e-Library of Evidence for Nutrition Actions (eLENA)

Reducing free sugars intake in children and adults

Guidance summary*

WHO recommendations

WHO recommends a reduced intake of free sugars throughout the lifecourse.

In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake.**

WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake.


  • Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

  • For countries with a low intake of free sugars, levels should not be increased. Higher intakes of free sugars threaten the nutrient quality of diets by providing significant energy without specific nutrients (1).

  • These recommendations were based on the totality of evidence reviewed regarding the relationship between free sugars intake and body weight (low and moderate quality evidence) and dental caries (very low and moderate quality evidence).

  • Increasing or decreasing free sugars is associated with parallel changes in body weight, and the relationship is present regardless of the level of intake of free sugars. The excess body weight associated with free sugars intake results from excess energy intake.

  • The recommendation to limit free sugars intake to less than 10% of total energy intake is based on moderate quality evidence from observational studies of dental caries.

  • The recommendation to further limit free sugars intake to less than 5% of total energy intake is based on very low quality evidence from ecological studies in which a positive dose–response relationship between free sugars intake and dental caries was observed at free sugars intake of less than 5% of total energy intake.

  • The recommendation to further limit free sugars intake to less than 5% of total energy intake, which is also supported by other recent analyses (2,3), is based on the recognition that the negative health effects of dental caries are cumulative, tracking from childhood to adulthood (4,5). Because dental caries is the result of lifelong exposure to a dietary risk factor (i.e. free sugars), even a small reduction in the risk of dental caries in childhood is of significance in later life; therefore, to minimize lifelong risk of dental caries, the free sugars intake should be as low as possible.

  • No evidence for harm associated with reducing the intake of free sugars to less than 5% of total energy intake was identified.

  • Although exposure to fluoride reduces dental caries at a given age, and delays the onset of the cavitation process, it does not completely prevent dental caries, and dental caries still progresses in populations exposed to fluoride (6-18).

  • Intake of free sugars is not considered an appropriate strategy for increasing caloric intake in individuals with inadequate energy intake if other options are available.

  • These recommendations do not apply to individuals in need of therapeutic diets, including for the management of severe and moderate acute malnutrition. Specific guidelines for the management of severe and moderate acute malnutrition are being developed separately.

* This is an extract from the relevant guideline (19). Additional guidance information can be found in this document.

** Total energy intake is the sum of all daily calories/kilojoules consumed from food and drink. Energy comes from macronutrients, such as fat (9 kcal/37.7 kJ per gram), carbohydrate (4 kcal/16.7 kJ per gram) including total sugars (free sugars + intrinsic sugars + milk sugars) and dietary fibre, protein (4 kcal/16.7 kJ per gram) and ethanol (i.e. alcohol) (7 kcal/29.3 kJ per gram). Total energy intake is calculated by multiplying these energy factors by the number of grams of each type of food and drink consumed and then adding all values together. A percentage of total energy intake is therefore a percentage of total calories/kilojoules consumed per day.


1. Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. WHO Technical Report Series, No. 916. Geneva: World Health Organization; 2003 (http://www.who.int/dietphysicalactivity/publications/trs916/en/).

2. Sheiham A, James WP. A reappraisal of the quantitative relationship between sugar intake and dental caries: the need for new criteria for developing goals for sugar intake. BMC Public Health. 2014; 14:863.

3. Sheiham A, James WP. A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. Public Health Nutr. 2014:1–9.

4. Broadbent JM, Thomson WM, Poulton R. Trajectory patterns of dental caries experience in the permanent dentition to the fourth decade of life. J. Dent. Res. 2008; 87(1):69–72.

5. Broadbent JM, Foster Page LA, Thomson WM, Poulton R. Permanent dentition caries through the first half of life. Br. Dent. J. 2013; 215(7):E12.

6. Slade GD, Sanders AE, Do L, Roberts-Thomson K, Spencer AJ. Effects of fluoridated drinking water on dental caries in Australian adults. J. Dent. Res. 2013; 92(4):376–382.

7. Sivaneswaran S, Barnard PD. Changes in the pattern of sugar (sucrose) consumption in Australia 1958–1988. Community Dent. Health. 1993; 10(4):353–363.

8. Ruottinen S, Karjalainen S, Pienihakkinen K, Lagstrom H, Niinikoski H, Salminen M et al. Sucrose intake since infancy and dental health in 10-year-old children. Caries Res. 2004; 38(2):142–148.

9. Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent school children. Arch. Oral Biol. 1984; 29(12):983–992.

10. Rodrigues CS, Sheiham A. The relationships between dietary guidelines, sugar intake and caries in primary teeth in low income Brazilian 3-year-olds: a longitudinal study. Int. J. Paediatr. Dent. 2000; 10(1):47–55.

11. Masson LF, Blackburn A, Sheehy C, Craig LC, Macdiarmid JI, Holmes BA et al. Sugar intake and dental decay: results from a national survey of children in Scotland. Br. J. Nutr. 2010; 104(10):1555–1564.

12. Marthaler TM. Changes in the prevalence of dental caries: how much can be attributed to changes in diet? Caries Res. 1990; 24 Suppl 1:3–15; discussion 16–25.

13. Leite TA. Dental caries and sugar consumption in a group of public nursery school children (In Portuguese). Rev. Odontol. Univ. Sao Paulo. 1999; 13:13–18.

14. Lawrence HP, Sheiham A. Caries progression in 12- to 16-year-old schoolchildren in fluoridated and fluoride-deficient areas in Brazil. Community Dent. Oral Epidemiol. 1997; 25(6):402–411.

15. Kunzel W, Fischer T. Rise and fall of caries prevalence in German towns with different F concentrations in drinking water. Caries Res. 1997; 31(3):166–173.

16. Holt RD. Foods and drinks at four daily time intervals in a group of young children. Br. Dent. J. 1991; 170(4):137–143.

17. Burt BA, Eklund SA, Morgan KJ, Larkin FE, Guire KE, Brown LO et al. The effects of sugars intake and frequency of ingestion on dental caries increment in a three-year longitudinal study. J. Dent. Res. 1988; 67(11):1422–1429.

18. Arnadottir IB, Rozier RG, Saemundsson SR, Sigurjons H, Holbrook WP. Approximal caries and sugar consumption in Icelandic teenagers. Community Dent. Oral Epidemiol. 1998; 26(2):115–121.

19. WHO. Guideline: Sugars intake for adult and children. Geneva, World Health Organization; 2015 (http://www.who.int/nutrition/publications/micronutrients/guidelines/vas_mtct_hiv/en/).