Sugar-sweetened beverage consumption and weight gain in children and adults: a systematic review and meta-analysis of prospective cohort studies and randomized controlled trials

Low- or No-Energy Sweeteners and Body Weight Management: Dissecting a "Minor" Effect

Nonnutritive sweeteners were introduced on the market over a century ago to displace the calories of added sugars in foods and beverages and, therefore, facilitate weight loss. In spite of their widespread use, obesity has reached epidemic proportions. The present paper addresses this apparent paradox. Low- or no-energy sweeteners (LNES) are a small group of widely different substances that can be used to modify one single aspect of energy intake, i.e., consumption of added sugars. Their potential benefits for weight management can be predicted by energy balance equations. Decades of research confirm that LNES affect weight via a purely nutritional mechanism, in proportion of their actual displacement of sugar energy. LNES allow a substantial decrease in energy density of beverages (as opposed to solid foods) and can be maximally effective in consumers of sugar-containing drinks. Their average effect is robust but modest (1-2-kg weight loss) compared to comprehensive weight-loss programs (±5 kg), medication, or surgery (+10% of initial weight). Other benefits of LNES include sensory-specific satiety for sweet foods, improved diet adherence, and facilitation of weight-loss maintenance. Whether these effects are considered minor or major benefits in the present obesogenic context is a matter of individual definition.

Associations of Academic Study- and Non-Study-Related Sedentary Behaviors with Incident Obesity in Children and Adolescents

Objective: To assess the associations between academic study- and non-study-related sedentary behaviors and the risk of overweight/obesity in children and adolescents, as well as their joint association with sugar-sweetened beverage (SSB) consumption. Methods: Sedentary behaviors and SSB consumption were assessed using self-reported questionnaires. Overweight/obesity were defined by age- and sex-specific body mass index cut-off values according to the criteria of "Screening for overweight and obesity among school-age children and adolescents" in China. Poisson regression with robust error variance was used to assess the associations of sedentary behaviors and/or SSB consumption with the risk of overweight/obesity, yielding relative risks (RRs) and 95% confidence intervals (CIs). The Shapley additive explanations (SHAP) method was used to rank the contribution of five specific sedentary behaviors to obesity risk. Results: Among 47,148 participants with a 3-year follow-up, longer durations of screen-related, academic study-related, and total sedentary time were each associated with a higher risk of overweight/obesity (adjusted RR (95% CI) per hour increment: 1.01 (1.00-1.02), 1.03 (1.01-1.06), and 1.02 (1.01-1.03)). After mutual adjustment, the associations of engaging in homework, attending tutorial classes, and using mobile electronic devices remained significantly associated with higher overweight/obesity risk. The SHAP summary plot shows that using mobile electronic devices, attending tutorial classes, and doing homework were the three most important sedentary obesogenic contributors. A significant interaction of age with sedentary time was found (p for interaction < 0.05). No significant interaction was found between SSB consumption and sedentary time. Conclusions: Excessive sedentary behaviors were associated with a higher risk of overweight/obesity, particularly due to mobile electronic device use, attending tutorial classes, and doing homework.

Joint association of physical activity and sugar-sweetened beverages with obesity in young U.S. adults: A cross-sectional analysis of NHANES 2007-2020

Objective

This study aimed to investigate the independent and joint association of sugar-sweetened beverages (SSBs) and physical activity with obesity among young U.S. adults.

Methods

We selected 11,318 U.S. young adults aged 20-44 years from the National Health and Nutrition Examination Survey (2007-2020). Physical activity was self-reported using the Global Physical Activity Questionnaire, while SSBs consumption was calculated from a single day of twenty-four-hour dietary recall. Multivariable logistic regression models, and sensitivity analyses were used to estimate the associations between SSBs, physical activity, and obesity.

Results

There were 4216 cases of obesity (35.5 %). A positive relationship between the consumption of SSBs and the prevalence of obesity was observed, while physical activity was negatively associated with the prevalence of obesity. Relative to the moderate SSBs consumption + inactive participants, those who were insufficiently active [adjusted odds ratio (AOR) = 0.75, 95 % CI: 0.58, 0.97] and physically active (AOR = 0.72, 95 % CI: 0.62, 0.85) had a lower likelihood of obesity among moderate SSBs consumers (1-499 kcal/day). However, this pattern was not found in the heavy SSBs consumers (≥ 500 kcal/day) (P > 0.05).

Conclusions

In conclusion, physical activity was associated with a lower prevalence of obesity among moderate SSBs consumers, while this pattern did not observe in heavy SSBs consumers. Further studies are needed to validate these results and determine causality.

Both absolute and relative sugar-sweetened beverage intake are associated with kidney stones in U.S. middle-aged and young adults

BACKGROUND

Sugar-sweetened beverage (SSB) intake is currently a public health concern. However, the relationship between SSB intake and the risk of kidney stones in middle-aged and young populations has not been thoroughly investigated.

METHODS

The National Health and Nutrition Examination Survey (NHANES) database (for 2007-2016) was used. SSB intake was assessed using 24-hour dietary recall interviews and evaluated through two distinct metrics: (1) absolute intake, defined as the total energy derived from SSB, and (2) relative intake, expressed as the percentage of total daily energy intake contributed by SSB. Multivariable logistic regression models were used to investigate the association between SSB intake and the prevalence of kidney stones, with stratified and interaction analyses performed for covariates. All analyses accounted for sample weighting to ensure accurate representation.

RESULTS

The study analyzed data from 15,779 nationally representative participants, of whom 1,224 had kidney stones. After adjusting for potential covariates, both the absolute intake of SSB (per 100 kcal/d) and the relative intake (per 1%) were positively associated with the risk of kidney stones. The odds ratios (ORs) were 1.065 (95% confidence interval [CI]: 1.038, 1.093) and 1.015 (95% CI: 1.009, 1.022), respectively. Compared to individuals who do not consume SSB, kidney stones risk increased with absolute SSB intake across ascending tertiles: the ORs were 1.231 (95% Cl: 0.995, 1.523), 1.335 (95% Cl: 1.075, 1.658), and 1.664 (95% Cl: 1.353, 2.048) for the lowest to highest tertiles, respectively. The ORs corresponding to the respective tertiles of relative intake were 1.224 (95% CI: 0.991, 1.511), 1.394 (95% CI: 1.128, 1.723), and 1.626 (95% CI: 1.317, 2.009). This association remained generally stable across stratified analyses. Additionally, obesity status and alcohol consumption status significantly interacted with the relative SSB intake-kidney stones relationship.

CONCLUSION

In middle-aged and young adults, higher SSB intake is linked to a greater kidney stone risk, indicating that limiting consumption may aid in prevention.

How Screen Time Affects Greek Schoolchildren's Eating Habits and Functional Food Consumption?-A Cross-Sectional Study

BACKGROUND

Television (TV), video games, PC and devices such as tablets and smart phones have become part of everyday life at an ever-younger age. Increased screen time correlates with unhealthy eating habits among children.

METHODS

374 children aged 9-12 years and their parents (n = 159), from 3 schools in Lemnos and 5 schools in Thessaloniki, Greece, took part in this cross-sectional study. The children completed the KIDMED score and a questionnaire about their physical activity, time spent watching TV, PC and playing electronic games, the frequency of cooking or shopping with their parents, the frequency of eating fast food, soft drinks and Functional Foods (FFs). Statistical analysis was performed with SPSS-29.0, using One Way ANOVA and Pearson chi-square.

RESULTS

As the hours of TV viewing increased, so did the percentage of children who consumed soft drinks (p = 0.03). A statistically significant association detected between television (p = 0.024), video games (p = 0.028), all screen categories (p = 0.011) and fast-food consumption. Increased screen time is associated with a higher weekly consumption of fast food (p = 0.011). The more hours children spent in front of screens, the less adherence they had to the Mediterranean Diet (p = 0.001) and less natural FFs consumption (p = 0.001).

CONCLUSIONS

The results suggest that screen time seems to affect children's eating behaviors. The study concluded that the longer the screen time, the unhealthier the dietary habits of schoolchildren become. Future research should focus on reducing screen time, as a means of improving dietary patterns and potentially reducing childhood obesity.

Next Steps in Efforts to Address the Obesity Epidemic

Obesity prevalence continues to rise globally at alarming rates, with adverse health and economic implications. In this state-of-the-art review, we provide an analysis of selected evidence about the current knowledge in the obesity literature, including a synthesis of current challenges in obesity and its determinants. In addition, we review past and current efforts to combat the obesity epidemic, highlighting both successful efforts and areas for further development. Last, we offer insights into the next steps to address the obesity epidemic and advance the field of obesity through both research and practice by (a) adopting a systems perspective, (b) fostering cross-sector and community collaborations, (c) advancing health equity, (d) narrowing the research-to-practice and research-to-policy gaps with multidisciplinary approaches, and (e) embracing complementary approaches for concurrent obesity prevention and treatment.

Added Sugar Intake from Infant Formula and Complementary Foods: A Longitudinal Investigation and Implications for Infant Weight Gain

BACKGROUND

Infant formula contains added sugar, although national recommendations are that added sugar should be avoided for infants.

OBJECTIVES

This study aims to estimate average daily added sugar intake from formula and complementary foods and examine associations between added sugar intake from formula and complementary foods and weight status among infants in low-income households.

METHODS

Between August 2019 and November 2021, mother-infant dyads were recruited from a pediatric clinic primarily serving Medicaid recipients, regardless of feeding type. 24-h feeding recalls were conducted on infants aged 6, 9, and 12 mo. For directly breast-fed infants, we used the average expected milk volume intake by age. Weight-for-age and weight-for-length z-scores were calculated from health record measurements. Descriptives, bivariate tests, and multilevel linear growth modeling were used.

RESULTS

Most participants (n = 234) were African American (39%) or Latino (38%). Infants' daily added sugar intake was on average 7 g from complementary foods and 33 g from formula, with formula being the major source at 6 and 9 mo. Daily intake of calories due to added sugar was significantly higher among formula-fed infants compared with breast milk or sugar-free formula-fed infants (P = 0.034). For every 10 g of added sugar from formula daily, infants' weight-for-length z-scores increased by an average of 0.060 (SE = 0.018, P = 0.001).

CONCLUSIONS

Formula significantly contributes to added sugar intake among infants compared with complementary foods. A significant positive association between added sugar from formula and infant weight gain suggests the need for regulations limiting added sugar in formula and including added sugar information on formula food labels.

'Soft drinks are normal': understanding the lived experiences of Dutch teenagers with respect to sugar-sweetened beverages: a qualitative context-mapping study

BACKGROUND

Despite continuing efforts to reduce teenagers' consumption of sugar-sweetened beverages (SSBs), intake remains high across the globe. Currently, we lack a holistic understanding that also includes the lived experiences of teenagers in today's online and offline environments regarding the role of SSB's. The aim of the present paper is therefore twofold: (1) to gain a holistic understanding of teenagers' perspectives, beliefs, barriers, contextual triggers and latent needs (that is, their lived experiences) in relation to SSB consumption; and (2) to explore their views about which intervention strategies would be most likely to reduce their SSB consumption.

METHODS

A qualitative context-mapping approach, including prior sensitising assignments, was used to gain in-depth insights into the lived experiences with regard to SSB consumption of teenagers attending prevocational-level secondary school (VMBO) and living in low socioeconomic position neighbourhoods in Amsterdam, the Netherlands. From March to April 2021, 48 teenagers, aged 12 to 16, took part in the study. Due to COVID-19 restrictions, data were collected partly online and partly in person. All data were coded and analysed using thematic analysis.

RESULTS

Four main themes were identified that appeared to influence the teenage SSB consumption: (1) social norms - drinking SSBs is normal; (2) attitudes and beliefs with regard to health versus enjoyment; (3) the easy availability and affordability of SSBs; and (4) intense industry marketing efforts. We additionally explored teenage views about changes most likely to reduce their SSB consumption and found that they would be receptive to population-level interventions such as taxation.

CONCLUSIONS

The study provides comprehensive insights into teenagers' lived experiences in relation to SSBs. It highlights the prominent roles of strong social norms, conflicting beliefs, and the pervasive marketing, easy availability and low prices of SSBs. This underlines the need for a systems approach, applying combinations of effective, integrated strategies that can be specifically tailored to the perspectives of today's teenagers.

Association of sugar-sweetened beverage consumption and cardiorespiratory fitness with executive function: a cross-sectional survey based on Tajik adolescents at high altitude in China

Background

Executive function has a significant impact on adolescents' academic and future achievement and is strongly associated with multiple factors. However, few studies have examined the association between sugar-sweetened beverage (SSB) consumption, cardiorespiratory fitness, and executive function. Moreover, no research studies have been found on Tajik adolescents at high altitudes in China. The present study aimed to understand the associations between SSB consumption, cardiorespiratory fitness, and executive function among Tajik adolescents in high-altitude areas of China. To accumulate information on the physical and mental health development of Tajik adolescents in high-altitude areas of China.

Methods

In this study, a cross-sectional assessment of SSB consumption, cardiorespiratory fitness, and executive function was conducted on 1,121 Tajik adolescents aged 13-15 years at high altitude in China in 2023. One-way analysis of variance (ANOVA), binary logistic regression analysis, and ordered logistic regression analysis with a generalized linear model were used to analyze the associations that existed between SSB consumption and cardiorespiratory fitness and executive function.

Results

The proportions of Tajik adolescents aged 13-15 years with SSB consumption of ≤1 time/week, 2-5 times/week, and ≥ 6 times/week were 14.6, 51.6, and 33.8%, respectively, in high-altitude areas of China. The VO2max of Tajik adolescents was (37.17 ± 5.52) ml.kg.min-1. The inhibit control function response, refreshing memory function response, and switching flexibility function response of Chinese Tajik adolescents were (19.71 ± 5.86) ms, (1114.39 ± 356.85) ms, (382.2 ± 213.4) ms. Overall, using the SSB consumption ≤1 times/w and VO2max of the Q4 group as the reference group, ordered logistic regression analysis showed that Tajik adolescents with SSB consumption ≥5 times/w and VO2max of the Q1 group experienced inhibit control function dysfunction (OR = 28.80, 95%CI: 10.23 ~ 81.07), refreshing memory function dysfunction (OR = 6.79, 95%CI: 3.19 ~ 14.43), switching flexibility function dysfunction (OR = 13.10, 95%CI: 5.59 ~ 30.70) were at increased risk (p < 0.001).

Conclusion

SSB consumption and cardiorespiratory fitness were associated with executive function in Tajik adolescents at high altitudes in China. Increased frequency of SSB consumption and decreased cardiorespiratory fitness increased the risk of executive function disorders in Tajik adolescents. In the future, SSB consumption and cardiorespiratory fitness should be effectively controlled in Tajik adolescents to improve their executive function and promote the physical and mental health of Tajik adolescents in high-altitude areas.

Effectiveness of behavioural and psychological interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) of behavioural and psychological interventions for managing paediatric obesity.

METHODS

Eligible studies, published between 1985 and 2022, included 0 to 18 year olds with outcomes reported ≥3 months post-baseline, including patient-reported outcome measures (PROMs), cardiometabolic and anthropometric outcomes, and adverse events (AEs). We pooled data using a random effects model and assessed certainty of evidence (CoE) related to minimally important difference estimates for outcomes using GRADE.

RESULTS

We included 73 unique RCTs (n = 6305 participants, 53% female). Intervention types included physical activity (n = 1437), nutrition (n = 447), psychological (n = 1336), technology-based (n = 901) or multicomponent (≥2 intervention types, n = 2184). Physical activity had a small effect on health-related quality of life (HRQoL), varying effects ranging from moderate to very large on blood pressure, lipids and insulin resistance, and a small effect on BMIz. Nutrition had a small effect on lipids, insulin resistance and BMIz. Psychological interventions showed a small effect on HRQoL and triglycerides and moderate benefits on depressive symptoms, while technology interventions showed small benefits on blood pressure and BMIz. Multicomponent interventions had a large benefit on anxiety, small benefit on depressive symptoms, with large to very large benefits on lipids, and small benefits for diastolic blood pressure, insulin resistance and BMIz. AEs were reported infrequently, and when reported, were described as mild.

CONCLUSION

Physical activity and multicomponent interventions showed improvements in PROMs, cardiometabolic and anthropometric outcomes. Future trials should consistently measure PROMs, evaluate outcomes beyond the intervention period, and study children <6 years of age.

Differences in frequency of selected risk factors of overweight and obesity in adolescents in various social environments within Slovakia

OBJECTIVES

Analysis of subnational regional differences in frequency of selected risk factors of overweight and obesity in adolescents in Slovakia.

STUDY DESIGN

Cross-sectional study.

METHODS

Health Behaviour in School-aged Children is an international cross-sectional questionnaire study using the standard protocol to create representative samples of adolescents. We analyse subnational regional differences in the occurrence of selected risk factors of overweight and obesity among 10-12-year-old (n = 4194) and 14-16-year-old (n = 3806) respondents of a survey conducted in Slovakia in 2022.

RESULTS

Overweight and obesity dominated especially in the regions with the Hungarian minority among boys aged 10-12 years (29.2 %) and 14-16 years (34.0 %). Consumption of energy (24.9 % of girls and 29.9 % of boys) and sweetened (25.0 % of girls and 27.1 % of boys) drinks dominated among 14-16-year-old respondents in the poverty regions with socio-economic problems. Skipping breakfast was most widespread among 14-16-year-old girls from regions with a Hungarian minority (72.6 %). Insufficient physical activity was most frequent among 10-12-year-old respondents, namely, in the poverty regions (85.0 % of girls) and the Hungarian minority (79.6 % of boys) regions. The differences also remained significant after weighting for a possible confounding effect of family socioeconomic status.

CONCLUSIONS

The regional social environment is associated with selected aspects of adolescents' behaviour related to overweight and obesity, namely, the poverty regions and Hungarian minority environments, and can be considered as an independent determinant regardless of a family background.

The Mediating Effect of Concurrent Changes in Dietary Behaviors on the Associations Between Intervention and Changes in Adiposity Outcomes: Evidence from a Cluster-Randomized Controlled Trial

Behavioral interventions have been shown to be effective in improving dietary behavior and reducing childhood obesity. There is limited evidence on how concurrent changes in dietary behavior from intervention studies affect childhood obesity. The present study aimed to evaluate the mediating effect of concurrent changes in dietary behaviors between the intervention and changes in adiposity indicators. This study included 1180 children from the DECIDE-Children study, which was conducted across three areas in China, aiming to promote children's healthy diet and physical activity, while also engaging schools and families to support children's behavioral changes. Dietary behaviors were collected by a revised version of the Food Frequency Questionnaire and a self-designed questionnaire. Adiposity outcomes were objectively measured by trained personnel. Generalized linear mixed models were used to estimate the association between scores of dietary behavioral changes and adiposity indicator changes. Mediation analyses were used to evaluate how scores of dietary behavioral changes mediated the effect of intervention on adiposity indicator changes. Six hundred children in the intervention group and five hundred and eight in the control group with both baseline and follow-up data were included. Each increase in dietary behavioral change score was associated with a 0.06 (p = 0.016) decrease in changes in BMI and other adiposity indicators. Scores of dietary behavioral changes mediated 13.87% (p < 0.001), 11.81% (p < 0.001), 17.60% (p = 0.024), and 16.78% (p = 0.032) of the association between intervention and changes in body mass index (BMI), BMI z-score, body fat percentage, and waist circumference, respectively. Scores of dietary behavioral changes mediated the intervention effect on adiposity indicator changes. Future interventions targeting childhood obesity should incorporate promoting multiple dietary behaviors simultaneously.

Association between body esteem and sugar-sweetened beverage intake among Chinese undergraduate students: a cross-sectional study

Background

High intake of sugar-sweetened beverages has been linked to a range of physical, psychological, and emotional issues. Although there were various factors influencing sugar-sweetened beverage intake, the relationship between body esteem and sugar-sweetened beverage intake remains unclear. This study aimed to investigate the association between three dimensions of body esteem (body esteem-appearance, body esteem-attribution, and body esteem-weight) and the likelihood of high sugar-sweetened beverage intake.

Methods

A cross-sectional study was conducted among undergraduate students at Nanjing University of Chinese Medicine. Logistic regression analyses were used to assess the association between the three dimensions of body esteem and the risk of high sugar-sweetened beverage intake. Additionally, restricted cubic splines and subgroup analyses were implemented to further explore the associations.

Results

A total of 969 participants were included in the study, with 771 females (79.6%). The mean age of the participants was 20.07 years (standard deviation [SD] = 1.65). After adjusting for covariates, body esteem-appearance was found to be negatively associated with high sugar-sweetened beverage intake (OR = 0.962, 95% CI = 0.935-0.989, p = 0.007), while body esteem-attribution was positively associated with high sugar-sweetened beverage intake (OR = 1.091, 95% CI = 1.046-1.139, p < 0.001). However, no significant association was found between body esteem-weight and high sugar-sweetened beverage intake (p = 0.781). Restricted cubic spline plots showed no non-linear associations between any dimensions of body esteem and the risk of high sugar-sweetened beverage intake (p-nonlinear was 0.912, 0.225, 0.109, respectively). Subgroup analyses revealed no significant interactions.

Conclusion

These findings underscored the significance of targeted health promotion strategies and provided references for educational institutions or governmental bodies to steer undergraduate beverage consumption toward healthier patterns.

Anthropometric Measurements and Weight Management Nutrition Knowledge: A Cross-Sectional Study in Turkey

This study aimed to examine the relationships between academic programs, gender, anthropometric measurements, and the Weight Management Nutrition Knowledge Questionnaire (WMNKQ) score. Results indicated that 37.7% of male and 15.3% of female students were overweight, with significant gender differences in BMI, waist/height ratio, waist/hip ratio, and waist circumference (all p < .001, except waist circumference p = .024). WMNKQ scores also varied significantly by gender and BMI classification (p < .05). Students in health-related fields scored higher on nutrition knowledge than those in other faculties (p = .000). Findings emphasize the importance of weight management among university students, who may face lifestyle changes affecting healthy eating habits.

Associations of Food Group Intakes with Serum Carbon Isotope Ratio Values in Youth: Results from 2 Prospective Pediatric Cohort Studies

BACKGROUND

The carbon isotope ratio (CIR) is a candidate biomarker for sugar-sweetened beverage (SSB) intake in the United States. However, research specific to youth, who differ in their physiology and dietary patterns compared with adults, is lacking.

OBJECTIVES

We evaluated longitudinal associations of SSB intakes across childhood/adolescence with serum CIR. We also explored the relationship between other dietary intakes and serum CIR.

METHODS

Data were from participants in two longitudinal, pediatric cohorts in Colorado: Exploring Perinatal Outcomes among CHildren (EPOCH) study (visits at median 10 and 16 y, n = 150) and Healthy Start Study (visits at median 5 and 9 y, n = 166). Serum CIR was measured using isotope ratio mass spectrometry. Diet was assessed by food-frequency questionnaires (EPOCH) or 24-h diet recalls (Healthy Start). We assessed associations of longitudinal dietary intakes (log2-transformed, standardized) with serum CIR using linear mixed models adjusted for age, sex, and energy intake, and associations of change values between visits using linear regression models.

RESULTS

In linear mixed models, higher SSB intake across visits was associated with higher serum CIR in both cohorts [β (95% confidence interval (CI)): 0.11 (0.06, 0.15) in EPOCH and 0.14 (0.07, 0.21) in Healthy Start]. Higher meat intake and a higher dietary animal protein ratio were also positively associated with serum CIR in both cohorts [β (95% CI): 0.08 (0.05, 0.12) and 0.18 (0.13, 0.23) in EPOCH; 0.08 (0.01, 0.16) and 0.28 (0.21, 0.35) in Healthy Start]. In change analyses, there were positive associations for changes in the dietary animal protein ratio between visits with changes in serum CIR in both cohorts, but not for changes in SSB intake.

CONCLUSIONS

Our findings support serum CIR as a potential biomarker of SSB intake in youth cross-sectionally; however, there was not a strong link between change values over longer-term follow-up. Meat/animal protein intake was also consistently and, at times, more strongly associated with serum CIR.

Associations Between Knowledge of Health Conditions and Sugar-Sweetened Beverage Intake Among US Adults, 2021

BACKGROUND

Frequent consumption of sugar-sweetened beverages (SSB) is associated with an increased risk of some health outcomes.

OBJECTIVE

We investigated the relationships between knowledge of health risks related to SSB and SSB intake among adults.

METHODS

This cross-sectional study utilized data from the 2021 SummerStyles survey. There were 4022 US adult participants (≥18 years). The outcome variable was SSB intake (none, >0 to <1, 1 to <2, or ≥2 times/day). The exposure variables were knowledge of the association between SSB and seven health conditions. Statistical analyses included seven multinomial regressions to estimate adjusted odds ratios (AOR) for the consumption of SSB according to knowledge of SSB-related health risks after controlling for sociodemographics.

RESULTS

Overall, about 30% of adults consumed SSB ≥ 2 times/day. While most adults identified SSB-related conditions such as weight gain (84.0%), diabetes (78.4%), and cavities (74.2%) as being related to drinking SSB, fewer adults recognized related conditions, such as some cancers (23.9%), high cholesterol (28.4%), heart disease (33.5%), and high blood pressure (37.8%). Knowledge of any of the health conditions was not significantly associated with consuming SSB ≥ 2 times/day compared to non-SSB consumers.

CONCLUSIONS

Knowledge of SSB-related health conditions varied by sociodemographics but was not associated with high SSB intake. Future studies could explore other factors beyond knowledge that may influence adults' high SSB intake.

Effects of increased availability and economic incentives on preadolescents' healthier beverages choices: An experimental study

This field experimental study examined how increased availability and economic incentives for healthier beverages affect preadolescents' actual healthier beverage choices in a real-world setting. In addition, the impact of preadolescents' descriptive norm towards healthier beverages, price awareness and parental restrictive rules regarding beverage consumption were explored. During the experiment, preadolescents could independently buy two beverages from an assortment with a total of eight beverages. A 2x2 between-subjects design was used, manipulating the presence of increased availability of healthier beverages and economic incentives (taxes for unhealthier beverages and subsidies for healthier beverages). A total of 305 preadolescents between 8 and 14 years old (M = 10.18, SD = 1.74) participated, each accompanied by one of their respective parents. Results showed that preadolescents were more likely to choose healthier beverages and perceived a higher descriptive norm towards healthier beverages when the assortment included increased relative availability of healthier beverages. Economic incentives and price awareness did not impact healthier beverage choices. Preadolescents were less likely to choose healthier beverages when parents reported higher levels of restrictive rules regarding beverage consumption. Results of the study suggest that increasing relative availability of healthier options could be a promising intervention strategy to support preadolescents in making healthier choices.

Temporal changes and educational disparities in the frequent consumption of sugar-sweetened beverages among Estonian adults during 2006-2022

Objectives

Excessive consumption of sugar-sweetened beverages (SSBs) contributes to adverse health outcomes but is differentiated by socio-economic indicators. The study analyses the educational disparities in adults frequent consumption of sugar-sweetened beverages (SSBs) in Estonia and its temporal changes between 2006 and 2022.

Study design

Repeated cross-sectional survey.

Methods

Nationally representative data from 9 biennial cross-sectional surveys on 25-64-year-old Estonian residents (n = 20396) was used for the study. Changes in frequent (on 6-7 days per week) consumption of SSBs by study year, sex, age, and education is analysed using descriptive statistics and binomial logistic regression. Prevalence and odds ratios (OR) with 95 % confidence intervals (CIs) are presented focusing on temporal and educational patterns in frequent SSB consumption.

Results

The prevalence of frequent SSB consumption among Estonian adults declined consistently from 2006 (14.0 %) to 2018 (5.2 %), followed by statistically non-significant increases in 2020 (6.8 %) and 2022 (7.1 %). Prevalence of frequent SSB consumption was significantly (p < 0.01) higher among adults with primary or lower education (12.4 %) compared to tertiary education group (4.8 %). The educational differences in SSB consumption (12.4 % in primary or lower vs. 4.8 % in tertiary education) were nearly three-fold after adjusting for sex, age, and period effects (OR 2.84, 95 % CI 1.71-4.74) and have been consistent since 2010.

Conclusions

Although frequent consumption of SSBs has been generally decreasing among Estonian adults, the findings illustrate the persisting educational gradients in exposure that expectedly translates into socio-economic inequalities in adverse health outcomes resulting from excessive SSB consumption.

Individual and environmental correlates of tap water consumption among adolescents in Canada

The study objective was to identify correlates of tap water consumption among adolescents. French-speaking adolescents from the province of Québec (Canada) were recruited in person and online from March to July 2023 using diverse recruitment strategies. Water consumption was measured using the validated French version of a questionnaire specifically designed to measure adolescents' beverage intake. Participants answered an online survey on their attitude towards tap and bottled water which also measured individual and environmental factors that can influence tap water consumption. A total of 218 adolescents (14-17 years; 55.5% female) completed the survey. On average, 79.2% of adolescents' water intake came from tap and 33.5% of them consumed exclusively tap water. Thinking that bottled water is more convenient than tap water was a significant correlate of adolescents' tap water consumption (OR = 0.70; 95% CI: 0.51, 0.95; p = 0.0219). Adolescents who believed that bottled water is more convenient than tap water were less likely to consume exclusively tap water. Public health interventions aimed at promoting adolescents' tap water should strive to make tap water intake be perceived as convenient as bottled water, such as encouraging teenagers to always carry along a reusable water bottle, installing drinking fountains in popular public areas, and increasing the visibility of such fountains.

The extent of outdoor food and beverage advertising surrounding primary and secondary schools in poorly resourced townships in Cape Town, South Africa

BACKGROUND

The targeted marketing of unhealthy food and beverages to vulnerable populations, particularly children and adolescents in lower-income communities, is pervasive and coincides with increased non-communicable disease (NCD) rates. This study examined the extent of food and beverage advertising surrounding schools in three townships in Cape Town, South Africa: Gugulethu, Nyanga, and Kensington.

METHODOLOGY

Trained fieldworkers used web-based surveys on smartphones to capture all observable outdoor food and beverage advertisements in the three townships. Surveys recorded product brand, type, placement, Global Positioning System (GPS) coordinates, and a digital photograph. Advertisements were categorised as sugar-sweetened beverages (SSBs), unhealthy food (excluding beverages), alcohol, staple food, and miscellaneous food, following the INFORMAS Outdoor Food Advertising Protocol. Advertisements visible within 100m- and 400m buffer zones surrounding primary and secondary schools were mapped using the Quantum Geographic Information System (QGIS) software. Descriptive analyses were conducted to determine the extent of outdoor food and beverage advertising surrounding schools.

RESULTS

We mapped 26 primary and 7 secondary schools, observing 253 and 1587 food and beverage advertisements within 100m and 400m of schools, respectively. Unhealthy advertisements comprised 69.9% and 68.5% of all observations within 100m- and 400m zones, respectively. There were 117 SSB, 57 unhealthy food, 3 alcohol, 64 staple food, and 12 miscellaneous food advertisements within 100m zones. Nyanga zones contained the most SSB (71, 60.7%) and unhealthy food advertisements (37, 64.9%). Secondary schools had higher SSB advertisement rates than primary schools (p < 0.001). Within 400m zones, there were 623 SSB, 370 unhealthy food, 93 alcohol, 445 staple food, and 56 miscellaneous food advertisements, with Nyanga leading in SSB (335, 53.8%) and unhealthy food advertisements (224, 54.9%).

CONCLUSION

The results highlight a concerning level of exposure to unhealthy food and beverage advertisements around schools, particularly secondary schools in low-income townships. This could have implications for the dietary choices and health of students in these areas. The findings underscore the need for policy interventions and community awareness programs to address and regulate the advertising environment around schools, promoting healthier food and beverage choices for students.

Practice Recommendations for Metabolic Dysfunction-Associated Steatotic Liver Disease by the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN)

JUSTIFICATION

There has been an alarming increase in metabolic dysfunction-associated steatotic liver disease (MASLD) and it is now the most common chronic liver disease worldwide, in both adult and pediatric populations. The lack of regional guidelines has hampered the formulation of national policies for prevention and management of MASLD in children. Therefore, we formulated recommendations for steatotic liver disease in children.

OBJECTIVES

To review the existing literature on the burden and epidemiology of pediatric MASLD and formulate recommendations for diagnostic evaluation, prevention, and management strategies.

PROCESS

The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international stakeholders to participate in a consensus meeting held on April 20, 2024, in Mumbai, Maharashtra, India. Various aspects of pediatric steatotic liver disease were deliberated upon and a consensus document and recommendations were formulated after several rounds of discussion.

RECOMMENDATIONS

Metabolic dysfunction-associated steatotic liver disease (MASLD) should be used as the preferred term in place of non-alcoholic fatty liver disease (NAFLD). There is a high prevalence of steatotic liver disease (SLD) among Indian children and adolescents, especially those who are overweight or obese. This condition may be progressive in childhood and associated with increased morbidity and mortality in adulthood. Various lifestyle, dietary, and genetic factors may predispose individuals to MASLD, including an increased intake of calorie-dense processed foods, sweetened sugar beverages, excessive screen time, higher sedentary time and lack of moderate to vigorous physical activity. MASLD is usually asymptomatic or presents with mild, non-specific symptoms and therefore, a high degree of suspicion is required for early diagnosis. MASLD is usually associated with cardiometabolic factors (hypertension, insulin resistance/diabetes mellitus, and/or dyslipidemia) and secondary causes should be excluded in all cases, particularly in the presence of red flag signs. Screening for MASLD should be considered in all obese children (body mass index or BMI ≥95th percentile) and in all overweight children (BMI ≥ 85th and <95thpercentile) with additional risk factors, such as prediabetes/diabetes, dyslipidemia, positive family history of metabolic syndrome, obstructive sleep apnea, and hypopituitarism. Abdominal ultrasound in combination with alanine aminotransferase (ALT) levels should be used as a screening test for MASLD in Indian children as per the proposed algorithm. Diet (any hypocaloric diet) and exercise (aerobic, resistance, or a combination of both; moderate to high intensity; regular in frequency) remain the cornerstones of pediatric MASLD management. Pharmacotherapy and/or endoscopic/surgical techniques for obesity should be considered as adjuncts and should be considered only after a failed adequate trial of lifestyle modifications.

Children's self-reported exposure to sugary beverage advertisements and association with intake across six countries before and during the COVID-19 pandemic: a repeat cross-sectional study

BACKGROUND

Children's exposure to sugary beverage advertising may have changed during the COVID-19 pandemic due to shifts in media habits, which could subsequently have influenced intake. This study aimed to examine: 1) children's frequency and setting of exposure to advertisements of sugary beverages in six countries before and during the COVID-19 pandemic; 2) the association between exposure to sugary beverage advertisements and intake.

METHODS

Children aged 10-17 years (n = 28,908) in Australia, Canada, Chile, Mexico, the United Kingdom (UK) and the United States (US) completed online surveys in 2019, 2020 and 2021 as part of the International Food Policy Study using a repeat cross-sectional study design. Respondents self-reported frequency and setting of exposure to sugary beverage advertisements, location of school classes (in-person/online, 2020-2021 only), screen time, and sugary beverage intake. Adjusted weighted logistic and negative binomial regression models stratified by country examined associations between year and reported sugary beverage advertising exposure, and associations between sugary beverage advertising exposure and intake. Differences in reported advertising exposure between students taking online or in-person school classes were explored.

RESULTS

Self-reported exposure to advertisements for sugary beverages at least weekly was relatively stable across years within countries, with differences in settings of exposure. Exposure to sugary beverage advertisements increased on digital media independently of screen time from 2019 to 2021 in Australia, Canada, the UK and US, with a concomitant decrease in exposure in retail settings in all countries except the UK. In Australia and the UK, children attending all classes online were more likely to report at least weekly (vs less than once a week) exposure to sugary beverage advertisements, and children attending all classes online were more likely to report exposure to advertisements on digital media and in other settings (e.g., billboard, magazines) compared to children attending in-person classes in Australia, Canada and the UK. Exposure to sugary beverage advertisements at least weekly (IRR = 1.12,99%CI:1.09-1.15) and in each of the settings was associated with sugary beverage intake.

CONCLUSIONS

Exposure to digital advertisements for sugary beverages increased from 2019 to 2021 in most countries, and exposure was associated with sugary beverage intake. Reducing children's exposure to advertising of less healthy foods, including on digital media, may reduce sugary beverage intake.

Long-term metabolic effects of non-nutritive sweeteners

OBJECTIVE

Excessive consumption of added sugars has been linked to the rise in obesity and associated metabolic abnormalities. Non-nutritive sweeteners (NNSs) offer a potential solution to reduce sugar intake, yet their metabolic safety remains debated. This study aimed to systematically assess the long-term metabolic effects of commonly used NNSs under both normal and obesogenic conditions.

METHODS

To ensure consistent sweetness level and controlling for the acceptable daily intake (ADI), eight weeks old C57BL/6 male mice were administered with acesulfame K (ace K, 535.25 mg/L), aspartame (411.75 mg/L), sucralose (179.5 mg/L), saccharin (80 mg/L), or steviol glycoside (Reb M, 536.25 mg/L) in the drinking water, on the background of either regular or high-fat diets (in high fat diet 60% of calories from fat). Water or fructose-sweetened water (82.3.gr/L), were used as controls. Anthropometric and metabolic parameters, as well as microbiome composition, were analyzed following 20-weeks of exposure.

RESULTS

Under a regular chow diet, chronic NNS consumption did not significantly affect body weight, fat mass, or glucose metabolism as compared to water consumption, with aspartame demonstrating decreased glucose tolerance. In diet-induced obesity, NNS exposure did not increase body weight or alter food intake. Exposure to sucralose and Reb M led to improved insulin sensitivity and decreased weight gain. Reb M specifically was associated with increased prevalence of colonic Lachnospiracea bacteria.

CONCLUSIONS

Long-term consumption of commonly used NNSs does not induce adverse metabolic effects, with Reb M demonstrating a mild improvement in metabolic abnormalities. These findings provide valuable insights into the metabolic impact of different NNSs, aiding in the development of strategies to combat obesity and related metabolic disorders.

Chronic Use of Artificial Sweeteners: Pros and Cons

Over the past few decades, the scientific community has been highly concerned about the obesity epidemic. Artificial sweeteners are compounds that mimic the sweet taste of sugar but have no calories or carbohydrates; hence, they are very popular among patients suffering from diabetes or obesity, aiming to achieve glycemic and/or weight control. There are four different types of sweeteners: artificial, natural, rare sugars, and polyols. Artificial and natural sweeteners are characterized as non-nutritional sweeteners (NNSs) since they do not contain calories. The extended use of sweeteners has been reported to have a favorable impact on body weight and glycemic control in patients with type 2 diabetes (T2DM) and on tooth decay prevention. However, there is concern regarding their side effects. Several studies have associated artificial sweeteners' consumption with the development of insulin resistance, nonalcoholic fatty liver disease (NAFLD), gastrointestinal symptoms, and certain types of cancer. The present review focuses on the description of different types of sweeteners and the benefits and possible deleterious effects of the chronic consumption of NNSs on children's health. Additionally, possible underlying mechanisms of the unfavorable effects of NNSs on human health are described.

The Impact of Light-Dark Cycle Alteration on the Acceleration of Type 1 Diabetes in NOD Mice Model

Objective

We aimed to evaluate the effect of light-dark cycle alteration and soft drink consumption on the acceleration of type 1 diabetes mellitus (T1DM) development among non-obese diabetic (NOD) mice model.

Methods

We exposed female NOD and C57BL/6 mice from the age of 5 weeks to either adlib soft drink consumption and/or T20 light-dark cycle alteration until the development of diabetes, or the mice reached the age of 30 weeks. Each group consisted of 7-15 mice. We monitored weight, length, blood glucose level, and insulin autoantibody (IAA) levels weekly.

Results

Out of 75 NOD and 22 C57BL/6 mice, 41 NOD mice developed diabetes, and 6 mice died between 7 and 8 weeks of age. The mean time to development of T1DM among NOD control mice was 20 weeks. The time to development of T1DM was accelerated by two weeks in the NOD mice exposed to light-dark cycle alteration, hazard ratio of 2.65,95th CI (0.70, 10.04) p = 0.15). The other groups developed T1DM, similar to the control group.

Conclusion

There was a trend toward earlier development of T1DM among NOD mice exposed to light-dark cycle alteration, but this difference was not statistically significant. Further studies are needed to confirm our findings using larger sample sizes and different animal species.

Development and Validation of the Meiji Nutritional Profiling System per Serving Size

Serving size may be the appropriate reference for calculating food nutritional value. We aimed to assess the nutritional values of Japanese foods based on serving sizes rather than per 100 g by adapting the Meiji Nutritional Profiling System (Meiji NPS). Given the variability in serving sizes across countries, we used Japanese serving sizes to calculate the Meiji NPS scores. We confirmed the convergent validity of the Meiji NPS scores per serving size with the Nutrient-Rich Food Index 9.3 using Spearman's correlation coefficients (r = 0.51, p < 0.001). Food groups recommended by official guidelines, such as pulses, nuts and seeds, fish and seafood, fruits, vegetables, and milk and milk products, scored relatively high. Furthermore, the nutrient density scores of food items with small serving sizes, such as mushrooms, algae, seasonings, and fats and oils, were moderated when calculated by per serving size, despite having considerably higher or lower scores per 100 g. These results indicate that calculating NPS per serving size allows for the assessment of the nutritional value of food items in accordance with actual consumption quantities. Therefore, the Meiji NPS calculated per serving size, alongside the per 100 g version, may be useful for dietary management depending on specific purposes.

Prevalence and Predictors of Soft Drink Consumption among Adolescents in the Gulf Countries: Findings from National Surveys

BACKGROUND AND OBJECTIVES

This study aimed to investigate the prevalence and predictors of soft drink consumption among adolescents in the Gulf Cooperation Council (GCC) countries using nationally representative data from the Global School-based Student Health Survey (GSHS).

MATERIALS AND METHODS

Cross-sectional data were collected using a self-administered questionnaire in a school survey and included 22,116 adolescents aged 12-18 years from Bahrain, Kuwait, Oman, Qatar, and the United Arab Emirates. Data were collected and analyzed using complex survey methods. The GSHS was not available for Saudi Arabia. Soft drink consumption was the main outcome variable. Multivariable logistic regression was used to examine its associations with sociodemographic characteristics, dietary behaviors, parental factors, and health-related behaviors.

RESULTS

The prevalence of soft drink consumption three or more times per day ranged from 10.6% to 26.8% across the countries, with the highest being in Qatar. Adjusted analyses showed that girls had lower odds of SD consumption compared to boys (OR = 0.66; 95% CI: 0.57-0.77). Food insecurity, a proxy for low socioeconomic status, was associated with twice the odds of frequent consumption (OR = 2.06; 95% CI: 1.75-2.43). Parental smoking and low physical activity levels were also associated with higher soft drink intake (OR = 1.46, 95% CI: 1.13-1.88 and OR = 1.18, 95% CI: 1.08-1.28, respectively), while obesity showed a weak positive association.

CONCLUSIONS

Daily soft drink consumption was highly prevalent among adolescents in the GCC countries. Sociodemographic, behavioral, and health-related factors were significantly associated with frequent intake. These findings highlight the need for comprehensive, multi-sectoral interventions to reduce soft drink consumption in the region.

Energy-Dense and Low-Fiber Dietary Pattern May Be a Key Contributor to the Rising Obesity Rates in Brazil

Hybrid methods are a suitable option for extracting dietary patterns associated with health outcomes. This study aimed to identify the dietary patterns of Brazilian adults (20-59 years old; n = 28,153) related to dietary components associated with the risk of obesity. Data from the 2017-2018 Brazilian National Dietary Survey were analyzed. Food consumption was obtained through 24 h recall. Dietary patterns were extracted using partial least squares regression, using energy density (ED), percentage of total fat (%TF), and fiber density (FD) as response variables. In addition, 32 food groups were established as predictor variables in the model. The first dietary pattern, named as energy-dense and low-fiber (ED-LF), included with the positive factor loadings solid fats, breads, added-sugar beverages, fast foods, sauces, pasta, and cheeses, and negative factor loadings rice, beans, vegetables, water, and fruits (≥|0.15|). Higher adherence to the ED-LF dietary pattern was observed for individuals >40 years old from urban areas, in the highest income level, who were not on a diet, reported away-from-home food consumption, and having ≥1 snack/day. The dietary pattern characterized by a low intake of fruits, vegetables, and staple foods and a high intake of fast foods and sugar-sweetened beverages may contribute to the obesity scenario in Brazil.

An Evaluation of Healthy Hydration Recommendations for 93 Countries with Sugary Beverage Tax Legislation Globally, 2000-2023

Adequate water intake is essential for human health. Sugary beverage taxes are a best buy policy to reduce obesity and diet-related non-communicable diseases. Food-based dietary guidelines (FBDGs) promote healthy dietary patterns. The study purpose was to evaluate national FBDGs for countries with sugary beverage tax legislation (2000-2023) to promote water and discourage sugary beverage consumption. We developed a coding framework to conduct a content analysis of FBDG documents, and used six indicators to identify messages and images to assign healthy hydration recommendation (HHR) scores from 0-12 to compare FBDGs across countries and six regions. Results showed 93 countries with sugary beverage tax legislation of which 58 countries (62%) had published FBDGs (1998-2023). Of 58 FBDGs reviewed, 48 (83%) had complementary recommendations that encouraged water and discouraged sugary beverages. Of 93 countries, 13 (14%) had the highest HHR scores (11-12); 22, (24%) had high HHR scores (9-10); 20 (21%) had medium HHR scores (4-8); 3 (3%) had low HHR scores (0-3); and 35 (38%) countries had no FBDGs. To reduce health risks for populations, governments must ensure policy coherence to optimize sugary beverage tax impacts by developing FBDGs that encourage water and discourage sugary beverages complementary to national policies.

"Coke's not a food": A critical discourse analysis of sugar-sweetened beverage tax acceptability by white residents from an upper-middle class neighborhood in Winnipeg Manitoba

Increasing concerns about the health impacts of sugar consumption has led to the proposition of a sugar-sweetened beverage (SSB) tax in Canada. However, competing concerns related to stigma and equity remain and have not been explored in a Canadian context. As part of a broader study examining the perspectives of various populations on SSB tax acceptability, we examined how residents of an upper-middle class neighborhood conceptualize SSB tax acceptability, and we explored the discourses that inform their discussion. We conducted and analyzed qualitative, semi-structured interviews with residents of an upper-middle class neighborhood in Winnipeg, Manitoba, Canada. Recruitment criteria were residence, adults, and English speaking. Critical discourse analysis methodology was used, and healthism (health moralism) and tax psychology informed the analysis. Eighteen participants volunteered: 15 females and 3 males; all self-identified as white, and all spoke about (grand)parenting. Healthist discourse was utilized in supportive discussion of SSB taxation. With the mobilization of healthism, ideal citizens and parents were described as "health conscious" and those who might be likely to reduce SSB intake because of taxation. Healthism also contributed to their identification of beverages targeted by a tax, versus those they deemed as having redeeming nutritional qualities. Limits to SSB tax support were expressed as fairness concerns, with a focus on the procedural justice of the tax. Participants supported SSB taxation and the discourses they employed suggested support for the tax was perceived as contributing to their construction of the kind of ideal, health-valuing citizens they hoped to embody. However, participants were also concerned about the fairness of implementation, although this did not outweigh the prioritization of good health.

Association of fat-to-muscle mass ratio with physical activity and dietary protein, carbohydrate, sodium, and fiber intake in a cross-sectional study

Higher fat-to-muscle mass ratio (FMR) is reported to be a risk factor for various diseases, including type 2 diabetes and cardiovascular diseases, and mortality. Although this association suggests that reducing FMR may help to prevent certain diseases and mortality, the relationship between FMR and lifestyle factors is unclear. Therefore, we performed a cross-sectional study with the aim to elucidate this relationship. This cross-sectional study included 1518 healthy Japanese adults aged 30 to 64 years. We measured FMR in the whole body, arms, legs, and trunk and assessed various lifestyle factors. Then, we performed forced entry multiple regression analyses for FMR with the following variables: sex, age, physical activity, dietary intake, sleep quality, cigarette smoking, stress levels, and body mass index. As a result, whole-body and regional FMRs were correlated with female sex (β = 0.71); age (β = 0.06); physical activity (β = - 0.07); dietary intake of protein (β = - 0.12), carbohydrate (β = 0.04), sodium (β = 0.13), and fiber (β = - 0.16); and body mass index (β = 0.70). The results suggest that in the Japanese middle-aged population, low FMR is associated with certain lifestyle factors, i.e. higher physical activity and a diet with higher protein and fiber and lower carbohydrate and sodium, independent of age, sex, and body mass index.

Child eating behaviors are consistently linked to intake across meals that vary in portion size

Prior studies evaluating a single meal in children characterized an "obesogenic" style of eating marked by larger bites and faster eating. It is unclear if this style is consistent across portion sizes within children so we examined eating behaviors in 91 children (7-8 years, 45 F) without obesity (BMI<90th percentile). Children consumed 4 ad libitum meals in the laboratory consisting of chicken nuggets, macaroni, grapes, and broccoli that varied in portion size (100%, 133%, 166%, 200%) with a maximum of 30 min allotted per meal. Anthropometrics were assessed using age and sex adjusted body mass index (BMI) percentile and dual energy x-ray absorptiometry. Bites, sips, active eating time, and meal duration were coded from meal videos; bite size (kcal and g/bite), proportion of active eating (active eating time/meal duration), and eating rate (kcal and g/meal duration) were computed. Intraclass correlation coefficients (ICC) showed that most eating behaviors were moderately consistent across portions (>0.50). The consistency of associations between eating behaviors and total meal intake and adiposity were assessed with general linear models adjusted for food liking, pre-meal fullness, age, and sex. Across all portions, more bites, faster eating rate, and longer meal duration were associated with greater intake. While higher BMI percentile was associated with faster eating rates across all meals, greater fat mass index was only associated with faster eating at meals with portions typical for children (i.e., 100% and 133%). In a primarily healthy weight sample, an 'obesogenic' style of eating was a consistent predictor of greater intake across meals that varied in portion size. The consistent relationship of these behaviors with intake makes them promising targets to reduce overconsumption.

Perceptions of Beverages With Non-nutritive Sweeteners Among Indigenous Adults Living in Manitoba and Implications for Type 2 Diabetes

OBJECTIVES

The purpose of this study was to explore the perspectives of Indigenous adults on consuming beverages with non-nutritive sweeteners.

METHODS

In this work, we used a community-based, participatory design in partnership with National Indigenous Diabetes Association, Four Arrows Regional Health Authority, and Fearless R2W. We conducted 74 qualitative interviews with Indigenous adults living in Manitoba, including Island Lake First Nations (n=39), Flin Flon (n=15), and the North End neighbourhood of Winnipeg (n=20). Data were indexed in NVivo, and transcripts were analyzed thematically.

RESULTS

Participants exclusively discussed beverages with non-nutritive sweeteners (BNNSs) as an alternative to regular pop or sugary drinks, which were widely available, accessible, and consumed. Why or how BNNSs were viewed as an alternative comprised 3 subthemes: an alternative for health reasons; divergent taste preferences; and an alternative with mysterious but negative health effects. Participants who reported regular consumption of BNNSs largely described consuming them to manage type 2 diabetes. Fewer participants discussed BNNS as a means of weight management or as a preventive health behaviour. Participants who did not report regular BNNS consumption described not liking the taste of BNNSs. Finally, many participants described negative health impacts of consuming BNNSs, and specifically aspartame, although few articulated what those negative impacts were.

CONCLUSIONS

Divergent perspectives among Indigenous adults regarding the health implications of consuming BNNSs may reflect ongoing scholarly debates. These findings have implications for the prevention and dietary management of type 2 diabetes in Indigenous communities.

An examination of sugar-sweetened beverage tax regulations in six jurisdictions: Applying a social justice perspective to beverage taxation and exemptions

Taxes, legislation and politics are social determinants of health, which can impact health through multiple pathways. The purpose of this study was to review regulations regarding sugar-sweetened beverage (SSB) taxation and describe taxation/exemption of various beverage categories. We reviewed SSB taxation regulations from Mexico, the United Kingdom, Berkeley, Philadelphia, San Francisco and South Africa. Supplementary government documents and academic publications were also reviewed to further discern beverage taxation/exemption and zero-rating. There were a number of beverage types that fell clearly into typically taxed or exempt/zero-rated categories across all six jurisdictions (e.g. pop/soda as taxed and water as zero-rated). Exemptions and ambiguities within the six regulations can generally be grouped as a lack of clarity regarding the meaning and use of milk; the meaning of 'medical purposes' and 'supplemental'; the point at which a beverage is prepared; the form of concentrate (i.e. liquid/frozen/powder) or medium used (e.g. water, coffee); and location of preparation or business size of retailer. SSB tax regulations are complex, unclear, vary across jurisdiction and leave several beverage types with added sugar exempt from taxation or at risk of a legal challenge. Lastly, tax exemptions generally reflect and perpetuate existing sociopolitical dynamics within the food system.

Sweetness preference and its impact on energy intake and body weight - a review of evidence

In the last few years, several approaches have been postulated for tackling the global increase in overweight and obesity rates, including different dietary macronutrient compositions or the timing of meals. Recently, taste modulation has come into focus as a possible approach for influencing dietary behavior. The perception of sweet taste is innate and an evolutionary protection mechanism to prevent primates from eating poisonous plants. It is hypothesized that this innate sweetness preference could be modulated by dietary sweetness, including sweet foods and beverages, which results in a learned sweetness preference that affects energy intake and body weight. However, this hypothesis is not supported by unanimous scientific evidence. This review provides an update of the current literature, regarding the modulation of sweetness preference as a possible new approach in the prevention of overweight and obesity. In general, results from observation as well as interventional studies in all age groups are heterogeneous. The majority showed no effect of dietary sweetness modulation on sweetness preference, energy intake or anthropometric measures. Therefore, the modulation of sweetness preference due to diet, foods or beverages is still a hypothesis and not scientifically proven. However, due to the lack of data, more research is necessary.

Longitudinal Patterns of Beverage Intake in Treatment-Seeking Children with Obesity in Eastern NC Using the Validated BEVQ-15

Sugar-sweetened beverage (SSB) consumption remains a major target for interventions to treat severe obesity in children. Understanding how total energy consumption is divided among different types of beverages remains unclear. This study retrospectively examined how the consumption of beverage calories (kcal) from 100% fruit juice and SSBs, and body mass index, assessed as a percent of the 95th sex- and age-specific percentile (%of 95BMI), changed during the treatment of children with obesity aged 2-18 years. Treatment was provided by an integrative multi-disciplinary team, comprising a physician, a dietician/ nutritionist and a behavioralist employing motivational interviewing and a small change approach to promote improved sustainable health habits and induce a net negative energy balance. The sample included 155 patients, with 341 visits. The median age was 11 years, 60% were girls, and there was a median follow-up of 3.1 months. At baseline, the median %of 95BMI was 135 and the median kcal/day intake was 436 from juice and 263 from SSB. For each additional 100 kcal consumed/day from SSB and juice, the %of 95BMI increased by 1.4 percentage points. In the follow-up, each additional month was associated with 7 fewer kcal/day from SSB and juice combined, with a 0.5 percentage point increase in %of 95BMI. Children in this treatment program consumed fewer calories from SSB over time, although the %of 95BMI did not decrease. SSBs other than soda accounted for the majority of beverage kcal intake, therefore potentially providing a targeted direction for interventions.

Weight trajectories and obesity remission among school-aged children

BACKGROUND

Many studies examining weight trajectories have used adiposity measures shown to be problematic for trajectory analysis in children with obesity, and remission of obesity remains poorly understood.

OBJECTIVES

To describe weight trajectories for school-aged children, the rate of obesity remission and factors associated.

METHODS

Children between 6 and 11 years of age with ≥3 valid height and weight measurements from an Oregon hospital-system over a minimum six-month period were included. Percent distance from the median body mass index (BMI) was used for modeling. Latent class analysis and linear mixed models were used to classify children based on their weight trajectory.

RESULTS

We included 11,247 subjects with a median of 2.1 years of follow-up, with 1,614 (14.4%) classified as overweight and 1,794 (16.0%) classified as obese. Of subjects with obesity, 1% experienced remission during follow-up, whereas 23% of those with overweight moved to within a healthy weight range. Latent class analysis identified three classes within each weight-based stratum over time. The majority of children with overweight or obesity had a flat trajectory over time. Lower socioeconomic status was associated with a worsening trajectory. Latent class models using alternate measures (BMI, BMI z-scores, tri-ponderal mass index (TMI)) differed substantially from each other.

CONCLUSIONS

Obesity remission was uncommon using the adiposity metric of distance from the median though transition from overweight to healthy weight was more common. Children with low socioeconomic status have worse trajectories overall. The choice of adiposity metric may have a substantial effect on the outcomes.

A Content Analysis of Persuasive Appeals Used in Media Campaigns to Encourage and Discourage Sugary Beverages and Water in the United States

The frequent consumption of sugary beverages is associated with many health risks. This study examined how persuasive appeals and graphics were used in different media campaigns to encourage and discourage sugary beverages and water in the United States (U.S.) The investigators developed a codebook, protocol and systematic process to conduct a qualitative content analysis for 280 media campaigns organized into a typology with six categories. SPSS version 28.0 was used to analyze rational and emotional appeals (i.e., positive, negative, coactive) for campaign slogans, taglines and graphic images (i.e., symbols, colors, audiences) for 60 unique campaigns across the typology. Results showed that positive emotional appeals were used more to promote sugary beverages in corporate advertising and marketing (64.7%) and social responsibility campaigns (68.8%), and less to encourage water in social marketing campaigns (30%). In contrast, public awareness campaigns used negative emotional appeals (48.1%), and advocacy campaigns combined rational (30%) and emotional positive (50%) and negative appeals (30%). Public policy campaigns used rational (82.6%) and positive emotional appeals (73.9%) to motivate support or opposition for sugary beverage tax legislation. Chi-square analyses assessed the relationships between the U.S. media campaign typology categories and graphic elements that revealed three variables with significant associations between the campaign typology and race/ethnicity (χ²(103) = 32.445, p = 0.039), content (χ²(103) = 70.760, p < 0.001) and product image (χ²(103) = 11.930, p = 0.036). Future research should examine how positive persuasive appeals in text and graphics can promote water to reduce sugary beverage health risks.

Switching from Sugar- to Artificially-Sweetened Beverages: A 12-Week Trial

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) forms the primary source of added sugar intake and can increase the risk of metabolic disease. Evidence from studies in humans and rodents also indicates that consumption of SSBs can impair performance on cognitive tests, but that removing SSB access can ameliorate these effects.

METHODS

The present study used an unblinded 3-group parallel design to assess the effects of a 12-week intervention in which young healthy adults (mean age = 22.85, SD = 3.89; mean BMI: 23.2, SD = 3.6) who regularly consumed SSBs were instructed to replace SSB intake with artificially-sweetened beverages (n = 28) or water (n = 25), or (c) to continue SSB intake (n = 27).

RESULTS

No significant group differences were observed in short-term verbal memory on the Logical Memory test or the ratio of waist circumference to height (primary outcomes), nor in secondary measures of effect, impulsivity, adiposity, or glucose tolerance. One notable change was a significant reduction in liking for strong sucrose solutions in participants who switched to water. Switching from SSBs to 'diet' drinks or water had no detectable impact on cognitive or metabolic health over the relatively short time frame studied here. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615001004550; Universal Trial Number: U1111-1170-4543).

How Many Diet-Related Non-Communicable Disease Deaths Could Be Averted or Delayed If Canadians Reduced Their Consumption of Calories Derived from Free Sugars Intake? A Macrosimulation Modeling Study

Free sugars are a major source of calories in diets and contribute to the burden of many non-communicable diseases (NCDs). The World Health Organization (WHO) recommends reducing free sugars intake to less than 10% of total energy. This study aimed to estimate the number of diet-related NCD deaths which could be averted or delayed if Canadian adults were to reduce their calorie intake due to a systematic 20% reduction in the free sugars content in foods and beverages in Canada. We used the Preventable Risk Integrated ModEl (PRIME) to estimate the potential health impact. An estimated 6770 (95% UI 6184-7333) deaths due to diet-related NCDs could be averted or delayed, mostly from cardiovascular diseases (66.3%). This estimation would represent 7.5% of diet-related NCD deaths observed in 2019 in Canada. A 20% reduction in the free sugars content in foods and beverages would lead to a 3.2% reduction in calorie intake, yet an important number of diet-related NCD deaths could be averted or delayed through this strategy. Our findings can inform future policy decisions to support Canadians' free sugars intake reduction, such as proposing target levels for the free sugars content in key food categories.

Packed School Lunch Food Consumption: A Childhood Plate Waste Nutrient Analysis

Packed school lunch consumption remains a sparsely studied aspect of childhood nutrition. Most American research focuses on in-school meals provided through the National School Lunch Program (NSLP). The wide variety of available in-home packed lunches are usually nutritionally inferior compared to the highly regulated in-school meals. The purpose of this study was to examine the consumption of home-packed lunches in a sample of elementary-grade children. Through weighing packed school lunches in a 3rd grade class, mean caloric intake was recorded at 67.3% (32.7% plate waste) of solid foods, while sugar-sweetened beverage intake reported a 94.6% intake. This study reported no significant consumption change in the macronutrient ratio. Intake showed significantly reduced levels of calories, sodium, cholesterol, and fiber from the home-packed lunches (p < 0.05). The packed school lunch consumption rates for this class were similar to those reported for the regulated in-school (hot) lunches. Calories, sodium, and cholesterol intake are within childhood meal recommendations. What is encouraging is that the children were not "filling up" on more processed foods at the expense of nutrient dense foods. Of concern is that these meals still fall short on several parameters, especially low fruit/vegetable intake and high simple sugar consumption. Overall, intake moved in a healthier direction compared to the meals packed from home.

The Impact of Free Sugar on Human Health-A Narrative Review

The importance of nutrition in human health has been understood for over a century. However, debate is ongoing regarding the role of added and free sugars in physiological and neurological health. In this narrative review, we have addressed several key issues around this debate and the major health conditions previously associated with sugar. We aim to determine the current evidence regarding the role of free sugars in human health, specifically obesity, diabetes, cardiovascular diseases, cognition, and mood. We also present some predominant theories on mechanisms of action. The findings suggest a negative effect of excessive added sugar consumption on human health and wellbeing. Specific class and source of carbohydrate appears to greatly influence the impact of these macronutrients on health. Further research into individual effects of carbohydrate forms in diverse populations is needed to understand the complex relationship between sugar and health.