# Health Reports Added, free and total sugar content and consumption of foods and beverages in Canada

by Siyuan Liu, Lalani L. Munasinghe, Arto Ohinmaa and Paul J. Veugelers

Release date: October 21, 2020

In Canada, chronic diseases account for 89% of all deathsNote 1 and more than \$80 billion in annual health care costs.Note 2 Adopting healthy lifestyle behaviours, such as healthy eating, has the potential to prevent 80% of type 2 diabetes and cardiovascular disease, 40% of cancers, and other chronic diseases.Note 1Note 3 Despite healthy eating recommendations issued by Health Canada,Note 4 eating habits continue to deteriorate, and overweight prevalence rates continue to increase.Note 5

Since sugars contribute to the overall energy composition of diet, excess sugar intake may lead to a positive energy balance and weight gain. Considerable epidemiological and experimental evidence has emerged suggesting an association between sugar consumption and obesity, high blood lipid levels, visceral adiposity, fatty liver disease, insulin resistance, type 2 diabetes, cardiovascular disease, metabolic syndrome, and dental caries.Note 6Note 7Note 8Note 9Note 10Note 11Note 12Note 13 While nutritious foods like fruits and milk contain naturally occurring sugarsNote 14 many other foods and beverages contain added and free sugars that, when consumed in excess amounts, increase calorie intake and displace consumption of nutritious foods.Note 15

The definitions of added, free and total sugars vary. This study uses the World Health Organization (WHO) definition of free sugars: “all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.”Note 6 Added sugars are defined as refined sugars added during cooking or manufacturing, not including naturally occurring sugars and fruit juice.Note 16Note 17 Total sugars are defined as the sum of all naturally occurring and added sugars.

In 2015, the WHO released new recommendations to reduce the consumption of free sugars to less than 10% of daily total energy intake (TEI), and ideally to less than 5% of TEI to achieve additional health benefits.Note 6 The 2015-to-2020 edition of Dietary Guidelines for Americans, released by the U.S. Department of Agriculture (USDA), recommends that Americans consume less than 10% of calories from added sugars.

Various countries have documented added and free sugar consumption. For example, in the United States, added sugars were estimated to comprise 13.1% to 17.5% >of TEI among children and 11.2% to 14.5% of TEI among adults.Note 18Note 19 Children in Greece were estimated to obtain 11.2% of TEI from free sugars.Note 20 These population averages exceed the sugar recommendations of the WHO and the USDA and call for interventions to reduce added and free sugar intake. Estimates of added and free sugar consumption are not available for Canada because the added and free sugar content of foods and beverages in Canada is not systematically documented.

In 2004, the average total sugar intake of Canadians was estimated to be 21.4% of daily TEI,Note 21 an estimate that includes both naturally occurring and added sugars. While subsequent work was done to quantify added sugar intake specifically, these estimates did not consider all sources of added sugars.Note 22 Research showed that 66% of 40,000 packaged food products in Canada contained at least one added sugar.Note 23 In a recent study, Bernstein et al.Note 24 estimated the free sugar content of prepackaged foods in Canada using the Food Label Information Program. Although the authors were able to estimate the free sugar content for a large number of prepackaged foods, their work did not include all dietary sources. Therefore, to date, there are no accurate population-based estimates of the added and free sugar content of the Canadian diet.

Given the increasing concerns about the health consequences of excess added and free sugar intake, there is growing interest in applying policies and programs to reduce this consumption. Various jurisdictions have introduced such policies and programs to reduce consumption at the population level.Note 25Note 26 For Canada, scientific research into the health effects of excess added and free sugar consumption and thepotential benefits of interventions starts with a good understanding of added and free sugar consumption at the population level. Therefore, to provide accurate sugar consumption information for researchers and policy makers, this study aims (1) to document the added, free and total sugar content of foods and beverages consumed in Canada; and (2) to estimate the consumption and dietary sources of added, free and total sugars in Canada.

## Data and methods

### Data sources

The 2015 Canadian Community Health Survey (CCHS) – Nutrition is a cross-sectional national survey that was conducted by Statistics Canada and Health Canada from January to December 2015. The survey recruited individuals aged 1 and older living in private dwellings in the 10 Canadian provinces using a multi-stage, clustered design.Note 27 A national response rate of 61.6% was achieved. The survey’s 24-hour dietary recall collected the food intakes of 20,487 respondents, 7,608 of whom completed a second 24-hour dietary recall. These 24-hour dietary recalls were administered using an Automated Multiple-Pass Method.Note 28 Respondents reported the consumption of 2,784 ingredient-level foods and 2,590 recipe-level foods in the 2015 CCHS – Nutrition. Recipe-level foods are foods that consist of two or more ingredients. A sandwich and Caesar salad are examples of recipe-level foods, and an apple and noodles are examples of ingredient-level foods.Note 27 The nutrient content of ingredient-level foods was used to calculate the nutrient content of recipe-level foods. The Canada Food Guide file was used to determine the serving sizes.Note 28

The University of Alberta Research Ethics Board approved this study (Pro00073295). The 2015 CCHS – Nutrition data were accessed through Statistics Canada’s Research Data Centres Program.

### Estimation of the added and free sugar content of foods and beverages

Statistics Canada calculated the nutrient intake, including total sugar intake, for respondents based on the consumption and nutrient content of the reported foods and beverages. However, this calculation does not include added and free sugar intake, as the added and free sugar content of foods and beverages is not systematically documented in Canada.

In 2015, Louie et al.Note 17 published a decision tree with a systematic methodology to estimate the added sugar content of foods in Australia. Their 10-step standardized approach had high inter-rater repeatability and was designed for both national (Australia) and international use.Note 17 The approach by Louie et al.Note 17 was adapted for use in Canada. Figure 1 illustrates the decision algorithm of the nine-step approach. Note that 1 of the 10 steps from the Louie et al. approach (step number 4) was omitted because recipe-level foods in the 2015 CCHS – Nutrition dataset used more than one recipe. A brief description of each of the nine steps is provided below. More details on each of the steps are provided elsewhere.Note 29

Step 1: Assign 0 g of added and free sugars for ingredient-level foods that contain 0 g in total sugars.

Step 2: Assign 0 g of added and free sugars for ingredient-level foods that are unprocessed or processed without added or free sugars.

Assign 0 g of added sugars for food types such as unsweetened fruit or vegetable juice (including concentrate), unsweetened dairy products, and all fats and oils. Assign 0 g of free sugars for these food types, except for fruit juice and foods with fruit juice.

Step 3: Assign 100% of total sugars as added and free sugars for ingredient-level foods with very little naturally occurring sugars.

Assign 100% of total sugars as added sugars for food types such as sugar-sweetened beverages, confectionery, sugars, syrups and sweetener without added fruits, chocolate, and dairy products. Assign 100% of total sugars as free sugars for these food types and for 100% fruit juice and foods that contain fruits.

Step 4: Calculate added and free sugar content by comparing the total sugar content of a food or beverage with the sugar content of an unsweetened version of this food or beverage.

Added sugars and free sugars per 100 g (AS100g and FS100g) were calculated using the following formulas:

, and

,

where ${\text{TS}}_{\text{s}}$ is the total sugar content per 100 g of the sweetened food or beverage, and ${\text{TS}}_{\text{us}}$ is the total sugar content per 100 g of the unsweetened food or beverage.

Step 5: Calculate added and free sugar content based on lactose and maltose content.

Where data for lactose and maltose were available in the Canadian Nutrient File or the USDA Food Composition Database, added sugar and free sugar content of ingredient-level foods was calculated using the following formulas:

, and

.

Step 6: Calculate added sugar and free sugar content using the content values of similar foods from steps 1 to 5 or other nutrient databases.

Similar foods captured in steps 1 to 5 and in the Australian Food, Supplement and Nutrient Database were searched for information on added and free sugars. Foods were considered to be similar if they differed only in water content, if they contained similar ingredients (such as similar vegetables in soup), or if they were reduced in calories or energy or fat. Where a similar food was identified (matching), the added and free sugar content of the target food was estimated using the following formulas:

,

and .

Step 7: Estimate added and free sugar content for ingredient-level foods subjectively based on common recipes and ingredient lists.

Step 8: Assign 50% of total sugars as added and free sugar content for all remaining ingredient-level foods.

Step 9: Calculate added and free sugar content for recipe-level foods using respondent-specific recipes and the above estimated added and free sugar content of ingredient-level foods.

After all ingredient-level foods in the 2015 CCHS – Nutrition were estimated (steps 1 to 8), the added and free sugar content of recipe-level foods was calculated using the following formulas:

and , where $R{W}_{i}$ is the raw weight of the ith ingredient in the recipe, ${W}_{i}$ is the weight of the $i$th ingredient in the recipe after cooking, $A{S}_{i}$ is the added sugar content per 100 g of the $i$th ingredient and $F{S}_{i}$ is the free sugar content per 100 g of the $i$th ingredient.

The average added and free sugar content of ingredient-level foods was calculated for 18 food groups (displayed in Figure 2). These food groups were based on the Bureau of Nutritional Sciences Food Group Codes and DescriptionsNote 30 and the Canadian Nutrient File food groups.Note 31

### Estimation of usual intake of added, free and total sugar

The National Cancer Institute (NCI) method was applied to estimate the distribution of usual intake of added, free and total sugar by Canadians.Note 32 The NCI method assumes that usual intake is equal to the probability of consumption on a given day times the average amount consumed on a “consumption day”Note 33 and uses repeated 24-hour recalls. Depending on whether certain nutrients are commonly consumed (i.e., daily and by most respondents), this method uses either a one-part or a two-part model.Note 34 The one-part model considers only the amount of a nutrient consumed and is to be applied to nutrients that are commonly consumed. The two-part model considers both the proportion of the population consuming the nutrient and the amount of the nutrient consumed, and it is to be applied to nutrients that are not commonly consumed. This study assumed that added, free and total sugars were consumed daily and by all members of the population. For the usual intake of added, free and total sugars for each of the 18 food groups, this study considered the proportion of the population that consumed no sugar. A one-part model was applied for food groups where less than 5% of the population consumed no sugar. A two-part model was applied for food groups where more than 20% of the population consumed no sugar. For food groups where 5% to 20% of the population consumed no sugar, both models were fitted, and the model with the best fit was used.Note 34 For the usual intake of added and free sugars expressed as a percentage of TEI, an extension of the NCI method was used.Note 34Note 35

All analyses included age, sex, the sequence of 24-hour recalls (first recall versus second recall), and the 24-hour recall collection day of the week (weekdays, or Monday to Thursday, versus weekends, or Friday to Sunday) as covariates when accommodating individual-level and within-individual variation. Sampling weights provided by Statistics Canada were used to ensure study estimates apply to residents of Canada (for ease of presentation referred to as Canadians). All statistical analyses were performed using SAS (version 9.4, SAS Institute) software. SAS Macros of the NCI method were available online.Note 36

## Results

### Estimated added, free and total sugar content of foods and beverages

The added and free sugar content of 2,784 ingredient-level foods and 2,590 recipe-level foods consumed in Canada was calculated using the nine-step method. Table 1 shows the sugar content of selected ingredient-level food items recorded in the 2015 CCHS – Nutrition. The table provides one example for each of the 18 food groups. A table with the added, free and total sugar content of all ingredient-level foods is available elsewhereNote 29 for public use. Recipes (and recipe-level foods) are respondent-specific and subject to restricted release for confidentiality reasons, but they can be calculated from the ingredient-level foods.

### Estimated added, free and total sugar content of food groups

For each of the 18 food groups, Figure 2 shows the average added, free and total sugar content of all foods and beverages reported by respondents. Desserts and sweets had the highest added, free and total sugar content, at 37.0, 38.1 and 42.9 g per 100 g, respectively. Except for fruits, all food groups high in total sugar also had high added and free sugar content. Breakfast cereals, baked products, beverages, baby foods and snacks were the food groups that contained high free and added sugar content. Fruit juice had high free sugar content (12.5 g / 100 g) but low added sugar content (1.9 g / 100 g). Fats and oils, meats, sausages and luncheon meats, pasta, grains and flours, eggs, vegetables, spices, soups, sauces and gravies, nuts and seeds, and dairy products had relatively low sugar content.

### Estimated added, free and total sugar consumption and adherence to recommendations

Table 2 shows the mean and percentiles of usual added, free and total sugar intake in Canada. Canadians consume daily, on average, 57.1 g of added sugars, 67.1 g of free sugars and 105.6 g of total sugars. On average, added sugars constitute approximately 54.1% of total sugars, and free sugars make up approximately 63.5% of total sugars. The average estimated added, free and total sugar intake contributed to 11.1%, 13.3% and 21.6% of TEI, respectively.

### Contribution of food groups to added, free and total sugar intake

The contribution of each of the 18 food groups to added, free and total sugar intake is summarized in Figure 3. Desserts and sweets and beverages were the two food groups that contributed the most to added, free and total sugar intake in the Canadian diet. An estimated 67.3%, 57.5% and 41.1% of added, free and total sugar intake, respectively, came from desserts and sweets, and an estimated 17.4%, 17.5% and 12.6% of added, free and total sugar intake, respectively, came from beverages. Other food groups, such as baked products, soups, sauces and gravies, and breakfast cereals, also contributed to added, free and total sugar intake.

There were some differences in the relative contribution of food groups to the intake of added, free and total sugars (Figure 3). Fruits (12.9%) and dairy products (11.6%) were significant sources of total sugar intake, but not primary sources of added and free sugar intake.

## Discussion

This study revealed the added, free and total sugar content and consumption of foods and beverages in Canada. For the majority of Canadians, consumption of added and free sugars exceeded USDA and WHO recommendations. Desserts and sweets and beverages contributed to most of the added, free and total sugar intake of Canadians.

Both the USDA’s added sugar definition and the WHO’s free sugar definition were applied in the present study. Added sugars differ from free sugars in their exclusion of naturally occurring sugars in fruit juices and fruit juice concentrates. Various studies have not clearly defined added and free sugars,Note 17Note 18Note 19Note 24 whereas the present study and othersNote 37Note 38 have demonstrated substantial differences in the consumption of added versus free sugars.

Total sugar intake in Canada was estimated at 110.0 g/day using the 2004 CCHS – Nutrition.Note 21 This seems higher than the 105.6 g/day that was estimated in this study using the 2015 CCHS – Nutrition. Langlois et al.,Note 39 who studied the temporal changes in total sugar consumption, concluded that the apparent reduction between 2004 and 2015 may actually be caused by misreporting as a result of changes in survey methodology. They also reported that total sugar consumption from foods actually increased between 2004 and 2015, while total sugar intake from beverages decreased.Note 39 Studies from other countries and of earlier time periods concluded that total sugar intake either decreased or levelled off, both in absolute terms (g/day) and in relative terms (percentage of total sugar in TEI).Note 40Note 41Note 42

To date, very few studies of added and free sugar consumption have been population-based, and very few have reported on compliance with USDA and WHO recommendations. Louie et al. found that 1% of Australian children and youth (aged 2 to 16) consumed added sugars below 5% of TEI, and 18.1% consumed added sugars below 10% of TEI.Note 42 Sluik et al. revealed that 29% of Dutch residents (aged 7 and older) met the recommendation for added sugars (less than 10% of TEI) and 19% met the recommendation for free sugars (less than 10% of TEI).Note 38 The present study’s estimates that 49.0% and 33.8% of Canadians met the existing recommendations for added and free sugars, respectively, are notably higher than these Australian and Dutch estimates.

This study revealed that desserts and sweets, breakfast cereals, baked products, beverages, and snacks are food groups with high added and free sugar content. This ranking seems consistent with the ranking by Bernstein et al. for prepackaged foods and beverages.Note 24 This study also showed that the intake of added, free and total sugars through desserts and sweets was substantially higher than the intake of these sugars through beverages. This appears to be consistent with observations from a review of 11 European studies that concluded that sweet products contributed to a higher proportion of added sugar intake (40% to 50% for children and 36% to 61% for adults) than beverages did (20% to 34% for children and 12% to 31% for adults).Note 43

Various countries and jurisdictions have adopted strategies to improve diet quality or reduce energy intake. These include food guides, school nutrition policies, front-of-package labelling, social marketing and various forms of taxation.Note 4Note 25Note 44Note 45 Several studies have reported on the effectiveness of these interventions and the extent to which they resulted in a decrease in added and free sugar consumption.Note 26Note 46Note 47 However, other studies have shown that there remains plenty of room for improvement. For example, economic evaluations revealed that Canada would have avoided health care costs of approximately \$863 million in 2014 and \$830 million in 2018 if Canadians had avoided consuming sugar-sweetened beverages.Note 48Note 49 The present study’s added and free sugar value and consumption estimates may support future research into the health and economic costs associated with the consumption of these sugars. They may also inform potential intervention targets for added and free sugar consumption.

The present study has several strengths. It uses the 2015 CCHS – Nutrition, which is a large population-based survey that included the 24-hour recall data of more than 20,000 respondents, with repeat measures, to allow for the estimation of usual intake. A study limitation relates to the subjective judgment used in steps 6, 7 and 8, as this may have introduced error in the estimates of added and free sugar content. However, these steps did involve a limited number of foods and beverages: Figure 1 shows that they involved 475 (8.8%) of the 5,374 recorded foods and beverages when estimating added sugars and 397 (7.4%) of the foods and beverages when estimating free sugars. In addition, Louie et al.Note 17 reported high inter-rater repeatability for this methodology. Another limitation relates to the use of 24-hour recalls, which are prone to error, as is every dietary assessment method.

## Acknowledgments

This research was funded through an operating grant by the Canadian Institutes of Health Research (grant number 384559) to Paul J. Veugelers. This research was also supported by funds to the Canadian Research Data Centres Network (CRDCN) from the Social Sciences and Humanities Research Council, the Canada Foundation for Innovation, and Statistics Canada. Although the research and analysis are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada or the CRDCN.

References

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