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Time and Age Trends in Free Sugar Intake from Food Groups Among Children and Adolescents Between 1985 and 2016

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Time and Age Trends in Free Sugar Intake from Food Groups Among Children and Adolescents Between 1985 and 2016 nutrients Article Time and Age Trends in Free Sugar Intake from Food Groups among Children and Adolescents between 1985 and 2016 Ines Perrar 1, Alena M. Schadow 1, Sarah Schmitting 1,2, Anette E. Buyken 3 and Ute Alexy 1,* 1 Institute of Nutritional and Food Sciences-Nutritional Epidemiology, University of Bonn, Donald Study Dortmund, Heinstück 11, 44225 Dortmund, Germany; [email protected] (I.P.); [email protected] (A.M.S.); [email protected] (S.S.) 2 Institute of General Practice and Family Medicine, Faculty of Medicine, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany 3 Institute of Nutrition, Consumption and Health, Faculty of Natural Sciences, Paderborn University, Warburger Straße 100, 33098 Paderborn, Germany; [email protected] * Correspondence: [email protected]; Tel.: +49-231-7922-1016 Received: 27 November 2019; Accepted: 17 December 2019; Published: 20 December 2019 Abstract: Trend analyses suggest that free sugar (FS) intake—while still exceeding 10%E—has decreased among German children and adolescents since 2005, yet that intakes may shift from sugars naturally occurring in foods to added sugars as children age. Thus, we analysed time and age trends in FS intake (%E) from food groups among 3–18 year-olds (1985–2016) using 10,761 3-day dietary records from 1312 DONALD participants (660 boys, 652 girls) by use of polynomial mixed-effects regression models. Among girls, FS from sugar & sweets decreased from 1985 to 2016 (linear trend p < 0.0001), but not among boys (p > 0.05). In the total sample, FS intake from juices increased until 2000 and decreased since 2005 (linear, quadratic trend p < 0.0001). FS from sugar sweetened beverages (SSB) decreased non-linearly from 1985 to 2016 (girls: linear, quadratic, cubic trend p < 0.0001; boys: linear, quadratic, cubic trend p < 0.02). Younger children consumed more FS from juices than older ones, who had a higher FS intake from SSB. FS intake from sugar & sweets increased until early adolescence and decreased afterwards. Since sugar & sweets represent the main source of FS intake and the source with the least pronounced decline in intake, public health measures should focus on these products. Keywords: free sugar; trends; children; adolescents; food groups 1. Introduction A high dietary sugar intake is thought to contribute to the development of several diseases such as dental caries [1], overweight and obesity [2–5], cardiovascular diseases [6–8] or metabolic syndrome [9]. With the recent shift towards food-based recommendations, evidence has emerged regarding the relevance of specific food source of sugar for health outcomes [10–16]. In particular, a high intake of sugars from liquid sources may be detrimental for health: Due to a lack of satiety [17] and incomplete compensation of liquid calories [10], a high sugar intake from SSB promotes weight gain and the development of overweight [3,12,13,18] or diabetes [11,15]. Since pure juices can have sugar and energy contents similar to SSB [16], intakes of juices are also of public health relevance. Within the term “free sugar” [15] the World Health Organization (WHO) considers “all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices” [19]. In addition, the UK Scientific Advisory Committee on Nutrition (SCAN) has recently recommended extending the term of FS to fruits and Nutrients 2020, 12, 20; doi:10.3390/nu12010020 www.mdpi.com/journal/nutrients Nutrients 2020, 12, 20 2 of 19 vegetables purees and pastes and similar products in which the cell structure was destroyed during processing [20,21]. International and national organizations recommend limitting FS intake to a maximum of 10% of energy intake (%E) [20–23]. However, this recommendation as well as some possible health consequences of high sugar intake are controversially discussed, in particular by the food industry [24,25]. As the sweet preference is higher in childhood and adolescence than in adulthood [26–28], these ages are particularly vulnerable to the health consequences of high sugar intakes. In fact, recent publications indicated a high intake of FS among European children and adolescents, exceeding the 10%E limit to a larger extent than among adults [29–31]. Such a high sugar intake may be of particular relevance, as adolescence is suggested to be a “critical period” for the development of various diseases in later life [32–35] and dietary patterns have been shown to track into adulthood [36]. However, dietary habits may change with time and with increasing age, as the sweet preference is already decreasing from childhood to adolescence [26–28]. Recent trend analyses among German children and adolescents from the DONALD (Dortmund Nutritional and Anthropometric Longitudinally Designed) study cohort showed a decline in free sugar intake (in %E, model adjusted among others for overweight status) since 1985, most notably since 2010 [30]. Age trends in total, added and free sugar intake suggest a shift from those sugars naturally occurring in fruits, milk, and juices to those added to foods and beverages, e.g., sweets and sweetened beverages from 3 to 18 years of age [30]. However, as daily FS intake still exceeded 10%E over the complete study course and age range [30], initiatives to further reduce FS intake among children and adolescents are needed. For the development of tailored public health measures for FS reduction, data on FS food sources preferred by children and adolescents are crucial. Therefore, we analysed time and age trends in food group sources of FS from three decades (1985–2016) among children and adolescents aged 3–18 years, using data from 3-day weighed dietary records from the DONALD study. 2. Materials and Methods 2.1. Study Sample The DONALD study is an ongoing, open cohort study conducted in Dortmund, Germany, which started to collect information on diet, growth, development and metabolism of healthy children and adolescents in 1985. Since then, 35–40 infants are newly recruited every year. Eligible are healthy German infants (i.e., infants free of diseases affecting growth and/or dietary intake), whose parents are willing to participate in a long-term study and of whom at least one has sufficient knowledge of the German language. The participants are first examined at the age of 3 months and return for three more visits in the first year, two in the second year and thereafter annually until young adulthood. In the first study years, approximately 300 participants >2 years old were also recruited. Yearly examinations include 3-day weighed dietary records, anthropometric measurements, collection of 24-h urine samples (starting at age 3–4 years), interviews on lifestyle and medical examinations. Parental examinations (anthropometric measurements, lifestyle interviews) take place every four years. Further details on the study have been described elsewhere [37,38]. The study was approved by the Ethics Committee of the University of Bonn according to the guidelines of the Declaration of Helsinki, and all examinations are performed with parental and later on, children’s written consent. At the start of the dataset compilation for the current investigation (October 2017) 17,107 records were available from the DONALD database. Incomplete records (<3 days, n = 176) were excluded as well as records from <3 years old (n = 5618) or >18 years old (n = 421) participants and records carried out after December 2016 (n = 131). For the present evaluation, we hence analysed 10,761 complete dietary records from 1312 DONALD study participants (660 boys, 652 girls). Per participant, between one (n = 153, 11.7%) and sixteen (n = 184, 14.0%) dietary records [median (Q1; Q3): 8 (3; 13)] were available. Nutrients 2020, 12, x FOR PEER REVIEW 3 of 19 Nutrients 2020, 12, 20 3 of 19 2.2. Nutrition Assessment 2.2. NutritionDietary intake Assessment in the DONALD study is assessed using 3-day weighed dietary records. All foodsDietary and beverages intake in theconsumed DONALD by studythe child, is assessed as well using as leftovers, 3-day weighed are weighed dietary and records. recorded All foods over andthree beverages consecutive consumed days by by the the parents child, asor wellby the as leftovers,older participants are weighed themselves, and recorded with overthe use three of consecutiveelectronic food days scales by the (±1 parents g). The or participants by the older participantschoose the day themselves, of the beginning with the useof dietary of electronic recording food scaleswithin ( a1 given g). The period participants of time. choose When the exact day weig of thehing beginning is not possible, of dietary household recording measures within a given(e.g., ± periodspoons, of cups) time. are When allowed exact for weighing semi-quantitative is not possible, recording. household Information measures on recipes (e.g., spoons, (ingredients cups) and are allowedpreparation) for semi-quantitative and on the types recording.and brands Information of food items on consumed recipes (ingredients is also requested. and preparation) Medication and and on thedietary types supplement and brands use of foodare also items recorded consumed but iswere also excluded requested. from Medication this analysis. and dietary A trained supplement dietitian usechecks are alsothe dietary recorded records but were for excludedaccuracy fromand thiscompleteness. analysis. ASubsequently, trained dietitian energy checks and the nutrition dietary
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