Tolerable upper intake level for dietary sugars

Dominique Turck; Torsten Bohn; Jacqueline Castenmiller; Stefaan de Henauw; Karen Ildico Hirsch-Ernst; Helle Katrine Knutsen; Alexander Maciuk; Inge Mangelsdorf; Harry J. McArdle; Androniki Naska; Carmen Peláez; Kristina Pentieva; Alfonso Siani; Frank Thies; Sophia Tsabouri; Roger Adan; Pauline Emmett; Carlo Galli; Mathilde Kersting; Paula Moynihan; Luc Tappy; Laura Ciccolallo; Agnès de Sesmaisons-Lecarré; Lucia Fabiani; Zsuzsanna Horvath; Laura Martino; Irene Muñoz Guajardo; Silvia Valtueña Martínez; Marco Vinceti; EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA)

doi:10.2903/j.efsa.2022.7074

Tolerable upper intake level for dietary sugars

Dominique Turck, Torsten Bohn, Jacqueline Castenmiller, Stefaan de Henauw, Karen Ildico Hirsch-Ernst, Helle Katrine Knutsen, Alexander Maciuk, Inge Mangelsdorf, Harry J. McArdle, Androniki Naska, Carmen Peláez, Kristina Pentieva, Alfonso Siani, Frank Thies, Sophia Tsabouri, Roger Adan, Pauline Emmett, Carlo Galli, Mathilde Kersting, Paula MoynihanLuc Tappy, Laura Ciccolallo, Agnès de Sesmaisons-Lecarré, Lucia Fabiani, Zsuzsanna Horvath, Laura Martino, Irene Muñoz Guajardo, Silvia Valtueña Martínez, Marco Vinceti, EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA)

NutriHealth

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Abstract

Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50–75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15–50% probability) and very low for hypertension (0–15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

Original language	English
Article number	e07074
Journal	EFSA Journal
Volume	20
Issue number	2
DOIs	https://doi.org/10.2903/j.efsa.2022.7074
Publication status	Published - 28 Feb 2022

Keywords

added sugars
chronic metabolic diseases
dental caries
free sugars
pregnancy-related endpoints
safe level of intake
Tolerable upper intake level

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Turck, D., Bohn, T., Castenmiller, J., de Henauw, S., Hirsch-Ernst, K. I., Knutsen, H. K., Maciuk, A., Mangelsdorf, I., McArdle, H. J., Naska, A., Peláez, C., Pentieva, K., Siani, A., Thies, F., Tsabouri, S., Adan, R., Emmett, P., Galli, C., Kersting, M., ... EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) (2022). Tolerable upper intake level for dietary sugars. EFSA Journal, 20(2), Article e07074. https://doi.org/10.2903/j.efsa.2022.7074

@article{eef6f432cb434fc2ae7f96fcbaff7962,

title = "Tolerable upper intake level for dietary sugars",

abstract = "Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50–75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15–50% probability) and very low for hypertension (0–15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.",

keywords = "added sugars, chronic metabolic diseases, dental caries, free sugars, pregnancy-related endpoints, safe level of intake, Tolerable upper intake level",

author = "Dominique Turck and Torsten Bohn and Jacqueline Castenmiller and {de Henauw}, Stefaan and Hirsch-Ernst, {Karen Ildico} and Knutsen, {Helle Katrine} and Alexander Maciuk and Inge Mangelsdorf and McArdle, {Harry J.} and Androniki Naska and Carmen Pel{\'a}ez and Kristina Pentieva and Alfonso Siani and Frank Thies and Sophia Tsabouri and Roger Adan and Pauline Emmett and Carlo Galli and Mathilde Kersting and Paula Moynihan and Luc Tappy and Laura Ciccolallo and {de Sesmaisons-Lecarr{\'e}}, Agn{\`e}s and Lucia Fabiani and Zsuzsanna Horvath and Laura Martino and {Mu{\~n}oz Guajardo}, Irene and {Valtue{\~n}a Mart{\'i}nez}, Silvia and Marco Vinceti and {EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA)}",

note = "Funding Information: 100% FJs 100% fruit juices, with no added sugars 24‐h DR 24‐h dietary recall 24uSF Urinary sucrose and fructose in 24‐h urine samples Added sugars Mono‐ and disaccharides added to foods as ingredients during processing or preparation at home, and sugars eaten separately or added to foods at the table AGAHLS Amsterdam Growth and Health Longitudinal Study AI Adequate intake AIC Akaike Information Criteria ALSPAC Avon Longitudinal Study of Parents and Children ALSWH Australian Longitudinal Study on Women's Health AMP Adenosine monophosphate ANSES French Agency for Food, Environmental and Occupational Health & Safety AOAC Association of Official Analytical Chemists ARIC Atherosclerosis Risk in Communities Study ASBs Artificially sweetened beverages ASSDs Artificially sweetened drinks ATP Adenosine triphosphate AUC Area under the curve BF Body fat BIA Bioelectrical impedance analysis BMES Blue Mountain Eyes Study BMI Body mass index BoE Body of evidence BP Blood pressure BW Body weight BWHS Black Women's Health Study CARDIA Coronary Artery Risk Development in Young Adults CHD Coronary heart disease CI Confidence interval CoSCIS Copenhagen School Child Intervention Study CTS California Teachers Study CVD Cardiovascular disease Daily‐D Daily‐D Health Study DBP Diastolic blood pressure DCH Diet, Cancer and Health Study DDHP Detroit Dental Health Project DFS Decayed, filled surfaces DMFS Decayed, missing and filled tooth surfaces DMFT Decayed, missing and filled teeth DNL De novo lipogenesis DONALD Dortmund Nutritional and Anthropometric Longitudinally Designed Study DRI Dietary Reference Intake DRV Daily reference values E% Percent energy intake EC European Commission EFSA European Food Safety Authority EKE Expert Knowledge Elicitation ELEMENT Early Life Exposure in Mexico to Environmental Toxicants EPIC‐Diogenes European Prospective Investigation into Cancer and Nutrition‐Diet, Obesity and Genes project EPIC‐E3N European Prospective Investigation into Cancer and Nutrition‐French cohort EPIC‐InterAct European Prospective Investigation into Cancer and Nutrition‐InterAct project EPIC‐Morgen European Prospective Investigation into Cancer and Nutrition‐Morgen cohort EPIC‐Multicentre European Prospective Investigation into Cancer and Nutrition‐Multicentre EPIC‐Norfolk European Prospective Investigation into Cancer and Nutrition‐Norfolk cohort EPICOR European Prospective Investigation into Cancer and Nutrition‐Italian cohort EPIC‐Utrecht European Prospective Investigation into Cancer and Nutrition‐Utrecht cohort ESPGHAN European Society for Paediatric Gastroenterology Hepatology and Nutrition EU European Union FBDG Food‐based dietary guidelines FCD Food composition database FFQ Food frequency questionnaire FJ Fruit juice FMCHES Finnish Mobile Clinic Health Examination Survey Framingham‐3Gen Framingham third Generation cohort Framingham‐Offspring Framingham offspring's cohort Free sugars Added sugars plus sugars naturally present in honey, syrups, fruit juices and juice concentrates GDM Gestational diabetes mellitus GeliS Healthy living in pregnancy study Generation R Generation R Study GI Glycaemic index GL Glycaemic load GLP1 Glucagon‐like peptide‐1 GLUT4 Glucose transporter type 4 GUTS Growing Up Today Study GUTS II Growing Up Today Study II HBW High birth weight HDL High‐density lipoprotein HFCS High fructose corn syrup HHS U.S. Department of Health and Human Services HOMA Homeostatic model assessment HPFS Health Professionals Follow‐up study HPAEC‐PAD High Performance Anion‐Exchange Chromatography with Pulsed Amperometric Detection HPLC High Performance Liquid Chromatography HPP Harvard Pooling Project of Diet and Coronary Disease HR Hazard ratio HSS‐DK Healthy Start Study‐Denmark HSS‐USA Healthy Start Study‐USA HTN Hypertension IFS Iowa Fluoride Study IGT Impaired glucose tolerance IL6 Interleukin 6 Inter99 Inter99 study IoM Institute of Medicine IR Insulin resistance ISI Insulin sensitivity index IUGR Intrauterine growth retardation iv Intravenous IVGTT Intravenous glucose tolerance test IVITT Intravenous insulin tolerance test JPHC Japan Public Health centre‐based study Cohort KoCAS Korean Child–Adolescent cohort Study KoGES Korean Genome and Epidemiology Study LBW Low birth weight LDL Low‐density lipoprotein LF Liver fat LGA Large‐for‐gestational age Linking category Categories established based on the distribution of total sugar values within each FoodEx2 level in order to match the total sugar content from the EFSA Nutrient Composition Database with the foods reported in the EFSA Comprehensive European Food Consumption Database LoE Line of Evidence MDCS Malmo Diet Cancer Study MIT‐GDS Massachusetts Institute of Technology Growth and Development Study MoBa Norwegian Mother and Child Cohort Study MONICA Monitoring Trends and Determinants of Cardiovascular Disease MOVE MOVE project Mr and Ms OS Mr and Ms OS of Hong Kong MTC Mexican Teachers' Cohort Na /K ATPase Sodium–potassium adenosine triphosphatase NAFLD Non‐alcoholic fatty liver disease NASH Non‐alcoholic steatohepatitis PCC Prospective case‐cohort NDA Panel EFSA Panel on Nutrition, Novel Foods and Food Allergens NGHS National Lung, Heart and Blood Institute{\textquoteright}s Growth and Health Study NGT Normal glucose tolerance NHS Nurses{\textquoteright} Health Study NHS‐II Nurses{\textquoteright} Health Study‐II NIH‐AARP National Institutes of Health‐American Association for Retired Persons Diet and Health Study NK cells Natural killer cells NPAAS Nutrition and Physical Activity Assessment Study NSHDS Northern Sweden Health and Disease Study NTP National Toxicology Program OGTT Oral glucose tolerance test OHAT Office of Health Assessment and Translation OPEN Observing Protein and Energy Nutrition P/S Polyunsaturated/Saturated fat PCs Prospective cohort studies PHHP Pawtucket Heart Health Program PHI Planet Health Intervention ppm parts per million Project Viva Project Viva PROMETHEUS PROmoting METHods for Evidence Use in Scientific assessments PYY Peptide YY QUALITY Quebec Adipose and Lifestyle InvesTigation in Youth RCS Restricted cubic splines RCTs Randomised controlled trials REGARDS Reasons for Geographic and Racial Differences in Stroke study RI Reference intake RoB Risk of bias RR Relative risk SACN Scientific Advisory Committee on Nutrition SAT Subcutaneous adipose tissue SBP Systolic blood pressure SCES Sydney Childhood Eye Study SCF Scientific Committee on Food SCHS Singapore Chinese Health Study SD Standard deviation SE Standard error SES Social economic score SFFQ Semi‐quantitative food frequency questionnaire SGA Small‐for‐gestational age SGLT1 Sodium‐Glucose‐coTransporter 1 SLIVGTT Stable labelled intravenous glucose tolerance test sQ Subquestion SSBs Sugar sweetened beverages SSFDs Sugar sweetened fruit drinks SSFJs Sugar sweetened fruit juices SSSDs Sugar sweetened soft drinks STRIP Special Turku Coronary Risk Factor Intervention Project SUN Seguimiento Universidad de Navarra T2DM Type 2 diabetes mellitus Table sugar Sucrose TEI Total energy intake TFJ Total fruit juice TG Triglyceride TLGS Teheran Lipid and Glucose Study TNF‐α Tumour necrosis factor alpha Total sugars All mono‐ and disaccharides found in mixed diets i.e. glucose, fructose, sucrose, galactose, lactose, trehalose and maltose TRL Triglyceride rich lipoprotein UA Uncertainty analysis UK United Kingdom UL Tolerable Upper Level of Intake US United States USDA U.S. Department of Agriculture VA‐DLS Department of Veterans Affairs‐Dental Longitudinal Study VAT Visceral adipose tissue VLDL Very low‐density lipoprotein WAPCS Western Australia Pregnancy Cohort (Reine) Study WC Waist circumference WGHS Women{\textquoteright}s Genome Health Study WHI Women's Health Initiative WHO World Health Organisation WHS Women's Health Study + + Funding Information: The Panel wishes to thank the following EFSA staff members for the support provided to this scientific output: Mathias Amundsen, Davide Arcella, Ester Artau Cortacans, Elisa Aiassa, Andrea Ba?, Janusz Ciok, Ionut Craciun, Valeria Ercolano, Ana Garc?a, Andrea Germini, Federico Morreale and Charlotte Salgaard Nielsen. The Panel also wishes to thank Monty Duggal for the support provided to the Working Group on Sugars until May 2018, Jean-Louis Bresson, Barbara Burlingame, Tara Dean, Susan Fairwheather-Tait, Marina Heinonen, John Kearney, Monika Nauhaeuser-Berthold, Grazyna Nowicka, Yolanda Sanz, Anders Mikael Sj?din, Martin Stern, Daniel Tom?, Hendrik van Loveren and Peter Willatts as members of the 5th NDA Panel for their contribution to the protocol; Julia Wanselius for the development of the food composition databases on added and free sugars on behalf of the mandate requestor, the authors of published papers on dietary sugars who provided individual data or additional information upon request, the national institutions of European countries which answered the questionnaire specifically developed for this scientific opinion and to those that provided food consumption data for the Comprehensive European Food Consumption Database used in this opinion. Publisher Copyright: {\textcopyright} 2022 Wiley-VCH Verlag GmbH & Co. KgaA on behalf of the European Food Safety Authority.",

year = "2022",

month = feb,

day = "28",

doi = "10.2903/j.efsa.2022.7074",

language = "English",

volume = "20",

journal = "EFSA Journal",

issn = "1831-4732",

publisher = "Wiley-Blackwell Publishing Ltd",

number = "2",

}

Turck, D, Bohn, T, Castenmiller, J, de Henauw, S, Hirsch-Ernst, KI, Knutsen, HK, Maciuk, A, Mangelsdorf, I, McArdle, HJ, Naska, A, Peláez, C, Pentieva, K, Siani, A, Thies, F, Tsabouri, S, Adan, R, Emmett, P, Galli, C, Kersting, M, Moynihan, P, Tappy, L, Ciccolallo, L, de Sesmaisons-Lecarré, A, Fabiani, L, Horvath, Z, Martino, L, Muñoz Guajardo, I, Valtueña Martínez, S, Vinceti, M & EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) 2022, 'Tolerable upper intake level for dietary sugars', EFSA Journal, vol. 20, no. 2, e07074. https://doi.org/10.2903/j.efsa.2022.7074

TY - JOUR

T1 - Tolerable upper intake level for dietary sugars

AU - Turck, Dominique

AU - Bohn, Torsten

AU - Castenmiller, Jacqueline

AU - de Henauw, Stefaan

AU - Hirsch-Ernst, Karen Ildico

AU - Knutsen, Helle Katrine

AU - Maciuk, Alexander

AU - Mangelsdorf, Inge

AU - McArdle, Harry J.

AU - Naska, Androniki

AU - Peláez, Carmen

AU - Pentieva, Kristina

AU - Siani, Alfonso

AU - Thies, Frank

AU - Tsabouri, Sophia

AU - Adan, Roger

AU - Emmett, Pauline

AU - Galli, Carlo

AU - Kersting, Mathilde

AU - Moynihan, Paula

AU - Tappy, Luc

AU - Ciccolallo, Laura

AU - de Sesmaisons-Lecarré, Agnès

AU - Fabiani, Lucia

AU - Horvath, Zsuzsanna

AU - Martino, Laura

AU - Muñoz Guajardo, Irene

AU - Valtueña Martínez, Silvia

AU - Vinceti, Marco

AU - EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA)

N1 - Funding Information: 100% FJs 100% fruit juices, with no added sugars 24‐h DR 24‐h dietary recall 24uSF Urinary sucrose and fructose in 24‐h urine samples Added sugars Mono‐ and disaccharides added to foods as ingredients during processing or preparation at home, and sugars eaten separately or added to foods at the table AGAHLS Amsterdam Growth and Health Longitudinal Study AI Adequate intake AIC Akaike Information Criteria ALSPAC Avon Longitudinal Study of Parents and Children ALSWH Australian Longitudinal Study on Women's Health AMP Adenosine monophosphate ANSES French Agency for Food, Environmental and Occupational Health & Safety AOAC Association of Official Analytical Chemists ARIC Atherosclerosis Risk in Communities Study ASBs Artificially sweetened beverages ASSDs Artificially sweetened drinks ATP Adenosine triphosphate AUC Area under the curve BF Body fat BIA Bioelectrical impedance analysis BMES Blue Mountain Eyes Study BMI Body mass index BoE Body of evidence BP Blood pressure BW Body weight BWHS Black Women's Health Study CARDIA Coronary Artery Risk Development in Young Adults CHD Coronary heart disease CI Confidence interval CoSCIS Copenhagen School Child Intervention Study CTS California Teachers Study CVD Cardiovascular disease Daily‐D Daily‐D Health Study DBP Diastolic blood pressure DCH Diet, Cancer and Health Study DDHP Detroit Dental Health Project DFS Decayed, filled surfaces DMFS Decayed, missing and filled tooth surfaces DMFT Decayed, missing and filled teeth DNL De novo lipogenesis DONALD Dortmund Nutritional and Anthropometric Longitudinally Designed Study DRI Dietary Reference Intake DRV Daily reference values E% Percent energy intake EC European Commission EFSA European Food Safety Authority EKE Expert Knowledge Elicitation ELEMENT Early Life Exposure in Mexico to Environmental Toxicants EPIC‐Diogenes European Prospective Investigation into Cancer and Nutrition‐Diet, Obesity and Genes project EPIC‐E3N European Prospective Investigation into Cancer and Nutrition‐French cohort EPIC‐InterAct European Prospective Investigation into Cancer and Nutrition‐InterAct project EPIC‐Morgen European Prospective Investigation into Cancer and Nutrition‐Morgen cohort EPIC‐Multicentre European Prospective Investigation into Cancer and Nutrition‐Multicentre EPIC‐Norfolk European Prospective Investigation into Cancer and Nutrition‐Norfolk cohort EPICOR European Prospective Investigation into Cancer and Nutrition‐Italian cohort EPIC‐Utrecht European Prospective Investigation into Cancer and Nutrition‐Utrecht cohort ESPGHAN European Society for Paediatric Gastroenterology Hepatology and Nutrition EU European Union FBDG Food‐based dietary guidelines FCD Food composition database FFQ Food frequency questionnaire FJ Fruit juice FMCHES Finnish Mobile Clinic Health Examination Survey Framingham‐3Gen Framingham third Generation cohort Framingham‐Offspring Framingham offspring's cohort Free sugars Added sugars plus sugars naturally present in honey, syrups, fruit juices and juice concentrates GDM Gestational diabetes mellitus GeliS Healthy living in pregnancy study Generation R Generation R Study GI Glycaemic index GL Glycaemic load GLP1 Glucagon‐like peptide‐1 GLUT4 Glucose transporter type 4 GUTS Growing Up Today Study GUTS II Growing Up Today Study II HBW High birth weight HDL High‐density lipoprotein HFCS High fructose corn syrup HHS U.S. Department of Health and Human Services HOMA Homeostatic model assessment HPFS Health Professionals Follow‐up study HPAEC‐PAD High Performance Anion‐Exchange Chromatography with Pulsed Amperometric Detection HPLC High Performance Liquid Chromatography HPP Harvard Pooling Project of Diet and Coronary Disease HR Hazard ratio HSS‐DK Healthy Start Study‐Denmark HSS‐USA Healthy Start Study‐USA HTN Hypertension IFS Iowa Fluoride Study IGT Impaired glucose tolerance IL6 Interleukin 6 Inter99 Inter99 study IoM Institute of Medicine IR Insulin resistance ISI Insulin sensitivity index IUGR Intrauterine growth retardation iv Intravenous IVGTT Intravenous glucose tolerance test IVITT Intravenous insulin tolerance test JPHC Japan Public Health centre‐based study Cohort KoCAS Korean Child–Adolescent cohort Study KoGES Korean Genome and Epidemiology Study LBW Low birth weight LDL Low‐density lipoprotein LF Liver fat LGA Large‐for‐gestational age Linking category Categories established based on the distribution of total sugar values within each FoodEx2 level in order to match the total sugar content from the EFSA Nutrient Composition Database with the foods reported in the EFSA Comprehensive European Food Consumption Database LoE Line of Evidence MDCS Malmo Diet Cancer Study MIT‐GDS Massachusetts Institute of Technology Growth and Development Study MoBa Norwegian Mother and Child Cohort Study MONICA Monitoring Trends and Determinants of Cardiovascular Disease MOVE MOVE project Mr and Ms OS Mr and Ms OS of Hong Kong MTC Mexican Teachers' Cohort Na /K ATPase Sodium–potassium adenosine triphosphatase NAFLD Non‐alcoholic fatty liver disease NASH Non‐alcoholic steatohepatitis PCC Prospective case‐cohort NDA Panel EFSA Panel on Nutrition, Novel Foods and Food Allergens NGHS National Lung, Heart and Blood Institute’s Growth and Health Study NGT Normal glucose tolerance NHS Nurses’ Health Study NHS‐II Nurses’ Health Study‐II NIH‐AARP National Institutes of Health‐American Association for Retired Persons Diet and Health Study NK cells Natural killer cells NPAAS Nutrition and Physical Activity Assessment Study NSHDS Northern Sweden Health and Disease Study NTP National Toxicology Program OGTT Oral glucose tolerance test OHAT Office of Health Assessment and Translation OPEN Observing Protein and Energy Nutrition P/S Polyunsaturated/Saturated fat PCs Prospective cohort studies PHHP Pawtucket Heart Health Program PHI Planet Health Intervention ppm parts per million Project Viva Project Viva PROMETHEUS PROmoting METHods for Evidence Use in Scientific assessments PYY Peptide YY QUALITY Quebec Adipose and Lifestyle InvesTigation in Youth RCS Restricted cubic splines RCTs Randomised controlled trials REGARDS Reasons for Geographic and Racial Differences in Stroke study RI Reference intake RoB Risk of bias RR Relative risk SACN Scientific Advisory Committee on Nutrition SAT Subcutaneous adipose tissue SBP Systolic blood pressure SCES Sydney Childhood Eye Study SCF Scientific Committee on Food SCHS Singapore Chinese Health Study SD Standard deviation SE Standard error SES Social economic score SFFQ Semi‐quantitative food frequency questionnaire SGA Small‐for‐gestational age SGLT1 Sodium‐Glucose‐coTransporter 1 SLIVGTT Stable labelled intravenous glucose tolerance test sQ Subquestion SSBs Sugar sweetened beverages SSFDs Sugar sweetened fruit drinks SSFJs Sugar sweetened fruit juices SSSDs Sugar sweetened soft drinks STRIP Special Turku Coronary Risk Factor Intervention Project SUN Seguimiento Universidad de Navarra T2DM Type 2 diabetes mellitus Table sugar Sucrose TEI Total energy intake TFJ Total fruit juice TG Triglyceride TLGS Teheran Lipid and Glucose Study TNF‐α Tumour necrosis factor alpha Total sugars All mono‐ and disaccharides found in mixed diets i.e. glucose, fructose, sucrose, galactose, lactose, trehalose and maltose TRL Triglyceride rich lipoprotein UA Uncertainty analysis UK United Kingdom UL Tolerable Upper Level of Intake US United States USDA U.S. Department of Agriculture VA‐DLS Department of Veterans Affairs‐Dental Longitudinal Study VAT Visceral adipose tissue VLDL Very low‐density lipoprotein WAPCS Western Australia Pregnancy Cohort (Reine) Study WC Waist circumference WGHS Women’s Genome Health Study WHI Women's Health Initiative WHO World Health Organisation WHS Women's Health Study + + Funding Information: The Panel wishes to thank the following EFSA staff members for the support provided to this scientific output: Mathias Amundsen, Davide Arcella, Ester Artau Cortacans, Elisa Aiassa, Andrea Ba?, Janusz Ciok, Ionut Craciun, Valeria Ercolano, Ana Garc?a, Andrea Germini, Federico Morreale and Charlotte Salgaard Nielsen. The Panel also wishes to thank Monty Duggal for the support provided to the Working Group on Sugars until May 2018, Jean-Louis Bresson, Barbara Burlingame, Tara Dean, Susan Fairwheather-Tait, Marina Heinonen, John Kearney, Monika Nauhaeuser-Berthold, Grazyna Nowicka, Yolanda Sanz, Anders Mikael Sj?din, Martin Stern, Daniel Tom?, Hendrik van Loveren and Peter Willatts as members of the 5th NDA Panel for their contribution to the protocol; Julia Wanselius for the development of the food composition databases on added and free sugars on behalf of the mandate requestor, the authors of published papers on dietary sugars who provided individual data or additional information upon request, the national institutions of European countries which answered the questionnaire specifically developed for this scientific opinion and to those that provided food consumption data for the Comprehensive European Food Consumption Database used in this opinion. Publisher Copyright: © 2022 Wiley-VCH Verlag GmbH & Co. KgaA on behalf of the European Food Safety Authority.

PY - 2022/2/28

Y1 - 2022/2/28

N2 - Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50–75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15–50% probability) and very low for hypertension (0–15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

AB - Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50–75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15–50% probability) and very low for hypertension (0–15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

KW - added sugars

KW - chronic metabolic diseases

KW - dental caries

KW - free sugars

KW - pregnancy-related endpoints

KW - safe level of intake

KW - Tolerable upper intake level

UR - http://www.scopus.com/inward/record.url?scp=85125341565&partnerID=8YFLogxK

UR - https://pubmed.ncbi.nlm.nih.gov/35251356

U2 - 10.2903/j.efsa.2022.7074

DO - 10.2903/j.efsa.2022.7074

M3 - Article

C2 - 35251356

AN - SCOPUS:85125341565

SN - 1831-4732

VL - 20

JO - EFSA Journal

JF - EFSA Journal

IS - 2

M1 - e07074

ER -

Tolerable upper intake level for dietary sugars

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