Perceived Associations between Excessive Sugar Intake and Health Conditions

Excessive sugar intake represents an increased risk of developing non-communicable diseases (e.g., obesity, cardiometabolic diseases, and dental diseases). Still, it is unclear whether people are aware of these adverse health outcomes. The current study systematically examined the extent to which people associate health conditions with excessive sugar intake. Participants (N = 1010 Portuguese volunteers) freely reported all health conditions they associated with excessive sugar consumption and rated the strength of these associations for eight specific health conditions. All participants reported health conditions associated with excessive sugar intake, with the most frequent being risk factors for cardiometabolic diseases (e.g., diabetes), cardiovascular diseases, oral problems, oncological and mental health conditions. Moreover, participants considered diabetes, overweight/obesity, and oral problems as being the conditions most related to excessive sugar intake. Women, participants with children in the household, and experts in health/nutrition rated excessive sugar intake as being more strongly linked to some of the health conditions. The identification of the health conditions that people associate with excessive sugar consumption may inform policymakers, educators, and health professionals and support interventions targeting the general public or specific groups (e.g., overweight people) in raising awareness of potential adverse health outcomes and, ultimately, contribute to reducing sugar intake.


Introduction
Poor eating habits, including high sugar intake, contribute to a decrease in the average life expectancy and are associated with many health conditions [1,2]. The excessive intake of free sugars increases the overall energy intake and may reduce the intake of nutritionally richer foods, and it has been associated with multiple adverse health outcomes (for a review, see [3]).
Free sugar is ubiquitous in current diets, corresponding to "all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juice concentrates" [2]. Its excessive intake has been associated with an increased risk of developing non-communicable diseases, such as overweight or obesity [4], cardiometabolic diseases [5], elevated blood pressure [6], some types of cancer [7,8], and dental caries [9], among others. For example, excessive sugar intake can predispose individuals to increased adiposity and, ultimately, overweight and obesity [10,11], especially when this consumption co-occurs with low levels of physical activity. Obesity, in turn, is currently considered a global epidemic with severe individual In other cases, individuals acknowledge the negative health outcomes but downplay the likelihood of experiencing them in the near future [24,28].
To the best of our knowledge, studies that are focused on examining the perceived health consequences of excessive sugar intake are still scarce. Although the reviewed qualitative studies provide important cues in this regard, these findings cannot be generalized, because they are based on small and specific samples (e.g., see [24,25]). Still, a few studies about sugar-sweetened beverages (SSB) consumption tackled this issue. For instance, research with large samples of US adults has shown that participants often associated weight gain and diabetes with excessive SSBs consumption [29,30]. However, because both studies required participants to select health conditions from a predefined set, this method does not allow to infer whether participants spontaneously identified these conditions, nor if they would also report other health conditions. In contrast, a recent study with Australian adults [28] included an open-ended question about the health effects associated with SSB consumption, and type 2 diabetes, weight gain, and heart disease were the most frequent responses. It is noteworthy that all these studies focused on conditions resulting from drinking SSBs (and not from overall excessive sugar consumption). It is possible that the associations with these negative health outcomes are driven from the unhealthfulness appraisal of SSBs, which, in turn, may result from several perceived attributes and not exclusively by their high sugar content (e.g., presence of additives, artificial sweeteners, caffeine content, fruit, etc. (see [31,32]). Moreover, these studies do not inform about the strength of the association between sugar intake and a given health condition.
Understanding the anticipated consequences of excessive sugar intake is relevant to developing strategies to address this problem. Hence, in the current study, we systematically examined Portuguese individuals' perceptions about the health-related consequences of high sugar intake by using both a free-association task and a rating task, in which participants rated the strength of the association between excessive sugar intake and a set of eight health conditions (e.g., diabetes, cancer, and hyperactivity). Additionally, we explored if these ratings varied according to sociodemographic variables (e.g., gender, age, and education level; see also [28]) and correlated with other self-reported measures (e.g., frequency of high-sugar foods intake and attention to sugar-content information).

Procedure and Instruments
This study was part of a broader project about eating behavior (for other instruments and results, see [22,33]), and we only focus on the relevant measures for the current paper. All procedures were reviewed and approved by an ethics committee of the Iscte-Instituto Universitário de Lisboa (approval #22/2019).), and all methods were performed by following the ethical guidelines and regulations of the host institution. Written informed consent was obtained from all participants. Instructions stated the goals and the duration of the study, as well as ethical considerations (e.g., anonymity, confidentiality, and possibility to withdraw at any time). The invitation to participate in a web survey (hosted in Qualtrics) about eating habits was shared via mailing lists and on social networks (e.g., Facebook and LinkedIn). Data were collected from 7 February to 19 February 2019, and all Portuguese adults were eligible to participate. The only incentive to participate was the opportunity to enter a raffle (three 50€ gift cards). The contact information provided to enter the raffle was archived in a separate database and subsequently deleted.
The goal of the main task was to understand the perceived health outcomes of sugar intake. First, participants were asked whether they associated excessive sugar intake with any health condition (1 = Yes, 2 = No). Those who responded affirmatively were asked to write all the health problems they could remember. Next, we presented a list of eight conditions (in random order) that have been associated with high-sugar dietshypertension, diabetes, overweight/obesity, dental caries or other oral health problems, cancer, high cholesterol, kidney disease [2,3], and hyperactivity. Participants were asked to indicate to what extent they considered each condition to be associated with excessive sugar intake (1 = Not at all associated to 7 = Strongly associated). Table 1 presents the measures used to assess participants' perceptions or behaviors toward sugar. Table 1. Measures used to assess participants' perceptions or behaviors toward sugar.

Item Scale Anchors
Attention to sugar content information [34] "How often do you look at the sugar content in the nutritional Participants also answered sociodemographic questions (e.g., gender, age, occupation, and education level) and questions about their overall lifestyle and health status (e.g., weight/height; type of diet; and the following two questions, "In general, you would say that your lifestyle is...", 1 = Very sedentary to 7 = Very active, and "In general, you would say that your health status is...", 1 = Very bad to 7 = Very good). At the end of the survey, participants were thanked and fully debriefed.

Data Analytic Plan
A total of 1483 participants agreed to participate in the survey. Only completed surveys were included in our analyses (n = 1010, 68.11% completion rate). A sensitivity power analysis using G*Power [36] indicated that the sample size allowed enough power (95%) to detect a small effect size of f(V) = 0.15. Data were analyzed with SPSS v29, and significance levels for inferential analyses were set to 0.05.
Our primary analyses included the categorization of participants' responses to the open-ended question about the health conditions they spontaneously associate with excessive sugar intake. We present the frequency observed for each health-condition category (Section 3.1). Moreover, a repeated-measures ANOVA was used to examine if the eight health conditions differ regarding how strongly they are associated with excessive sugar (multiple comparisons between health conditions with Bonferroni correction, Section 3.2). As additional analyses, we used independent-samples t-tests to explore if the perceived association between excessive sugar intake and each health condition varied according to individual characteristics (i.e., gender, presence of children, and expertise in health and nutrition). Finally, in Section 3.3, we use Pearson's Correlation Coefficient to explore the pattern of associations between the overall association with health conditions and the variables related to the perception and behavior toward sugar and participants' reported lifestyle.

Excessive Sugar Intake and Health Conditions: Spontaneous Associations
The results indicated that only 13.7% (n = 138) of participants did not report any association between excessive sugar intake and health conditions. The remaining 86.3% (n = 872) responded "yes", but 76 participants did not further indicate any health condition(s). In total, 796 participants indicated at least one health condition associated with excessive sugar intake (total of 1812 responses). These responses were categorized by two expert judges (one nurse and one general practitioner [37,38]). Different designations for the same health condition (e.g., "cholesterol"/"hypercholesterolemia"/"high cholesterol") were aggregated. Results are summarized in Figure 1, and Table 2 presents the health conditions frequencies per category.
sugar (multiple comparisons between health conditions with Bonferroni correcti tion 3.2). As additional analyses, we used independent-samples t-tests to explor perceived association between excessive sugar intake and each health condition according to individual characteristics (i.e., gender, presence of children, and exp health and nutrition). Finally, in Section 3.3, we use Pearson's Correlation Coeffi explore the pattern of associations between the overall association with health con and the variables related to the perception and behavior toward sugar and parti reported lifestyle.

Excessive Sugar Intake and Health Conditions: Spontaneous Associations
The results indicated that only 13.7% (n = 138) of participants did not report sociation between excessive sugar intake and health conditions. The remaining 86 872) responded "yes", but 76 participants did not further indicate any health cond In total, 796 participants indicated at least one health condition associated with ex sugar intake (total of 1812 responses). These responses were categorized by two judges (one nurse and one general practitioner [37,38]). Different designations same health condition (e.g., "cholesterol"/"hypercholesterolemia"/"high chole were aggregated. Results are summarized in Figure 1, and Table 2 presents the conditions frequencies per category.   As shown in Figure 1, most participants associated excessive sugar intake with conditions that constitute risk factors for cardiovascular diseases. Other health conditions categories (although much less pervasive) were cardiovascular diseases, oral health problems, oncological diseases, and mental-health conditions.
Within risk factors for cardiovascular diseases, diabetes and obesity/overweight were widespread associations (56.1 and 32.3% of the total number of responses). Indeed, these health conditions were mentioned by 72.0 and 41.5% of the total sample, respectively. Cardiovascular diseases were primarily described in general terms (e.g., "heart conditions"). For the oral-health category, the most frequent associations were cavities. In the case of oncological diseases, most responses were specifically "cancer". The mental-health category was more heterogeneous and included responses such as depression, anxiety, or fatigue. Noteworthy, the remaining responses (i.e., categories 6 to 13) were mentioned by very few participants (less than 1% of the total sample) and included diseases associated with diverse systems/organs (e.g., gastrointestinal, dermatologic, ophthalmic, etc.). Nutrients 2022, 14, x FOR PEER REVIEW 7 Note: n refers to the frequency of health conditions (total = 1812). %P refers to the percenta participants (N = 1010) that mentioned a given health condition.

Excessive Sugar Intake and Health Conditions: Ratings of Strength of Association
Within risk factors for cardiovascular diseases, diabetes and obesity/overw were widespread associations (56.1 and 32.3% of the total number of responses). In these health conditions were mentioned by 72.0 and 41.5% of the total sample, re tively. Cardiovascular diseases were primarily described in general terms (e.g., " conditions"). For the oral-health category, the most frequent associations were caviti the case of oncological diseases, most responses were specifically "cancer". The me health category was more heterogeneous and included responses such as depression iety, or fatigue. Noteworthy, the remaining responses (i.e., categories 6 to 13) were tioned by very few participants (less than 1% of the total sample) and included dis associated with diverse systems/organs (e.g., gastrointestinal, dermatologic, ophtha etc.).  We also explored if the perceived association between excessive sugar intake each health condition varied according to individual characteristics (see Table 3). Wo We also explored if the perceived association between excessive sugar intake and each health condition varied according to individual characteristics (see Table 3). Women  Note. 1 Based on the description of their occupation and study area, we categorized participants according to their expertise in the health and nutrition domains. Experts include doctors, nurses, nutritionists, and pharmacists (n = 105; 13.2% of the total sample). The remaining participants with a higher education degree (n = 690) were from diverse study areas (e.g., psychology, marketing, and journalism). The p refers to the significance level of the difference test according to each individual characteristic (i.e., independent samples t-tests for gender, presence of children in the household, and expertise in health and nutrition).

Excessive Sugar Intake and Health Conditions: Ratings of Strength of Association
In contrast, we did not observe differences in the ratings for any of the health conditions according to BMI level (i.e., normal weight vs. overweight), all p > 0.203, or education level (i.e., with vs. without higher education), all p > 0.111, except for kidney disease, such that participants with higher education (M = 4.48; SD = 1.64) perceived a stronger association between this condition and excessive sugar intake than participants without higher education (M = 4.20; SD = 1.83), t(1008) = 2.20, p = 0.028.

Correlations
As shown in Table 4, participants who perceived the health conditions as more associated with sugar intake also reported higher intention to reduce sugar intake, to attend to information about sugar more frequently, and to perceive more health benefits from reducing their sugar intake, as well as considering more critically the reduction of sugar intake in Portugal, all p < 0.001. Importantly, higher associations with health conditions were also negatively associated with the frequency of sugar intake, p = 0.006. Still, these associations were very weak in magnitude. Table 4. Descriptive results (M and SD) and correlations between the overall association ratings with the variables related to the perception and behavior toward sugar and participants' reported lifestyle. Note. *** p < 0.001, ** p < 0.010, and * p < 0.050. a Average of the association between excessive sugar intake and the set of eight health conditions.

Discussion
The primary goal of this study was to examine the health conditions that participants associated with excessive sugar intake. We achieved this by asking participants to describe all health conditions they associated with excessive sugar intake and rate this association's strength for eight conditions. We also explored whether individual characteristics determined these association ratings.
Overall, we observed that most participants reported at least one health condition associated with excessive sugar intake. The most frequent association was related to risk factors for cardiovascular diseases, such as diabetes and overweight/obesity, followed by actual cardiovascular diseases. Although much less prevalent than these two categories, participants also mentioned the association with cavities, cancer, and conditions related to mental health. The remaining responses were relatively infrequent but allowed us to characterize the spectrum of associations to excessive sugar intake. For instance, participants mentioned conditions affecting specific organs (e.g., the skin, eyes, bones, joints, etc.) and general adverse health outcomes (e.g., sugar as contributing to inflammatory processes or a weakened immune system). We also chose to include examples of the terms or expressions mentioned by participants that may not correspond to the medical designations (e.g., "heart attack" used as equivalent to "myocardial infarction"). This may provide important cues to health professionals about how to communicate about specific conditions with their patients. According to a recent study [39], the use of technical terminology, medical vernacular, acronyms, and abbreviations is still common in certain clinical contexts. To empower patients to manage their conditions, doctors are advised to consider their patients' level of health literacy when communicating, using lay terms, and avoiding the use of medical jargon whenever possible [40].
The results of the open-ended question are in line with those of the rating task, in which diabetes, overweight/obesity, and oral-health problems emerged as the health conditions more strongly associated with excessive sugar intake. Kidney disease was the health problem that was least associated with sugar consumption in the assessment task. However, some studies show that (added) sugar consumption is related to kidney damage [41].
It is noteworthy that, in contrast to the results of the free-association task, oral-health problems were rated as strongly associated with sugar intake. This discrepancy may be related to the typical separation between medical and oral healthcare systems, being the latter less prioritized [42]. For instance, the consequences of oral health problems (e.g., cavities) are possibly downplayed compared to other diseases strongly associated with excessive sugar intake (e.g., diabetes). However, this problem cannot be undervalued. For instance, tooth decay has been described as the most common non-communicable disease in Europe. In addition to all the individual consequences of this problem (e.g., impact on nutrition, self-esteem, quality of life [43,44]), this represents a great economic cost [44].
As in Miller et al. [28], we also observed the impact of some individual characteristics in these ratings. For instance, women considered sugar intake to be more strongly associated with several health conditions than men did. Individuals with children in the household also rated the associations with cancer and hyperactivity as stronger than those without children. Finally, experts rated the associations with obesity, cancer, and kidney disease as stronger than non-experts. Noteworthy, the association between excessive sugar intake and hyperactivity does not seem to vary according to expertise in health or nutrition, even though this association is not scientifically substantiated [27,45]. This result reveals the need to clarify the association between sugar consumption and hyperactivity, both in the general population and health professionals. Finally, we did not observe differences in ratings according to participants' weight status (i.e., normal vs. overweight), and differences based on education level were limited to kidney disease.
Our results must be interpreted with caution, due to the characteristics of our sample. As in other studies conducted with volunteers in the health and nutrition domain [22,46], our sample included a higher proportion of women and individuals with higher education.
Another limitation of the current study concerns the rating task, which included a limited list of possible health conditions [29,30] related to excessive sugar intake. Participants may have inferred that the mere inclusion of the health conditions on the list of options signaled that they were indeed associated with excessive sugar consumption. For this reason, future studies could include a more comprehensive list of health conditions varying in their strength of association with excessive sugar intake, but also unrelated ones.

Conclusions
An important step in developing effective interventions to reduce sugar intake is acquiring an in-depth understanding of its consumption, including the underlying individual drivers, such as consumers' perceptions. By identifying the diseases that consumers mostly associated with excessive sugar consumption, this study can inform policymakers, educators, and health professionals. For example, interventions involving nutrition care provided by primary health professionals can promote healthy eating behaviors (for a systematic review, see [47]). Indeed, health professionals can be instrumental in sharing information and clarifying some misconceptions regarding the associations between excessive sugar intake and its adverse outcomes in health. Notably, a study with over 1500 physicians [48] showed that the majority reported counseling overweight/obese patients about the consequences of excessive SSBs. However, the most frequently addressed topic focused on the contribution of sugary beverages to weight gain, with its nutritional profile (e.g., sugar content) and a referral to an expert in nutrition being less commonly addressed. These results highlight that this approach may not be sufficient. Further studies should be directed to health professionals to understand their perceptions regarding the barriers and facilitators they face in promoting healthy eating habits in their patients. Moreover, alongside improving knowledge about the short-and long-term health consequences of excessive sugar, it is highly relevant to help individuals to identify which ingredients constitute sugar sources [33,34], how much sugar is harmful to health [28,31], and strategies to enhance comprehension and compliance with sugar-intake guidelines. It is also vital to disrupt potential optimistic bias [49] and promote individuals' awareness of their susceptibility to sugar consumption's health risks [50]. Finally, our results may also support the development of campaigns to raise awareness of the diverse health outcomes resulting from excessive sugar intake. As stated in an educational brochure about sugar-intake health risks (University of California-SugarScience.ucsf.edu), "Too much added sugar doesn't just make us fat. It can also make us sick".
Author Contributions: M.P., conceptualization, formal analysis, funding acquisition, methodology, writing-original draft, and writing-review and editing; M.S., data curation, formal analysis, writing-original draft, and writing-review and editing; M.V.G., conceptualization, funding ac-quisition, writing-original draft, and writing-review and editing; A.S., writing-original draft; A.T., data collection; D.L., methodology and writing-review and editing; D.A.S., data curation, and Formal analysis; D.L.R., methodology and writing-review and editing. All authors have read and agreed to the published version of the manuscript.
Funding: This research was financially supported by Project LISBOA-01-0145-FEDER-028008, cofunded by the Lisboa 2020 Program, Portugal 2020, and European Union through FEDER funds, and by national funds through the Foundation for Science and Technology. Part of this work was also funded by a grant awarded by Fundação para a Ciência e a Tecnologia to DLR (Reference: 2020.00523.CEECIND).

Institutional Review Board Statement:
The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Iscte-Instituto Universitário de Lisboa (approval #22/2019).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data that support the findings of this study are available from the corresponding author upon reasonable request.

Conflicts of Interest:
The authors declare no conflict of interest.