Abstract
Background: To reduce morbidity associated with dental caries and weight gain, the World Health Organisation recommends intakes of free sugars should be less than 5% of total energy intake. Free sugars are defined as monosaccharides and disaccharides added to foods by the manufacturer, cook, or consumer and sugars naturally present in honey, syrups, unsweetened fruit juices and fruit juice concentrates. Current population intakes of free sugars in New Zealand are unknown and few studies have investigated the barriers and facilitators to following this recommendation. This mixed-methods exploratory study aimed to investigate the feasibility of following a low free sugars diet in healthy New Zealand adults, and whether this influences intakes of other nutrients associated with healthy eating and cardiovascular risk.
Methods: Fourteen university students from Dunedin participated in a four-week low free sugars nutrition intervention. Participants attended weekly clinics for nutrition advice which incorporated label reading, including the supporting smart-phone application FoodSwitch, food exchanges, low free sugars recipes and recommendations to use non-nutritive artificial sweeteners. Participants provided baseline and follow-up dietary intake data via a 3-day weighed diet record. Semi-structured interviews at baseline addressed participant rationale for joining the study, perceived challenges in following this diet and perceived main sources of free sugars. Follow-up interviews assessed barriers and facilitators experienced and other changes in dietary intake. Interviews were analysed using thematic template analysis.
Results: From baseline to follow-up, mean daily intakes of free sugars decreased from 14.1% to 3.0% of total energy intake (95% confidence interval -15.2 to -7.1; P < 0.0001), mean daily intakes of total carbohydrate decreased from 282g to 222g (-100.8 to -18.2; P = 0.0082) and mean daily intakes of saturated fat decreased from 27.5g to 20.8g (-12.2 to -1.2; P = 0.0204). From baseline to follow-up, mean body weight decreased from 68.9kg to 67.9kg (-1.8 to -0.2; P = 0.0141) and mean body mass index decreased from 25.0kg/m2 to 24.7kg/m2 (-0.6 to -0.1; P = 0.0217). Eight significant themes emerged from analysis of interview transcripts; Changing mentality around sugar consumption; Love for sugar - cravings, addiction and a sweet tooth; Going low sugar; Sugar in social situations; Becoming sugar aware; A shift in eating norms; The challenge of the current food environment and; The usefulness and awareness raising potential of the study and its supports. Main barriers were: managing sweetness desire; finding alternatives low in sugars; laxative side-effects and financial cost of artificially sweetened products; investing time and effort to plan and prepare food in advance; reading and interpreting nutrition labels; resisting social pressure to eat sugary foods and beverages; and choosing options low in sugars away from home. Main facilitators were planning and preparing food in advance; cooking meals from scratch; reading and interpreting nutrition labels to find options low in sugars with the support of the FoodSwitch application and the label-reading wallet card; replacing options high in sugars for those low in sugars; and the support of weekly clinics.
Conclusion: With support, university students were able to reduce their free sugars intake to align with the World Health Organisation recommendation that this should be less than 5% of total energy intake. However, there are many barriers to reducing intakes of free sugars in modern food environments and as a consequence of modern lifestyles. More supportive food environments, community action and health policies are needed to help individuals and populations adhere to this recommendation.