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How much sugar is hidden in drinks marketed to children? A survey of fruit juices, juice drinks and smoothies. Strengths and limitations of this study. A comprehensive assessment of the sugars content of fruit juice, juice drinks and smoothies (FJJDS) marketed to children. Assessment of standard portion size (2. Only FJJDS available at supermarket chains were recorded. New varieties of FJJDS appear in the market steadily and may be different.

Introduction. Free sugars are the most important dietary cause of dental caries. When consumed as a drink, fructose derived from fruit is as likely to cause dental caries as all other sugars. In the 2. 01. 2 Children's Local Dental Health Survey, 2. England had obvious decay in their primary teeth, rising to 3. North West. 4 In 2. Dental decay is the most common reason for children in England being admitted to hospital.

Furthermore, an increased intake of fructose and sugar- sweetened drinks has been associated with childhood obesity. However, this can also have a negative health impact if the sugars content of FJJDS is equal to or higher than sugar- sweetened carbonated drinks.

This study aimed to record the sugars content of FJJDS marketed to children and determine which FJJDS contain sugar (sucrose), syrups, non- caloric sweeteners and free sugars derived from fruit. Online supplementary appendix 1 provides definitions for the various types of sugars referred to in this paper. Methods. This survey looked at sugars per 1.

FJJDS from seven supermarkets (Tesco, Asda, Sainsbury's, Marks & Spencer, Waitrose, The Co- operative and Morrisons) in the UK. FJJDS were identified by the definitions provided by the British Soft Drinks Association (box 1). It is not permitted to add sugars, sweeteners, preservatives, flavourings or colourings to fruit juice’. Non- pure fruit smoothies may contain other ingredients such as yoghurt or milk, which must be labelled. Only products that were specifically marketed towards children were included.

Sugar- sweetened drinks, sports drinks and iced teas were excluded. Cordials were also excluded.

Although cordials are marketed towards children, they are not single- serve portions that were the focus of this survey. Cordials should be diluted one part cordial to nine parts water (with nutritional typical values shown with this dilution); however, people generally dilute to taste, so the sugar content of a single serve would vary from person to person. Furthermore, they are not suitable for lunchboxes.

Only single- portion cartons were recorded. This was determined using the supermarkets’ online shopping system and recording products under their children's FJJDS section—for example, . For supermarkets with no online shopping, size and design of packaging determined if the products were aimed towards children.

Some drinks manufacturers produce products specifically designed for children—for example, Tropicana Kids, only products in these ranges were recorded. Both supermarket own and branded products were recorded. Product sizes ranged from 6. Teaspoons of sugar per standardised 2. The ingredient list was recorded for the analysis of sugar (sucrose), syrups, free sugars derived from fruit and non- caloric sweeteners (table 1). Table 1. Identification of sugars and sweeteners translated into specific terms from the product ingredients list. Data were retrieved online or in- store between July and August 2.

Results. In total, 2. FJJDS were identified. Of the 2. 03 products, 2. Table 2. Number and average sugars content of products included. Of the 1. 79 fruit juices and juice drinks, 6.

Sugars content ranged from 0 to 1. The average sugars content was 7. In total 1. 17 of the 2. FJJDS surveyed would receive a Food Standards Agency (FSA) . On average, juice drinks contained the lowest amounts (mean 5.

Of the 1. 58 juice drinks, 8. A total of 6. 0 products contained sugar (sucrose), 6. The majority of products were sweetened with acesulfame K, sucralose and aspartame. Of the 7. 8/2. 03 products, 1.

Of the 2. 03 products, 7 contained glucose- fructose syrup. A total of 1. 40 products contained no sugars or non- caloric sweeteners. Online supplementary appendix 2 provides the full list of results. Discussion. The World Health Assembly (WHA) recently adopted a global target of 2. This includes policies to reduce the content of sugars in non- alcoholic beverages, as well as to reduce the impact of marketing of non- alcoholic beverages high in sugars on children. In the UK, a national childhood obesity prevention strategy for England is expected in summer 2. This is likely to include measures to reduce the consumption of sugar- sweetened carbonated soft drinks.

Using a standardised 2. FJJDS surveyed would contain at least half of a young child's maximum sugar intake for the day (9. Current guidelines state a 1.

Of the products included in this survey, only five produced products at a 1. All other products exceeded the recommended serving size and are likely to be consumed in a single seating as a single portion, therefore greatly increasing the child's sugars intake. Furthermore, the FSA thresholds relate to adult intake of sugars; therefore, we can speculate that the number of FJJDS with a . For young children, this 5% limit will represent a maximum of around 1. A recent critical in- depth review goes further, recommending that an intake below 2–3% is necessary to avoid dental caries. The review suggests that an increase from near- zero free sugars to 5% of energy intake doubles the prevalence of caries in children.

Figures from the latest UK National Diet and Nutrition Survey data show that in children aged 4–1. One key difference between whole fruit and juice is fibre content.

Whole fruit slows down consumption and has a satiating effect. Research shows the body metabolises fruit juice in a different way compared to whole fruit. After whole fruit consumption, the body seems to adjust its subsequent energy intake appropriately, whereas after fruit juice consumption, the body does not compensate for the energy intake.

We did not initially set out to record the number of products containing non- caloric sweeteners. However, of the 2. FJJDS included in our study, 7. K, sucralose and aspartame. Although all these non- caloric sweeteners have been declared safe by the European Food Safety Authority,3. Although replacing sugars with non- caloric sweeteners may lead to improved markers of long- term metabolic health and weight loss, it will not necessarily provide a long- term solution to reducing sugar consumption and subsequent health problems. All labels on products recorded contained a reference intake, in line with European law.

The reference intake provides one figure, which applies to an average- sized adult female doing an average amount of physical activity. This figure is not appropriate for children who have very different energy intake requirements and energy expenditure. Furthermore, pure fruit juices are labelled as Fruit Juice, while products with any other added ingredients are known as Juice Drinks. With all this in mind, it is fair to say that labelling of fruit juice and juice drinks marketed towards children can be unclear and thus potentially confusing for parents trying to make healthier choices. Study limitations.

We acknowledge a number of limitations to this study. First, only FJJDS available at supermarket chains were recorded, but there may be other products available to the public in other smaller independent stores.

Second, new varieties of FJJDS appear in the market steadily and may have different properties from those recorded. Results, comparisons or conclusions drawn from this survey can thus only apply to the products in this time period (July and August 2. Third, we only focused on sugars content and did not include an assessment of the portion size of beverages marketed to children, which could be considerably larger than the recommended amount. Fourth, no lactose added to food or drink is now considered as free sugars.