LAUSR

To the Editor: I really appreciate the comments made by Perrar and Alexy, and their interest in my narrative review regarding the role of dietary sugars in health. The authors stated that my conclusion has some gaps and could lead to a misunderstanding [1]. I have consequently read their comments carefully, reread the articles that they highlighted and have come to the following conclusion. Perrar and Alexy stated that the SACN Report on Carbohydrates and Health suggests an inadequate compensation for energy delivered as sugars. It must be kept in mind that the analysis of the SACN Report included 11 intervention trials focusing on sugar intake and energy intake. Of these 11 intervention trials, six focused on sugarsweetened beverages (SSBs) [2]. Since beverages in general, including SSBs, are less filling than solid foods, it cannot be excluded that an increase of energy intake is due to a faster recurring feeling of hunger, which in turn results in an overall increased energy intake during subsequent meals [3, 4]. Therefore, the results of the SACN report regarding sugar and energy intake must be assessed with caution, because the analysis did not clearly separate whether the effect of increased energy intake was due to dietary sugars or to a less pronounced effect on satiety by SSBs. Perrar and Alexy also criticized that I misinterpreted the findings of the systematic review and meta-analysis of Malik and colleagues regarding the effect of SSB consumption and type 2 diabetes. It is correct that the conclusion of the abstract states that “in addition to weight gain, higher consumption of SSBs is associated with development of metabolic syndrome and type 2 diabetes”, but by reading the whole manuscript, it clearly shows that six of the 11 prospective cohort studies included were not adjusted for total energy intake and adiposity. In line with that, Malik and colleagues stated that, “because the association between SSB consumption and these outcomes is likely to be mediated in part by an increase in overall energy intake or adiposity, adjusting for these factors is expected to attenuate the effect” [5]. Therefore, Malik and colleagues indirectly confirmed my hypothesis that SSB consumption contributes to the development of type 2 diabetes by providing extra calories to the diet and that this will result in weight gain. The hypothesis that the development of type 2 diabetes is due to extra calories that is further highlighted by the systematic review and meta-analysis of controlled intervention studies by Choo and colleagues, which show that SSBs do not have a detrimental effect on glycemic control in energy matched substitution studies when fructose-containing sugars are compared with other macronutrients [6]. In addition, Perrar and Alexy pointed out that the review in the section of type 2 diabetes did not clearly separate between the definition of total sugars, dietary sugars, fructose, or sucrose. Here, I referred exactly to the definitions of sugars as they were used in the original articles, including the SACN report, Hauner et al. as well as Tsilas et al. [2, 7, 8]. For the EFSA Scientific Opinion on Dietary Reference Values for carbohydrates and dietary fibre, the term “sugars” was used in the section of diabetes but the EFSA stated that the current data is insufficient to set an upper limit for (added) sugar intake [9]. Furthermore, Perrar and Alexy stated that the similar effect of fruit juices and SSBs on body weight and type 2 diabetes emphasizes the definition, and recommendations on the intake of free sugars of the WHO. Since the main problem of energy-containing beverages, in general, is that they provide calories without an adequate effect on satiety compared to energy-matched solid foods [3, 4, 10], all energy-containing beverages, including alcoholic-beverages (which were out of the scope of this review) must be assessed in the same way regarding their effect on body weight. Therefore, a recommendation for energy-containing * Philip Prinz [email protected]