Maternal consumption of artificially sweetened beverages during pregnancy, and offspring growth through 7 years of age: a prospective cohort study

Maternal low-dose aspartame and stevia consumption with an obesogenic diet alters metabolism, gut microbiota and mesolimbic reward system in rat dams and their offspring

OBJECTIVE

We examined the impact of maternal low-dose aspartame and stevia consumption on adiposity, glucose tolerance, gut microbiota and mesolimbic pathway in obese dams and their offspring.

DESIGN

Following obesity induction, female Sprague-Dawley rats were allocated during pregnancy and lactation to: (1) high fat/sucrose diet (HFS) +water (obese-WTR); (2) HFS +aspartame (obese-APM; 5-7 mg/kg/day); (3) HFS +stevia (obese-STV; 2-3 mg/kg/day). Offspring were weaned onto control diet and water and followed until 18 weeks. Gut microbiota and metabolic outcomes were measured in dams and offspring. Cecal matter from offspring at weaning was used for faecal microbiota transplant (FMT) into germ-free (GF) mice.

RESULTS

Maternal APM and STV intake with a HFS diet increased body fat in offspring at weaning and body weight long-term with APM. Maternal APM/HFS consumption impaired glucose tolerance in male offspring at age 8 weeks and both APM and STV altered faecal microbiota in dams and offspring. Maternal obesity/HFS diet affected offspring adiposity and glucose tolerance more so than maternal LCS consumption at age 12 and 18 weeks. APM and STV altered expression of genes in the mesolimbic reward system that may promote consumption of a palatable diet. GF mice receiving an FMT from obese-APM and obese-STV offspring had greater weight gain and body fat and impaired glucose tolerance compared with obese-WTR.

CONCLUSION

Maternal low-calorie sweetener consumption alongside HFS may disrupt weight regulation, glucose control and gut microbiota in dams and their offspring most notably in early life despite no direct low-calorie sweetener consumption by offspring.

Consumption of non-nutritive sweeteners during pregnancy

In an effort to reduce sugar consumption to prevent diabetes mellitus and cardiovascular diseases, "sugar-free" or "no added sugar" products that substitute sugar with non-nutritive sweeteners (NNSs) (eg, Splenda, Sweet'N Low, and Stevia) have become increasingly popular. The use of these products during pregnancy has also increased, with approximately 30% of pregnant women reporting intentional NNS consumption. In clinical studies with nonpregnant participants and animal models, NNSs were shown to alter gut hormonal secretion, glucose absorption, appetite, kidney function, in vitro insulin secretion, adipogenesis, and microbiome dysbiosis of gut bacteria. In pregnant animal models, NNS consumption has been associated with altered sweet taste preference later in life and metabolic dysregulations in the offspring (eg, elevated body mass index, increased risk of obesity, microbiome dysbiosis, and abnormal liver function tests). Despite the accumulating evidence, no specific guidelines for NNS consumption are available for pregnant women. Furthermore, there are limited clinical studies on the effects of NNS consumption during pregnancy and postpartum and long-term outcomes in the offspring.

Consumption of the Artificial Sweetener Acesulfame Potassium throughout Pregnancy Induces Glucose Intolerance and Adipose Tissue Dysfunction in Mice

BACKGROUND

Sugar-sweetened beverage consumption is associated with metabolic dysfunction. Artificially sweetened beverages (ASBs) are often promoted as an alternative. However, evidence for the safety of ASB consumption during pregnancy is lacking.

OBJECTIVES

The effects of sugar-sweetened beverage and ASB consumption during pregnancy in mice were examined, and we hypothesized that both sugar-sweetened beverages and ASBs would impair maternal metabolic function.

METHODS

Pregnant female C57BL/6J mice received control drinking water (CD), high-fructose corn syrup (Fr; 20% kcal intake; 335 mM), or the artificial sweetener acesulfame potassium (AS; 12.5 mM) in their drinking water, from gestational day (GD) 0.5 (n = 8/group). Body weights and food and water intakes were assessed every second day, an oral-glucose-tolerance test (OGTT) was performed at GD 16.5, and mice were culled at GD 18.5. RT-PCR was carried out on adipose tissue, liver, and gut. Adipose tissue morphology was assessed using histological methods. In a separate cohort of animals, pregnancy length was assessed. Repeated-measures ANOVA was performed for the OGTT and weight gain data. All other data were analyzed by 1-way ANOVA.

RESULTS

Fr and AS significantly impaired glucose tolerance, as demonstrated by OGTT (21% and 24% increase in AUC, respectively; P = 0.0006). Fr and AS reduced expression of insulin receptor (39.5% and 33% reduction, respectively; P = 0.02) and peroxisome proliferator-activated receptor γ (45.2% and 47%, respectively; P = 0.039), whereas Fr alone reduced expression of protein kinase B (36.9% reduction; P = 0.048) and resulted in an increase in adipocyte size and leptin concentrations (40% increase; P = 0.03). AS, but not Fr, reduced male fetal weight (16.5% reduction; P = 0.04) and female fetal fasting blood glucose concentration at cull (20% reduction; P = 0.02) compared with CD. AS significantly reduced the length of pregnancy compared with the CD and Fr groups (1.25 d shorter; P = 0.02).

CONCLUSIONS

Fr and AS consumption were associated with maternal metabolic dysfunction in mice. AS was also associated with reduced fetal growth and fetal hypoglycemia. Therefore, ASBs may not be a beneficial alternative to sugar-sweetened beverages during pregnancy.

Effects of Non-nutritive Sweeteners on Sweet Taste Processing and Neuroendocrine Regulation of Eating Behavior

PURPOSE OF REVIEW

Non-nutritive sweeteners (NNS) are increasingly used as a replacement for nutritive sugars as means to quench the desire for "sweets" while contributing few or no dietary calories. However, there is concern that NNS may uncouple the evolved relationship between sweet taste and post-ingestive neuroendocrine signaling. In this review, we examine the effects of NNS exposure on neural and peripheral systems in humans.

RECENT FINDINGS

NNS exposure during early development may influence sweet taste preferences, and NNS consumption might increase motivation for sweet foods. Neuroimaging studies provide evidence that NNS elicit differential neuronal responsivity in areas related to reward and satiation, compared with caloric sweeteners. Findings are heterogenous regarding whether NNS affect physiological responses. Additional studies are warranted regarding the consequences of NNS on metabolic outcomes and neuroendocrine pathways. Given the widespread popularity of NNS, future studies are essential to establish their role in long-term health.

Nonnutritive sweetener consumption during pregnancy, adiposity, and adipocyte differentiation in offspring: evidence from humans, mice, and cells

BACKGROUND

Obesity often originates in early life, and is linked to excess sugar intake. Nonnutritive sweeteners (NNS) are widely consumed as "healthier" alternatives to sugar, yet recent evidence suggests NNS may adversely influence weight gain and metabolic health. The impact of NNS during critical periods of early development has rarely been studied. We investigated the effect of prenatal NNS exposure on postnatal adiposity and adipocyte development.

METHODS

In the CHILD birth cohort (N = 2298), we assessed maternal NNS beverage intake during pregnancy and child body composition at 3 years, controlling for maternal BMI and other potential confounders. To investigate causal mechanisms, we fed NNS to pregnant C57BL6J mice at doses relevant to human consumption (42 mg/kg/day aspartame or 6.3 mg/kg/day sucralose), and assessed offspring until 12 weeks of age for: body weight, adiposity, adipose tissue morphology and gene expression, glucose and insulin tolerance. We also studied the effect of sucralose on lipid accumulation and gene expression in cultured 3T3-L1 pre-adipocyte cells.

RESULTS

In the CHILD cohort, children born to mothers who regularly consumed NNS beverages had elevated body mass index (mean z-score difference +0.23, 95% CI 0.05-0.42 for daily vs. no consumption, adjusted for maternal BMI). In mice, maternal NNS caused elevated body weight, adiposity, and insulin resistance in offspring, especially in males (e.g., 47% and 15% increase in body fat for aspartame and sucralose vs. controls, p < 0.001). In cultured adipocytes, sucralose exposure at early stages of differentiation caused increased lipid accumulation and expression of adipocyte differentiation genes (e.g., C/EBP-α, FABP4, and FASN). These genes were also upregulated in adipose tissue of male mouse offspring born to sucralose-fed dams.

CONCLUSION

By triangulating evidence from humans, mice, and cultured adipocytes, this study provides new evidence that maternal NNS consumption during pregnancy may program obesity risk in offspring through effects on adiposity and adipocyte differentiation.

Rebaudioside affords hepatoprotection ameliorating sugar sweetened beverage- induced nonalcoholic steatohepatitis

Sugar-sweetened beverage consumption is a known independent risk factor for nonalcoholic steatohepatitis (NASH). Non-caloric sweeteners (NCS) are food additives providing sweetness without calories and are considered safe and/or not metabolized by the liver. The potential role of newer NCS in the regulation of NASH, however, remain unknown. Our study aimed to determine the impact of newer NCS including Rebaudioside A and sucralose on NASH using high fat diet induced obesity mouse model by substituting fructose and sucrose with NCS in the drinking water. We characterized the phenotype of NCS- treated obesity and investigated the alterations of hepatic function and underlying mechanisms. We found that NCS have no impact on weight gain and energy balance in high fat diet induced obesity. However, in comparison to fructose and sucrose, Rebaudioside A significantly improved liver enzymes, hepatic steatosis and hepatic fibrosis. Additionally, Rebaudioside A improved endoplasmic reticulum (ER) stress related gene expressions, fasting glucose levels, insulin sensitivity and restored pancreatic islet cell mass, neuronal innervation and microbiome composition. We concluded that Rebaudioside A significantly ameliorated murine NASH, while the underlying mechanisms requires further investigation.

Poor diet quality in pregnancy is associated with increased risk of excess fetal growth: a prospective multi-racial/ethnic cohort study

BACKGROUND

Nutritional perturbations during pregnancy may impact fetal and long-term childhood growth, although there are limited data on overall diet quality. We investigated whether diet quality, measured by the Healthy Eating Index-2010 (HEI-2010), during pregnancy was related to birthweight z-score (BWZ) and the clinically relevant birth outcomes of large- and small-for-gestational age (LGA and SGA).

METHODS

In a prospective cohort of 2269 multi-racial/ethnic women from the Pregnancy Environment and Lifestyle Study (2014-2017), dietary intake was assessed by a food frequency questionnaire during early pregnancy. Offspring BWZ and LGA or SGA were derived based on gestational age-, sex-, and racial/ethnic-specific birthweight distributions. Multivariable linear and Poisson regression with robust standard errors were used.

RESULTS

About 80% of women did not achieve good diet quality (HEI-2010 < 80). After adjusting for covariates, infants born to women in the lowest vs highest quartile of HEI-2010 (37.5-64.4 vs 78.7-94.2) had a 0.12 standard-deviation [95% confidence interval (CI) 0.01-0.23, P-for-trend = 0.023] greater BWZ and 1.76-fold (1.08-2.87, P-for-trend = 0.037) increased risk of LGA. No association was observed between HEI-2010 and SGA. Per-5-point substitution of the reversely coded empty calories component score with the whole grains component score in the HEI-2010 was related to a 25% (95% CI 0.66-0.86) lower risk of LGA.

CONCLUSIONS

Poor diet quality in pregnancy was associated with higher birthweight and increased risk of LGA independent of maternal obesity and other covariates. Substitution of empty calories with whole grains may mitigate the risk of excess fetal growth. Our findings may inform potential prevention strategies and dietary guidelines for pregnant women.

Effects of timing of food intake on eating patterns, diet quality and weight gain during pregnancy

Studies have suggested that meal timing plays a role in nutritional health, but this subject has not been sufficiently studied in pregnant women. We analysed the effect that timing of food intake has on eating patterns, diet quality and weight gain in a prospective cohort study with 100 pregnant women. Data were collected once per trimester: 4th-12th, 20th-26th and 30th-37th weeks. Food intake was evaluated using three 24-h dietary recalls, which were used to assess eating patterns and diet quality. Distribution of energy and macronutrient intake throughout the day was considered eating patterns. Diet quality was assessed using the Brazilian Healthy Eating Index-Revised. Weight gain was evaluated during each trimester. Women were classified as early or late timing of the first and last eating episodes if these values were below or above the median of the population, respectively (first eating episode = 08.38 hours; last eating episode = 20.20 hours). Generalised estimating equation models adjusted for confounders were used to determine the effects of timing of the first and last eating episodes (groups) and gestational trimesters (time) (independent variable) on eating patterns, diet quality and weight gain (dependent variables). Early eaters of the first eating episode have a higher percentage of energy and carbohydrate intake in morning and a lower at evening meals. They also have a better diet quality for fruit components when compared with late eaters of the first eating episode. Our results emphasise the importance of considering meal timing in the nutritional antenatal guidelines to promote maternal-fetal health.

Preconception Lifestyle and Cardiovascular Health in the Offspring of Overweight and Obese Women

Women’s lifestyle has important implications for the development and health of their offspring. Yet little is known about the association between women’s preconception dietary intake and physical activity with cardiovascular health of the offspring. We therefore examined this association in a group of Dutch women with overweight or obesity (BMI ≥ 29 kg/m²) and infertility, who participated in a 6-month randomized preconception lifestyle intervention trial, and their offspring (n = 46). Preconception dietary intake and physical activity were assessed during the 6-month intervention using a food frequency questionnaire and the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH), respectively. Offspring cardiovascular health (i.e., BMI, waist:height ratio, systolic and diastolic blood pressure, fat and fat free mass, and pulse wave velocity) was measured at age 3–6 years. Multivariable linear regression analyses were used to examine the associations between preconception lifestyle and offspring cardiovascular health. Higher preconception vegetable intake (per 10 g/day) was associated with lower offspring diastolic blood pressure (Z-score: −0.05 (−0.08; −0.01); p = 0.007) and higher preconception fruit intake (per 10 g/day) was associated with lower offspring pulse wave velocity (−0.05 m/s (−0.10; −0.01); p = 0.03). Against our expectations, higher preconception intake of sugary drinks was associated with a higher offspring fat free mass (0.54 kg (0.01; 1.07); p = 0.045). To conclude, preconception dietary intake is associated with offspring health.

Can a Simple Dietary Screening in Early Pregnancy Identify Dietary Habits Associated with Gestational Diabetes?

Gestational diabetes mellitus (GDM) is predominantly a lifestyle disease, with diet being an important modifiable risk factor. A major obstacle for the prevention in clinical practice is the complexity of assessing diet. In a cohort of 1651 Icelandic women, this study examined whether a short 40-item dietary screening questionnaire administered in the 1st trimester could identify dietary habits associated with GDM. The dietary variables were aggregated into predefined binary factors reflecting inadequate or optimal intake and stepwise backward elimination was used to identify a reduced set of factors that best predicted GDM. Those binary factors were then aggregated into a risk score (range: 0–7), that was mostly characterised by frequent consumption of soft drinks, sweets, cookies, ice creams and processed meat. The women with poor dietary habits (score ≥ 5, n = 302), had a higher risk of GDM (RR = 1.38; 95%CI = 3, 85) compared with women with a more optimal diet (score ≤ 2, n = 407). In parallel, a pilot (n = 100) intervention was conducted among overweight and obese women examining the effect of internet-based personalized feedback on diet quality. Simple feedback was given in accordance with the answers provided in the screening questionnaire in 1st trimester. At the endpoint, the improvements in diet quality were observed by, as an example, soft drink consumption being reduced by ~1 L/week on average in the intervention group compared to the controls. Our results suggest that a simple dietary screening tool administered in the 1st trimester could identify dietary habits associated with GMD. This tool should be easy to use in a clinical setting, and with simple individualized feedback, improvements in diet may be achieved.

[Non-caloric sweeteners in pregnancy and lactation]

Many pregnancies have a weight gain that is higher than recommended, situation that carries several risks for the mother and her child. As a strategy to achieve a lower weight gain, the replacement of sugar-sweetened foods and beverages by those with non-caloric sweeteners could be a choice for pregnant or puerperal mothers. The objective of this article is to review the available evidence regarding the use of non-caloric sweeteners during pregnancy and lactation. Pregnancy is not a period to lose weight, so it would not be advisable to perform hypocaloric diets. However, to achieve an adequate weight gain during pregnancy, many women choose to consume food and beverages with non-caloric sweeteners. During pregnancy, the consumption of cyclamate, saccharin and crude stevia leaf should be avoided, as well as that of stevia infusions or extracts of the whole leaf. Regarding the rest of the approved non-caloric sweeteners, their consumption during pregnancy and lactation is considered to be safe, as long as they are consumed in moderation, adhering to their admissible daily intake levels. Aspartame does not reach breast milk. While saccharin, sucralose, and acesulfame-K are detectable in breast milk, their concentration is several orders of magnitude below their admissible daily intake levels.

Low-calorie sweetener use, weight, and metabolic health among children: A mini-review

A reduction in the consumption of added sugars and sugar-sweetened beverages (SSBs) is a key focus of public health recommendations for a healthy diet among children. One approach to lower added sugar intake is to instead use low-calorie sweeteners (LCSs), which contain no or few calories. Consumption of LCSs is increasing worldwide, with the most marked rise observed among children and adolescents. However, the extent to which LCS consumption is helpful or harmful for weight management is controversial, particularly when LCS consumption begins in childhood. Herein, we summarize the limited existing literature examining effects of paediatric LCS consumption on appetite, energy intake, and body weight. While positive associations between LCS consumption and weight gain are reported in observational analyses, the majority of intervention studies, some of which blinded children to the contents of the drinks, report benefits of LCSs for reducing excessive child weight gain. Several potential mechanisms have been proposed to explain LCS effects on body weight, including LCS-induced promotion of appetite and energy intake. Yet studies assessing effects of beverages with LCSs (LCSBs) compared with SSBs on child appetite report mixed findings. Some demonstrate that children completely compensate for the diluted energy content of LCSBs by eating more solid food calories at subsequent meals compared with children administered SSBs, while others report a reduction in total energy intake with LCSB ingestion. Given the limited studies and resulting uncertainty as to whether LCSs benefit or worsen weight and metabolic health in children is integral that effects of LCS use during childhood continue to be investigated in future prospective studies.

Effects of consuming sugars and alternative sweeteners during pregnancy on maternal and child health: evidence for a secondhand sugar effect

Consumption of sugar and alternative low- or no-energy sweeteners has increased in recent decades. However, it is still uncertain how consumption of sugar and alternative sweeteners during pregnancy affects pregnancy outcomes and long-term offspring health. This review aims to collate the available evidence surrounding the consequences of sugar and alternative sweetener consumption during pregnancy, a so-called secondhand sugar effect. We found evidence that sugar consumption during pregnancy may contribute to increased gestational weight gain and the development of pregnancy complications, including gestational diabetes, preeclampsia and preterm birth. Further, we found a growing body of the animal and human evidence that maternal sugar intake during pregnancy may impact neonatal and childhood metabolism, taste perception and obesity risk. Emerging evidence also suggests that both maternal and paternal preconception sugar intakes are linked to offspring metabolic outcomes, perhaps via epigenetic alterations to the germline. While there have been fewer studies of the impacts of alternative sweetener consumption before and during pregnancy, there is some evidence to suggest effects on infant outcomes including preterm birth risk, increased infant body composition and offspring preference for sweet foods, although mechanisms are unclear. We conclude that preconception and gestational sugar and alternative sweetener consumption may negatively impact pregnancy outcomes and offspring health and that there is a need for further observational, mechanistic and intervention research in this area.

A prospective study of artificially sweetened beverage intake and cardiometabolic health among women at high risk

BACKGROUND

Artificially sweetened beverages (ASBs) are commonly consumed and recommended for individuals at high risk for cardiometabolic diseases; however, the health effects of ASBs remain contradictory. Given that cross-sectional analyses are subject to reverse causation, prospective studies with long-term follow-up are needed to evaluate associations between ASBs and cardiometabolic health, especially among high-risk individuals.

OBJECTIVE

The aim of this study was to examine associations of ASB intake and cardiometabolic health among high-risk women with prior gestational diabetes mellitus (GDM).

METHODS

We included 607 women with GDM from the Danish National Birth Cohort (DNBC; 1996-2002) who completed a clinical exam 9-16 y after the DNBC pregnancy for the Diabetes & Women's Health (DWH) Study (2012-2014). We assessed ASB intake using FFQs completed during the DNBC pregnancy and at the DWH Study clinical exam. We examined cardiometabolic outcomes at the DWH clinical exam. We estimated percentage differences in continuous cardiometabolic markers and RRs for clinical endpoints in association with ASB intake both during pregnancy and at follow-up adjusted for prepregnancy BMI, diet, and lifestyle factors. Sensitivity analyses to account for reverse causation were performed.

RESULTS

In pregnancy and at follow-up, 30.4% and 36.4% of women regularly (≥2 servings/wk) consumed ASB, respectively. Consumption of ASBs, both during pregnancy and at follow-up, was associated with higher glycated hemoglobin (HbA1c), insulin, HOMA-IR, triglycerides, liver fat, and adiposity and with lower HDL at follow-up. After adjustment for covariates, particularly prepregnancy BMI, the majority of associations between ASB intake in pregnancy and outcomes at follow-up became null with the exception of HbA1c. ASB intake at follow-up (≥1 serving/d compared with <1 serving/mo) was associated with higher HbA1c (6.5%; 95% CI: 1.9, 11.3; P-trend = 0.007); however, associations were not upheld in sensitivity analyses for reverse causation.

CONCLUSIONS

Among Danish women with a history of GDM, ASB intake was not significantly associated with cardiometabolic profiles.

Trends in Low-Calorie Sweetener Consumption Among Pregnant Women in the United States

BACKGROUND

Minimizing consumption of added sugars is recommended to prevent excessive weight gain among pregnant women. A common approach to lowering sugar intake is the use of low-calorie sweeteners (LCSs), yet little is known about LCS use during pregnancy or its effects on infant weight and health.

OBJECTIVE

The aim of the study was to investigate temporal trends in LCS consumption by source (foods, beverages, or packets) among pregnant women in the United States from 1999 to 2014 and to compare recent LCS consumption patterns across sociodemographic subgroups and product categories.

METHODS

Data were collected from pregnant women aged 20-39 y (n = 1,265) who participated in the NHANES from 1999-2000 through 2013-2014. Prevalence of LCS consumption was assessed using two 24-h dietary recalls. Analytical procedures for complex survey design were used, and sampling weights were applied to estimate national prevalence of LCS use. Rao-Scott modified chi-square tests were used to compare consumption prevalence across sociodemographic subgroups, and logistic regression was used to examine trends in LCS use over time.

RESULTS

The prevalence of LCS consumption among pregnant women increased by approximately 50% rising from 16.2% in 1999-2004 to 24.0% in 2007-2014, P = 0.04, with the highest prevalence observed in 2005-2006 (38.4%). This trend was driven predominantly by increases in LCS beverage use (9.9% in 1999-2004 compared with 18.3% in 2007-2014, P = 0.02). Prevalence of LCS consumption was highest among non-Hispanic white women and increased with education and income. No differences were observed based on prepregnancy weight status or trimester of pregnancy.

CONCLUSIONS

Approximately one-quarter of pregnant women in the United States reported consumption of LCS during at least 1 of 2 dietary recalls. Given the widespread LCS consumption during pregnancy, research to elucidate potential effects of early life LCS exposure on taste preferences, weight trajectory, and risk of later metabolic disease is needed.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.

Artificial sweeteners in food and beverage products at school

Objective

Experts recommend that products containing artificial sweeteners are not marketed to children or sold at schools. The present study aimed to provide a baseline assessment of the extent to which state laws and local school district wellness policies (LWP) address restrictions on the use of artificial sweeteners in competitive foods and beverages (CF&B) sold at schools.

Design

A descriptive, cross-sectional study of policies in place for the 2014–15 school year.

Setting

Data were collected on laws in all fifty states and Washington, DC. LWP were compiled for 496/518 school food authorities (SFA) for which data were collected as part of the US Department of Agriculture’s School Nutrition and Meal Cost Study.

Subjects

State laws and LWP respectively were coded on a 0–3 ordinal scale for the strength of their restrictions on artificial sweeteners in CF&B sold in each of five CF&B venues, separately by grade level. Prevalence of state laws and LWP for SFA nationwide was computed.

Results

Thirteen states addressed the use of artificial sweeteners. Six states addressed the use of artificial sweeteners in both CF&B. District-level artificial sweetener policies were most frequently addressed for beverages in elementary schools’ vending machines. District policies also were more likely to address artificial sweeteners in states with laws addressing artificial sweeteners.

Conclusions

Most state laws and LWP do not address artificial sweeteners in CF&B. This is not surprising given the Food and Drug Administration has approved eight artificial sweeteners for consumption and the Smart Snacks regulation does not limit artificial sweeteners for CF&B.

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.

Development of a dietary screening questionnaire to predict excessive weight gain in pregnancy

Excessive gestational weight gain (GWG) is a risk factor for several adverse pregnancy outcomes, including macrosomia. Diet is one of the few modifiable risk factors identified. However, most dietary assessment methods are impractical for use in maternal care. This study evaluated whether a short dietary screening questionnaire could be used as a predictor of excessive GWG in a cohort of Icelandic women. The dietary data were collected in gestational weeks 11–14, using a 40‐item food frequency screening questionnaire. The dietary data were transformed into 13 predefined dietary risk factors for an inadequate diet. Stepwise backward elimination was used to identify a reduced set of factors that best predicted excessive GWG. This set of variables was then used to calculate a combined dietary risk score (range 0–5). Information regarding outcomes, GWG (n = 1,326) and birth weight (n = 1,651), was extracted from maternal hospital records. In total, 36% had excessive GWG (Icelandic criteria), and 5% of infants were macrosomic (≥4,500 g). A high dietary risk score (characterized by a nonvaried diet, nonadequate frequency of consumption of fruits/vegetables, dairy, and whole grain intake, and excessive intake of sugar/artificially sweetened beverages and dairy) was associated with a higher risk of excessive GWG. Women with a high (≥4) versus low (≤2) risk score had higher risk of excessive GWG (relative risk = 1.23, 95% confidence interval, CI [1.002, 1.50]) and higher odds of delivering a macrosomic offspring (odds ratio = 2.20, 95% CI [1.14, 4.25]). The results indicate that asking simple questions about women's dietary intake early in pregnancy could identify women who should be prioritized for further dietary counselling and support.

Developmental Origins of Disease: Emerging Prenatal Risk Factors and Future Disease Risk

Purpose of review

Many of the diseases and dysfunctions described in the paradigm of the developmental origins of health and disease have been studied in relation to prenatal nutrition or environmental toxicant exposures. Here, we selectively review the current research on four exposures-two nutritional and two environmental-that have recently emerged as prenatal risk factors for long-term health outcomes.

Recent findings

Recent studies have provided strong evidence that prenatal exposure to (1) excessive intake of sugar-sweetened beverages, (2) unhealthy dietary patterns, (3) perfluoroalkyl substances, and (4) fine particulate matter, may increase risk of adverse health outcomes, such as obesity, cardiometabolic dysfunction, and allergy/asthma.

Summary

Emerging prenatal nutritional factors and environmental toxicants influence offspring long-term health. More work is needed to identify the role of paternal exposures and maternal exposures during the preconception period and to further elucidate causality through intervention studies. The ubiquity of these emerging nutritional and environmental exposures makes this area of inquiry of considerable public health importance.

Nonnutritive Sweeteners in Weight Management and Chronic Disease: A Review

OBJECTIVE

The objective of this review was to critically review findings from recent studies evaluating the effects of nonnutritive sweeteners (NNSs) on metabolism, weight, and obesity-related chronic diseases. Biologic mechanisms that may explain NNS effects will also be addressed.

METHODS

A comprehensive review of the relevant scientific literature was conducted.

RESULTS

Most cross-sectional and prospective cohort studies report positive associations between NNS consumption, body weight, and health conditions, including type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease. Although findings in cellular and rodent models suggest that NNSs have harmful effects on metabolic health, most randomized controlled trials in humans demonstrate marginal benefits of NNS use on body weight, with little data available on other metabolic outcomes.

CONCLUSIONS

NNS consumption is associated with higher body weight and metabolic disease in observational studies. In contrast, randomized controlled trials demonstrate that NNSs may support weight loss, particularly when used alongside behavioral weight loss support. Additional long-term, well-controlled intervention studies in humans are needed to determine the effects of NNSs on weight, adiposity, and chronic disease under free-living conditions.

Early-Life Exposure to Non-Nutritive Sweeteners and the Developmental Origins of Childhood Obesity: Global Evidence from Human and Rodent Studies

Non-nutritive sweeteners (NNS) are increasingly consumed by children and pregnant women around the world, yet their long-term health impact is unclear. Here, we review an emerging body of evidence suggesting that early-life exposure to NNS may adversely affect body composition and cardio-metabolic health. Some observational studies suggest that children consuming NNS are at increased risk for obesity-related outcomes; however, others find no association or provide evidence of confounding. Fewer studies have examined prenatal NNS exposure, with mixed results from different analytical approaches. There is a paucity of RCTs evaluating NNS in children, yielding inconsistent results that can be difficult to interpret due to study design limitations (e.g., choice of comparator, multifaceted interventions). The majority of this research has been conducted in high-income countries. Some rodent studies demonstrate adverse metabolic effects from NNS, but most have used extreme doses that are not relevant to humans, and few have distinguished prenatal from postnatal exposure. Most studies focus on synthetic NNS in beverages, with few examining plant-derived NNS or NNS in foods. Overall, there is limited and inconsistent evidence regarding the impact of early-life NNS exposure on the developmental programming of obesity and cardio-metabolic health. Further research and mechanistic studies are needed to elucidate these effects and inform dietary recommendations for expectant mothers and children worldwide.

Noncaloric Sweeteners in Children: A Controversial Theme

Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.