Intake of Free Sugar and Micronutrient Dilution in Lebanese Children and Adolescents

Abstract

Lebanon is witnessing the nutrition transition, with its characteristic shifts in diet and lifestyle. One of the hallmarks of the nutrition transition is the increase in sugar intake and the consumption of sweetened processed foods. The population groups that may be the most vulnerable to the ongoing nutrition transition and the concurrent shifts in diet are children and adolescents. Recent studies have suggested that high sugar intake, and particularly free sugars (FS), may be associated with poor dietary quality and micronutrient dilution, the latter being defined as a decrease in micronutrient intakes. The WHO recommended the decrease in FS intake to less than 10% of total energy intake (EI%) and provided another conditional recommendation of further reducing it to <5% EI. While the WHO recommendations aim to prevent dental caries, it remains unknown whether micronutrient intakes would also benefit from these recommendations. This study aims to investigate the association (1) between FS and micronutrient intakes amongst Lebanese children and adolescents and (2) between adherence to the WHO recommended cutoffs and micronutrient intakes.

The study is based on secondary analysis of data stemming from two cross-sectional national surveys conducted among under-five children (survey1) and 5–18-year children and adolescents (survey 2) in Lebanon. In both surveys, data on dietary intake (24-hour recall), socio-demographic and anthropometric characteristics were collected. The Nutritionist Pro software was used for the analysis of dietary intake data and thereafter the calculation of FS intake. For the purpose of this study, six cutoffs of percentages of total energy intake from FS intake (%EFS) were created based on 5% increments: <5% EFS (C1), 5% to <10% EFS (C2), 10% to <15% EFS (C3), 15% to <20% EFS (C4), 20% to <25% EFS (C5), and ≥25% EFS (C6). Absolute micronutrient intakes and micronutrient density (per 1000 kcal) were assessed. Participants’ characteristics and mean intake of micronutrients at different FS cutoffs were compared using ANOVA and Pearson Chi square. The odds ratios (OR) of not meeting the nutrient reference values (NRVs) were calculated for each micronutrient using logistic regression models across the 5% increments cutoffs of FS, after adjustment for covariates. Further analyses were conducted in both age groups to calculate the odds of not meeting NRVs across the FS categories that coincided with the WHO recommendations (i.e. <5% EFS compared to >5%; and <10% EFS compared to >10%).

The results showed that 41.4% of the under-fiver children and 59.9% of participants aged 5 to 18 years exceed the WHO recommendation of FS intake (>10% of energy intake). As FS intakes increased, significant decreases were observed in the intakes of most micronutrients, including vitamin D, vitamin A, calcium, iron, folate, and zinc. The absolute intake of micronutrients was observed to be highest when the percent energy intake from FS was between 5% and 10% in both groups, while an excessive intake of FS especially more than 20% energy intake, was associated with significantly lower micronutrient intakes. Nutrient density, was also the highest within the <5% EFS (C1) category followed by 5%-10% EFS (C2) in both age groups. The odds of not meeting the respective NRVs increased with increasing FS consumption, especially for participants with intakes falling within 20-25%EFS (C5) and ≥25%EFS (C6). In children aged 6 months to 5 years, participants with FS intake <5% had lower absolute intake of several micronutrients and significant higher odds of not meeting NRVs, a reflection of the lower energy intake in this category. Further logistic regression analyses with adjustment for energy intake showed that participants consuming <5%EFS and <10%EFS had significantly higher odds of meeting the requirements of most nutrients compared to others.

In conclusion, a significant association between FS intake and micronutrient dilution was found in Lebanese children and adolescents. The findings also show that the FS recommendations set by the WHO of <5%EFS or <10%EFS have a positive impact on micronutrient adequacy. This study is the first to provide this evidence among children and adolescents in Lebanon and the Eastern Mediterranean Region in general. Taken together, the results emphasize the need for nutrition education interventions to improve micronutrient intake and diet quality among Lebanese children and adolescents on the short term and decrease NCDs on the long-term.