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Total and Added Sugars Consumption in Argentina : Their Contribution to 1 Daily Energy Intake . Results from Latin American Study of Nutrition and 2 Health ( ELANS )

AIM
The aim of the present study is to determine the intake of total sugars (TS) and added sugars (AS) in Argentina based on the local data of the Latin American Study of Nutrition and Health (ELANS).


METHODS
This is a cross-sectional study of a representative sample of the urban Argentine population (n = 1266). The sample was stratified by age group (15-65 years), gender, geographic region and socioeconomic level (SEL). TS and AS intake were obtained by two 24-hour recalls (R24) and analysed using the Nutrition Data System for Research Software 2013.


RESULTS
On average, TS consumption in Argentina was 114.3 g/day, accounting for 39.8% of the total carbohydrate intake and 20.6% total energy (TE) intake. Overall, 77.2% of the TS intake consisted of AS (90.4 g/day), contributing to 30.4% of total carbohydrate intake and 15.9%TE. Men consume more TS and AS (in g/day), with no difference in the AS %TE between men and women. The consumption of sugars decreased with age, with adolescents consuming more AS and older adults more intrinsic sugars. The intake of AS was higher in low SEL.


CONCLUSIONS
In Argentina, the intake of AS was 50% above the recommendations. Younger and socially vulnerable people are at higher risk of excessive intake.


Introduction 1
Sugars are naturally present in fruits, vegetables, and dairy products. 2 Additionally, sugars may also be added to foods, both because of their 3 sweetening power and their other functions needed in food technology. 1 The 4 term "Total Sugars (TS)" refers to monosaccharides (glucose, fructose, 5 galactose, etc.) and disaccharides (lactose, sucrose, maltose, etc.), and 6 includes intrinsic sugars (incorporated in the structures of fruits and whole 7 vegetables), milk sugars (lactose and galactose), and free sugars (FS). The 8 term "FS" has been defined by the Technical Expert Advisory Group on 9 Nutrition Monitoring from the World Health Organization (WHO) as the 10 following: "Free sugars include monosaccharides and disaccharides added to 11 foods and beverages by the manufacturer, cook or consumer, and sugars 12 naturally present in honey, syrups, fruit juices and fruit juice concentrates". Decreasing sugar intake is a good strategy to reduce excessive intake, which is 20 pivotal in the fight against the current epidemic of chronic, non-communicable 21 diseases. 4 To date, there is no evidence that the consumption of intrinsic sugars 22 or milk extrinsic sugars have an adverse effect on health. Therefore, the WHO 23 recommendations are focused on the intake of free sugars. 2 24 It is strongly recommended that the intake of FS should be reduced to 1 less than 10% of total calorie intake. A further reduction to below 5% of total 2 caloric intake leads to additional beneficial effects on health. 2 These 3 recommendations will be revised in 2020. 2 4 For public health policies to be efficient and controllable, adequate 5 knowledge of the current situation regarding total and AS intake in each country 6 is necessary. 4 Unfortunately, data on AS intake are scarce and data on FS 7 intake are practically non-existent. 5 Recently, the Latin American Study of 8 Nutrition and Health (ELANS) has published the regional results for sugars 9 intake in eight countries in the region; varying between 18.7-21.1%TE intake for 10 TS, and between 10.3-16.4%TE for AS. Sugars intake in Argentina was found 11 to be the highest in the study. 6 12 The main aim of this study was to determine for the first time the intake of 13 TS and AS of the Argentine population, based on the Argentinean data that are 14 part of the ELANS study. Secondary aims were to 1) stratify the sugar content 15 of the Argentine diet by gender, age, region of the country and Socio Economic 16 Level; and 2) present, in a stratified manner, the percentages of the 17 Argentinean population who meet the criteria for maximum FS intake 18 recommended by the WHO. 19 20

Methods 21
The ELANS study was approved by by the Western Institutional Review 22 Board (#20140605) and it is registered at Clinical Trials (#NCT02226627). 23 Written informed consent/ assent was obtained from all individuals before 1 commencement of the study. In this study compliance with STROBE has been addressed. More details 9 of this point can be found in a previous publication. 7 10 The sample consisted of men and women, between 15-and 65-years-of-11 age, living in urban areas in the most densely populated regions. In Argentina, 12 the urban population accounts for 91% of the total population. 8 The population 13 was stratified into four age groups (15-19, 20- Two R24 were performed with each participant on non-consecutive days. 1 They were conducted face-to-face by a trained interviewer using the Multiple 2 Pass Method, a technique that was validated to standardize food data 3 collection. 11 A visual guide was used for servings and foods to help the 4 participant refer their intake quantities. Each R24 was analysed using the 5

Nutrition Data System for Research (NDS-R) 2013, developed by the Nutrition 6
Coordination Centre of the University of Minnesota (USA). 12 A process of food-7 matching for the standardization of the local foods was performed to be able to 8 use the NDS-R. As a result of this process, 638 local foods and 195 recipes 9 were standardized. For more details on the food standardization process see 10 Kovalskys et al. 13 The NDS-R software analyses TS and AS intake, but not the 11 intake of FS, according to the WHO definition. To calculate the content of FS, 12 we also identified those foods that were included as "FS" in the WHO 13 classification. The difference found between total AS (NDS-R), and total FS, 14 was 2 g/day per subject (2,642 g for the total population; n=1266). 15 Usual daily intake of TS and AS was estimated using the online Multiple 16

Source Method (MSM) tool, developed by the European Prospective 17
Investigation into Cancer and Nutrition (EPIC). 14 TS and AS intake in grams and 18 as %TE are presented as mean and SD, as well as in percentiles for our 19 sample, which was stratified according to gender, age, SEL and geographical 20 region. The percentage of individuals that adhered to the WHO's sugar 21 performed by T test for independent samples with Levene's test on the equality 24 of the variances and a 95% confidence interval for the difference between the 1 means. The one-way analysis of variance (ANOVA) was used to determine 2 whether there were any statistically significant differences between the age and 3 SEL groups. 4

5
TS and AS intake according to age and gender is shown in Table 1 Table 2 shows sugar intake according to SEL, age and gender. In 16 general, it was found that the higher the SEL, the lower the TS and AS intake, 17 both in grams per day and as part of %TE. AS intake was significantly different 18 among SEL groups (p<0.001). In the group with the lowest SEL, AS intake was 19 98.6 g/day (17.0%TE) while in middle-and high SEL groups, AS intake was 20 84.0 g/d (14.9%TE) and 80.7 g/d (14.5%TE), respectively. 21 using commercialization data 15 that tended to overestimate consumption. To the 16 best of our knowledge, this is the first time that sugar intake (total and added) is 17 evaluated in Argentina, using methods to measure direct consumption in 18 adolescents and adults (15-65-years-of-age), living in urban areas, stratified by 19 gender, age, geographic region and SEL of a representative weighted sample. 20 We found that sugar intake (g/day and %TE) is high in the Argentinean 21 population and was inversely related to age and SEL and varied according to 22 the geographic region. 23 In Europe, mean consumption of AS accounts for 7.3-11.4% of the total 1 calorie intake in adults. 4 In North America, this number increases to between 2 10-14% of the total calorie intake. 3,16 Recently, the first data on dietary intake 3 were published for eight countries in Latin America showing that mean AS 4 intake in these countries accounted for 13.2%TE consumption. 6 In this study, 5 we confirmed that in Argentina the intake of AS exceeded the current 6 recommendations, accounting for a mean of 15.9%TE intake, which is twice the 7 amount consumed in countries such as Spain. 17 8 All previous publications have noticed that men consumed more TS and 9 AS than women (expressed in g/day or in total calories). 3, 4, 18 Nevertheless, 10 when calculated as percentage of total calorie intake, AS intake was higher in 11 women, probably because the TE intake is higher in men. 3, 4, 18 The same trend 12 is observed in the US and Europe. 3 In Argentina, there was a higher AS intake 13 in men than in women but unlike the rest of the world there was no statistically 14 significant difference between men and women in the contribution of AS to %TE 15 In Argentina, the %TE from AS was higher in the age group of 15-19-16 year-olds (17.5%) and decreased with age,, similar to the findings in the 17 literature for other countries. As reported in other countries, the contribution of 18 intrinsic sugars (whole fruits and vegetables) to the TE intake is higher in the 19 older age groups. 17, 18 Unlike in Spain, where only adolescents reach 10% of 20 total daily calories from AS, 17, 18 in Argentina all age groups exceeded this cut-21 off point. In Latin America, a similar trend toward a decrease in AS intake (and 22 %TE) with increasing age was found, with a mean of 13.9%TE intake consisting 23 of AS in adolescents, against 12.1% in older adults. 6 Data from the US has 24 shown a linear decrease in calorie intake from AS with age, both in men and in 1 women. A linear decrease in %TE consisting of AS was also reported. 3 The 2 results of different studies conducted in European countries found that a higher 3 intake of AS was observed in adolescence, ranging from 12.4-18.6%TE 4 consumption.. It is noteworthy that for the majority of the analysed countries, AS 5 intake was higher than 10% in children and adolescents and lower than 10% in 6 older adults. 5 7 The %TE from AS increased linearly with the SEL among the countries 8 evaluated by ELANS, only in Argentina an inverse relationship was observed 6 . 9 Data from the National Health and Nutrition Examination Survey in the US 10 (2005-2010) also showed the same trend. 3 It is noteworthy that this trend 11 toward the consumption of higher amounts of sugars in lower-income 12 populations was observed just for AS but not for TS (21.0%TE, 20.3%TE and 13 20.1%TE in the population for low, middle and high SEL, respectively). These 14 findings would reflect a higher intake of intrinsic sugars (fruits and vegetables) 15 and/or milk sugars in higher-income populations. 19 In Argentina, this may be 16 explained by the fact that fruits and vegetables are usually expensive and 17 therefore difficult to obtain in the recommended amounts by people with a lower 18

income. 19
The exception to this inverse relationship between AS consumption and SEL is 20 observed only in adolescents (15 to 19 years), where those with higher SEL 21 consume significantly more AS. This may be due to the fact that, while in many 22 parts of the world discretionary food and beverages are relatively inexpensive, 23 in Argentina they are quite expensive and therefore access is restricted.
In four out of the six geographic regions into which the country was 1 divided, mean %TE from TS was 20% (range, 19.5-20.4%) and mean %TE 2 from AS was around 15% (range, 14.5-15.6%). 3 TS and AS intake were higher in two regions: Patagonia (23.1%TE from 4 TS and 18.6%TE from AS) and North-west (23.9%TE from TS and 19.3%TE 5 from AS), the latter of which was the region with the highest sugar intake in the 6 country. 7 Sugar cane in the North-west of Argentina is a crop with a strong cultural 8 identity and key to the regional economy of Tucuman, Salta, and Jujuy (three 9 north-western provinces), accounting for 98% of the total production of the 10 country. Many of the regional foods are characterized by high sugar content. 11 Future research relating sugars intake to food sources may allow for a better 12 understanding of this association (data in progress). 13 One of the possible reasons that could explain the higher sugar intake of 14 Argentineans when compared with other countries of the region is their cultural 15 customs. As an example, the "mate", a typical infusion which is mostly 16 consumed with table sugar, thus representing a substantial part of the 17 contribution of AS in the Argentinean diet (manuscript in progress). 18 High AS intake is associated with a poor quality of diet as it leads to a 19 decrease in the intake of essential micronutrients, 20 an increase in body 20 weight, 21, 22 development of obesity and the subsequent risk of chronic and non-21 communicable diseases, 2, 23 cardio-metabolic risk factors, and mortality. 24

22
Another worrisome impact on health is the association of AS intake and dental 23 caries. [25][26][27] Considering all of the above, a decrease in AS intake would be a 1 good strategy to improve the health of the population. 2 In this article, we present for the first time an estimate of the AS intake. The present study has some limitations. The content of FS or AS in food 20 products may be under-or over-estimated. Estimates of AS or FS are based on 21 the information provided by food manufacturers. This information may be 22 difficult to obtain and to keep updated, as the composition of the food products 23 reformulations. 5,15 Additionally, in Argentina it is not mandatory to disclose 1 sugar contents on the label. To resolve this inconvenience, information on sugar 2 content of the foods was obtained through the list of ingredients and 3 consultation with the manufacturers. Overall, 638 foods were standardized, and 4 195 recipes were created to facilitate data entry in the NDS-software. 13 5 The definition of "AS" and the method to calculate them also differ 6 between databases. Therefore, it is extremely difficult for consumers to 7 understand how to adhere to a diet that meets the WHO recommendations for 8 sugar intake (less than 10% of the calories from FS) without a previous 9 agreement on the definitions of TS, AS, and FS. 28 10 The present study also has several strengths. There is no flawless 11 method to assess dietary intake, as different methods may be appropriate for 12 specific purposes. For instance, self reported dietary intake data have been 13 found to be associated with underreporting of the intake of TE and different 14 macro and micro-nutrients. 5 On the other hand, R24 only require short-term 15 memory, are less expensive, and less prone to change reporting of food intake 16 behaviour than food records. Additionally, as a high educational level is not 17 required to perform the R24, they may be used in different populations. 1 Indeed, 18 it is the method of choice to quantify "absolute intake" in large population 19 studies. 1, 5 20 A strength of this study is the use of a two-day food intake record, as an 21 accurate technology for the data collection on the individual intake of sugars 22 (both total and added) in foods and beverages. 23 In conclusion, the Argentinean population consumed 114.3 g/day of TS 1 and 90.4 g/day of AS, being the country with the highest consumption of sugars 2 in the region. No difference was found in the %TE intake as AS between men 3 and women. The consumption of sugars (total and added) decreased with age, 4 with adolescents consuming larger amounts of added sugars and older adults 5 consuming more intrinsic sugars. The regions of the country that lead the 6 consumption of sugars were the Patagonian region and the North-west region. 7 The intake of AS was inversely proportional to the SEL of the population. In 8 Argentina the intake of AS exceeded 50% the current recommendations. IK conceived and designed the study; IK and VG coordinated the study; IK and 3 VG performed the local implementation of the study. All authors analysed, 4 interpreted the data and drafted the manuscript. AG, IK and VG did the 5 statistical analysis. All authors read the manuscript, revising it critically for 6 important intellectual content, and approved this submitted version. The authors 7 also state that the content has not been published elsewhere.