Q1. There are many studies that look at the health risks associated with sugary snacks and beverages. Why did you decide to look at the impact on micronutrient status? Has it got something to do with dietary habits in the population studied?

Vitamin and mineral deficiencies are considered diseases in their own right. However, the effect that certain subclinical micronutrient insufficiencies might have on more complex diseases is often overlooked. We are talking about diseases and conditions such as obesity, diabetes, cardiovascular disease and many others. With our study, we hoped to shed some light on this subject from the perspective of micronutrient dilution or displacement of micronutrient intake in relation to added sugar intake. In addition, a high intake of added sugar has also often been related to the aforementioned diseases. The fact that we observed negative associations between added sugar intake and micronutrient intake, shows that an increased added sugar intake and a decreased micronutrient intake usually go hand in hand in our diets.

In Sweden, where both our study populations originate from, there is a strong fika culture. This is a gathering with friends, family or colleagues where a hot beverage, usually coffee, is accompanied with a sweet treat or pastry and lively conversation. This innate cultural aspect of the Swedish population made us wonder about whether these fika breaks might be having an effect on the quality of the overall diet and micronutrient intake. In addition, we hoped that our study would also help inform the upcoming Nordic Nutrition Recommendations which are currently being discussed by nutrition experts across the Nordic region and are set to be published in 2022.

Q2. Have the current dietary guidelines failed to address micronutrient dilution issue when they make recommendations on upper limit of free sugar intake? What are the possible health consequences for that at population level?

The current Nordic Nutrition Recommendations (published in 2012) address the requirements and limits for both micronutrients and added sugar. However, while some of the recommendations included in said document have been set on the basis of micronutrient dilution, they have not presented direct evidence of this phenomenon in relation to added sugar, which is why our study presents novel key information.

Nutrition guidelines and recommendations across the globe differ greatly based on type of sugar to be addressed and amounts to which it should be limited. Certain systematic reviews have noticed these discrepancies and highlighted how often those recommendations are based on a single disease instead of a myriad of potential outcomes. Likewise, the science behind some guidelines is not as accurate as we would hope. Some guidelines only offer qualitative recommendations and of the few that offer quantitative recommendations, even fewer offer recommendations based on the effect on micronutrient levels. When it comes to nutrition recommendations it is challenging to set a “one size fits all” recommendation.

There is an increasing trend in personalized medicine and nutrition and how our individual characteristics, genetic or otherwise, play a role into our health at all levels. And while it would make sense to take different outcomes and levels into consideration, until we can do that more accurately we should still aim to have a more uniform approach to the design of nutritional recommendations. They should be informed with rigorous scientific evidence that is easy for consumers to understand and apply to their everyday life.

Q3. Using the data you’ve got from the survey, do you plan to research other aspects of the health impact that free sugar may have?

Well, of course. As a Medical Doctor and Master in Public Health graduate I have made the focus of my PhD project to study the effect of added sugar on different health conditions and within the greater context of policymaking. I am already working on data from the Malmö Diet and Cancer Study, used for this paper, to study different types of sugar intake with the development of atherosclerosis. I have other projects lined up for the future as well, but they are still in the planning phase, so you will have to wait and see. You can stay updated about my news on my twitter page (@Esther_G_P). Our research group Nutritional Epidemiology at Lund University has been studying the health effects of sugar for many years, more information about mine and other projects within our group can be found on our soon to be launched blog (www.nutrition.blogg.lu.se).