Compendium of the most significant studies with reference to properties, intake, effects.

Rippe JM, Angelopoulos TJ. Sugars, obesity, and cardiovascular disease: results from recent randomized control trials. Eur J Nutr. 2016 Nov;55(Suppl 2):45-53. doi: 10.1007/s00394-016-1257-2. 

Abstract. The relationship between sugar consumption and various health-related sequelas is controversial. Some investigators have argued that excessive sugar consumption is associated with increased risk of obesity, coronary heart disease, diabetes (T2D), metabolic syndrome, non-alcoholic fatty liver disease, and stimulation of reward pathways in the brain potentially causing excessive caloric consumption. These concerns have influenced organizations such as the World Health Organization, the Scientific Advisory Committee on Nutrition in England not to exceed 5 % of total energy and the Dietary Guidelines for Americans Advisory Committee 2015 to recommend upper limits of sugar consumption not to exceed 10 % of calories. Data from many randomized control trials (RCTs) do not support linkages between sugar consumption at normal levels within the human diet and various adverse metabolic and health-related effects. Fructose and glucose are typically consumed together in roughly equal proportions from high-fructose corn syrup (also known as isoglucose in Europe) or sucrose. The purpose of this review is to present data from recent RCTs and findings from recent systematic reviews and meta-analyses related to sugar consumption and its putative health effects. This review evaluates findings from recent randomized controlled trials, systematic reviews and meta-analyses into the relationship of sugar consumption and a range of health-related issues including energy-regulating hormones, obesity, cardiovascular disease, diabetes, and accumulation of liver fat and neurologic responses. Data from these sources do not support linkages between sugar consumption at normal levels within the human diet and various adverse metabolic and health-related effects.

Freeman CR, Zehra A, Ramirez V, Wiers CE, Volkow ND, Wang GJ. Impact of sugar on the body, brain, and behavior. Front Biosci (Landmark Ed). 2018 Jun 1;23(12):2255-2266. doi: 10.2741/4704. 

Abstract. Sugar is highly palatable and rewarding, both in its taste and nutritive input. Excessive sugar consumption, however, may trigger neuroadaptations in the reward system that decouple eating behavior from caloric needs and leads to compulsive overeating. Excessive sugar intake is in turn associated with adverse health conditions, including obesity, metabolic syndrome, and inflammatory diseases. This review aims to use recent evidence to connect sugar's impact on the body, brain, and behavior to elucidate how and why sugar consumption has been implicated in addictive behaviors and poor health outcomes.

Collin LJ, Judd S, Safford M, Vaccarino V, Welsh JA. Association of Sugary Beverage Consumption With Mortality Risk in US Adults: A Secondary Analysis of Data From the REGARDS Study. JAMA Netw Open. 2019 May 3;2(5):e193121. doi: 10.1001/jamanetworkopen.2019.3121. 

Abstract. Importance: Research has linked sugar-sweetened beverage (SSB) consumption to coronary heart disease (CHD) risk, but the role of nutritionally similar fruit juice and the association of these beverages with mortality risk is unknown. Objective: To assess the association of SSBs and 100% fruit juices, alone and in combination (sugary beverages), with mortality.... Conclusions and relevance: These findings suggest that consumption of sugary beverages, including fruit juices, is associated with all-cause mortality. Well-powered and longer-term studies are needed to inform their association with CHD mortality risk.

Liu L, Volpe SL, Ross JA, Grimm JA, Van Bockstaele EJ, Eisen HJ. Dietary sugar intake and risk of Alzheimer's disease in older women. Nutr Neurosci. 2022 Nov;25(11):2302-2313. doi: 10.1080/1028415X.2021.1959099. 

Abstract. Background: Despite some reports of cardiometabolic disorders associated with the risk of Alzheimer's disease (AD), limited studies have been conducted to examine the association between excessive sugar intake (a risk factor for cardiometabolic disorders) and AD risk. Aim: The purpose of our study was to evaluate if excessive sugar intake has a significant long-term effect on the risk of AD....Conclusions: Our study indicates that excessive total sugar intake was significantly associated with AD risk in women. Of six subtypes of sugar intake, lactose had a stronger impact on AD risk.

Paglia L. The sweet danger of added sugars. Eur J Paediatr Dent. 2019 Jun;20(2):89. doi: 10.23804/ejpd.2019.20.02.01. 

Abstract. Dietary behaviour is determined by community, family and individual factors, including availability and costs of foods. Preference for sweetness starts early in life and remains throughout childhood, and starts declining to adult levels only during mid-adolescence. This explains why children are at high risk of sugar overconsumption. The empty calories of added sugar hinder the proper growth and development, due to the lack of nutrients. The relationship between added sugar consumption and possibile negative health consequences is controversial. For added sugars we mean all those sugars added to food or drinks, or present naturally in unsweetened fruit juices, honey or syrups. It does not include natural sugar found in vegetables, fruits and milk. Some investigators claim that excessive sugar consumption is associated with increased risk of caries [Paglia et al., 2016], obesity [Costacurta et al., 2014], cardiovascular disease (CVD) [Vos et al., 2017], type-2 diabetes mellitus (T2DM), metabolic syndrome, nonalcoholic fatty liver disease (NAFLD). In addition, obesity is the primary risk factor for the development of SDB (sleep-disordered breathing). Inadeguate sleep duration and quality in children and adolescents is associated with an increase in body weight and adiposity, decreased insulin sensitivity, hyperglycemia, and prevalent cardiometabolic risk factors. Finally, the interest in attention deficit and hyperactivity disorder (ADHD) during childhood has recently increased. Some researchers are looking for a link between high sugar consumption over a long period and ADHD [Del-Ponte et al., 2019]. These statements have influenced organisations such as the American Hearth Association (AHA), the American Academy of Pediatrics (AAP) and the World Health Organization (WHO), who recommend to limit free sugars intake to less than 10% of the total energy intake for adults and children, observing that a further reduction of 5% would provide additional health benefits [WHO, 2015]. The first few months of life are crucial for the flavour learning process in humans. Early experience with different tastes is very important for later acceptance of foods, especially the healthy ones. Clinicians and parents can and should support in synergy the healthy development of children's taste preference and eating behaviour.

Moore JB, Fielding BA. Sugar and metabolic health: is there still a debate? Curr Opin Clin Nutr Metab Care. 2016 Jul;19(4):303-9. doi: 10.1097/MCO.0000000000000289. 

Abstract. Purpose of review: There is considerable political and public awareness of new recommendations to reduce sugars and sugar-sweetened beverages in our diets. It is therefore timely to review the most recent changes in guidelines, with a focus on evidence for metabolic health, recent research in the area and gaps in our knowledge....Summary: There are many challenges faced by healthcare professionals and government bodies in order to improve the health of individuals and nations through evidence-based diets. Sufficiently powered long-term mechanistic studies are still required to provide evidence for the effects of reducing dietary sugars on metabolic health. However, there are many challenges for research scientists in the implementation of these studies.

Mooradian AD. In search for an alternative to sugar to reduce obesity. Int J Vitam Nutr Res. 2019 Sep;89(3-4):113-117. doi: 10.1024/0300-9831/a000531. 

Abstract. Consumption of table sugar has been increasing despite the warnings of public health officials as to the potential adverse consequences of sugar consumption. The World Health Organization recommends restricting consumption of sugars to no more than 10% of daily caloric intake, with a proposal to lower this level to 5% or less for optimal health. Unfortunately substituting sugar with the currently available artificial sweeteners does not appear to have favorable clinical effects. Given the health-related concerns with the currently available sweeteners such as increased risk of obesity and type 2 diabetes there is renewed interest in identifying a safe and palatable sweetener. The sweet extracts of natural plants such as stevia and monk fruit as well as naturally occurring rare sugars have become attractive alternatives. Although most of the sweeteners are sugars, there are some proteins such as braziien and miraculin that have intense sweetness and are being developed as sweeteners. Several companies are pursuing the development of "bitterness-blockers" to remove flavor defects. Other novel approaches include coating mineral carriers with sugar or hollowing out the sugar crystals. Naturally occurring rare sugars such as D-allulose (D-psicose), D-tagatose, D-sorbose and D-allose are attractive sweeteners. They do have the bulk and the mouth fill of table sugar with reduced caloric content (0.2 kcal/g for D-allulose). Additional randomized controlled trials are necessary to define the long term safety and efficacy of these sugars.

Tappy L, Morio B, Azzout-Marniche D, Champ M, Gerber M, Houdart S, Mas E, Rizkalla S, Slama G, Mariotti F, Margaritis I. French Recommendations for Sugar Intake in Adults: A Novel Approach Chosen by ANSES. Nutrients. 2018 Jul 29;10(8):989. doi: 10.3390/nu10080989. 

Abstract. This article presents a systematic review of the scientific evidence linking sugar consumption and health in the adult population performed by a group of experts, mandated by the French Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement, et du travail (ANSES). A literature search was performed by crossing search terms for overweight/obesity, diabetes/insulin resistance, dyslipidemia/cardiovascular diseases, non-alcoholic fatty liver diseases (NAFLD), and uric acid concentrations on one hand and for intake of sugars on the other. Controlled mechanistic studies, prospective cohort studies, and randomized clinical trials were extracted and assessed. A literature analysis supported links between sugar intake and both total energy intake and body weight gain, and between sugar intake and blood triglycerides independently of total energy intake. The effects of sugar on blood triglycerides were shown to be mediated by the fructose component of sucrose and were observed with an intake of fructose >50 g/day. In addition, prospective cohort studies showed associations between sugar intake and the risk of diabetes/insulin resistance, cardiovascular diseases, NAFLD, and hyperuricemia. Based on these observations, ANSES proposed to set a maximum limit to the intake of total sugars containing fructose (sucrose, glucose⁻fructose syrups, honey or other syrups, and natural concentrates, etc.) of 100 g/day.

Moreira ARO, Batista RFL, Ladeira LLC, Thomaz EBAF, Alves CMC, Saraiva MC, Silva AAM, Brondani MA, Ribeiro CCC. Higher sugar intake is associated with periodontal disease in adolescents. Clin Oral Investig. 2021 Mar;25(3):983-991. doi: 10.1007/s00784-020-03387-1. 

Abstract. Analyze the association between higher added sugar exposure and periodontal disease in adolescents (18-19 years old)....Conclusion: High level of added sugar intake was associated with greater extent of periodontal disease in adolescents. Clinical relevance: High sugar intake was associated with periodontal disease in adolescents, supporting the integrated hypothesis of dental caries and periodontal disease and giving impetus to future clinical investigation on the effect of restriction of added sugar consumption in periodontal parameters, which potentially may change traditional treatment protocols of periodontal disease.

Chazelas E, Srour B, Desmetz E, Kesse-Guyot E, Julia C, Deschamps V, Druesne-Pecollo N, Galan P, Hercberg S, Latino-Martel P, Deschasaux M, Touvier M. Sugary drink consumption and risk of cancer: results from NutriNet-Santé prospective cohort. BMJ. 2019 Jul 10;366:l2408. doi: 10.1136/bmj.l2408. 

Abstract. Objective: To assess the associations between the consumption of sugary drinks (such as sugar sweetened beverages and 100% fruit juices), artificially sweetened beverages, and the risk of cancer. ... Conclusions: In this large prospective study, the consumption of sugary drinks was positively associated with the risk of overall cancer and breast cancer. 100% fruit juices were also positively associated with the risk of overall cancer. These results need replication in other large scale prospective studies. They suggest that sugary drinks, which are widely consumed in Western countries, might represent a modifiable risk factor for cancer prevention.

Twarog JP, Peraj E, Vaknin OS, Russo AT, Woo Baidal JA, Sonneville KR. Consumption of sugar-sweetened beverages and obesity in SNAP-eligible children and adolescents. Prim Care Diabetes. 2020 Apr;14(2):181-185. doi: 10.1016/j.pcd.2019.07.003.

Abstract. Background: Low-income individuals who are eligible for nutrition assistance have been shown to consume a larger portion of their daily calories from beverages with added sugar. We examined the association between Supplemental Nutrition Assistance Program (SNAP) participation and self-reported sugar sweetened beverage (SSB) consumption as well as the association between self-reported consumption of SSBs and overweight/obesity in low-income children....Conclusion: Among youth, SNAP recipients drink more SSBs than their eligible non-recipient peers. Our results indicate that certain populations of children receiving SNAP benefits and consuming SSBs are more likely to be overweight or obese when compared to their peers who receive SNAP benefits but do not consume SSBs. Copyright © 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

O'Connor TM, Yang SJ, Nicklas TA. Beverage intake among preschool children and its effect on weight status. Pediatrics. 2006 Oct;118(4):e1010-8. doi: 10.1542/peds.2005-2348. 

Objective: The obesity epidemic in the United States continues to increase. Because obesity tends to track over time, the increase in overweight among young children is of significant concern. A number of eating patterns have been associated with overweight among preschool-aged children. Recently, 100% fruit juice and sweetened fruit drinks have received considerable attention as potential sources of high-energy beverages that could be related to the prevalence of obesity among young children. Our aim was to evaluate the beverage intake among preschool children who participated in the National Health and Nutrition Examination Survey 1999-2002 and investigate associations between types and amounts of beverages consumed and weight status in preschool-aged children.... Conclusions: On average, preschool children drank less milk than the 2005 Dietary Guidelines for Americans recommendation of 16 oz/day. Only 8.6% drank low-fat or skim milk, as recommended for children who are older than 2 years. On average, preschool children drank < 6 oz/day 100% fruit juice. Increased beverage consumption was associated with an increase in the total energy intake of the children but not with their BMI. Prospectively studying preschool children beyond 2 to 5 years of age, through their adiposity rebound (approximately 5.5-6 years) to determine whether there is a trajectory increase in their BMI, may help to clarify the role of beverage consumption in total energy intake and weight status.

Drewnowski A, Tappy L, Forde CG, McCrickerd K, Tee ES, Chan P, Amin L, Trinidad TP, Amarra MS. Sugars and sweeteners: science, innovations, and consumer guidance for Asia. Asia Pac J Clin Nutr. 2019;28(3):645-663. doi: 10.6133/apjcn.201909_28(3).0025. 

Abstract. Background and objectives: Rising obesity in Southeast Asia, one consequence of economic growth, has been linked to a rising consumption of energy from added sugars. This symposium, organized by ILSI Southeast Asia, explored regional issues related to dietary sugars and health and identified ways in which these issues could be addressed by regional regulatory agencies, food producers, and the consumer....Results: Excessive consumption of energy in the form of added sugars can have adverse consequences on diet quality, lipid profiles, and health. There is a need for better surveillance of total and added sugars intakes in selected Southeast Asian countries. Among feasible alternatives to corn sweeteners (high fructose corn syrup) and cane sugar are indigenous sweeteners with low glycemic index (e.g., coconut sap sugar). Their health benefits should be examined and regional sugar consumption tracked in detail. Product reformulation to develop palatable lower calorie alternatives that are accepted by consumers continues to be a challenge for industry and regulatory agencies. Conclusions: Public-private collaborations to develop healthy products and effective communication strategies can facilitate consumer acceptance and adoption of healthier foods.

Mansoori S, Kushner N, Suminski RR, Farquhar WB, Chai SC. Added Sugar Intake is Associated with Blood Pressure in Older Females. Nutrients. 2019 Sep 3;11(9):2060. doi: 10.3390/nu11092060. 

Abstract. Hypertension or high blood pressure (BP) is highly prevalent in the aging population. Notably, diet and lifestyle have a strong influence on BP. We investigated the association between dietary factors and BP in older adults. This cross-sectional study included 128 participants, aged 65-80 years. Multiple linear regressions were conducted to examine the associations between diet, including meats, vegetables, grains, fruits, dairy, fats, and added sugar, and BP. There was a significant association between intake of added sugar and systolic BP and diastolic BP in females after controlling for age, income, body mass index, physical activity levels, daily calorie intake, and BP medication use. The model predicted that a decrease of 2.3 teaspoons (0.5 standard deviation) of added sugar would result in a 8.4 mmHg drop in systolic BP and a 3.7 mmHg drop in diastolic BP. Whole fruit was associated with a reduction in diastolic BP in both males and females, and the model predicted that, for every 0.71 cup increase in whole fruit consumption, there would be a decrease in diastolic BP of 2.8 mmHg. Our findings support the dietary guidelines of limiting daily intake of added sugar and increasing fruit consumption to promote overall cardiovascular health in older adults.

Vieira R, Souto SB, Sánchez-López E, Machado AL, Severino P, Jose S, Santini A, Silva AM, Fortuna A, García ML, Souto EB. Sugar-Lowering Drugs for Type 2 Diabetes Mellitus and Metabolic Syndrome-Strategies for In Vivo Administration: Part-II. J Clin Med. 2019 Aug 28;8(9):1332. doi: 10.3390/jcm8091332. 

Abstract. Diabetes is a complex disease characterized by hyperglycemia, together with polyuria, polydipsia, and polyphagia. While Type 1 diabetes mellitus (T1DM) results from genetic, environmental, or immune dysfunction factors leading to pancreatic β-cell destruction depriving the organism from endogenous insulin, Type 2 diabetes mellitus (T2DM) is characterized by peripheral insulin resistance. Depending on the type of diabetes mellitus and drug mechanism to study, the animal model should be carefully selected among the wide variety of the currently available ones. This review discusses the most common animal models currently employed to study T1DM and T2DM. Moreover, an overview on the administration routes that could be used is also discussed.