Are Dietary Sugar Guidelines Based on Low-Quality Evidence?

Guidelines on dietary sugar do not meet criteria for trustworthy recommendations and are based on low-quality evidence, according to a new study.

“Public health officials (when promulgating these recommendations) and their public audience (when considering dietary behavior) should be aware of these limitations,” the researchers said.
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They sought to systematically review guidelines on sugar intake and assess consistency of recommendations, methodological quality of guidelines, and the quality of evidence supporting each recommendation.

Three reviewers independently assessed guideline quality using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) instrument. To assess evidence quality, they independently reviewed articles supporting recommendations and determined their quality by using Grading of Recommendations Assessment, Development, and Evaluation methods.

The search identified 12 recommendations from 9 guidelines by the following agencies: the US Department of Agriculture and the US Department of Health and Human Services; WHO; SACN and Public Health England; the Ministry of Health of Brazil; the Australian National Health and Medical Research Council; the Nordic Council of Ministers; the German Nutrition Society; the Food Safety Authority of T1 Ireland; and the Institute of Medicine.

Each of the reviewed guidelines indicated a suggested decrease in the consumption of foods containing nonintrinsic sugars. The guidelines scored poorly on AGREE II criteria, specifically in rigor of development, applicability, and editorial independence. Seven recommendations provided nonquantitative guidance; 5 recommended <25% to <5% of total calories from nonintrinsic sugars. The recommendations were based on various health concerns, including nutrient displacement, dental caries, and weight gain. The researchers found the quality of evidence supporting recommendations to be low to very low.

“At present, there seems to be no reliable evidence indicating that any of the recommended daily caloric thresholds for sugar intake are strongly associated with negative health effects,” they concluded. “The results from this review should be used to promote improvement in the development of trustworthy guidelines on sugar intake.”

—Mike Bederka


Erickson J, Sadeghirad B, Lytvyn L, Slavin J, Johnston BC. The scientific basis of guideline recommendations on sugar intake: a systematic review [published online Dec. 19, 2016]. Ann Intern Med. doi: 10.7326/M16-2020.