Substitution of sugar-sweetened beverages with other beverage alternatives: a review of long-term health outcomes

Towards healthier low-sugar and low-fat beverages: Design, production, and characterization

Many consumers are adopting low-sugar and low-fat beverages to avoid excessive calories and the negative impact of high trans- and/or saturated fat on health and wellbeing. This article reviews strategies to reduce sugar, fat, and high trans- and/or saturated fat content in beverages while maintaining their desirable physicochemical and sensory attributes. It assesses the impact of various sugar and fat replacers on the aroma, taste, texture, appearance, and nutritional profile of beverages. Combinations of natural sugar replacers and protein or polysaccharide-based fat replacers have shown partial success in mimicking the qualities of sucrose and fat. Future strategies for designing low-sugar and low-fat beverages include developing novel replacers and using odorants to enhance sensory profiles. The article also highlights methods for flavor detection and oral tribology methods, emphasizing their role in development of low-sugar and low-fat beverages. The information presented in this review article is intended to stimulate research into the design of healthier low-sugar and low-fat beverages in the future.

Consumption of Sugar-Sweetened Beverages by Polish Young Adults: A Preliminary Study on the Importance of Sugar Tax Familiarity and Health Effects

Consumption of sugar-sweetened beverages (SSBs) contributes to the risk of developing overweight and obesity in children and adults. Thus, reducing free sugar is a globally recognized public health priority. The implementation of a sugar tax is one way of achieving this goal. This study aimed to investigate the relationship between familiarity with the sugar tax and its importance in reducing obesity, the perceived health consequences of SSBs, situations and reasons for consumption, and the frequency of SSB consumption. A cross-sectional study was conducted in May 2022 among 216 Polish adults (age 18-45). Hierarchical cluster analysis was used to identify three homogeneous clusters with regard to the perceived health consequences of consuming SSBs. A logistic regression model was used to verify the relationship between the frequency of SSB consumption (dependent variable) and other variables. Respondents with higher familiarity with the sugar tax (OR: 0.594; 95% CI: 0.42-0.85) and those in the "Unaware of disease" (OR: 0.437; 95% CI: 0.18-0.94) and "Disease-conscious" (OR: 0.484; 95% CI: 0.24-0.97) clusters were less likely to consume SSBs at least once per week than those in the "Moderately disease-conscious" cluster. Both the place of SSB consumption (i.e., restaurant-OR: 1.847; 95% CI: 1.14-3.64, work or university-OR: 3.217; 95% CI: 1.51-6.88, family home-OR: 2.877; 95% CI: 1.50-5.53) as well as a preference for their taste (OR: 4.54; 95% CI: 1.66-12.45) increased the chance of consuming SSBs at least once a week. In conclusion, it is necessary to continue educating the public about the health consequences of SSB consumption. The use of legislative measures (i.e., sugar tax) also contributes to reducing SSB consumption and can thus counteract the increasing obesity rate.

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 effect of a multi-component school-based social network intervention on children's body mass index: a four-arm intervention study

Methods: Four schools were randomly allocated to one of four conditions: a social network intervention using influence agents focusing on water consumption, physical activity, a combination of the two, or a passive control condition. Participants included a total of 201 6- to-11-year-old children (53.7% girls; Mage = 8.51, SDage = 0.93). At baseline, 149 (76.0%) participants had a healthy weight, 29 (14.8%) had overweight and 18 (9.2%) had obesity.

Results: Linear mixed effect models indicated that a multi-component school-based social network intervention targeting both water consumption and physical activity was most effective in decreasing children's zBMI.

Conclusion: This study suggests that schools can contribute to the intervention of childhood obesity-even without involving the parents-by targeting both children's water consumption and physical activity through influential peers, but more research is needed to identify mechanisms of change.

Association of plain water intake with risk of all-cause and cause-specific mortality in individuals with non-alcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease

Non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD)-related mortality have increased dramatically in past decades. Our study aims to investigate the association between plain water and this prevalent metabolic disease, as water plays a crucial role in regulating metabolic processes. A total of 3,543/3,428 individuals with NAFLD/MASLD were included in this study from National Health and Nutrition Examination Survey (NHANES). Daily plain water intake was recorded, and mortality status was tracked until December 31, 2019. Multivariate Cox regression models and restricted cubic spline (RCS) regression models were used to assess the association between plain water intake and long-term all-cause as well as cause-specific mortality among participants with NAFLD/MASLD. Furthermore, we investigated the relationship between substituting other beverages with plain water intake and the risk of mortality. The multivariate Cox regression analyses revealed a significant association between higher plain water intake and lower all-cause mortality, cerebrovascular diseases mortality, and cancer mortality in both NAFLD or MASLD patients. Dose-response analyses revealed a non-linear trend between plain water intake and mortality among NAFLD/MASLD patients. Additionally, replacing sugar or artificial beverages with plain water was linked to reduced all-cause mortality, cerebrovascular diseases mortality, and cancer mortality in patients with NAFLD/MASLD. Higher plain water intake is independently linked to lower risk of all-cause, cerebrovascular diseases mortality, and cancer mortality in NAFLD/MASLD patients. Increasing plain water intake may be an effective way for these patients to reduce their risk of mortality.

Nutrition users' guides: systematic reviews part 1 -structured guide for methodological assessment, interpretation and application of systematic reviews and meta-analyses of non-randomised nutritional epidemiology studies

Due to the challenges of conducting randomised controlled trials (randomised trials) of dietary interventions, evidence in nutrition often comes from non-randomised (observational) studies of nutritional exposures-called nutritional epidemiology studies. When using systematic reviews of such studies to advise patients or populations on optimal dietary habits, users of the evidence (eg, healthcare professionals such as clinicians, health service and policy workers) should first evaluate the rigour (validity) and utility (applicability) of the systematic review. Issues in making this judgement include whether the review addressed a sensible question; included an exhaustive literature search; was scrupulous in the selection of studies and the collection of data; and presented results in a useful manner. For sufficiently rigorous and useful reviews, evidence users must subsequently evaluate the certainty of the findings, which depends on assessments of risk of bias, inconsistency, imprecision, indirectness, effect size, dose-response and the likelihood of publication bias. Given the challenges of nutritional epidemiology, evidence users need to be diligent in assessing whether studies provide evidence of sufficient certainty to allow confident recommendations for patients regarding nutrition and dietary interventions.

Own price elasticities of the demand for sugar-sweetened beverages in Bangladesh

BACKGROUND

Consumption of sugar-sweetened beverages (SSB) is a major global public health problem. Increasing the price of SSBs through taxation is an effective tool to reduce SSB consumption. Price-elasticity estimates are useful in measuring the effect of taxation on consumption. We estimated the own price elasticities of demand for SSBs in Bangladesh, which will inform how SSB taxes could affect behaviour.

METHODS

We used Household Income and Expenditure Survey (HIES) 2016 data, which is a nationally representative dataset at the household level across the country and is conducted using stratified random sampling method. Deaton's method was used to estimate the price elasticities for SSBs in Bangladesh.

RESULTS

We found that the own price elasticity for SSBs varied between - 0.53% to -1.17% by types of SSBs in Bangladesh. The price elasticity for soft drinks was - 1.17, indicating that if the price of soft drinks increases by 10% via taxes, the quantity consumed of these beverages would reduce by 11.7%.

CONCLUSION

This is the first study that estimates the own price elasticities of demand for SSBs in Bangladesh. Our results suggest to raise SSB prices through increased taxation in order to reduce SSB consumption and ensure public health gains in Bangladesh.

Beverages - a scoping review for Nordic Nutrition Recommendations 2023

Background: Coffee, tea, sugar-sweetened beverages (SSBs), and low- and no-calorie sweetened beverages (LNCSBs) are generally frequently consumed in the Nordic and Baltic countries. These beverages have also been related to potential health effects. This scoping review describes the evidence for the role of coffee, tea, SSBs, and LNCSBs for health-related outcomes as a basis for setting and updating food-based dietary guidelines. We used evidence from several qualified systematic reviews (i.e. World Cancer Research Fund, US Dietary Guidelines Advisory Committee, European Food Safety Authority, and World Health Organization) and performed a search for additional systematic reviews. The evidence suggests that moderate coffee and tea consumption do not have long-term adverse health effects. The long-term favorable effects of coffee consumption are related to reduced risk of endometrial and liver cancer, type 2 diabetes, and cardiovascular deaths. However, results from randomized controlled trials (RCTs) suggest that coffee brews that are rich in diterpenes, such as boiled coffee, increase serum cholesterol concentrations. High caffeine intake in pregnancy is associated with higher risk of pregnancy loss, preterm birth, and low birth weight. High consumption of SSBs has been associated with increased risk of obesity, type 2 diabetes, hypertension, and cardiovascular disease, based on data from RCTs and prospective cohort studies. The consumption of LNCSBs may result in a small reduction in body weight in adults, likely mediated through the effect of reduced energy intake, but has neutral effects on other cardiometabolic risk markers using evidence from RCTs. However, evidence from observational studies indicates increased risk of cardiometabolic diseases among high LNCSB consumers. In conclusion, current evidence suggests that moderate coffee and tea consumption have no long-term adverse health effects. The evidence of beneficial effects of coffee consumption on liver and endometrial cancer risk, and some cardiovascular outcomes, comes from observational studies. High consumption of boiled coffee should be avoided due to negative effect on lipid profile. Pregnant women should not exceed the recommended daily dose of caffeine intake of 200 mg set by the European Food Safety Authority as a safe level for the fetus. High consumption of SSBs has consistently been associated with adverse health effects, which is mainly due to excess energy intake, and should be limited. The conflicting results from RCTs and observational studies regarding LNCSBs may be due to revere causation and should be explored further.

Estimated reductions in type 2 diabetes burden through nutrition policies in AZAR cohort population: A PRIME microsimulation study for primary health care

Background

Given the impact of high intake of sugar-sweetened beverages on type 2 diabetes, intervention to reduce their consumption can be a top priority for any health system. Thus, the purpose of the present study is to simulate the impact of policy options related to reduce consumption of sugar-sweetened beverages (SSBs) on the prevalence and mortality of type 2 diabetes in Iranian men and women.

Methods

A discrete event simulation (DES) model was used to predict the effect of several policy options on the prevalence and death from type 2 diabetes in Azar Cohort Databases. Population age- and sex-specific prevalence and incidence rate of diagnosed diabetes were derived from the national health data. The Preventable Risk Integrated Model (PRIME) model was used for coding the input parameters of simulation using R and Python software.

Results

The prevalence and mortality rate of type 2 diabetes under the scenario of reduced consumption of SSBs indicated that the highest and the lowest prevalence and mortality rates of type 2 diabetes for men and women were related to no policy condition and replacing SSBs with healthy drinks, like water, respectively. Also, the maximum "number of deaths postponed/ prevented" from type 2 diabetes was related to replacing SSBs with water (n=2015), and an integration of reformulation and applying 10% tax on SSBs (n=1872), respectively.

Conclusion

Simulating the effect of different policy options on reducing the consumption of SSBs showed "replacing of SSBs with water" as the most effective policy option in Iranian setting.

Association between Beverage Consumption and Sleep Quality in Adolescents

The objective of this study was to verify if the consumption of different beverages (such as water, 100% pure fruit juice, and sugar-sweetened beverages (SSBs)) is associated with adolescents' sleep quality. French-speaking adolescents were recruited in person and online throughout the province of Québec (Canada) from the end of March to early July 2023. Beverage consumption and sleep quality were measured using French versions of validated questionnaires specifically designed for adolescents. A total of 218 adolescents (14-17 years; 55.5% female) completed the online survey. Among caffeinated SSBs, energy drink (rs = -0.16; p = 0.0197) and sugar-sweetened coffee (rs = -0.33; p < 0.0001) intake was correlated with adolescents' sleep quality. Energy drink consumption (β = -0.0048; p = 0.0005) and being male (β = 0.6033; p < 0.0001) were associated with adolescents' sleep quality. There was an interaction between sugar-sweetened coffee intake and biological sex that was associated with adolescents' sleep quality (p = 0.0053). Sugar-sweetened coffee consumption was correlated with adolescent girls' abilities to go to bed (rs = -0.21; p = 0.0203) and fall asleep (rs = -0.28; p = 0.0020), while in boys, it was only significantly correlated with their abilities to go to bed (rs = -0.27; p = 0.0069). Public health interventions aimed at adolescent boys should primarily target lowering energy drink consumption, while those aimed at girls should prioritize sugar-sweetened coffee intake to possibly improve their sleep quality.

Understanding the behavioral determinants of adolescents' water consumption: A cross-country comparative study

Substituting the consumption of sugar-sweetened beverages (SSB) with that of water can have a positive effect on adolescents' health. However, despite the attention on this topic in the Global North, it is relatively understudied in other regions of the world, such as the Caribbean. To guide the development of future interventions, understanding the factors determining water consumption among Caribbean adolescents is important. This study examined the behavioral determinants of water consumption among adolescents in Aruba (the Caribbean) and compared them to those in the Netherlands (Western Europe). We used a theoretical model that integrates the dominant theoretical perspectives in the field of public health, including theories of planned behavior, social norms, and intrinsic motivation. This cross-country study included 1,584 adolescents from Aruba and the Netherlands (52% girls; M = 12.34 years; SD = 2.14). The data were analyzed using regression analyses. This study found that in Aruba, adolescents with higher scores of intrinsic motivation, friends' descriptive norms, attitudes, and behavioral control regarding water consumption drank more water. Moreover, the associations between water consumption and both intrinsic motivation as well as friends' descriptive norms for adolescents in Aruba were stronger than those found in the Netherlands. These associations imply that it is even more important for Aruban adolescents than Dutch adolescents to be intrinsically motivated or to perceive their friends often consuming water to drink more water. The cross-country comparison implies that future interventions in Aruba aimed at increasing adolescents' water consumption as an alternative to SSB should focus on enhancing their intrinsic motivation while considering their friends' social norms.

Assessment of Beverage Trends and Replacing Nondairy Caloric Beverages with Milk at Meals across Childhood Improves Intake of Key Nutrients at Risk of Inadequate Consumption: An NHANES Modeling Study

Background

Milk is a key source of important nutrients including the nutrients of public health concern. However, most Americans do not meet current (dairy) United States Department of Agriculture (USDA) dietary guideline recommendations, and the intake has been declining.

Objective

The aim of this study was to investigate milk and beverage intake trends and nutrient intakes from these products in United States children aged 6-18 y and to model the effect of isocaloric substitution of nondairy beverages with milk.

Methods

Data from National Health and Nutrition Examination Survey (NHANES) 2001-2018 for children age 6-8 (N = 4696), 9-13 (N = 8117) and 14-18 y (N = 8514) were used with milk and other beverage intakes determined from the first 24-h in-person dietary recall. Nutrient intake was determined using the NHANES cycle-specific total nutrient intake files. Nutrient modeling was performed by isocaloric substitution with milk of all nondairy beverages consumed during lunch and dinner meals combined. Sample-weighted analyses were performed using SAS 9.4.

Results

Between ages 6-8 and 14-18 y, daily intake of milk and flavored milk decreased by 10% and 62%, respectively, while daily intake of caloric beverages excluding milk increased by 96%. Daily intake from caloric beverages and milk combined decreased for fiber, protein, fat, saturated fat, calcium, magnesium, potassium, vitamin A, and vitamin D and increased for energy, carbohydrates, added sugars, and folate between ages 6-8 y and 14-18 y. Isocaloric substitution of all caloric nondairy beverages at meals with milk (using nutrient contribution of USDA milk, not further specified (NFS)) resulted in increases in protein, fat, saturated fat, calcium, magnesium, potassium, sodium, vitamin A, folate, vitamin B12, and vitamin D and decreases in carbohydrate, fiber, and added sugar.

Conclusion

These findings provide additional evidence to support dietary recommendations for milk, and efforts should be made on behalf of leading health professionals and childhood meal programs to highlight milk as a beverage of choice in children and adolescents.

How Could Taxes on Sugary Drinks and Foods Help Reduce the Burden Of Type 2 Diabetes?

PURPOSE OF REVIEW

Taxes on sugary drinks and foods have emerged as a key strategy to counteract the alarming levels of diabetes worldwide. Added sugar consumption from industrialized foods and beverages has been strongly linked to type 2 diabetes. This review provides a synthesis of evidence on how taxes on sugary products can influence the onset of type 2 diabetes, describing the importance of the different mechanisms through which the consumption of these products is reduced, leading to changes in weight and potentially a decrease in the incidence of type 2 diabetes.

RECENT FINDINGS

Observational studies have shown significant reductions in purchases, energy intake, and body weight after the implementation of taxes on sugary drinks or foods. Simulation studies based on the association between energy intake and type 2 diabetes estimated the potential long-term health and economic effects, particularly in low- and middle-income countries, suggesting that the implementation of sugary food and beverage taxes may have a meaningful impact on reducing type 2 diabetes and complications. Public health response to diabetes requires multi-faceted approaches from health and non-health actors to drive healthier societies. Population-wide strategies, such as added sugar taxes, highlight the potential benefits of financial incentives to address behaviors and protective factors to significantly change an individual's health trajectory and reduce the onset of type 2 diabetes worldwide, both in terms of economy and public health.

Drink Tap: A Multisector Program to Promote Water Access and Intake in San Francisco Parks

Taxes on sugar-sweetened beverages (SSBs), or drinks with added sugars, show promise in decreasing purchases and consumption of SSBs. Some have called for coupling such taxes with improvements in access to safe drinking water as a strategy for reducing inequities in SSB intake, yet no studies have examined such an approach. Drink Tap is a San Francisco-based program in which public tap water stations were installed in parks and public spaces (winter 2017) and promotional efforts (fall and winter 2018) encouraged water intake. At the same time, San Francisco and surrounding communities were also implementing SSB taxes. We conducted a quasi-experimental study to examine whether water access and promotion combined with SSB taxes affected beverage intake habits more than SSB taxes alone. We conducted 1-hour observations (N = 960) at 10 intervention parks (Drink Tap plus SSB taxes) and 20 comparison parks (SSB taxes only) in San Francisco Bay Area cities before (July-September 2016) and after (June-August 2019) implementation of Drink Tap. We found significant adjusted percentage increases in drinking water among visitors to intervention parks, compared with comparison parks: water from park water sources (+80%, P < .001) and water from reusable bottles (+40%, P = .02). We found no significant reductions in visitors observed drinking bottled water, juices, or SSBs. The Drink Tap intervention led to increases in water intake from park sources and reusable bottles across parks that surpassed increases achieved through SSB taxes alone. Jurisdictions should consider coupling tap water access and promotion with policies for reducing intake of SSBs.

The crowding-out effect of sugar-sweetened beverages (SSBs) on household expenditure patterns in Bangladesh

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) or sugary drinks may reduce or even eliminate the household income allocation for other essential commodities. Reducing expenditure for consumption of other household commodities is known as the crowding-out effect of SSB. We aimed to determine the crowding-out effect of SSB expenditure on other household commodities. In addition, we also identified the factors influencing the household's decision to purchase of SSBs.

METHODS

We used the logistic regression (logit and multinomial logit models) and the Seemingly Unrelated Regression (SUR) models. In order to find the probability of a given change in the socio-demographic variables, we also estimated the average marginal effects from the logistic regression. In addition, we regressed the SUR model by gender differences. We used Household Income and Expenditure Survey (HIES) 2016 data to estimate our chosen econometric models. HIES is nationally representative data on the household level across the country and is conducted using a multistage random sampling method by covering 46,075 households.

RESULTS

The findings from the logit model describe that the greater proportion of male members, larger household size, household heads with higher education, profession, having a refrigerator, members living outside of the house, and households with higher income positively affect the decision of purchasing SSB. However, the determinants vary with the various types of SSB. The unadjusted crowding out effect shows that expenditure on SSB or sugar-added drinks crowds out the household expenditure on food, clothing, housing, and energy items. On the other hand, the adjusted crowding out effect crowds out the spending on housing, education, transportation, and social and state responsibilities.

CONCLUSION

Although the household expenditure on beverages and sugar-added drinks is still moderate (around 2% of monthly household expenditure), the increased spending on beverages and sugar-added drinks is a concern due to the displacement of household expenditure for basic commodities such as food, clothing, housing, education, and energy. Therefore, evidence-based policies to regulate the sale and consumption of SSB are required for a healthy nation.

Effect of School-Based Educational Intervention on Promoting Healthy Dietary Habits in Danish Schoolchildren: The FOODcamp Case Study

The present study aimed to evaluate the effect of the school-based educational intervention "FOODcamp" on dietary habits among 6th-7th graders (aged 11-13 years), focusing on the food groups: fruits and vegetables, fish, meat, discretionary food, and sugar-sweetened beverages. In this cluster-based quasi-experimental controlled intervention study, 16 intervention classes (322 children) and 16 control classes (267 children) from nine schools were recruited during the school year 2019-2020. The children were asked to record their food intake for four consecutive days (Wednesday to Saturday) before (baseline) and after (follow-up) attending FOODcamp, using a validated self-administered web-based dietary record. Eligible dietary intake registrations from 124 and 118 children from the control and interventions classes, respectively, were included in the final statistical analysis. Hierarchical mixed model analysis was used to evaluate the effect of the intervention. No statistically significant effects of participating in FOODcamp were found on the average food intake of the food groups eaten regularly (vegetables, fruit, vegetables/fruit/juice combined, or meat) (p > 0.05). Among the food groups not eaten regularly (fish, discretionary foods, and sugar-sweetened beverages), a non-significant tendency to lower odds of consuming sugar-sweetened beverages from baseline to follow-up (OR = 0.512; 95% CI: 0.261-1.003; p = 0.0510) was seen among FOODcamp participants compared to control participants. In conclusion, this study found no effect of the educational intervention FOODcamp on the dietary intake of vegetables, fruit, vegetable/fruit/juice combined, meat, fish, or sugar-sweetened beverages. The intake frequency of sugar-sweetened beverages tended to decrease among FOODcamp participants.

Health outcomes of 100% orange juice and orange flavored beverage: A comparative analysis of gut microbiota and metabolomics in rats

A high intake of sugar-sweetened fruity beverage (FB) is associated with a higher risk of metabolic syndromes, but the health outcome of 100% fruit juice (FJ) intake remains unclear. We aim to reveal health outcomes of diet intervention (FJ or FB) with system profiling via interaction of gut microbiota and metabolomics in a rat (Rattus norvegicus) model. Firstly, the glucose, sucrose, fructose, and bioactive metabolites of FJ and FB were analyzed, and FJ possessed higher sucrose and flavonoids, while FB showed higher glucose and fructose. Secondly, C0 was set as the control group on Day 0, and a 4-week diet invention was performed to control, FJ-intake, and FB-intake groups with normal saline, FJ, and FB, respectively. The results showed that FJ improved alpha diversity and decreased the Firmicutes/Bacteroidota ratio (F/B ratio) of gut microbiota and prevented insulin resistance. However, FB possessed unchanged microbial diversity and enhanced F/B ratio, causing insulin resistance with renal triglyceride accumulation. In summary, FJ, although naturally containing similar amounts of total free sugars as FB, could be a healthier drink choice.

Sugary beverages and genetic risk in relation to brain structure and incident dementia: a prospective cohort study

BACKGROUND

The relation of intake of sugary beverages and genetic predisposition to the long-term risk of dementia and brain structure remains unclear.

OBJECTIVES

This study aimed to assess the associations of sugar-sweetened beverages (SSBs), artificially-sweetened beverages (ASBs), and natural juices (NJs) and the genetic predisposition with dementia risk and brain structure.

METHODS

We included 177,926 UK Biobank participants without dementia at baseline and followed them until March 2021. Intake of SSBs, ASBs, and NJs was assessed using repeated web-based 24-h dietary recalls from 2009 to 2012. We calculated a polygenic risk score (PRS) to indicate genetic predisposition of dementia for each individual. We estimated the HRs and 95% CIs using Cox proportional hazard models for dementia risk and β coefficients and 95% CIs using linear models for brain imaging markers.

RESULTS

During study follow-up (mean = 9.5 years), 1293 participants developed dementia (69.1 cases/100,000 person-years) excluding dementia cases within the first 2 years. Higher intake of SSBs and ASBs (>2 units/d compared with none) was each associated with a higher risk of dementia (HR: 1.34; 95% CI: 1.01, 1.77; P-trend = 0.040 for SSBs and 1.20; 95% CI: 0.84, 1.72; P-trend = 0.004 for ASBs). In contrast, moderate intake of NJs (>0-1 unit/d compared with none) was related to a lower dementia risk (HR: 0.77; 95% CI: 0.68, 0.87), a larger volume of brain gray matter (β = 0.05; 95% CI: 0.02, 0.08), and a lower volume of white matter hyperintensities (β = -0.07; 95% CI: -0.11, -0.03). The associations were not significantly modified by genetic risk (P-interactions = 0.839 for SSB × PRS, 0.732 for ASB × PRS, and 0.950 for NJ × PRS).

CONCLUSIONS

Higher SSB and ASB intake was associated with higher risk of dementia, and moderate NJ intake was associated with a lower risk of dementia. Am J Clin Nutr 20XX;xx:xx-xx.

Just noticeable difference in sweetness perception of cola: Small changes in sugar are noticeable

Sugar-sweetened beverage consumption contributes to obesity and related diseases. Fortunately, beverages with reduced sweetness are a growing category in the beverage industry. These lower sweetness products could be useful for reducing the total dietary intake of sugar, but publicly available data are sparse on how much sweetness can be reduced without the change becoming noticeable to consumers. We investigated the just noticeable difference (JND) in sweetness of a cola-flavored carbonated beverage. Two sensory tests were conducted to detect the JND from 12.00% w/w sucrose. In each test, we used cola-flavored seltzer water with five decreasing sucrose concentrations (test 1:8.02-12.00% w/w; test 2:10.21-12.00% w/w). In both tests, samples were paired with the 12.00% reference, and participants were instructed to identify the sweeter sample. Participants correctly identified the reference sample at 10.21% in test one (p = .0039) and at 10.89% (p = .014) in test two. The data indicate that in a cola beverage, sucrose can be reduced by ~9.25% of the original concentration (12.00-10.89% w/w) before the sweetness becomes apparent to consumers. However, further work should consider whether sugar reductions greater than 9.25% would be acceptable, even if the difference in sweetness is apparent.

Practical Applications

These data could help researchers and industry product developers know how much sugar can be reduced from a cola-flavored beverage before the change is apparent to consumers.

Effect of saccharin, a non-nutritive sweeteners, on insulin and blood glucose levels in healthy young men: A crossover trial

BACKGROUND AND AIMS

Artificial sweeteners used instead of sugar were considered as the best alternatives that have no endocrine effects. However, it has recently been suggested that artificial sweeteners may cause impaired metabolic parameters. The hypothesis of the study was there is an association between acute saccharin consumption and both glycemia and insulin response in young healthy adult men.

METHODS

9 healthy adult males were included in this study. This study randomly provided participants with preloads as (a)300 ml of water, or 300 ml of water sweetened with (b)75 g of sucrose, (c)240 mg of saccharine (adjusted to the sweetness of 75 g of sucrose) 1 h before a standard breakfast.

RESULTS

Compared to mean blood glucose and serum insulin after test drinks consumption, there was only one difference between sucrose and saccharin trials in the 15th minute (117.0 ± 18.70, 95.4 ± 5.64 mg/dl respectively, p < 0.05). At the 60th minute, insulin secretion (0.80 ± 0.27 pg/dl) after the sucrose trial was found significantly higher than the saccharin trial (0.53 ± 0.09 pg/dl) and water (0.49 ± 0.06 pg/dl) (p < 0.05). Although at all intervals (except 90th minute), the mean insulin is higher after the saccharin trial compared to the water trial, these were non-statistically significant differences (p > 0.05).

CONCLUSIONS

Consequently, it was determined that saccharin had no glycemic effect. However, for the effect on serum insulin to be clarified, the long-term effects should be investigated.

Sugar-sweetened beverages, effects on appetite and public health strategies to reduce the consumption among children: a review

Sugar-sweetened beverages (SSBs) consumption have been of public health concern and a target of interventions due to their high consumption and burden in health-related consequences, particularly in children and adolescents. SSBs provide high energy intake with low nutritional value and are a major contributor for added and free sugars intake of Portuguese in all age-groups, especially adolescents. Despite its recognized effect on weight gain, it might also disrupt appetite regulation. Research on the effect of SSBs on appetitive traits is still scarce and unclear, and the current knowledge of these potential effects will be discussed in this review. This review also aims to describe public health strategies implemented to decrease SSBs consumption among children, particularly in Portugal, such as: (i) implemented taxation measures and its impact in sales and in preventable cases of disease and death, (ii) marketing regulations applied to children and adolescents, and ultimately (iii) the intention of application of a single Front-of-Package labeling system in all countries, aiming to increase consumers’ food literacy.

Effect of the multicomponent healthy high school intervention on meal frequency and eating habits among high school students in Denmark: a cluster randomized controlled trial

BACKGROUND

Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up.

METHODS

The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data.

RESULTS

At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33).

CONCLUSION

No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting.

TRIAL REGISTRATION

ISRCTN, ISRCTN43284296 . Registered 28 April 2017 - retrospectively registered.

Improved food literacy among schoolchildren as an effect of a food camp intervention: Results of a controlled effectiveness trial

Food literacy (FL) refers to an individual's prerequisites for their engagement with food. Schoolchildren's FL has been defined in terms of five competencies: "to know"(e.g food-related knowledge), "to do" (e.g cooking skills), "to sense" (e.g. less well-explored sensory experiences), "to care" (e.g. taking care of oneself and others) and "to want" (e.g. willingness to take a stand and act). A cluster-based quasi-experimental effectiveness trial on the effects of a school-based intervention, "FOODcamp," on FL, health literacy, and school well-being was conducted. A total of 640 school children in grades 6 and 7 (mean age = 12 years) attended this one-week camp and participated in different food-related classes and activities. Linear mixed models controlling for the nested structure of data showed small but significant effects for the following FL dimensions: "to do (E = 0.098, CI (0.035-0.161), p = 0.002), "to sense" (E = 0.152, CI (0.073-0.232), p < 0.001), and "to know" (E = 0.086, CI (0.022-0.150), p = 0.009) as well as for overall FL (E = 0.078, CI (0.034-0.122), p = 0.001). No effects were found for the dimensions "to want" or "to care". The intervention also had a small but significant effect on children's health literacy but not on school well-being. These findings demonstrate the value of FOODcamp and the positive impacts of a relatively brief intervention on children's FL.

Substitution of Sugar-Sweetened Beverages for Other Beverages: Can It Be the Next Step Towards Healthy Aging?

PURPOSE OF REVIEW

With the prolongation of life expectancy, the gap between lifespan and "health span," the disease-free lifespan, has been widening due to the massive burden of age-related chronic diseases and research on healthy aging has been gaining momentum. A growing body of evidence suggests that diet is a strong determinant of healthy aging and consumption of sugar-sweetened beverages (SSB), a major source of added sugars, predicts poor health outcomes in the aging population, including cardiovascular disease, diabetes, and cancer. Evidence further supports a link between sugar-sweetened beverages-triggered pathological processes and biologic factors of aging, including inflammaging, oxidative stress, and alterations in intestinal microbiota. At present, substitution of sugar-sweetened beverages with healthier alternative beverage remains the most robust strategy to limit the deleterious effects of sugar-sweetened beverages on health worldwide and may help achieve healthy longevity. The purpose of this review is to provide an overview of mechanisms by which sugar-sweetened beverages consumption may impact the physiological aging process and how a simple intervention of beverage replacement may promote healthy aging.

RECENT FINDINGS

Recent findings indicate that SSB are associated with accelerated aging phenotype and activate various adverse biological processes such as chronic inflammation, oxidative stress, insulin resistance, and gut dysbiosis. Replacing SSB with healthier beverages may be a reasonable option to reduce the burden of chronic disease in the aging population and even prolong life and healthspan.

Disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens, 2007-2013

The objective of this study was to estimate disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens. Data (2007-2013) came from the National Consumer Survey and included 115,510 adult respondents (age 18+) and 8635 teen respondents (age 12-17). The data was originally accessed in 2018 and analyzed in 2019-2020. The main outcomes were individual-level estimated exposure to advertisements for regular soda, diet soda, and energy/sport drinks. The main exposures were by race/ethnicity, household income, and educational attainment. Non-white adults (teens) were exposed to an estimated (per year) 101.5 (190.1) regular soda ads, 49.5 (61.2) diet soda ads, and 157.1 (279.6) energy/sport ads per year while white respondents were exposed to 97.5 (127.7) regular soda ads, 45.8 (44.2) diet soda ads, and 123.9 (192.0) energy/sport ads per year. Adult (teen) respondents who were non-white with low incomes and with low educational attainment were exposed to 4.7% (53.7%) more regular soda ads, 6.6% (43.8%) more diet ads, and 23.2% (56.2%) more energy/sport ads than respondents who were white with high incomes and high educational attainment. Demographic and socio-economic groups with a higher prevalence of obesity were exposed to significantly more advertisements for sugar-sweetened beverages. When evaluating potential policies to regulate marketing of sugar-sweetened and non-nutritive sweetened beverages, policymakers should consider the disparate exposure of at-risk populations to advertising of sugar-sweetened and non-nutritive sweetened beverages.

Associations between ultraprocessed food consumption and total water intake in the US population

BACKGROUND

Longitudinal studies have shown significant dose-response associations between dietary share of ultraprocessed foods and the incidence of several noncommunicable diseases and all-cause mortality. Several attributes of ultraprocessed foods are potential mechanisms for their link with health outcomes, including their typically unbalanced nutrient profile, high glycemic loads, high energy intake rate, and the presence of food additives, neoformed substances, and substances released by synthetic packaging materials. However, no studies have assessed the plausibility of reduced water intake as an additional association of diets rich in ultraprocessed foods.

OBJECTIVE

To assess the association between ultraprocessed food consumption and total water intake.

DESIGN

This cross-sectional secondary analysis used data from the National Health and Nutrition Examination Survey, cycles 2011 to 2016, in the United States.

PARTICIPANTS/SETTINGS

This study included 24,505 participants aged ≥1 year who completed the first 24-hour dietary recall interview.

MAIN OUTCOMES MEASURES

The main outcome evaluated was the mean of total water intake.

STATISTICAL ANALYSIS

Crude and adjusted linear regressions were applied to investigate the association between quintiles of the dietary share of ultraprocessed foods and the total water intake.

RESULTS

A significant linear reduction in the daily mean total water intake was observed across ultraprocessed food quintiles, amounting to 706 mL between the lower and the upper quintiles. Important increases across quintiles were observed for the intake of sugar-sweetened and artificially sweetened drinks, whereas important reductions occurred for unsweetened drinks, plain water, and water present in solid foods and dishes.

CONCLUSIONS

Reduced total water intake and an imbalance between sources of water that favors energy-dense and nutrient-poor sources were associated with increased consumption of ultraprocessed food, suggesting that decreased total water consumption might be a negative outcome of diets rich in ultraprocessed foods. This relationship should be further investigated in longitudinal or clinical trials.

Promoting water consumption among Dutch children: an evaluation of the social network intervention Share H2O

Background

There is a need to develop and improve interventions promoting healthy drinking behaviors among children. A promising method could be to stimulate peer influence within children’s social networks. In the Share H₂O social network intervention (SNI), peer influence was utilized by selecting a subset of influential children and training them as ‘influence agents’ to promote water consumption—as an alternative to SSBs. Previous research has mainly focused on the process of selecting influence agents. However, the process of motivating influence agents to promote the behavior has hardly received any research attention. Therefore, in the SNI Share H₂O SNI, this motivation process was emphasized and grounded in the self-determination theory (SDT). This study evaluated the implementation of the Share H₂O SNI, focusing on whether and how applying SDT-based techniques can motivate the influence agents and, indirectly, their peers.

Methods

This study included data collected in the Netherlands from both the influence agents (n = 37) and the peers (n = 112) in the classroom networks of the influence agents.

Self-reported measurements assessed the influence agents’ enjoyment of the training, duration and perceived autonomy support during the training, and changes in their intrinsic motivation and water consumption before and after the start of the intervention. Changes in the peers’ intrinsic motivation, perceived social support, and social norms were measured before and after the start of the intervention.

Results

The influence agents enjoyed the training, the duration was adequate, and perceived it as autonomy supportive. There was an increase in the influence agents’ intrinsic motivation to drink water and their actual water consumption. Providing personal meaningful rationales seemed to have motivated the influence agents. The intrinsic motivation and perceived descriptive norm of the peers remained stable. The peers reported an increase in their perceived social support and injunctive norm concerning water drinking after the intervention. Influence agents appeared to mainly use face-to-face strategies, such as modeling, talking to peers, and providing social support to promote the behavior.

Conclusions

The current findings provided preliminary evidence of the promising effects of using SDT-based techniques in an SNI to motivate the influence agents and, indirectly, their peers.

Trial registration

NTR, NL6905, Registered 9 January 2018, https://www.trialregister.nl/trial/6905

Price impact of taxes on sugary drinks in Brazil

Sugary drink consumption is an important contributor to the current global epidemic of obesity. In recent years, 50 countries or jurisdictions have implemented taxes on sugary drinks as an instrument to discourage consumption. Against the tide, Brazil reduced taxes on these beverages in 2017 and 2018. However, a recent debate - raised by the federal government - has started over taxation of sugary and alcoholic beverages (sin taxes). The effectiveness of this policy will depend on how the taxes are transferred to prices. In this sense, this paper we aim to quantify the impacts of the tax reduction on prices of sugary drinks in Brazil, and therefore to contribute to the debate by calculating the pass-through of taxes to prices of these products in the Brazilian context. We analyze the Brazilian market using a panel data of products, by brand, collected by Euromonitor from 2013 to 2018. Our results suggest that the transfer of taxes to prices depends on the firm size and the type of product, with pass-through rates ranging from 15% to 124%.

Promoting water consumption among children: a three-arm cluster randomised controlled trial testing a social network intervention

Objective:

To test the effectiveness of a social network intervention (SNI) to improve children’s healthy drinking behaviours.

Design:

A three-arm cluster randomised control trial design was used. In the SNI, a subset of children were selected and trained as ‘influence agents’ to promote water consumption–as an alternative to sugar-sweetened beverages (SSB)–among their peers. In the active control condition, all children were simultaneously exposed to the benefits of water consumption. The control condition received no intervention.

Setting:

Eleven schools in the Netherlands.

Participants:

Four hundred and fifty-one children (M_age = 10·74, SD_age = 0·97; 50·8 % girls).

Results:

Structural path models showed that children exposed to the SNI consumed 0·20 less SSB per day compared to those in the control condition (β = 0·25, P = 0·035). There was a trend showing that children exposed to the SNI consumed 0·17 less SSB per day than those in the active control condition (β = 0·20, P = 0·061). No differences were found between conditions for water consumption. However, the moderation effects of descriptive norms (β = –0·12, P = 0·028) and injunctive norms (β = 0·11–0·14, both P = 0·050) indicated that norms are more strongly linked to water consumption in the SNI condition compared to the active control and control conditions.

Conclusions:

These findings suggest that a SNI promoting healthy drinking behaviours may prevent children from consuming more SSB. Moreover, for water consumption, the prevailing social norms in the context play an important role in mitigating the effectiveness of the SNI.

A Habit-Based Randomised Controlled Trial to Reduce Sugar-Sweetened Beverage Consumption: the Impact of the Substituted Beverage on Behaviour and Habit Strength

BACKGROUND

Excess sugar consumption has been linked to numerous negative health outcomes, such as obesity and type II diabetes. Reducing sugar-sweetened beverage (SSB) consumption may reduce sugar intake and thus improve health. The aim of the study was to test the impact of the potentially different rewarding nature of water or diet drinks as replacements for SSB, using a habit and implementation intention-based intervention.

METHOD

An online randomised, two-arm parallel design was used. One hundred and fifty-eight participants (mainly from the UK and USA) who regularly consumed SSBs (M_age = 31.5, 51% female) were advised to create implementation intentions to substitute their SSB with either water or a diet drink. Measures of SSB consumption, habit strength and hedonic liking were taken at baseline and at 2 months. Water or diet drink consumption was only measured at 2 months.

RESULTS

There was a large and significant reduction in SSB consumption and self-reported SSB habits for both the water and diet drink groups, but no difference between groups. There were no differences in hedonic liking for the alternative drink, alternative drink consumption and alternative drink habit between the two groups. Reduction in SSB hedonic liking was associated with reduced SSB consumption and habit.

CONCLUSION

This study demonstrates that an implementation intention-based intervention achieved substantial reductions in SSB consumption and habits. It also indicates that hedonic liking for SSBs and alternative drinks are associated with changes in consumption behaviour. Substituting SSBs with water or diet drinks was equally as effective in reducing SSB consumption.

Trends in Store-Level Sales of Sugary Beverages and Water in the U.S., 2006-2015

INTRODUCTION

Previous research on sugar-sweetened beverage trends has focused on self-reported consumption from surveys. Few studies used objective store sales or explored differences by area-level demographics and store type.

METHODS

The average volume of beverages sold per store per 3-digit zoning improvement plan code from 2006 to 2015 was calculated using national Nielsen Retail Scanner point-of-sale data from 24,240 stores. A multilevel regression model analyzed annual trends, with random intercepts for state and separate models for beverage type (regular soda, no/low-calorie soda, other sugary drinks, 100% fruit juice, bottled water). Differences by store type (convenience, supermarkets, drug stores, mass merchandisers) and area-level demographics (categorized as tertiles) were examined. Data were analyzed in 2019.

RESULTS

The model-based estimates indicated that sales of regular soda (-11.8%), no/low-calorie soda (-19.8%), and 100% fruit juice (-31.9%) decreased over time, whereas sales of bottled water (+34.4%) increased and sales of other sugary drinks remained stable (+2.4%). Decreases in sugar-sweetened beverage sales were largely concentrated in supermarkets and larger in areas with high income and education levels and a high percentage of black and Hispanic people. There were also relatively larger increases in bottled water sales in states located in the South and Midwest.

CONCLUSIONS

The finding that sales of sugar-sweetened beverages decreased over time, whereas sales of bottled water increased is encouraging because sugar-sweetened beverage consumption is linked to obesity and other chronic conditions. This study provides a novel, rigorous assessment of U.S. beverage sales trends and differences by community and store characteristics.

A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption

OBJECTIVE

To examine whether the promotion of water intake could reduce sugar-sweetened beverage (SSB) consumption or purchases independent of interventions that target SSBs.

METHODS

Seven databases were systematically searched. Included studies used water promotion as the primary intervention; used a controlled trial, single group pre-post, or prospective cohort study design; included a measure of SSB consumption or purchase; enrolled human participants of any age who lived in high-income or middle-income countries; contained original data; and appeared in a peer-reviewed English-language article published from 1 January 2000 to January 4, 2019. The search yielded 7068 publications, from which 108 were chosen for full-text review. Seventeen were included in this review.

RESULTS

Nine of the 17 studies were randomized controlled trials, six were nonrandomized controlled trials, and 2 were single-group pre-post studies. Participants were primarily children and adolescents. Interventions included water provision, education or promotion activities. Ten of 17 studies were at low or some/moderate risk of bias. Seven studies showed a statistically significant decrease in SSB consumption of which only 2 were at low or some/moderate risk of bias.

CONCLUSIONS

This review found limited evidence that interventions aimed solely at increasing water consumption reduce SSB intake. Further research is needed to investigate whether interventions that combine water promotion and SSB reduction strategies could be synergistic for reducing SSB intake.

Water intake and intra-meal fluid consumption in relation to general and abdominal obesity of Iranian adults

OBJECTIVE

The aim of this study was to examine the association between whole-day water intake and intra-meal fluid consumption and odds of general and abdominal obesity among adults.

METHODS

This cross-sectional study was conducted among 7958 adults in Isfahan, Iran. Daily water consumption was assessed through the use of a pre-tested questionnaire by asking questions about the average number of glasses of water consumed in a day. Intra-meal fluid consumption was also analysed. Data regarding height, weight and waist circumference were collected using a validated self-administered questionnaire. Obesity was defined as body mass index ≥30 kg/m2, and abdominal obesity was defined as waist circumference >88 cm for women and >102 cm for men.

RESULTS

After taking potential confounders into account, individuals who were taking more than eight glasses of water in a day had 78% greater odds of general obesity (OR: 1.78; 95% CI: 1.08-2.94) compared with those who were taking less than two glasses of water. Individuals with much water intake had no significant greater odds of abdominal obesity. Compared with those who were consuming less than a glass of intra-meal fluids, subjects with 1-2 glasses of fluids between meals had 34% greater odds of general obesity (OR: 1.34; 95% CI: 1.04-1.59). Although subjects with greater intra-meal fluid intake had greater odds of abdominal obesity in crude model, this association became non-significant after adjustment for potential confounders (comparing > 4 glasses vs. ≤1 glass: OR: 1.65; 95% CI: 0.81-3.34).

CONCLUSIONS

We observed that taking more than eight glasses of water in a day and consuming 1-2 glasses of fluids between meals was associated with greater odds of general obesity.

Do prices and purchases respond similarly to soft drink tax increases and cuts?

While in January 2012, Denmark increased the long-standing tax on sugary soft drinks, the tax was cut by half in July 2013 and then completely repealed in January 2014. In this study, we examine whether increases and cuts of the soft drink tax lead to similar over- or under-shifting to prices and to similar demand responses. We use longitudinal scanner data of 1,282 Danish households to estimate within-product changes in prices and within-household changes in purchase quantity. The tax hike was overshifted by a factor of 1.6-1.8, while the tax repeal was fully passed through with a factor of 0.9-1.2. On average, consumption was 13.4 percent lower the year after the tax increase compared to the year before. The repeal of the tax was associated with an increase in purchase quantity of 31.0 percent. This is equivalent to price elasticities of -1.3 for both tax hikes and cuts. The results suggest that consumers react similarly to tax cuts compared to tax increases. Furthermore, the increase in purchases following a tax cut has no limiting effect on purchases of other beverages suggesting an increase in the intake of calories. This might have implications for health in countries that consider repealing current taxes on soft drinks.

A narrative review of the effects of sugar-sweetened beverages on human health: A key global health issue

The provision of healthy and safe food is vital for human health, and the addition of unnecessary sugars in foodstuffs is an important global issue, leading to multiple long- and short-term health issues and spiraling costs for individuals and governments alike. The negative effect of excess sugar consumption contributes to adverse health conditions, including obesity, type 2 diabetes, and poor oral health in both high and low resource settings. A key plank of governmental and health promotion bodies' nutritional guidance is to raise public awareness of "hidden" sugars, salt, and fats, such as found in processed foods and sugar-sweetened beverages (SSBs), and guide individuals to reduce their consumption. This rapid narrative review brings together some of the key issues identified in the literature around the consumption of SSBs, including patterns of consumption, the general impact on human health and nutrition, specific effects on oral health and the oral microbiome, and strategies to address over-consumption. The range of long-term adverse effects on health is often misunderstood or unknown by the public. However, some strategies have succeeded in reducing the consumption of SSBs, including public health strategies and interventions and the imposition of taxes or levies, and this article makes recommendations for action.

Substitution of sugar-sweetened beverages for other beverages and the risk of developing coronary heart disease: Results from the Harvard Pooling Project of Diet and Coronary Disease

Sugar-sweetened beverage (SSB) intake is associated with metabolic disorders. The reduction of SSB intake has been promoted to prevent death and disability from chronic diseases. We investigated the association between SSB intake and the risk of coronary events and death, and assessed if substitution of coffee, tea, milk, fruit juice and artificially-sweetened beverages (ASB) for SSBs was associated with a reduced risk of coronary events and death. This was a follow-up study in which data from six studies were pooled and standard observational analyses were performed. Diet intake was assessed at baseline by food-frequency questionnaires. Hazard ratios (HRs) with 95% confidence intervals for the incidence of coronary events and deaths were calculated by Cox proportional hazards regression. The effect of substituting another beverage for SSBs was calculated by taking the difference in the individual effect estimates. During the median 8.2-year follow-up, 4248 coronary events and 1630 coronary deaths were documented among 284,345 individuals. 355 ml daily increase of SSB intake was associated with an increased risk of coronary events (HR: 1.08; 95%CI: 1.02, 1.14) and possibly coronary death (HR: 1.05; 95%CI: 0.96, 1.16). Substitution analyses suggested that replacing SSBs with coffee (HR: 0.93; 95%CI: 0.87, 1.00) or ASB (HR: 0.89; 95%CI: 0.83, 0.97), might be associated with a lower risk of developing coronary events. We found that SSB intake was associated with an increased risk of coronary events and possibly coronary death. Our findings also suggest that replacing SSB's with ASBs or coffee may lower the risk of developing CHD.

Modelling the Effects of Beverage Substitution during Adolescence on Later Obesity Outcomes in Early Adulthood: Results from the Raine Study

High sugar-sweetened beverage (SSB) consumption has been linked with obesity. The present study examined the associations between adolescent SSB intake and body mass index (BMI), waist circumference (WC), and overweight status in early adulthood, and modelled the association of alternative beverage substitution with BMI and WC. Data of offspring from the Western Australian Pregnancy Cohort (Raine) Study at ages 14 and 22 years were used (n = 667). SSB intake at 14 years (100 g/day) was associated with higher BMI (β = 0.19 kg/m², 95% CI 0.04, 0.33), WC (β = 0.41cm, 95% CI 0.04, 0.78), and being overweight at 22 years (OR 1.10, 95% CI 1.02, 1.18). Every 100g modelled substitution of SSB with milk at age 14 years was associated with lower BMI (−0.19 kg/m²) and WC (−0.52 cm) at age 22 years. Replacement of SSB with diet drink was associated with higher BMI and WC. No association was found for substitutions of SSB with water, tea/coffee, or 100% fruit juice with BMI or WC. SSB intake during adolescence was associated with higher BMI, WC, and being overweight in early adulthood. Milk as an alternative to SSB was associated with less adiposity. Caution is necessary in recommending diet drinks as a SSB alternative.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

I was truly addicted to sugar: A consumer-focused classification system of behaviour change strategies for sugar reduction

The reduction of free sugars has been identified as a priority issue internationally. A range of public health initiatives have been recommended, including the provision of information and support for sugar reduction. To inform these approaches, it is important to know what people actually do in real world settings to reduce their consumption. This study documents and defines the range of consumer-based behaviour change strategies for sugar reduction. A total of 1145 strategies were extracted from 47 internet sources (i.e., consumer, popular and professional). Using a pragmatic content analysis, hundreds of strategies were organized into 25 discrete categories of strategies. Categories were grouped into the Rubicon Model of Action Phases and classified as pre-decisional (i.e., decisional balance, feedback, realisation, seek knowledge and information), post-decisional (i.e., action planning, coping planning, set goal intention, sugar guidelines) and actional phase. Actional strategies were the most prolific and included avoidance, consumption control, consumption planning, environmental restructuring, healthy eating focus, maintain readiness, professional support, refocusing, self-monitoring, social support, substance substitution, tapering, address underlying issues, urge management, well-being and withdrawal management. There was one post-actional strategy which was associated with self-evaluation (i.e., reviewing a change attempt in order to plan for the future). Four categories of strategies differed according to the source. Substance substitution was substantially less frequently discussed by consumers than professionals and few professional sites acknowledged or advised strategies to manage the struggle of maintaining readiness following a change attempt. Hundreds of individual strategies are discussed or promoted in online settings, and more information is needed on the effectiveness of these self-initiated approaches.

Factors associated with water consumption among children: a systematic review

BACKGROUND

Water is recommended as the main beverage for daily fluid intake. Previous systematic reviews have studied the consumption of sugar-sweetened beverages (SSBs) among children, but none have focused on water consumption. Insight into factors that are associated with children's water intake is needed to inform the development of interventions aimed at the promotion of water consumption. The objective of this review was therefore to summarize the current evidence on factors associated with water consumption among children aged 2 to 12 years.

METHODS

A systematic literature search in seven electronic databases was conducted in May, 2018 and retrieved 17,850 unique records. Two additional studies were identified by hand-searching references of included articles. Studies were selected if they had a cross-sectional or longitudinal study design, focused on children aged 2-12 years and published in an English language peer-reviewed journal. Participants from clinical populations, studies that included data of < 10 participants and non-human studies were excluded.

RESULTS

A total of 63 articles met inclusion criteria and were included in the analysis. We identified 76 factors that were investigated in these studies; 17/76 were investigated in a longitudinal study. There was evidence of positive associations between water consumption and child's self-efficacy, parental education level, parental self-efficacy, use of feeding practices such as restriction or encouraging healthy eating and study year. Evidence was inconsistent (< 60% of studies reported an association) for child's age, sex, BMI, consumption of SSBs and ethnic background of the parent. There was no evidence (≤33% of studies reported an association) of associations between consumption of milk or juice, parental emotional-, modelling- or instrumental feeding practices, eating school lunch or outside temperature and water consumption. The remaining 54 factors were investigated in fewer than three studies.

CONCLUSIONS

There is some evidence for an association between potentially modifiable parental and child-related factors and water consumption. However, most factors identified in this review were only studied by one or two studies and most studies were cross-sectional. More longitudinal research is necessary to investigate environmental, parental and child-related factors associated with water consumption that are currently under-studied and could further inform intervention strategies.

TRIAL REGISTRATION

PROSPERO ID# CRD42018093362 , registered May 22, 2018.

Impact of Public Health Interventions on Obesity and Type 2 Diabetes Prevention: A Simulation Study

INTRODUCTION

Little is known about what interventions worked or did not work in slowing the obesity epidemic. The long-term comparative effectiveness of environmental and behavioral public health interventions for obesity and type 2 diabetes prevention over an individual's life course is relatively unexplored. The potential impact and long-term collective effectiveness of environmental and behavioral interventions on obesity and type 2 diabetes throughout the life course was evaluated.

METHODS

The Virtual Los Angeles Obesity Model developed in 2016 was used to estimate the incidence and prevalence of obesity and type 2 diabetes under current and hypothetical interventions among 98,000 individuals born in 2009 and followed from birth to age 65 years. Analyses were performed in 2016 and completed in 2018.

RESULTS

The 48-year risk of type 2 diabetes was 0.533 (95% CI=0.446, 0.629) under the natural course, 0.451 (95% CI=0.334, 0.570) under the physical activity intervention, and 0.443 (95% CI=0.389, 0.495) under the fast-food intervention. The 64-year risk of obesity was 0.892 (95% CI=0.879, 0.903) under the natural course, 0.876 (95% CI=0.850, 0.899) under the physical activity intervention, and 0.864 (95% CI=0.856, 0.873) under the fast-food intervention. The other interventions had little or no long-term effects. When all the interventions were applied, the population risk ratios were 0.942 (95% CI=0.914, 0.967) and 0.634 (95% CI=0.484, 0.845) for obesity and type 2 diabetes, respectively.

CONCLUSIONS

Implementing health interventions continuously throughout the life span and in combination with other interventions could substantially halt the obesity and the type 2 diabetes epidemics.

Patterns and trends in the intake distribution of manufactured and homemade sugar-sweetened beverages in pre-tax Mexico, 1999-2012

OBJECTIVE

To describe trends across the intake distribution of total, manufactured and homemade sugar-sweetened beverages (SSB) from 1999 to 2012, focusing on high SSB consumers and on changes by socio-economic status (SES) subgroup.

DESIGN

We analysed data from one 24 h dietary recall from two nationally representative surveys. Quantile regression models at the 50th, 75th and 90th percentiles of energy intake distribution of SSB were used.

SETTING

1999 Mexican National Nutrition Survey and 2012 Mexican National Health and Nutrition Survey.ParticipantsSchool-aged children (5-11 years) and women (20-49 years) for trend analyses (n 7718). Population aged &gt;1 year for 2012 (n 10 096).

RESULTS

Over the 1999-2012 period, there were significant increases in the proportion of total and manufactured SSB consumers (5·7 and 10·7 percentage points), along with an increase in per-consumer SSB energy intake, resulting in significant increases in per-capita total SSB energy intake (142, 247 and 397 kJ/d (34, 59 and 95 kcal/d) in school-aged children and 155, 331 and 456 kJ/d (37, 79 and 109 kcal/d) in women at the 50th, 75th and 90th percentile, respectively). Total and manufactured SSB intakes increased sharply among low-SES children but remained similar among high-SES children during this time span.

CONCLUSIONS

Large increases in SSB consumption were seen between 1999 and 2012 during this pre-tax SSB period, particularly for the highest consumers. Trends observed in school-aged children are a clear example of the nutrition transition experienced in Mexico. Policies to discourage high intake of manufactured SSB should continue, joined with strategies to encourage water and low-calorie beverage consumption.

Aspartame Consumption for 12 Weeks Does Not Affect Glycemia, Appetite, or Body Weight of Healthy, Lean Adults in a Randomized Controlled Trial

Background

Low-calorie sweeteners are often used to moderate energy intake and postprandial glycemia, but some evidence indicates that they may exacerbate these aims.

Objective

The trial's primary aim was to assess the effect of daily aspartame ingestion for 12 wk on glycemia. Effects on appetite and body weight were secondary aims.

Methods

One hundred lean [body mass index (kg/m2): 18-25] adults aged 18-60 y were randomly assigned to consume 0, 350, or 1050 mg aspartame/d (ASP groups) in a beverage for 12 wk in a parallel-arm design. At baseline, body weight and composition were determined, a 240-min oral-glucose-tolerance test (OGTT) was administered, and measurements were made of appetite and selected hormones. Participants also collected a 24-h urine sample. During the intervention, the 0-mg/d ASP group consumed capsules containing 680 mg dextrose and 80 mg para-amino benzoic acid. For the 350-mg/d ASP group, the beverage contained 350 mg aspartame and the 1050-mg/d ASP group consumed the same beverage plus capsules containing 680 mg dextrose and 700 mg aspartame. Body weight, blood pressure, heart rate, and waist circumference were measured weekly. At weeks 4, 8, and 12, participants collected 24-h urine samples and kept appetite logs. Baseline measurements were repeated at week 12.

Results

With the exception of the baseline OGTT glucose concentration at 60 min (and resulting area under the curve value), there were no group differences for glucose, insulin, resting leptin, glucagon-like peptide 1, or gastric inhibitory peptide at baseline or week 12. There also were no effects of aspartame ingestion on appetite, body weight, or body composition. Compliance with the beverage intervention was ∼95%.

Conclusions

Aspartame ingested at 2 doses for 12 wk had no effect on glycemia, appetite, or body weight among healthy, lean adults. These data do not support the view that aspartame is problematic for the management of glycemia, appetite, or body weight. This trial was registered at www.clinicaltrials.gov as NCT02999321.

Perspective: Total, Added, or Free? What Kind of Sugars Should We Be Talking About?

There is consistent public guidance to limit sugars intakes. However, WHO recommendations are for "free" sugars, whereas some other guidance documents and public discussion focus on "added" sugars, and globally most food labeling states "total" sugars. Total sugars comprise all mono- and disaccharides, regardless of source, whereas both added and free sugars exclude the sugars that naturally occur in dairy products and intact fruit and vegetables. Definitions of added and free sugars differ mainly in their respective exclusion or inclusion of sugars in juiced or pureed fruit and vegetables. To date, there has been little evidence-based analysis of the scientific basis for these different sugar classifications or implications of their adoption for consumer communication and nutrition labeling. Evidence of discriminating relations of total compared with added or free sugars with weight gain or energy intake, type 2 diabetes, and dental caries was identified from recent systematic reviews and meta-analyses. The relations were weakest for total sugars and most consistent for dietary sources corresponding to free sugars (including sugars added to and in fruit juices). Consideration of these health outcomes suggests that the emphasis for intake monitoring, public health guidance, and consumer communication should be on free sugars. However, at present, the adoption of free sugars for these purposes would also carry challenges related to implementation, including consumer understanding, consensus on specifications, and current (labeling) regulations.