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Article

Changes in Intakes of Total and Added Sugar and their Contribution to Energy Intake in the U.S.

1
Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA
2
Food and Nutrition, Ansan College, Ansan, Korea
3
Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI 48824, USA
*
Author to whom correspondence should be addressed.
Submission received: 17 June 2010 / Revised: 28 July 2010 / Accepted: 30 July 2010 / Published: 3 August 2010
(This article belongs to the Special Issue Carbohydrates)

Abstract

:
This study was designed to document changes in total sugar intake and intake of added sugars, in the context of total energy intake and intake of nutrient categories, between the 1970s and the 1990s, and to identify major food sources contributing to those changes in intake. Data from the NHANES I and III were analyzed to obtain nationally representative information on food consumption for the civilian, non-institutionalized population of the U.S. from 1971 to 1994. In the past three decades, in addition to the increase in mean intakes of total energy, total sugar, added sugars, significant increases in the total intake of carbohydrates and the proportion of carbohydrates to the total energy intake were observed. The contribution of sugars to total carbohydrate intake decreased in both 1–18 y and 19+ y age subgroups, and the contribution of added sugars to the total energy intake did not change. Soft drinks/fluid milk/sugars and cakes, pastries, and pies remained the major food sources for intake of total sugar, total carbohydrates, and total energy during the past three decades. Carbonated soft drinks were the most significant sugar source across the entire three decades. Changes in sugar consumption over the past three decades may be a useful specific area of investigation in examining the effect of dietary patterns on chronic diseases.

Abbreviations

NHANES
National Health and Nutrition Examination Survey
CVD
cardiovascular diseases
NCHS/CDC
National Center for Health Statistics and the Centers for Disease Control and Prevention
FSD
U.S. Food Supply Data
CSFII
Continuing Survey of Food Intakes by Individuals
HFCS
high-fructose corn syrup

1. Introduction

Sugars are a ubiquitous component of our food supply. They are consumed as a naturally occurring component of our diet and as additions to foods during processing, preparation, or at the table. A healthy diet contains at least some amount of naturally occurring sugars, because monosaccharides, such as glucose and fructose, and disaccharides, such as sucrose and lactose, are integral components of fruit, vegetables, dairy products, and many grains [1]. Sugars also add desirable sensory effects and promote enjoyment of foods. Over the years, however, sugar intake has been claimed to be associated with several diet-related chronic diseases: diabetes, CVD, obesity, dental caries, and hyperactivity in children [2,3]. One of overwhelming concerns regarding sugars is the potential for excess energy intake from sugars resulting in weight gain and displacement of more nutrient-dense foods [2]. However, little attention has been given to the contribution of sugar and carbohydrates to total energy intake.
In explaining the relationship of certain nutrients or dietary patterns to chronic disease, it is important to examine not only the total intake of macronutrients and their components, but also their contribution to total energy intake. We have reported on the association between diabetes biomarkers and increased percent of energy intake from carbohydrates [4], and reported changes in U.S. children’s beverage consumption patterns in the past decades [5]. However, previous studies on the trends of nutrient intakes in the U.S. [6,7,8,9] provided only limited evidence to help explain health impacts associated with consumption of simple and complex carbohydrates, with their ratios to total carbohydrate intake, and with changes in food supply and processing practices. Furthermore, these earlier studies utilized vastly different methodologies, complicating any effort to draw inferences about the relationship of sugar intake to health impacts [10].
Trends of sugar consumption in the U.S. have typically been calculated based on the per capita sugar consumption estimates reported annually by the Economic Research Service using the market disappearance data [11]. These per capita estimates, however, do not take account of differences between the amount purchased and the amount actually consumed. Therefore, it is important to use data on actual consumption, gathered utilizing relatively consistent survey and sampling methods to achieve representative results for the national population. Previous studies analyzing a series of NHANES data documented a steep increase in the prevalence of obesity from mid 1970s through 2000 [12], and a number of studies have shown a significant association between sugar and obesity, especially in children and adolescents [13,14,15]. Therefore, the objectives of this study were to determine trends in the U.S. population and age subgroups, from the 1970s to the 1990s, in total sugar intake and intake of added sugars, in their contribution to total energy intake, and in the food groups contributing principally to sugar and energy intakes. The data for the study were drawn from the National Health and Nutrition Examination Survey, NHANES, I and III (National Center for Health Statistics 1985; 1998).

2. Methods

2.1 Characteristics of Datasets

The NHANES I and III were conducted by the National Center for Health Statistics and the Centers for Disease Control and Prevention (NCHS/CDC) through interviews, questionnaires and examinations. The purpose of the surveys was to obtain nationally representative information on the health and nutritional status of the civilian, non-institutionalized population of the U.S. (NHANES I, 1971–1975; NHANES III, 1988–1994) [16,17,18]. Details of survey procedures, handling of samples and analytical procedures are described elsewhere [18]. The characteristics of the NHANES I and NHANES III data sets are shown in Table 1. Data for NHANES I were gathered from 20,195 participants, ages 1 to 74 y, and for NHANES III were gathered from 28,663 participants, ages 1 to 90 y. Subjects with unreliable and incomplete dietary recall records as coded by NCHS were excluded in this study. A listing of the 1,823 unique foods recorded during collection of the 24-hour dietary recall data in the NHANES I was matched to a corresponding food item listed in the NHANES III nutrient database by name and nutrient composition. Both criteria were used to determine the most suitable match for all 1,823 foods. An appropriate match could not be identified for 12 foods (Table 1).

2.2 Study Design

An individual’s total sugar (g·d−1) intake was calculated as the sum of glucose, fructose, galactose, sucrose, maltose, and lactose intakes. The definition of “added sugars” was taken from the National Cancer Institute [19]: white sugar, brown sugar, raw sugar, corn syrup, corn syrup solids, high fructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, liquid fructose, honey, molasses, anhydrous dextrose, crystal dextrose, saccharin, and aspartame that are eaten separately or used as ingredients in processed or prepared foods. Data of total and added sugars were not available in the NHANES I database. Thus intakes of these nutrients for NHANES I were estimated by matching food codes to those listed in the NHANES III food composition tables. U.S.D.A.’s 53 food categories were used to estimate the food sources of dietary sugar and other nutrients [20].

2.3 Statistical Methods

All data analyses were carried out using SAS, release 8.1 (SAS Institute Inc, Cary, NC, USA) and Survey Data Analysis for multi-stage sample designs professional software package (SUDAAN, release 8.01, Research Triangle Institute, Research Triangle Park, NC, USA) [21]. SUDAAN was used to increase the validity of the results by computing variance estimates and test statistics for a stratified, multistage probability survey design. Sample weights were applied to all analyses to account for the unequal probability of selection, non-coverage, and non-response bias resulting from over-sampling of low-income persons, adolescents, the elderly, African-Americans, and Hispanics. Means and standard errors for all nutrients examined were calculated using PROC DESCRIPT in SUDAAN.
Table 1. Characteristics of NHANES I and NHANES III datasets.
Table 1. Characteristics of NHANES I and NHANES III datasets.
NHANES I (1971–1975)NHANES III (1988–1994)
Sample size20,19528,663
Age range1–74 y1–90 y
Individual food intake data353,664430,050
Number of individual foods3,4627,096
in the data set
Numbers of total sugar is _4,000
greater than 0 in NHANES III
Numbers of added sugar is_2,226
greater than 0 in NHANES III
Number of consumed foods1,8234,732
Number of non-matched foods12a_
Number of matched foods 1,811_
Nutrient variables in the datasetenergy, protein, fat, carbohydrate, saturated fatty acid,energy, protein, fat, carbohydrate, saturated fatty acid, oleic acid,
oleic acid, linoleic acid, cholesterol, vitamin A,linoleic acid, linolenic acid, monounsaturated fatty acid, polyunsaturated
thiamin, riboflavin, niacin, vitamin C, calcium,fatty acid, cholesterol, fiber, alcohol, vitamin A, retinol, β-carotene,
Phosphorus, iron, sodium, potassiumtocopherol, thiamin, riboflavin, niacin, vitamin B6, vitamin B12, folate,
vitamin C, calcium, phosphorus, manganese, iron, sodium, potassium,
glucose, fructose, galactose, sucrose, lactose, maltose, sugar, added sugar
Matched variables with NHANES IIIsugar, added sugar, fiber, β-carotene, folate,_
food composition tablevitamin B6, vitamin B12
a 12 food items in the individual food consumption data file of NHANES I could not be matched, because these items were not described in the food description file of NHANES I.

3. Results

3.1 Food Code Matches between NHANES I and NHANES III

Estimates of the NHANES I subjects’ nutrient intake levels generated by our food code matching technique (adopted from NHANES III) were comparable to those resulting from analysis of the original food codes of NHANES I. The values resulting from the food code matching technique and the analysis of the NHANES I data were, respectively: for total intake of food and beverages, 2,070 vs. 2,070 g·d−1; for total energy intake, 1,988 vs. 2,000 kcal·d−1; for total carbohydrate intake, 224 vs. 236 g·d−1; and for percent of energy intake from fat, 36% vs. 36% (Table 2).
Since the original NHANES I database did not contain sugar intake data, some means of estimating those intakes had to be devised. Since nearly identical values were obtained for the four test nutrient variables from food code matching estimates and from analysis of the original NHANES I data, we felt confident in using the food code matching technique to estimate sugar intake levels for NHANES I participants.

3.2 Changes in Sugar and Added Sugar Intake Levels from NHANES I to NHANES III

Compared with NHANES I, the mean dietary intake levels in NHANES III were greater for total energy intake (+144 kcal d−1; +7%), total sugar intake (+10 g d−1; +8%), intake of added sugars (+9 g d−1; +12%), and total carbohydrate intake (+40 g d−1; +18%) (Table 3). The results differed considerably by age subgroup. The change in mean total energy intake for participants ages 1 to 18 was lower by 3%, whereas it was higher by 11% for participants ages 19+ (Table 3). Mean total sugar intake and intake of added sugars increased for participants ages 1–18 by +0% and +5%, respectively, whereas the means for participants ages 19+ increased by +14% and +18%, respectively.
Table 2. Comparison of the mean nutrient intakes of the subjects in the NHANES I estimated based on the original and matched data.a,b
Table 2. Comparison of the mean nutrient intakes of the subjects in the NHANES I estimated based on the original and matched data.a,b
NutrientMeans from original datac (N = 20,195)Means from matched datad (N = 20,195)Differencee (%)
Energy (kcal·d−1)1,9882,0001
Carbohydrate (g·d−1)2242365
Protein (g·d−1)7976−4
Fats (g·d−1)8281−1
%Energy from fats (%)36360
Saturated fatty acid (g·d−1)30313
Cholesterol (mg·d−1)372329−12
Calcium (mg·d−1)8568580
Iron (mg·d−1)12138
Sodium (mg·d−1)2,2622,90128
Vitamin A (I.U.·d−1)4,7284,7831
Thiamin (mg·d−1)1.11.645
Riboflavin (mg·d−1)1.82.117
Niacin (mg·d−1) 172018
Vitamin C (mg·d−1)85906
Phosphorus (mg·d−1)1,2531,225−2
Potassium (mg·d−1)2,3252,62713
Total grams of food or beverage (g·d−1)2,0702,0700
a Sample includes those with reliable and complete dietary interview data.b Means are sample-weighted.c Nutrient intakes were calculated from original data of NHANES I (1971–1975).d Nutrient intakes were estimated by NHANES III food composition table through matching food codes of NHANES I to NHANES III.e Percent differences of matched means compared with original means.

3.3 Sources of Energy and Sugars in the U.S. Diets

Appendix A shows the changes in major contributing food items, from NHANES I to NHANES III, for participants ages 1–18 y. Major contributing food items for total energy intake changed (in descending order of importance) from fluid milk/breads/meats to mixtures of mainly grain/fluid milk/breads. Major contributing food items for total carbohydrate intake changed from breads/fluid milk/carbonated soft drinks to carbonated soft drinks/mixtures of grain/breads. Major contributing food items for total sugar intake changed from fluid milk/carbonated soft drinks/cakes, pastries, pies to carbonated soft drinks/ fluid milk/fruitades and drinks. Major contributing food items for intake of added sugars changed from carbonated soft drink/candies, sweets/cakes, pastries, pies to carbonated soft drinks/fruitades and drinks/candies, sweets.
Appendix B shows the changes in major contributing food items for adult participants (age 19+ y) for the same period. Major contributing food items for total energy intake changed from meats/breads/fluid milk to mixtures of mainly grain/breads/mixed meat dishes. Major contributing food items for total carbohydrate intake changed from breads/carbonated soft drinks/cakes, pastries, pies to breads/carbonated soft drinks/mixtures of grain. Major contributing food items for total sugar intake changed from carbonated soft drinks/fluid milk/sugars to carbonated soft drinks/cakes, pastries, pies/fluid milk. Major contributing food items for intake of added sugars changed from carbonated soft drinks/sugars/cakes, pastries, pies to carbonated soft drinks/cakes, pastries, pies/sugars.
The most salient feature of the changes in food items contributing to total energy intake is the rise of “mixtures of mainly grain” from relatively insignificant to the most significant contributor in both age subgroups. This food item includes mixtures having a grain product as a main ingredient, such as burritos, tacos, pizza, egg rolls, quiche, spaghetti with sauce, rice and pasta mixtures; frozen meals in which the main course is a grain mixture; noodle and rice soups; and baby-food macaroni and spaghetti mixtures [20].
Table 3. Comparison of the mean daily nutrient intakes between the NHANES I (1971-75) and NHANES III (1988-94).a, b
Table 3. Comparison of the mean daily nutrient intakes between the NHANES I (1971-75) and NHANES III (1988-94).a, b
All age1–18 y19+ y
NutrientNHANES INHANES IIIMean differencec (%)NHANES INHANES IIIMean difference (%)NHANES INHANES IIIMean difference (%)
n = 20,195n = 28,663n = 7,090n = 12,715n = 13,105n = 48,159
Total sugar (g·d−1)d, e1201308138139011012614
Added sugar (g·d−1)e, f77861288925718418
Calories (kcal·d−1)1,9882,13272,0181,962−31,9722,19811
Total fats (g·d−1)828208375−1081855
Percent energy from total fat (%)3634−63734−83634−6
Saturated fatty acid (g·d−1)3029−33228−133029−3
Cholesterol (g·d−1)372269−28328225−32396286−28
Total carbohydrates (g·d−1)22426418244259621326625
Dietary fiber (g·d−1)e13161913130141725
Protein (g·d−1)7978−17668−1180822
Calcium (mg·d−1)856837−21,043908−137558107
Iron (mg·d−1)121529111433121626
Total vitamin A (IU·d−1)4,7285,916254,1874,56595,0216,43828
Beta Carotene (µg·d−1)e1,9292,535311,6141,69452,1002,86036
Folate (µg·d−1)e23426514242238−122927520
Vitamin B-6 (mg·d−1)e1.61.8131.51.631.61.917
Vitamin B-12 (µg·d−1)e5.35.304.94.4−105.55.62
Thiamine (mg·d−1)1.11.7571.11.7481.11.861
Riboflavin (mg·d−1)1.82.0142.02.041.72.020
Vitamin C (mg·d−1)859058389787915
Total grams of food or beverage (g·d−1)2,0702,289111,7221,71802,2592,51011
a Sample includes those with reliable and complete dietary interview data. b Means are sample-weighted. c Percent differences of means of NHANESIII compared with NHANES I. d Total sugar is the sum of total glucose, fructose, galactose, sucrose, lactose, and maltose intakes. e Intakes of total sugar, added sugar, fiber, beta carotene, folate, vitamin B6, and vitamin B12 in NHANES I were estimated by NHANESIII food composition table through matching food codes of NHANES I to NHANES III. f One teaspoon of added sugars is converted to the quantity of a sweetener that contains the same amount of carbohydrate as 4.1 g of table sugar.
Table 4. Comparisons of food items which contribute to nutrient intake between the NHANES I and III by age subgroups.
Table 4. Comparisons of food items which contribute to nutrient intake between the NHANES I and III by age subgroups.
Age1–18 y19+ y
SurveyNHANES INHANES IIINHANES INHANES III
EnergyFluid milk321Mixtures of mainly grain230Meats (beef, pork, lamb, veal)236Mixtures of mainly grain175
(kcal d−1)Yeast breads and rolls193Fluid milk155Yeast breads and rolls204Yeast breads and rolls170
Meats (beef, pork, lamb, veal)150Yeast breads and rolls129Fluid milk156Mixtures mainly meat, poultry, fish151
Potatoes105Regular carbonated soft drinks105Cakes, pastries, pies104Meat (beef, pork, lamb, veal)123
Cakes, pastries, pies98Potatoes100Fats and oils95Cakes, pastries, pies110
Carbohydrate Yeast breads and rolls36Regular carbonated soft drink27Yeast breads and rolls38Yeast breads and rolls31
(g d−1)Fluid milk26Mixtures of mainly grain25Regular carbonated soft drink16Regular carbonated soft drink27
Regular carbonated soft drink18Yeast breads and rolls23Cakes, pastries, pies15Mixtures of mainly grain18
Cakes, pastries, pies15RTE cereals16Potatoes13Potatoes15
Potatoes14Fluid milk14Fluid milk13Cakes, pastries, pies15
Total sugar Fluid milk25Regular carbonated soft drink27Regular carbonated soft drink17Regular carbonated soft drink27
(g d−1)Regular carbonated soft drink18Fluid milk14Fluid milk13Cakes, pastries, pies9
Cakes, pastries, pies13Regular fruitades and drinks11Sugar and sugar substitutes12Fluid milk8
Regular fruitades and drinks9Candies, sweets9Cakes, pastries, pies11Tea6
Candies, sweets8Cakes, pastries, pies8Citrus juices6Regular fruitades and drinks6
Added sugarRegular carbonated soft drink18Regular carbonated soft drink27Regular carbonated soft drink17Regular carbonated soft drink27
(g d−1)Candies, sweets9Regular fruitades and drinks10Sugar and sugar substitutes12Cakes, pastries, pies7
Cakes, pastries, pies9Candies, sweets9Cakes, pastries, pies8Sugar and sugar substitutes6
Regular fruitades and drinks9Syrups, jellies and desserts6Syrups, jellies and desserts5Regular fruitades and drinks6
Sugar and sugar substitutes6Cakes, pastries, pies6Yeast breads and rolls4Candies, sweets5
The major food groups contributing to total sugar intake and intake of added sugars have remained carbonated soft drinks/fluid milk/sugars, cakes, pastries, and pies. Soft drinks were identified as the most significant source of added sugars, contributing 27 g of sugar intakes daily in NHANES III. The percentage of total sugar intake from soft drinks significantly increased by 49% and 39% for ages 1–18 and 19+, respectively, from NHANES I to NHANES III. In contrast, total sugar intake from milk and milk products dropped by 44% in 1–18 y subjects and 46% in 19+ y subjects, respectively, during the same time period. Sugar intake levels from cookies and breakfast grains remained relatively the same during this time period (Table 4).

3.4 Contribution of Individual Sugars to Total Sugar Intakes

There were differences in the two time periods in the relative contribution of major food groups to average intakes of individual sugars, as a consequence both of changes in food processing and changes in food preferences [22,23]. Carbonated soft drinks, however, remained the greatest contributor to glucose and fructose intakes in all age groups, and fluid milk remained the principal source for lactose intake (Appendix A and Appendix B). Cakes, pastries and pies remained the principal source for sucrose intake in the 1–18 y age subgroup. Contribution of glucose and fructose to total sugar intake increased from 17% to 22% (23.4 to 30.7 g·d−1) and 16% to 21% (22 to 27 g·d−1), respectively, for 1–18 y old subjects and 18% to 22% (20.3 to 27.9 g·d−1) and 18% to 21% (21.7 to 29.7 g·d−1) for over 19 y old subjects, respectively. Lactose intake has deceased for three decades owing to the decrease in milk consumption and the contribution of lactose to total sugar intake decreased from 22% to 16% (30.9 to 21.6 g·d−1) for 1–18 y old subjects and from 16% to 11% (17.3 to 14.2 g·d−1) for over 19 y old subjects, respectively (Figure 1).
Figure 1. Comparison of the contribution (%) of individual sugars* to the total sugar intakes between the NHANES I and III by age subgroups.
Figure 1. Comparison of the contribution (%) of individual sugars* to the total sugar intakes between the NHANES I and III by age subgroups.
Nutrients 02 00834 g001

4. Discussion

Research findings on the assessment of added sugar intake in the U.S. population have been based on two main sources of data: the U.S. Food Supply Data (FSD) series [24] and the Continuing Survey of Food Intakes by Individuals (CSFII) [25,26], both products of the USDA. The Food Supply Series tracks the quantities of foods that flow through the food marketing system.
The FSD estimates are made at the commodity level. As a result, the data can be used to track changes in the total volumes (and population averages) of specific wholesale products (cane sugar, beet sugar, the various corn sweeteners) that contribute to sugar intake, and categories of their uses (as in beverages and baked goods, for example) [27]. However, since there are losses to domestic use by individual consumers through both waste at various stages of processing, and export, use of these data for population averages requires adjustment of the estimates to account for these losses. The resulting data is therefore less exact than could be hoped for [24]. The CSFII, which has been considered an ideal metric for the concept of added sugars in both Dietary Guidelines and the Food Guide Pyramid [27], provides data on food and nutrient intakes during only 1988–1991, 1994–1996 and 1998. Since 2002, this nationwide dietary intake database has been integrated with NHANES and the data collected as part of NHANES on a yearly basis. The NHANES databases provide a superior longitudinal data source, since they contain earlier data than the CSFII and have a longer period of continuity.
The Institute of Medicine [28] reported that people whose diets are high in added sugars have lower intakes of essential nutrients (Ca, Mg, Mg, Fe, Zn, vitamin A and E). It further suggests that added sugars should comprise no more than 25 percent of total calories consumed. In the present study, contribution of each macronutrient to the increased total energy intake was taken into consideration. We observed a significant increase in the total intake of carbohydrates (224 to 264 g·d−1) and the ratio of carbohydrates to the total energy intake (45 to 50%), while the contribution of sugars to total carbohydrate intake has decreased in both 1–18 y (57 to 54%) and 19+ y (52 to 47%) (Figure 2); while the contribution of added sugars to the total energy intake has not changed. These findings point to the need for more research into the particular nutritional components related to specific health concerns.
Several recent studies have suggested total sugar intake and intake of added sugars in the U.S. is related to the development of chronic diseases [26]. Some of these studies in particular identify carbonated soft drinks as a major contributor to energy intake and body weight gain [13,14,15]. Harnack et al. [29] reported that children's soft drink consumption had increased during the past three decades by providing 188 kcal·d−1 extra energy to soft drink consumers beyond that to non-consumers [29]. St-Onge [15] further suggested that these changes in food intakes among children may partly explain the rise in childhood obesity in the past few years. Adolescents consuming high sugar diets are also reported to be at increased risk for poor health [30] and consumption of sugar-added beverages may contribute to weight gain among adolescents probably due to their contribution to total energy intake [13].
The present study shows that energy intake in the 1–18 y subgroup actually decreased during the past three decades, unlike the increase of energy intake among 19+ y age subgroup. In addition, the percentages of energy intake from total carbohydrates increased by 4% and 5% in the 1–18 y and 19+ y age subgroups, respectively, while those from added sugar intake increased by only 1% in both age subgroups. Therefore, even though current trends in health promotion emphasize the importance of increasing carbohydrate intake and reducing fat intake (particularly saturated fat intake), concern has focused on sugar consumption from soft drinks as a main contributor to total energy intake.
Consumption of added sugars in the U.S. has increased steadily as documented by both FSD and nationwide food consumption survey data. According to U.S. FSD, per capita consumption of added sugars by Americans went from 111 g·d−1 in 1970 to 131 g d−1 in 1996, an increase of 23% [24]. These data are adjusted for spoilage, other losses accumulated throughout the marketing system and home waste losses. Food consumption survey data also demonstrate an increase in intake of added sugars. According to the USDA CSFII of Americans over 2 y old, consumption of added sugars rose from 64 g·d−1 in 1989–1991 to 84 g·d−1 in 1994–1996, an increase of 31% in less than ten years. In 1989–1991, added sugars accounted for 13.2% of total daily energy intake, whereas in 1994–1996 they accounted for 15.8% [27]. Although the data from each source indicate an increase in the consumption of added sugars, these increases have not previously been considered in the context of overall changes in macronutrient contribution to total energy intake. Data in the present study confirm the increase in intake of added sugars found in earlier studies, but while the increase in the intake of added sugars during the past three decades was 12% (77 g·d−1 to 86 g·d−1), its contribution to the energy intake rose less than 4%. This may be too little to account for the increased prevalence in obesity during the same period. Consistently, Sun and Empie [31] failed to find any association between obesity risk and usual sugar-sweetened beverage consumption in adults via analyzing databases of CSFII-1989–1991, CSFII-1994–1998, NHANES III, and combined NHANES 1999–2002 [31]. Animal studies show that carbohydrate-induced obesity is not unique to sweet-tasting sugars, but can also be produced by bland-tasting polysaccharides [32]. These studies as well as the present findings suggest that other carbohydrate categories which contribute more to total energy intake may be more important in examining the growing prevalence of obesity.
A more serious nutritional change related to the increase in intake of added sugars may be the apparent substitution of carbonated soft drink consumption for consumption of fluid milk [5]. Fluid milk was the principal nutritional contributor of energy intake for the 1–18 y age group in the 1970s. Its decreased contribution in the 1990s, and the increased contribution of carbonated soft drinks, may account for much of the decrease in total energy intake and percent energy intake from fat in that age group, as well as the decrease in intakes of calcium and lactose [6]. Overall, the effect of increased intake of added sugars, as it has replaced intake of intrinsic sugars such as lactose and fructose, has been to compromise the intake of more nutritious foods and impeded compliance with current dietary guidelines [6].
The amount and type of carbohydrate intake have also received significant attention with increasing prevalence of type 2 diabetes [33], which is highly associated with overweight. The switch from sucrose to high-fructose corn syrup (HFCS) as the sweetener, particularly in the US beverage industry since 1980s, has been suggested to explain the exponential growth of obesity in the U.S. [10] Gross et al. [33] reported that increased consumption of HFCS contributed to the increase of energy intakes and consequently to the prevalence of chronic diseases such as type 2 diabetes. Since fructose has higher sweet intensity than sucrose, theoretically the amount of HFCS to yield the same hedonic values would be less than that of sucrose. Clinical and epidemiological studies [10,34,35] have studied the effects of sucrose and fructose on incidence of obesity and other chronic diseases based on the estimates of consumption. Teff et al. [10], for example, estimated per capita consumption of added fructose being 81 g·d−1. The authors based their estimation of added fructose consumption on the average per capita FSD of 1997 [36], and then combined fructose from HFCS and fructose in the sucrose molecule [10]. In the present study of the NHANES III, we documented that American’s fructose consumption is 30 g·d−1 and 27 g·d−1 for 1–18 y and 19+ y sub-groups, respectively. Both groups consumed an average of 54 g·d−1 of sucrose.
Differences between the two studies are noteworthy (28 g·d−1vs. 81 g·d−1). We find it important to understand why, in order to assist future investigations in this important area of research. First, per capita disappearance data differ vastly from actual consumption [36]. According to the USDA report [24], loss of refined and beet sugars at retail, food service and consumer levels is estimated to be 31%. Secondly, dietary intake data of an individual or population are reported as consumed in the form of food, beverage and supplements, not in metabolized forms. The USDA [20] and DHHS [17] provide dietary intake data of individual forms of simple sugars, i.e., glucose, fructose, galactose, lactose, sucrose, maltose, etc. If one was to estimate the total fructose intake by including fructose metabolized from sucrose, others may argue that glucose metabolized from maltose or starch should be considered in the glucose consumption estimates. Another consideration coming from the study of Duffey and Popkin [37] is that the concept of “total fructose” (including metabolized fructose from sucrose) might hide the truth that fructose consumption has been increasing, because their study showed that total fructose has changed relatively little compared with the change in free fructose and HFCS over the past two decades. American’s per capita consumption of HFCS has increased along with glucose consumption in the U. S. However, the estimated fructose intake cited in the research papers has been overestimated, and might potentially mislead the nutritional science community.
Figure 2. Comparison of the contribution (%) of individual carbohydrates to the total carbohydrate intakes between the NHANES I and III by age subgroups.
Figure 2. Comparison of the contribution (%) of individual carbohydrates to the total carbohydrate intakes between the NHANES I and III by age subgroups.
Nutrients 02 00834 g002
Our study has limitations. Firstly, since NHANES I included people aged 1–74 years, while NHANES III included people aged 1–90 years, the data for 19+ y subpopulation in the two datasets were not identical. NHANES I (1971–1975) and NHANES III (1988–1994) had different food codes to reflect changes in prevalent dietary behaviors, food commodities and lifestyles in the different time periods. The NHANES I database did not contain estimates of sugar intake levels. Using NHANES I and NHANES III to examine trends in sugar intakes, therefore, required us to develop a food code matching technique. Considering the long time span between the two surveys, the food composition under the same food name might have changed. For example, high-fructose corn syrup (HFCS) has been used as added sweetener, however, the percentage of HFCS of total sweetener has dramatically increased from 0.5% to 37.5%, although total fructose (sum of free fructose and fructose contained in sucrose) availability changed only slightly over the same time period [37]. Although data for HFCS consumption are not available in 1970’s, the results in Table 2 showed that our matching technique was effective and efficient in analyzing unknown sugar information in NHANES I.

5. Conclusions

The choice of database is critical in estimating food and nutrient intake. The technique we developed to match food codes in the NHANES datasets allows for their use as a source of reliable data on nutrient and energy intakes in general, and sugar intakes in particular, in the U.S. increased intakes of total and added sugars and carbohydrates have primarily accounted for the increase in energy intakes over the last two decades. The present study indicates that the overall increase in carbohydrate intake has by far exceeded the increase in intake of added sugars, and, thus, more specifically identifies the principal nutritional contribution associated with the rapid rise in obesity in the U.S. over the past three decades. In particular, although soft drink consumption is a major contributor to increased energy intake, the contribution to energy intake from “mixtures of mainly grain” has increased dramatically and is now the principal contributor to energy intake. Increased carbohydrate intake overall is mainly due to the increased availability and consumption of prepared, frozen and takeout meal combinations. Overall, this study points to the need for ongoing research on the specific nutritional contributors to total energy intake, and their potential contribution to increasing prevalence of obesity.

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Appendix A. Comparisons of the order of food items which contribute to energy, carbohydrate and sugar intakes of the subjects aged 1–18 y between the NHANES I and III.
Appendix A. Comparisons of the order of food items which contribute to energy, carbohydrate and sugar intakes of the subjects aged 1–18 y between the NHANES I and III.
NutrientsMacronutrientsIndividual sugars
Food itemsEnergyCHOTotal sugarAdded sugarGlucoseFructoseGalactoseSucroseLactoseMaltose
SurveyIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Apples3135192315181924814452836142133472025
Bananas3838282924224651141519152937182034424149
Beer4140394342474952373530344248515345531916
Cakes, pastries, pies574735351112172123251111121011
Candies, sweets1212795423448103510334732
Cheese211743383635443947404741234750963731
Citrus fruits3644253517283736132711202533152730441621
Citrus juices2423151687242223242634201931453548
Coffee5353515152524745525052525240524852485250
Cookies713614912882421212345514813172717
Crackers2927232734292221333732364621272349392435
Creams and cream substitutes4645474840413031354543481428364016162327
Dark green vegetables4847464644435349343833354824404250195143
Deep yellow vegetables434636392936283031332833495226325131813
Dried fruit4749424235344244262323192735464632464039
Eggs1624414430384143212648421613454312133832
Fats and oils818444133321520293024243215373314144233
Fish and shellfish283138374851323341463945926434948414953
Fluid milk1225123447465141507183551112842
Hot cereals3332272838303838283627301930342524151728
Legumes262820242737202527322531107233125293326
Low-calorie carbonated soft drinks4952525253533634535353535343535253505351
Low-calorie fruitades and drinks45363426511331115075063945491442513146
Meats (beef, pork, lamb, veal)3848473948514145472946119334123384744
Melons and berries4043313620262926202510183038162435331222
Milk desserts101611186107710172222155792313
Milk drinks181117101361293819382713611632227
Miscellaneous alcoholic beverages5148535349505046514951494349394546354647
Miscellaneous nonalcoholic beverages425133491144103215441538404683643264541
Mixtures of mainly graina61922117161616914941241810499
Mixtures mainly meat, poultry, fishb146221226202115231320121192817882614
Mixtures of mainly vegetables3942354046422542433936371220443819252919
Noncitrus juices and nectars34252415188352395733114301337323030
Nuts and seeds2022323331332627323145291727252926373429
Organ meat, sausages, lunchmeat1114404532394048252242444450323947361315
Other fruits and mixtures303018201416131771057541315362455
Other vegetables2229162123242329191816165112172620201423
Pasta3737303041454550394135392232414428431818
Popcorn, pretzel, corn chips2719261937312728302831282423313029271512
Potatoes455625253340172013174782934795040
Poultry191045324549525336423743622424722404852
Quick breads, pancakes, fresh toast13151213222317182224262681719225112120
Regular carbonated soft drinks943121111111374262404964
Regular fruitades and drinks17201084342323238445541284436
Rice3221211143403935403434322116383527213934
RTE cereals1598416911618161814203110418231110
Sugar and sugar substitutes2539143172151242484447333921138304338
Syrups, jellies and desserts23261317101164569113411910212221
Tea443337222815181349524951364122739342545
Tomatoes35342925191914141211121350532116151876
Wine5050495050464837444340404147503744523237
Yeast breads and rolls231312149106868182912126548
Yogurt52415034472743194829462532482817103624
a Mixtures of mainly grain include mixtures having a grain product as a main ingredient, such as burritos, tacos, pizza, egg rolls, quiche, spaghetti with sauce, rice and pasta mixtures; frozen meals in which the main course is a grain mixture; noodle and rice soups; and baby-food macaroni and spaghetti mixtures.b Mixtures mainly meat, poultry, fish includes mixtures having meat, poultry, or fish as a main ingredient, such as chicken cacciatore; beef loaf; chili con carne; venison stew; hash; tuna salad; corn dog; chicken soup; frozen meals in which the main course is a meat, poultry, or fish item; meat, poultry, or fish sandwiches coded as a single item (for example, cheese burger on a bun); and baby-food meat and poultry mixtures.
Appendix B. Comparisons of the order of food items which contribute to energy, carbohydrate and sugar intakes of the subjects aged 19+ y between the NHANES I and III
Appendix B. Comparisons of the order of food items which contribute to energy, carbohydrate and sugar intakes of the subjects aged 19+ y between the NHANES I and III
NutrientsMacronutrientsIndividual sugars
Food itemsEnergyCHOTotal sugarAdded sugarGlucoseFructoseGalactoseSucroseLactoseMaltose
SurveyIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Apples35432229131922321017343037182234442228
Bananas443629232518465119918143138221335424252
Beer10121219283549522414152143505153465343
Cakes, pastries, pies45354232111514182521219121012
Candies, sweets202215171087512103023361445101165
Cheese151442473337444446464744234751453837
Citrus fruits3649234015293527132812222734132631461725
Citrus juices212891557254722222835202032473650
Coffee4541513252474728534852525242523752215232
Cookies1918111612129102726232746525616192920
Crackers2931252638382423364134424725292949402734
Creams and cream substitutes3237354430311420253143431630374059811
Dark green vegetables5045464345445349353932334920394150175145
Deep yellow vegetables47483437323030333235293050292424513798
Dried fruit5151414636343845232221192936404733484144
Eggs1219434531364241142548381812464212143930
Fats and oils59443835281516282420201313343014153026
Fish and shellfish232340344951323440473645822434948434951
Fluid milk3851023364347514450154146113338
Hot cereals4140313141464046334431412131363823181831
Legumes24252121343221223034263198252526253127
Low-calorie carbonated soft drinks4953525353533429535353535345535253515353
Low-calorie fruitades and drinks5250474151263714501650124047492843353247
Meats (beef, pork, lamb, veal)1449503950514245502548317324424414748
Melons and berries424728351823262616209153239141836361322
Milk desserts17171418798715182224176772212
Milk drinks3333262719161312443241351591510332414
Miscellaneous alcoholic beverages2230534821335025513051254451113147284624
Miscellaneous nonalcoholic beverages485238521441103722371932414883444294546
Mixtures of mainly graina1118326202019201317116228231381210
Mixtures mainly meat, poultry, fishb7319722151913181216101272715842515
Mixtures of mainly vegetables4346364246482739394235391123384518223439
Non-citrus juices and nectars4044273020212931911853340262738492835
Nuts and seeds2724373940393338373845361927313227393536
Organ meat, sausages, lunchmeat813455137433948262742474528334325341519
Other fruits and mixtures30341824111311216656741214373256
Other vegetables1820101316172324881081411161620201621
Pasta3935302848494550434338402433454829451923
Popcorn, pretzel, corn chips3821322243423135343639372624353530302116
Potatoes664424272836172113174816303311105040
Poultry161048364752525338453346519445022384849
Quick breads, pancakes, fresh toast1311792325181821232828101821176132318
Regular carbonated soft drinks972211111111384434415074
Regular fruitades and drinks282716126564334339469842334442
Rice311520650454140424037342310423928264043
RTE cereals26161782714161129192416223219919231413
Sugar and sugar substitutes142961436234149404934411339164333
Syrups, jellies and desserts25321320811465511133515611212721
Tea4626331129412849524951374317240312041
Tomatoes34382425172217177779515323211724119
Wine3739394942404830313327294249503645522629
Yeast breads and rolls2211910594467202610127637
Yogurt5342503344244315482946264148191573717
a Mixtures of mainly grain include mixtures having a grain product as a main ingredient, such as burritos, tacos, pizza, egg rolls, quiche, spaghetti with sauce, rice and pasta mixtures; frozen meals in which the main course is a grain mixture; noodle and rice soups; and baby-food macaroni and spaghetti mixtures.b Mixtures mainly meat, poultry, fish includes mixtures having meat, poultry, or fish as a main ingredient, such as chicken cacciatore; beef loaf; chili con carne; venison stew; hash; tuna salad; corn dog; chicken soup; frozen meals in which the main course is a meat, poultry, or fish item; meat, poultry, or fish sandwiches coded as a single item (for example, cheese burger on a bun); and baby-food meat and poultry mixtures.

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Chun, O.K.; Chung, C.E.; Wang, Y.; Padgitt, A.; Song, W.O. Changes in Intakes of Total and Added Sugar and their Contribution to Energy Intake in the U.S. Nutrients 2010, 2, 834-854. https://0-doi-org.brum.beds.ac.uk/10.3390/nu2080834

AMA Style

Chun OK, Chung CE, Wang Y, Padgitt A, Song WO. Changes in Intakes of Total and Added Sugar and their Contribution to Energy Intake in the U.S. Nutrients. 2010; 2(8):834-854. https://0-doi-org.brum.beds.ac.uk/10.3390/nu2080834

Chicago/Turabian Style

Chun, Ock K., Chin E. Chung, Ying Wang, Andrea Padgitt, and Won O. Song. 2010. "Changes in Intakes of Total and Added Sugar and their Contribution to Energy Intake in the U.S." Nutrients 2, no. 8: 834-854. https://0-doi-org.brum.beds.ac.uk/10.3390/nu2080834

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