Numerous countries have established recommendations on the maximum intake of added sugars or non-milk extrinsic sugars (NMES) based on the documented relationship with dental caries formation. In the UK, the recommendation for the total population is that NMES sugars intakes should be kept below 60 g/d, which relates to ≤ 10 % total energy ( ≤ 11 % food energy)(1).
A WHO report on diet, nutrition and the prevention of chronic diseases found that the best available evidence indicates that the level of dental caries is low in countries where the consumption of free sugars is < 15–20 kg/year (40–55 g/d). This relates to 6–10 % of energy intake and approximately ten to fourteen level teaspoons of sugar (one level teaspoon contains 4 g sugar and 67 kJ (16 kcal))(2). The report also highlighted that in addition to population targets given in terms of the amount of free sugars, targets for the frequency of consumption of foods containing free sugars are important. The report presented several studies(Reference Gustafsson, Quensel, Lanke, Lundquiat, Grahnen, Bonow and Krasse3–Reference Holbrook, Arnadottir, Takazoe, Birkhed and Frostell6) which indicate that when the frequency of sugar intake exceeds four times per d, there is a marked increase in caries prevalence. Based on these findings, the recommendations on sugar intakes given in the report also advises that frequency of consumption of foods and/or drinks containing free sugars should be limited to a maximum of four times per d.
To the best of our knowledge, no other study has examined the quantitative relationship between 10 % total energy from added sugars and frequency (four times per d) of added sugar intakes in children, teenagers and adults. The aims of the present paper are to assess the frequency of consumption of added sugars in Irish children, teenagers and adults and to determine if there is a quantitative relationship between 10 % total energy from added sugar and frequency (four times per d) of added sugar intake.
Methods
Population samples
The analysis for the present paper is based on data from the cross-sectional North/South Ireland Food Consumption Survey (NSIFCS), the National Children's Food Survey (NCFS) and the National Teen Food Survey (NTFS). The NSIFCS (1997–9), NCFS (2003–4) and NTFS (2005–6) were carried out on representative samples of Irish adults (aged 18–64 years; n 1379), children (aged 5–12 years; n 594) and teenagers (aged 13–17 years; n 441) respectively. A more detailed account of the sampling methods and methodology used in the NSIFCS(Reference Harrington, Robson, Kiely, Livingstone, Lambe and Gibney7, Reference Kiely, Harrington, Robson, Flynn and Cran8) and the NCFS(9) are available elsewhere.
Data collection in the National Teen Food Survey
A 7 d food diary was used to collect food and beverage intake data. During the 7 d period the researcher made four visits to the respondent: a training visit to show how the food diary was kept; a second visit 24–36 h into the recording period to review the diary, check for completeness and clarify details regarding specific food descriptors and quantities; a third visit 4 or 5 d into the recording period to check the previous 2 or 3 d and to encourage completion; a final visit 1 or 2 d after the recording period to check the last days and to collect the diary.
The respondents were asked to record detailed information regarding the types and amounts of all foods, beverages and nutritional supplements consumed over the 7 d period, the cooking method used (where applicable), the brand name of foods (where appropriate), details of recipes and any leftovers and food packaging information. Data were also collected on the time of each eating or drinking occasion, the respondent's definition of each eating or drinking occasion (for example, morning snack, lunch, etc) and the location of the preparation or source of the meal or snack consumed (for example, home, work, takeaway, etc). Self-administered questionnaire data were obtained on socio-demographic factors and health and lifestyle parameters. The division of the sample into social-class groups was based on the parents' occupation (including last main occupation for those not working or retired). All subjects were classified according to the Central Statistics Office, Census 2002 Occupations(10).
Food quantification in the National Teen Food Survey
On the basis that different foods are best quantified using different methods and some methods of quantification are more precise than are others, a hierarchical approach to food quantification was used as follows:
(1) Portable food scales (Tanita, Japan) were given to each respondent. The fieldworker gave detailed instructions as to how to use the food scales to respondents and/or parents or guardians during the training session on the first visit. This included a demonstration where the researcher weighed typical portions of certain foods and beverages, particularly those that were consumed most commonly (for example, ready-to-eat breakfast cereals (RTEBC), homemade bread) as defined by each subject;
(2) a photographic food atlas developed by the Food Standards Agency in the UK was used to quantify food and beverages(Reference Nelson, Atkinson and Meyer11);
(3) suggested serving sizes indicated on food labels;
(4) a database of average portions of certain foods (for example, sliced meats, takeaway foods) was compiled by the research team;
(5) food weights and average food portion sizes estimated for UK adults by the Ministry of Agriculture, Fisheries and Food(12);
(6) household measures;
(7) the researcher estimated portion sizes based on the respondents' eating patterns.
In the event that a quantity was not assigned to a given eating occasion by the respondent, the weight of food eaten on previous occasions by the respondent was used.
Estimation of nutrient intake in the National Teen Food Survey
Food intake data were analysed using WISP© (Tinuviel Software, Warrington, UK). WISP© uses data from McCance and Widdowson's The Composition of Foods, fifth(Reference Holland, Welch, Unwin, Buss, Paul and Southgate13) and sixth editions(14) plus supplemental volumes(Reference Chan, Brown and Buss15–Reference Holland, Welch and Buss23) to generate nutrient intake data. The food consumption database generated from the survey listed each individual food item as consumed by each respondent together with the nutrient composition for the quantity of each food consumed.
Validation of food intake data
Several steps were taken to ensure the validity of the food intake data. At the end of the survey week the teenager was asked if his/her food intake was the same as usual, less than usual or more than usual during the preceding week. If their intake was different to usual the teenager was asked if they were unwell, if it was not a typical week for them or if there was another reason for the unusual pattern of food intake. The teenager was also asked if they were on a weight-reducing or -gain diet while participating in the survey. Furthermore, the teenager was asked if there was any food or drink consumed during the 7 d that was not written down. If the teenager answered yes to this question, the fieldworker recorded the day and time of the foods and drinks consumed. Finally, the fieldworker was asked to comment on their opinion of the respondent's food diary. The diary was rated on a scale of 1 to 4: 1, accurate and complete; 2, inaccurate and complete; 3, accurate and incomplete; or 4, inaccurate and incomplete. More exact methods of validation will be carried out in the future which will use cut-off points based on BMR to identify over- and under-reporting.
Generation of added sugar intakes from raw data
In the NSIFCS, NCFS and the NTFS, sixty-eight food groups were formed. These food groups were used to identify and classify whether they contained purely natural or added sugars or a combination of both of these sugars. To determine the amount of added sugar in recipes, the McCance and Widdowson's recipe database and the recipe database compiled by IUNA were used. Other sources of information used were manufacturer's information and the McCance and Widdowson's food tables(Reference Holland, Welch, Unwin, Buss, Paul and Southgate13, 14) and supplemental volumes(Reference Chan, Brown and Buss15–Reference Holland, Welch and Buss23). The actual amounts (in g) of added sugar in the food were calculated using the recipes and food tables which were divided by the total sugar content to calculated the percentage contribution of added sugar to total sugar. The percentage values were transferred directly into the NSIFCS, NCFS and NTFS databases to compute an actual amount (in g) of added sugar for each food. If a food was not found in any food tables or a recipe was unavailable, the most comparable food or dish was selected.
Under-reporting of food intake in the North/South Ireland Food Consumption Survey
As with any dietary survey where food intake is self-reported there is evidence of mis-reporting, in particular under-reporting, as was found in the NSIFCS(Reference McGowan, Harrington, Kiely, Robson, Livingston and Gibney24). Under-reporting can affect the validity of the results. The analysis in the present study was carried out excluding under-reporters of energy intake, identified as having an energy intake:BMR ratio of less than 1·05(Reference Black25). Under-reporters were not assessed for children and teenagers.
Quartiles of added sugar eating occasions per day
The number of meals consumed per d by subjects from the NSIFCS ranged from one to twenty-two meals per d and from one to twelve meals per d for the NCFS and the NTFS. Further analysis was conducted to determine if there was a significant difference in the results if adults consuming more than nine meals per d (98·7 % of the meal frequencies in the database) were excluded from the database. However, there was no significant difference in the results and therefore all meals (one to twenty-two) were included in the analysis. After the exclusion of under-reporters in the NSIFCS, the final sample contained 1097 subjects and quartiles of added sugar eating occasions were determined using these subjects. Quartiles of added sugar eating occasions in children and teenagers were also created using all meals (one to twelve).
Statistical analysis
All statistical analyses were carried out using SPSS® version 12.0 for Windows™ (SPSS Inc., Chicago, IL, USA). The Zpopulation samples were divided into quartiles of added sugar eating occasions. One-way ANOVA was used to test for significant differences (P < 0·05) in means for total energy (MJ/d), total and added sugars (g/d and % food energy), added sugar eating occasions, food groups intakes (g/d) and percentage contribution of food groups to added sugar intakes between the quartiles of mean daily added sugar eating occasions. One-way ANOVA was also used to test for significant differences (P < 0·05) in means for percentage total energy from fat, carbohydrate, total and added sugar across quartiles of percentage total energy from total fat. Equality of variance was assessed using Levene's test, which determined which post hoc test was used. For groups of equal variance, the Scheffe post hoc test was used to determine significant differences between the means for each quartile. For values that did not comply with Levene's test for homogeneity of variance, the Tamhane post hoc multiple-comparisons test was used to identify significant differences between the means(Reference Coakes and Steed26).
Results
In Table 1, mean daily added sugar eating occasions and mean daily intake of energy (MJ/d), total and added sugar (g/d and % energy) in children, teenagers and adults across quartiles of mean daily added sugar eating occasions are presented. In children, teenagers and adults, added sugar eating occasions significantly increased (P < 0·001) across the quartiles of mean daily added sugar eating occasions. In adults, added sugar (% energy, P < 0·01 and g/d, P < 0·001) and total sugar intakes (% energy, P < 0·05 and g/d, P < 0·001) significantly increased across the quartiles and energy intake (MJ/d) was significantly higher (P < 0·05) in the 3rd and 4th quartiles in comparison with quartiles 1 and 2. In children and teenagers, total energy (MJ/d) (P < 0·001), total sugar (g/d, P < 0·05 children, P < 0·001 teenagers; % energy, P < 0·05) and added sugar (g/d, P < 0·01; % energy, P < 0·01 children, P < 0·05 teenagers) intakes were significantly higher in the higher quartiles compared with the lower quartiles of mean daily added sugar eating occasions.
Table 1 Mean daily eating occasions and mean daily intake of energy (MJ/d), total and added sugar (g/d and % total energy) across quartiles of mean daily added sugar eating occasions in Irish children, teenagers and adults
(Mean values and standard deviations)
a,b,c,d Mean values within a row with unlike superscript letters were significantly different: *P < 0·05; **P < 0·01; ***P < 0·001.
Fig. 1 shows the graph of percentage total energy from added sugar v. quartiles of added sugar eating occasions in children, teenagers and adults. This highlights how children obtained the highest percentage total energy from added sugar at each quartile of mean daily added sugar occasions. In addition it clearly shows that mean percentage total energy intakes of added sugar was above the recommendation ( ≤ 10 %) in each quartile in children and teenagers.
Fig. 1 Relationship between the mean values for percentage total energy from added sugar and the quartiles of added sugar intake in Irish children (■), teenagers (▲) and adults (♦).
Table 2 presents the percentage energy intake from fat, carbohydrate, and total and added sugar across quartiles of percentage total energy intake from fat in Irish children, teenagers and adults. There was a significant decrease in percentage energy from carbohydrate (P < 0·01 adults, P < 0·001 children and teenagers) across increasing quartiles of percentage energy from fat in children, teenagers and adults. Intakes of total sugar (% energy) were significantly lower (P < 0·01) in quartile 4 compared with all other quartiles in children, teenagers and adults. In adults, added sugar intake (% energy) was significantly (P < 0·05) lower in quartile 4 compared with the other quartiles while in children, intakes of added sugar (% energy) were significantly lower (P < 0·05) in quartiles 3 and 4 compared with quartiles 1 and 2. In teenagers, intakes of added sugar (% energy) were significantly lower (P < 0·01) in quartile 4 compared with quartiles 1 and 2.
Table 2 Percentage total energy from fat, carbohydrates, and total and added sugars across quartiles of percentage total energy from fat in Irish children, teenagers and adults
(Mean values and standard deviations)
a,b,c,d Mean values within a row with unlike superscript letters were significantly different: *P < 0·05; **P < 0·01; ***P < 0·001.
Table 3 presents the mean intake (g/d) and percentage contribution of the main food groups to mean daily added sugar intakes across quartiles of mean daily added sugar eating occasions in all Irish children, teenagers and adults. In adults, the main contributors to added sugars intakes were sugars, syrups, preserves and sweeteners (22·9 %), biscuits, cakes, buns and pastries (15·6 %), carbonated beverages, squashes and cordials (14·2 %) and confectionery (12·2 %). The percentage contribution of sugars, syrups, preserves and sweeteners (P < 0·01) was significantly higher in the highest quartile compared with the other quartiles. Intakes of all food groups examined, excluding alcohol, breads, RTEBC and carbonated beverages, squashes and cordials (including the individual food groups squashes and cordial and carbonated beverages) were significantly higher in the highest quartile compared with the lowest quartile of mean daily added sugar intake in adults. In children and teenagers, the main contributors to added sugar intakes were carbonated beverages, squashes and cordials (27·7 %), confectionery (21·6 % children, 22 % teenagers), biscuits, cakes, buns and pastries (11·8 % children, 9·9 % teenagers) and RTEBC (11·1 % children, 10·6 % teenagers). The percentage contribution of several food groups, for example confectionery (P < 0·05) was significantly higher in the highest quartiles compared with the lowest quartiles of mean daily added sugar intake. In addition, there was a significantly higher intake of several food groups such as breads and scones (P < 0·01), confectionery, ice cream, pudding and chilled desserts and biscuits, cakes, buns and pastries (P < 0·05 children, P < 0·01 teenagers) in quartile 4 compared with quartile 1 in children and teenagers.
Table 3 Intake (g/d) and contribution (%) of the main food groups to mean daily added sugar intakes across quartiles of mean daily added sugar eating occasions in Irish children, teenagers and adults in all consumers
(Mean values and standard deviations)
% contr, % Contribution of food groups to added sugar intakes; RTEBC, ready-to-eat breakfast cereal.
a,b,c Values with unlike superscript letters denote significant differences in mean percentage contributions of food groups to added sugar intakes between quartiles of added sugar eating occasions (P wt): * P < 0·05; ** P < 0·01; *** P < 0·001; NS, P ≥ 0·05.
w,x,y,z Values with unlike superscript letters denote significant differences in mean intake of food groups between quartiles of mean daily added sugar eating occasions (P%): * P < 0·05; ** P < 0·01; *** P < 0·001; NS, P ≥ 0·05.
In Table 4 mean daily intakes and percentage contribution of the main food groups to mean daily added sugar intakes are shown across mean daily added sugar eating occasions in Irish children, teenagers and adults in consumers only. The main food groups contributing to added sugar intakes were sugars, syrups, preserves and sweeteners (13·6 % teenagers, 27·7 % adults), carbonated beverages, squashes and cordials (29·3 % children, 31·2 % teenagers, 21·4 % adults), biscuits, cakes buns and pastries (12·4 % children, 12 % teenagers, 17·6 % adults) and confectionery (23·3 % children, 23·9 % teenagers, 16·7 % adults) and RTEBC (12 % children, 13 % teenagers). The intake and percentage contribution of several food groups varied across the quartiles of added sugar eating occasions in children, teenagers and adults; for example, the intake of RTEBC was significantly higher and their percentage contribution to added sugar intakes was significantly lower (P < 0·05) in quartile 4 compared with quartile 1 in teenagers.
Table 4 Intake (g/d) and contribution (%) of the main food groups to mean daily added sugar intakes across quartiles of mean daily added sugar eating occasions in Irish children, teenagers and adults in consumers only
(Mean values and standard deviations)
% Cons, % consumers of each food groups; % contr, % contribution of food groups to added sugar intakes, RTEBC, ready-to-eat breakfast cereal.
a,b,c Values with unlike superscript letters denote significant differences in mean percentage contributions of food groups to added sugar intakes between quartiles of mean daily added sugar eating occasions (P%): *P < 0·05; **P < 0·01; ***P < 0·001; NS, P ≥ 0·05.
w,x,y,z Values with unlike superscript letters denote significant differences in mean intake of food groups between quartiles of mean daily added sugar eating occasions (P wt): *P < 0·05; **P < 0·01; *** P < 0·001; NS, P ≥ 0·05.
Discussion
The present paper analysed the frequency of consumption of added sugars in Irish children, teenagers and adults to determine if there is a quantitative relationship between 10 % total energy from added sugars and frequency (four times per d) of added sugar intake. An exhaustive search of the literature failed to reveal studies directly relating the association between variability in the frequency of intake of added sugars and the percentage energy from sugars. The present study clearly shows that while the pattern of percentage energy from added sugars varies considerably across age groups, the frequency of added sugar intake varies much less. Thus in general terms it is correct to say that as the frequency of eating occasions of added sugar intakes increases, the percentage energy from added sugar intakes increases. However, there are marked differences in the overall levels of percentage energy from added sugars in the three age groups. Moreover, there are marked differences in the foods contributing to added sugar intake across age groups.
The results of our analysis highlight how the intake of added sugar varies depending on the age and population group examined. In their report on dietary sugars and human disease, the UK Department of Health noted that children derived a higher proportion of their energy intakes from sugars than adults(27). Although mean percentage energy intake from added sugar in the present study was below the WHO recommended guideline of ≤ 10 % total energy in adults (9 %), the mean percentage energy intake from added sugars exceeded the guideline in children (14·6 %) and teenagers (12·4 %). In addition, mean intake of added sugars in absolute terms in children, teenagers and adults was above 40–55 g/d, the intake below which studies have shown a low incidence of dental caries in countries(2). Although mean added sugar eating occasions (4·2 children, 3·7 teenagers and 4·2 adults) and added sugar intakes were similar in children, teenagers and adults, energy intake (MJ/d) was lower in children (7 MJ/d) and teenagers (8·3 MJ/d) in comparison with adults (10·2 MJ/d). As a result, children and teenagers obtained a higher percentage energy intake from added sugars than adults.
Numerous studies have examined the intake of added sugars in children(Reference Andersen, Nes, Sandstad, Bjorneboe and Drevon28–Reference Kranz, Smiciklas-Wright, Siegz-Riz and Mitchell31), teenagers(Reference Munoz, Krebs-Smith, Ballard-Barbash and Cleveland32–Reference Somerset34) and adults(Reference Charlton, Wolmarans and Lombard35). However, results from these studies vary on the age, sex, population group and type of sugar analysed, for example, total sugar, NMES and added sugar. As a result, comparisons between surveys can be difficult. Charlton et al. (Reference Charlton, Wolmarans and Lombard35) reported that added sugar intake in adults (aged ≥ 65 years) living in South Africa was 17·5 % while in Britain, NMES intake in men and women (aged 19–64 years) has been reported to be 13·6 and 11·9 % respectively(Reference Henderson, Gregory, Irving and Swan36). It should be noted that NMES include fruit juices and honey and ‘added sugar’ which comprise recipe and table sugars(27) while the US Department of Agriculture defined added sugars as sugars and syrups that are added to foods during processing or preparation(37).
Added sugar intakes in the NCFS (14·6 %) were similar to those reported by Farris et al. (Reference Farris, Nicklas, Myers and Berenson29) who showed that added sugar intakes (% energy) in American children (aged 10 years) was 15·2 %. In addition, Munoz et al. (Reference Munoz, Krebs-Smith, Ballard-Barbash and Cleveland32) reported that mean daily added sugars intake in American children and adolescents (aged 2–19 years) was 15·9 %. Kranz et al. (Reference Kranz, Smiciklas-Wright, Siegz-Riz and Mitchell31) reported that added sugar intakes in American children (aged 2–5 years) was 14·9 % in 2–3-year-olds and 16·5 % in 4–5-year-olds. However, intakes vary widely in studies. Somerset(Reference Somerset34) reported that refined sugar intakes in Australian children and adolescents aged 2–18 years ranged from 26·9 to 78·3 g/d (6·6–14·8 % total energy) for girls and from 27 to 81·6 g/d (8–14 % total energy) for boys. Kersting et al. (Reference Kersting, Sichert-Hellert, Alexy, Manz and Schoch33) reported that mean energy intake from added sugars in German children and adolescents aged 1–18 years was 12 %. In Norwegian studies, added sugar intakes have been reported at 15·1 % energy (55 g/d) in 4-year-olds(Reference Overby, Lillegaard, Johansson and Andersen30), 16·8 % (80 g/d) energy in 9-year-olds(Reference Overby, Lillegaard, Johansson and Andersen30) and at 11 %(Reference Andersen, Nes, Sandstad, Bjorneboe and Drevon28) and 18·4 % (95 g/d)(Reference Overby, Lillegaard, Johansson and Andersen30) in 13-year-olds.
Mean daily total sugar intake in children (106·6 g/d; 23·9 %) in the present study was lower than that reported by Gibson(Reference Gibson38) (123 g/d; 23 %), Morgan & Zabik(Reference Morgan and Zabik39) (134 g/d), Hackett et al. (Reference Hackett, Rugg-Gunn, Appleton, Parkin and Eastoe40) (boys 124 g/d; girls 113 g/d), Burt et al. (Reference Burt, Eklund, Morgan, Larkin, Guire, Brown and Weintraub41) (boys 156 g/d; girls 127 g/d) and Strain et al. (Reference Strain, Robson, Livingstone, Primrose, Savage, Cran and Boreham42) (139 g/d boys; 121 g/d girls; aged 12 years) but higher than the total sugar (% energy) intake reported by Farris et al. (Reference Farris, Nicklas, Myers and Berenson29) (15·2 %). The variation in added and total sugar intakes between studies clearly shows that research analysing sugar intakes is needed in each individual country before sugar recommendations should be established to determine if sugar intakes are acceptable or excessively high. Furthermore, a standardised definition and method of determining added sugar intakes may help reduce the variation in added sugar intakes in future studies.
Numerous studies have shown an inverse relationship between fat and sugar intakes where, in general, as sugar intakes (total, added or NMES) increase, fat intakes decrease(Reference Farris, Nicklas, Myers and Berenson29, Reference Kranz, Smiciklas-Wright, Siegz-Riz and Mitchell31, Reference Charlton, Wolmarans and Lombard35, Reference Gibson38, Reference Rugg-Gunn, Hackett, Jenkins and Appleton43–Reference Alexy, Sichert-Hellert and Kersting48). There is concern that if individuals are advised to limit foods high in added sugars they may increase their intake of foods high in fat(Reference Lewis, Park, Dexter and Yetley44) and that dietary goals advising a simultaneous reduction in fat and sugar may not be achievable(Reference Gibson38). We found that as the intake of fat increased (% energy) in children (28·6 to 39·3 %), teenagers (29·3 to 41·9 %) and adults (28·8 to 35·8 %), there was a significant decrease (P < 0·05) in total and added sugar intakes. Studies would be required to assess how both these recommendations can be simultaneously achieved.
In general, the main sources and contributors to added sugars have been shown to be soft drinks, confectionery, cakes, biscuits and ice cream(Reference Overby, Lillegaard, Johansson and Andersen30, Reference Kranz, Smiciklas-Wright, Siegz-Riz and Mitchell31, 37, Reference Alexy, Sichert-Hellert and Kersting48). However, the main contributors to sugar intake vary depending on the age, sex and population group studied. For example, one of the main contributors to added sugar intake in children are non-diet soft drinks(Reference Farris, Nicklas, Myers and Berenson29, Reference Overby, Lillegaard, Johansson and Andersen30, Reference Somerset34, Reference Morgan and Zabik39, Reference Krebs-Smith49, Reference Guthrie and Morton50), the percentage contribution of which has been shown to decrease with age(Reference Linseisen, Gedrich, Karg and Wolfram51).
The present results showed that the main contributors to mean daily added sugar differed for children, teenagers and adults. In addition, the percentage contribution and intake of the main contributors to mean daily added sugar intake were significantly different across the quartiles of mean daily added sugar eating occasions in children, teenagers and adults. The main contributors to added sugar intake in all children, teenagers and adults were biscuits, cakes, buns and pastries, carbonated beverages, squashes and cordials, confectionery, sugars, syrups, preserves and sweeteners (adults only) and RTEBC (children and teenagers). It may therefore be important to target these food groups to help reduce added sugar intakes, especially in children and teenagers.
There are concerns that high intake of added sugars may dilute micronutrients, displace nutrient-dense foods(Reference Forshee and Storey52) and that sugar-sweetened beverages may be a contributor to the rise in overweight and obesity(Reference Malik, Schulze and Hu53). These issues were not addressed in the present study as the recommendation limiting the intake of food and beverages containing added sugars to a maximum intake of four meals per d was developed by the WHO(2) to help prevent against dental caries. In the present study, 7 d food diaries were used to collect dietary information. Therefore changes in the frequency of consumption of foods and beverages containing added sugar is more likely to be accounted for across the week using this data collection method in comparison with data collection methods of shorter duration.
Information on under-reporting was available for the NSIFCS and under-reporters were excluded in the present study as there is evidence to suggest that in adults, low energy reporters tend to report foods such as cakes, cookies, sugar and candies less often compared with non-low energy reporters(Reference Livingstone and Black54). In the UK National Diet and Nutrition Study of young people aged 4–18 years, Gregrory et al. (Reference Gregory, Low, Bates, Prentice, Jackson, Smithers, Wenlock and Farron55) reported that those classified as under-reporters tended to selectively under-report foods that were high in NMES. It would be an advantage to account for under-reporting in children and teenagers to determine if this affects the relationship between energy from added sugars and frequency of added sugars intake.
In conclusion, the key findings of the present study are that the frequency of added sugar intake is similar but percentage energy from added sugars varies considerably across the three age groups. Furthermore, sources of added sugar vary with age. Food-based dietary guidelines may need to be tailored to specific age groups.
