Subject
Modify the Dietary Guidance of Added Sugars in the United States

Synopsis/Call to Action
Ask the U.S. Department of Health & Human Services (HHS) and the United States Department of Agriculture (USDA) to modify the Dietary Guidelines for Americans

Introduction
Sugars are the smallest and simplest type of carbohydrate[5]. They are easily digested and absorbed by the body as a source of energy[5]. By law, the Nutrition Facts Label must list the grams of sugar in each product[6] and the total amount of sugar per serving[15]. The total amount of sugar in a product is subcategorized into natural sugars and added sugars[5]. Naturally occurring sugars are found in many nutritious foods such as fruit (fructose) and milk (lactose), while added sugars are sugars that are added during the processing of foods such as sucrose (table sugar) and dextrose[5]. The leading sources of added sugars in the US diet are sugar-sweetened beverages, grain-based desserts like cakes and cookies, candy, and dairy desserts like ice cream[4]. Currently, roughly half of all Americans have one or more preventable, diet-related chronic diseases[11]. The intake of too much added sugars can lead to preventable health problems such as weight gain and obesity, type 2 diabetes, and heart disease[4].

Obesity
According to a data brief by the National Center for Health Statistics (NCHS), the age-adjusted prevalence of obesity in adults was 42.4% in 2017-2018, with no significant differences between men and women[18]. The age-adjusted prevalence of severe obesity in adults was 9.2%, with higher rates in women than in men. They found that from 1999-2000 through 2017-2018, the prevalence of both obesity and severe obesity increased among adults[18]. In 2009-2010, more than 78 million adults in the United States were obese[19]. Obesity is associated with serious health risks, while severe obesity further increases the risk of obesity-related complications, such as coronary heart disease and end-stage renal disease[18]. Obesity raises the risk for morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart disease (CHD), stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers[19]. Obesity is also associated with increased risk in all-cause and cardiovascular disease (CVD) mortality[19]. The biomedical, psychosocial, and economic consequences of obesity have substantial implications for the health and well-being of the U.S. population[19].

Type 2 Diabetes
According to a report released by the Centers for Disease Control and Prevention (CDC), more than 100 million U.S. adults are now living with diabetes or prediabetes[1]. The report found that roughly 30.3 million Americans have diabetes while another 84.1 million have prediabetes, affecting over 30% of the U.S. population[1]. It should be noted that these numbers do not include adults with undiagnosed diabetes. In 2018, it was crudely estimated that an additional 7.3 million adults who met laboratory criteria for diabetes were not aware of or did not report having diabetes[2]. In 2017, diabetes was the seventh leading cause of death in the United States[2]. In the same year, the total direct and indirect estimated costs of diagnosed diabetes in the United States was $327 billion[2].

Heart Disease
According to the CDC, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States[20]. One person dies every 37 seconds in the United States from cardiovascular disease[20]. More than 600,000 Americans die from heart disease each year[20]. That is one in every four deaths in this country[20]. The economic toll of heart disease is devastating, with heart disease costing the United States about $219 billion each year from 2014 and 2015[20]. This includes the cost of health care services, medicines, and lost productivity due to death[20]. Several other medical conditions can increase the risk for/of heart disease, including obesity and diabetes[20].

Petition
Every five years, the HHS and USDA produce the Dietary Guidelines for Americans, which provides evidence-based nutrition information and advice for people ages two and older[7]. According to these guidelines, Americans should keep their intake of added sugars to less than 10% of their total daily calories as part of a healthy diet[4]. In a 2,000 daily calorie diet, no more than 200 calories (50 grams of sugar) should come from added sugars[4]. However, the average American consumes about 71 grams of sugar every day[10]. Another study determined the usual intake of added sugars for Americans to be 22.2 teaspoons per day between 2001 and 2004[16]. One teaspoon of sugar is equivalent to 4.2 grams, so 22.2 teaspoons are equal to approximately 93 grams of sugar per day. For comparison, a 12 fl oz can of Coca Cola contains 39 grams of added sugar[14].

In contrast to the guidelines recommended by the Dietary Guidelines for Americans, multiple organizations and countries suggest limiting daily sugar intake far below the recommendations provided by the Dietary Guidelines. For example, the World Health Organization (WHO) recommends that adults and children should have less than 10% (50 grams) of their total energy intake but suggests that a further reduction to below 5% (25 grams) per day would provide additional health benefits[12]. Similarly, the American Heart Association (AHA) suggests that added sugar should not exceed 100 calories (24 grams) per day for women and no more than 150 calories per day (36 grams) for men[6]. In the United Kingdom, the National Health Service (NHS) recommends that adults should not have more than 30 grams of free sugars a day[17]. Free sugars include added sugars AND naturally occurring sugars[17].
This petition asks the U.S. Department of Health & Human Services (HHS) and the United States Department of Agriculture (USDA) to reduce their recommendation on the daily intake of added sugars in the Dietary Guidelines for Americans. In an ideal situation, by putting a stronger emphasis on the health consequences of added sugars, Americans will work harder to reduce the consumption of certain food and beverages, such as sugar-sweetened beverages, ultimately leading to healthier Americans, lower rates of preventable, diet-related chronic diseases and less annual deaths. In addition, there should be some response from manufacturers to create healthier products.

Review
Adult Guidelines for Added Sugars According to Organization*:

• HHS & USDA
  50 grams of added sugars[4]
• AHA
  >36g/24g of added sugars (male/female)[6]
• WHO
  >25 grams of added sugars[12]
• NHS
  >30 grams of free sugars[17]
• Petition
  ≥25 grams of added sugars

Organizations Listed:
HHS - U.S. Department of Health & Human Services (HHS)
USDA -  U.S. Department of Agriculture (USDA)
AHA - American Heart Association
WHO - World Health Organization
NHS - U.K. National Health Service

Additional Information:
Type 2 Diabetes
Diabetes is a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces[3]. Insulin is a hormone made by the pancreas, that acts like a key to let glucose from the food we eat pass from the bloodstream into the cells in the body to produce energy[3]. All carbohydrate foods are broken down into glucose in the blood, where insulin helps glucose get into the cells[3]. Prediabetes is a condition that if not treated often leads to type 2 diabetes within five years[1]. There are three main types of diabetes are Type 1, Type 2, and gestational[3]. With Type 1 diabetes, your body produces too little or no insulin[3]. With Type 2 diabetes, which is more common in adults and accounts for 90% to 95% of all diabetes cases[2][3]. Finally, gestational diabetes is a type of diabetes that consists of high blood glucose during pregnancy[3].

Heart Disease
The term “heart disease” refers to several types of heart conditions. The most common type is coronary artery disease, which can cause a heart attack[21]. Heart disease occurs when a substance called plaque builds up in your arteries[21]. When this happens, your arteries can narrow over time, reducing blood flow to the heart[21].

Works Cited:
[1] https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html
[2] https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
[3] https://www.idf.org/aboutdiabetes/what-is-diabetes.html
[4] https://www.cdc.gov/nutrition/data-statistics/know-your-limit-for-added-sugars.html
[5] https://www.accessdata.fda.gov/scripts/interactivenutritionfactslabel/added-sugars.cfm
[6] https://www.hsph.harvard.edu/nutritionsource/carbohydrates/added-sugar-in-the-diet/
[7] https://health.gov/our-work/food-nutrition
[8] https://www.hhs.gov/fitness/eat-healthy/dietary-guidelines-for-americans/index.html
[9] https://www.who.int/publications-detail/9789241549028
[10] https://sugarscience.ucsf.edu/the-growing-concern-of-overconsumption.html#.Xpz9TchKhPa
[11] https://health.gov/sites/default/files/2019-09/2015-2020_Dietary_Guidelines.pdf
[12] https://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/
[13] https://www.hsph.harvard.edu/nutritionsource/2016/05/20/updated-nutrition-facts-panel-makes-significant-progress-with-added-sugars-but-there-is-room-for-improvement/
[14] https://us.coca-cola.com/products/coca-cola/original/
[15] https://www.hsph.harvard.edu/nutritionsource/carbohydrates/added-sugar-in-the-diet/
[16] https://www.ncbi.nlm.nih.gov/pubmed/19704096
[17] https://www.nhs.uk/live-well/eat-well/how-does-sugar-in-our-diet-affect-our-health/
[18] https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf
[19] https://www.nhlbi.nih.gov/sites/default/files/media/docs/obesity-evidence-review.pdf
[20] https://www.cdc.gov/heartdisease/facts.htm
[21] https://www.cdc.gov/heartdisease/docs/ConsumerEd_HeartDisease.pdf