WHO Sugar Guideline 2015: A summary for health professionals

In light of the recent public debate and the rise of anti-sugar advocates, the World Health Organisation (WHO) decided to revise their 2003 guideline on sugar intake. A draft was released in 2014 for comment and now has been revised as the final publication. So, how did they finish up with a sugar guideline and what does it relate to in practical terms?

While the main guideline didn’t change, WHO did retain a controversial ‘conditional recommendation’ to further reduce sugar intake by half - from 10 to 5%en. Read on for more ...

The final two recommendations from WHO

For sugar intake, the 2015 final WHO guideline states:

1.    WHO recommends reducing the intake of free sugars to less than 10 per cent of total energy intake (strong recommendation).

2.    WHO suggests a further reduction of the intake of free sugars to below 5 per cent of total energy intake (conditional recommendation).

The purpose of the guideline

The WHO publication suggests its recommendation be used by policy-makers to assess current intakes of free sugars and to guide public health interventions in decreasing consumption of free sugars.

Why the term ‘free sugars’?

Used by the 2002 WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases when updating the population nutrient intake goals, this term is not commonly used amongst dietitians as it adds a third dimension to the commonly-used (and easy to explain) distinctions of ‘added’ vs ‘natural’ sugars.

The WHO definition has been updated since 2002 though, and now includes fruit juice concentrates which are often added to many processed snack foods.

Specifically, it defines free sugars as “all monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates”.  Here's the direct link to the WHO Report.

Importantly, it does not include sugars naturally present in milk, fruit and vegetables because there is no reported evidence of adverse effects of consuming these sugars. However  those popular ‘sugar alternatives’ such as rice malt syrup and agave syrup still count as free sugars. Fruit juice is also sidelined, which is something dietitians have been recommending for years.

WHO released a draft late in 2014 (you can read Catherine’s summary here) but now they have published the final publication.

The evidence

The WHO Nutrition Guidance Expert Advisory Group (an international group of multidisciplinary experts), plus an external expert and stakeholder panel, reviewed evidence from randomized controlled trials, prospective cohort studies, non-randomised studies and observational studies in both adults and children.

More than 120 studies met the strict inclusion criteria, including over 260 000 participants from the studies looking at sugar and dental caries in children. They found the overall quality of available evidence on the effect of free sugars on excess weight gain and dental caries to be only ‘moderate’.

The strongest findings related to children: that “children with the highest intakes of sugar-sweetened beverages had a greater likelihood of being overweight or obese than children with the lowest intakes”, and that there were higher rates of dental caries in children with a level of free sugars intake >10% total energy (i.e. a positive association). This informed the main guideline.

A ‘conditional recommendation’

The second suggestion, of aiming for less than 5% total energy from free sugars, was based on (self-reported) low quality evidence from three national population studies around levels of dental caries development and per capita sugars intake.

Hence it is only a conditional recommendation, as there is less certainty around the effects of its implementation. The publication notes that “policy-making will require substantial debate and involvement of various stakeholders” before putting it into action. One has to wonder why it was included at all if the level of evidence was so poor?

So what does <10% total energy actually look like?

Unfortunately we don’t get a nice clean number of grams or teaspoons of free sugars to recommend the public limit their intake to. This will vary depending on energy intakes, leaving those with sedentary lifestyles with less room to move than, say, athletes or growing teenage boys.

But if we base it on the oft-used 8700kJ or 2080 Cals (the average Australian adult intake, cited on the back of many food products’ packaging), then 10% equates to 870kJ (or 208 Cal). That’s 54g or 13 teaspoons of free sugars (dividing by 4 grams of sugar per level teaspoon).

This figure of approx 50g or 12-13 teaspoons a day is what most dietitians have already been suggesting, so this WHO Guideline of 10% energy is not startlingly new.

Here’s how you could reach that goal of 13 teaspoons free sugars over a day:

Brown sugar on porridge oats        2 teaspoons
Muesli bar                                                   2 teaspoons
Tub of berry yoghurt                            3 teaspoons
Chocolate, 4 squares                           3 teaspoons
Ice cream, 1 scoop                                 3 teaspoons
TOTAL                                                        13 teaspoons

A labelling headache

Remember that Australian nutrition information panels list ALL ‘sugars’ (natural and added, free and intrinsic), meaning it’s hard to differentiate between types of sugars and add up the amount of free sugars consumed in a day.

Remind your clients to look at the ingredient list for clues as to the types of sugars that may be adding to the sugars total. This applies to foods which contains mixtures of sugars like dairy foods (fruit yoghurts, flavoured milks), fruit-based products like canned peaches or apple puree, breakfast cereals with dried fruit, muesli bars and similar bar snacks with dried fruit.

You can find the full publication here: http://who.int/nutrition/publications/guidelines/sugars_intake/en/

Reference for 2015 Guideline:
Guideline: Sugars intake for adults and children. Geneva: World Health Organization; 2015.

Thanks to APD Megan Cameron-Lee (BND) for research and the first draft.