The US Food and Drug Administration (FDA) recently proposed that the Nutrition Facts label, the way North American consumers are informed about the nutritional composition of packaged foods, be redesigned.1 There are several good things to say about the proposed new label, which is easier to read, more clearly indicates the serving size and energy content of the food and includes welcome new information about potassium. However, recent comments hardly mention these things; instead, they focus on the proposal to declare the added sugars. Kessler2 argues that merely declaring added sugars does not go far enough, whereas Sylvetsky and Dietz3 argue that declaring added sugars goes too far and may confuse consumers. We are concerned that the rationale for declaring added sugars is based on popular misconceptions rather than high-quality evidence and may do harm.

In explaining why it proposes to require the declaration of added sugars in addition to total sugars, which the label currently shows, the FDA indicates that it takes into account new data, recommendations from federal agencies and expert groups, citizen petitions and public comments. According to the FDA, ‘On average, Americans get 16 percent of their total calories from added sugars.’ However, this is misleading, as 16% is the estimated added sugars intake for children and adolescents but US adults consume ~13% energy from added sugars.4 It is widely believed, as FDA states, that consuming added sugars can cause people to consume less nutrient-rich foods and increase the energy intake and that added sugars are ‘empty calories’.1 However, these oversimplifications are not supported by high-quality evidence.

In fact, we do not know how much added sugars Americans consume, because the US Department of Agriculture nutrient database does not contain any values for added sugars; even values for total sugars are missing for over 23% of the 8463 foods in the database.5 Thus, published information about the amount of added sugars consumed by Americans are only estimates, and there is very little information about how the level of added sugars intake affects nutrient intakes in North American populations. Surely we ought to have such information before making recommendations that are aimed at reducing the intake of added sugars.

Both the FDA1 and Kessler2 indicate that added sugars cause overconsumption of energy. The implication is that excess energy from added sugars causes weight gain and that reducing energy from added sugars will promote weight loss. Evidence supports this view to some extent, but not entirely. A recent WHO-sponsored meta-analysis showed that reducing the intake of energy from added sugars reduces excess body fat in adults, but not in children, and no difference was seen where added sugars isocalorically replaced other sources of carbohydrate.6 In addition, the data are open to various interpretations. The CArbohydrate Ratio Management in European National diets (CARMEN) study,7 the results of which were included in the WHO meta-analysis, is the largest and longest trial to date to use an ad libitum design to assess the effect of sugars on weight gain. It compared between an ad libitum high-sugar diet (~55% energy carbohydrate, 29% energy sugars) and an ad libitum high-complex-carbohydrate diet (~51% energy carbohydrate, 19% energy sugars); more weight tended to be lost on the high-complex-carbohydrate diet (−1.8 vs −0.9 kg, ns). However, participants on the high-sugar diet lost significantly more weight than those on the ad libitum control (higher fat) diet (~46% energy carbohydrate, 21% energy sugars; −0.9 vs +0.8 kg, P<0.05). Thus, people can lose weight on an energy-reduced diet even if it is high in simple sugars.

Both the FDA (1) and Kessler (2) suggest that it is well known that the consumption of foods containing added sugars is at the expense of nutrient-dense foods. If this were so, then people with the highest intakes of added sugars would have lower intakes of vitamins and minerals than those with the lowest intakes of added sugars. However, UK survey data (1087 men and 1110 women aged 16–64 years) show that people with intakes of added sugars in the second (10% energy) or third (13% energy) quintiles tended to have higher intakes of nutrients such as calcium, iron and folate than those in both the lowest (5% energy) and highest (22% energy) quintiles of added sugars intake.8 Similar observations were shown across octiles of added sugar exposure (where the lowest and highest level of exposures were 5% and 35%, respectively) in the National Health and Nutrition Examination Survey in different sex and age groups for calcium, vitamin A, vitamin E and iron, with few exceptions.9 Some foods containing added sugars, such as sweetened breakfast cereals, contain more nutrients than their unsweetened counterparts, and some nutritious foods such as yogurt, high-fiber breakfast cereals and canned beans are made palatable by the addition of sugars. Undue avoidance of foods containing added sugars could have the deleterious effect of reducing intakes of certain nutrients; even wholewheat bread could be avoided because it contains 2–3 g of sugars per slice.

The public demand for information about added sugars in foods is driven by the media, which sells its stories by providing the public with sensational news; however, stories about the toxic effect of added sugars often contain dangerously exaggerated and incorrect information. For example, a story aired on national television in Canada recently10 featured a nutritionist (rather than a qualified Registered Dietitian) who indicated that the most sugar you could have without increasing the risk of death is two sugar cubes (8 g) per day. She then went on to indicate the amount of sugar contained in a breakfast meal of bagel, peanut butter and jam: 4 g in the bagel, 8 g in the peanut butter and 48 g in 2 tbsp of jam. Not only was the stated recommended maximum sugar intake (1.6% energy) 3–15 times less than what is actually recommended, but also the bagel meal was said to contain nearly 3 times more sugar than it actually contains (17 g, 4 g in the bagel, 3 g in a 2-tbsp serving of peanut butter and 10 g in a 1-tbsp serving of jam). No wonder the public is scared!

As physicians with an interest in nutrition, we are not going to tell people to eat more sugar. However, we believe, along with Joanne Slavin,11 that driving out added sugars could detract from public health; like the blind leading the blind, we could all fall into a pit.