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Carbohydrate intake for adults and children: WHO guideline [Internet]. Geneva: World Health Organization; 2023.
Noncommunicable diseases (NCDs) are the world’s leading cause of death, responsible for an estimated 41 million of the 55 million deaths in 2019 (1). Nearly half of these deaths were premature (i.e. in people aged less than 70 years) and occurred in low- and middle-income countries (LMICs). Obesity is a risk factor for diet-related NCDs and is linked to millions of deaths globally (2, 3). In 2016, more than 1.9 billion adults aged 18 years and older were overweight (4) and, of these, more than 600 million were obese. The spotlight on prevention and management of NCDs and obesity has intensified recently as a result of the COVID-19 pandemic, as there is increasing recognition that those with obesity or certain NCDs are at increased risk of adverse outcomes associated with COVID-19 (5–9). Modifiable risk factors such as unhealthy diets, physical inactivity, tobacco use and harmful use of alcohol are major risk factors for NCDs and obesity. The quality of carbohydrates in the diet has been extensively explored as a potential modulator of NCD and obesity risk.
Carbohydrates are found in a wide variety of primarily plant-based foods and are the principal source of energy (i.e. calories) in the diets of many people. Metabolism of carbohydrates produces glucose, which is the primary source of metabolic “fuel” for the brain, and other organs and tissues of the body. Carbohydrates can be grouped in many different ways and referred to using a variety of terms. At the most basic level, carbohydrates comprise monosaccharide building blocks and can be categorized based on the degree of polymerization (i.e. number of connected monosaccharides) as either sugars (mono- and disaccharides), oligosaccharides (short-chain carbohydrates) or polysaccharides (i.e. starch) (10).
The concept of carbohydrate “quality” refers to the nature and composition of carbohydrates in a food or in the diet, including the proportion of sugars, how quickly polysaccharides are metabolized and release glucose into the body (i.e. digestibility), and the amount of dietary fibre (11–13). Carbohydrates that are slowly digested in the small intestine or pass through undigested are generally considered “high quality“, and rapidly digested carbohydrates such as sugars are considered “low quality“. Dietary fibre, in particular, is an important element of carbohydrate quality. It can be defined in various ways, although virtually all definitions share the concept that dietary fibre is resistant to digestion by enzymes in the small intestine of humans (10). 1 Consumption of low-quality carbohydrates is often associated with poor overall dietary quality and may have a negative health impact, whereas consumption of high-quality carbohydrates is often associated with high overall dietary quality and has been shown to have a positive health impact (14). A high intake of free sugars, for example, is associated with increased risk of obesity and diet-related NCDs. Consequently, the World Health Organization (WHO) has previously issued guidance on limiting intake of free sugars (15). Conversely, high intakes of dietary fibre and consumption of foods generally containing high-quality carbohydrates – such as whole grains, fruits, vegetables and pulses – have been shown to broadly improve health (16–20).
The inclusion of dietary fibre and high-quality carbohydrates in the diet from whole grains, vegetables, fruits and pulses has long been recommended to improve and maintain cardiometabolic and overall health. Although current intakes of these nutrients and foods are highly variable across and within populations in different settings, they are generally low at the global level relative to recommended intakes in this guideline, and other national reference values (21–28). Low vegetable and fruit intake in LMICs is of particular concern: recent estimates suggest that less than 20–30% of individuals in many LMICs meet WHO recommendations for vegetable and fruit consumption (29, 30).
Following the work of the 1989 WHO Study Group on Diet, Nutrition and the Prevention of Chronic Diseases (31), the 2002 Joint WHO/Food and Agriculture Organization of the United Nations (FAO) Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases updated guidance on carbohydrate intake as part of the guidance on population nutrient intake goals for the prevention of NCDs (32). WHO guidance on free sugars intake was further updated and released in 2014 (15). The guidance on carbohydrate intake from the 2002 Joint WHO/FAO Expert Consultation includes a statement that dietary fibre should come from foods; however, the evidence available at the time was insufficient to support a recommended level of dietary fibre intake. Since the guidance was released, new evidence has become available that was expected to facilitate the setting of quantitative recommendations on dietary fibre, and offer an opportunity to re-evaluate the recommended level of vegetable and fruit consumption. In addition, the available evidence was expected to facilitate the development of guidance on carbohydrate quality. Therefore, it was considered important to review the evidence in a systematic manner, and update the WHO guidance on carbohydrate intake through the WHO guideline development process.
This guideline is part of the larger effort to update the population nutrient intake goals for the prevention of NCDs established by the 2002 Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases (32). It is intended to complement other WHO guidance on healthy diets, particularly the WHO guideline on free sugars intake (15). The recommendations in this guideline are intended for the general population of adults and children. Setting a recommended level of carbohydrate intake (i.e. the amount of carbohydrate that should be consumed as a percentage of overall energy intake) was not included in the updating of the guidance on carbohydrate intake because the amount of carbohydrate, as determined by the 2002 Joint WHO/FAO Expert Consultation, was based on the percentage of energy intake remaining after accounting for empirically determined total fat and protein intakes (32). The guidance in this guideline replaces previous WHO guidance on carbohydrate intake, including that from the 1989 WHO Study Group on Diet, Nutrition and the Prevention of Chronic Diseases (31) and the 2002 Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases (32).
The objective of this guideline is to provide evidence-informed guidance on carbohydrate intake. 2 The recommendations in this guideline can be used by policy-makers and programme managers to address various aspects of carbohydrate intake in their populations through a range of policy actions and public health interventions.
Updating the WHO recommendations on carbohydrate intake is an important element of WHO’s efforts to implement the NCD agenda and achieve the “triple billion” targets set by the 13th General Programme of Work (2019–2023), including 1 billion more people enjoying better health and well-being. In addition, the recommendations and other elements of this guideline will support: ▶
implementation of the political declarations of the United Nations (UN) high-level meetings on the prevention and control of NCDs held in New York in September 2011 and 2018, and the outcome document of the high-level meeting of the UN General Assembly on NCDs (A/RES/68/300) held in New York in July 2014;
implementation of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2030, which was adopted by the 66th World Health Assembly held in May 2013 (the timeline was extended to 2030 at the 72nd World Health Assembly held in May 2019);
implementation of the recommendations of the high-level Commission on Ending Childhood Obesity established by the WHO Director-General in May 2014;
Member States in implementing the commitments of the Rome Declaration on Nutrition and recommended actions in the Framework for Action, including a set of policy options and strategies to promote diversified, safe and healthy diets at all stages of life – these were adopted by the Second International Conference on Nutrition (ICN2) in 2014 and endorsed by the 136th Session of the WHO Executive Board held in January 2015 and the 68th World Health Assembly held in May 2015, which called on Member States to implement the commitments of the Rome Declaration across multiple sectors;
achievement of the goals of the UN Decade of Action on Nutrition (2016–2025), declared by the UN General Assembly in April 2016, which include increased action at the national, regional and global levels to achieve the commitments of the Rome Declaration, through implementing policy options included in the Framework for Action and evidence-informed programme actions; and
the 2030 Agenda on Sustainable Development and achieving the Sustainable Development Goals, particularly Goal 2 (Zero hunger) and Goal 3 (Good health and well-being).
This guideline is intended for a wide audience involved in the development, design and implementation of policies and programmes in nutrition and public health. The end users for this guideline are thus: ▶
policy-makers at the national, local and other levels;
managers and implementers of programmes relating to nutrition and NCD prevention;
nongovernmental and other organizations, including professional societies, involved in managing and implementing programmes relating to nutrition and NCD prevention;
health professionals in all settings;
scientists and others involved in nutrition and NCD-related research;
educators teaching nutrition and prevention of NCDs at all levels; and
representatives of the food industry and related associations.
Information on sources of dietary fibre for the purposes of this guideline can be found in the section Recommendations and supporting information.
One of the original aims of updating the guidance on carbohydrate intake was to provide guidance on carbohydrate quality. Having considered the available evidence relating to food sources of carbohydrate and dietary fibre, starch digestibility and glycaemic response, as measured by glycaemic index and glycaemic load, the WHO Nutrition Guidance Expert Advisory Group Subgroup on Diet and Health concluded that providing guidance on dietary fibre and food sources of carbohydrate with proven benefit in terms of important health outcomes was the most effective means of addressing carbohydrate quality.
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