DID YOU KNOW...Sugar Sweetened Beverages: should we be limiting their consumption?

Prepared by John. A. Sawdon M.Sc. Public Education & Special Projects Director,
Cardiac Health Foundation of Canada, January 2020

In January 2019 the Government of Canada changed its Food Guide to reflect Health Canada guidelines and considerations for healthy eating. Within this Food Guide the recommendation for beverages was to drink water and reduce or eliminate sugar sweetened beverages.

This recommendation came from a review of the scientific literature and the association between added sugars and chronic disease in addition to dental decay. There is ample evidence that sugar sweetened beverages have contributed to an increased risk of weight gain, being overweight and obesity. Obesity is a risk factor for type 2 diabetes, some forms of cancer and cardiovascular disease. In addition free sugars which are found in 100% fruit juice have been associated with dental decay. (1)

Sugary drinks can include:
“Iced tea; fruit juice; soft drinks; sports drinks; energy drinks; alcoholic beverages; fruit flavoured drinks and punches; sweetened plant-based beverages; flavoured waters with added sugars; sweetened milks like chocolate milk,; sweetened hot or cold tea, coffee, hot chocolate, and other specialty drinks; 100% fruit juice; flavoured plant based beverages”(2)

Granulated Sugar Nutrition Facts

White table sugar and brown sugar are the recognizable forms of granulated sugar. The United States Drug Authority indicates that one teaspoon(4g) of granulated sugar contains: 16 Calories, 0 grams of Fat, 0mg of Sodium, 4.2grams of Carbohydrates, 0 grams of Fiber, 4.2grams of Sugar, 0 grams of Protein. One teaspoon of sugar contains 16 calories from about 4 grams of simple carbohydrates. Sugar has no nutritional value with empty calories. Sugar is often used to add sweetness, colour (brown) and texture. In controlling sugar intake it is important to both know what ingredients are sugar and to know what is the amount of sugar that is considered ok within acceptable guidelines.(3)

Should I choose Beet Sugar or Cane Sugar, which is better?

Irrespective of what you buy―beet or cane sugar―it is refined white sugar (sucrose). It is a known fact that white sugar is not that nutritious. So, though sugar cane and sugar beet are good sources of vitamins, minerals, and phytonutrients, their extracted product (sugar) has 4.2 g of carbs that's just 1% in a teaspoon of sugar with a whopping 16 calories, thanks to the refining process. The refined sugar is a simple carbohydrate that rapidly turns into glucose to cause insulin spikes. No wonder, excess of sugar intake has been linked to weight gain, obesity, diabetes, and cardiovascular problems.

On the whole, both beet sugar and cane sugar are nutritional failures due to the refining process, and as such, there is nothing healthy about this calorie-laden food. So eating sugar in moderation should be your top priority and is also the key to healthy eating. (4)

The Problem with Sugar Sweetened Beverages

There are 4.2 grams of sugar in a single teaspoon. A typical 12 ounce can of soda contains between 7 to 10 teaspoons of sugar which means there are between 29.4 grams and 42 grams of sugar in each can. The average can of sugar sweetened soda or fruit punch provides 150 calories, almost all because of added sugar. By drinking one can a day and not cutting back these calories elsewhere, you gain 5 lbs a year. In addition to weight gain, routine drinking of these beverages places you at risk for type 2 diabetes, heart disease and other chronic diseases. (5) The portion sizes of soft drinks have also increased over the years. A 32 ounce which is a standard large size drink has 374 calories and 102 grams of added sugar. Before the 1950’s a soft drink bottle was 6.5 ounces, this increased in the 50’s to a 12 ounce can. In the 1990’s a 20 ounce plastic bottle was introduced and today we have 1 litre bottle with a large drink being as high as 40 ounces. (6) Individuals who drink sugary drinks do not feel as full as they do if they eat the same number of calories from solid food. This leads to excess calorie intake.

In 2015 Canadians consumed most of their diets total sugars through sugar sweetened beverages, sugars, syrups, preserves, confectionaries, desserts and bakery products. In Canada, about one quarter of those 5 to 19 years of age report daily consumption of sugary drinks. Research shows that sugar sweetened beverages including soda, energy and sport drinks are the top calorie source for those aged 12 to 50 years. Boy’s average daily consumption is 68 grams at ages 4 to 8 years and increases to 376 grams between 14 and 18 years of age. Girls consume less, from 47 grams to 179 grams daily. Canadian consumption is 162 litres a year which works out to 444ml a day. This exceeds the daily recommended intake by Heart & Stroke, The World Health Organization and Diabetes Canada. (7)(8).

The American Heart Association, the American Academy of Pediatrics recommend that children 2years and older consume less than 25 grams (6.25teaspoons) of added sugars per day and no more than 8 oz of sugary drinks per week. Added sugars should not be in the habitual diet of children under 2years. In the United States children and adolescents consume 17% of their calories from added sugars, nearly half of which come from sugary drinks. Many of these high consumers of sugar sweetened beverages are adolescent boys who consume 278kcal per day. (Canada does not have a guideline specific to total or added sugars intake as part of a healthy diet.)

Currently the World Health Organization Guidelines for Adults and Children presents two strong recommendations and one conditional recommendation on free sugar intake. In both adults and children, WHO recommends reducing intake of free sugars to less than 10% of total energy intake based on moderate quality evidence from observational studies related to dental carries. WHO recommends a reduced intake of free sugars throughout the life course. WHO conditionally recommends furthering limiting free sugars intake to less than 5% of total calories.

In 2019 the Healthy Eating Research, a national program of the Robert Wood Johnson Foundation convened an expert panel representing 4 leading Health & Nutrition organizations, the American Academy of Pediatrics (AAP), American Heart Association(AHA), Academy of Nutrition & Dietetics and American Academy of Pediatric Dentistry to develop evidence based recommendations for beverage consumption by children from Birth to age 5. An earlier Healthy Eating Research panel made recommendations for up to 18 years as follows: (9)

Recommended Consumption of Sugar Sweetened Beverages:
Type of drink Young children
(6 Years)
1 to Children years 7-13 Adolescents
(14-18 years)
Sugary drinks: All drinks that contain any type of added sugars (e.g., fruit drinks, soda, sweetened teas, flavoured waters, sports drinks, energy drinks, flavoured milk, toddler milk) Do not consume
(6 Years)
Do not consume Do not consume
Drinks with low-calorie sweeteners: All drinks that contain non-nutritive sweeteners (also known zero-calorie, non-caloric, or diet sweeteners) including sucralose, acelsufame potassium, and stevia Do not consume Do not consume Lower-calorie drinks (≤ 40 kcal per container) may be appropriate to help prevent excess weight gain
100% juice, including 100% juice combined with water 12-36 months: No more than 4 oz/day;
3-6 years: No more than 6 oz/day
No more than 8 oz/day No more than 8 oz/day
Plain milk: Recommended types 12-24 months: Unflavoured whole milk;
2-6 years: Unflavoured low-fat and non-fat milk
Unflavoured low-fat and non-fat milk and soy beverages Unflavoured low-fat and non-fat milk and soy beverages
Plain water, without sweeteners (including added sugars or low-calorie) Recommended for thirst Recommended for thirst Recommended for thirst

In Canada the Heart & Stroke Association, Diabetes Canada among others have called upon the Government of Canada to limit advertising of sugar sweetened beverages to children and adolescents. With every sugary drink a child consumes on a daily basis raises the risk of obesity by 60%. Obesity is an epidemic in North America with 62% of adults and 32% of children and youth between 6 to 17 years in Canada being overweight or obese. Although a 2016 Standing Senate committee report on obesity in Canada called upon the Federal Government to consider a levey on sugary drinks, this has not yet been passed by parliament. The Liberal government also appears to have dismissed this idea druing their recent campaign as announced the Minister of Health Ginette Petitpas Taylor in the runup to the federal election.(10 )

Strategies that seem to Work in Reducing Consumption of Sugar Sweetened Beverages

Initiatives and strategies that seek to reduce both availability of and consumption of sugar sweetened beverages have been gaining significant traction over the last few years. Much of this is aimed at reducing the obesity epidemic and the healthcare costs that are impacted through consumption. In 2018 a Cochrane Library review (11) was conducted that looked at strategies that were effective in reducing consumption of sugar sweetened beverages. This review analyzed 58 studies resulting in a reinforcement of strategies that limit access to sugar sweetened drinks. This limiting of access includes sale tax imposed on drinks, a manufacturers levy on sugary drinks, the banning of sugar sweetened drinks from both workplaces and schools. In general municipalities that levied sales taxes saw consumption fall. In schools water and milk became the beverages of choice. Currently there is a concerted effort by about 30 large Health organizations in the United States (12) that includes University of Michigan Health System and the Cleveland Clinic who have stopped selling sugary drinks on their premises. In Mexico a one peso per ounce tax that was imposed on sugar sweetened drinks saw a 12% decrease in purchased taxed beverages. On October 28, 2019 a study published in JAMA Intern Med reported on a before and after randomized trial conducted from July 28th 2015 to October 16 2016 at a northern California University and Hospital. The employer stopped selling sugar sweetened beverages in all workplace venues. A total of 214 English speaking employees were recruited who consumed at least 12 ounces per day (360mL) of sugar sweetened beverages before the ban. All of the 214 completed an intake including anthropometrics and cardio-metabolic biomarkers. Half of the group were given a brief motivational intervention that promoted health information and goal setting. The results saw a total decrease of 25.4 fl oz in the consumption of sugar sweetened beverages by those receiving the brief motivation and follow up telephone calls compared to 8.2 fl oz decreases by those who did not receive the intervention. Both groups had reduction in abdominal fat, including waist sizes, which shrank 2.1 centimeters. Dr. Epel a central investigator indicated that sugar intake is strongly linked to belly fat. The study found that overweight people who were assigned to the motivational sessions made the biggest improvements. (13)

In Canada, The University of British Columbia signed on to the Okanagan Charter: An International Charter for Health Promoting Universities and Colleges. In 2017 this led to adoption of a UBC action framework for a Nutritionally Sound Campus. (14)This was also partly in response to a Public Health Agency of Canada 2016 report in which it found youth and young adults report the highest intake of sugar sweetened beverages in the Canadian population. The initiative here is to conduct a research project into change including a questionnaire on perceptions of sugar sweetened beverages. The action plans include providing healthy alternatives to sugar sweetened beverages, in all food outlets and vending machines, install more complimentary water stations throughout the campus and investigating quality drinking water in campus residences. The goal is to reduce consumption via working collaboratively with the campus population.

Conclusion:

Health Canada, Heart & Stroke and Diabetes Canada among others have called for a concerted strategy to reduce and eliminate sugar sweetened beverages in Canada. This includes replacing sugar sweetened beverages with water as the beverage of choice and reducing advertising aimed at children and adolescents. It also calls for a manufacturer’s tax on sugar sweetened beverages, the elimination of sugar sweetened drinks at sporting and recreation events and a commitment by employers to eliminating access in the workplace of sugar sweetened beverages.

The linkage between obesity and sugar is clear. It is also clear that obesity is linked to chronic disease and ultimately increased healthcare costs. In starting this article I posed the question “should we limit access to Sugar Sweetened Beverages?” The answer is clear, if our children and adolescents are sacred in our lives, our families and our societies then we need to support the Canada Food Guide, Heart & Stroke and Diabetes Canada by taking steps to reduce and or eliminate consumption of sugar sweetened beverages.

References:

  1. Canada’s Dietary Guidelines, Canada.ca/Foodguide @Her majesty the queen in Right of Canada, as represented by the Minister of Health 2019; cat:H164-231/2019E-ADF; ISBN:978-0-660-25310-7
  2. Government of Canada; Sugars-Canada.ca 1/21/2020; https://www.canada.ca/en.health-canada/services/nutritients/sugars.html
  3. Lehman, Shereen MS, Fogoros Richard N. MD “Granulated Sugar Nutrition Facts” “Calories, Carbs, and Health Benefits of Granulated Sugar; VerywellFit https://www.verywellfit.com/granulated-sugar-nutrition-facts-calories-and-health-benefits-4119871?print
  4. Canadian Sugar Institute Dietary Guidelines on Sugars; https://sugar.ca/Sugars-Consumption-and-Dietary-Guidelines/Dietary-Guidelines-on-SUgars.aspx
  5. Harris, Jennifer L PhD, MBA; Romo-Palafox, Maria PhD,RD; Choi,Yoon-Young MS; Kibwana Ahmad; “Children’s Drink FACTS 2019 /Sales, Nutrition, and Marketing of Children’s Drinks ; UConn Rudd Center for Food Policy & Obesity October 2019
  6. Liquid Candy: Working Together to Reduce Consumption of Sugary Drinks; Heart & Stroke; https://www.heartandstroke.ca/-/media/pdf-files/canada/position-statement/liquidcandy-factsheet-en.ashx?la=en&hash=E21D8E5A8708FD82915931DEC2C768
  7. Canadian Sugar Institute Dietary Guidelines on Sugars; https://sugar.ca/Sugars-Consumption-and-Dietary-Guidelines/Dietary-Guidelines-on-SUgars.aspx
  8. Diabetes Canada; Sugar and Diabetes; https://www.diabetes.ca/advocacy-policies/our-policy-positions/sugar-diabetes.
  9. Harris, Jennifer L PhD, MBA; Romo-Palafox, Maria PhD,RD; Choi,Yoon-Young MS; Kibwana Ahmad; “Children’s Drink FACTS 2019 /Sales, Nutrition, and Marketing of Children’s Drinks ; UConn Rudd Center for Food Policy & Obesity October 2019
  10. Zimonjic Peter, Simpson Katie CBC News May 28th 2019 “ No tax on Sugary Drinks in Federal Liberal platform, says health minister
  11. Cutting back on sugar-sweetened beverages: What works?/Cochrane; von Philipsborn P, Strail JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, HaunerH, Rehfuess E, “Environmental Interventions to reduce the consumption of sugar-sweetened beverages and their effects on health. Cochrane Database of Systematic Reviews 2019, issue6, Art.No.:CD012292.DOI:10.1002/14651858.CD012292.pub2
  12. O’Connor Anahad; Sugary Drink Ban Tied to Health Improvements at Medical Center, The New York Times; https://nyti.ms/2Pnn50m
  13. Alford Morgan BSc Voice 4 Co-researcher, UBC Sustainability Scholar 2018’ Research to Support the Development of a Healthy Beverage Initiative at UBC Okanagan
  14. Baker Melissa, Dolf Matt, Wellbeing Food and Nutrition Working Group; UBC Wellbeing, the University of British Columbia, A Healthy Beverage Initiative at UBC , http://www.jneb.org/article/S1499-4046(14)00575-2/pdf

The articles, on the Cardiac Health Foundation of Canada website, are presented with the understanding that the Foundation is providing information only and not rendering medical advice. Please check with your family physician, specialist or health care professional before implementing any of the ideas expressed in these articles.