Bethany Rittle-Johnson didn't grow up with fruit punch in the fridge or marshmallows in her cereal bowl. Her mom wouldn't buy that kind of stuff -- so she never developed a taste for it, says Rittle-Johnson. When she had her own kids, the Nashville mom wanted the same for her two daughters, now 7 and 11. Instead of poring over ingredients lists, she goes with her gut and categorically avoids the main offenders. No sweetened drinks, no cereals that resemble miniature cookies, and dessert only occasionally. But simply banning the overtly sweet stuff may not be enough anymore.
These days, the staples of kids' diets -- such as granola bars, flavored milk, and fruit snacks -- all contain sugar of one kind or another. When researchers from the University of Calgary analyzed foods like yogurt and cereal marketed specifically for toddlers, they found that more than half contained at least 20 percent of their calories from sugar.
And thanks to the craze for low-fat and fat-free foods that began in the 1990s, manufacturers started pulling out fat from products and replacing it with sugar. So you'll also see it in some pretty surprising places, including salad dressing, crackers, hamburger buns, pretzels, and chips.
Whether it's evaporated cane juice in organic cookies or high-fructose corn syrup in a squirt of ketchup, it's all adding up to very real health concerns. That's especially scary for a generation of children who are heavier than ever and increasingly burdened by grown-up problems such as type 2 diabetes and metabolic syndrome, which is a cluster of symptoms like high blood pressure and extra belly fat that raise the risk for heart disease. "Sugar is being consumed in massive amounts by children," says Parents advisor David Ludwig, M.D., Ph.D., director of the New Balance Foundation Obesity Prevention Center at Children's Hospital Boston. "It's delivering huge numbers of extra calories and placing young bodies under tremendous stress."
In fact, while many kids continue to fall short on nutrients necessary for growth -- like calcium, iron, vitamin D, and potassium -- their consumption of added sugars (the kind put into foods, not the natural sugar in fruit and milk) has reached alarming levels. It's fine for children to have some sugar. But health experts recommend no more than 5 teaspoons of added sugar every day, and the most recent government surveys show that toddlers and preschoolers get 16. The average 6- to 11-year-old gobbles up 24 teaspoons (nearly 20 percent of his daily calories). An analysis of the same data by the National Cancer Institute found that some 4- to 8-year-olds are getting as many as 36 teaspoons every day.
Eating a lot of high-sugar, high-calorie foods contributes to obesity (not to mention cavities), which can usher in serious health problems -- even during childhood. But according to the American Heart Association's last scientific statement about sugar, high-sugar diets themselves may also trigger elevated triglycerides and a kind of chronic, internal inflammation that can damage arteries and raise the risk for heart disease in adulthood.
The Sweet Truth
To grasp the risks of added sugar, you have to understand this first: "Sugar is sugar," says Barry Popkin, Ph.D., director of the Inter-Disciplinary Obesity Center at The University of North Carolina at Chapel Hill. Though manufacturers use more than a dozen different kinds of sweeteners in foods and drinks -- and some are being touted as more wholesome than others -- the body simply doesn't know the difference between them.
Eighty percent of foods in stores today are sweetened by either sucrose (table sugar) or high-fructose corn syrup (HFCS), a cheaper liquid sweetener alternative to sucrose introduced in the 1970s. Though HFCS has been cast as a nutritional villain -- and regular table sugar has been given a "health halo" for being more pure and less processed -- it actually doesn't matter metabolically. "Within a nanosecond of hitting the small intestine, high-fructose corn syrup and sucrose both break down into two molecules, glucose and fructose," says Robert Lustig, M.D., professor of clinical pediatrics at the University of California, San Francisco. "HFCS and sucrose are virtually equivalent."
The same goes for honey, fruit-juice concentrate, molasses, raw sugar, maple syrup, and agave nectar. They all become glucose and fructose molecules in the digestive system, and they all contribute extra calories to a kid's diet. And though many parents are seeking out less-processed foods, most sweeteners are processed to some degree. The raw materials for sucrose (sugar cane and sugar beets) undergo plenty of processing too. "It's a devious thing that some added sugars are being promoted as relatively healthy," says Dr. Popkin. "We should be cutting back on sugar in all its forms." That's big news coming from Dr. Popkin, whose own 2004 paper in The American Journal of Clinical Nutrition first proposed a link between HFCS and the obesity epidemic, and helped ignite a frenzy among scientists and consumers.
The Fructose Factor
Yet it's possible that added sugar may have health risks even beyond what is commonly known. According to an emerging body of research, the fructose that comes from the breakdown of these sweeteners may put a unique kind of stress on the body. The reason: Fructose is processed entirely by the liver. Faced with a big load of fructose, the liver struggles to handle it and ends up converting a portion of fructose to fat molecules. Some of the fat then enters the bloodstream, where it can raise cholesterol and triglyceride levels.
Dr. Lustig says that the way fructose is metabolized by the liver -- the pathways it goes through and the enzymes it activates -- shares eerie similarities with alcohol. "A can of soda and a can of beer have the same strain on the liver," he says. "Fructose is alcohol without the buzz." Both fructose and alcohol cause the liver to trigger fat production that can boost cholesterol levels and belly fat.
And, he says, both can stimulate overconsumption. In research on monkeys, fructose didn't trigger the release of leptin -- the feel-full hormone that tells your brain that it's time to stop eating. When leptin is blocked, not only are you still hungry, you also crave more food, creating a vicious cycle.
Thankfully, the fructose found naturally in fruit (and in lesser amounts, vegetables) is not a problem. Since fruit contains fiber and is naturally filling, kids (and adults) usually don't eat it in large quantities. You'd have to eat three small apples to get the amount of fructose in a 20-ounce bottle of soda. Plus, the fiber in fruits and veggies slows digestion, so the liver doesn't get overwhelmed by a lot of fructose at once. "I'm not worried about the fructose in fruit," says Dr. Lustig. "Kids can eat as much fruit as they want." Fruit juice is different, though. Sure, juice has nutrients like vitamin C that soda doesn't. But that doesn't entirely make up for its fructose. A 6-ounce glass of juice every day is fine, but unlimited access isn't.
Some experts question the relevance of the research on fructose. "Many studies have used fructose in amounts much higher than people typically consume," says John White, Ph.D., a nutritional biochemist with White Technical Research who consults with the Corn Refiners Association, the trade group currently defending HFCS in a public-relations campaign. The highest consumers of fructose (18- to 22-year-olds) take in about 18 percent of calories from fructose, but researchers typically give study subjects 25 to 35 percent of their calories from fructose -- and some animal studies have used up to 60 percent. Furthermore, pure fructose is often used in studies, though in real life, people typically consume it with glucose (such as in fruits). Both factors may exaggerate the studies' outcomes, says Dr. White.
What You Can Do
"It's difficult and unnecessary to erase all added sugar from your child's diet," says Jeannie Moloo, Ph.D., R.D., a spokesperson for the Academy of Nutrition and Dietetics. Everybody's diet -- including children's -- has room for some. We asked our experts for their advice on how to cut back on the amount your child gets.
- Read the fine print.
Don't be fooled by claims on the label like "simple" and "no high-fructose corn syrup." Instead, go straight to the Nutrition Facts Panel and look for "sugar." Check to see how many grams it contains. Though the food label doesn't distinguish between added sugars and natural sugars, you can still use this rule of thumb for processed foods such as cereal, cookies, and crackers: Every 4 grams of sugar equals 1 teaspoon.
- Ban sweetened beverages.
Eliminate regular soda, fruit punch, and other sweet drinks from your fridge -- and if your child has some, consider it a sweet treat, as you would a cookie. (If your child's already getting lots of sugary drinks, artificially sweetened beverages can help cut calories and sugar. Otherwise, teaching your child to drink plain water to quench thirst is a smarter move, says Rachel Johnson, Ph.D., R.D., professor of nutrition at the University of Vermont and spokesperson for the American Heart Association, who helped create its latest guidelines for added sugar intake.) If you want to serve juice, stick to the guidelines set by the American Academy of Pediatrics: no more than 4 to 6 ounces a day for children ages 1 to 6, and no more than 8 to 12 ounces for older kids.
- Use sugar strategically.
On most days, aim to spend your child's sugar allowance on healthy foods like yogurt, whole-grain cereal, and flavored milk. "Consider the vehicle that sugar comes in," says Dr. Johnson. "I'd much rather see kids getting sugar in a whole-grain cereal than in candy or soda." You'll stretch your sugar budget further by buying plain, unsweetened versions of whole-grain cereal, oatmeal, and yogurt and sweetening them yourself with a small amount of sugar, honey, or maple syrup. Putting in just 1 teaspoon of these sweeteners will add 4 grams of added sugar, far less than manufacturers typically add.
- Rethink Dessert.
"I actually recommend having dessert every night because it brings the meal to a close and helps you feel satisfied," explains Dr. Ludwig. In his family, they splurge on something like ice cream once a week. Otherwise, dessert is usually a small square of dark chocolate, a slice of melon, or a cup of berries.
- Be Flexible.
"Totally restricting sweet treats will backfire on you because they'll become so much more desirable to your kids," points out Dr. Johnson. So it's perfectly fine to relax your rules occasionally for birthday parties, playdates, and special occasions. "What you keep in your own house and the patterns you develop as a family are what matter most," she says.
We hit the grocery store using Dr. Lustig's own shopping strategy -- no foods with sugar (of any form) listed in the first three ingredients -- and found these standouts.
Cereal Puffed Rice, Shredded Wheat, Grapenuts
Crackers Triscuit Original, Wasa Crispbread, Kashi Heart to Heart Whole Grain
Peanut Butter Smucker's Natural, 365 Everyday Value, Justin's Classic Peanut Butter
Pasta Sauce Seeds of Change Marinara, Mario Batali Tomato Basil, Classico Tomato & Basil
Fruit Snacks Earthbound Farm Organic Mangoes, Sensible Foods Crunch-Dried Snacks, Trader Joe's Unsweetened Dried Cherries
Originally published in the July 2012 issue of Parents magazine