The EU Starch Industry Association, the AAF, represents the EU producers of starch and starch derivatives. The EU starch industry produces annually approximately 10 million tonnes of starch and starch derivatives and 5 million tonnes of starch co-products. Of the EU’s starch production, 23% are native starches, 20% modified starches and 57% starch sweeteners. 60% of EU starch goes to food uses and 40% to non-food uses. The starch sweeteners used in food use fall under the WHO definition of free sugars. As such, the AAF has a significant interest in the WHO’s draft guideline on sugars intake for adults and children, and welcomes the opportunity to comment. We believe that any recommendations from the WHO on sugars intake must be based on all the highest quality relevant scientific evidence available.
When the WHO recommended the target for <10% Energy from added sugars back in 2003, it acknowledged that the basis for this target was controversial.
On dental caries, OECD data demonstrates that the average number of decayed, missing or filled teeth amongst 12 year old children has fallen from 4.7 to 1.6 teeth between 1980 and 2006, despite stable sugars supply/consumption. This decline should be welcomed and is primarily the result of improved oral hygiene and exposure to fluoride.
Regarding body weight, sugars, whether ‘free’ or ‘intrinsic’ are treated the same way by the human body and contribute the same energy value as all other carbohydrates; 4kcal/g. The vast majority of the scientific evidence available acknowledges that obesity is a multifactorial disease most successfully improved by combining healthy overall dietary patterns and moderating total energy intake with energy expenditure. The evidence to demonstrate that decades of dietary advice to single out one macro- or micro nutrient to reverse rates of obesity have succeeded, is limited, at best.
Summary of evidence: body weight
The Te Morenga review on dietary sugars and body weight, upon which, regarding body weight, the draft WHO guideline is based, gives no recommendation on free sugars intake in the context of preventing weight gain. It concluded that intake of sugars, whether in food or drink, is a determinant of body weight and this is due to energy intake but it also specifically states that ‘exchange of sugars with other carbohydrates was not associated with weight change’. This is consistent with the conclusions reached by Expert Committees like EFSA in 2010 .
Summary of evidence: dental caries
The Moynihan and Kelly study, which concerns dental caries only, provides the basis of the draft WHO guideline that free sugars should not exceed 10% of total energy and the conditional recommendation to implement a further reduction to below 5% of total energy intake.
The 10% recommendation is based on the evidence of 8 cohort studies, of which only 2 reported on total sugar intake. The quality of the evidence was classified as moderate and most of the studies were already available in 2002 when the WHO made its previous <10% recommendation.
The suggestion to implement a further reduction to below 5% of total energy intake is based on the evidence of 3 population studies in Japan. The studies date back to 1959 and 1960 and were all studies of children with low fluoride exposure. The quality of the evidence was graded as very low.
In the same EFSA 2010 opinion referenced above, it considered that caries development does not depend only on the amount of sugar consumed, but is also influenced by oral hygiene, exposure to fluoride, and various other factors concluding that ‘available data do not allow the setting of an upper limit for sugars on the basis of a risk reduction for dental caries’
The main recommendation relating to the intake of free sugars not exceeding 10% total energy intake, classified as a ‘strong’ recommendation was based on evidence regarded as ‘moderate’ for dental caries prevention and not related to the impact of sugars on body weight.
The recommendation of a further reduction to below 5% total energy intake is a ‘conditional’ recommendation based on evidence in relation only to dental caries and regarded as ‘very low’ in quality.
Because of the effect these recommendations may have on global health policy, the evidence base must be robust, of the highest quality and representative of the majority of populations. Evidence rated as ‘moderate’ to ‘very low’ does not meet these conditions.
Any recommendation from the WHO should be based on the totality of the evidence, including that provided by well reputed organisations like EFSA. It should also be accurate , implementable and not result in possible misinformation of consumers as regards their dietary choices by singling out one single nutrient.
Research gaps and future initiatives: implications for future research
Nutritionally-oriented recommendations must be based on evidence related to individuals’ entire diets and lifestyles and not focused on one single nutrient. This should be the focus of future research.
Any additional comments
We welcome the recognition of the need for further substantial involvement and collaboration with stakeholders before this can be put forward as an official WHO recommendation and look forward to a continued constructive dialogue.
 OECD report on the oral health status in children (2009).
 EFSA Scientific Opinion on Dietary Reference Values for carbohydrates and dietary fibre (2010).