Adequacy of the dietary intake of total and added sugars in the Spanish diet to the recommendations: ANIBES study

With the participation of: Spanish Nutrition Society (SEÑ) Spanish Society of Community Nutrition (SENC) Spanish Foundation for Nutrition Studies Improvement of Health by Fitness Nutrition and Exercise Research Group NUMBER 22 Adequacy of the dietary intake of total and added sugars in the Spanish diet to the recommendations: ANIBES study With the participation of: Spanish Nutrition Society (SEÑ) Spanish Society of Community Nutrition (SENC) Spanish Foundation for Nutrition Studies Improvement of Health by Fitness, Nutrition and Exercise Research Group

NUMBER 22 Adequacy of the dietary intake of total and added sugars in the Spanish diet to the recommendations: ANIBES study Introduction The term «sugars» has traditionally been used to refer to monosaccharides and disaccharides, which are types of carbohydrate. Its main function is to provide the body with energy. s are the nutrients which produce the cleanest and quickest combustion in the cells and which leave fewer residues in the body. Despite this, from a nutritional perspective, sugars are not essential nutrients, as glucose may be produced by the body. In this sense, no precise daily recommended levels of carbohydrates have been established for human nutrition, although the European Food Security Authority (EFSA) has proposed a range of reference intakes of between 45-60 % of the total energy, with total monosaccharides and disaccharides remaining below 10 %. The World Health Organization (WHO), on the other hand, recommends reducing consumption of free (added) sugars throughout the life course to less than 10 % of total calorie intake. Moreover, according to the WHO, a recommended reduction to less than 5 % would result in additional health benefits. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 2

Very little reliable data on the intake of sugars and their subtypes is available, due primarily to the lack of information on sugars in most food composition tables and databases, as well as to the usual methodological issues in dietary surveys, which complicate the collection of precise information on actual food and beverage consumption. This article presents information from the ANIBES study in relation to the intake of total sugars as well as natural or intrinsic sugars and so-called added sugars, and primary food sources. Also pioneering information on the percentage of the Spanish population which adheres to the maximum intake level recommended by the WHO and other institutions is presented. In this regard, it seems increasingly important to obtain up-to-date information based on scientific evidence, such as that derived from the ANIBES study, to enable and promote specific education and awareness-raising actions tailored to the different age groups. r Nutrition Studies 3

Materials and Methods The design, protocol and methodology have been already described in detail in previous scientific works belonging to the ANIBES Study; as well as the total distribution of macronutrients and dietary sources in the Spanish population which are included in this study. Moreover, the dietary intake of added and intrinsic sugars and their dietary sources expressed in g/day are detailed in Ruiz E. et al, 2017. To estimate the intake of total, intrinsic and added sugars, once the energy and nutrients had been calculated from the consumption data collected, an estimate of the proportion of intrinsic sugar and added sugar was derived from product labels produced by the brand with regards to the total sugars, obtained according to data from food composition tables (Moreiras O. et al, 2013). Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 4

The sugars present in the foods were classified in line with the following criteria: Foods and beverages without added sugars: In order to classify and quantify foods and beverages with no added sugars (intrinsic sugars), all of those fresh and unprocessed foods which do not carry labelling and without any added ingredient were considered. In this group are included most fresh foods, such as fruits, vegetables, meats or fish and shellfish, among others. Foods and beverages with added sugars: In this group were included all those labelled foods and beverages for which the ingredients list indicated the inclusion of any type of sugar. The sugars content was calculated based on the content of each of the ingredients in the product that appear on the labelling, and also through the nutritional composition from the food composition tables. The added sugars content was calculated from the total sugars information that appears on the nutritional labelling in those foods and beverages with no intrinsic sugars. In the case of those with intrinsic sugars, added sugars were calculated taking into account the difference between the sugar shown on the nutritional information and the estimation of intrinsic sugars obtained from the nutritional labelling. For its part, intrinsic sugars were calculated based on the total sugars labelling in the food composition tables. r Nutrition Studies 5

Distribution of macronutrients and carbohydrates It is known that developed societies consume high levels of foods of animal origin and of convenience and sweetened products, which consequently reduces the total carbohydrate content of the diet and increases levels of lipids and proteins, leading to an unbalanced caloric profile, with a potential increase in sugar intake and a reduction in starch and dietary fibre. Contribution of macronutrients to total energy intake in the population (9-75 years old): ANIBES study Fibre 1.4 % Alcohol 1.9 % Protein 16.8 % CARBOHYDRATES 41.1 % TOTAL SUGARS 17.0 % Intrinsic sugars 9.6 % Added sugars 7.3 % Starch 24.1 % PUFA 6.6 % SFA 11.7 % MUFA 16.8 % LIPIDS 38.5 % In relation to carbohydrates, the results of the ANIBES study show that they as a whole provide 41.1 % of total energy intake. Within carbohydrates, 24.1 % comes from starch, and 17 % from total sugars, representing 9.6 % intrinsic sugars and 7.3 % added sugars. In this regard, the average proportion of carbohydrates in energy intake in the ANIBES study shows none of the population groups by either age or gender reaching the recommended levels. Spanish Foundation fo 6 12.71 % Other dairy products 3.17 % and dairy products 23.26 % Yogurt and fermented milks 0.55 % Ready-to-eat meals 6.82 % 1.30 % Other 2.10 % Non-alcoholic Alcoholic beverages beverages 18.57 % practice of physical 3.60 % activity, socioeconomic data and lifestyles 7.28 % 16.78 % ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, ed soft drinks 10.01 % Juices and nectars 6.55 % Other 2.02 %

Carbohydrate profile (%) by age group: ANIBES study Older adults 65-75 22.5 c 13.0 c 5.1 c Adults 18-64 24.1 a 9.3 a 7.1 b Adolescents 13-17 26.6 b 7.6 b 10.0 a Children 9-12 25.0 a 8.8 a 9.8 a 0 10 20 30 40 50 Starch Intrinsic sugars Added sugars a,b,c The values which do not share a superscript are significantly different between ages, p 0.05. s intake There are significant differences in terms of compliance with WHO recommendations for sugars intake among the different age groups in the ANIBES population. Regarding the total ANIBES sample, intrinsic sugars intake was 9.6 % of the total energy intake and added sugars intake was 7.3 % of the total energy intake, complying with the WHO recommendation that added sugars intake should represent less than 10 % of total energy intake. Intake of intrinsic sugars is higher among older people; on the other hand, the consumption of added sugars is significantly higher in young people, particularly in adolescents, reaching an average of 10 % of the total energy intake. r Nutrition Studies 7

Compliance with the WHO recommendations for added sugars 58.2 % of the ANIBES child population between 9 and 12 years old, regardless of gender, comply with the WHO recommendation that added sugars intake should represent less than 10 % of total energy intake. In the case of adolescents (13-17 years), compliance is lower (52.6 %), yet it is much higher in men (56.2 %) than in women (46.0 %). Among the adult population (18-64 years old) and in older adults (65-75 years old), the fulfilment of the WHO recommendations is markedly higher, 76.7 % and 89.8 % respectively. When considering the conditional additional recommendation that added sugars intake should remain below 5 % of the total energy intake, 9.4 % of the child population and 13.3 % of adolescents would meet the recommendation, far below the levels observed in older populations: 37.5 % for adults, and up to 55.3 % in older adults. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 8

Distribution of the Spanish population by age and gender according to the different levels of intake (% total energy intake) of added sugars Age groups (years) 9-12 13-17 18-64 65-75 Added sugars < 5 % TEI 5-10 % TEI 10-15 % TEI 15-20 % TEI 20-25 % TEI 25-30 % TEI Total Men Women Total Men Women Total Men Women Total Men Women n 20 11 9 28 21 7 621 330 291 114 59 55 % 9.4 8.7 10.3 13.3 15.3 9.5 37.5 41.4 34.0 55.3 59.6 51.4 n 104 63 41 83 56 27 649 280 369 71 33 38 % 48.8 50.0 47.1 39.3 40.9 36.5 39.2 35.1 43.1 34.5 33.3 35.5 n 63 35 28 67 41 26 266 129 137 19 7 12 % 29.6 27.8 32.2 31.8 29.9 35.1 16.1 16.2 16.0 9.2 7.1 11.2 n 23 16 7 31 17 14 94 46 48 2 0 2 % 10.8 12.7 8.0 14.7 12.4 18.9 5.7 5.8 5.6 1.0 0.0 1.9 n 2 0 2 1 1 0 20 10 10 0 0 0 % 0.9 0.0 2.3 0.5 0.7 0.0 1.2 1.3 1.2 0.0 0.0 0.0 n 1 1 0 1 1 0 5 3 2 0 0 0 % 0.5 0.8 0.0 0.5 0.7 0.0 0.3 0.4 0.2 0.0 0.0 0.0 TEI: Total Energy Intake. r Nutrition Studies 9

Dietary sources of sugars Added sugars Food and beverage groups and subgroups that contributed as dietary sources of added sugars in the total population of the ANIBES study were: sugar and sweets (34.1 %), nonalcoholic beverages (30.8 %, mainly sugar-sweetened drinks, 25.5 %) and cereals and grains (19.1 %, including 15.2 % bakery and pastry). With regards to age, in the child and adult groups, but particularly among adolescents, the sugar-sweetened soft drinks subgroup represents a relevant source (18.0 % among children, 26.0 % among adults and 30.2 % among adolescents), while in the case of older adults it stands at 9.5 %. are also a significant source among all age groups. In the group of children and adolescents, the subgroups of chocolate, other dairy products, yogurt and fermented milks, juices and nectars, and breakfast cereals and cereal bars represent the next groups in terms of intake. Among adults and older adults, the sugar and sweets group is substantial. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 10

Low alcohol content beverages 4.94 % 1.76 % 2.24 % 2.91 % Ready-to-eat meals 1.08 % 1.06 % Other foods 5.22 % Yogurt and fermented milks 7.18 % 31.80 % 9.89 % 11.10 % Main dietary sources of added 19.60 % sugars (%) from food and beverage groups and subgroups in the total population 15.20 % 11.40 % Yogurt and fermented milks 6.44 % 5.99 % 3.58 % 2.91 % 1.30 % 1.00 % Breakfast cereals and cereal bars 2.78 % Other foods and beverages 4.96 % Sports drinks 1.14 % 17.80 % 25.50 % r Nutrition Studies 11

6.6 % Intrinsic sugars Food and beverage groups and subgroups that contributed as dietary sources of intrinsic Ready-to-eat meals 6.82 % sugars in the total 1.30 population % of the ANIBES study were: fruit (31.8 ed %), milk and dairy Other soft drinks Other products (29.3 %) and non-alcoholic beverages (15.0 %), such as juices 10.01 and % nectars 2.02 (11.1 % %). 2.10 % Alcoholic beverages Regarding age, 3.60 differences % relating to intrinsic sugars may be observed: higher intake by Juices and adults and older adults, deriving mainly from fruit and vegetable consumption, nectars than in 7.28 % 6.55 % children and adolescents, among whom the milk and juice and nectar subgroups are more widely present. Low-alcohol-content beverages are 16.78 also % a source to be taken into account among adults Bakery and older adults. Breakfast cereals and cereal bars 1.29 % Other 1.16 % 2.84 % and pastry 6.69 % and dairy products 23.26 % Cereals and grains 11.98 % 12.71 % s and sweets 15.13 % Yogurt and fermented milks Other dairy products 3.17 % 0.55 % Non-alcoholic beverages 18.57 % 8.18 % Jams and other 1.77 % Main dietary sources of intrinsic sugars (%) from food and 4.74 % 0.44 % beverage groups and subgroups in the total population 1.22 % Low alcohol content beverages 4.94 % 1.76 % 2.24 % 2.91 % Ready-to-eat meals 1.08 % 1.06 % Other foods 5.22 % Yogurt and fermented milks 7.18 % 31.80 % 9.89 % Spanish Foundation fo 11.10 % 19.60 % 12 Yogurt and fermented milks 6.44 % 5.99 % 3.58 % 2.91 % ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 11.40 % Breakfast cereals and cereal bars 2.78 % Sports drinks

Fibre 1.4 % Alcohol 1.9 % Protein 16.8 % CARBOHYDRATES 41.1 % TOTAL SUGARS 17.0 % Total sugars Intrinsic sugars 9.6 % Added sugars 7.3 % SFA 11.7 % LIPIDS 38.5 % Food and beverage groups and subgroups that contributed 16.8 as % dietary sources of total Starch sugars in the total population 24.1 % of the ANIBES study were: milk and dairy products (23.2 %), non-alcoholic beverages (18.6 %), fruit (16.8 %), sugar PUFA and sweets (15.1 %) and cereals and 6.6 % grains (12.0 %), which cover 85 % of the sugar consumed. MUFA Main dietary sources of total sugars (%) from food and beverage groups and subgroups in the total population r Breakfast cereals and cereal bars 1.29 % Nutrition Studies Other 1.16 % Ready-to-eat meals 1.30 % Other 2.10 % Alcoholic beverages 3.60 % 7.28 % 2.84 % Bakery and pastry 6.69 % and dairy products 23.26 % Cereals and grains 11.98 % 12.71 % s and sweets 15.13 % Yogurt and fermented milks 6.82 % 16.78 % Other dairy products 3.17 % 0.55 % Non-alcoholic beverages 18.57 % 8.18 % 4.74 % Jams and other 1.77 % ed soft drinks 10.01 % 0.44 % Juices and nectars 6.55 % Other 2.02 % 1.22 % Low alcohol content beverages 4.94 % 1.76 % 2.24 % 2.91 % Ready-to-eat meals 1.08 % 1.06 % Other foods 5.22 % 13 Yogurt and fer-

Dietary sources of added sugars (%) from food and beverage groups and subgroups. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 14

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 1. General 9-75 Years Sample: 2,009 individuals* 25.50 17.80 15.20 11.40 Yogurt and fermented milks 6.44 5.99 3.58 2.91 Breakfast cereals and cereal bars 2.78 1.30 Sports drinks 1.14 1.00 Ready-to-eat-meals 0.90 Sauces and condiments 0.68 Energy drinks 0.67 Other drinks (non-alcoholic) 0.59 0.59 Sausages and other meat products 0.53 High alcohol content beverages 0.28 0.23 0.19 Low alcohol content beverages 0.16 Grains and flours 0.06 Appetizers 0.05 Supplements and meal replacements Meat Pulses 0.02 r Nutrition Studies Unsweetened soft drinks Butter, margarine and shortening Fish and shellfish Eggs Olive oil Other oils Viscera and offal Water *Random sample 15

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 2. General men 9-75 years Sample: 1,013 individuals* Yogurt and fermented milks Breakfast cereals and cereal bars Sports drinks Ready-to-eat-meals Energy drinks Sauces and condiments Sausages and other meat products Other drinks (non-alcoholic) High alcohol content beverages Low alcohol content beverages Appetizers Grains and flours Supplements and meal replacements Meat Pulses Unsweetened soft drinks Butter, margarine and shortening Fish and shellfish Eggs Olive oil Other oils Viscera and offal Water *Random sample 3.16 2.97 2.72 1.47 1.02 0.95 0.93 0.93 0.72 0.58 0.57 0.48 0.36 0.29 0.18 0.11 0.06 0.04 0.02 6.59 6.24 11.30 16.00 14.40 27.90 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 16

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 3. General women 9-75 years Sample: 996 individuals* r Nutrition Studies Yogurt and fermented milks Breakfast cereals and cereal bars Ready-to-eat-meals Sports drinks Other drinks (non-alcoholic) Sauces and condiments Sausages and other meat products Energy drinks Low alcohol content beverages High alcohol content beverages Grains and flours Appetizers Supplements and meal replacements Pulses Meat Unsweetened soft drinks Butter, margarine and shortening Fish and shellfish Eggs Olive oil Other oils Viscera and offal Water 6.68 5.27 4.58 2.62 2.56 1.74 1.07 0.77 0.75 0.73 0.63 0.61 0.49 0.33 0.22 0.19 0.18 0.17 0.08 0.05 0.02 22.60 2 16.10 11.50 *Random sample 17

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 4. children boys and girls 9-12 years Sample: 213 individuals* Yogurt and fermented milks Breakfast cereals and cereal bars Sports drinks Ready-to-eat-meals Sauces and condiments Sausages and other meat products Appetizers Grains and flours Meat Pulses Butter, margarine and shortening Unsweetened soft drinks Other drinks (non-alcoholic) Fish and shellfish Eggs Energy drinks High alcohol content beverages Low alcohol content beverages Olive oil Other oils Supplements and meal replacements Viscera and offal Water *Random sample plus boost 1.96 1.59 1.53 1.00 0.88 0.78 0.70 0.62 0.21 0.02 0.01 0.01 9.69 8.32 6.57 5.27 4.06 17.90 16.10 22.70 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 18

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 5. children boys 9-12 years Sample: 126 individuals* r Yogurt and fermented milks Breakfast cereals and cereal bars Sports drinks Ready-to-eat-meals Sauces and condiments Sausages and other meat products Appetizers Meat Granos y harinas Pulses Other drinks (non-alcoholic) Butter, margarine and shortening Unsweetened soft drinks Fish and shellfish Eggs Energy drinks High alcohol content beverages Low alcohol content beverages Olive oil Other oils Supplements and meal replacements Viscera and offal Water *Random sample plus boost Nutrition Studies 9.83 8.49 6.14 5.08 4.07 2.10 1.56 1.32 1.00 0.83 0.79 0.67 0.61 0.19 0.04 0.01 0.01 0.01 0.01 14.90 22.10 20.20 19

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 6. children girls 9-12 years Sample: 87 individuals* Yogurt and fermented milks Breakfast cereals and cereal bars Ready-to-eat-meals Sauces and condiments Sports drinks Sausages and other meat products Grains and flours Meat Pulses Appetizers Butter, margarine and shortening Unsweetened soft drinks Fish and shellfish Eggs Other drinks (non-alcoholic) Energy drinks High alcohol content beverages Low alcohol content beverages Olive oil Other oils Supplements and meal replacements Viscera and offal Water *Random sample plus boost 9.47 8.05 7.25 5.57 4.04 2.61 1.86 1.02 0.99 0.96 0.77 0.62 0.49 0.24 0.05 0.02 0.02 0.01 14.30 18.00 23.70 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 20

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 7. Adolescents 13-17 years Sample: 211 individuals* r Nutrition Studies Yogurt and fermented milks Breakfast cereals and cereal bars Energy drinks Ready-to-eat-meals Sauces and condiments Sausages and other meat products Sports drinks Other drinks (non-alcoholic) Grains and flours Supplements and meal replacements Meat Appetizers Pulses Low alcohol content beverages Unsweetened soft drinks Butter, margarine and shortening Eggs Fish and shellfish High alcohol content beverages Olive oil Other oils Viscera and offal Water 7.66 6.47 5.74 5.36 5.04 1.72 1.24 1.13 1.10 0.86 0.73 0.45 0.41 0.32 0.32 0.21 0.16 0.12 0.01 13.10 17.60 30.20 *Random sample plus boost 21

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 8. Adolescent boys 13-17 years Sample: 137 individuals* Breakfast cereals and cereal bars Yogurt and fermented milks Energy drinks Ready-to-eat-meals Sauces and condiments Sausages and other meat products Sports drinks Other drinks (non-alcoholic) Grains and flours Supplements and meal replacements Meat Appetizers Pulses Low alcohol content beverages Unsweetened soft drinks Butter, margarine and shortening Eggs Fish and shellfish High alcohol content beverages Olive oil Other oils Viscera and offal Water *Random sample plus boost 1.70 1.21 1.14 1.04 0.87 0.71 0.45 0.41 0.38 0.20 0.17 0.13 0.10 0.05 0.01 6.05 5.97 5.71 4.61 8.20 13.50 16.20 31.10 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 22

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 9. Adolescent girls 13-17 years Sample: 74 individuals* r Nutrition Studies Yogurt and fermented milks Breakfast cereals and cereal bars Ready-to-eat-meals Sauces and condiments Sports drinks Sausages and other meat products Other drinks (non-alcoholic) Grains and flours Meat Appetizers Pulses Low alcohol content beverages Unsweetened soft drinks Fish and shellfish Butter, margarine and shortening Eggs Energy drinks High alcohol content beverages Supplements and meal replacements Olive oil Other oils Viscera and offal Water 7.31 6.85 6.59 5.30 3.72 2.89 1.63 0.89 0.85 0.76 0.55 0.45 0.45 0.30 0.22 0.14 0.14 0.02 0.01 12.40 20.20 28.30 *Random sample plus boost 23

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 10. AdultS 18-64 years Sample: 1,655 individuals* Yogurt and fermented milks Breakfast cereals and cereal bars Sports drinks Ready-to-eat-meals Other drinks (non-alcoholic) Sauces and condiments Energy drinks Sausages and other meat products High alcohol content beverages Low alcohol content beverages Grains and flours Appetizers Supplements and meal replacements Meat Pulses Unsweetened soft drinks Butter, margarine and shortening Fish and shellfish Eggs Olive oil Other oils Viscera and offal Water *Random sample 3.47 2.41 2.36 1.42 1.20 1.03 0.87 0.73 0.67 0.64 0.62 0.54 0.34 0.24 0.18 0.10 0.06 0.06 6.07 5.85 10.30 15.10 19.70 26.00 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 24

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 11. Adult men 18-64 years Sample: 798 individuals* r Yogurt and fermented milks Breakfast cereals and cereal bars Sports drinks Ready-to-eat-meals Energy drinks Sauces and condiments Other drinks (non-alcoholic) Sausages and other meat products High alcohol content beverages Low alcohol content beverages Appetizers Grains and flours Supplements and meal replacements Meat Pulses Unsweetened soft drinks Butter, margarine and shortening Fish and shellfish Eggs Olive oil Other oils Viscera and offal Water *Random sample Nutrition Studies 9.87 6.47 6.17 2.63 2.47 2.36 1.96 0.98 0.98 0.86 0.81 0.71 0.69 0.61 0.59 0.44 0.34 0.14 0.07 0.07 0.05 0.02 14.20 18.10 28.30 25

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 12. Adult women 18-64 years Sample: 857 individuals* Yogurt and fermented milks Breakfast cereals and cereal bars Sports drinks Other drinks (non-alcoholic) Ready-to-eat-meals Sauces and condiments Sausages and other meat products Energy drinks High alcohol content beverages Low alcohol content beverages Grains and flours Appetizers Supplements and meal replacements Pulses Meat Unsweetened soft drinks Butter, margarine and shortening Fish and shellfish Eggs Olive oil Other oils Viscera and offal Water *Random sample 2.47 2.25 1.60 1.08 0.86 0.78 0.75 0.67 0.63 0.48 0.38 0.24 0.22 0.15 0.13 0.07 0.04 0.02 5.97 5.20 4.33 23.60 21.30 16.00 10.70 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 26

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 13. elderly 65-75 years Sample: 206 individuals* r Nutrition Studies Yogurt and fermented milks Breakfast cereals and cereal bars Ready-to-eat-meals Other drinks (non-alcoholic) High alcohol content beverages Sausages and other meat products Sports drinks Low alcohol content beverages Sauces and condiments Appetizers Grains and flours Supplements and meal replacements Pulses Meat Butter, margarine and shortening Fish and shellfish Unsweetened soft drinks Eggs Energy drinks Olive oil Other oils Viscera and offal Water 12.80 11.20 9.46 5.66 5.39 1.79 1.51 1.13 0.61 0.55 0.53 0.49 0.48 0.47 0.38 0.26 0.23 0.20 0.15 0.08 0.07 0.05 0.04 0.01 21.40 25.10 *Random sample 27

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 14. elderly men 65-75 years Sample: 99 individuals* Yogurt and fermented milks Breakfast cereals and cereal bars High alcohol content beverages Ready-to-eat-meals Sports drinks Sausages and other meat products Other drinks (non-alcoholic) Sauces and condiments Supplements and meal replacements Low alcohol content beverages Pulses Appetizers Grains and flours Meat Butter, margarine and shortening Fish and shellfish Unsweetened soft drinks Eggs Energy drinks Olive oil Other oils Viscera and offal Water *Random sample 1.65 1.48 0.98 0.93 0.80 0.72 0.52 0.50 0.50 0.35 0.20 0.19 0.15 0.09 0.04 0.02 0.01 0.01 4.71 11.10 10.10 9.41 7.53 25.20 22.80 Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 28

Dietary sources of added sugars (%) from food and beverage groups and subgroups. 15. elderly women 65-75 years Sample: 107 individuals* r Nutrition Studies Yogurt and fermented milks Breakfast cereals and cereal bars Other drinks (non-alcoholic) Ready-to-eat-meals Sausages and other meat products Low alcohol content beverages Sports drinks Sauces and condiments Appetizers Grains and flours Pulses Meat Butter, margarine and shortening Fish and shellfish Unsweetened soft drinks Eggs Supplements and meal replacements High alcohol content beverages Energy drinks Olive oil Other oils Viscera and offal Water 8.86 6.60 3.28 1.93 1.54 1.32 0.74 0.49 0.45 0.44 0.43 0.33 0.25 0.25 0.21 0.15 0.14 0.13 0.05 0.02 14.30 13.10 2 25.00 *Random sample 29

Dietary sources of intrinsic sugars (%) from food and beverage groups and subgroups. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 30

Dietary sources of intrinsic sugars (%) from food and beverage groups and subgroups. 1. General 9-75 Years Sample: 2,009 individuals* 31.80 19.60 11.10 9.89 Yogurt and fermented milks 7.18 Low alcohol content beverages 4.94 2.91 2.24 1.76 1.22 Ready-to-eat-meals 1.08 1.06 0.82 Pulses 0.73 0.70 0.57 Sauces and condiments 0.42 Grains and flours 0.33 Other drinks (non-alcoholic) 0.32 0.30 Sausages and other meat products 0.27 Breakfast cereals and cereal bars 0.26 Appetizers 0.20 0.15 Unsweetened soft drinks 0.08 Butter, margarine and shortening Fish and shellfish Supplements and meal replacements r Nutrition Studies Eggs 0.01 High alcohol content beverages Energy drinks Sports drinks Meat Olive oil Other oils Viscera and offal Water *Random sample 31

Dietary sources of total sugars (%) from food and beverage groups and subgroups. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 32

Dietary sources of total sugars (%) from food and beverage groups and subgroups. 1. General 9-75 Years Sample: 2,009 individuals* r Nutrition Studies Yogurt and fermented milks Low alcohol content beverages Ready-to-eat-meals Breakfast cereals and cereal bars Sauces and condiments Pulses Sausages and other meat products Energy drinks Sports drinks Grains and flours Other drinks (non-alcoholic) Appetizers High alcohol content beverages Unsweetened soft drinks Supplements and meal replacements *Random sample Fish and shellfish Butter, margarine and shortening Meat Eggs Olive oil Other oils Viscera and offal Water 12.71 10.01 8.18 7.28 6.82 6.69 6.55 4.74 3.51 3.17 2.84 1.77 1.30 1.29 0.94 0.91 0.70 0.57 0.56 0.55 0.49 0.44 0.35 0.25 0.16 0.15 0.09 0.08 0.04 0.02 0.02 0.01 16.78 33

References Aranceta-Bartrina J, Varela-Moreiras G, Serra-Majem LL, Perez-Rodrigo C, Abellana R, Ara I, et al. Consensus document and conclusions. Methodology of dietary surveys, studies on nutrition, physical activity and other lifestyles. Nutr Hosp, 2015;31(Supp 3):9-11. European Food Safety Authority (EFSA). Scientific opinion on dietary reference values for carbohydrates and dietary fibre. EFSA Journal, 2010;8(3):1462. Hess J, Latulippe ME, Ayoob K, Slavin J. The confusing world of dietary sugars: Definitions, intakes, food sources and international dietary recommendations. Food Funct, 2012;3(5):477-86. Ruiz E, Ávila JM, Valero T, del Pozo S, Rodríguez P, Aranceta-Bartrina J, Gil A, González- Gross M, Ortega RM, Serra-Majem Ll, Varela-Moreiras G. Macronutrient Distribution and Dietary Sources in the Spanish Population: Findings from the ANIBES Study. Nutrients, 2016;8(3):177; doi:10.3390/nu8030177. Ruiz E, Rodríguez P, Valero T, Ávila JM, Aranceta-Bartrina J, Gil A, González-Gross M, Ortega RM, Serra-Majem Ll, Varela-Moreiras G. Dietary Intake of Individual (Free and Intrinsic) s and Food Sources in the Spanish Population: Findings from the ANIBES Study. Nutrients, 2017;9(3):275; doi:10.3390/nu9030275. Ruiz E, Varela-Moreiras G. Adequacy of the dietary intake of total and added sugars in the Spanish diet to the recommendations: ANIBES study. Nutr Hosp, 2017;34(4):45-52; doi:http://dx.doi.org/10.20960/nh.1571. Varela-Moreiras G, Avila JM, Ruiz E. Energy balance, a new paradigm and methodological issues: The ANIBES study in Spain. Nutr Hosp, 2015;31(Suppl 3):101-12. World Health Organization (WHO). Guideline: s Intake for Adults and Children; World Health Organization (WHO): Geneva, Switzerland; 2015. Spanish Foundation fo ANIBES Study >> Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles 34

Scientific Committee Prof. Javier Aranceta-Bartrina, MD, PhD Chairman of the Scientific Committee of the Spanish Society of Community Nutrition (SENC), Clinical Director of the Spanish Foundation for and Professor of Community Nutrition at the University of Navarra Prof. Ángel Gil, PhD Chairman of the Iberoamerican Nutrition Foundation (FINUT), Director of the BioNit Scientific Group and Professor of Biochemistry and Molecular Biology at the University of Granada Prof. Marcela González-Gross, PhD Vice President of the Spanish Nutrition Society (SEÑ), Head of the imfine Research Group and Professor of Sports Nutrition and Exercise Physiology at the Technical University of Madrid Prof. Rosa Mª Ortega, PhD Director of the VALORNUT Research Group and Professor of Nutrition at the Complutense University of Madrid Prof. Lluìs Serra-Majem, MD, PhD Chairman of the Spanish Foundation for, Chairman of the, Director of the Biomedical and Health Research Institute and Professor of Preventive Medicine and Public Health at the University of Las Palmas de Gran Canaria Prof. Gregorio Varela-Moreiras, PhD Chairman of the Spanish Nutrition Foundation (FEN), Director of the Nutrition and Food Sciences Research Group (CEUNUT) and Professor of Nutrition and Bromatology at CEU San Pablo University of Madrid r Nutrition Studies The final protocol of the ANIBES scientific study was previously approved by the Clinical Research Ethics Committee of the Autonomous Region of Madrid (Spain). 35