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EFSA: how much sugar is safe?
Tolerable upper intake level for dietary sugars.
Overview
EFSA NDA Panel et al.. EFSA J 2022 · PMID 35251356 · DOI 10.2903/j.efsa.2022.7074
EFSA found no safe intake level and advises keeping added and free sugars as low as possible.
Does the study support the specific claim? No · Methodological quality: high
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Can a UL or safe level for dietary sugars be set?
- How was the study done?
Regulatory scientific opinion with systematic reviews.
- How many people, animals or samples were studied?
Not applicable; General population
- What was actually found?
Sugars are a well-established hazard for caries; RCTs on surrogate endpoints show causal positive relationship of added/free sugars with obesity and dyslipidaemia (moderate certainty), NAFLD and T2D (low), hypertension (very low); no safe level identified; intake of added and free sugars should be as low as possible in a nutritionally adequate diet.
- How large was the observed effect?
Not applicable
- What do the results mean in everyday life?
Applies to sugar, honey and syrups alike.
- What are the study's limitations?
Trials looked at markers (weight, liver fat, blood fats) rather than diseases; cohort studies mostly compared sugar with other calories at equal total energy; few data below 10% of energy.
- What does it say about Elawady's specific claim?
Contradicts C-SUG-01, C-SUG-05 (health relevance); supports C-SOD-01.
- Do the results apply to Germany and Europe?
Directly applicable in EU/Germany.
- What can explicitly not be concluded from this study?
It cannot name a safe daily amount of sugar; it does not show that sugar is harmful when it does not add extra calories, except for tooth decay.
Scientific in-depth review
1. Full reference
- Authors
- EFSA NDA Panel et al.
- Journal
- EFSA J
- Year
- 2022
- Identifier
- PMID 35251356 DOI 10.2903/j.efsa.2022.7074
- Verification
- verified – PubMed efetch 2026-10-25
- Retracted
- no
- Corrections
- none
- Extent checked
- full text
- Conflicts of interest and funding
EFSA scientific opinion; declarations of interest of all experts published on the EFSA website (not reproduced in the full text).
2. Research question
Can a UL or safe level for dietary sugars be set?
3. Study design and population
- Study design
- Risk assessment – EFSA NDA Panel scientific opinion (EFSA-Q-2016-00414), following a request from five Nordic countries: protocol-based systematic reviews of RCTs and prospective cohort studies with risk-of-bias assessment, formal uncertainty analysis and probability-based levels of certainty; plus European intake assessment. Adopted 15 December 2021.
- Population
General European population (children, adults, pregnant women)
- Country
EU
- Period
Literature per pre-specified protocol; adopted 15 December 2021
- Sample size
Not applicable
- Inclusion and exclusion criteria
Systematic reviews of RCTs (high vs low sugar, surrogate endpoints: body weight, liver fat, fasting glucose, fasting triglycerides, systolic BP) and prospective cohorts (incident disease) on total/added/free sugars, fructose, sugar-sweetened beverages (SSBs) and fruit juices.
4. Methods and endpoints
- Exposure / intervention
Total, added and free sugars; fructose; SSBs; fruit juices
- Comparator
High vs low intake (RCTs, often isocaloric); isocaloric exchange with other macronutrients (most cohort analyses)
- Endpoints
Obesity, NAFLD/NASH, type 2 diabetes, dyslipidaemia, hypertension, CVD, gout, gestational diabetes, pregnancy outcomes, dental caries
- Statistical methods
Systematic review and meta-analysis by sub-question, risk-of-bias appraisal, dose-response modelling, levels of certainty expressed as probability ranges (high >75-100%, moderate >50-75%, low >15-50%, very low 0-15%)
5. Actual results
- Results
Dietary sugars are a well-established hazard for dental caries. RCTs on surrogate endpoints: positive and causal relationship of added/free sugars with obesity and dyslipidaemia (moderate certainty, >50-75%), NAFLD/NASH and T2DM (low, >15-50%), hypertension (very low, 0-15%). Prospective cohorts, with sugars mostly in isocaloric exchange with other macronutrients, did not support a positive relationship with any chronic metabolic disease or pregnancy endpoint. SSBs: high certainty (>75-100%) of a positive causal relationship with obesity, T2DM, hypertension and CVD; moderate for gout; low for NAFLD and dyslipidaemia; dose-response linear for T2DM, hypertension and CVD (attribution to the sugar fraction is more questionable for hypertension and CVD). Fruit juices: moderate certainty for T2DM and gout, low for CVD. Fructose: moderate for gout, low for CVD. Excess energy intake leading to positive energy balance appears to be the main mechanism; no intake level without increased risk could be identified; relationships at <10% of energy could not be explored adequately. No UL or safe level could be set; intake of added and free sugars should be as low as possible within a nutritionally adequate diet.
- Absolute risks
not applicable (no UL; absolute risks not reported in the opinion's conclusions)
- Authors' conclusion
A UL or safe level for total, added or free sugars could not be established; dietary sugars are a well-established hazard for dental caries; there is evidence of a causal relationship between added/free sugars and some chronic metabolic diseases; intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet.
6. Strengths
- Protocol-driven systematic reviews with risk-of-bias assessment and explicit uncertainty analysis
- Separate conclusions for RCTs and cohorts and for sugar types and sources
- Directly relevant to EU/German populations
7. Weaknesses
- RCT evidence on surrogate endpoints only, mostly at intakes >=10% of energy
- Cohort analyses mostly isocaloric, which limits detection of energy-mediated effects
- Added vs free sugars could not be compared; non-SSB food sources not analysed in cohorts
- External validity of gout findings for Europe unclear (Panel)
8. Risk of bias
- Orienting tool
- none applicable (regulatory scientific opinion with embedded systematic reviews; structured judgement)
- Type of assessment
- structured assessment based on the full text by a single reviewer (no formal double review)
- Full formal assessment
- no
- Overall risk of bias
- low
- Rationale
Changed from not_assessable: the opinion embeds systematic reviews with formal appraisal, allowing a structured judgement of low risk of bias. Structured single-reviewer judgement; a complete formal assessment requires two independent reviewers.
| Domain | Judgement | Rationale |
|---|---|---|
| Protocol and evidence identification | low | Pre-specified protocol and systematic literature searches by sub-question. |
| Appraisal of included studies | low | Formal risk-of-bias ratings for RCTs and cohorts. |
| Synthesis and uncertainty | low | Explicit probability-based certainty levels and uncertainty analysis; null cohort findings reported. |
| Directness | some concerns | RCTs use surrogate endpoints; cohorts isocaloric; data sparse below 10% of energy. |
| Conflicts of interest | low | EFSA declarations of interest system. |
Full-text review (25 October 2026): Main conclusions confirmed. Added: certainty levels for SSBs (high for obesity, T2DM, hypertension, CVD; moderate for gout), fruit juices (moderate for T2DM and gout) and fructose; excess energy intake as main mechanism; limited data <10% of energy; adoption date and question number; EFSA DoI system. Structured judgement; bias overall changed from not_assessable to low; bias_risk dimension set to low.
9. Assessment of the statistical interpretation
Not a single pooled estimate; certainty levels are probability ranges. The strongest conclusions concern SSBs (high certainty for obesity, T2DM, hypertension, CVD) and caries; for sugars in general, certainty is moderate to very low and largely mediated by excess energy intake.
10. Relevance to the specific claim
Contradicts C-SUG-01, C-SUG-05 (health relevance); supports C-SOD-01.
11. Independent contrary findings
Prospective cohorts did not show associations when sugars replaced other macronutrients isocalorically.
12. Transferability to Germany and Europe
Directly applicable in EU/Germany.
13. Overall methodological judgement
Authoritative EU position: added and free sugars should be as low as possible; no safe level identified; high certainty of harm from sugar-sweetened beverages; harm from sugars appears mainly through excess energy intake.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | high |
| Risk of bias | low |
| Precision of results | not applicable |
| Directness | direct |
| Reproducibility | replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
Effects at intakes below 10% of energy; comparison of added vs free sugars; role of non-beverage sources.
15. Linked fact checks
- Regular consumption of sugar-sweetened soft drinks increases the risk of type 2 diabetes (and metabolic syndrome); one to two cans per day raise type 2 diabetes risk by about 26%, and each daily serving by about 18%. – Studies supporting the claim
- White sugar is the greatest product humans ever made; any amount of sugar per day is beneficial, and one can eat a kilogram of white sugar or honey. – Studies contradicting or limiting the claim
- White sugar is not an industrial/manufactured product but an extract of plants, so it does not belong with processed foods. – Studies contradicting or limiting the claim
- Calories are not a relevant concept ('there is no such thing as calories'); his system is based on high calorie intake, and people lose weight while eating sugar, juices, fats, potatoes and rice, because with 'zero insulin' no fat is formed (the passage continues: 'even if you drink oil, even if you swallow bags of sugar'). Elsewhere he says he drinks 6 litres of sugar-cane juice and eats baladi ghee, rice and potatoes every day. – Studies contradicting or limiting the claim
- Sugar-sweetened soft drinks raise the risk of coronary heart disease, cardiovascular death and early death (e.g., two or more daily servings: +35% coronary heart disease in women; +31% cardiovascular and +21% total mortality). – Studies supporting the claim
- Two sugary sodas a day double the risk of gout in men. – Studies supporting the claim
- Soft drinks cause tooth decay. – Studies supporting the claim