Data on food intake data in the first two years of life is limited, but there are some studies that report sugar intake in toddlers, including research conducted in Australia.

Generally, these studies compare sugar intakes to the World Health Organisation (WHO) sugar intake guidelines.

REMINDER: WHO defines free sugars as 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. The inclusion of fruit juices in the WHO free sugars is different from the definition of ‘added sugars’.

The Australian National Nutrition and Physical Activity Survey (NNPAS, 2011-12) found just over half of children aged two to three years exceeded the WHO < 10% energy from free sugars guideline.

Most children (93%) aged two to three years exceeded the WHO conditional guideline of < 5% energy from added sugar.

The SMILE (Study of Mothers’ and Infants’ Life Events affecting oral health) study is one of the few that reports intake in children aged one and two years. It found almost all children (97.6%) aged between one and two years of age met the WHO < 10% free sugars guideline, and the majority (77.2%) also met the conditional < 5% guideline.

Just under 33% of children aged one to two years exceeded the < 5% guideline.

Mean free sugars intake was 8.8g/day, contributing 3.6% energy. Children from disadvantaged households were more likely to have free sugars intakes at or above 5% energy. The major food sources were commercial infant foods (26.6%), cereal-based products (19.7%) e.g. biscuits, cakes, breakfast cereals, yoghurt (9.6%) and fruit and vegetable beverages (7.4%).

In a follow up study of the same SMILE cohort at two years of age, both amounts of free sugars and percent energy from free sugars were higher. While different methods were used to calculate total energy intake, an overall upward trend over time is evident.

Thirty eight percent of children exceeded the WHO < 10% guideline and the majority (71.1%) of two-year olds exceeded the WHO conditional < 5% guideline.

The median intake of free sugars was 22.5g, or 8% of the Estimated Energy Requirement (EER). Mean intake was 29.3g, or 10.4% of EER. Again, children from disadvantaged households were more likely to exceed the < 10% guideline and be in the highest tertile (highest third) of free sugars intake.

In this group of two year olds, the greatest overall contribution to free sugars came from:

• fruit and vegetable juices and drinks (11%)
• infant custards and yoghurts (10%)
• other yoghurts (9%)
• cakes, muffins, doughnuts and cake-type desserts (8%)
• biscuits (7%)
• sugar, honey and syrups (5%)
• chocolate-type confectionery (5%).

An Irish study analysing national survey data in three-year-old children found 75% had free sugar intakes greater than the WHO < 10% energy threshold, and 96% exceeded the WHO conditional < 5% threshold - results very similar to the Australian two-year olds in the SMILE study.

A UK study examining free sugars intake in preschool children 1.5-3 years found 58% of pre-school children exceeded the WHO < 10% guideline, and 93% of preschool children exceeded the WHO conditional < 5% guideline. Mean intake was 11.8% of energy as free sugars (median 11.2%).

Beyond two years of age, only a small minority of children consume less than 5% of their energy as free sugars.

How much free sugar is in Fruit juice?

A panel of experts from the Academy of Nutrition and Dietetics, the American Academy of Paediatrics, the American Academy of Paediatric Dentistry and the American Heart Association have produced beverage guidelines for young children in which they recommend toddlers aged one to three years limit 100% fruit juice to ½ cup per day (see our News item in this issue).

The Australian Dietary Guidelines list 100% fruit juice as a core food, albeit with the caveat, “only to be used occasionally as a substitute for other foods in the group”, similar to dried fruit. There are 10g of free sugars in half a cup (125ml) of pure (100%) orange and mango juice. According to the Nutrient Reference Values for Australia and New Zealand this represents 3.7% of the Estimated Energy Requirement (EER) for an average two year old (4300kJ/day).

Adding a small tub of strawberry yoghurt containing 7.6g added sugar to the half a cup of juice in the example above takes the total free sugars to 17.6g, or 6.5% of the EER for a two year old.

The WHO sugars guidelines

The WHO Guidelines for sugars intake for adults and children (2015) was written for policy-makers to compare their nation’s intakes with recommendations and implement public health interventions, with a particular focus on control of unhealthy weight gain and dental caries. The guidelines are designed to be used in conjunction with dietary guidelines in order to promote a healthy diet.

In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake (strong recommendation)

WHO suggests a further reduction of the free sugars to below 5% of total energy intake (conditional recommendation)

What is a strong vs a conditional recommendation according to WHO?

A strong recommendation indicates that “the desirable effects of adherence to the recommendation outweigh the undesirable consequences”. This means that the recommendation can be adopted as policy in most situations.

Conditional recommendations are made when there is less certainty “about the balance between the benefits and harms or disadvantages of implementing a recommendation”. This means that “policy-making will require substantial debate and involvement of various stakeholders” for translating them into action.

What is “less certain” about a 5% free sugars guideline?

The WHO recommendation to further limit free sugars intake to less than 5% of total energy intake is based on very low quality evidence from ecological studies in which a positive dose–response relationship between free sugars intake and dental caries was observed at free sugars intakes less than 5% of total energy intake.

This evidence consists of three population studies conducted in Japan before the second World War when sugar availability dropped dramatically to less than 10kg per person per year ( < 5% of total energy intake). The children in these studies had low fluoride exposure.

The WHO recommendation to further limit free sugars intake to less than 5% of total energy intake is based on evidence it says is very low quality

What is the evidence behind the WHO sugars guidelines?

The WHO guidelines are based on reviewed evidence between free sugars intake and body weight (low and moderate quality evidence) and dental caries (very low and moderate quality evidence). No age for children is specified in the guidelines.

WHO says the overall quality of the available evidence for an association between a reduction of free sugars intake and reduced body weight in children is moderate. They say the quality of the evidence for an association between an increase in free sugars intake and increased body weight is low.

An analysis of cohort studies in children suggests a positive association between the level of free sugars intake and dental caries, which WHO says overall is moderate quality evidence).

This evidence suggests higher rates of dental caries when the level of free sugars intake is more than 10% of total energy intake compared with it being less than 10% of total energy intake.

Relationship between free sugars and nutrient intake.

A UK study examining associations between free sugars and nutrient intakes in children and adolescents aged 4-18 identified optimal intakes at 7-14% energy from free sugars. It found subjects with free sugars intake above 13% energy had lower diet quality (lower nutrient intake) than those consuming < 10% energy from sugars. There was insufficient data to assess diets with 5% free sugars.

The authors also suggest diets very low in free sugars may also be unbalanced and low in nutrients, citing an analysis of data from the U.S. National Health and Nutrition Examination Survey (NHANES) III that reported reduced intakes of calcium, iron, zinc and vitamin A at low levels of added sugars ( < 5 % energy) as well as at high levels ( > 25% energy).

The study’s authors suggest,

“To improve public health, food-based guidelines should focus on discouraging sources of sugars that are low in nutrients or fibre, such as high-sugar soft drinks, confectionery…. This is likely to achieve better nutrient intake than limiting all sugar-containing foods”.