Intake of Free Sugars and Main Food Category Contributors among French Children, Adolescents and Adults

Abstract

A high intake of free sugars (FS) is assumed to be associated with overweight and obesity as well as type 2 diabetes mellitus and cardiovascular diseases. Therefore, the World Health Organization (WHO) recommends an intake of FS of less than 10% of daily total energy intake (TEI). The purpose of this study was to update the FS intake data for the French population, including children and adolescents as well as adults, based on the 2019 French Food Behavior and Consumption survey (CCAF). FS intakes were assessed at 67 g/day (15.3% of TEI) in children and adolescents as well as 57 g/day (10.5% of TEI) in adults. The main FS contributors were cakes/pastries, sugary drinks and fruit juices in children as well as sugary products, cakes/pastries and fruit juices in adults. The contribution of FS intakes to TEI fell with age, from 15.6% of TEI in 3–6 years children to around 8–9% for adults older than 50 years. On average, children were above the WHO recommendation of FS intake, but adults were close to or even below the threshold of 10% TEI. These observations are of great importance to prospective public health activities focusing on changes in FS intakes.

1. Introduction

High intakes of dietary sugars and/or sugary drinks have been assumed to be associated with a higher risk of dental caries [1], overweight [2,3] and chronic illnesses such as type 2 diabetes mellitus and cardiovascular diseases [4,5]. However, besides dental caries, isocaloric studies confirmed that these associations with metabolic diseases are rather due to energy intake than dietary sugars as such, which was demonstrated in various systematic reviews and meta-analyses [2,4]. Furthermore, two recently published observational studies in European children and adolescents showed that neither the intake of total sugars nor free sugars (FS) is associated with body weight gain [6,7].

However, it has to be mentioned that the intake of sugar-sweetened beverages (SSBs) can promote weight gain in children and adults [3], an effect that is mediated by the less pronounced effect of satiety of SSBs (compared to solid foods that contain the same amount of calories), which can result in increased total energy intake and a resulting promotion of body weight gain [8]. This physiological mechanism is known for all energy-containing beverages.

In 1989, the World Health Organization (WHO) drew up dietary sugars intake recommendations focusing specifically on “free sugars” [9]. The limit was set at 10% of total energy intake (TEI) to prevent dental caries as well as obesity, type 2 diabetes and cardiovascular diseases. This 10% limit of TEI was clarified in 2002 with a definition of “free sugars” as sugars “added to foods and drinks by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices” [10]. In 2015, WHO restated the limit of FS intake at 10% of TEI and proposed a further reduction to less than 5% of TEI, as a “conditional” recommendation based on a low level of evidence on the risks of dental caries [11].

Data on dietary sugar intakes have been published for various countries in Europe, among them Spain [12], the United Kingdom [13], the Netherlands [14], Switzerland [15] and Greece [16,17], or outside of Europe, e.g., Australia [18]. A very recently published review recorded only 27 surveys worldwide that provide an estimate for FS intakes [19]. This review points out that more data (both in terms of quantity and harmonization) are required to give a complete picture of dietary sugar intakes, and that despite the development of protocols to estimate added/free sugars composition, detailed food composition data are necessary.

Data for France are available for the 2006–2007 period from the National Individual Food Consumption study 2 (INCA2) [20,21] and 2016 from the Food Behavior and Consumption survey in France (CCAF) [22]. The purpose of this study is to update FS intakes in France based on the 2019 CCAF and to compare them with the data from different European Countries.

2. Materials and Methods

2.1. Study Sample

The CCAF survey is conducted periodically (every 3 or 4 years) by CREDOC Institute on a representative sample of the French population. The CCAF survey method has been published previously [23]. The 2019 wave of the CCAF survey took place between November 2018 and August 2019 on representative national samples. The survey included an initial sample of 1845 adults aged 18 years and older as well as a second sample of 1102 children and adolescents aged 3 to 17 years. Age, socio-economic status (based on occupation of head of household as classified by the National Institute of Statistics), geographical region, town size and household size were taken into consideration in the quota sampling method.

2.2. Nutritional Assessment

Food intake data of participants were compiled using a seven-day food log, in which participants indicated all the different food and drink products consumed along with the amounts ingested during main meals and between meals at and away from home.

The energy intake reported by the participants was compared with the estimated energy requirements (at least 1.55 times the metabolic rate), according to Schofield’s equation [24]. Adults were considered underreporters and excluded if their reported energy intake was lower than the estimated energy requirements. Children were considered underreporters and excluded if their total energy intake divided by their estimated basal metabolic rate was lower than 0.5.

The nutritional compositions of foods and drinks were taken from the ANSES CIQUAL table updated in 2020 [25].

Thirty-four food and drink groups were considered to cover all food: meat, poultry and offal, fats, alcoholic drinks, hot drinks, juices and soft-drinks, breakfast cereals, deli meats, compotes and fruit in syrup, sauces and condiments, waters, dairy desserts, cheeses, fruit, dried fruit, savory biscuits, seeds, unprocessed milk, vegetables, dried vegetables, eggs and derivatives, bread and rusks, pasta, pastries, pizzas and quiches, mixed dishes, fish and shellfish, potatoes and allied products, rice and semolina, sandwiches, soups, sweet products, yoghurts and fresh dairy products, cakes and pastries and sweet biscuits. Certain groups of sugary foods were sub-divided to clarify the analysis of the sugar vectors: juices and soft-drinks (fruit juices and nectars/light drinks (sugar-free)/sugary drinks) and sweet products (chocolates and chocolate bars/sugar confectionery/sugary products—sugar, honey, jams, etc.).

2.3. Estimation of Free Sugar Intakes

The FS content of each food and drink product was estimated according to a systematic methodology based on the use of a 10 stage decision tree by Louie et al., 2015 to calculate added sugars [26]. Thus, over 95% of FS contents of foods in the CIQUAL base were estimated from steps 1 to 6 in the methodology, qualified as objective (steps 7 to 10 are subjective, see Supplementary Material). As in the WHO definition [11], sugars naturally present in honey, syrups and 100% pure fruit juices were considered as free sugars.

2.4. Statistical Analyses

The SAS 9.4 software (SAS Institute, Inc., Cary, NY, USA) was used for statistical analyses and for database management.

3. Results

3.1. Energy and Macronutrient Intakes

In this representative sample of the French population, the average TEI was 1760.9 kcal/day in children and adolescents (3–17 years) and 2156.6 kcal/day in adults (older than 18 years). Carbohydrates account for 48.1% of TEI in children and adolescents (212.0 g/day) and 43.5% in adults (243.3 g/day). Total sugars account for 23.0% of TEI in children and adolescents (100.1 g/day) and 17.9% in adults (96.2 g/day) (

Table 1. Overall intake of macronutrients in children and adolescents as well as in adults.

Population		Mean	Standard-Deviation	% of Total Energy Intake
Children and adolescents (3–17 years) N = 1102	Total energy intake (kcal/day)	1760.9	18
	Carbohydrates (g/day)	212.0	2.3	48.1
	Total sugars (g/day)	100.1	1.2	23.0
	Free sugars (g/day)	67.1	1.0	15.3
	Fats (g/day)	66.7	0.7	34.0
	Proteins (g/day)	67.9	0.7	15.6
	Alcohol (g/day)	5.8	0.06	2.3
Adults (≥18 years) N = 1845	Total energy intake (kcal/day)	2156.6	12.3
	Carbohydrates (g/day)	234.3	1.5	43.5
	Total sugars (g/day)	96.2	0.9	17.9
	Free sugars (g/day)	56.6	0.8	10.5
	Fats (g/day)	84.9	0.6	35.4
	Proteins (g/day)	83.1	0.6	15.5
	Alcohol (g/day)	17.5	0.02	5.6

).

3.2. Free Sugars Intake

The average FS intake accounted for 11.5 ± 0.1% of TEI (58.2 ± 0.6 g/day) of the general population (aged 3 and over); i.e., 15.3 ± 0.1% of TEI in children and adolescents (67.1 ± 1.0 g/day) and 10.5 ± 0.1% in adults (56.6 + 0.8 g/day) (Table 1). The FS contribution to TEI decreased with age, thus starting from 15.1% in the 3–6 years to 8.2% in the 66–75 years groups. However, with 9.4 ± 0.4% of TEI in participants aged 76 years and older, free sugars intake did increase compared to participants aged 50–75 years (

Table 2. Free sugars intake in children and adolescents as well as in adults (g/day and % of total energy intake (TEI)), stratified by age.

	N	Mean	Standard-Deviation	10th Percentile	50th Percentile	90th Percentile
Free sugars intake (g/day)
Total (≥3 years)	2947	58.2	0.6	23.1	52.8	98.0
Children and adolescents (3–17 years)	1102	67.1	1.0	34.1	62.5	106.2
Adults (≥18 years)	1845	56.6	0.8	21.5	50.5	97.4
3–6 years	300	56.5	1.3	29.1	53.3	85.7
7–12 years	439	62.3	1.1	32.7	60.6	92.1
13–17 years	363	81.7	2.4	40.0	77.0	118.3
18–34 years	465	66.4	1.6	31.5	61.1	100.1
35–49 years	461	63.2	2.0	22.1	56.5	110.2
50–64 years	459	50.9	1.2	22.2	45.2	86.8
65–75 years	361	44.5	1.4	13.2	41.6	78.0
≥76 years	99	49.7	2.2	22.1	46.0	78.9
Free sugars intake (% of TEI)
Total (≥3 years)	2947	11.5%	0.1%	4.8%	11.0%	18.7%
Children and adolescents (3–17 years)	1102	15.3%	0.1%	9.5%	15.0%	21.1%
Adults (≥18 years)	1845	10.5%	0.1%	4.3%	9.8%	17.5%
3–6 years	300	15.6%	0.3%	9.9%	15.4%	21.6%
7–12 years	439	15.1%	0.2%	9.6%	14.8%	21.0%
13–17 years	363	15.1%	0.3%	9.4%	15.0%	21.7%
18–34 years	465	12.7%	0.3%	6.1%	12.4%	19.5%
35–49 years	461	11.6%	0.3%	4.4%	11.0%	19.1%
50–64 years	459	9.3%	0.2%	3.9%	8.7%	14.7%
65–75 years	361	8.2%	0.2%	2.7%	7.7%	13.5%
≥76 years	99	9.4%	0.4%	4.4%	9.2%	15.4%

).

In terms of distribution, 48% of adults and 87% of children and adolescents were found to have FS intakes above the 10% TEI limit defined by the WHO.

3.3. Food Vectors of Calories and Free Sugars

The main contributors of TEI in children and adolescents were pastries (9.5% of TEI), mixed dishes (8.1% of TEI) and bread as well as rusks (7.6% of TEI). In adults, main contributors were bread and rusks (11.9% of TEI), mixed dishes (7.5% of TEI) and pastries (7.2% of TEI) (data not shown).

The leading contributors to FS intakes in children and adolescents are cakes and pastries (16.2% of total FS intake), sugary drinks (14.5% of total FS intake) and fruit juices (13.8% of total FS intake). In adults, leading contributors to FS intakes are sugary products (sugar, honey, jam, etc.) (17.6% of total FS intake), cakes and pastries (16.9% of total FS intake) and fruit juices (12.9% of total FS intake) (Figure 1).

4. Discussion

In this 2019 survey, which is representative of the French population, the average FS intakes have been evaluated at 15.3% in children and adolescents (67.1 g/day) and 10.5% in adults (56.6 g/day) of the average TEI of 1760.9 kcal/day and 2156.6 kcal/day, respectively. FS intakes were consistent with the previous data available in France, with a trend of a slight increase over the years. In the analyses of the INCA 2 data (2006–2007) [20,21], the average FS intakes of children and adolescents were 14.7% of TEI and 9.5% of TEI in adults. In the previous 2016 CCAF survey, the average FS intakes were 14.8% of TEI (61.6 g/day) in children and adolescents and 10.2% of TEI (50.7 g/day) in adults [22]. In addition, the proportion of adults as well as children and adolescents exceeding the WHO recommendations of less than 10% TEI FS intake did not change in both CCAF surveys (85% of children and adolescents and 48% of adults in the 2019 CCAF survey against 84% and 46% in 2016).

A slight increase in FS intake in both children and adolescents as well as in adults has been seen in the last 10 years, although a precise comparison is impossible given the different methodologies used in these two separate surveys and the lack of a nutritional table published on FS contents. Between the two CCAF surveys, the method for estimating the FS contents of foods has been improved, as the CIQUAL nutritional composition table was enriched by contents of different dietary sugars (lactose and maltose especially). These new data have resulted in an additional objective step being used to estimate FS intakes in the 2019 survey compared with the 2016 survey.

Other FS intake data have been published for France as part of the NutriNet-Santé cohort, with average intakes of 9.0% of the TEI noted in adults. However, the volunteer population of this cohort is not representative of the French population and tends to have more health-conscious dietary habits than the general population [27].

Moreover, the CCAF 2019 study shows that the contribution of FS to TEI falls with age (15.6% of TEI in the 3–6 age group to around 9% in the over 50s). However, it has to mentioned that in the current study, FS intakes increased again in participants 76 years and older. However, in general, there are more children and adolescents than adults who exceed the WHO FS intake recommendation. This observation is also noted in other countries for free [12,13,14,15] and total or added sugars [28,29].

Furthermore, this decrease is also confirmed in the worldwide review of free sugars intake [19], showing that children’s FS intake ranged from 9.1% of TEI in up to 10-year-old boys in Portugal and from 19.5% of TEI in up to 8-year-old girls in the Netherlands. For adolescents, intakes of FS ranged from 9.1% of TEI in 10 to 17-year-old boys in Portugal to 17.9% of TEI for 9 to 13-year-old boys in the Netherlands. For adults, intakes of FS ranged from 6.9% in 18 to 64-year-old men in Portugal to 18.1% in 51 to 64-year-old women in Austria and from 4.4% in 65 to 84-year-old men in Portugal to 12.5% for men aged >75 years old in the UK.

The greater preference for the sugary taste in children and adolescents compared with adults is innate and is seen in different cultures and eras [30,31]. One hypothesis is the acceptance of sweet-tasting foods, such as breast milk and fruit, at an early age, and this could be an adaptative response to higher energy needs during growth.

At this stage, it has to be mentioned that FS intakes can contribute to overweight and obesity, if total energy intake exceeds energy expenditure. However, this effect is rather due to an excess in calories than FS per se [2,4]. Furthermore, this effect is not related to dietary sugars but to all macronutrients, which do not differ in their effect on body weight [32,33]. Obesity is a concern especially for children, because infant obesity can be a risk factor for obesity [34] and cardiometabolic diseases in adults [35]. The Greco study conducted on children (aged 10–12 years) showed anthropometric characteristics (i.e., BMI, body weight, waist and hip circumferences, waist-to-height and waist-to-hip ratios) did not differ between children who exceed or respect the WHO 10% free sugars recommendation [16]. Again, in children and adolescents, an Australian study showed that the absolute intakes of most micronutrients were not significantly different between participants who exceed or respect the 10% free sugars recommendation. Only those with an FS intake of greater than 20% of total energy intake were less likely to meet the NRVs of more than half of the required micronutrients [36].

Regarding food groups, “cakes and pastries” and fruit juices were in the top three of the main FS contributors in both adults and children and adolescents. For children and adolescents, soft drinks were also mentioned, and “sugary products” were mentioned for adults. For children and adolescents, many of whom exceed the threshold, the French agency ANSES specifically recommends reducing the sugary drinks and cakes and pastries frequently consumed as an afternoon snack at first. Some countries—for example, the US [37] or Canada [38]—do not use the WHO definition of free sugars but prefer to use the term “added sugars”. The major difference between added and free sugars is in fruit juices. It can be noted that, in Europe, most fruit juices are 100% pure juice and do not contain added sugars, according to the regulations. Only nectars can contain added sugars, but they represent only a minority of the French market. However, 100% fruit juice could also by a risk factor for body weight gain in children, if consumed in amounts of approximately 200 mL/day [39], and therefore are part of current public health debates.

Time and age trends in FS intake (%E) from food contributors were analyzed in Germany in children and adolescents (3 to 18-year-olds) between 1985 and 2016 [40,41]. FS intake from juices increased between 1985 and 2005, contributing largely to the increase in total FS intake in this time. Since 2005, FS intake from juices and SSB as well as FS from sugar and sweets among girls started to decline. FS intake from dairy products only decreased from 2010 onwards, hence explaining the notable decrease in total FS intake since 2010. While FS intake from different food groups declined, especially in recent years, overall FS intakes continue to exceed the recommendations of 10% TEI in children and adolescents but have decreased since 2005.

The study has some strengths and limitations. One strength of the current study is that it was carried out in four successive phases to control for seasonal differences in intake (November–December, January–February, March–April, May–August), during each of which approximately a quarter of the participants were included. Moreover, the seven-day food record method used to obtain intake data during the whole week and the current study has a large, nationally representative sample.

A potential limitation of the present design is the fact that participants were recruited as members of households, which may have decreased the variability of dietary responses. Another point to note is the existence of underreporting in the survey, which may affect the results of this analysis. Even if underreporters have been excluded from their energy intake regarding the estimated energy requirements, underreporting is a well-known phenomenon for food items with a negative health image such as sugary foods [42] and could also not be systematically excluded in the current study. Furthermore, socioeconomic status was not addressed as in previous studies, which also used CCAF surveys [43]. This study only looks at consumption but does not address the link between sugar consumption and health or weight.

Furthermore, a strict comparison to previous surveys is difficult due to the different methods used. Additionally, there is a lack of published data on the FS contents of foods and a need to evaluate the contents using partly subjective methods. The 2020 update for the CIQUAL table included the composition of sugars such as lactose and maltose for the first time and included a more exhaustive list of food references (3185 items against 2000 in the previous version). This improvement allowed the qualitative assessment of the FS content by using the sixth step of the method of Louie et al. [26], which would not be possible without lactose and maltose composition (see Supplementary Material). Again, the improved data sets and analysis hamper the comparison with previous surveys. Moreover, one recurrent problem in such food survey is the lack of harmonization of food group names and classifications.

5. Conclusions

This representative survey of the French population in 2018–2019 updated data on FS intakes. A significant proportion of individuals was above the WHO recommendation that limits the FS contribution to 10% of TEI. The average FS contribution to the TEI was above the threshold mainly in children and adolescents. However, current data demonstrate that FS intakes decrease with age. The FS contribution to the energy intake seems to be relatively stable since 2006–2007 and 2016, even if a strict comparison is not possible because of differences in methodologies and the lack of a common FS composition table.