Jimmy Louie is an Associate Professor of Dietetics at the Department of Nursing and Allied Health of the Swinburne University of Technology. A/Prof Louie has a strong track record in nutritional epidemiology and is best known for his research on the association between carbohydrate nutrition (specifically glycemic index and added sugar consumption) and health outcomes.

The National Health and Medical Research Council (NHMRC) is currently reviewing the Australian Dietary Guidelines. So, does the evidence support a quantitative recommendation for added/free sugars intake? 

The available evidence suggests we need evidence-based recommendations on free sugars intake that consider individual circumstances and overall dietary patterns. While a reduction in free sugar intake is generally beneficial, strict quantitative recommendations may not be suitable nor practical for everyone. The absence of mandatory added/free sugar labelling means that the public does not have sufficient information to effectively implement quantitative guidelines.[1] Some public health agencies provide an example upper limit of 50 grams of free sugars per day based on a 2,000 kcal/day diet.[2] However, without nutrition labels indicating the free sugars content, consumers face difficulties in assessing their free sugars intake, especially since differentiating between total, added, and free sugars has already proved challenging for most.[1] Given the lack of easily accessible information on the free sugars content of foods and beverages, the practical advice given to the public regarding free sugars intake often revolves around limiting the consumption of high-sugar foods and beverages such as sugar-sweetened beverages (SSBs) and confectionery.[3,4] In this context, it is uncertain how the quantitative guidelines, which recommend limiting the intake of free sugars to below 10% (or 5%) of daily energy intake, offer additional clarity beyond the standard advice.

A new World Health Organisation (WHO) guideline recommends against the use of non-sugar sweeteners to control body weight or reduce the risk for non-communicable diseases.  What are your thoughts on this?

This recommendation [5] is based on emerging evidence suggesting potential adverse effects of these sweeteners on metabolic health, gut microbiota, and appetite regulation. There are food products on the market with excessive amounts of free sugars beyond what’s required to achieve a pleasant taste and could have their sugar content reduced quite easily. However, it is naïve to believe that the food industry can remove free sugars from other food products without the need to replace the sweetness and other functions (e.g., browning) with other ingredients or food additives.[6] This unintended consequence of free sugars-reduction in guidelines and policies is rarely considered in the public health debate. It is important to consider the potential health implications of increased exposure to non-caloric and low-calorie sweeteners, as they are now present in a significant proportion of non-low-calorie products. [7,8]

Your previous academic post was at University of Hong Kong. How does Hong Kong differ in public health policy and general community attitudes around sugar?

Public health policies and community attitudes play a vital role in shaping the approach towards sugar consumption and its impact on public health, but countries differ significantly in their stance and approach to sugar. Australia has taken proactive measures to address sugar consumption, recognising it as a significant public health issue. Key initiatives include restricting high sugar foods and drinks in school canteens and health care settings, health promotion messages through social marketing,[9] as well as a reformulation program under the Healthy Food Partnership.[10] Critics argue that these initiatives are less stringent compared to other countries with more developed sugar-related policies in place.

In contrast, jurisdictions like Hong Kong place a stronger emphasis on personal responsibility and education when it comes to sugar consumption. While public awareness campaigns and educational programs have been implemented, the focus has been more on individual choices rather than policy interventions. This approach may be influenced by the fact that Hong Kong imports around 90% of its food from other countries,[11] limiting its jurisdictional control over the composition of imported food. However, there is growing recognition of the need for stricter regulations and public health policies to address the rising prevalence of chronic diseases linked to sugar consumption.

Regardless of the stringency in sugar policies, the general trend around the world is to aim for a reduction in free sugars consumption in the population, as per the WHO recommendations.

References

1. The American Heart Association, Tips for Cutting Down on Sugar, The American Heart Association, Dallas, TX, USA, 2018
2. World Health Organization, Guideline: Sugar intake for adults and children, WHO Department of Nutrition for Health and Development (NHD), Geneva, Switzerland, 2015, pp. 50
3. National Health Services (UK), How to cut down on sugar in your diet, NHS (UK), London, UK, 2018
4. National Health Services (UK), How to cut down on sugar in your diet, NHS (UK), London, UK, 2018.
5. K.R. Goldfein, and J.L. Slavin, Why Sugar Is Added to Food: Food Science 101. Comprehensive Reviews in Food Science and Food Safety 14 (2015) 644-656
6. National Health Services (UK), How to cut down on sugar in your diet, NHS (UK), London, UK, 2018
7. B.Y.S. O, D.H. Coyle, E.K. Dunford, J.H.Y. Wu, and J.C.Y. Louie, The Use of Non-Nutritive and Low-Calorie Sweeteners in 19,915 Local and Imported Pre-Packaged Foods in Hong Kong. Nutrients 13 (2021) 1861.
8. Food Standards Australia New Zealand, Literature review on consumer knowledge, attitudes and behaviours relating to sugars and food labelling, FSANZ, Canberra, ACT, Australia, 2018
9. Policy context relating to sugars in Australia and New Zealand. https://www.health.gov.au/internet/fr/publishing.nsf/Content/C6995F10A56B5D56CA2581EE00177CA8/$File/Policy%20Context%202017.pdf
10. Food and Health Bureau (Hong Kong). Frequently Asked Questions on Food Supply of Hong Kong. 2016. https://www.fhb.gov.hk/download/press_and_publications/otherinfo/110318_food_supply_faq/e_food_supply_faq.pdf 
11. Y. Wang, R. Zhao, B. Wang, C. Zhao, B. Zhu, and X. Tian, The Dose-Response Associations of Sugar-Sweetened Beverage Intake with the Risk of Stroke, Depression, Cancer, and Cause-Specific Mortality: A Systematic Review and Meta-Analysis of Prospective Studies. Nutrients 14 (2022) 777