Much emphasis has been placed on understanding the dietary intakes and behaviors of infants and toddlers to set them on the pathway to optimal health and reduce the burden of obesity, dietary risks of dental caries, and chronic degenerative diseases in adulthood. Indeed, early life nutritional exposures are also likely to be critical for modifying the diet-related risks of chronic degenerative diseases later in life such as obesity, type 2 diabetes mellitus, and cardiovascular disease. For much of the 20th century, carbohydrates, and sugars in particular, received little attention from nutritionists. In part, this was because until 1990s, analytical values for sugars and starch were not available, and their content was calculated by difference rather than being chemically analyzed. In the 21st century, the story has been different. Sugar has been one of the most contentious nutrition topics in the past decade.
Sugars consist of monosaccharides (glucose, galactose, and fructose) and disaccharides (common examples are sucrose, lactose, and maltose). For the most part, concern about sugars is focused on “added” or “free” sugars rather than “naturally occurring” sugars found in fruits, vegetables, and milk. The term “added sugars” refers to any sugars or caloric sweeteners added to food during processing, preparation, or at the time of consumption. Examples of added sugars include table sugar, syrups (eg, corn syrup, high-fructose corn syrup, maple syrup, and agave syrup), honey, and molasses. “Free sugars” are similar to added sugars but include sugars present in 100% fruit juice. Although the body does not differentiate between a sugar molecule added to a food and one that occurs in the food naturally, this distinction has been made based on epidemiological data showing adverse health outcomes associated with high intakes of foods and beverages containing added/free sugars.
As Achterberg1 points out, food plays many roles in infants and children aside from its nutritional and health functions. In infancy, food is seen as a milestone at times and a stressor at others. Toddlers view food as play, may use it as a sense of autonomy, and begin to develop specific preferences about what foods agree or do not agree with them (ie, pickiness). Johnson and Hayes2 describe social, emotional, and physical aspects of food consumption in children. Very little consideration has been given to how foods actually taste to young children; Hayes and Johnson3 provide interesting insights on how multiple senses coordinate to tailor child taste preferences. Their article also raises the question of whether adding small amounts of sugar to bitter-tasting foods such as vegetables could facilitate toddlers' acceptance of these foods, even when the sugar is subsequently reduced or removed. There is a sound theoretical rationale for this suggestion, because humans have an innate preference for sweetness and an aversion to bitterness. Nevertheless, much research is needed to establish whether this strategy would be effective over the long term, and if so, on how to effectively communicate it to caregivers. Parents often feel uninformed on how much and what types of foods to offer children. As children age, food often becomes a reward or part of a reward system, “eat this and you can have dessert” and “do what I told you and then you can have some candy.” For parents and caregivers, food presents a simultaneous opportunity to improve health and set a course for a healthy relationship with food, but it can also create stress and anxiety because feeding occasions become a dreaded routine of the day. Thus, tailoring specific dietary guidance to the variation in ages, needs, goals, and acceptance of nutrition in the B24 life stage is of upmost importance, but it will also serve as a tremendous challenge to the researchers and policy makers who are tasked with developing such recommendations.
The recent 2015–2020 Dietary Guidelines for Americans recommends that no more than 10% of daily calories should come from added sugars for reduced risk of chronic disease.4 However, the dietary guidelines are for Americans aged 2 years and older. Similarly, the World Health Organization (WHO) suggests less than 10% of total energy from “free” sugars among children (and adults) to prevent dental caries and excess weight gain.5 Although these recommendations seem similar, the difference between “added” and “free” sugars may have substantial implications for the diets of toddlers, specifically related to the inclusion of 100% fruit juice as “free” sugar.
Two articles in this supplement explore the dietary intakes of children using the National Health and Nutrition Examination Survey (NHANES), the national monitoring system that continuously collects data across the United States in 2-year cycles. The data on added sugars intakes of toddlers were provided by Welsh and Figueroa,6 who used NHANES data between 2009 and 2012, and focused on toddlers age 12 to 24 months. Their data indicated that added sugars provided an average of 8.4% of energy in this age range and that the leading source was sweetened fruit juices and fruit-flavored drinks.6 She also noted that added sugar intakes increased progressively across the second year of life, from approximately 6% in those aged 13 to 15 months to almost 12% in those aged 22 to 24 months. This suggests that the second year of life may be a key period for educating parents and caregivers about potential risks of excessive added sugars intake. In that regard, if further research substantiates the suggestion that adding small amounts of sweeteners may facilitate toddlers' acceptance of bitter-tasting vegetables,3,7 it is clear that caregiver education will need to be carefully crafted to avoid seemingly contradictory messages. Moshfegh8 used data from NHANES 2011-2012 and determined that added sugars provided an average of 10% of energy intake in the diets of toddlers aged 12 to 35 months, but approximately 40% of toddlers exceeded this suggested limit8 without the inclusion of sugars from 100% fruit juice contributing toward added sugar. She also found that 100% fruit juice provided an average of 6% of total energy. Furthermore, among the 53% of toddlers who consumed 100% fruit juice on the day of the recall, 100% fruit juices provided an average of approximately 11% of total energy. In other words, fruit juice alone led these children to exceed the WHO recommendation of less than 10% of energy as “free” sugars. For US toddlers to meet the WHO recommendation, 100% fruit juice would need to be virtually eliminated from their diets. This is not consistent with guidance from the American Academy of Pediatrics,9 which recommends that intake of fruit juice should be limited to 4 to 6 oz/d for children aged 1 to 6 years. Clearly, more data are required to establish the optimal guidance for intake of free versus added sugars in the toddler age range. We note that the data reported in this supplement on toddlers' added sugars intake provide a valuable cross-sectional “snapshot.” Assessing how (or if) these intakes change in future years, however, may not be possible, because the United States Department of Agriculture (USDA) Database for the Added Sugars content of selected foods has been withdrawn from the USDA Nutrient Data Laboratory Web site.10 This decision was justified based on rapid changes in the formulation of commercial foods (and thus their added sugars content) and the inability to analytically verify the values. Nevertheless, it will make monitoring adherence to guidelines for added sugar intake challenging, if not impossible.
One of the primary concerns for added sugars in young children is the risk of dental caries. Palmer11 provided insights that the timing of sugar exposure relative to the number of cariogenic exposures, to sleep, and to the combinations of other nutrients with sugars (eg, bacterial interactions in the mouth) are more likely to promote caries than simply the amount of sugar. She also emphasized that naturally occurring and added sugars are equally cariogenic and that fluoridation and oral hygiene are key elements of caries prevention. Of course, it is also important to acknowledge the important effects of fluoridation of the water supply in preventing caries.
Murray12 presented the importance of establishing sound nutrition practices from infancy to promote a lifelong healthy dietary pattern. From our perspective, this is particularly salient in our environment where obesity is a concern. Accordingly, limiting the intake of foods/beverages that provide large amounts of added sugars and little, if any, other nutrients makes intuitive sense. What is less clear is whether efforts to substantially limit added/free sugars (eg, the WHO conditional recommendation that free sugars comprise <5% of energy) in infancy and early childhood will lead to long-term improvement in health or whether it is possible that a more nuanced approach could be used to build a strong foundation for lifelong healthy eating. In either case, more research is needed, and there is a role for food industry to contribute to a more healthful food environment for children. In addition to a need for evidence-based guidelines for how parents and caregivers should feed their young children, there is also an urgent need for knowledge on how to communicate those guidelines effectively.
1. Achterberg C. A perspective: toddler feeding, science, and nutrition policy. Nutr Today
. 2017;52(2 Suppl):S6–S13.
2. Johnson SL, Hayes JE. Developmental readiness, caregiver and child feeding behaviors, and sensory science as a framework for feeding young children. Nutr Today
. 2017;52(2 Suppl):S30–S40.
3. Hayes JE, Johnson SL. Sensory aspects of bitter and sweet tastes during early childhood. Nutr Today
. 2017;52(2 Suppl):S41–S51.
6. Welsh AJ, Figueroa J. Intake of added sugars during the early toddler period. Nutr Today
. 2017;52(2 Suppl):S60–S68.
7. Murray R, American Academy of Pediatrics, Committee on Nutrition, Council on School Health. Snacks, sweetened beverages, added sugars, and schools. Pediatrics
8. Moshfegh AJ, Rhodes DG, Goldman JD, Clemens JC. Characterizing the dietary landscape of children, 12 to 35 months old. Nutr Today
. 2017;52(2 Suppl):S52–S59.
9. Committee on Nutrition. American Academy of Pediatrics: the use and misuse of fruit juice in pediatrics. Pediatrics
11. Palmer C. Oral and dental health considerations in feeding toddlers. Nutr Today
. 2017;52(2 Suppl):S69–S75.
12. Murray RD. Influences on the initial dietary pattern among children from birth to 24 months. Nutr Today
. 2017;52(2 Suppl):S25–S29.