EXPO Briefing

Dietary Quality:How Sweeteners Fit

Rosanne Rust, MS, RDN, LDN @rustnutritionMonday, October 21, 201412:45-1:05 p.m.Expo Hall B2Georgia World Conference Center

Disclosure

• Nutrition Communications Consultant– 2014 FNCE® speaker expenses and honorarium underwritten by the Corn

Refiners Association– Consultant to the American Beverage Association’s Let’s Clear It Up campaign– Consultant to the Calorie Control Council on topic of fructose– Author – Chapter 10, “Sweeteners and Dietary Quality,” Fructose, High Fructose Corn

Syrup, Sucrose and Health (2014) – Author – consumer For Dummies® books

• Member, Academy of Nutrition and Dietetics– Member, Nutrition Entrepreneurs (NE), Dietitians in Business and Communication, and

Weight Management (WM), Sports, Cardiovascular and Wellness Nutrition (SCAN)

Session Objectives

• Define the concept of diet quality• Identify factors affecting diet quality• Identify top sources of sugars and sweeteners in the diet• Present arguments for why added sugars are, and are not, associated

with diet quality

DEFINING DIET QUALITY

Defining Diet Quality

Dietary quality refers to the overall quality of the diet based on its nutrient profile• Nutrient density refers to the overall quality of the diet based on its nutrient profile• Energy density refers to total caloric load

Defining Diet Quality — Tools

• Benchmarks for diet quality– DGA: Evidence-based dietary guidelines to encourage a lifestyle approach to weight

control that integrates all key nutrients (foods to limit, foods to encourage).• 2010: Unique task to address an overweight or obese population, who are

undernourished in several key nutrients

• Assessment tools– Not one measure, but a range of tools– DRI: US Dietary Reference Intakes help determine minimum and maximum

requirements for energy and essential nutrients RDA (Recommended Dietary Allowances) and the AI (Adequate Intake) EAR (Estimated Average Requirements) UL (Tolerable Upper Intake Levels)

Defining Diet Quality — Tools

Indexes and scoring systems used to evaluate diet quality• Healthy Eating Index — assess diet quality with regard to DGA

– Youth Healthy Eating Index– Alternative Healthy Eating Index — distinguishes quality within food groups, better

indicator for cardiovascular risk• Recommended Food Score• Nutrient Rich Food Index

Guenther, PM, Cassavale, KO, Reedy, J et al. Update of the Healthy Eating Index: HEI 2010. J Acad Nutr Diet. 2013 Apr;113(4):569-80.

FACTORS AFFECTING DIETARY QUALITY

• Socioeconomic • Cultural• Education• Culinary skills• Beverage choice

Factors Impacting Diet Quality

• Socioeconomic status– Body of data showing diet quality runs along the socioeconomic gradient– The mean percentage of total calories from added sugars decreases with increasing age and

increasing income– Recent Harvard study shows while diet quality is improving overall, the gap between low and

high socioeconomic status widened

http://www.cdc.gov/nchs/data/databriefs/db122.htm Darmon, N., Drewnowski, A. Does social class predict diet quality, Am J Clin Nutr, 2008Wang, DD, Leung, CW, Yanping, L, et al, Trends in Dietary Quality Among Adults in the US, 1999-2010. JAMA, Sept 1, 2014 Drewnowski A, Specter, SE. Peerty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79:6-16 http://www.hsph.harvard.edu/news/press-releases/u-s-diet-shows-modest-improvement-but-overall-remains-poor/

• Sociocultural aspects of diet quality– Family dinner, meal style– Ethnic foods, holiday traditions– Racial differences — non-Hispanic black men and women consumed a larger percentage

of their total calories from added sugars than non-Hispanic white and Mexican-American men and women

– Forbidden foods

Factors Impacting Diet Quality

• Education level– Less education often correlated to poor diet quality

Nicklas RA, Baranowski, R Baranowski J, et al. Family and child-care provider influences on pre-school children's fruit juice and vegetable consumption. Nutr Rev 2001; 59:224-35Variham JN, Blaylock J, Smallwood DM. Modeling nutrition knowledge, attitudes and diet-disease awareness: The case of dietary fibre. Stat Med, 1996;15:23-35Birch, LL, Fisher, JO. Development of eating behaviors among children and adolescents. Pediatrics. 1998;101:539-49

• Culinary skills– Lack of skills, lack of interest– Skills handed down through generations– Learned skills

Factors Impacting Diet Quality• Beverage choice and diet quality

– Milk consumption in children is directly correlated to better overall diet quality; dairy is often used as a benchmark for diet quality in children since it delivers a host of nutrients, and soft drinks are associated with lower milk consumption

– Higher juice and sugar-sweetened beverage consumption associated with lower milk consumption

Marshall RA, Eichenberger Gilmore, JM, Broffitt B, et al. Diet quality in young children is influenced by beverage consumption. J Am Coll Nutr. 2005;24:65-75.

ROLE OF ADDED SUGAR IN

DIETARY QUALITY

• Sources of sugar• Recommendations for sugar intake

Sources of Added Sugars

National Cancer Institute. Sources of added sugars in the diets of the U.S. population ages 2 years and older, NHANES 2005–2006. Risk Factor Monitoring and Methods. Cancer Control and Population Sciences. http://riskfactor.cancer.gov/diet/foodsources/added_sugars/table5a.html

Role of Added Sugars in Dietary Quality — Competing Recommendations

According to USDA Food Availability Data, calorie intake in 1970 was ~2100. In 2010 it was ~2570.• Most of calorie increase attributed to fats

and grain products• AHA says primary reason to reduce

added sugars is generally to lower total calorie intake or glycemic load and promote adequate nutrition, but added sugars only contributing ~4% of the +470 calorie increase since 1970

Added sugars4%

Added fats53%

Flour/cereal products

40%

Other3%

USDA, Economic Research Service data: U.S. per capita calories loss-adjusted food availability: “Total Calories” 1970-2010

Role of Added Sugars in Dietary Quality — Competing Recommendations

Is sugar the big issue?• Adults underconsume fruits and vegetables (<2 cups/day)• SOFAS:

– Fat: 94-98% of males exceed recs for added solid fats, 92-97% of females do – Sugar: 68-85% adult females exceed discretionary calorie for sugar, 55-80%

of males do• Bray and Popkin blame dietary fat for obesity in 1998, then in 2004 blame sugar • Children and adults consume more sugar at home than away from home • Consideration of “nutrients of concern” (vitamin D, fiber, calcium, potassium,

B vitamins)

Krebs-Smith, SM, Guenther PM, Subar AF, et al. Americans do not meet federal dietary recommendations. J Nutr. 2010;140:1832-8.Consumption of Added Sugars Among US Children and Adolescents, 2005-2008 http://www.cdc.gov/nchs/data/databriefs/db87.pdfhttp://www.nutritionj.com/content/12/1/116Forshee, RA, Storey, ML The role of sugars in the diet quality of children and adolescents. J Am Coll Nutr. 2001;20:32-43Bray, GA, Popkin, BM. Dietary fat intake doss affect obesity! Am J Clin Nutr 1998;68:1157-73.Bray, GA, Popkin BM. Consumption of high fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr. 2004;79:537-43.

Role of Added Sugars in Dietary Quality — Competing Recommendations• No definitive guideline for sugar intake• Differentiating between sugar and added sugar• General dietary recommendations:

– The Dietary Guidelines for Americans, 2010 Limit total intake of discretionary calories, including both solid fats and

sugars (SOFAS), to 5-15% per day – American Heart Association general guidelines

Minimize beverages and foods with added sugars

Sweeteners and Dietary Prescription

Competing Recommendations: How much sugar is optimal in the diet?• AHA: no more than 6 tsp for women, 9 tsp for men• IOM: RDA – minimum recommendation for carbohydrate 130g/day• DGA: General recommendations to ‘reduce’• WHO: <10% of daily calories should come from added sugars; in

process of drafting new guideline

Conflicting Recommendation for Diet Quality and Carbohydrate in Cardiovascular Risk

Fat vs. Sugar?• Fat recommendations have moved from the ‘fat-phobic’ 1990s to

current recs to increase “heart-healthy” fats• Conflicting studies — some show low carb, high protein increase

mortality, others show that moderate amounts of carb (50-55%) along with diet low in saturated fat, are associated with lower CVD risk

Coulston, AM, Liu, GC, Reaven, GM, Plasma Glucose, insulin, and lipid responses to high-carbohydrate diets in normal humans. Metabolism. 1983;32:52-6Yang, EF, Chung, HK, Kim, WY, et al. Carbohydrate intake is associated with diet quality and risk factors for cardiovascular disease in US adults. NHANES III. J Am Coll Nutr. 2002;22:71-9

Body of research showing a diet high in whole grains low in fat and saturated fat reduces cardiovascular disease (sources cited).

PRACTICAL APPLICATIONS

Take-away Points

Practical Applications

• There are benchmarks for diet quality and several tools to evaluate diet quality

• We often over focus on one nutrient, rather than observing overall eating patterns and intake; sugar recommendations vary, as do individual needs for carbohydrates; the data shows that, singularly, sugar does not appear to impact diet quality on its own

Practical Applications

• Nutrients are not eaten in isolation, but are combined• Consider all factors that impact an individual’s food and beverage choices• Educate clients in a meaningful way, considering the cultural and

socioeconomic factors that may influence the choices they can make

• There should be agreement that diets must be individualized, particularly for those with medical issues, and that the registered dietitian is the most equipped to evaluate individual diets, and prescribe the best diet plan for desired results

Sweeteners & Dietary Quality

 

QUESTIONS Rosanne@rustnutrition.com

Visit Sweetener Studies

Booth #2110

Reference list and slides published:

http://sweetenerstudies.com/dietitian2014