Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct

A multilevel life course perspective on type 2 diabetes

The prevalence of type 2 diabetes has increased over the past 3 decades, particularly among adolescents as obesity also increases in this age group. Given the long-term effects associated with type 2 diabetes, public health intervention is needed. However, simply advising a patient to lose weight and increase physical exercise ignores the complex interplay of many levels of influences throughout a patient's life. This article describes type 2 diabetes from a multilevel life course perspective that can help clinicians find areas of possible intervention and understand the challenges patients face.

Non-nutritive Sweeteners and Glycaemic Control

PURPOSE OF REVIEW

The consumption of foods and beverages containing non-nutritive sweeteners (NNS) has increased worldwide over the last three decades. Consumers' choice of NNS rather than sugar or other nutritive sweeteners may be attributable to their potential to reduce weight gain.

RECENT FINDINGS

It is not clear what the effects of NNS consumption are on glycaemic control and the incidence of type 2 diabetes. This review aims to examine this question in epidemiological, human intervention and animal studies. It is not clear that NNS consumption has an effect on the incidence of type 2 diabetes or on glycaemic control even though there is some evidence for the modification of the microbiome and for interaction with sweet taste receptors in the oral cavity and the intestines' modification of secretion of glucagon-like peptide-1 (GLP-1), peptide YY (PYY), ghrelin and glucose-dependent insulinotropic polypeptide (GIP), which may affect glycaemia following consumption of NNS. In conclusion, long-term studies of NNS consumption are required to draw a firm conclusion about the role of NNS consumption on glycaemic control.

Type 2 diabetes and pre-diabetes mellitus: a systematic review and meta-analysis of prevalence studies in women of childbearing age in the Middle East and North Africa, 2000-2018

BACKGROUND

Investing in women's health is an inevitable investment in our future. We systematically reviewed the available evidence and summarized the weighted prevalence of type 2 diabetes (T2DM) and pre-diabetes mellitus (pre-DM) in women of childbearing age (15-49 years) in the Middle East and North African (MENA) region.

METHODS

We comprehensively searched six electronic databases to retrieve published literature and prevalence studies on T2DM and pre-DM in women of childbearing age in the MENA. Retrieved citations were screened and data were extracted by at least two independent reviewers. Weighted T2DM and pre-DM prevalence was estimated using the random-effects model.

RESULTS

Of the 10,010 screened citations, 48 research reports were eligible. Respectively, 46 and 24 research reports on T2DM and pre-DM prevalence estimates, from 14 and 10 countries, were included. Overall, the weighted T2DM and pre-DM prevalence in 14 and 10 MENA countries, respectively, were 7.5% (95% confidence interval [CI], 6.1-9.0) and 7.6% (95% CI, 5.2-10.4). In women sampled from general populations, T2DM prevalence ranged from 0.0 to 35.2% (pooled, 7.7%; 95% CI, 6.1-9.4%) and pre-DM prevalence ranged from 0.0 to 40.0% (pooled, 7.9%; 95% CI, 5.3-11.0%). T2DM was more common in the Fertile Crescent countries (10.7%, 95% CI, 5.2-17.7%), followed by the Arab Peninsula countries (7.6%, 95% CI, 5.9-9.5%) and North African countries and Iran (6.5%, 95% CI, 4.3-9.1%). Pre-DM prevalence was highest in the Fertile Crescent countries (22.7%, 95% CI, 14.2-32.4%), followed by the Arab Peninsula countries (8.6%, 95% CI, 5.5-12.1%) and North Africa and Iran (3.3%, 95% CI, 1.0-6.7%).

CONCLUSIONS

T2DM and pre-DM are common in women of childbearing age in MENA countries. The high DM burden in this vital population group could lead to adverse pregnancy outcomes and acceleration of the intergenerational risk of DM. Our review presented data and highlighted gaps in the evidence of the DM burden in women of childbearing age, to inform policy-makers and researchers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017069231.

Estimated Substitution of Tea or Coffee for Sugar-Sweetened Beverages Was Associated with Lower Type 2 Diabetes Incidence in Case-Cohort Analysis across 8 European Countries in the EPIC-InterAct Study

INTRODUCTION

Beverage consumption is a modifiable risk factor for type 2 diabetes (T2D), but there is insufficient evidence to inform the suitability of substituting 1 type of beverage for another.

OBJECTIVE

The aim of this study was to estimate the risk of T2D when consumption of sugar-sweetened beverages (SSBs) was replaced with consumption of fruit juice, milk, coffee, or tea.

METHODS

In the European Prospective Investigation into Cancer and Nutrition (EPIC)-InterAct case-cohort study of 8 European countries (n = 27,662, with 12,333 cases of incident T2D, 1992-2007), beverage consumption was estimated at baseline by dietary questionnaires. Using Prentice-weighted Cox regression adjusting for other beverages and potential confounders, we estimated associations of substituting 1 type of beverage for another on incident T2D.

RESULTS

Mean ± SD of estimated consumption of SSB was 55 ± 105 g/d. Means ± SDs for the other beverages were as follows: fruit juice, 59 ± 101 g/d; milk, 209 ± 203 g/d; coffee, 381 ± 372 g/d; and tea, 152 ± 282 g/d. Substituting coffee for SSBs by 250 g/d was associated with a 21% lower incidence of T2D (95% CI: 12%, 29%). The rate difference was -12.0 (95% CI: -20.0, -5.0) per 10,000 person-years among adults consuming SSBs ≥250 g/d (absolute rate = 48.3/10,000). Substituting tea for SSBs was estimated to lower T2D incidence by 22% (95% CI: 15%, 28%) or -11.0 (95% CI: -20.0, -2.6) per 10,000 person-years, whereas substituting fruit juice or milk was estimated not to alter T2D risk significantly.

CONCLUSIONS

These findings indicate a potential benefit of substituting coffee or tea for SSBs for the primary prevention of T2D and may help formulate public health recommendations on beverage consumption in different populations.

Corporations' use and misuse of evidence to influence health policy: a case study of sugar-sweetened beverage taxation

Background

Sugar sweetened beverages (SSB) are a major source of sugar in the diet. Although trends in consumption vary across regions, in many countries, particularly LMICs, their consumption continues to increase. In response, a growing number of governments have introduced a tax on SSBs. SSB manufacturers have opposed such taxes, disputing the role that SSBs play in diet-related diseases and the effectiveness of SSB taxation, and alleging major economic impacts. Given the importance of evidence to effective regulation of products harmful to human health, we scrutinised industry submissions to the South African government’s consultation on a proposed SSB tax and examined their use of evidence.

Results

Corporate submissions were underpinned by several strategies involving the misrepresentation of evidence. First, references were used in a misleading way, providing false support for key claims. Second, raw data, which represented a pliable, alternative evidence base to peer reviewed studies, was misused to dispute both the premise of targeting sugar for special attention and the impact of SSB taxes on SSB consumption. Third, purposively selected evidence was used in conjunction with other techniques, such as selective quoting from studies and omitting important qualifying information, to promote an alternative evidential narrative to that supported by the weight of peer-reviewed research. Fourth, a range of mutually enforcing techniques that inflated the effects of SSB taxation on jobs, public revenue generation, and gross domestic product, was used to exaggerate the economic impact of the tax. This “hyperbolic accounting” included rounding up figures in original sources, double counting, and skipping steps in economic modelling.

Conclusions

Our research raises fundamental questions concerning the bona fides of industry information in the context of government efforts to combat diet-related diseases. The beverage industry’s claims against SSB taxation rest on a complex interplay of techniques, that appear to be grounded in evidence, but which do not observe widely accepted approaches to the use of either scientific or economic evidence. These techniques are similar, but not identical, to those used by tobacco companies and highlight the problems of introducing evidence-based policies aimed at managing the market environment for unhealthful commodities.

Electronic supplementary material

The online version of this article (10.1186/s12992-019-0495-5) contains supplementary material, which is available to authorized users.

Labelling changes in response to a tax on sugar-sweetened beverages, United Kingdom of Great Britain and Northern Ireland

Objective

To evaluate the changes in sugar and energy labelling of carbonated sugar-sweetened soft drinks after the implementation of a tax on sugar-sweetened drinks in the United Kingdom of Great Britain and Northern Ireland.

Methods

We visited nine main supermarkets before (May 2014) and after (April 2018) the tax came into effect and obtained data from product packaging and nutrition information panels of carbonated sugar-sweetened soft drinks. We used the paired t-test to assess differences in sugar and energy content of the same products between 2014 and 2018.

Findings

We obtained data from 166 products in 2014 and 464 products in 2018, of which 83 products were the same in both years. Large variations in stated sugar content were found between the different carbonated sugar-sweetened soft drinks in both 2014 and 2018 for all products and for the 83 products. The mean sugar content of the 83 products decreased by 42% between 2014 and 2018, from 9.1 g/100 mL (standard deviation, SD: 3.3) to 5.3 g/100 mL (SD: 3.5; P < 0.001). The mean energy content decreased by 40%, from 38 kcal/100 mL (SD: 13) in 2014 to 23 kcal/100 mL (SD: 15) in 2018 (P < 0.001).

Conclusion

The significant decreases in the labelling of sugar and energy content of carbonated sugar-sweetened soft drinks after the levy came into effect suggest this tax has been effective. The sugar content of drinks still varied considerably in 2018, suggesting further reductions in sugar content of these drinks is possible. The levy thresholds should be reduced and the tax increased to drive further reformulation of soft drinks to reduce their sugar content.

Consumption of Raw Orange, 100% Fresh Orange Juice, and Nectar- Sweetened Orange Juice-Effects on Blood Glucose and Insulin Levels on Healthy Subjects

Objective: The aim of this study is to investigate the effect of consumption of raw orange (RO), 100% fresh orange juice (FOJ), and nectar-sweetened orange juice (NSOJ) on postprandial glucose and insulin levels in non-diabetic young Emirati women. Research Methods: This is a prospective, three-way, crossover study design. Blood records of thirteen normal weight and seven healthy obese university students were analyzed from Zayed University on three random days with the following three meal samples: 2 ROs, 100% FOJ, and NSOJ. Venous blood was collected at 0, 30, 60, 90, and 120 minutes after the respective meal consumption. Statistical analyses included repeated measures analysis of variance and calculations of the area under the glucose and insulin curves (AUC) for each one of the meal samples. Results: Total fasting glucose and insulin levels did not differ by treatment in the normal versus obese group. All three meals had no significant effects on the plasma glucose levels. However, there was a significant change in plasma insulin concentrations at 120 min compared with that at 0 min for RO: −14 (−27.05, −0.90, P < 0.001); 100% FOJ −13.7 (−28.80, 1.44, P < 0.001); and NSOJ: −9.2 (−28.75, 10.30, P < 0.001). Conclusions: This study shows that whole fresh fruit, 100% fruit juice, and sweetened fruit juice did not have a significant effect on the blood glucose levels in non-diabetic Emirati university students. However, a significant decrease in insulin response and HOMA-IR on all three sample meals was observed.

Association of artificially sweetened and sugar-sweetened soft drinks with β-cell function, insulin sensitivity, and type 2 diabetes: the Maastricht Study

Purpose

Artificially sweetened and sugar-sweetened beverage consumptions have both been reported to be associated with type 2 diabetes mellitus (T2D) risk. The aim of the current study was to investigate the potential underlying associations with dynamic pancreatic β-cell function (BCF) and insulin sensitivity.

Methods

We evaluated cross-sectional associations in 2240 individuals (mean ± SD age 59.6 ± 8.18, 49.4% male, 21.9% T2D) participating in a diabetes-enriched population-based cohort. Artificially sweetened and sugar-sweetened soft drinks and juice consumption were assessed by a food-frequency questionnaire. Glucose metabolism status, insulin sensitivity, and BCF were measured by a seven-point oral glucose tolerance test. Regression analyses were performed to assess associations of artificially and sugar-sweetened beverage consumption with measures of glucose homeostasis. Associations were adjusted for potential confounders, and additionally with and without total energy intake and BMI, as these variables could be mediators.

Results

Moderate consumption of artificially sweetened soft drink was associated with lower β-cell glucose sensitivity [standardized beta (95% CI), − 0.06 (− 0.11, − 0.02)], total insulin secretion [β − 0.06 (− 0.10, − 0.02)], and with lower β-cell rate sensitivity [odds ratio (95% CI), 1.29 (1.03, 1.62)] compared to abstainers. Daily artificially sweetened soft drink consumption was associated with lower β-cell glucose sensitivity [β − 0.05 (− 0.09, 0.00)], and total insulin secretion [β − 0.05 − 0.09, − 0.01)] compared to abstainers.

Conclusions

Moderate and daily consumption of artificially sweetened soft drinks was associated with lower BCF, but not with insulin sensitivity. No evidence was found for associations of sugar-sweetened soft drink and juice consumption with BCF or insulin sensitivity in this middle-aged population. Prospective studies are warranted to further investigate the associations of artificially and sugar-sweetened beverage consumption with non-fasting insulin sensitivity and multiple BCF aspects.

Electronic supplementary material

The online version of this article (10.1007/s00394-019-02026-0) contains supplementary material, which is available to authorized users.

Non-nutritive sweeteners and type 2 diabetes: Should we ring the bell?

Non-nutritive sweeteners (NNS) were thought to be healthy sugar substitutes used instead of sugar for caloric and glycemic control but evidences blaming them for contributing to type 2 diabetes (T2D) are rising. We aim to investigate whether NNS consumption prevents or causes T2D. Articles of all designs conducted on humans were retrieved from three databases in addition to manually reviewed articles. The literature is highly heterogeneous, and conclusions vary with different studies' types and designs. While some studies highlighted the neutral effect of NNS on T2D or reported inconclusive evidences to make their conclusion, others either found NNS culprit for increasing the risk for T2D or reported their protective effect against it. Those results were changing after adjustment for confounders. Due to the inconsistency in the literature, well-designed studies that take into consideration all types of confounders are needed. RESEARCH IN CONTEXT: Evidence before this study: The epidemic of obesity is the result of many factors and causes several chronic diseases where its association with type 2 diabetes is well established. The first line of treatment for obesity is lifestyle changes including physical activity and dietary intervention where non-nutritive sweeteners have received a high attention; those were thought to be healthy sugar substitutes used instead of sugar for caloric and glycemic control but several evidences have blamed them for having a role in the development of type 2 diabetes. In our paper, we aim to investigate whether non-nutritive sweeteners consumption prevents or causes type 2 diabetes. To respond to this question, an extensive search of the literature was conducted between October and December 2018 using the key terms "non-nutritive sweeteners", "artificial sweeteners", "high-intensity sweeteners", "type 2 diabetes" and "prediabetes" on three databases including Pubmed, Science direct and Scopus. Additional search for relevant articles was carried out manually from the reference list of selected articles. Animal studies, studies involving sugar alcohols or those conducted on children, adolescents, pregnant women, or on participants with diabetes were excluded. Human studies conducted from January 2004 to October 2018 were included and divided into observational, interventional, and systematic review and meta-analysis for discussion and analysis Added value of this study: In the literature, the term high-intensity sweeteners has been used interchangeably with non-nutritive sweeteners, artificial sweeteners or low-calorie sweeteners but few articles, if any, clarified the difference between them. In our review, we gathered the different definitions and classifications and summarized them to help the reader understand the difference. Since artificial sweeteners are nowadays widely used and prescribed for caloric and glycemic control, and are unintentionally consumed because they enter in the manufacturing process of thousands of products and due to their potential side effects reported in several studies, we found it interesting to gather, summarize and discuss the available results assessing the role of non-nutritive sweeteners in the development of type 2 diabetes. Those results showed the heterogeneity of the literature and the difficulty in having a firm conclusion; this helps researchers to profit from our study and to conduct well-designed studies leading to firm conclusions and recommendations. Implications of all the available evidence: Despite the absence of strong conclusion that confirms the fact that non-nutritive sweeteners consumption increases the risk for diabetes, no firm conclusion rejects this statement. In result, the existing evidences in addition to our study should ring the bell for clinicians and practitioners who are prescribing those sugar-alternatives as "healthy substitute" to white sugar. Moreover, this encourages the manufacturers to search for a healthy natural alternative to artificial sweeteners to be used in the manufacturing process.

Cumulative intake of artificially sweetened and sugar-sweetened beverages and risk of incident type 2 diabetes in young adults: the Coronary Artery Risk Development In Young Adults (CARDIA) Study

BACKGROUND

Epidemiological evidence has demonstrated a positive association between artificially sweetened beverage (ASB) and sugar-sweetened beverage (SSB) consumption and type 2 diabetes (T2D) risk. However, research informing this topic in young adults is limited.

OBJECTIVE

This study examined the association between ASB, SSB, and total sweetened beverage (TSB; combined ASB and SSB) consumption and T2D risk in young adults.

METHODS

A prospective analysis of 4719 Black and White men and women aged 18-30 y at baseline was conducted from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Each participant's beverage intake was assessed using the CARDIA Diet History at baseline and at study Years 7 and 20. Multivariable Cox proportional hazards regression models were used to examine cumulative average ASB, SSB, and TSB intakes and risk of T2D.

RESULTS

During the 30-y follow-up period, 680 participants developed T2D. ASB consumption was associated with a 12% greater risk of T2D per serving/day (HR 1.12, 95% CI 1.04-1.20) in a model adjusted for lifestyle factors, diet quality, and dieting behavior. Further adjustments for baseline BMI (HR 1.07, 95% CI 0.99-1.14) and weight change during follow-up (HR 1.04, 95% CI 0.97-1.12) attenuated the association. SSB and TSB consumption as continuous variables per 1 serving/day of intake were associated with 6% and 5% increased risks of T2D, respectively (HRSSB 1.06, 95% CI 1.01-1.10; HRTSB 1.05, 95% CI 1.01-1.09), in the model accounting for lifestyle factors, dieting behavior, baseline BMI, and weight change. Results were consistent when the exposures were modeled in categories of consumption and quintiles.

CONCLUSIONS

In young adults, long-term ASB, SSB, and TSB consumption were associated with increased risks of T2D. However, the estimates for ASB were attenuated when accounting for weight changes.

Sugar-Sweetened Beverages and Cardiometabolic Health: An Update of the Evidence

Sugar-sweetened beverages (SSBs) have little nutritional value and a robust body of evidence has linked the intake of SSBs to weight gain and risk of type 2 diabetes (T2D), cardiovascular disease (CVD), and some cancers. Metabolic Syndrome (MetSyn) is a clustering of risk factors that precedes the development of T2D and CVD; however, evidence linking SSBs to MetSyn is not clear. To make informed recommendations about SSBs, new evidence needs to be considered against existing literature. This review provides an update on the evidence linking SSBs and cardiometabolic outcomes including MetSyn. Findings from prospective cohort studies support a strong positive association between SSBs and weight gain and risk of T2D and coronary heart disease (CHD), independent of adiposity. Associations with MetSyn are less consistent, and there appears to be a sex difference with stroke with greater risk in women. Findings from short-term trials on metabolic risk factors provide mechanistic support for associations with T2D and CHD. Conclusive evidence from cohort studies and trials on risk factors support an etiologic role of SSB in relation to weight gain and risk of T2D and CHD. Continued efforts to reduce intake of SSB should be encouraged to improve the cardiometabolic health of individuals and populations.

Cross-Sectional Survey of the Amount of Sugar and Energy in Chocolate Confectionery on Sold in the UK in 1992 and 2017

The study aimed to compare the sugar (1992, 2017) and energy (2017) content of chocolate confectionery available in the UK between 1992 and 2017 using cross-sectional surveys. All major UK retailers operating at the time were included. Sugar content in 1992 was obtained from a booklet and sugar and energy content from 2017 were collected from product packaging in-store. In 1992, the average sugar content of chocolate confectionery was 46.6 ± 10.3 g/100 g and in 2017 it was 47.3 ± 12.1 g/100 g. Sugar content ranged from 0.5 to 75.2 g/100g, with large variations between different categories of chocolate and within the same category of chocolate. There were 23 products found in both 1992 and 2017. The average sugar content per 100 g for these products was 44.6 ± 9.4 g in 1992 and 54.7 ± 6.3 g in 2017, representing a 23% increase in sugar content (p < 0.001). The results show that the sugar content of chocolate confectionery has increased since 1992, which is concerning. However, they also suggest sugar levels can be reduced because (a) lower sugar versions of the same products existed in 1992 and (b) there is a large variation in sugar and energy content between different categories of chocolate and within the same category in 2017.

Amelioration of nonalcoholic fatty liver disease by swertiamarin in fructose-fed mice

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease. Swertia bimaculata (Sieb. et Zucc.) Hook. Thoms.ex Clarke, a glabrous or procumbent perennial herb, is a traditional herb medicine. Swertiamarin, a secoiridoid glycoside, is a representative ingredient in this medical plant crude extract and shows antidiabetic and antihyperlipidaemic activities and protective effect against hepatic injury.

PURPOSE

The present study aimed to determine whether swertiamarin can attenuate NAFLD in fructose-fed mice.

METHODS

Healthy male mice freely drank water containing 10% fructose for 12 consecutive weeks, whereas animals in those swertiamarin tested groups received different doses of swertiamarin (25, 50 and 100 mg/kg) by intragastric administration once a day from the ninth week to the twelfth week.

RESULTS

At the end of the experiment, fructose-fed mice administrated with swertiamarin showed low levels of serum glucose, triglycerides, uric acid, alanine aminotransferase and aspartate transaminase. Histological examinations suggested the alleviation of hepatic ballooning degeneration and steatosis by swertiamarin treatment. Moreover, swertiamarin administration mitigated hepatic oxidative stress along with decreases of hepatic pro-inflammation cytokines, which was associated with decrease of hepatic xanthine oxidase (XO) activity and enhancements of anti-oxidant defense system enzymes, as well as activation of nuclear factor E2-related factor 2 (Nrf2) in fructose-fed mice. In addition, swertiamarin down-regulated expression of sterol-regulatory element-binding protein-1 (SREBP-1), fatty acid synthase (FAS) and acetyl-CoA carboxylase 1 (ACC1) in liver of fructose-fed mice.

CONCLUSION

The present study demonstrates that swertiamarin alleviates NAFLD and metabolic alterations in fructose-fed mice.

Generalizability of a Diabetes-Associated Country-Specific Exploratory Dietary Pattern Is Feasible Across European Populations

BACKGROUND

Population-specificity of exploratory dietary patterns limits their generalizability in investigations with type 2 diabetes incidence.

OBJECTIVE

The aim of this study was to derive country-specific exploratory dietary patterns, investigate their association with type 2 diabetes incidence, and replicate diabetes-associated dietary patterns in other countries.

METHODS

Dietary intake data were used, assessed by country-specific questionnaires at baseline of 11,183 incident diabetes cases and 14,694 subcohort members (mean age 52.9 y) from 8 countries, nested within the European Prospective Investigation into Cancer and Nutrition study (mean follow-up time 6.9 y). Exploratory dietary patterns were derived by principal component analysis. HRs for incident type 2 diabetes were calculated by Prentice-weighted Cox proportional hazard regression models. Diabetes-associated dietary patterns were simplified or replicated to be applicable in other countries. A meta-analysis across all countries evaluated the generalizability of the diabetes-association.

RESULTS

Two dietary patterns per country/UK-center, of which overall 3 dietary patterns were diabetes-associated, were identified. A risk-lowering French dietary pattern was not confirmed across other countries: pooled HRFrance per 1 SD: 1.00; 95% CI: 0.90, 1.10. Risk-increasing dietary patterns, derived in Spain and UK-Norfolk, were confirmed, but only the latter statistically significantly: HRSpain: 1.09; 95% CI: 0.97, 1.22 and HRUK-Norfolk: 1.12; 95% CI: 1.04, 1.20. Respectively, this dietary pattern was characterized by relatively high intakes of potatoes, processed meat, vegetable oils, sugar, cake and cookies, and tea.

CONCLUSIONS

Only few country/center-specific dietary patterns (3 of 18) were statistically significantly associated with diabetes incidence in this multicountry European study population. One pattern, whose association with diabetes was confirmed across other countries, showed overlaps in the food groups potatoes and processed meat with identified diabetes-associated dietary patterns from other studies. The study demonstrates that replication of associations of exploratory patterns with health outcomes is feasible and a necessary step to overcome population-specificity in associations from such analyses.

Modifying effect of metabotype on diet-diabetes associations

Purpose

Inter-individual metabolic differences may be a reason for previously inconsistent results in diet–diabetes associations. We aimed to investigate associations between dietary intake and diabetes for metabolically homogeneous subgroups (‘metabotypes’) in a large cross-sectional study.

Methods

We used data of 1517 adults aged 38–87 years from the German population-based KORA FF4 study (2013/2014). Dietary intake was estimated based on the combination of a food frequency questionnaire and multiple 24-h food lists. Glucose tolerance status was classified based on an oral glucose tolerance test in participants without a previous diabetes diagnosis using American Diabetes Association criteria. Logistic regression was applied to examine the associations between dietary intake and diabetes for two distinct metabotypes, which were identified based on 16 biochemical and anthropometric parameters.

Results

A low intake of fruits and a high intake of total meat, processed meat and sugar-sweetened beverages (SSB) were significantly associated with diabetes in the total study population. Stratified by metabotype, associations with diabetes remained significant for intake of total meat (OR 1.67, 95% CI 1.04–2.67) and processed meat (OR 2.23, 95% CI 1.24–4.04) in the metabotypes with rather favorable metabolic characteristics, and for intake of fruits (OR 0.83, 95% CI 0.68–0.99) and SSB (OR:1.21, 95% CI 1.09–1.35) in the more unfavorable metabotype. However, only the association between SSB intake and diabetes differed significantly by metabotype (p value for interaction = 0.01).

Conclusions

Our findings suggest an influence of metabolic characteristics on diet–diabetes associations, which may help to explain inconsistent previous results. The causality of the observed associations needs to be confirmed in prospective and intervention studies.

Electronic supplementary material

The online version of this article (10.1007/s00394-019-01988-5) contains supplementary material, which is available to authorized users.

Did high sugar-sweetened beverage purchasers respond differently to the excise tax on sugar-sweetened beverages in Mexico?

OBJECTIVE

To estimate changes in taxed and untaxed beverages by volume of beverage purchased after a sugar-sweetened beverage (SSB) tax was introduced in 2014 in Mexico.

DESIGN

We used household purchase data from January 2012 to December 2015. We first classified the sample into four groups based on pre-tax purchases of beverages: (i) higher purchases of taxed beverages and lower purchases of untaxed beverages (HTLU-unhealthier); (ii) higher purchases of both types of beverages (HTHU); (iii) lower purchases of taxed and untaxed beverages (LTLU); and (iv) lower purchases of taxed beverages and higher purchases of untaxed beverages (LTHU-healthier). Next, we estimated differences in purchases after the tax was implemented for each group compared with a counterfactual based on pre-tax trends using a fixed-effects model.

SETTING

Areas with more than 50 000 residents in Mexico.ParticipantsHouseholds (n 6089).

RESULTS

The HTLU-unhealthier and HTHU groups had the largest absolute and relative reductions in taxed beverages and increased their purchases of untaxed beverages. Households with lower purchases of untaxed beverages (HTLU-unhealthier and LTLU) had the largest absolute and relative increases in untaxed beverages. We also found that among households with higher purchases of taxed beverages, the group with lowest socio-economic status had the greatest reduction in purchases of taxed beverages.

CONCLUSIONS

Evidence associating the SSB tax with larger reductions among high purchasers of taxed beverages prior to the tax is relevant, as higher SSB purchasers have a greater risk of obesity, diabetes and other cardiometabolic outcomes.

Pathways and mechanisms linking dietary components to cardiometabolic disease: thinking beyond calories

Calories from any food have the potential to increase risk for obesity and cardiometabolic disease because all calories can directly contribute to positive energy balance and fat gain. However, various dietary components or patterns may promote obesity and cardiometabolic disease by additional mechanisms that are not mediated solely by caloric content. Researchers explored this topic at the 2017 CrossFit Foundation Academic Conference 'Diet and Cardiometabolic Health - Beyond Calories', and this paper summarizes the presentations and follow-up discussions. Regarding the health effects of dietary fat, sugar and non-nutritive sweeteners, it is concluded that food-specific saturated fatty acids and sugar-sweetened beverages promote cardiometabolic diseases by mechanisms that are additional to their contribution of calories to positive energy balance and that aspartame does not promote weight gain. The challenges involved in conducting and interpreting clinical nutritional research, which preclude more extensive conclusions, are detailed. Emerging research is presented exploring the possibility that responses to certain dietary components/patterns are influenced by the metabolic status, developmental period or genotype of the individual; by the responsiveness of brain regions associated with reward to food cues; or by the microbiome. More research regarding these potential 'beyond calories' mechanisms may lead to new strategies for attenuating the obesity crisis.

Excess Free Fructose Beverages and Allergy in Children and Adolescents: Results From NHANES 2005-2006

PURPOSE

Our purpose was to investigate the relationship between intake of excess free fructose beverages and allergy among children and adolescents.

METHODS

We analyzed data of 860 children (aged 6 to 12 years) and 1,142 adolescents (aged 13 to 19 years) from the National Health and Nutrition Examination Survey 2005-2006. Logistic regression analyses were performed to determine the associations between consumption of excess free fructose beverages and allergic symptoms or allergic sensitization.

RESULTS

The pattern of findings was not entirely consistent, but some analyses supported the hypothesis of an association between intake of excess free fructose beverages and allergy. After controlling for the potential confounders, children who consumed nondiet fruit drinks at least 5 times per week had a nearly 2.5-fold greater odds of allergic sensitization than did those who consumed such drinks only 1 to 3 times per month (OR = 2.446; 95% CI, 1.583-3.780). Adolescents who consumed excess free fructose beverages at least 5 times per week or 1 to 4 times per week had about fivefold greater odds of presence of allergic symptoms than did those who seldom consumed these beverages (OR = 5.164; 95% CI, 1.866-14.297 and OR = 4.112; 95% CI, 1.857-9.107, respectively). Adolescents who consumed apple juice at least 5 times per week had a twofold greater odds of presence of allergic sensitization than did the seldom consumers (OR = 2.215; 95% CI, 1.178-4.164).

CONCLUSIONS

These findings provide some support for the hypothesis of a link between intake of excess free fructose beverages and allergic symptoms or allergic sensitization in children and adolescents.

Western diet given to healthy rats mimics the human phenotype of diabetic cardiomyopathy

Diabetes mellitus (DM) is a major problem worldwide. Within this patient group, cardiovascular diseases are the biggest cause of morbidity and mortality. Diabetic cardiomyopathy (DCM) is defined as diabetes-associated structural and functional changes in the myocardium, not directly attributable to other confounding factors such as coronary artery disease or hypertension. Pathophysiology of DCM remains unclear due to a lack of adequate animal models reflecting the current pandemic of diabetes, associated with a high increased sugar intake and the 'Western' lifestyle. The aim of this study was to develop an animal model mimicking this 'Western' lifestyle causing a human-like phenotype of DCM. Twenty-four Sprague-Dawley rats were randomly assigned into a normal or a 'Western' diet group for 18 weeks. Glucose and insulin levels were measured with an OGTT. Heart function was assessed by echocardiography and hemodynamic measurements in vivo. Cardiac fibrosis and inflammation were investigated in vitro. 'Western' diet given to healthy rats for 18 weeks induced hyperglycemia together with increased AGEs levels, insulin levels and hypertriglyceridemia. Heart function was altered with increased end-diastolic pressure, left ventricle hypertrophy. Changes in vivo were associated with increased collagen deposition and increased PAI-1 levels in the heart. High-sugar diet or 'Western' diet causes T2DM and the hallmarks of DCM in rats, reflecting the phenotype of the disease seen in patients. Using this new model of T2DM with DCM might open new insight in understanding the pathophysiology of DCM and on a long term, test targeted therapies for T2DM with DCM patients.

Intakes and sources of dietary sugars and their association with metabolic and inflammatory markers

BACKGROUND & AIMS

Associations of dietary sugars with metabolic and inflammatory markers may vary according to the source of the sugars. The aim of this study was to examine the association of dietary sugars from different sources [beverages (liquids), foods (solids), extrinsic (free) or intrinsic (non-free)] with metabolic and inflammatory markers.

METHODS

Population-based cross-sectional study of adults in the East of England (n = 9678). Sugar intakes were estimated using food frequency questionnaires. Fasting glycated haemoglobin, glucose, insulin, and C-Reactive Protein (CRP) were measured and indices of metabolic risk were derived (homeostatic model of insulin resistance, HOMA-IR and metabolic risk z-score).

RESULTS

In multiple linear regression analyses adjusted for potential confounders including BMI and TEI, sugars from liquids were positively associated with ln-CRP [b-coefficient (95%CI), 0.14 (0.05,0.22) per 10%TEI] and metabolic risk z-score [0.13 (0.07,0.18)]. Free sugars were positively associated with ln-HOMA-IR [0.05 (0.03,0.08)] and metabolic risk z-score [0.09 (0.06,0.12)]. Sugars from solids were not associated with any outcome. Among major dietary contributors to intakes (g/d), sugars in fruit, vegetables, dairy products/egg dishes, cakes/biscuits/confectionary and squash/juice drinks were not associated, but sugar added to tea, coffee, cereal was significantly positively associated with all outcomes. Sugars in 100% juice [0.16 (0.06,0.25) per 10%TEI] and other non-alcoholic beverages [0.13 (0.03,0.23)] were positively associated with metabolic risk z-score.

CONCLUSION

Higher intakes of sugars from non-alcoholic beverages and sugar added to tea, coffee, cereal were associated with glycaemia and inflammatory markers. Sugars from solids were not associated, irrespective of whether they were intrinsic or extrinsic. Positive associations of free sugars were largely explained by contribution of beverages to intake.

Consumption of a Carbonated Beverage with High-Intensity Sweeteners Has No Effect on Insulin Sensitivity and Secretion in Nondiabetic Adults

Background

The effects of the regular intake of beverages containing high-intensity sweeteners on insulin sensitivity in healthy individuals remain controversial.

Objective

This trial compared the effects of the consumption of a carbonated beverage containing aspartame and acesulfame K (high-intensity sweeteners beverage-HISB) with those of an unsweetened, no-calorie carbonated beverage (UB) on insulin sensitivity and secretion in nondiabetic adults.

Methods

SEDULC was a randomized, double-blind, crossover study. Nondiabetic adults [mean age 31 y, 44% men, body mass index (BMI; kg/m²) 19-29] who did not consume high-intensity sweeteners were randomized 1:1 to drink 1 of the 2 carbonated beverages, 2 cans (330 mL each)/d, for 12 wk. After a 4-wk washout period, participants were switched to the opposite beverage for 12 wk. The primary outcome tested was the change in insulin sensitivity as assessed by the Matsuda Insulin Sensitivity Index (MISI) after an oral glucose load. Secondary outcomes were indexes of insulin secretion.

Results

Sixty individuals were enrolled and 50 completed the study (28 nonoverweight and 22 overweight participants). The change in MISI from baseline did not significantly differ between beverages and noninferiority was demonstrated (difference = -0.23; 95% CI: -1.31, 0.85; P < 0.0001). The change in insulinogenic (means ± SEMs: 0.23 ± 0.14 for HISB compared with 0.08 ± 0.1 for UB) and disposition indexes (2.70 ± 0.99 for HISB compared with 1.62 ± 0.90 for UB) did not differ, and no differences in insulin secretion estimates were confirmed by the Stumvoll indexes. Consuming the high-intensity sweeteners did not affect body weight, self-reported dietary consumption, or self-reported physical activity.

Conclusions

These findings suggest that the daily consumption of 2 cans of a beverage containing aspartame and acesulfame K over 12 wk has no significant effect on insulin sensitivity and secretion in nondiabetic adults. This trial was registered at clinicaltrials.gov as NCT02031497.

Cross-sectional survey of the amount of sugar and energy in cakes and biscuits on sale in the UK for the evaluation of the sugar-reduction programme

OBJECTIVES

To investigate the variation in sugar and energy content of cakes and biscuits available in the UK.

DESIGN

We carried out a cross-sectional survey in 2016 of 381 cakes and 481 biscuits available in nine main UK supermarkets.

METHODS

The sugar and energy content was collected from product packaging and nutrition labelling of cake and biscuit products.

RESULTS

The average sugar content in cakes and biscuits was 36.6±7.6 and 30.0±9.2 g/100 g, respectively. The mean energy content was 406±37 for cakes and 484±38 kcal/100 g for biscuits. There was a large variation in sugar and energy content between different cake and biscuit categories and within the same category. 97% of cakes and 74% of biscuits would receive a 'red' (high) label for sugar.

CONCLUSIONS

This research makes available baseline data of the cakes and biscuits market in the UK for future evaluation of the recently launched sugar-reduction programme. The study showed that reductions in sugar and energy content of cakes and biscuits are possible, since there was a large variation in sugar and energy content between different cake and biscuit categories and within the same category. A reduction in sugar and energy content, and overall cake and biscuit consumption, can help reduce overall sugar and energy intake in the UK and thus reduce the risk of obesity and dental caries.

Associations of artificially sweetened beverage intake with disease recurrence and mortality in stage III colon cancer: Results from CALGB 89803 (Alliance)

Purpose

Observational studies have demonstrated increased colon cancer recurrence and mortality in states of excess energy balance, as denoted by factors including sedentary lifestyle, diabetes, increased dietary glycemic load, and increased intake of sugar-sweetened beverages. Nonetheless, the relation between artificially sweetened beverages, a popular alternative for sugar-sweetened beverages, and colon cancer recurrence and survival is unknown.

Methods

We analyzed data from 1,018 patients with stage III colon cancer who prospectively reported dietary intake during and after chemotherapy while enrolled in a National Cancer Institute-sponsored trial of adjuvant chemotherapy. Using Cox proportional hazards regressions, we assessed associations of artificially sweetened beverage intake with cancer recurrence and mortality.

Results

Patients consuming one or more 12-ounce servings of artificially sweetened beverages per day experienced an adjusted hazard ratio for cancer recurrence or mortality of 0.54 (95% confidence interval, 0.36 to 0.80) when compared to those who largely abstained (P_trend = .004). Similarly, increasing artificially sweetened beverage intake was also associated with a significant improvement in both recurrence-free survival (P_trend = .005) and overall survival (P_trend = .02). Substitution models demonstrated that replacing a 12-ounce serving of a sugar-sweetened beverage with an isovolumetric serving of an artificially sweetened beverage per day was associated with a 23% lower risk of cancer recurrence and mortality (relative risk, 0.77; 95% confidence interval, 0.63 to 0.95; P = .02).

Conclusion

Higher artificially sweetened beverage consumption may be associated with significantly reduced cancer recurrence and death in patients with stage III colon cancer. This association may be mediated by substitution for sugar-sweetened alternatives. Further studies are needed to confirm these findings.

Prevalence of type 2 diabetes, prediabetes, and gestational diabetes mellitus in women of childbearing age in Middle East and North Africa, 2000-2017: protocol for two systematic reviews and meta-analyses

BACKGROUND

Diabetes mellitus (DM) in women of childbearing age may affect the fetus, thereby accelerating the intergenerational risk of DM. The Middle East and North Africa (MENA) region is experiencing a growing epidemic of DM. We aim to conduct two systematic reviews to summarize the burden of DM in women of childbearing age in the MENA region. In the systematic review 1, we aim to (1) systematically aggregate the evidence on type 2 DM (T2DM) and prediabetes and (2) to synthesize overall estimate on the prevalence of T2DM and overall estimate on the prevalence of prediabetes, in women of childbearing age (15-49 years). In the systematic review 2, we aim to (1) systematically aggregate the evidence on gestational DM (GDM) and (2) to synthesize overall estimate on the prevalence of GDM in pregnant women.

METHODS

For systematic reviews 1 and 2, we will conduct a comprehensive search of the literature published in six electronic databases (MEDLINE-PubMed, EMBASE, Web of Science, SCOPUS, Cochrane Library, and Academic Search Complete). Variant and broad search terms will be designed to identify epidemiologic studies on the prevalence of T2DM and prediabetes in women of childbearing age, and GDM in pregnant women, published between 2000 and 2017. The MENA region will be defined according to the World Bank Country and Lending Groups. Retrieved citations will be screened, and data from the eligible research reports against specific eligibility criteria will be extracted. The findings of each systematic review will be reported separately following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA).

DISCUSSION

Published literature on the prevalence of different types of DM among different population groups has been recently increased in the MENA region. This is the first review to fill an evidence gap on the overall burden, in the form of prevalence, of T2DM, prediabetes, and GDM in women of childbearing age in the MENA region. The findings of the two reviews will help in understanding the regional burden of these three types of DM in specific population groups to identify priority areas for interventions.

SYSTEMATIC REVIEW REGISTRATION

The PROSPERO registration number for the systematic review 1 is " CRD42017069231 " dated 12/06/2017 and for the systematic review 2 is " CRD42018100629 " dated 18/06/2018.

Sugar sweetened beverages and cardiometabolic health

PURPOSE OF REVIEW

It is widely accepted that sugar sweetened beverages (SSB) are implicated in weight gain and adverse cardiometabolic heath. To make informed recommendations about SSB, new evidence needs to be considered against existing literature. The present review will provide an update on the epidemiological and trial evidence linking intake of SSB to cardiometabolic outcomes.

RECENT FINDINGS

The weight of the evidence from prospective cohort studies supports a strong positive association between intake of SSB and weight gain and risk type 2 diabetes (T2D) and coronary heart disease (CHD) that is independent of adiposity. Associations with stroke are less clear and suggestive of greater risk in women than men. Findings from short-term trials of SSB and markers of cardiometabolic risk including lipids, glucose, blood pressure, and inflammatory cytokines provide mechanistic support for associations with T2D and CHD. Putative underlying mechanisms include adverse glycemic effects and increased hepatic metabolism of fructose.

SUMMARY

Conclusive evidence from epidemiological studies and trials on markers of cardiometabolic risk support an etiologic role of SSB in relation to weight gain and risk of T2D and CHD that is independent of weight. Continued efforts to reduce intake of SSB should be encouraged to improve the cardiometabolic health of individuals and populations.

Fluid intake of Latin American adults: results of four 2016 Liq.In7 national cross-sectional surveys

PURPOSE

To report total fluid intake (TFI) and the intake of different fluid types in adults (≥ 18 years old) from Mexico, Argentina, Brazil and Uruguay. To compare intakes between countries and with recommended adequate intake (AI) of water from fluids.

METHODS

Cross-sectional data were collected using a validated liquid intake 7-day record (Liq.In 7 ) in populations from Argentina (n = 1089), Brazil (n = 477), Mexico (n = 1677) and Uruguay (n = 554). Population characteristics, including age, gender, body mass index and socioeconomic level were recorded. Mean TFI was compared with the AI of water from fluids set by the USA Institute of Medicine.

RESULTS

The lowest TFI was recorded in Mexican women (1748 mL/day) and the highest in Argentinean men (2318 mL/day). Median daily TFI was significantly different between countries; Uruguay and Argentina had higher values than Mexico and Brazil. In the former, plain water contributed to only 25% of TFI, the remainder being predominantly from hot beverages. Approximately, a third of adults did not drink enough fluid to meet the recommended AI. High SSB consumption was reported, which was significantly different between countries (p < 0.05), the highest being in Mexico (median 25-75th percentiles): 531 (300-895 mL/day.

CONCLUSIONS

This survey highlights the need to increase water consumption and reduce SSB intake in this region to avoid potential associated health risks. These findings may be useful information in monitoring public health policy strategies.

Fluid intake in urban China: results of the 2016 Liq.In 7 national cross-sectional surveys

PURPOSE

To describe total fluid intake (TFI) and types of fluid consumed in urban China by age, gender, regions and city socioeconomic status relative to the adequate intakes (AI) set by the Chinese Nutrition Society.

METHODS

In 2016, participants aged 4-9, 10-17 and 18-55 years were recruited via a door-to-door approach in 27 cities in China. In total, 2233 participants were included. The volumes and sources of TFI were collected using the Liq.In 7 record, assisted by a photographic booklet of standard fluid containers.

RESULTS

The mean daily TFI among children, adolescents and adults were 966, 1177 and 1387 mL, respectively. In each age group, TFI was significantly higher in male vs female (981 vs 949, 1240 vs 1113, 1442 vs 1332; mL). Approximately 45, 36 and 28% of children, adolescents and adults reached the AI. Although plain water was the highest contributor to TFI, the contribution of sugar sweetened beverages (SSB) was ranked in the top three together with water and milk and derivatives. Approximately 27, 48 and 47% of children, adolescents and adults consumed more than one serving of SSB per day, respectively.

CONCLUSIONS

A relatively large proportion of participants did not drink enough to meet the AI in urban China. Many children, adolescents and adults consumed more than one serving of SSB per day. A majority of children, adolescents and adults in the study population do not meet both quantitative and qualitative fluid intake requirements, and signal socioeconomic disparities.

The science against sugar, alone, is insufficient in tackling the obesity and type 2 diabetes crises – We must also overcome opposition from vested interests

No abstract available.

Diet Soda and Sugar-Sweetened Soda Consumption in Relation to Incident Diabetes in the Northern Manhattan Study

BACKGROUND

Artificially (diet) and sugar-sweetened (regular) soda consumption have been associated with an increased risk of diabetes, but the literature on diet soda is inconsistent and the mechanisms unclear.

OBJECTIVE

We examined the relation between diet soda and regular soda consumption with the risk of incident diabetes in a longitudinal multiethnic population-based cohort.

METHODS

The study population included 2019 participants (mean ± SD age:  69 ± 10 y; 64% women; 23% white, 22% black, 53% Hispanic) in the Northern Manhattan Study who were free of diabetes and stroke at baseline. Soda consumption was assessed by a food-frequency questionnaire at baseline and examined continuously and categorically (<1/mo: sugar-sweetened = 908, diet = 1615; 1/mo-6/wk: sugar-sweetened = 830, diet = 298; daily: sugar-sweetened = 281, diet = 106). Weibull regression models were used to estimate the associations between soda consumption and incident diabetes, adjusting for demographics and vascular risk factors including body mass index (BMI) and calorie consumption.

RESULTS

During a mean ± SD follow-up of 11 ± 5 y, 368 participants developed diabetes. Sugar-sweetened soda was positively associated with incident diabetes (per soda per day HR = 1.15, 95% CI:  1.02, 1.31). The observed association between diet soda and elevated risk of diabetes was largely explained by BMI at the time of diet assessment, though the association remained strong and independent of BMI among those who were overweight or obese (daily compared to <1/mo: HR = 1.63, 95% CI:  1.04, 2.55).

CONCLUSIONS

This study supports the importance of sugar-sweetened beverage consumption in the diabetes epidemic. However, the results support previous studies suggesting that switching to artificially sweetened diet beverages may not lower the risk of diabetes, as diet soda consumption cannot be ruled out as an independent diabetes risk factor.

Soft drink consumption: Do we know what we drink and its implication on health?

BACKGROUND: Intake of sugar sweetened beverages has been consistently linked to increased risk of obesity, type 2 diabetes, osteoporosis and cardiovascular disease, among other diseases. Putative underlying mechanisms include incomplete compensation for liquid calories, adverse glycemic effects, and increased hepatic metabolism of fructose leading to de novo lipogenesis, production of uric acid, and accumulation of visceral and ectopic fat. OBJECTIVE: This study aims to elucidate any existing link between energy-containing liquids, as consumed in various forms within the diet, and the effect they may have on body weight or other diseases; and whether soft drink consumption displaces water consumption. METHODS: A self-administered online survey was conducted in 2496 participants from different countries, in six languages (Spanish, English, Chinese, French, German and Portuguese). Questions referred to their soft drink and water consumption habits, physical exercise performed, presence or absence of certain diseases and medication. RESULTS: There is statistically significant difference (p < 0.001) in BMI and consumption of cola per week: those who consumed 0–3 cans a week have a lower BMI than those who consume >7 cans of cola a week. Statistically significant difference (p = 0.02) was found when consuming soft drinks different from cola. There is greater presence of obesity (p < 0.001), gastritis (p < 0.001), constipation (p < 0.001) and mental illness (p = 0.003) among people who drink cola soft drinks. CONCLUSION: Removal of energy-containing beverages from our diet may be an appropriate public health message to support those interested in preventing weight gain as well as other diseases.

Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

Globally, the number of people with diabetes mellitus has quadrupled in the past three decades, and diabetes mellitus is the ninth major cause of death. About 1 in 11 adults worldwide now have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Asia is a major area of the rapidly emerging T2DM global epidemic, with China and India the top two epicentres. Although genetic predisposition partly determines individual susceptibility to T2DM, an unhealthy diet and a sedentary lifestyle are important drivers of the current global epidemic; early developmental factors (such as intrauterine exposures) also have a role in susceptibility to T2DM later in life. Many cases of T2DM could be prevented with lifestyle changes, including maintaining a healthy body weight, consuming a healthy diet, staying physically active, not smoking and drinking alcohol in moderation. Most patients with T2DM have at least one complication, and cardiovascular complications are the leading cause of morbidity and mortality in these patients. This Review provides an updated view of the global epidemiology of T2DM, as well as dietary, lifestyle and other risk factors for T2DM and its complications.

Sources of Added Sugars in Young Children, Adolescents, and Adults with Low and High Intakes of Added Sugars

High intake of added sugars is associated with excess energy intake and poorer diet quality. The objective of this cross-sectional study (n = 16,806) was to estimate usual intakes and the primary food sources of added sugars across the range of intakes (i.e., deciles) among U.S. children (2-8 years), adolescents and teens (9-18 years), and adults (≥19 years) using the National Health and Nutrition Examination (NHANES) data from 2009-2012. The percent energy contributed by added sugars was 14.3 ± 0.2% (2-8 years), 16.2 ± 0.2% (9-18 years), and 13.1 ± 0.2% (≥19 years), suggesting the highest intakes are among adolescents and teens. However, the primary foods/beverages that contribute to added sugars were remarkably consistent across the range of intakes, with the exception of the lowest decile, and include sweetened beverages and sweet bakery products. Interestingly across all age groups, even those in the lowest decile of added sugars exceed the 10% guidelines. Additional foods contributing to high intakes were candy and other desserts (e.g., ice cream) in children and adolescents, and coffee and teas in adults. Tailoring public health messaging to reduce intakes of these identified food groups may be of utility in designing effective strategies to reduce added sugar intake in the U.S.

Cross-sectional surveys of the amount of sugar, energy and caffeine in sugar-sweetened drinks marketed and consumed as energy drinks in the UK between 2015 and 2017: monitoring reformulation progress

OBJECTIVES

To investigate the sugar, energy and caffeine content of sugar-sweetened drinks marketed and consumed as energy drinks available in the UK.

STUDY DESIGN

We carried out a cross-sectional survey in 2015 and 2017 of energy drinks available in the main UK retailers.

METHODS

The sugar (sugars g/100 mL), energy (kcal/100 mL), caffeine (mg/100 mL) and serving size were collected from product packaging and nutrition information panels of energy drinks available in the nine main UK grocery retailers, three health and beauty retailers and one convenience store.

RESULTS

The number of formulations (per 100 mL) and number of products (per serving) have fallen (from 75 to 49 and from 90 to 59) between 2015 and 2017, respectively. Energy drinks surveyed showed a 10% reduction in sugar, from 10.6 to 9.5 g/100 mL (P=0.011) and a 6% reduction in energy content (P=0.005) per 100 mL between 2015 and 2017. The average caffeine content of energy drinks, with a warning label, has remained high at 31.5±0.9 in 2015 and 31.3±1.0 mg/100 mL in 2017. Despite there being reductions, sugar, energy and caffeine content remain at concerning levels in 2017.

CONCLUSIONS

To reduce the harmful impact of energy drinks, further reduction in sugar and a reduction in caffeine by reformulation are urgently needed. Other measures such as ban on the sale of energy drinks to children and smaller product sizes should also be explored, while warning labels should be kept. A reduction in sugar, energy and caffeine content and overall energy drinks consumption could be beneficial in reducing sugar, energy and caffeine intake of consumers of energy drinks.

Frequent Sugar-Sweetened Beverage Consumption and the Onset of Cardiometabolic Diseases: Cause for Concern?

The incidence of noncommunicable diseases is on the rise and poses a major threat to global public health. This is in parallel to a steady increase in worldwide intake of sugar-sweetened beverages (SSBs) among all age groups. As several studies demonstrated a controversial relationship between SSB consumption and the metabolic syndrome (MetS), this mini-review focuses on links between its intake and (1) MetS, (2) prediabetes/type 2 diabetes mellitus (T2DM), and (3) hypertension. A detailed search for clinical and observational studies published during the past 10 years was conducted using key terms that link SSBs to the MetS, T2DM, and hypertension. Here we excluded all meta-analyses and also literature that solely focused on obesity. The analysis revealed that most epidemiological studies strongly show that frequent SSB intake contributes to the onset of the MetS in the longer term. Some of the findings also show that regular SSB intake can alter glucose handling and insulin sensitivity, thereby contributing to the development of the MetS and T2DM. There is also evidence that frequent SSB intake (and particularly fructose) is linked to hypertension and well-known cardiovascular disease risk factors. However, some studies report on the lack of negative effects as a result of SSB consumption. Because of this discrepancy, we propose that well-designed long-term clinical studies should further enhance our understanding regarding the links between SSB consumption and the onset of cardiometabolic diseases.

Sociodemographic, lifestyle and behavioural factors associated with consumption of sweetened beverages among adults in Cambridgeshire, UK: the Fenland Study

OBJECTIVE

We aimed to identify sociodemographic, lifestyle and behavioural determinants of consumption of sugar-sweetened beverages (SSB) and artificially sweetened beverages (ASB) among adults in Cambridgeshire, UK.

DESIGN

Cross-sectional data were obtained from a cohort of 9991 adults born between 1950 and 1975. An FFQ was used to assess consumption of beverages and other dietary factors. Multivariable logistic regression was used to examine potential determinants of consuming SSB and ASB (≥1 serving/d).

SETTING

Recruitment from general practice surgeries to participate in the ongoing population-based Fenland Study.

SUBJECTS

Adults (n 9991) aged 30-64 years from three areas of Cambridgeshire, UK.

RESULTS

Prevalence estimates for daily SSB and ASB consumption were 20·4 % (n 2041) and 8·9 % (n 893), respectively. SSB consumption (OR; 95 % CI) was more common in men than women (1·33; CI 1·17, 1·50) and among those reporting lower income (£40 000/year; 1·31; 1·09, 1·58). In contrast, daily ASB consumption was more common among women than men (1·62; 1·34, 1·96), those on weight-loss diets than those who were not (2·58; 2·05, 3·24) and those reporting higher income than lower income (1·53; 1·16, 2·00). Factors associated with higher consumption of each of SSB and ASB included being a younger adult, being overweight/obese, having shorter education, eating meals or snack foods while watching television, and skipping breakfast (P<0·05 each).

CONCLUSIONS

Frequent consumers of SSB and ASB differ by several sociodemographic characteristics. However, increased BMI, younger age and unhealthy eating behaviours are common to both groups.

Substitution of water or fresh juice for bottled juice and type 2 diabetes incidence: The SUN cohort study

BACKGROUND AND AIMS

The relationship between juice consumption and type 2 diabetes (T2D) has not been widely evidenced. Our aims were to prospectively evaluate the associations with T2D incidence of: 1) isovolumetric substitution of a water serving/day for one of fruit juice (different types), and of fresh fruit juice for its bottled version; 2) consumption of total, fresh or bottled juice; 3) energy intake from juices.

METHODS AND RESULTS

We followed 17,518 adults without T2D at baseline. Beverage consumption was assessed at baseline through a validated food-frequency questionnaire. The outcome was T2D incidence, according to American Diabetes Association's criteria. During a median follow-up of 10.2 years, 142 incident cases of T2D were identified. In substitution models, the substitution of water for bottled juice was associated with a lower T2D incidence, and also if the replacement was done by fresh juice, or especially fresh orange juice [HR 0.75 (95% CI 0.57-0.99), 0.65 (95% CI 0.43-0.98) and 0.56 (95% CI 0.34-0.92); respectively]. Each additional serving/day of bottled juice was directly associated with T2D incidence [HR 1.33 (95% CI 1.01-1.75)]. No significant association was observed for energy coming for bottled juice [HR 1.74 (95% CI 0.94-3.20)].

CONCLUSION

Our results suggest that isovolumetric substitution of water or fresh juice for bottled juice was inversely associated with T2D incidence in a long-term prospective study. Thus, these substitutions could be useful to tackle the diabetes epidemic.

Health outcomes of non-nutritive sweeteners: analysis of the research landscape

BACKGROUND

Food products containing non-nutritive sweeteners (NNSs) instead of sugar have become increasingly popular in the last decades. Their appeal is obviously related to their calorie-free sweet taste. However, with the dramatic increase in their consumption, it is reasonable and timely to evaluate their potential health benefits and, more importantly, potential adverse effects. The main aim of this scoping review was to map the evidence about health outcomes possibly associated with regular NNS consumption by examining the extent, range, and nature of research activity in this area.

METHODS

We systematically searched Ovid MEDLINE, EMBASE and the Cochrane CENTRAL databases for studies on NNSs (artificial sweeteners or natural, non-caloric sweeteners, either used individually or in combination) using text terms with appropriate truncation and relevant indexing terms. All human studies investigating any health outcomes of a NNS intervention or exposure were eligible for inclusion. No studies were excluded based on language, study design or methodological quality. Data for each health outcome were summarized in tabular form and were discussed narratively.

RESULTS

Finally, we included 372 studies in our scoping review, comprising 15 systematic reviews, 155 randomized controlled trials (RCTs), 23 non-randomized controlled trials, 57 cohort studies, 52 case-control studies, 28 cross sectional studies and 42 case series/case reports. In healthy subjects, appetite and short term food intake, risk of cancer, risk of diabetes, risk of dental caries, weight gain and risk of obesity are the most investigated health outcomes. Overall there is no conclusive evidence for beneficial and harmful effects on those outcomes. Numerous health outcomes including headaches, depression, behavioral and cognitive effects, neurological effects, risk of preterm delivery, cardiovascular effects or risk of chronic kidney disease were investigated in fewer studies and further research is needed. In subjects with diabetes and hypertension, the evidence regarding health outcomes of NNS use is also inconsistent.

CONCLUSIONS

This scoping review identifies the needs for future research to address the numerous evidence gaps related to health effects of NNSs use.It also specifies the research questions and areas where a systematic review with meta-analyses is required for the proper evaluation of health outcomes associated to regular NNSs consumption.

Prevention and Therapy of Type 2 Diabetes-What Is the Potential of Daily Water Intake and Its Mineral Nutrients?

We aim to present an overview of the possible influence of drinking water in general and mineral water in particular in improving glycemic parameters in persons with or without type 2 diabetes. We performed a literature search that produced 15 randomized controlled trials (RCTs) on this topic with mainly small sample sizes. We also discuss relevant observational and animal studies as well as the effects of important supplements in mineral water such as hydrogencarbonate and magnesium. There is low evidence for the positive effects of water or mineral water in improving glycemic parameters in diabetic and non-diabetic persons, and the results are heterogenous, making it difficult to reach an unequivocal conclusion. Meta-analyses of prospective cohort studies and other observational studies, studies with animal models and interventional studies using hydrogencarbonate and magnesium supplements suggest a probable positive effect of drinking water and mineral water in particular on glycemic parameters, supporting the positive results found in some of the RCTs, especially those substituting diet beverages or caloric beverages with water, or those using bicarbonate and magnesium-rich water. Regarding the high prevalence, the associated suffering and the resulting health expenditures of type 2 diabetes, it is imperative to conduct larger and more rigorous trials to answer the question whether drinking water or mineral water can improve glycemic parameters in diabetic and non-diabetic persons.

Health and economic benefits of reducing sugar intake in the USA, including effects via non-alcoholic fatty liver disease: a microsimulation model

OBJECTIVES

Excessive consumption of added sugars in the human diet has been associated with obesity, type 2 diabetes (T2D), coronary heart disease (CHD) and other elements of the metabolic syndrome. Recent studies have shown that non-alcoholic fatty liver disease (NAFLD) is a critical pathway to metabolic syndrome. This model assesses the health and economic benefits of interventions aimed at reducing intake of added sugars.

METHODS

Using data from US National Health Surveys and current literature, we simulated an open cohort, for the period 2015-2035. We constructed a microsimulation model with Markov chains for NAFLD (including steatosis, non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC)), body mass index, T2D and CHD. We assessed reductions in population disease prevalence, disease-attributable disability-adjusted life years (DALYs) and costs, with interventions that reduce added sugars consumption by either 20% or 50%.

FINDINGS

The model estimated that a 20% reduction in added sugars intake will reduce prevalence of hepatic steatosis, NASH, cirrhosis, HCC, obesity, T2D and CHD. Incidence of T2D and CHD would be expected to decrease by 19.9 (95% CI 12.8 to 27.0) and 9.4 (95% CI 3.1 to 15.8) cases per 100 000 people after 20 years, respectively. A 20% reduction in consumption is also projected to annually avert 0.767 million (M) DALYs (95% CI 0.757M to 0.777M) and a total of US$10.3 billion (B) (95% CI 10.2B to 10.4B) in discounted direct medical costs by 2035. These effects increased proportionally when added sugars intake were reduced by 50%.

CONCLUSIONS

The decrease in incidence and prevalence of disease is similar to results in other models, but averted costs and DALYs were higher, mainly due to inclusion of NAFLD and CHD. The model suggests that efforts to reduce consumption of added sugars may result in significant public health and economic benefits.

Artificially sweetened beverages, sugar-sweetened beverages, plain water, and incident diabetes mellitus in postmenopausal women: the prospective Women's Health Initiative observational study

Background: Sugar-sweetened beverages (SSBs) have been associated with an increased risk of diabetes mellitus (DM), whereas the association with artificially sweetened beverages (ASBs) is unclear.Objective: We aimed to evaluate the associations of ASB and SSB consumption with the risk of developing DM and the potential benefit of replacing SSBs with ASBs or water.Design: The national Women's Health Initiative recruited a large prospective cohort of postmenopausal women between 1993 and 1998. ASB, SSB, and water consumption was measured by lifestyle questionnaires, and DM was self-reported.Results: Of 64,850 women, 4675 developed diabetes over an average of 8.4 y of follow-up. ASBs and SSBs were both associated with an increased risk of DM with an HR of 1.21 (95% CI: 1.08, 1.36) comparing ASB consumption of ≥2 serving/d to never or <3 serving/mo, and an HR of 1.43 (95% CI: 1.17, 1.75) comparing SSB consumption of ≥2 serving/d to <1 serving/wk (1 serving = one 12-ounce can or 355 mL). Subgroup analysis found an increased risk of DM associated with ASBs only in the obese group. Modeling the substitution of SSBs with an equal amount of ASBs did not significantly reduce the risk of developing DM. However, statistically substituting 1 serving of ASBs with water was associated with a significant risk reduction of 5% (HR: 0.95; 95% CI: 0.91, 0.99), whereas substituting 1 serving of SSBs with water was associated with a risk reduction of 10% (HR: 0.90; 95% CI: 0.85, 0.95).Conclusions: ASBs were associated with a 21% increased risk of developing DM, approximately half the magnitude of SSBs (associated with a 43% increased risk). Replacing ASBs and SSBs with water could potentially reduce the risk. However, caution should be taken in interpreting these results as causal because both residual confounding and reverse causation could explain these results.

Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies

BACKGROUND

Nonnutritive sweeteners, such as aspartame, sucralose and stevioside, are widely consumed, yet their long-term health impact is uncertain. We synthesized evidence from prospective studies to determine whether routine consumption of non-nutritive sweeteners was associated with long-term adverse cardiometabolic effects.

METHODS

We searched MEDLINE, Embase and Cochrane Library (inception to January 2016) for randomized controlled trials (RCTs) that evaluated interventions for nonnutritive sweeteners and prospective cohort studies that reported on consumption of non-nutritive sweeteners among adults and adolescents. The primary outcome was body mass index (BMI). Secondary outcomes included weight, obesity and other cardiometabolic end points.

RESULTS

From 11 774 citations, we included 7 trials (1003 participants; median follow-up 6 mo) and 30 cohort studies (405 907 participants; median follow-up 10 yr). In the included RCTs, nonnutritive sweeteners had no significant effect on BMI (mean difference -0.37 kg/m²; 95% confidence interval [CI] -1.10 to 0.36; I² 9%; 242 participants). In the included cohort studies, consumption of nonnutritive sweeteners was associated with a modest increase in BMI (mean correlation 0.05, 95% CI 0.03 to 0.06; I² 0%; 21 256 participants). Data from RCTs showed no consistent effects of nonnutritive sweeteners on other measures of body composition and reported no further secondary outcomes. In the cohort studies, consumption of nonnutritive sweeteners was associated with increases in weight and waist circumference, and higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. Publication bias was indicated for studies with diabetes as an outcome.

INTERPRETATION

Evidence from RCTs does not clearly support the intended benefits of nonnutritive sweeteners for weight management, and observational data suggest that routine intake of nonnutritive sweeteners may be associated with increased BMI and cardiometabolic risk. Further research is needed to fully characterize the long-term risks and benefits of nonnutritive sweeteners. Protocol registration: PROSPERO-CRD42015019749.

Research Priorities for Studies Linking Intake of Low-Calorie Sweeteners and Potentially Related Health Outcomes: Research Methodology and Study Design

Background: In a world of finite research funding, efforts to prioritize future research topics are increasingly necessary. Objective: The aim of this study was to identify and prioritize the direction of future research in the broad area of low-calorie sweetener (LCS) intake and potentially related health outcomes by using a novel method that incorporates evidence mapping in the Agency for Healthcare Research and Quality's Future Research Needs (FRN) process. Methods: A diverse expert stakeholder panel was convened and engaged to identify research gaps and prioritize future research needs. An independent research team hosted a number of interactive webinars and elicited feedback through surveys and individual interviews with the stakeholder panel, which included policymakers, lay audience members, health providers, a research funder, individuals with food industry experience, and researchers of several different specialties. Results: The stakeholder panel generated and ranked a list of 18 FRN questions across 5 broad research areas. Overall, stakeholder panel members unanimously agreed that the research questions that will have the largest public health impact are those that address outcomes related to body weight, appetite, and dietary intake. Although the LCSs included in this FRN project have all been Generally Recognized as Safe by the FDA or approved as food additives, the recurrent concerns and confusions with regard to the "safety" of LCSs by consumers underscore the importance of communicating the science to the general public. Conclusion: Our project provides evidence that engaging a diverse expert stakeholder panel is an effective method of translating gaps in nutrition research into prioritized areas of future research.

Consumption of sugar-sweetened beverages and type 2 diabetes incidence in Thai adults: results from an 8-year prospective study

Background:

The global prevalence of type 2 diabetes mellitus (T2DM) is high and is increasing in countries undergoing rapid socio-economic development, including Thailand. Sugar-sweetened beverage (SSB) intake may contribute to the risk of developing T2DM. However, few studies have assessed this association in Asian populations, and the results have been inconsistent. We aimed to assess that association in a prospective study of Thai adults.

Methods:

Data were from Thai Cohort Study participants surveyed in 2005, 2009 and 2013. The nation-wide sample included adult cohort members who were free of diabetes in 2005 and who were followed-up in 2013 (n=39 175). We used multivariable logistic regression to assess associations between SSB intake and eight-year T2DM incidence. We used a counterfactual mediation analysis to explore potential mediation of the SSB intake and T2DM-risk relationship.

Results:

In women (but not men) consuming SSBs once or more per day (versus rarely) was associated with increased T2DM incidence at the 8-year follow-up (odds ratio (OR)=2.4, 95% confidence interval (CI) 1.5–3.9). Obesity in 2009 was found to mediate ~23% of the total association between SSB intake in 2005 and T2DM risk in 2013 (natural indirect effect 1.15, 95% CI (1.02, 1.31).

Conclusions:

Frequent SSB consumption associated with higher T2DM incidence in women but not men. We found that a moderate proportion of the SSB-T2DM relationship was mediated through body mass index (BMI). Our findings suggest that targeting SSB consumption can help prevent a national rise in the incidence of T2DM.

Fructose intervention for 12 weeks does not impair glycemic control or incretin hormone responses during oral glucose or mixed meal tests in obese men

BACKGROUND AND AIMS

Incretin hormones glucagon-like peptide (GLP)-1 and glucose-dependent insulinotropic polypeptide (GIP) are affected early on in the pathogenesis of metabolic syndrome and type 2 diabetes. Epidemiologic studies consistently link high fructose consumption to insulin resistance but whether fructose consumption impairs the incretin response remains unknown.

METHODS AND RESULTS

As many as 66 obese (BMI 26-40 kg/m²) male subjects consumed fructose-sweetened beverages containing 75 g fructose/day for 12 weeks while continuing their usual lifestyle. Glucose, insulin, GLP-1 and GIP were measured during oral glucose tolerance test (OGTT) and triglycerides (TG), GLP-1, GIP and PYY during a mixed meal test before and after fructose intervention. Fructose intervention did not worsen glucose and insulin responses during OGTT, and GLP-1 and GIP responses during OGTT and fat-rich meal were unchanged. Postprandial TG response increased significantly, p = 0.004, and we observed small but significant increases in weight and liver fat content, but not in visceral or subcutaneous fat depots. However, even the subgroups who gained weight or liver fat during fructose intervention did not worsen their glucose, insulin, GLP-1 or PYY responses. A minor increase in GIP response during OGTT occurred in subjects who gained liver fat (p = 0.049).

CONCLUSION

In obese males with features of metabolic syndrome, 12 weeks fructose intervention 75 g/day did not change glucose, insulin, GLP-1 or GIP responses during OGTT or GLP-1, GIP or PYY responses during a mixed meal. Therefore, fructose intake, even accompanied with mild weight gain, increases in liver fat and worsening of postprandial TG profile, does not impair glucose tolerance or gut incretin response to oral glucose or mixed meal challenge.

Predicting type 2 diabetes using genetic and environmental risk factors in a multi-ethnic Malaysian cohort

OBJECTIVE

Malaysia has a high and rising prevalence of type 2 diabetes (T2D). While environmental (non-genetic) risk factors for the disease are well established, the role of genetic variations and gene-environment interactions remain understudied in this population. This study aimed to estimate the relative contributions of environmental and genetic risk factors to T2D in Malaysia and also to assess evidence for gene-environment interactions that may explain additional risk variation.

STUDY DESIGN

This was a case-control study including 1604 Malays, 1654 Chinese and 1728 Indians from the Malaysian Cohort Project.

METHODS

The proportion of T2D risk variance explained by known genetic and environmental factors was assessed by fitting multivariable logistic regression models and evaluating McFadden's pseudo R² and the area under the receiver-operating characteristic curve (AUC). Models with and without the genetic risk score (GRS) were compared using the log likelihood ratio Chi-squared test and AUCs. Multiplicative interaction between genetic and environmental risk factors was assessed via logistic regression within and across ancestral groups. Interactions were assessed for the GRS and its 62 constituent variants.

RESULTS

The models including environmental risk factors only had pseudo R² values of 16.5-28.3% and AUC of 0.75-0.83. Incorporating a genetic score aggregating 62 T2D-associated risk variants significantly increased the model fit (likelihood ratio P-value of 2.50 × 10^-4-4.83 × 10^-12) and increased the pseudo R² by about 1-2% and AUC by 1-3%. None of the gene-environment interactions reached significance after multiple testing adjustment, either for the GRS or individual variants. For individual variants, 33 out of 310 tested associations showed nominal statistical significance with 0.001 < P < 0.05.

CONCLUSION

This study suggests that known genetic risk variants contribute a significant but small amount to overall T2D risk variation in Malaysian population groups. If gene-environment interactions involving common genetic variants exist, they are likely of small effect, requiring substantially larger samples for detection.

Patterns of sugar-sweetened beverage consumption amongst young people aged 13-15 years during the school day in Scotland

BACKGROUND

There is currently little research regarding sugar-sweetened beverage (SSB) consumption patterns of young people though adolescents are thought to be frequent consumers of these drinks. There is no research regarding the other foods and drinks consumed alongside SSBs by young people. The aim of this paper is to explore the patterns of SSB purchase and consumption amongst young people aged 13-15 years.

METHODS

A purchasing recall questionnaire (PRQ) was administered online in seven case study schools with 535 young people aged 13-15 years. Nutrient composition (kilocalories, fat, saturated fat, sodium and sugar) was also calculated for food/drink purchases. Chi-Square and Wilcoxon-Mann Whitney tests were conducted to examine patterns of SSB consumption and sugar/kilocalories consumption for SSB consumers and non-consumers.

RESULTS

SSB consumers were significantly more likely to consume a drink at mid-morning break. Fewer consumed food at mid-morning break, ate food before school or ate food at lunchtime, but this was not statistically significant. A higher percentage of SSB consumers consumed 'unhealthy' food and drinks in comparison to young people who did not consume a SSB. Both median lunchtime sugar consumption (40.7 g vs 10.2 g) and median sugar as a percentage of Kcals (39% vs 14%) were significantly higher for SSB purchasers in comparison to non-purchasers.

CONCLUSION

The analysis highlights that SSB purchasers consume significantly more sugar at lunchtime than non-purchasers. However, both purchasers and non-purchasers exceeded WHO (2015) recommendations that sugar consumption be halved to form no more than 5% of daily energy intake. This study provides new insights for public health stakeholders and schools. Multifaceted and inventive strategies relevant to young people will be required to achieve the new WHO recommendations.