This document summarizes a presentation on how sweeteners fit into dietary quality. It defines diet quality as the overall nutrient profile and energy density of a diet. Several factors can affect diet quality, including socioeconomic status, education level, culinary skills, and beverage choice. While added sugars make up a small portion of increased calorie intake since 1970, there is no consensus on optimal sugar intake. The presentation emphasizes considering overall eating patterns rather than single nutrients, and notes diet quality is individualized.

1. EXPO Briefing
Dietary Quality:
How Sweeteners Fit
Rosanne Rust, MS, RDN, LDN
@rustnutrition
Monday, October 21, 2014
12:45-1:05 p.m.
Expo Hall B2
Georgia World Conference Center

2. • Nutrition Communications Consultant
– 2014 FNCE® speaker expenses and honorarium underwritten by the Corn
Refiners Association
– Consultant to the American Beverage Association’s Let’s Clear It Up campaign
– Consultant to the Calorie Control Council on topic of fructose
– Author – Chapter 10, “Sweeteners and Dietary Quality,” Fructose, High Fructose Corn
Syrup, Sucrose and Health (2014)
– Author – consumer For Dummies® books
• Member, Academy of Nutrition and Dietetics
– Member, Nutrition Entrepreneurs (NE), Dietitians in Business and Communication, and
Weight Management (WM), Sports, Cardiovascular and Wellness Nutrition (SCAN)

3. • Define the concept of diet quality
• Identify factors affecting diet quality
• Identify top sources of sugars and sweeteners in the diet
• Present arguments for why added sugars are, and are not,
associated with diet quality

4. DEFINING DIET QUALITY

5. Dietary quality refers to the overall quality of the diet based on its
nutrient profile
• Nutrient density refers to the overall quality of the diet based on its nutrient profile
• Energy density refers to total caloric load

6. • Benchmarks for diet quality
– DGA: Evidence-based dietary guidelines to encourage a lifestyle approach to weight
control that integrates all key nutrients (foods to limit, foods to encourage).
• 2010: Unique task to address an overweight or obese population, who are
undernourished in several key nutrients
• Assessment tools
– Not one measure, but a range of tools
– DRI: US Dietary Reference Intakes help determine minimum and maximum
requirements for energy and essential nutrients
 RDA (Recommended Dietary Allowances) and the AI (Adequate Intake)
 EAR (Estimated Average Requirements)
 UL (Tolerable Upper Intake Levels)

7. Indexes and scoring systems used to evaluate diet quality
• Healthy Eating Index — assess diet quality with regard to DGA
– Youth Healthy Eating Index
– Alternative Healthy Eating Index — distinguishes quality within food groups,
better indicator for cardiovascular risk
• Recommended Food Score
• Nutrient Rich Food Index
Guenther, PM, Cassavale, KO, Reedy, J et al. Update of the Healthy Eating Index: HEI 2010. J Acad Nutr Diet. 2013 Apr;113(4):569-80.

8. FACTORS AFFECTING DIETARY QUALITY
• Socioeconomic
• Cultural
• Education
• Culinary skills
• Beverage choice

9. • Socioeconomic status
– Body of data showing diet quality runs along the socioeconomic gradient
– The mean percentage of total calories from added sugars decreases with increasing age
and increasing income
– Recent Harvard study shows while diet quality is improving overall, the gap between low
and high socioeconomic status widened
• Sociocultural aspects of diet quality
– Family dinner, meal style
– Ethnic foods, holiday traditions
– Racial differences — non-Hispanic black men and women consumed a larger percentage
of their total calories from added sugars than non-Hispanic white and Mexican-American
men and women
– Forbidden foods
http://www.cdc.gov/nchs/data/databriefs/db122.htm
Darmon, N., Drewnowski, A. Does social class predict diet quality, Am J Clin Nutr, 2008
Wang, DD, Leung, CW, Yanping, L, et al, Trends in Dietary Quality Among Adults in the US, 1999-2010. JAMA, Sept 1, 2014
Drewnowski A, Specter, SE. Peerty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79:6-16
http://www.hsph.harvard.edu/news/press-releases/u-s-diet-shows-modest-improvement-but-overall-remains-poor/

10. • Education level
– Less education often correlated to poor diet quality
• Culinary skills
– Lack of skills, lack of interest
– Skills handed down through generations
– Learned skills
Nicklas RA, Baranowski, R Baranowski J, et al. Family and child-care provider influences on pre-school children's fruit juice and vegetable consumption. Nutr
Rev 2001; 59:224-35
Variham JN, Blaylock J, Smallwood DM. Modeling nutrition knowledge, attitudes and diet-disease awareness: The case of dietary fibre. Stat Med, 1996;15:23-35
Birch, LL, Fisher, JO. Development of eating behaviors among children and adolescents. Pediatrics. 1998;101:539-49

11. • Beverage choice and diet quality
– Milk consumption in children is directly correlated to better overall diet
quality; dairy is often used as a benchmark for diet quality in children
since it delivers a host of nutrients, and soft drinks are associated with
lower milk consumption
– Higher juice and sugar-sweetened beverage consumption associated
with lower milk consumption
Marshall RA, Eichenberger Gilmore, JM, Broffitt B, et al. Diet quality in young children is influenced by beverage consumption. J Am Coll Nutr. 2005;24:65-75.

12. ROLE OF ADDED SUGAR IN
DIETARY QUALITY
• Sources of sugar
• Recommendations for sugar intake

13. National Cancer Institute. Sources of added sugars in the diets of the U.S. population ages 2 years and older, NHANES 2005–2006. Risk Factor Monitoring and
Methods. Cancer Control and Population Sciences. http://riskfactor.cancer.gov/diet/foodsources/added_sugars/table5a.html

14. According to USDA Food Availability
Data, calorie intake in 1970 was
~2100. In 2010 it was ~2570.
• Most of calorie increase attributed to
fats and grain products
• AHA says primary reason to reduce
added sugars is generally to lower
total calorie intake or glycemic load
and promote adequate nutrition, but
added sugars only contributing
~4% of the +470 calorie increase
since 1970
Added
sugars
4%
Added fats
53%
Flour/
cereal
products
40%
Other
3%
USDA, Economic Research Service data: U.S. per capita calories loss-adjusted food availability: “Total Calories” 1970-2010

15. Is sugar the big issue?
• Adults underconsume fruits and vegetables (<2 cups/day)
• SOFAS:
– Fat: 94-98% of males exceed recs for added solid fats, 92-97% of females do
– Sugar: 68-85% adult females exceed discretionary calorie for sugar, 55-80%
of males do
• Bray and Popkin blame dietary fat for obesity in 1998, then in 2004 blame sugar
• Children and adults consume more sugar at home than away from home
• Consideration of “nutrients of concern” (vitamin D, fiber, calcium, potassium,
B vitamins)
Krebs-Smith, SM, Guenther PM, Subar AF, et al. Americans do not meet federal dietary recommendations. J Nutr. 2010;140:1832-8.
Consumption of Added Sugars Among US Children and Adolescents, 2005-2008 http://www.cdc.gov/nchs/data/databriefs/db87.pdf
http://www.nutritionj.com/content/12/1/116
Forshee, RA, Storey, ML The role of sugars in the diet quality of children and adolescents. J Am Coll Nutr. 2001;20:32-43
Bray, GA, Popkin, BM. Dietary fat intake doss affect obesity! Am J Clin Nutr 1998;68:1157-73.
Bray, GA, Popkin BM. Consumption of high fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr. 2004;79:537-43.

16. • No definitive guideline for sugar intake
• Differentiating between sugar and added sugar
• General dietary recommendations:
– The Dietary Guidelines for Americans, 2010
 Limit total intake of discretionary calories, including both solid fats and
sugars (SOFAS), to 5-15% per day
– American Heart Association general guidelines
 Minimize beverages and foods with
added sugars

17. Competing Recommendations: How much sugar is optimal in
the diet?
• AHA: no more than 6 tsp for women, 9 tsp for men
• IOM: RDA – minimum recommendation for carbohydrate 130g/day
• DGA: General recommendations to ‘reduce’
• WHO: <10% of daily calories should come from added sugars; in process
of drafting new guideline

18. Fat vs. Sugar?
• Fat recommendations have moved from the ‘fat-phobic’ 1990s to current
recs to increase “heart-healthy” fats
• Conflicting studies — some show low carb, high protein increase mortality,
others show that moderate amounts of carb (50-55%) along with diet low in
saturated fat, are associated with lower CVD risk
Body of research showing a diet high in whole grains low in fat and
saturated fat reduces cardiovascular disease (sources cited).
Coulston, AM, Liu, GC, Reaven, GM, Plasma Glucose, insulin, and lipid responses to high-carbohydrate diets in normal humans. Metabolism. 1983;32:52-6
Yang, EF, Chung, HK, Kim, WY, et al. Carbohydrate intake is associated with diet quality and risk factors for cardiovascular disease in US adults. NHANES III. J Am Coll
Nutr. 2002;22:71-9

19. PRACTICAL APPLICATIONS
Take-away Points

20. • There are benchmarks for diet quality and several tools to evaluate
diet quality
• We often over focus on one nutrient, rather than observing overall
eating patterns and intake; sugar recommendations vary, as do
individual needs for carbohydrates; the data shows that, singularly,
sugar does not appear to impact diet quality on its own

21. • Nutrients are not eaten in isolation, but are combined
• Consider all factors that impact an individual’s food and beverage choices
• Educate clients in a meaningful way, considering the cultural and
socioeconomic factors that may influence the choices they can make
• There should be agreement that diets must be individualized,
particularly for those with medical issues, and that the registered
dietitian is the most equipped to evaluate individual diets, and
prescribe the best diet plan for desired results

22. Sweeteners & Dietary Quality
Visit
Sweetener Studies
Booth #2110
QUESTIONS
Rosanne@rustnutrition.com
Reference list and slides published:
http://sweetenerstudies.com/dietitian2014