Sugars in the Australian diet: results from the 1995 National Nutrition Survey.

Introduction

Sugars have been a part of our diet for thousands of years, being present in fruits, milk products, vegetables, grains and honey. Sugars are well appreciated for providing sweetness and pleasantness to foods and can be classified in many ways. The term 'sugars' is no longer widely used by carbohydrate chemists, but it is still a useful term to collectively describe the simpler carbohydrates i.e. monosaccharides (glucose, fructose), and disaccharides (sucrose, lactose, maltose) that occur naturally in foods or are added during food processing. Others have attempted to classify sugars according to whether they are a natural part of the food or not (i.e. added to foods). This type of classification has led to categories such as 'extrinsic' (outside the cell structure and therefore supposedly added sugars) and 'intrinsic' (inside the cell structure) sugars. However this raised the problem of how to classify lactose, as it is naturally present in many dairy foods but is extrinsic to the cell structure. A further classification of 'non-milk extrinsic sugars' (NME) was an attempt to define those sugars that are not naturally present in foods. However, a recent FAO/WHO publication on carbohydrates in human nutrition has recommended that we avoid the use of such terms in favour of terminology such as 'glycaemic carbohydrates' with less emphasis on whether the carbohydrate was a mono-, di-, tri- or polysaccharide or whether it was added or naturally present(1). Food Standards Australia New Zealand has recently changed labelling regulations for Australian foods to require total sugar content to be shown on food lables (Standard 1.2.3), in response to consumers wishing to have this information so that they can make informed choices when buying manufactured foods.

According to the recommendation from the FAO/WHO publication, there should be no distinction between the different sources of sugars, i.e. whether or not they are added or naturally occurring, as the body does not differentiate between the two types. However, it is still of interest to health professionals to know whether the sugars we consume are naturally present in food, or are being added during processing or preparation of foods, and therefore capable of being excluded from the diet. In addition, it is not clear whether the same people are high consumers of both added and natural sugars, or whether their overall nutrient profile differs, depending on the source of dietary sugars.

Dietary guidelines in Australia and the US currently include a recommendation to moderate the intake of sugars. In 1987 the Better Health Commission published a dietary target that by the year 2000, added sugars on average should contribute no more than 12% of total energy of Australian diets in order to improve the health of Australians (2). However, as this was based on relatively old food composition data, some researchers have suggested that the target may have been too strict (3). The National Health and Medical Research Council (NHMRC) 2001 Draft Dietary Guidelines for Australians advocates consuming only moderate amounts of sugars and foods containing added sugars, because of concern that substantial amounts of sugars in the diet may dilute the nutrient density of the diet (4). There has been debate among health professionals as to whether or not such public health recommendations need to be given (e.g. 5-7) as the literature relating higher intakes of sugars to compromised health outcomes is inconclusive.

Although there is a body of literature establishing the link between sugars intake and dental caries, in recent years there has been a dramatic decline in dental caries in Australia, while sugars consumption has remained relatively high (8). There are suggestions from older Australian data (9) and other countries (10,11) that for some age groups, and for some nutrients, higher intakes of sugars can result in lower intakes of some nutrients i.e. nutrient dilution has been identified with increasing consumption of sugars. Nutrient dilution has also been observed with increasing intakes of fat (12-15). Other studies have made suggestions of links between higher intakes of sugars and obesity (16), heart disease (17-20), cancer (21-25) and dental caries (26) but the evidence is not conclusive and there are many aetiological and potentially confounding factors (1). There are no long-term intervention studies that can link specific intakes of sugars to increased risk of developing chronic diseases--most of the data are observational and as such cannot be used to describe causative associations.

This paper presents analyses of the food and nutrient intake of a national nutrition survey conducted in Australia in 1995-96 on nearly 14 000 individuals aged two years and over (27). It is a cross-sectional study based on 24-hour dietary recall data and describes the intake of sugars (total, added and naturally-occurring), their major sources, and whether there are any associations between current intakes of sugars, other nutrients and some health parameters such as body mass index (BMI), blood pressure, self-reported exercise and health status in the Australian population.

Methods

These analyses are based on the Australian National Nutrition Survey (NNS) conducted by the Australian Bureau of Statistics (ABS) in collaboration with the then Commonwealth Department of Health and Family Services in 1995 and 1996. Respondents were a subsample of the 1995 National Health Survey. Dietary data were collected using 24-hour recall methodology on 13 858 individuals aged two years and over. One day's consumption data were collected on each respondent at interview. Although most of the survey respondents were involved in only one 24-hour recall, these data covered all days of the week and every month of the year over the whole population. A second 24-hour recall was collected on approximately 10% of the sample. The NNS data were released as a computerised unit record file (CURF) (27,28) and as a series of published reports (29,30).

The NNS was conducted using a multi-stage area sample to select private dwellings and a sub-sample of participants in those dwellings was then selected for the survey. Thus a person's chance of selection in the survey varied, depending on the State/Territory and region in which they lived (27). Survey weights were calculated by the ABS to take into account a person's probability of selection in the sample derived from region, age, sex and part of the state categories. These weightings, when applied to the results from the sample population in this survey, ensure the results are more representative of the national population of Australia. These weightings were used throughout the analyses included in this paper, but scaled to the magnitude of 13 858 so that appropriate standard errors could be determined for the size of the sample. However, since adults were over-sampled and children were under-sampled when compared to the proportions present in the Australian population, applying the weightings has resulted in slightly different numbers in some of the age-gender categories compared to the actual number of participants in the survey. Weighted numbers are referred to as the weighted sample count.

Using the repeat 24-hour recall data, the ABS has calculated adjustment factors for nutrients. These are applied to nutrient intake data at the individual level to reduce within-person variation in intakes, and provide a better measure of the 'usual' distribution of intakes in the population (28,31). Separate adjustment factors were included in the CURF for a range of age groups for each gender. The mathematical effect of the adjustment process is to move outlying values closer to the mean value for the group, thus narrowing the distribution of values. The adjustments are applied to intakes of individuals, giving a better estimation of the distribution of usual intakes of groups of respondents and are therefore more appropriate than unadjusted values for estimating the likelihood of nutrient deficiency or excess (28). Throughout this paper, data to which these adjustments have been applied are referred to as 'day-2-adjusted'.

In this paper, the term 'sugars' refers to the monosaccharides and disaccharides present in foods, both naturally occurring and added during processing or food preparation. This definition is the same as that used by the authors of the NNS (27). It does not include oligosaccharides (i.e. degree of polymerisation greater than two but less than ten). The NNS nutrient data set provides information on intakes of total sugars but not added sugars or natural sugars. For each food, the total sugars content was apportioned by the authors between 'added' and 'natural' sugars. 'Added' sugars content of each food was defined as the quantity of sugars added as sweetening agents during the manufacture, cooking or preparation of the food (e.g. granular sugar, syrups, honey, but not fruit or fruit juice). For every food it was assumed that 'added' sugars plus 'natural' sugars equalled the total sugars value.

Of the 4550 foods and 3012 modified versions of these foods used in the NNS, 3% of foods were, by definition, declared to contain only added sugars. These foods included granulated sugar, honey and syrup taken as discretionary items, and soft drinks and confectionery which did not contain milk, fruit, nuts or grains. Staple foods without additional ingredients, unsweetened foods and artificially sweetened foods comprised 19% of foods, all of which were deemed to contain no added sugars. A further 21% of foods contained negligible sugars, all of which was assigned to natural sugars. For 26% of foods, the recipes supplied with the CURF were used to determine the amounts of added and natural sugars. For 21% of foods, comparison with similar unsweetened or artificially sweetened versions of the foods enabled the added sugars to be calculated. For 2% of foods, the NUTTAB2000 carbohydrate database (compiled by ANZFA), USDA and UK food composition data (32-34) were used to determine the lactose, galactose and maltose (i.e. natural sugars) content. For 3% of foods, all of which were low-usage savoury items (e.g. terrine), the entire sugar content was deemed to be natural sugars. Manufacturers' data and food labels were used to assign sugars to 3% of foods, and the sugars in the remaining 2% of foods were calculated by averaging the composition of similar foods for which the sugars composition had already been determined. All product comparisons and calculations were on a dry-weight basis.

Once the types of sugars had been assigned for each food, these values were used to calculate the sugars intakes for each person in the CURF, and mean intakes of the various population groups were determined. When calculating the percentage contributions of sugars, the percentages were calculated for each person, and the mean of these percentages calculated.

Tertiles of sugars intakes

The day-2-adjustment factors for total sugars were applied to individuals' intakes of total sugars, added sugars and natural sugars, in the absence of individual adjustment factors for added and natural sugars. These intakes of sugars, expressed as percentage of energy (%E) from sugars, were divided into tertiles of intakes for children and for adults and for each gender separately. Tertiles were chosen in preference to quartiles or quintiles, as these included tertile boundaries for added sugars which approximated the 12% recommendation proposed previously (2). The day-2-adjustments were applied to nutrient distributions in the original published reports of the NNS (29) and were therefore also applied to nutrients in the current study. With this adjustment applied, the cut-off values for the tertiles more closely approximated tertile cut-off values for usual intake. The day-2-adjustment process had very little effect on the allocation of people to the tertiles, nor on measures of statistical differences between the tertiles, but did affect the tertile boundaries (e.g. for total sugars in men, the middle tertile range was > 16.0-22.5 %E unadjusted compared with > 16.5-21.5 %E when adjusted). The cut-off values for the tertiles are described in Table 1. The ratio of energy intake (EI) to basal metabolic rate (BMR) was calculated, and those with EI:BMR < 0.9 were classified as possible under-reporters (35). Tertile cut-offs were similar whether or not the under-reporters were included; hence tertiles of sugars intakes have been determined on the whole sample including those that could be classified as under-reporters.

Food sources of sugars

The food categories developed by the ABS (27) were used when describing food sources of sugars in this paper. In addition, two sub-categories were defined for non-alcoholic beverages: 'juice-based drinks' which included fruit juice, fruit juice drinks and juice-based cordial, and 'sugar-based drinks' which included aerated soft drinks, sports drinks, flavoured mineral water and non-fruit-based cordials. The percentages of total, added and natural sugars supplied by each of these food categories were determined separately for boys, girls (aged two to 18 years), men and women (aged 19 years and over).

Mean intakes of each food category were calculated for each of the sugar tertiles. Since the tertiles were based on the percentage of energy supplied by each sugar, the mean intakes of foods were also expressed as densities (g of food per 1000 kJ of energy), which also tended to correct for differences in total food consumption between tertiles and between age groups. It was not possible to apply day-2-adjustment to these, as adjustment factors have not been produced for food intakes.

Nutrient profiles

To evaluate whether or not the intake of other nutrients varied with different levels of sugars intakes, the day-2-adjusted nutrient densities (per 1000 kJ) of diets in the different tertiles were determined. For these calculations, both the nutrients and the energy values were day-2-adjusted, so that the values more closely reflected usual intake levels. To further characterise the nutrient profiles of diets containing varying levels of added, natural and total sugars, the percentages of day-2-adjusted diets below 70% of the Recommended Dietary Intake (RDI) (36) for micronutrients and percentage outside the dietary goals set by the Better Health Commission (2) for each of the sugars tertiles for boys, girls, men and women were calculated.

Health variables

Actual measurements of height and weight were used to calculate body mass index (BMI) values which were subsequently categorised by the ABS into: (1) underweight (BMI < 18.5); (2) acceptable weight (BMI [is greater than or equal to] 18.5 and < 25); (3) overweight (BMI [is greater than or equal to] 25 and < 30) and (4) obese (BMI [is greater than or equal to] 30).

Systolic (SBP) and diastolic (DBP) blood pressures were measured twice, five minutes apart, by a mercury sphygmomanometer with the survey respondents seated in their own homes. These blood pressure measurements were averaged and subsequently categorised by the ABS into broad blood pressure risk categories: (1) normal (SBP < 140 mmHg); (2) mild (SBP [is greater than or equal to] 140 mmHg and < 160 mmHg); (3) moderate (SBP [is greater than or equal to] 160 mmHg and < 180 mmHg); and (4) severe (SBP [is less than or equal to] 180 mmHg).

Data on self-reported exercise levels for sport, recreation or fitness were collected. Respondents were asked to indicate whether or not they had exercised (including information on the frequency, duration and intensity) in the two weeks preceding the respondents' interview for the National Health Survey, which may have been several weeks before the NNS. These data were then categorised by the ABS into four levels of exercise from none to a high exercise level. Only information from adults was used in this paper due to incomplete information being available for children.

Data on self-reported health status were also collected in five categories of excellent, very good, good, fair and poor. This variable was available for adults only in this study.

Statistical analyses

Sugars intakes were analysed and reported separately for boys, girls, men and women.

Linear regressions across the tertiles were conducted separately for boys, girls, men and women, to determine if there were any systematic changes between the tertiles in day-2-adjusted nutrient densities and unadjusted food densities with changing densities of total, added and natural sugars (expressed as %E). Due to the large survey population, a substantial proportion of the regression coefficients examined were found to be statistically significant, even when the slopes were not large in magnitude. The standardised slopes were examined to determine the intakes of nutrients and foods that varied to the greatest extent with increasing intakes of sugars. Mean intake densities of foods and nutrients for each tertile are also shown.

Tertiles of total, added and natural sugars intakes were entered into a linear regression for BMI, to see if the different levels of sugars intakes could significantly predict BMI after adjusting for age, exercise level, whether or not respondents were on a weight reducing diet, whether or not they were classified as an under-reporter (EI:BMR < 0.9) (35) and total energy intake. Similar regressions were also performed with SBP and DBP after adjusting for age, physical activity, whether or not respondents were on a weight reducing diet, total energy intake, and BMI. In order to determine whether or not sugars intakes were significant predictors of these variables, the risk group categorical variables were also dichotomised (underweight and acceptable weight versus overweight and obese; normal blood pressure versus mild, moderate or severe risk category) and adjusted for the same variables as outlined before and subjected to a logistic regression. In addition, self-reported health status was dichotomised (excellent, very good or good health status versus poor or fair) and subjected to a logistic regression to determine if the different tertiles of sugars could predict health status after adjusting for age, total energy, BMI and whether or not individuals were on a weight reduction diet. Cox and Snell [R.sup.2] was used to summarise the predictive ability of the logistic regression models.

The relationships between BMI and sugars intakes were examined for children using a linear regression after adjusting for age and energy intake. Graphical inspection of the data revealed slight non-linearity and the BMI data were therefore log transformed. The categories of BMI for classifying children into overweight and normal weight were not used as the categories provided by the ABS did not cover all age groups and there is no expert consensus on what is the appropriate method of defining overweight and obesity in children (37). There were 37 children who stated they were on a weight reducing diet and they were excluded from the analysis.

Finally, whether or not sugars intakes (using tertiles of sugars expressed as %E) could significantly predict exercise status of adults was determined by logistic regression (no or low level exercise versus medium or high exercise level) after adjusting for age, total energy, whether or not individuals were on a weight reduction diet and BMI.

Due to the large sample number and the relatively high numbers of statistical tests undertaken, only those associations with a P value of less than or equal to 0.001 have been indicated in the tables.

Statistical analyses were performed with SPSS version 10.0.7 (SPSS Inc, Chicago, SPSS for Windows, version 10.07, 2000), and weighting factors were applied in all analyses.

Results

Intakes of sugars

Total sugars

The estimated day-2-adjusted average intake of total sugars for the total population was 123 g on the day of the survey, approximately 22% of the total energy intake (%E). On average, children consumed greater amounts of total sugars and greater %E than adults. Males consumed greater amounts of sugars than females for both children and adults, but there was little gender difference in %E (see Table 2). Older children consumed more total sugars on the day of the survey than either younger children or adults, with the highest mean estimate being 212 g for 16- to 18-year-old males. However, the 16- to 18-year-old males were also consuming a greater amount of energy, so that %E contributed by total sugars was less than the average estimated for all children on the day of the survey. Very young children (two to seven years) had the greatest %E from total sugars (28 to 30%).

Added sugars

The estimated average intake of added sugars for the total population on the day of the survey was 66 g/day, approximately 11% of the total energy intake. In general, adolescents (12 to 18 years) consumed more added sugars than either younger children or adults on the day of the survey, both in terms of absolute amount and in %E supplied. For almost every age group, males consumed more added sugars than females, with the greatest amount of added sugars (140 g) consumed by males 16 to 18 years, which contributed 16%E, the highest %E over all the groups.

Natural sugars

The estimated average intake of natural sugars for the total population on the day of the survey was 57 g/day, approximately 10% of the total energy intake. Children consumed greater absolute amounts of natural sugars than adults on the day of the survey and received a greater %E from natural sugars but the differences were not as large as those seen with total and added sugars. As age increased, the mean %E contributed by natural sugars declined from 16% in the youngest age group to 9% in those aged 19 to 24 years, then increased in older adults. Males consumed greater absolute amounts of natural sugars than females on the day of the survey but had a lower %E coming from natural sugars. Males 16 to 18 years consumed the greatest absolute amount of natural sugars on the day of the survey but had one of the lowest values for %E from natural sugars.

Food sources of sugars

Total sugars

On the day of the survey, the greatest source of total sugars for both children and adults was non-alcoholic beverages, followed by milk products and dishes (including ice cream). Together, these food groups supplied more than half of all sugars consumed. Similar sources of total sugars were seen for both boys and girls on the day of the survey. Women tended to obtain less of their total sugar from non-alcoholic beverages than men; more from fruit products and dishes and slightly less from sugar products and dishes (see Figure 1). In those aged two to 18 years, of the non-alcoholic beverage types, juice-based drinks contributed 21% of total sugars and sugar-based drinks contributed 15% in males and 12% in females (data not shown). In adults, fruit-based drinks contributed 10% of total sugars and sugar-based drinks contributed 16% in men and 9% in women (data not shown).

[FIGURE 1 OMITTED]

Added sugars

Non-alcoholic beverages were the greatest source of added sugars, and supplied almost half of all added sugars in the diets of children aged two to 18 years, with a higher proportion coming from this source for boys compared to girls. For children, the next greatest source was cereal-based products and dishes (e.g. cakes, biscuits), whereas for adults, the next greatest source was sugar products and dishes (e.g. discretionary sugars, jam, honey), (see Figure 2). Of the non-alcoholic beverage types (data not shown), sugar-based drinks and juice-based drinks were the major contributors to the added sugars intake, with each type of drink contributing 21% of added sugars intake in children. In adults, sugar-based drinks supplied 27% of added sugars intake in men and 19% in women, and juice-based drinks supplied 10% in both men and women (data not shown).

[FIGURE 2 OMITTED]

Natural sugars

On the day of the survey, the greatest source of natural sugars for children was milk products and dishes, with boys obtaining a greater proportion from this source than girls. The next greatest source was fruit products and dishes (higher for girls than for boys). For adults, the greatest source of natural sugars was fruit products and dishes, with women obtaining a greater percentage of natural sugars from this source than men. The milk products and dishes food group was also a major source of natural sugars for adults (see Figure 3).

[FIGURE 3 OMITTED]

Allocation of subjects to sugars tertiles

It was clear from comparisons of the different tertiles that an individual classified into one tertile for one type of sugar was not always in the same tertile for another type of sugar. This was especially true for tertiles of total sugars and natural sugars where the Spearman correlations of the tertile categories were very low (in the ranges of r = 0.10 to 0.26 for boys, girls, men and women separately) although they were statistically significant. The Spearman correlations for added and natural sugars were moderate in magnitude but negative (in the ranges of r = -0.40 to -0.61) indicating that an individual in a lower tertile for added sugars was likely to be in a higher tertile for natural sugars and vice versa. The correlation coefficients for total sugars with added sugars were positive and of a reasonable magnitude (range from 0.45 to 0.60).

Food intakes according to sugars tertiles

Mean densities of intake of food categories, expressed as g/1000 kJ, were calculated for each tertile for each of total sugars, added sugars and natural sugars. As there were no day-2 adjustments available for food intakes, the kJ were also not day-2-adjusted for this calculation. Due to the large numbers of respondents, statistically significant results were frequently observed, even when the magnitudes of differences were small. In order to narrow the focus to key items of interest, the results are only discussed where the absolute magnitude of the standardised slope exceeded 0.2 with P < 0.001, and the numeric difference between tertiles exceeded 5 g/1000 kJ, which is likely to be of practical dietary significance.

Total sugars

The intake densities of several food groups changed in linear fashion with increasing density of total sugars. In those aged two to 18 years, the greatest effect of increasing density of total sugars was seen in the higher intake density of non-alcoholic beverages, particularly juice-based drinks. Substantial increases were also observed for fruit products and dishes. Conversely, there were appreciably lower densities of meat, poultry and game products and dishes, and of cereals and cereal products (see Table 3). In both men and women the greatest effects occurred with progressively higher intake densities on the day of the survey for fruit products and dishes, milk products and dishes, sugar-based and juice-based non-alcoholic beverages, and lower intake densities on the day of the survey for alcoholic beverages and for meat and meat products, although the effects were stronger in men than in women. There were also greater densities of total non-alcoholic beverage intakes (which included tea and coffee) for men than for women as total sugars densities increased.

Added sugars

In both children and adults, as added sugars densities increased, the greatest increases in intake densities on the day of the survey were for non-alcoholic beverages, particularly sugar-based non-alcoholic beverages, and substantially lower intake densities for cereals and cereal products (e.g. breads, pasta, grains and breakfast cereals), (see Table 4). In those aged two to 18 years, lower densities of milk products and dishes, and especially in girls, vegetables, were associated with higher added sugars densities on the day of the survey. For men, substantially lower intake densities of alcoholic beverages were also associated with higher densities of added sugars. In women, although a similar effect was observed, the magnitude of the effect was relatively small (see Table 4).

Natural sugars

As was the case for the other two sugars, the intake densities of some food categories (expressed as density g/1000 kJ) changed in a linear fashion with increasing natural sugars density. The greatest effects occurred with higher intake densities on the day of the survey for fruit products and dishes and milk products and dishes, but lower intake densities of sugar-based non-alcoholic beverages as densities of natural sugars increased (see Table 5). For men, higher density of natural sugars was associated with lower intake density of alcoholic beverages. While this effect was also observed in women, the trend was weaker.

Nutrient profile of diets with different sugars levels

Densities of intake of nutrients, expressed either per 1000 kJ or as percentage of energy supplied, were calculated using day-2-adjusted data. As with the food intakes, statistically significant trends across the tertiles were frequently observed, even when the magnitudes of differences were small. In order to narrow the focus to key items of interest, the results are only discussed where the absolute magnitude of the standardised slope exceeded 0.2 with P < 0.001, which equates to a difference in nutrient density of approximately 10% or more between tertiles.

Total sugars

In both adults and children, as relative intakes of total sugars increased, there were appreciably lower %E from protein, total fat, monounsaturated fats and starch, and higher %E from added sugars, natural sugars and total carbohydrate. In those aged two to 18 years, increased densities of total sugars were also associated with lower densities of polyunsaturated fats (see Table 6). Other substantial trends associated with increasing total sugar density included reduced niacin density, increased vitamin C, and particularly in adult males, reduced %E supplied by alcohol.

Added sugars

In both children and adults, with increasing densities of added sugars, there were lower %E from protein, natural sugars and starch. In children, but not in adults, higher densities of added sugar were also associated with lower %E from total fat and saturated fats. In both children and adults, as added sugar densities increased, density of dietary fibre fell substantially, as did the density of most of the micronutrients examined, with the strongest effects being observed for magnesium, potassium and phosphorus (see Table 7).

Natural sugars

In general, as densities of natural sugars increased, energy intakes declined, while the density of dietary fibre increased appreciably, as did the density of most micronutrients, with the strongest effects seen in the densities of potassium, magnesium and vitamin C (see Table 8). This trend was in the opposite direction of the trend observed with added sugars (see Table 7). Of the macronutrient densities that changed significantly in a linear fashion with increasing tertiles of natural sugars intake densities, the largest difference observed was a decrease in added sugars densities as natural sugars density increased.

Nutrient adequacy: Percentage of diets below the RDIs and outside guidelines 

The nutrient levels of the 24-hour recall diets in each tertile of sugars were examined to determine differences in the percentage of diets which conformed with Australian RDIs and dietary guidelines.

Total sugars

Table 9 shows that, for all groups of respondents on the day of the survey, diets in the upper tertile of total sugars density were more likely to meet the guideline for total fat density ([is less than or equal to] 30%E from fat) and (in adults) dietary fibre ([is greater than or equal to] 30g fibre) than diets in the upper tertile. For women only, diets with higher density of total sugars were more likely to meet the guideline for saturated fat diets ([is less than or equal to] 10%E).

For boys, there were no statistically significant differences in the percentage of diets containing < 70% RDI for any micronutrients. For girls, men and women, there were higher percentages of diets containing < 70% of the RDI for calcium in the lower tertile of total sugars, although for girls, the trend across the tertiles was not consistent. For women in the upper tertile for total sugars, a greater percentage of diets was below 70% RDI for magnesium and zinc on the day of the survey. A statistically significant but small increase in the percentage below 70% RDI for phosphorus was also seen in women, and a similar decrease in men for riboflavin.

Added sugars

Table 10 shows that, in boys, diets with higher densities of added sugars were more likely to meet the guideline for total fat. For girls, men and women, the middle tertile for added sugars had the greatest percentage of higher fat diets (> 30%E). Thus the suggested inverse association between fat and sugars that was seen for total sugars was not observed consistently for added sugars. In men the percentage of diets exceeding 10%E from saturated fat rose as the density of added sugars increased. For both men and women, the upper tertile added sugars contained the greatest percentage of diets with dietary fibre below 30 g.

The relationship between calcium adequacy and added sugars density was inconsistent. Boys in the upper tertile for added sugars were significantly more likely to be below 70% RDI for calcium than boys in the other two tertiles. Conversely men in the lowest tertile had the greatest proportion below 70% RDI for calcium. In girls, there was no statistically significant association between added sugars and calcium, while in women, although differences were statistically significant, the middle tertile for added sugars had the lowest proportion of women below 70% RDI for calcium. For zinc, almost no boys or men were below 70% of RDI, irrespective of added sugars intake. However, for both girls and women, those in the highest tertile for added sugars were significantly more likely to be below 70% RDI for zinc. Smaller differences were also noted for riboflavin and magnesium for boys and girls, and folate for girls. For men the greatest difference observed was that those in the lower tertile for added sugars had the highest percentage below 70% RDI for calcium. Smaller differences were observed for riboflavin. A slightly higher proportion of men at risk of inadequate magnesium intakes were in the upper tertile. For women, the upper tertile of added sugars had the highest percentage of diets containing < 70% RDI for iron, magnesium and zinc. Smaller significant differences in the same direction were noted for riboflavin, folate and phosphorus.

Natural sugars

Table 11 shows the percentages of participants whose 24-hour recall diets failed to achieve either 70% RDI or the dietary guideline, according to tertiles of natural sugars intakes (expressed as %E), when adjusted for day-2 intakes.

For boys and girls there were no statistically significant differences in the percentage of diets achieving recommended levels of the macronutrient intakes across the tertiles for natural sugars. For both men and women, the lowest percentage of diets outside the guidelines for total fat and saturated fat were in the upper tertile for natural sugars, with very little difference seen between the lower and middle tertiles for natural sugars. In adults, compliance with the guideline for dietary fibre improved as density of natural sugars increased.

For all groups of respondents, diets in the lower tertile for natural sugars had the greatest percentage with calcium below 70% RDI. Smaller but similar differences were observed for magnesium (all groups), riboflavin (boys, men and women) and folate (girls only). For women, the lowest tertile of natural sugars also had the highest percentages of diets containing < 70% RDI for iron, magnesium and zinc, although the trend was not consistent across the tertiles.

The association between sugar intake and BMI

For men, intakes of total, added and natural sugars based on the 24-hour recall data did not significantly contribute to the variance of BMI after including age, exercise level, whether or not they were on a weight reducing diet, whether or not they were classified as an under-reporter or not and total energy intake in the multiple linear regression model or in the logistic regression using dichotomised BMI variables (underweight and acceptable as one category versus overweight and obese as the other).

In women, using the same multiple linear regression procedure as that used for men, total and added sugars intakes from the 24-hour recall data did not significantly contribute to the variance of BMI, but intake of natural sugars was statistically significant. Those with higher intakes of natural sugars tended to have lower BMIs but the inclusion of the natural sugars intake variable in the model only increased the amount of variance explained to 12.9% from a baseline of 12.4%. Overall, the whole model in general, and natural sugars intake in particular, was a poor predictor of BMI.

In children, sugars intake did not significantly contribute to BMI variance after adjusting for age. The same conclusions were reached whether or not the BMI values were log transformed.

The relationship between sugar intake and blood pressure

For both men and women, after adjusting for age, physical activity, whether or not they were on a weight reducing diet, total energy intake, and BMI in a multiple regression, none of the sugars intake variables significantly contributed to the variance of either SBP or DBP. Likewise, in a logistic regression model carried out separately for each gender for the blood pressure risk categories (normal versus mild to severe risk), sugars intakes did not significantly predict the blood pressure risk category.

The relationship between sugar intake and exercise in adults

In the logistic regression after the exercise variable had been dichotomised into 'no and little exercise' and 'medium to high exercise' categories and after adjusting for age, total energy, whether or not individuals were on a weight reduction diet and BMI, for both men and women, only natural sugars intake contributed significantly to the variance in exercise level. However, the total model only explained two to six percent of the variance. Those in the lower tertile for natural sugars intake had an odds ratio for being in the medium to high exercise category of 0.60 (CI 0.51 to 0.71) for women and 1.42 (1.16 to 1.73) for men when compared to the upper tertile for natural sugars intakes. Similar results were obtained for those in the middle tertile of natural sugars intakes, odds ratio of 0.70 (CI 0.61 to 0.82) for women and 1.35 (1.11 to 1.64) for men in the medium to high exercise category.

The relationship between sugar intake and self-reported health status in adults

None of the sugar intake variables contributed significantly to variance in self-reported health status in a logistic regression after dichotomising health status into those with 'good to excellent' self-reported health status and 'fair to poor' self-reported health status and after adjusting for age, total energy, BMI and whether or not individuals were on a weight reduction diet.

Discussion

The intakes of total sugars for this representative Australian population was 123 g/day, which contributed 20 to 26% of the total energy intake (%E), and intake of added sugars was ten to 15%E (66 g/day) with the higher amounts being consumed by children and adolescents. In the current study, approximately half of the total sugars intake was added sugars, although this percentage varied with age and gender. In the US, the Nationwide Food Consumption Survey indicates that, population-wide, the US averaged 22% of energy in the diet from sugars (38), which is comparable to the intakes seen in the NNS. The Continuing Survey of Food Intakes by Individuals (CFSII) aged two years and over is also based on 24-hour recall data but includes trisaccharides and higher saccharides in their estimate of added sugars, so the results are not directly comparable with the current study, which has estimated the intake of added sugars based on monosaccharides and disaccharides. The estimated intake of added sweeteners in the CFSII was 82 g/day which contributed around 16%E and those in the upper tertiles were consuming 137 g/day of added sweeteners, which contributed 27% of total energy (39,43). These are higher estimates than found in the NNS95 but as noted earlier there are differences in methodology, although similar trends were reported.

It is impossible to determine the historical trends in sugars intake, as Australia has no consistent dietary intake monitoring system in place. Although a direct comparison cannot be made with earlier national Australian studies due to different methodologies, we can garner some broad information from such comparisons. In the 1985 national dietary survey of schoolchildren aged ten to 15 years, total sugars intakes ranged from 121 to 176 g/day for boys and 109 to 123 g/day for girls (41). Similar age groups in the current study were consuming, on average 152 to 181 g/day of total sugars for boys and 132 to 137 g/day for girls, suggesting a possible increase in intakes of total sugars in this age group. The earlier 1983 national adult survey reported total sugars intakes of 123 g/day for men and 92 g/day for women (42). Values in the current study or 134 g for men and 97 g for women, suggesting a small increase in absolute intakes of total sugars, although this conclusion should be treated with caution due to differences in sampling and methodologies.

Some countries have established recommendations suggesting that added sugars should contribute less than ten to 15% of total energy intake (2,43,44). Overall, intakes in the current Australian study were within these suggested guidelines. However, those in the upper tertiles for added sugars were having a moderately high percentage of energy contributed by added sugars--23 to 24% for children and 17 to 18% for adults.

In this study, nutrient and food densities were compared for different tertiles of total, added and natural sugars density. Although the nutrient values were day-2-adjusted, to more closely reflect the distribution of usual intakes of nutrients, this does not obviate the fact that the intake data are still based on 24-hour dietary recalls. However, the intakes can be regarded as a collection of dietary patterns, which, when divided into tertiles of intake of sugars, may be used to characterise differences in intakes of nutrients and foods associated with varying levels of sugars.

Food intake profiles in this survey did vary according to whether the diet was high in total, added or natural sugars on the day of the survey. The greatest differences observed were the association of increased intakes of non-alcoholic beverages with increased densities of total sugars and added sugars, in both adults and children. Both the juice-based drinks and the sugar-based drinks were strongly and positively associated with higher intakes of both total sugars and added sugars and negatively with intakes of natural sugars, although the effects tended to be greater in children than adults. In terms of absolute intake, diets of children in the upper tertile for added sugars contained, on average, 440g more sugar-based drinks (approximately two standard serves) and 276 g more juice-based drinks, 70 g less cereals and cereal products (e.g. bread, breakfast cereal), and 23 g more sugar products. While there were statistically significant differences in the intakes of other food groups with increasing sugars intakes, these varied by much less than one theoretical standard serve of food. These results suggest that although food choices did differ with increasing sugars, the population as a whole was not displacing any particular food group with sugar-rich foods. The practical significance of these differences in food intakes needs to be evaluated according to whether nutrient intakes are compromised with changing sugars intake.

Differences in nutrient consumption

From a nutritional perspective, higher intakes of sugars do not have a strong association with the aetiology of any particular chronic disease (except perhaps dental caries) and so should only be of concern if they displace key nutrients. It has been suggested that a higher intake of sugars or sugar-rich foods may displace nutrient-rich foods, resulting in inadequate intakes of some nutrients (10,45,46). The Draft Dietary Guidelines for Australians recommends consuming only moderate amounts of sugars, on the grounds that significant amounts of sugars dilute the nutrient density in the diet (4). However the draft guidelines do not quantify the recommendation.

We explored the issue of nutrient dilution in two ways in this paper, firstly by examining differences in micronutrient density with increases in sugars intakes and secondly by looking at any differences in the percentages of diets that failed to reach dietary recommendations or at least 70% RDIs in each tertile of sugars intakes. While the RDI comparisons in this report are based on 24-hour recall data from the NNS, rather than usual intakes, on which the RDIs are based, the comparisons can give an indication of relative, rather than absolute, differences between the terfiles of sugars intake.

The current study did observe some dilution of micronutrients as intakes of total sugars and added sugars increased. Although many statistically significant differences were found, notably lower densities of most micronutrients with increasing added sugars and higher densities of most micronutrients with increasing natural sugars intakes, from a public health perspective, only the differences that significantly affected the risk of nutrient inadequacy are likely to be of practical significance. Using < 70% RDI as the criterion, the great majority of people appeared to have adequate intakes of all the vitamins examined, irrespective of the level of intakes of sugars, whereas mineral intakes appeared at rather greater risk of inadequacy. Higher densities of total sugars or added sugars noticeably increased the proportion who were below 70% RDI for zinc and magnesium (women and girls), iron (women only), and calcium (boys only) whereas other differences were relatively small. However, it was only in the highest tertile for added sugars density (mean of 23%E for girls, 24%E for boys and 17%E for women) that the intakes of these minerals appeared to be compromised enough to increase the risk of inadequacy. These added sugars intakes are well above the 12% dietary target recommended for the average Australian population (2). For women, the intake of calcium appeared to be rather compromised in those in the middle tertile for added sugars (9%E) but, as such did not therefore appear to be linearly related to added sugars intake.

In women only there was consistent evidence of nutrient dilution accompanied by significant numbers who failed to achieve 70% RDI. Women are at greater risk of nutritional inadequacy because of their lower energy intakes, and the intakes of iron, zinc and magnesium by women were already marginal. Hence women consuming higher sugars diets (27%E and 17%E from total and added sugars respectively) may be further increasing their risk of inadequate intakes of some nutrients that are already marginal in the general population. The intakes of these at-risk micronutrients could be improved by recommending some increase in the consumption of lean red meat, who-legrain cereals and seafood.

It was observed that the densities of added sugars varied with age in both children and adults (see Table 2). It was beyond the scope of this study to investigate each age group separately, and it is therefore possible that there were sub-groups within our categories with greater than average risk of nutrient inadequacy.

In an Australian study in 1992 (9), higher intakes of added sugars appeared to only consistently increase the percentage of adults who had diets < 70% of the RDI for folate and vitamin A. The reasons for the different findings between the two Australian studies could relate to true differences in dietary intake due to changes in food consumption since the 1992 study was completed, or it could relate to differences in dietary intake methodology, as the 1992 study examined usual intakes using a semi-quantified food frequency.

Overseas studies differ as to the effects of increasing %E from total sugars on intakes of other nutrients. Studies have variously reported that increased total sugars density tended to be positively related to calcium and riboflavin intakes, negatively related to iron and nicotinic acid, and unrelated to thiamin and vitamins A and C (45) and that increased total sugar density did not displace nutrients, although niacin intake was reduced, but that total food energy intake was more important (11).

Similarly, those studies which investigated the relationship of added sugars intake and nutrient levels show diverse findings. One study of preschool children observed that, with increasing intake of non-milk extrinsic sugars (NME), increased proportions of children had intakes less than the recommendations for vitamin D (which was not measured in the NNS), iron and zinc (47,48), while in a smaller study of children aged 11 to 13 years, vitamin D and folate intakes decreased with increasing added sugars intakes (46). A recently published report on the US CSFII concluded that increasing added sugars did not compromise the nutrient intakes of children or adolescents using percentage of RDA reached as the criterion (49). For adults, diets higher in added and NME sugars tended to be of lower nutrient density (47). The authors stated that low nutrient intakes tended to occur when the energy intake was low and that nutrients were only affected once NME contributed above 17%E, which is similar to the findings for women in the current study. Bowman also reported micronutrient dilution for vitamin B12 (which was not measured in the NNS), vitamin A, folate, magnesium and iron with increasing added sugars intakes, although the methodology in this US study differed in that its tertiles were determined across the whole aggregated population rather than separately for males and females, children and adults (39).

In contrast to added sugars, most of the micronutrient densities were higher for both children and adults with increasing natural sugars intakes. However, all groups of subjects in the lower tertile for natural sugars were at substantially greater risk of having an inadequate intake of calcium. In addition, girls and women appeared to be at greater risk of inadequate intakes of magnesium and, for women, possibly zinc, intakes of which are already marginal for women.

In the current study, diets containing higher intakes of total sugars did appear to be associated with lower total fat and higher carbohydrate intakes. This has been described as the sugar/fat seesaw (11,50), and may be beneficial in lowering the risk of developing coronary heart disease (51). Children in the upper tertiles for added sugars were, on average, able to achieve lower fat diets closer to the recommended levels of 30%E from fat although this effect was not apparent in adults' diets. However, there was no consistent association between levels of sugars and saturated fats in the diet, so the impact on reducing the risk of coronary heart disease may be limited and dietary guidance on less saturated fat food choices is still needed.

The sugar/fat seesaw was observed for higher consumers of added sugars as well as for total sugars, although the trend was not linear across all the tertiles of added sugars for either men or women, suggesting that some of the sources of added sugars may also be sources of fat. Indeed, higher added sugars intakes were associated with higher intakes of cereal-based products and dishes (which included cakes, pizzas and pies), confectionery and health bars.

Increasing body weight is becoming a problem worldwide and Australia is no exception. In Australia, 55% of the adult population is overweight or obese, with the percentage higher in men (63%) than women (47%) (52) and this appears to be increasing (53). In the past, links have been made between higher intakes of sugars and increased risk of becoming overweight or obese. The FAO/WHO expert consultation group 1998 report on carbohydrates stated that there was no evidence to support such claims (1). A recent draft report from another FAO/WHO expert consultation group has cited studies that suggest high consumption of sugar-rich drinks may be associated with increased levels of obesity (54). However, the cited papers mainly describe short-term weight-loss studies in obese adult subjects where sugars in drinks were removed. One longer prospective study (19 months) cited in the report observed increased BMI over the period, in association with increased intake of sugar-containing drinks (55). However, that study was limited to adolescents around puberty. Overall energy intakes also increased substantially during the study, to which the increase in sugar-containing drinks made only a minor contribution. Indeed, many observational studies have found an inverse association between the intakes of sugars and current body weight (56-58); and others have made no association (59).

In the current study, intakes of sugars, no matter how they were defined, were not powerful predictors of current BMI or whether or not an individual was overweight, after adjustments for other variables known to affect BMI were made. The apparent lack of any strong relationships may relate to the sugar/fat seesaw in that higher intakes of sugars tend to be associated with lower fat diets and higher intakes of fat have been implicated as a potential risk factor for developing obesity. As BMI is the result of long-term dietary intake and physical activity patterns, current intakes of sugars, especially based on 24-hour recall, may not necessarily be expected to be strong predictors of BMI, as there are many other longer-term dietary and behavioural patterns that may have caused differences in weight long before the current survey was conducted. Furthermore, current BMI level may in turn influence dietary choices, with some overweight individuals attempting to restrict intake of certain foods or nutrients such as sugars.

The FAO/WHO expert group on carbohydrates concluded that there was no evidence of any direct involvement of sugars in the aetiology of lifestyle-related diseases and the results from the current observational study concur with those conclusions. In the current study, intakes of sugars were not or were only weakly associated with measured blood pressure, blood pressure risk categories, self-reported exercise levels or health status. There was a positive association between natural sugars and an increased self-reported exercise level but very little of the variance was explained by the model, suggesting that natural sugars, as measured by 24-hour recall, and the other variables (age, total energy intake, BMI and whether or not individuals were on a weight reducing diet) included in the model were not good predictors of self-reported exercise levels. A higher consumption of natural sugars may be related to other lifestyle variables or psychological variables not included in the current model that in turn are related to increased levels of exercise. As noted for BMI, 24-hour recall diets may not necessarily be expected to be strong predictors of these health variables, and it is possible that measures of dietary intake over a longer period could yield different results.

Conclusions

It appears that women consuming diets which are very high in total sugars or added sugars may be increasing their risk of inadequate intakes of some minerals that are already marginal. Children and men appeared to be at less risk of inadequate mineral intakes, and there was little evidence of inadequate intakes of vitamins at higher levels of total sugars or added sugars intake. Conversely, there was evidence that a low density of natural sugars in the diet was associated with substantially higher risk of inadequate intake of calcium. Intakes of sugars (as measured by 24-hour recall) appeared to be poor predictors of health variables.

Figure 1. Sources of total sugars (as percentage of total
sugars) for adult men and women (aged 19 years
and over) and boys and girls (aged two to 18 years)
on the day of the 1995 National Nutrition Survey

                            Women   Men   Girls   Boys

Confectionery                  5     3     8       7

Sugar products and
dishes                        11    14     7       7

Vegetable products
and dishes                     5     4     2       2

Milk products and
dishes                        17    16    20      21

Fruit products and
dishes                        17    12    11       9

Cereal-based products and
dishes                        11    10     9       8

Cereals and cereal
products                       6     6     5       6

Non-alcoholic
beverages                     20    26    33      35

Note: Table made from bar graph.

Figure 2. Sources of added sugars (as percentage of added sugars) for
adult men and women (aged 19 years and over) and boys and girls (aged
two to 18 years) on the day of the 1995 National Nutrition Survey

                            Women   Men   Girls   Boys

Confectionery                  9     6     13      10

Sugar products and
dishes                        22    24     11      11

Vegetable products
and dishes                     1     1      0       0

Milk products and
dishes                         9     8     11      11

Fruit products and
dishes                         2     1      0       1

Cereal-based products and
dishes                        18    14     13      11

Cereals and cereal
products                       4     4     5       6

Non-alcoholic
beverages                     29    37    43      47

Note: Table made from bar graph.

Figure 3. Sources of natural sugars (as percentage of natural sugars)
for adult men and women (aged 19 years and over) and boys and girls
(aged two to 18 years) on the day of the 1995 National Nutrition Survey

                            Women   Men   Girls   Boys

Confectionery                  1     1     2       2

Sugar products and
dishes                         0     0     0       0

Vegetable products
and dishes                     9     9     5       5

Milk products and
dishes                        25    27    32      37

Fruit products and
dishes                        31    27    26      23

Cereal-based products and
dishes                         4     5     4       4

Cereals and cereal
products                       8     9     6       7

Non-alcoholic
beverages                     12    12    20      17

Note: Table made from bar graph.

Table 1. Tertile cut-off points used to classify low, medium and high
consumers of sugars intakes on the day of the 1995 National Nutrition
Survey for both children and adults (a)

                                             Children 2 to 18 years
                              Lower                      Middle

Males
Total sugars %E     [is less than or equal to] 23.5   > 23.5-28.5
Added sugars %E     [is less than or equal to] 11.5   > 11.5-18.5
Natural sugars %E   [is less than or equal to] 8.0    > 8.0-13.0

Females
Total sugars %E     [is less than or equal to] 23.5    > 23.5-28.5
Added sugars %E     [is less than or equal to] 11.0    > 11.0-17.5
Natural sugars %E   [is less than or equal to] 9.0     > 9.0-14.0

                     Upper                 Lower

Males
Total sugars %E     > 28.5     [is less than or equal to] 16.5
Added sugars %E     > 18.5     [is less than or equal to]  7.0
Natural sugars %E   > 13.0     [is less than or equal to]  6.0

Females
Total sugars %E     > 28.5     [is less than or equal to] 18.0
Added sugars %E     > 17.5     [is less than or equal to]  6.0
Natural sugars %E   > 14.0     [is less than or equal to]  8.5

                 Adults 19 years and older
                        Middle       Upper

Males
Total sugars %E      > 16.5-21.5    > 21.5
Added sugars %E       > 7.0-12.5    > 12.5
Natural sugars %E     > 6.0-10.5    > 10.5

Females
Total sugars %E      > 18.0-23.0    > 23.0
Added sugars %E       > 6.0-11.5    > 11.5
Natural sugars %E     > 8.5-13.5    > 13.5

(a) The tertiles were derived from the day 2-adjusted percentage of
energy contributed by each of the sugars.

Table 2. Mean intakes (g/day) on the day of the 1995 National
Nutrition Survey and percentage energy contributed by total,
added and natural sugars using day-2-adjusted nutrient data
and the population weighted sample (a)

                      Weighted     Total     Total        Added
                       sample      sugars    sugars %     sugars
                        count       (g)      energy (b)    (g)

Males
Children
2-3 years               209          124        30.3         59
4-7 years               421          134        27.4         75
8-11 years              416          152        25.3         90
12-15 years             413          181        25.1        113
16-18 years             307          212        25.1        140
2-18 years             1767          161        26.3         97

Adults
19-24 years             684          177        21.6        115
25-44 years            2205          139        18.8         79
45-64 years            1499          118        18.4         58
65 years and over       741          109        20.6         53
19 years and over      5129          134        19.3         74

Females
Children
2-3 years               199          106        28.1         49
4-7 years               396          124        28.3         67
8-11 years              398          132        25.3         79
12-15 years             391          137        25.9         80
16-18 years             291          133        24.6         79
2-18 years             1675          128        26.4         73

Adults
19-24 years             657          117        22.7         67
25-44 years            2206           99        19.9         48
45-64 years            1461           92        20.4         39
65 years and over       964           87        22.1         35
19 years and over      5288           97        20.8         45

                       Added      Natural    Natural
                      sugars %     sugars     sugars %
                      energy (b)    (g)      energy (b)

Males
Children
2-3 years               14.3         65        16.0
4-7 years               15.3         59        12.2
8-11 years              14.8         62        10.5
12-15 years             15.4         69         9.7
16-18 years             16.4         72         8.7
2-18 years              15.3         65        11.0

Adults
19-24 years             14.0         61         7.6
25-44 years             10.6         60         8.2
45-64 years              8.9         60         9.5
65 years and over        9.8         56        10.8
19 years and over       10.4         60         8.9

Females
Children
2-3 years               12.8         58        15.3
4-7 years               15.1         57        13.2
8-11 years              14.9         53        10.4
12-15 years             14.8         58        11.1
16-18 years             14.2         54        10.4
2-18 years              14.6         56        11.8

Adults
19-24 years             12.9         50         9.9
25-44 years              9.5         50        10.4
45-64 years              8.3         54        12.1
65 years and over        8.6         52        13.5
19 years and over        9.4         52        11.4

(a) Percentages and numbers may not add up due to rounding.
(b) Since separate day-2-adjustment factors are applied to sugars
and to energy, the resulting calculated percentage of energy can
vary slightly from unadjusted mean % energy values.

Table 3. Mean intakes of selected food groups (a), expressed as
density, g/1000 kJ (not day-2-adjusted) according to tertiles (b)
of total sugars on the day of the 1995 National Nutrition Survey

                                          Males
                                                          Std
                              Lower   Middle   Upper   slope (c)

                                Respondents aged 2 to 18 years

Non-alcoholic beverages         47      68      107   *   0.44
- Sugar-based non-alcoholic
  beverages                     11      20       34   *   0.28
- Juice-based non-alcoholic
  beverages                     15      30       53   *   0.40
Cereals and cereal products     26      22       17   *  -0.20
Cereal-based products and
 dishes                         16      13       12   *  -0.11
Fats and oils                    1       1        1   *  -0.10
Meat, poultry and game
 products and dishes            15      11       10   *  -0.20
Milk products and dishes        43      54       51   *   0.09
Vegetable products and
 dishes                         20      17       14   *  -0.13
Fruit products and dishes       10      14       21   *   0.22
Sugar products and dishes        2       3        5   *   0.18
Confectionery and health
 bars                            1       2        3   *   0.24

                             Respondents aged 19 years and over

Non-alcoholic beverages        133     125      159   *   0.22
- Sugar-based non-alcoholic
  beverages                      5      14       34   *   0.35
- Juice-based non-alcoholic
  beverages                      5      12       22   *   0.28
Cereals and cereal products     26      25       20   *  -0.13
Cereal-based products and
 dishes                         12      14       12       0.00
Fats and oils                    2       1        1   *  -0.10
Fruit products and dishes        7      15       22   *   0.28
Meat, poultry and game
 products and dishes            22      18       14   *  -0.20
Milk products and dishes        19      33       38   *   0.28
Vegetable products and
 dishes                         29      28       27      -0.03
Sugar products and dishes        1       2        3   *   0.23
Confectionery and health
 bars                            0       1        1   *   0.18
Alcoholic beverages             66      26       13   *  -0.33

                                         Females
                                                          Std
                              Lower   Middle   Upper   slope (c)

                                Respondents aged 2 to 18 years

Non-alcoholic beverages         54      72      110   *   0.35
- Sugar-based non-alcoholic
  beverages                      9      15       31   *   0.25
- Juice-based non-alcoholic
  beverages                     18      38       59   *   0.39
Cereals and cereal products     27      21       17   *  -0.22
Cereal-based products and
 dishes                         14      13       12      -0.04
Fats and oils                    1       1        1   *  -0.11
Meat, poultry and game
 products and dishes            17      11        9   *  -0.23
Milk products and dishes        38      51       49   *   0.12
Vegetable products and
 dishes                         24      20       16   *  -0.17
Fruit products and dishes       12      18       23   *   0.21
Sugar products and dishes        1       3        4   *   0.18
Confectionery and health
 bars                            2       2        4   *   0.21

                             Respondents aged 19 years and over

Non-alcoholic beverages        158     177      193   *   0.08
- Sugar-based non-alcoholic
  beverages                      3       8       23   *   0.27
- Juice-based non-alcoholic
  beverages                      5      12       27   *   0.30
Cereals and cereal products     29      26       20   *  -0.17
Cereal-based products and
 dishes                         13      13       11      -0.04
Fats and oils                    2       1        1   *  -0.11
Fruit products and dishes       10      21       34   *   0.32
Meat, poultry and game
 products and dishes            19      16       12   *  -0.18
Milk products and dishes        25      38       45   *   0.25
Vegetable products and
 dishes                         35      35       34      -0.01
Sugar products and dishes        1       2        3   *   0.20
Confectionery and health
 bars                            1       1        2   *   0.15
Alcoholic beverages             22       9        7   *  -0.17

(a) Any food groups not shown had standardised slopes between -0.10
and +0.10 inclusive, for both males and females.

(b) The tertiles were derived from the percentage of energy
contributed by the total sugars.

(c) Standardised sloped across the tertiles.

* Regression slope significantly different from zero,
P [is less than or equal to] 0.001

Table 4. Mean intakes of selected food groups (a), expressed as
density, g/1000 kJ (not day-2-adjusted) according to tertiles (b)
of added sugars on the day of the 1995 National Nutrition Survey

                                          Males
                                                          Std
                              Lower   Middle   Upper   slope (c)

                                Respondents aged 2 to 18 years

Non-alcoholic beverages         43      71      109   *   0.49
- Sugar-based non-alcoholic
  beverages                      4      18       44   *   0.49
- Juice-based non-alcoholic
  beverages                     20      32       45   *   0.26
Cereals and cereal products     26      22       16   *  -0.23
Cereal-based products and
 dishes                         15      12       14      -0.04
Fats and oils                    1       1        1   *  -0.09
Fruit products and dishes       19      14       10   *  -0.17
Meat, poultry and game
 products and dishes            14      12       10   *  -0.12
Milk products and dishes        58      50       40   *  -0.20
Vegetable products and
 dishes                         19      17       15   *  -0.10
Sugar products and dishes        1       3        5   *   0.19
Confectionery and health
 bars                            1       2        3   *   0.25

                             Respondents aged 19 years and over

Non-alcoholic beverages        147     117      156   *   0.17
- Sugar-based non-alcoholic
  beverages                      1       9       41   *   0.47
- Juice-based non-alcoholic
  beverages                      9      11       18   *   0.13
Cereals and cereal products     29      23       19   *  -0.20
Cereal-based products and
 dishes                         10      14       14   *   0.10
Fats and oils                    1       2        1      -0.04
Fruit products and dishes       18      14       11   *  -0.12
Meat, poultry and game
 products and dishes            21      18       16   *  -0.13
Milk products and dishes        26      31       31   *   0.08
Vegetable products and
 dishes                         32      27       25   *  -0.12
Sugar products and dishes        1       2        4   *   0.26
Confectionery and health
 bars                            0       1        1   *   0.21
Alcoholic beverages             60      34       18   *  -0.25

                                         Females
                                                          Std
                              Lower   Middle   Upper   slope (c)

                                Respondents aged 2 to 18 years

Non-alcoholic beverages         52      71      110   *   0.36
- Sugar-based non-alcoholic
  beverages                      3      12       39   *   0.42
- Juice-based non-alcoholic
  beverages                     27      35       49   *   0.21
Cereals and cereal products     27      22       16   *  -0.23
Cereal-based products and
 dishes                         11      13       15   *   0.09
Fats and oils                    1       1        1   *  -0.12
Fruit products and dishes       22      16       13   *  -0.17
Meat, poultry and game
 products and dishes            14      14       10   *  -0.13
Milk products and dishes        52      47       38   *  -0.15
Vegetable products and
 dishes                         26      18       16   *  -0.21
Sugar products and dishes        1       3        5   *   0.22
Confectionery and health
 bars                            1       2        4   *   0.25

                             Respondents aged 19 years and over

Non-alcoholic beverages        171     178      180       0.02
- Sugar-based non-alcoholic
  beverages                      0       4       29   *   0.39
- Juice-based non-alcoholic
  beverages                     11      13       20   *   0.12
Cereals and cereal products     31      25       20   *  -0.21
Cereal-based products and
 dishes                         10      14       14   *   0.09
Fats and oils                    1       1        1   *  -0.06
Fruit products and dishes       28      21       15   *  -0.18
Meat, poultry and game
 products and dishes            17      16       13   *  -0.11
Milk products and dishes        35      38       34      -0.01
Vegetable products and
 dishes                         41      34       28   *  -0.17
Sugar products and dishes        1       2        4   *   0.27
Confectionery and health
 bars                            0       1        2   *   0.23
Alcoholic beverages             17      12        9   *  -0.09

(a) Any food groups not shown had standardized slopes between -0.10
and +0.10 inclusive, for both males and females.

(b) The tertiles were derived from the percentage of energy
contributed by the added sugars.

(c) Standardised slope across the tertiles.

* Regression slope significantly different from zero,
P [is less than or equal to] 0.001

Table 5. Mean intakes of selected food groups (a), expressed as
density, g/1000 kJ (not day-2-adjusted) according to tertiles (b)
of natural sugars on the day of the 1995 National Nutrition Survey

                                          Males
                                                          Std
                              Lower   Middle   Upper   slope (c)

                                Respondents aged 2 to 18 years

Non-alcoholic beverages         83      69       67   *  -0.11
- Sugar-based non-alcoholic
  beverages                     35      19        9   *  -0.32
- Juice-based non-alcoholic
  beverages                     24      32       42   *   0.19
Cereals and cereal products     21      21       23       0.05
Cereal-based products and
 dishes                         16      15       10   *  -0.16
Fats and oils                    1       1        1       0.00
Fruit products and dishes        3      12       30   *   0.48
Meat, poultry and game
 products and dishes            14      13       10   *  -0.13
Milk products and dishes        27      50       72   *   0.49
Vegetable products and
 dishes                         17      17       17      -0.01
Sugar products and dishes        3       3        2      -0.05
Confectionery and health
 bars                            2       2        2      -0.03
Snack foods                      1       1        1   *  -0.11

                             Respondents aged 19 years and over

Non-alcoholic beverages        155     124      137       0.04
- Sugar-based non-alcoholic
  beverages                     26      15        9   *  -0.21
- Juice-based non-alcoholic
  beverages                      7      11       20   *   0.21
Cereals and cereal products     21      24       25   *   0.08
Cereal-based products and
 dishes                         15      13       11   *  -0.09
Fats and oils                    1       2        1      -0.04
Fruit products and dishes        2      10       32   *   0.54
Meat, poultry and game
 products and dishes            20      19       15   *  -0.14
Milk products and dishes        14      32       43   *   0.43
Vegetable products and
 dishes                         25      28       31   *   0.10
Sugar products and dishes        2       2        2       0.00
Confectionery and health
 bars                            1       1        1       0.00
Alcoholic beverages             57      31       20   *  -0.23

                                         Females
                                                          Std
                              Lower   Middle   Upper   slope (c)

                                Respondents aged 2 to 18 years

Non-alcoholic beverages         86      70       76      -0.06
- Sugar-based non-alcoholic
  beverages                     32      14        7   *  -0.28
- Juice-based non-alcoholic
  beverages                     24      35       52   *   0.26
Cereals and cereal products     22      20       24       0.04
Cereal-based products and
 dishes                         16      14        9   *  -0.18
Fats and oils                    1       1        1      -0.02
Fruit products and dishes        4      16       32   *   0.52
Meat, poultry and game
 products and dishes            14      13       10   *  -0.12
Milk products and dishes        25      49       63   *   0.40
Vegetable products and
 dishes                         20      20       19      -0.01
Sugar products and dishes        3       3        2      -0.04
Confectionery and health
 bars                            3       2        2      -0.08
Snack foods                      2       1        1   *  -0.14

                             Respondents aged 19 years and over

Non-alcoholic beverages        172     170      187       0.03
- Sugar-based non-alcoholic
  beverages                     20       9        5   *  -0.21
- Juice-based non-alcoholic
  beverages                      8      13       24   *   0.21
Cereals and cereal products     25      25       25       0.00
Cereal-based products and
 dishes                         15      13        9   *  -0.15
Fats and oils                    1       1        1   *  -0.08
Fruit products and dishes        4      16       46   *   0.57
Meat, poultry and game
 products and dishes            17      16       14   *  -0.09
Milk products and dishes        20      37       51   *   0.37
Vegetable products and
 dishes                         29      33       42   *   0.17
Sugar products and dishes        2       2        2      -0.03
Confectionery and health
 bars                            1       1        1   *  -0.05
Alcoholic beverages             19      13        6   *  -0.14

(a) Any food groups not shown had standardized slopes between -0.10
and +0.10 inclusive, for both males and females.

(b) The tertiles were derived from the percentage of energy
contributed by the natural sugars.

(c) Standardised slope across the tertiles.

* Regression slope significantly different from zero,
P [is less than or equal to] 0.001

Table 6. Mean day-2-adjusted nutrient density (nutrient/1000kJ)
according to tertiles (a) of intakes of total sugars on the day
of the 1995 National Nutrition Survey

                                       Males
                                                      Std
                          Lower   Middle    Upper    slope (b)

                              Respondents aged 2 to 18 years

Energy kJ                10 884   10 161     8936     * -0.22

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                      15.7     14.6     13.5   * -0.33
Total fat                    35.9     33.1     30.8   * -0.46
Saturated fat                15.1     14.5     14.0   * -0.16
Monounsaturated fat          12.9     11.5     10.6   * -0.48
Polyunsaturated fat           4.9      4.6      4.1   * -0.30
Total sugars                 20.1     26.0     32.8   *  0.88
Added sugars                 10.2     15.1     20.5   *  0.66
Natural sugars                9.9     10.9     12.4   *  0.18
Starch                       26.4     24.4     21.0   * -0.46
Total carbohydrate           45.9     50.4     54.3   *  0.60

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Cholesterol (mg)             29.0     27.0     26.0   * -0.15
Dietary fibre (g)             2.2      2.1      2.0   * -0.09
Niacin equivalents (mg)       4.1      3.9      3.6   * -0.27
Vitamin C (mg)               11.0     12.0     16.0   *  0.24
Calcium (mg)                 97.0    105.0    106.0   *  0.12
Phosphorus (mg)             157.0    155.0    146.0   * -0.15
Iron (mg)                     1.3      1.4      1.3     -0.07
Zinc (mg)                     1.1      1.1      1.1   * -0.15

                         Respondents aged 19 years and over

Energy kJ                11 005   10 988   11 158        0.02

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                      17.8     17.2     16.0   * -0.25
Total fat                    33.8     33.3     31.2   * -0.21
Saturated fat                13.0     13.1     12.6     -0.05
Monounsaturated fat          12.6     12.3     11.3   * -0.25
Polyunsaturated fat           5.1      5.0      4.7   * -0.16
Total sugars                 13.1     18.9     26.2   *  0.88
Added sugars                  5.8      9.7     16.0   *  0.63
Natural sugars                7.3      9.2     10.2   *  0.26
Starch                       25.4     24.5     22.2   * -0.27
Total carbohydrate           38.8     43.5     48.5   *  0.60
Alcohol                       8.4      3.7      2.0   * -0.33

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Cholesterol (mg)             35.0     33.0     31.0   * -0.17
Dietary fibre (g)             2.3      2.5      2.5   *  0.12
Provitamin A (ug)           356.0    368.0    369.0      0.03
Riboflavin (mg)               0.2      0.2      0.2   *  0.14
Niacin equivalents (mg)       4.9      4.7      4.4   * -0.23
Vitamin C (mg)               11.0     13.0     14.0   *  0.17
Calcium (mg)                 77.0     89.0     93.0   *  0.21
Potassium (mg)              338.0    350.0    349.0   *  0.07

                                      Females
                                                      Std
                          Lower   Middle    Upper    slope (b)

                             Respondents aged 2 to 18 years

Energy kJ                  8189     7803     7575     * -0.11

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                      15.7     14.7     13.4   * -0.36
Total fat                    35.6     33.7     31.3   * -0.38
Saturated fat                14.9     14.9     14.1   * -0.12
Monounsaturated fat          12.7     11.8     10.8   * -0.42
Polyunsaturated fat           4.9      4.5      4.3   * -0.28
Total sugars                 20.2     26.0     32.8   *  0.89
Added sugars                 10.0     13.8     19.8   *  0.54
Natural sugars               10.2     12.2     13.0   *  0.19
Starch                       26.1     23.7     21.3   * -0.44
Total carbohydrate           46.3     49.6     54.3   *  0.57

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Cholesterol (mg)             30.0     27.0     25.0   * -0.21
Dietary fibre (g)             2.3      2.2      2.1   * -0.13
Niacin equivalents (mg)       4.1      3.9      3.6   * -0.29
Vitamin C (mg)               13.0     15.0     16.0   *  0.20
Calcium (mg)                 94.0    104.0    102.0   *  0.11
Phosphorus (mg)             154.0    155.0    144.0   * -0.15
Iron (mg)                     1.3      1.3      1.2   * -0.11
Zinc (mg)                     1.1      1.1      1.0   * -0.23

                         Respondents aged 19 years and over

Energy kJ                  7637     7379     7430       -0.04

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                      17.6     17.2     16.2   * -0.19
Total fat                    35.2     33.5     31.0   * -0.35
Saturated fat                13.6     13.1     12.3   * -0.18
Monounsaturated fat          12.9     12.1     11.1   * -0.37
Polyunsaturated fat           5.5      5.2      4.8   * -0.19
Total sugars                 14.9     20.2     26.9   *  0.87
Added sugars                  5.7      8.9     13.5   *  0.50
Natural sugars                9.3     11.4     13.3   *  0.31
Starch                       25.7     24.7     22.6   * -0.28
Total carbohydrate           41.1     45.2     49.4   *  0.56
Alcohol                       4.4      1.9      1.5   * -0.19

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Cholesterol (mg)             35.0     33.0     31.0   * -0.17
Dietary fibre (g)             2.6      2.9      2.9   *  0.14
Provitamin A (ug)           435.0    482.0    497.0   *  0.11
Riboflavin (mg)               0.2      0.3      0.3   *  0.16
Niacin equivalents (mg)       4.7      4.7      4.5   * -0.13
Vitamin C (mg)               13.0     16.0     18.0   *  0.24
Calcium (mg)                 92.0    102.0    107.0   *  0.18
Potassium (mg)              361.0    388.0    398.0   *  0.17

(a) The tertiles were derived from the percentage of energy
contributed by the total sugars.

(b) Standardised slope across the tertiles.

* Regression slope significantly different from zero,
P[is less than or equal to] 0.001

Table 7. Mean day-2-adjusted nutrient density (nutrient/1000 kJ)
according to tertiles (a) of intakes of added sugars on the
day of the 1995 National Nutrition Survey

                                                 Males

                                                              Std
                                      Lower   Middle   Upper  slope(b)

                                        Respondents aged 2 to 18 years

Energy kJ                             9625    10 004   10 353   *  0.08

Percentage energy (standardised slopes > 0.10 or <-0.10)

Protein                                 15.7      14.6     13.4 * -0.35
Total fat                               34.6      33.6     31.5 * -0.28
Saturated fat                           15.1      14.8     13.8 * -0.19
Monounsaturated fat                     12.1      11.8     11.0 * -0.22
Polyunsaturated fat                      4.7       4.5      4.3 * -0.11
Total sugars                            22.7      25.9     30.5 *  0.54
Added sugars                             7.3      15.0     23.7 *  0.89
Natural sugars                          15.4      10.9      6.8 * -0.62
Starch                                  25.4      23.9     22.4 * -0.26
Total carbohydrate                      47.7      49.8     53.3 *  0.40

Nutrient/1000 kJ (standardised slopes > 0.10 or <-0.10)

Cholesterol (mg)                        28.0      27.0     27.0   -0.08
Dietary fibre (g)                        2.3       2.1      1.9 * -0.36
Vitamin A (retinol equivalents) (ug)   110.0     103.0     97.0 * -0.11
Provitamin A (ug)                      277.0     261.0    227.0 * -0.13
Thiamin (mg)                             0.2       0.2      0.2 * -0.21
Riboflavin (mg)                          0.3       0.3      0.2 * -0.24
Niacin equivalents (mg)                  4.2       3.9      3.6 * -0.33
Folate (ug)                             26.0      24.0     22.0 * -0.29
Vitamin C (mg)                          15.0      13.0     11.0 * -0.18
Calcium (mg)                           114.0     104.0     90.0 * -0.30
Phosphorus (mg)                        166.0     153.0    138.0 * -0.42
Magnesium (mg)                          32.0      29.0     26.0 * -0.48
Iron (mg)                                1.4       1.3      1.3 * -0.19
Zinc (mg)                                1.2       1.1      1.1 * -0.23
Potassium (mg)                         340.0     311.0    276.0 * -0.43

                                    Respondents aged 19 years and over

Energy kJ                            10 408   11 250   11 519   *  0.15

Percentage energy (standardised slopes > 0.10 or <-0.10)

Protein                                18.0     17.0       16.0 * -0.29
Total sugars                           15.3     18.4       24.5 *  0.62
Added sugars                            3.9      9.7       18.0 *  0.87
Natural sugars                         11.4      8.7        6.5 * -0.43
Starch                                 25.3     24.3       22.5 * -0.24
Total carbohydrate                     40.8     42.9       47.0 *  0.39
Alcohol                                 7.0      4.7        2.5 * -0.23

Nutrient/1000 kJ (standardised slopes > 0.10 or <-0.10)

Cholesterol (mg)                       34.0     33.0       32.0 * -0.12
Dietary fibre (g)                       2.6      2.4        2.1 * -0.26
Vitamin A (retinol equivalents) (ug)  138.0    123.0      117.0 * -0.15
Preformed vitamin A (ug)               71.0     64.0       62.0 * -0.13
Provitamin A (ug)                     403.0    358.0      330.0 * -0.16
Thiamin (mg)                            0.2      0.2        0.2 * -0.12
Riboflavin (mg)                         0.2      0.2        0.2 * -0.05
Niacin equivalents (mg)                 4.9      4.7        2.3 * -0.29
Folate (ug)                            32.0     29.0       26.0 * -0.30
Vitamin C (mg)                         15.0     13.0       11.0 * -0.22
Calcium (mg)                           89.0     86.0       83.0 * -0.07
Phosphorus (mg)                       170.0    162.0      153.0 * -0.28
Magnesium (mg)                         38.0     35.0       32.0 * -0.37
Iron (mg)                               1.5      1.5        1.4 * -0.20
Zinc (mg)                               1.4      1.3        1.3 * -0.14
Potassium (mg)                        373.0    346.0      317.0 * -0.32

                                                    Females

                                                                  Std
                                     Lower   Middle    Upper   slope (b)

                                       Respondents aged 2 to 18 years

Energy kJ                               516   7922    8131    *  0.11

Percentage energy (standardised slopes > 0.10 or <-0.10)

Protein                                15.8     14.8     13.3  *  -0.39
Total fat                              34.2     34.3     32.0  *  -0.19
Saturated fat                          14.6     15.1     14.2  *  -0.06
Monounsaturated fat                    12.1     12.0     11.2  *  -0.19
Polyunsaturated fat                     4.8      4.5      4.4  *  -0.18
Total sugars                           23.3     25.1     30.8  *   0.54
Added sugars                            6.8     14.1     22.9  *   0.89
Natural sugars                         16.5     11.0      7.9  *  -0.60
Starch                                 25.0     23.8     22.2  *  -0.25
Total carbohydrate                     48.1     48.9     53.3  *   0.37

Nutrient/1000 kJ (standardised slopes > 0.10 or <-0.10)

Cholesterol (mg)                       28.0     28.0     25.0  *  -0.13
Dietary fibre (g)                       2.5      2.2      1.9  *  -0.38
Vitamin A (retinol equivalents)
(ug)                                  123.0    117.0    103.0  *  -0.10
Provitamin A (ug)                     367.0    303.0    284.0  *  -0.17
Thiamin (mg)                            0.2      0.2      0.2  *  -0.25
Riboflavin (mg)                         0.3      0.2      0.2  *  -0.21
Niacin equivalents (mg)                 4.2      3.9      3.5  *  -0.38
Folate (ug)                            27.0     24.0     22.0  *  -0.35
Vitamin C (mg)                         17.0     14.0     13.0  *  -0.28
Calcium (mg)                          108.0    101.0     91.0  *  -0.22
Phosphorus (mg)                       162.0    153.0    138.0  *  -0.38
Magnesium (mg)                         32.0     29.0     26.0  *  -0.49
Iron (mg)                               1.4      1.3      1.2  *  -0.24
Zinc (mg)                               1.2      1.1      1.0  *  -0.29
Potassium (mg)                        354.0    314.0    285.0  *  -0.46

                                     Respondents aged 19 years and over

Energy kJ                              7061     7577     7817  *   0.16

Percentage energy (standardised slopes > 0.10 or <-0.10)

Protein                                18.1     17.1     15.7  *  -0.33
Total sugars                           18.0     19.8     24.7  *   0.49
Added sugars                            3.1      8.6     16.9  *   0.87
Natural sugars                         14.9     11.3      7.8  *  -0.54
Starch                                 25.3     24.4     23.2  *  -0.19
Total carbohydrate                     43.7     44.5     47.8  *   0.28
Alcohol                                 3.2      2.7      1.8  *  -0.10

Nutrient/1000 kJ (standardised slopes > 0.10 or <-0.10)

Cholesterol (mg)                       34.0     33.0     31.0  *  -0.13
Dietary fibre (g)                       3.1      2.8      2.4  *  -0.32
Vitamin A (retinol equivalents)
(ug)                                  161.0    147.0    136.0  *  -0.17
Preformed vitamin A (ug)               74.0     68.0     65.0  *  -0.14
Provitamin A (ug)                     525.0    470.0    419.0  *  -0.20
Thiamin (mg)                            0.2      0.2      0.2  *  -0.17
Riboflavin (mg)                         0.3      0.3      0.2  *  -0.13
Niacin equivalents (mg)                 4.9      4.7      4.3  *  -0.31
Folate (ug)                            35.0     32.0     29.0  *  -0.27
Vitamin C (mg)                         18.0     15.0     13.0  *  -0.23
Calcium (mg)                          107.0    103.0     92.0  *  -0.17
Phosphorus (mg)                       181.0    174.0    158.0  *  -0.31
Magnesium (mg)                         42.0     39.0     34.0  *  -0.36
Iron (mg)                               1.6      1.6      1.4  *  -0.26
Zinc (mg)                               1.4      1.3      1.3  *  -0.21
Potassium (mg)                        418.0    388.0    341.0  *  -0.36

(a) The tertiles were derived from the percentage of energy
contributed by the added sugars.

(b) Standardised slope across the tertiles.

* Regression slope significantly different from zero,
P [is less than or equal to] 0.001

Table 8. Mean day-2-adjusted nutrient density (nutrient/1000kJ)
according to tertiles (a)of intakes of natural sugars on the
day of the 1995 National Nutrition Survey

                                                  Males
                                                                  Std
                                  Lower    Middle    Upper    slope (b)

                                        Respondents aged 2 to 18 years

Energy kJ                         11 077    10 369     8469   *   -0.31

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                             13.8      15.1     14.9   *    0.17
Monounsaturated fat                 11.9      11.8     11.2   *   -0.15
Total sugars                        26.4      25.1     27.5        0.07
Added sugars                        21.0      14.6      9.8   *   -0.62
Natural sugars                       5.4      10.5     17.6   *    0.89
Starch                              24.1      24.3     23.4       -0.06

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Dietary fibre (g)                      1.9     2.1      2.3   *    0.36
Vitamin A (retinol equivalents (ug)   93.0   104.0    113.0   *    0.18
Preformed vitamin A (ug)              57.0    62.0     64.0   *    0.11
Provitamin A (ug)                    221.0   249.0    297.0   *    0.19
Thiamin (mg)                           0.2     0.2      0.2   *    0.23
Riboflavin (mg)                        0.2     0.3      0.3   *    0.37
Niacin equivalents (mg)                3.6     4.0      4.0   *    0.20
Folate (ug)                           22.0    24.0     26.0   *    0.33
Vitamin C (mg)                         9.0    12.0     17.0   *    0.40
Calcium (mg)                          85.0   102.0    122.0   *    0.50
Phosphorus (mg)                      138.0   155.0    166.0   *    0.42
Magnesium (mg)                        25.0    29.0     32.0   *    0.54
Iron (mg)                              1.2     1.4      1.4   *    0.18
Zinc (mg)                              1.1     1.1      1.1   *    0.18
Potassium (mg)                       271.0   307.0    353.0   *    0.56

                         Respondents aged 19 years and over

Energy kJ                          11 644   11 144   10 312   *   -0.18

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                              16.6     17.1     17.3   *    0.12
Total fat                            33.6     33.3     31.4   *   -0.18
Saturated fat                        13.2     13.3     12.1   *   -0.15
Monounsaturated fat                  12.5     12.1     11.6   *   -0.17
Total sugars                         18.3     18.3     21.4   *    0.20
Added sugars                         14.0      9.9      7.1   *   -0.43
Natural sugars                        4.3      8.4     14.3   *    0.87
Starch                               23.9     24.3     24.0        0.01
Total carbohydrate                   42.4     42.8     45.6   *    0.20
Alcohol                               5.9      4.9      3.5   *   -0.12

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Dietary fibre (g)                     2.0      2.4      2.9   *    0.49
Vitamin A (retinol equivalents
(ug)                                116.0    126.0    138.0   *    0.15
Preformed Vitamin A (ug)             62.0     65.0     70.0   *    0.11
Provitamin A (ug)                   312.0    358.0    427.0   *    0.25
Thiamin (mg)                          0.1      0.1      0.2   *    0.20
Riboflavin (mg)                       0.2      0.2      0.3   *    0.28
Niacin equivalents (mg)               4.5      4.7      4.8   *    0.12
Folate (ug)                          26.0     28.0     32.0   *    0.32
Vitamin C (mg)                        9.0     12.0     17.0   *    0.47
Calcium (mg)                         71.0     87.0    100.0   *    0.39
Phosphorus (mg)                     150.0    163.0    173.0   *    0.35
Magnesium (mg)                       31.0     35.0     39.0   *    0.46
Iron (mg)                             1.3      1.5      1.6   *    0.30
Zinc (mg)                             1.3      1.3      1.4   *    0.10
Potassium (mg)                      304.0    343.0    394.0   *    0.51

                                                  Females
                                                                  Std
                                   Lower   Middle    Upper    slope (b)

                                      Respondents aged 2 to 18 years

Energy kJ                            8535     7898     7129   *   -0.25

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                              14.1     14.6     15.1   *    0.15
Monounsaturated fat                  12.0     11.8     11.4   *   -0.14
Total sugars                         25.6     26.1     27.4   *    0.12
Added sugars                         20.0     15.0      8.7   *   -0.61
Natural sugars                        5.7     11.2     18.7   *    0.88
Starch                               24.1     23.5     23.5       -0.05

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Dietary fibre (g)                     2.0      2.2      2.5   *    0.35
Vitamin A (retinol equivalents
(ug)                                108.0    113.0    122.0        0.07
Preformed vitamin A (ug)             61.0     61.0     63.0   *    0.02
Provitamin A (ug)                   273.0    322.0    359.0   *    0.17
Thiamin (mg)                          0.2      0.2      0.2   *    0.27
Riboflavin (mg)                       0.2      0.3      0.3   *    0.35
Niacin equivalents (mg)               3.7      3.8      4.0   *    0.18
Folate (ug)                          22.0     24.0     27.0   *    0.37
Vitamin C (mg)                       11.0     14.0     19.0   *    0.48
Calcium (mg)                         84.0    100.0    115.0   *    0.39
Phosphorus (mg)                     139.0    151.0    162.0   *    0.36
Magnesium (mg)                       26.0     29.0     33.0   *    0.53
Iron (mg)                             1.2      1.3      1.3   *    0.20
Zinc (mg)                             1.0      1.1      1.1   *    0.14
Potassium (mg)                      276.0    314.0    364.0   *    0.57

                         Respondents aged 19 years and over

Energy kJ                            7925     7680     6811   *   -0.23

Percentage energy (standardised slopes > 0.10 or < -0.10)

Protein                              16.2     17.0     17.7   *    0.20
Total fat                            34.4     33.8     31.3   *   -0.25
Saturated fat                        13.6     13.3     12.0   *   -0.23
Monounsaturated fat                  12.4     12.2     11.4   *   -0.21
Total sugars                         19.7     19.7     23.1   *    0.24
Added sugars                         14.0      8.8      5.5   *   -0.53
Natural sugars                        5.7     10.9     17.6   *    0.89
Starch                               24.5     24.3     24.0       -0.05
Total carbohydrate                   44.5     44.2     47.3   *    0.19
Alcohol                               3.0      3.0      1.7   *   -0.09

Nutrient/1000 kJ (standardised slopes > 0.10 or < -0.10)

Dietary fibre (g)                     2.3      2.7      3.4   *    0.50
Vitamin A (retinol equivalents
(ug)                                132.0    145.0    168.0   *    0.23
Preformed Vitamin A (ug)             64.0     67.0     76.0   *    0.17
Provitamin A (ug)                   393.0    458.0    568.0   *    0.32
Thiamin (mg)                          0.2      0.2      0.2   *    0.22
Riboflavin (mg)                       0.2      0.2      0.3   *    0.32
Niacin equivalents (mg)               4.4      4.6      4.9   *    0.22
Folate (ug)                          28.0     32.0     37.0   *    0.36
Vitamin C (mg)                       11.0     15.0     21.0   *    0.48
Calcium (mg)                         83.0    103.0    116.0   *    0.38
Phosphorus (mg)                     156.0    172.0    185.0   *    0.39
Magnesium (mg)                       34.0     38.0     44.0   *    0.49
Iron (mg)                             1.4      1.5      1.7   *    0.29
Zinc (mg)                             1.3      1.3      1.4   *    0.17
Potassium (mg)                      324.0    375.0    450.0   *    0.58

(a) The tertiles were derived from the percentage of energy
contributed by the natural sugar.

(b) Standardised slope across the tertiles.

* Regression slope significantly different from zero,
P [is less than or equal to] 0.001

Table 9. Percentage of respondents who had day-2-adjusted intakes below
70% of the RDI and relative to general dietary
recommendations for selected nutrients according to tertiles (a) of
intake of total sugars on the day of the 1995
National Nutritional Survey

                     Boys 2 to 18 years         Girls 2 to 18 years

                   Lower   Middle   Upper     Lower   Middle    Upper

% Outside guideline

Total fat (b)       91       80      60 (e)     88      84      68 (e)
Saturated fat (c)   97       95      95         92      94      93
Fibre (d)

% below 70% RDI

Protein              0        0       0          0       1       1
Vitamin A            0        0       0          0       0       0
Thiamin              0        0       0          0       0       0
Riboflavin           4        3       1          4       3       6
Niacin               0        0       0          0       0       0
Folate               0        0       0          1       1       3
Vitamin C            0        0       0          0       0       0
Calcium             13       13      13         34      20      24 (e)
Iron                 0        1       1          5       7       7
Magnesium            2        2       3          6       4       6
Phosphorus           0        1       1          5       3       7
Zinc                 0        0       0         15      17      20

                    Men 19 years and over     Women 19 years and over

                   Lower   Middle   Upper     Lower   Middle    Upper

% Outside guideline

Total fat (b)       76       77      62 (e)     85      80      60 (e)
Saturated fat (c)   83       86      83         91      89      80
Fibre (d)           78       70      68 (e)     96      92      91 (e)

% below 70% RDI

Protein              0        0       0          0       0       1
Vitamin A            0        0       0          0       0       0
Thiamin              0        0       0          0       0       0
Riboflavin           7        4       4 (e)      2       2       3
Niacin               0        0       0          0       0       0
Folate               0        1       0          2       2       4
Vitamin C            0        0       0          0       0       0
Calcium             21       11      10 (e)     42      35      33 (e)
Iron                 0        0       0         10       9      12
Magnesium            3        3       4          6       7      11 (e)
Phosphorus           0        0       1          2       2       5 (e)
Zinc                 0        0       0         23      25      34 (e)

(a) The tertiles were derived from the percentage of energy contributed
by total sugars.

(b) % above 30% energy.

(c) % above 10% energy.

(d) [is less than or equal to] 30 g/day. Not calculated for children
less than 19 years.

(e) Significant [Chi]2 (P [is less than or equal to] 0.001).

Table 10. Percentage of respondents who had day-2-adjusted intakes
below 70% of the RDI and relative to general dietary
recommendations for selected nutrients according to tertiles (a) of
intake of added sugars on the day of the 1995
National Nutritional Survey

                     Boys 2 to 18 years         Girls 2 to 18 years

                   Lower   Middle   Upper     Lower   Middle    Upper

% Outside guideline

Total fat (b)       85       80      65 (e)      83      86      70 (e)
Saturated fat (c)   96       97      94          92      94      93
Fibre (d)

% below 70% RDI

Protein              0        0       0          0       0       1
Vitamin A            0        0       0          0       0       0
Thiamin              0        0       1          0       0       0
Riboflavin           1        2       5 (e)      3       2       7 (e)
Niacin               0        0       0          0       0       0
Folate               0        0       1          1       0       4 (e)
Vitamin C            0        0       0          0       0       0
Calcium              8        9      21 (e)     23      23      31
Iron                 0        0       1          5       5       9
Magnesium            0        1       5 (e)      4       3       9 (e)
Phosphorus           0        0       1          6       3       7
Zinc                 0        0       0         16      14      22 (e)

                    Men 19 years and over     Women 19 years and over

                   Lower   Middle   Upper     Lower   Middle    Upper

% Outside guideline

Total fat (b)       69       75      71 (e)     72      80      73 (e)
Saturated fat (c)   78       86      88 (e)     83      90      87 (e)
Fibre (d)           69       69      79 (e)     91      91      96 (e)

% below 70% RDI

Protein              0        0       0          0       0       1
Vitamin A            0        0       0          0       0       0
Thiamin              0        0       0          0       0       0
Riboflavin           7        3       5 (e)      2       1       4 (e)
Niacin               0        0       0          0       0       0
Folate               0        0       1          3       2       4 (e)
Vitamin C            0        0       0          0       0       0
Calcium             18       13      13 (e)     37      33      39 (e)
Iron                 0        0       0          9       7      16 (e)
Magnesium            3        2       5 (e)      6       5      12 (e)
Phosphorus           0        0       1          2       2       5 (e)
Zinc                 1        0       0         24      25      34 (e)

(a) The tertiles were derived from the percentage of energy contributed
by added sugars.

(b) % above 30% energy.

(c) % above 10% energy.

(d) [less than or equal to] 30 g/day. Not calculated for children less
than 19 years.

(e) Significant [X.sup.2] (P [less than or equal to] 0.001).

Table 11. Percentage of respondents who had day-2-adjusted intakes
below 70% of the RDI and relative to general dietary
recommendations for selected nutrients according to tertiles (a) of
intake of natural sugars on the day of the 1995
National Nutritional Survey

                     Boys 2 to 18 years         Girls 2 to 18 years

                   Lower   Middle   Upper     Lower   Middle    Upper

% Outside guideline

Total fat (b)       76       80      74         80      81      78
Saturated fat (c)   96       97      95         94      93      92
Fibre (d)

% below 70% RDI

Protein              0        0       0          1       0       1
Vitamin A            0        0       0          0       0       0
Thiamin              1        0       0          0       0       0
Riboflavin           6        1       0 (e)      6       4       2
Niacin               0        0       0          0       0       0
Folate               1        0       0          4       1       0 (e)
Vitamin C            0        0       0          0       0       0
Calcium             23        9       6 (e)     39      22      18 (e)
Iron                 1        0       0          9       4       6
Magnesium            4        2       1 (e)     10       4       3 (e)
Phosphorus           1        0       0          7       3       5
Zinc                 0        0       0         21      15      15

                    Men 19 years and over     Women 19 years and over

                   Lower   Middle   Upper     Lower   Middle    Upper

% Outside guideline

Total fat (b)       77       77      60 (e)     82      81      61 (e)
Saturated fat (c)   88       87      76 (e)     92      90      78 (e)
Fibre (d)           86       73      58 (e)     98      93      88 (e)

% below 70% RDI

Protein              0        0       0          1       0       0
Vitamin A            0        0       0          0       0       0
Thiamin              0        0       0          0       0       0
Riboflavin           7        4       4 (e)      4       1       2 (e)
Niacin               0        0       0          0       0       0
Folate               1        0       0          3       3       3
Vitamin C            0        0       0          0       0       0
Calcium             21       11      11 (e)     45      31      34 (e)
Iron                 0        0       0         16       8       7 (e)
Magnesium            5        3       3 (e)     12       5       7 (e)
Phosphorus           1        0       0          4       2       3 (e)
Zinc                 1        0       0         33      22      29 (e)

(a) The tertiles were derived from the percentage of energy
contributed by natural sugars.

(b) % above 30% energy.

(c) % above 10% energy.

(d) [less than or equal to] 30 g/day. Not calculated for children less
than 19 years.

(e) Significant [X.sup.2] (P [less than or equal to] 0.001).

References

(1.) FAO, WHO. Carbohydrates in human nutrition. Report of a joint FAO/WHO expert consultation April 1997. Rome: Food and Agriculture Organization of the United Nations; 1998.

(2.) Commonwealth Department of Health Nutrition Taskforce of the Better Health Commission. Towards better nutrition for Australians. Canberra: Australian Government Publishing Service; 1987.

(3.) Cashel K, Greenfield H. Population nutrition goals and targets for Australia: Influences of new Australian food composition data. J Food Comp Anal 1997;10:176-89.

(4.) National Health and Medical Research Council. Draft dietary guidelines for Australians. Canberra: 2001. http://www.health.gov.au/nhmrc/advice/diet.htm

(5.) O'Dea K, Mann JI. Importance of retaining a national dietary guideline for sugar. Med J Aust 2001;175:165-6.

(6.) Williams R Sugar: is there a need for a dietary guideline in Australia'? Aust J Nutr Diet 200 1;58:26-31.

(7.) Stanton R. Sugar: why Australia should retain a dietary guideline. Aust J Nutr Diet 2001;58:31-6.

(8.) Sivaneswaran S, Barnard PD. Changes in the pattern of sugar (sucrose) consumption in Australia 1958-1988. Community Dent Health 1993;10:353-63.

(9.) Baghurst KI, Baghurst PA, Record SJ. Demographic and nutritional profiles of people consuming varying levels of added sugars. Nutr Res 1992;12:1455-65.

(10.) Bolton-Smith C, Woodward M. Antioxidant vitamin adequacy in relation to consumption of sugars. Eur J Clin Nutr 1995;49:124-33.

(11.) Naismith DJ, Nelson M, Burley V, Gatenby S. Does a high-sugar diet promote overweight in children and lead to nutrient deficiencies? J Hum Nutr Diet 1995;8:249-54.

(12.) Tonstad S, Sivertsen M. Relation between dietary fat and energy and micronutrient intakes. Arch Dis Child 1997;76:416-20.

(13.) Flynn MA, Sugrue DD, Codd MB, Gibney MJ. Women's dietary fat and sugar intakes: implications fur food based guidelines. Eur J Clin Nutr 1996;50:713-9.

(14.) Baghurst KI, Baghurst PA, Record SJ. Demographic and dietary profiles of high and low fat consumers in Australia. J Epidemiol Comm Health 1994;48:26-32.

(15.) Kant AK, Schatzkin A. Consumption of energy-dense, nutrient-poor foods by the US population: effect on nutrient profiles. J Am Coll Nutr 1994;13:285-91.

(16.) Ministry of Health. Dietary reference values for food energy and nutrients for the United Kingdom. London: HMSO; 1991.

(17.) International Food Information Council, USA. Questions and answers about sugars, http://ificinfo.health.org/brochure/sugar.htm Accessed: 18 September 2000.

(18.) Ernst N, Fisher M, Smith W, Gordon T, Rifkind BM, Little JA, et al. The association of plasma high-density lipoprotein cholesterol with dietary intake and alcohol consumption. The Lipid Research Clinics Prevalence Study. Circulation 1980;62:IV41-IV52.

(19.) The US-USSR Steering Committee for Problem Area I. The pathogenesis of atherosclerosis: Nutrient intake and its association with high-density lipoprotein and low-density lipoprotein cholesterol in selected US and USSR subpopulations. Am J Clin Nutr 1984;39:942-52.

(20.) Yarnell JW, Milbank J, Walker CL, Fehily AM, Hayes TM. Determinants of high density lipoprotein and total cholesterol in women. J Epidemiol Comm Health 1982;36:167-71.

(21.) Tuyns AJ, Kaaks R, Haelterman M, Riboli E. Diet and gastric cancer. A case-control study in Belgium. Int J Cancer 1992;51:1-6.

(22.) Wu AH, Yu MC, Mack TM. Smoking, alcohol use, dietary factors and risk of small intestinal adenocarcinoma, Int J Cancer 1997;70:512-7.

(23.) Franceschi S. Nutrients and food categories and large bowel cancer in Europe. Eur J Cancer Prev 1999;8 Suppl 1:49S-52S.

(24.) Moerman CJ, Bueno-de-Mesquita HB, Smeets FW, Runia S. Consumption of foods and micronutrients and the risk of cancer of the biliary tract. Prey Med 1995;24:591-602.

(25.) Slattery ML, Benson J, Berry TD, Duncan D, Edwards SL, Caan BJ, et al. Dietary sugar and colon cancer. Cancer Epidemiol Biomarkers Prey 1997;6:677-85.

(26.) Ministry of Health. Dietary sugars and human disease. London: HMSO; 1989.

(27.) McLennan W, Podger A. National Nutrition Survey User's Guide 1995. ABS Catalogue No 4801.0. Canberra: Australian Bureau of Statistics; 1998.

(28.) Australian Bureau of Statistics. 1995 National Nutrition Survey Confidentialised Unit Record File (CURF). Canberra: Australian Bureau of Statistics; 1998 (updated 1999).

(29.) McLenman W, Podger A. National Nutrition Survey: Nutrient Intakes and Physical Measurements. ABS Catalogue No 4805.0. Canberra: Australiun Bureau of Statistics; 1998.

(30.) McLennan W, Podger, A. National Nutrition Survey 1995: Foods Eaten. Australia. ABS Catalogue No. 4804.0. Canberra: Australian Bureau of Statistics; 1998.

(31.) Rutishauser IHE. Getting it right: how to use the data from the 1995 National Nutrition Survey. Canberra: Commonwealth of Australia; 2000.

(32.) Australia New Zealand Food Authority. Supplement to NUTTAB95 Nutrient Composition Database. Canberra: Ausinfo; 1999.

(33.) Matthews RH, Pehrsson PR. Farhat-Sabet M. Sugar content of selected foods: individual and total sugars. Report 48. United States Department of Agriculture, Human Nutrition Service. Home Economics Research Report; 1987.

(34.) Paul AA, Southgate DAT. McCance and Widdowson's The Composition of Foods, 4th ed. Amsterdam: Elsevier/North Holland Biomedical Press; 1978.

(35.) Goldberg GR, Black AE, Jebb SA, Cole T J, Murgatroyd PR, Coward WA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr 1991;45:569-81.

(36.) National Health and Medical Research Council. Recommended dietary intakes for use in Australia. Canberra: Commonwealth of Australia; 1991.

(37.) Cole T J, Bellizi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey: BMJ 2000;320:1-6.

(38.) Gibney M, Sigman-Grant M, Stanton Jnr JM, Keast DR. Consumption of sugars. Am J Clin Nutr 1995;10:178S-94S.

(39.) Bowman SA. Diets of individuals based on energy intakes from added sugars. Fam Econ Nutr Rev 1999;12:31-8.

(40.) Guthrie JK Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc 2000;100:43-51.

(41.) Department of Community Services and Health. National dietary survey of schoolchildren (aged 10-15 years): 1985. No 2 Nutrient intakes. Canberra: Australian Government Publishing Service; 1989.

(42.) Department of Community Services and Health. National dietary survey of adults: 1983. No.2 Nutrient intakes. Canberra: Australian Government Publishing Service; 1987.

(43.) Ruxton CH, Garceau F J, Cottrell RC. Guidelines for sugar consumption in Europe: is a quantitative approach justified? Eur J Clin Nutr 1999;53:503 13.

(44.) Nutbeam D, Wise M, Bauman A, Harris E, Leeder S. Goals and targets for Australia's health in the year 2000 and beyond. Sydney, Department of Public Health, University of Sydney; 1993, p. 1-271.

(45.) Gibson SA. Consumption and sources of sugars in the diets of British schoolchildren: are high-sugar diets nutritionally inferior? J Hum Nutr Diet 1993;6:355-71.

(46.) Rugg-Gunn AJ, Hackett AF, Jenkins GN, Appleton DR. Empty calories? Nutrient intake in relation to sugar intake in English adolescents. J Hum Nutr Diet 1991;4:101-11.

(47.) Gibson SA. Do diets high in sugars compromise micronutrient intakes? J Hum Nutr Diet 1997;10:125-33.

(48.) Gibson SA. Non-milk extrinsic sugars in the diets of pre-school children: association with intakes of micronutrients, energy, fat and NSR. Br J Nutr 1997;78:367-78.

(49.) Forshee RA, Story ML. The role of added sugars in the diet quality of children and adolescents. J Am Coll Nutr 2001;20:132-43.

(50.) Gibson SA. Are high-fat, high-sugar foods and diets conducive to obesity? Int J Food Sc Nutr 1996;47:405.

(51.) National Heart Foundation of Australia. Review of the relationship between dietary fat and cardiovascular disease. Aust J Nutr Diet 1999;56(4 Suppl):1S-22S.

(52.) McLennan W, Podger A. National Nutrition Survey: Selected Highlights. ABS Catalogue No 4802.0. Canberra: Australian Bureau of Statistics; 1995.

(53.) Dunstan D, Zimmett P, Welborn T, Sicree R, Armstrong T, Atkins R, et al. Diabesity and associated disorders in Australia--2000. The accelerating epidemic. Melbourne: International Diabetes Institute; 2001.

(54.) WHO. Diet, nutrition and the prevention of chronic diseases (Final draft copy). Report of a joint FAO/WHO expert consultation January February 2002. Geneva: Food and Agriculture Organization of the United Nations; 2003.

(55.) Ludwig DS. Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective observational analysis. Lancet 2001;357:505-8.

(56.) Bolton-Smith C, Woodward M. Dietary composition and fat to sugar ratios in relation to obesity. Int J Obes Relat Metab Disord 1994;18:820-8.

(57.) Oosthuizen W, van der Merwe AM, Kotze JP. Vorster HH, Steyn HS, Dietary composition and body mass index at different levels of added sugar consumption--the VIGHOR study, S Afr Med J 1998:88:1212-17.

(58.) Lewis CJ, Park YK, Dexter PB, Yetley EA. Nutrient intakes and body weights of persons consuming high and moderate levels of added sugars, J Am Diet Assoc 1992:92:708-13.

(59.) Tucker LA. Kano MJ. Dietary fat and body fat: a multivariate study of 205 adult females. Am J Clin Nutr 1992;56:616-22.