Is my kid getting too much sugar?

The World Health Organization (WHO) recommends limiting free sugars to less than 10% of total energy intake for children and adults. Let me summarize the evidence that the WHO used to make this recommendation.

Why do they make this recommendation?

The concern is that free sugar intake is associated with higher body weights and tooth decay (cavities).

What are free sugars?

Free sugars are sugars that are added to foods or drinks during processing or cooking. Additionally, they also include sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Free sugars do not include sugars found naturally in whole, unprocessed fruits.

Is there a clear link between weight and sugar intake?

There was no association between advice to reduce intake of dietary sugars and change in weight in kids (measured by standardized body mass index (BMI) or BMI z score (0.09; 95% CI: –0.14, 0.32).

An analysis of five studies that followed children over longer periods of time (1 year or more), found that kids who drank 1 or more sugar-sweetened beverages every day had a greater likelihood of being overweight or obese compared to kids who drank less than 1 sugar sweetened beverage every day (odds ratio [OR] 1.55; 95% CI: 1.32, 1.82).

The WHO concluded that in children, the quality of evidence for an association between a reduction in free sugars intake and reduced body weight was considered to be moderate. The quality of the evidence for an association between an increase in free sugars intake and increased body weight was considered to be low.

WHO Guideline: Sugars Intake for Adults and Children, page 13

Is there a clear link between cavities and sugar intake?

All studies reported higher levels of dental caries (cavities) when the amount of free sugars intake was more than 10% of total energy intake compared with it being less than 10% of total energy intake. The quality of the evidence was considered to be moderate.

My two-cents on what this evidence means and why

Despite the recommendation to limit sugar intake, the evidence that backs this recommendation is only considered low or moderate. Part of this is likely related to the fact that things like body weight or oral health are multifactorial.

For example, when it comes to diet, if a child consumes 11% of their energy intake from sugars but otherwise has a healthy diet and is active, it doesn’t necessarily mean that this child will be heavier than a similar child who consumes 9% of their energy from sugar intake.

I often use the term “Line in the Sand” when I am talking with clients. By this I mean that limit is somewhat flexible and that it shifts depending on what is right for that person at that moment. The other thing about nutrition is that the body “works in averages” which means that if some days your kid eats 15% of their energy from sugar and the next day they only eat 5% of their energy from sugar – the end result is the same as two days back to back at 10%.

With regards to oral health, while sugar might increase the risk, things like teeth brushing, flossing, the microbiome of the mouth likely all have a part to play in the development of cavities. This means that sugar intake alone is likely not the be-all, end-all when it comes to predicting a child’s risk of cavities.

What dose less than 10% of energy intake from free sugars mean?

The recommendations for energy intake in kids will depend on how much a child weights, how tall they are and how active they are. But here are some example of some different energy intake estimates and what 10% of that energy from sugar could look like for children of different ages.

How many grams of sugar are in different foods that my children eat?

Using the nutrition facts table and scanning down to the Sugars allows us to see how much sugar is in a product. In these examples of a 355mL can of pop or a 200mL juice box there are 45g and 9g.

The sugar in these products would be considered 100% free sugar.

But the amount of sugar listed in the nutrition facts table is the TOTAL sugar – so it includes both the natural occurring and the added “free sugar” that might in a product.

It can be confusing to figure out what is free vs naturally occurring sugars.

In these two products – plain yogurt and unsweetened applesauce. Both products contain some naturally occurring sugars that wouldn’t count. But because the unsweetened apple sauce has fruit juice concentrate, at least a portion of the sugar reported on this label would count as free sugar.

The clues that can help you determine if the sugar listed on the label is natural vs free sugar are:

• Ingredient list – are sugars added as an ingredient? In the case of yogurt there is no sugar added so you know that all the sugar in this product is naturally occurring sugar. For the applesauce, the “Concentrated black carrot and blueberry juice” would count as added sugar.
• The order of the ingredient list – Ingredient lists are ordered by weight, which means that the heaviest components appear first and the lightest components appear last. In the case of the apple sauce, apples occur first and would contribute natural occurring sugars. Later down in the list in the concentrated fruit juice. If the concentrated juice occurred before the apples then you could conclude that the majority of the sugar is free vs naturally-occurring.

So what?

Well, some studies reports that higher sugar intake is linked to higher body weights and an increased risk of dental carries in children, but other studies have found that higher sugar intake isn’t linked to higher body weights or dental carries. So we really don’t know for sure.

While the scientific community tries to figure this out, what can you do as a parent?

1. Teach kids how to include sugar as part of a healthy diet by doing things like Candy Friday to help them learn how to enjoy sweets on occasion.
2. Limit sugar sweetened beverages (like juice or pop) to less than one a day.
3. Read food labels and look for products that are high in added sugars. Consider these treat foods and budget for the accordingly in your kids meal environments.