s10654-020-00655-y
  16. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). European Heart Journal. 2020;41(1):111-188. doi:10.1093/eurheartj/ehz455
  17. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice: Developed by the Task Force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies With the special contribution of the European Association of Preventive Cardiology (EAPC). European Heart Journal. 2021;42(34):3227-3337. doi:10.1093/eurheartj/ehab484
  18. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678
  19. Gugliucci A. Sugar and Dyslipidemia: A Double-Hit, Perfect Storm. Journal of Clinical Medicine. 2023;12(17):5660. doi:10.3390/jcm12175660
  20. NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. Clinical guideline CG181. Published May 2023. Accessed September 29, 2023. https://www.nice.org.uk/guidance/cg181/chapter/Recommendations#lifestyle-changes-for-the-primary-and-secondary-prevention-of-cardiovascular-disease
  21. Veit M, van Asten R, Olie A, Prinz P. The role of dietary sugars, overweight, and obesity in type 2 diabetes mellitus: a narrative review. Eur J Clin Nutr. 2022;76(11):1497-1501. doi:10.1038/s41430-022-01114-5
  22. NHS. Sugar: the facts. NHS.UK. Published March 3, 2022. Accessed September 29, 2023. https://www.nhs.uk/live-well/eat-well/food-types/how-does-sugar-in-our-diet-affect-our-health/
  23. NatCen, NIHR BRC. National Diet and Nutrition Survey Rolling Programme Years 9 to 11 (2016/2017 to 2018/2019). Public Health England & FSA UK; 2020:29. https://www.gov.uk/government/statistics/ndns-results-from-years-9-to-11-2016-to-2017-and-2018-to-2019
  24. PHE. Calorie reduction: the scope and ambition for action. GOV.UK. Accessed September 28, 2023. https://www.gov.uk/government/publications/calorie-reduction-the-scope-and-ambition-for-action

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