Gradual reduction of sugar in soft drinks without substitution as a strategy to reduce overweight, obesity, and type 2 diabetes: a modelling study

County-level association of diabetes and obesity with premature mortality

Objective

The association between the prevalence of diabetes and obesity and premature mortality at the county-level has not been well characterized. This study aims to elucidate the relationship between county-level prevalence of diabetes and obesity and premature mortality.

Methods

We utilized the data from the 2022 County Health Rankings which obtained the data from Behavioral Risk Factor Surveillance System in 2019, and National Center for Health Statistics Mortality Files 2018-2020. The county prevalence of diabetes and obesity was determined, and univariable and multivariable associations with premature mortality were identified.

Results

Among 3082 counties, the percentage of individuals with diabetes ranged from 5.5 to 21.0 % and the percentage of individuals with obesity ranged from 16.4 to 51.0 %. Our analysis revealed a stepwise increase in premature age-adjusted death rates (AADR) with rising deciles of county-level diabetes (P < 0.001) and obesity (P < 0.001) in both univariable and multivariable models.

Conclusions

These findings underscore the significance of addressing diabetes and obesity at the county-level to reduce premature mortality and improve population health outcomes across varied communities in the United States.

Comparative effects of different beverages on weight loss in adults: a systematic review and network meta-analysis of randomized trials

BACKGROUND

There is a lack of clarity on the comparative effects of different beverages on weight loss in adults.

OBJECTIVE

This study aimed at quantifying and ranking the effects of different beverages on weight loss.

METHODS

We searched PubMed, Scopus, and Web of Science up to January 2023. We included randomized trials evaluating the comparative effects of two or more beverages, or compared a beverage against a control group (water, no intervention), for weight loss in adults. We conducted a random-effects network meta-analysis (NMA) with a Bayesian framework to estimate mean difference [MD] and 95% credible interval [CrI].

RESULTS

In total, 78 randomized trials with 4168 participants were eligible. Low/no-calorie sweetened beverages (LNCSB) was effective for weight loss compared with water (MD: -0.79 kg, 95% CrI: -1.35, -0.18), milk (MD: -0.80 kg, 95% CrI: -1.59, -0.01), fruit juice (MD: -0.83 kg, 95% CrI: -1.47, -0.13), sugar-sweetened beverages (SSB) (MD: -1.08 kg, 95% CrI: -1.65, -0.50), and no intervention (MD: -1.19 kg, 95% CrI: -1.93, -0.41). However, in sensitivity analyses, no significant effect was seen in trials with a low risk of bias and those that implemented calorie restriction. LNCSB drinking was effective for waist circumference reduction compared with water (MD: -1.85 cm, 95% CrI: -3.47, -0.22). The certainty of evidence from most comparisons was rated low.

CONCLUSIONS

This study suggested evidence of low certainty that intake of LNCSBs can result in a small weight loss when used as a substitute for other beverages. Considering the low certainty of evidence, more research is needed to compare the effects of different beverages on body weight.

TRIAL REGISTRATION

Not applicable, but the protocol of this systematic review was registered at PROSPERO (registration number: CRD42023407937).

Assessing food vendor receptiveness to healthier options: a study of knowledge, attitudes, practices, and perceived barriers regarding salt, sugar, and oil reduction in cafeteria food vendors

BACKGROUND

Prioritizing policies that address major non-communicable disease (NCD) risk factors, such as poor diet, is a cost-effective way to improve health outcomes. While education can enhance knowledge and practices in the short term, recent trends show that structural and policy-based initiatives, such as setting mandatory salt, sugar, and oil (SOS) targets are effective means of changing dietary behaviours and reducing NCD risk factors. However, few studies have surveyed the KAP of food vendors in workplaces and educational institutions and assessed their receptiveness to serving low-SOS dishes. This study aimed to evaluate the knowledge, attitudes, and practices (KAP) regarding salt, oil, and sugar (SOS) consumption and use, as well as the barriers, and enablers of these practices amongst food operators within Malaysia's out-of-home sector.

METHODS

This study employed a cross-sectional, descriptive survey design to assess knowledge, attitudes, and practices (KAP) related to the consumption of salt, oil, and sugar and their use in food preparation amongst campus canteen staff at two Malaysian higher education institutions. Data were collected anonymously from 38 participants, which included representatives from all independent canteen operators on the premises. The study also explored the barriers and enablers vendors encounter in reducing salt and sugar usage.

RESULTS

The study found that most participants were aware of the health risks associated with high salt, oil, and sugar (SOS) consumption and had positive attitudes towards reducing dietary SOS intake in general, though these attitudes did not extend to their own food preparations. However, their knowledge of recommended dietary guidelines was poor, and actual practices related to SOS reduction were inadequate. Barriers to reducing SOS included concerns about taste and customer acceptance, as well as the lack of standardized guidelines and tools for measuring SOS in food preparation.

CONCLUSIONS

This study identifies gaps in knowledge and practices related to SOS reduction among the surveyed food vendors. While vendors acknowledge the health risks of high SOS consumption, there is a lack of awareness of dietary guidelines and practical low-SOS cooking methods, highlighting the need for regular monitoring, vendor education, and support in promoting healthier food options.

Evidence on the effectiveness and equity of population-based policies to reduce the burden of type 2 diabetes: a narrative review

There is increasing evidence for the effectiveness of population-based policies to reduce the burden of type 2 diabetes. Yet, there are concerns about the equity effects of some policies, whereby socioeconomically disadvantaged populations are not reached or are adversely affected. There is a lack of knowledge on the effectiveness and equity of policies that are both population based (i.e. targeting both at-risk and low-risk populations) and low agency (i.e. not requiring personal resources to benefit from the policy). In this narrative review, we selected 16 policies that were both population based and low agency and reviewed the evidence on their effectiveness and equity. Substantial evidence suggests that fruit and vegetable subsidies, unhealthy food taxes, mass media campaigns, and school nutrition and physical activity education are effective in promoting healthier lifestyle behaviours. Less evidence was available for mandatory food reformulation, reduced portion sizes, marketing restrictions and restriction of availability and promotion of unhealthy products, although the available evidence suggested that these policies were effective in reducing unhealthy food choices. Effects could rarely be quantified across different studies due to substantial heterogeneity. There is an overall lack of evidence on equity effects of population-based policies, although available studies mostly concluded that the policies had favourable equity effects, with the exception of food-labelling policies. Each of the policies is likely to have a relatively modest effect on population-level diabetes risks, which emphasises the importance of combining different policy measures. Future research should consider the type of evidence needed to demonstrate the real-world effectiveness and equity of population-based diabetes prevention policies.

Public health interventions against childhood obesity in China

China is confronted with the challenge of increasing childhood obesity. Although interventions for childhood obesity have been developed, their effectiveness and implementation can vary considerably across nations. In this paper, we review and consolidate the evidence on childhood obesity intervention strategies aimed at multiple levels and components across life, in China. School-based interventions, primarily delivered with group-based dietary and physical education, have shown potential efficacy and can be enhanced by integrating food environment reform and family support. However, most interventional studies were done in eastern and urban areas of China, which highlights the need for attention in regions with insufficient health resources where policies and initiatives are less accessible. In addition, the sparse reporting on implementation design and delivery might hinder the scalability of potentially effective strategies. Amid rapid social and economic development over the past few decades, China faces unique challenges on urbanisation, physical inactivity, and nutritional transitions, necessitating an updated policy agenda for primary prevention of childhood obesity. Structural longitudinal evaluations of public initiatives led by the government and organisations along with inclusive and equitable interventions targeting children of different ages, urban-rural regions, and different ethnic and socioeconomic groups are warranted. Tackling childhood obesity in China needs a cohesive approach that integrates social, economic, cultural, and environmental strategies, combining school-based, family-based, and individual-based approaches, and concerted efforts from multiple sectors and entities within China.

Development of food literacy in children and adolescents: implications for the design of strategies to promote healthier and more sustainable diets

Food literacy has emerged as a key individual trait to promote the transformation of food systems toward healthy and sustainable diets. Childhood and adolescence are key periods for establishing the foundations of eating habits. Different food literacy competencies are acquired as children develop different cognitive abilities, skills, and experiences, contributing to the development of critical tools that allow them to navigate a complex food system. Thus, the design and implementation of programs to support the development of food literacy from early childhood can contribute to healthier and more sustainable eating habits. In this context, the aim of the present narrative review is to provide an in-depth description of how different food literacy competencies are developed in childhood and adolescence, integrating the extensive body of evidence on cognitive, social, and food-related development. Implications for the development of multisectoral strategies to target the multidimensional nature of food literacy and promote the development of the 3 types of competencies (relational, functional, and critical) are discussed.

Smartphone-based educational and counseling interventions for women with high body mass index at Urmia's health centers

BACKGROUND AND PURPOSE

Overweight and obesity in women of reproductive age not only contribute to chronic diseases but also lead to fertility issues, adverse pregnancy outcomes, and psychological challenges. Among the detrimental behaviors associated with obesity, the consumption of fast foods and sedentary lifestyles have the most significant impact on weight gain and require effective interventions. This study aims to examine the effectiveness of an educational and counseling smartphone intervention in raising awareness and modifying behaviors related to sedentary behavior and fast food consumption in women with high body mass index.

MATERIALS AND METHODS

This randomized controlled trial was conducted with two parallel groups comprising 106 women of reproductive age who sought assistance at Urmia health centers in 2022. Participants with diverse social and economic backgrounds were included. They were randomly assigned to either a control group or an intervention group. Valid and reliable questionnaires were administered to assess awareness regarding sedentary behaviors and fast foods consumption, as well as engagement in sedentary behaviors and consumption of fast foods. In addition to standard care, the intervention group received educational and counseling sessions through a dedicated smartphone application. Data analysis was performed using SPSS 20 software at a significance level of P < 0.05.

FINDINGS

The results of a statistical t-test indicated a noteworthy disparity between the control and intervention groups concerning the average awareness scores related to fast foods consumption (P < 0.001) and sedentary behaviors (P < 0.001) before and 3 months after the intervention. Additionally, a substantial statistical difference was observed in the mean consumption of fast foods (P < 0.001) and hours of sedentary behaviors (P < 0.001) before and 3 months after the intervention when comparing the two groups.

CONCLUSION

Educational and counseling programs, when applied effectively, can serve the dual purpose of enhancing awareness concerning sedentary behaviors and fast foods consumption while concurrently fostering a reduction in the prevalence of these behaviors. The study was registered in the Iranian Registry of Clinical Trials (IRCT Id: IRCT20210722051953N1) at 04/08/2021.

Precision Medicine in Type 2 Diabetes Mellitus: Utility and Limitations

Type 2 diabetes mellitus (T2DM) is one of the most widespread diseases in Western countries, and its incidence is constantly increasing. Epidemiological studies have shown that in the next 20 years. The number of subjects affected by T2DM will double. In recent years, owing to the development and improvement in methods for studying the genome, several authors have evaluated the association between monogenic or polygenic genetic alterations and the development of metabolic diseases and complications. In addition, sedentary lifestyle and socio-economic and pandemic factors have a great impact on the habits of the population and have significantly contributed to the increase in the incidence of metabolic disorders, obesity, T2DM, metabolic syndrome, and liver steatosis. Moreover, patients with type 2 diabetes appear to respond to antihyperglycemic drugs. Only a minority of patients could be considered true non-responders. Thus, it appears clear that the main aim of precision medicine in T2DM is to identify patients who can benefit most from a specific drug class more than from the others. Precision medicine is a discipline that evaluates the applicability of genetic, lifestyle, and environmental factors to disease development. In particular, it evaluated whether these factors could affect the development of diseases and their complications, response to diet, lifestyle, and use of drugs. Thus, the objective is to find prevention models aimed at reducing the incidence of pathology and mortality and therapeutic personalized approaches, to obtain a greater probability of response and efficacy. This review aims to evaluate the applicability of precision medicine for T2DM, a healthcare burden in many countries.

Role of parenting practices and digital media on beverage intake in European schoolchildren of different weight status. Feel4Diabetes-study

OBJECTIVES

Halting the rise in childhood obesity is an ongoing challenge in Europe. Sugar-sweetened beverage (SSB) and artificially sweetened beverage (ASB) consumption has become common practice at home and during family meals. The objective of this study was to investigate associations of parenting practices and home digital media availability with beverage intake in European schoolchildren of different weight groups.

METHODS

Cross-sectional data were derived from six countries taking part in the multicentered Feel4Diabetes-study. Anthropometric data were measured for 12 030 schoolchildren (n = 6097 girls; median age = 8.1 y). Details on sociodemographic characteristics, beverage intake, food parenting practices, and home availability of digital media were collated from questionnaires. The outcomes, daily SSB and ASB intakes, were included as dependent variables in multivariable regression models that provided odds ratios reflecting their association with parenting practices and digital media (exposures), after stratifying for children's weight status (underweight or normal versus overweight or obese).

RESULTS

After controlling for children's sex, region, maternal body mass index, and education, the multivariate model found that in both body mass index groups, permissive parenting practices, such as rewarding and allowing consumption of unhealthy foods "very often or often," as compared with "rarely or never," were associated with a high daily intake of SSBs and ASBs in children, while parents "watching television together with their child," rewarding with screen time, and availability of television in children's rooms increased the likelihood of both beverages in the underweight or normal-weight group.

CONCLUSIONS

Modification of permissive parenting practices and removal of television from children's rooms could effectively reduce SSB intake and curb the ongoing threat of child obesity in Europe.

Children's reaction to sugar reduced dairy desserts in the context of the implementation of nutritional warning labels: An exploratory study

The aim of the present work was to explore children's reaction to sugar reduction in the context of the implementation of nutritional warnings in Uruguay. The study was composed of two sessions involving three evaluation conditions: tasting without package information, package evaluation without tasting, and tasting with package information. A total of 122 children, ages ranging between 6 and 13 years old (47% girls) were involved in the study. In the first session, children's hedonic and emotional response to a regular and a sugar-reduced chocolate dairy dessert (without other sweeteners) was evaluated. In the second session, children first evaluated their expected liking, emotional associations and choice of packages differing in the presence of warning labels for excessive sugar content and cartoon character (2x2 design). Finally, they tasted the selected sample in the presence of the package and evaluated their liking, emotional associations, and intention to re-taste it. Although sugar reduction led to a significant reduction in overall liking, the dessert with 40% sugar reduction showed a mean overall score of 6.5 in a 9-point hedonic scale and was described using positive emoji (, , ). When the desserts were tasted with package information, no significant differences in the expected overall liking of the regular and sugar-reduced dessert were found. Regarding the effect of packaging elements, the presence of a warning label highlighting excessive content of sugar did not have a significant effect on children's choice. Instead, children's choices were defined by the presence of a cartoon character. Results from the present work provide additional evidence about the feasibility of reducing the sugar content and sweetness of dairy products targeted at children and stress the need to regulate the use of cartoon characters on products with an unfavorable nutritional profile. Methodological recommendations for sensory and consumer research with children are also discussed.

Global nutritional challenges of reformulated food: A review

Food reformulation, the process of redesigning processed food products to make them healthier, is considered a crucial step in the fight against noncommunicable diseases. The reasons for reformulating food vary, with a common focus on reducing the levels of harmful substances, such as fats, sugars, and salts. Although this topic is broad, this review aims to shed light on the current challenges faced in the reformulation of food and to explore different approaches that can be taken to overcome these challenges. The review highlights the perception of consumer risk, the reasons for reformulating food, and the challenges involved. The review also emphasizes the importance of fortifying artisanal food processing and modifying microbial fermentation in order to meet the nutrient requirements of people in developing countries. The literature suggests that while the traditional reductionist approach remains relevant and yields quicker results, the food matrix approach, which involves engineering food microstructure, is a more complex process that may take longer to implement in developing economies. The findings of the review indicate that food reformulation policies are more likely to succeed if the private sector collaborates with or responds to the government regulatory process, and further research is conducted to establish newly developed reformulation concepts from different countries. In conclusion, food reformulation holds great promise in reducing the burden of noncommunicable diseases and improving the health of people around the world.

Current perspectives on global sugar consumption: definitions, recommendations, population intakes, challenges and future direction

Currently, there is considerable emphasis on the relationship between dietary sugar consumption and various health outcomes, with some countries and regions implementing national sugar reduction campaigns. This has resulted in significant efforts to quantify dietary sugar intakes, to agree on terms to describe dietary sugars and to establish associated recommendations. However, this information is infrequently collated on a global basis and in a regularised manner. The present review provides context regarding sugar definitions and recommendations. It provides a global review of the available data regarding dietary sugar intake, considering forms such as total, free and added sugars. A comprehensive breakdown of intakes is provided by age group, country and sugar form. This analysis shows that free sugar intakes as a percentage of total energy (%E) are the highest for children and adolescents (12-14%E) and the lowest for older adults (8%E). This trend across lifecycle stages has also been observed for added sugars. The available data also suggest that, while some reductions in sugar intake are observed in a few individual studies, overall intakes of free/added sugars remain above recommendations. However, any wider conclusions are hampered by a lack of detailed high-quality data on sugar intake, especially in developing countries. Furthermore, there is a need for harmonisation of terms describing sugars (ideally driven by public health objectives) and for collaborative efforts to ensure that the most up-to-date food composition data are used to underpin recommendations and any estimates of intake or modelling scenarios.

Modelling health and economic impact of nutrition interventions: a systematic review

Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.

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.

Association between Free Sugars Intake and Risk of Metabolic Syndrome in Chinese Adults: Results from the China Health and Nutrition Survey, 2000-2018

The association of free sugars intake with metabolic syndrome (MetS) is controversial. This study aimed to examine the association between free sugars intake and risk of MetS in Chinese adults. The data were from seven waves of the China Health and Nutrition Survey (2000−2018), a longitudinal and open prospective cohort study. Dietary intake was calculated based on the data collected by consecutive 3-day 24-h dietary recalls combined with household weighing for foods or condiments. Cox proportion hazard regressions and restricted cubic spline (RCS) were performed to explore the associations between free sugars intake and the risk of MetS. The present study selected 12,048 adults aged 18 years and above. During a median (IQR) follow-up of 9.0 (7.0, 15.0) years with 131,844.0 person-years, 3970 (32.95%) MetS occurred. After adjusting for all potential confounders, compared to adults with free sugars intake of <5 g/day group, adults with free sugars intake of 5−20 g/day were associated with a higher risk of MetS (HR, 1.094; 95% CI, 1.009−1.186). No significant association was observed between free sugars intake of >20 g/day and the risk of MetS (HR, 1.011; 95% CI, 0.800−1.277). There is an urgent need to pay attention to the intake of free sugars and comprehensive measures such as the improvements in the processing of sugary foods, and sugar composition should be included on food nutrition labels to control intake of free sugars in China.

The Potential Impact of Different Taxation Scenarios towards Sugar-Sweetened Beverages on Overweight and Obesity in Brazil: A Modeling Study

The adoption of fiscal policies based on the specific taxation of sugar-sweetened beverages (SSBs) has been recommended by international health agencies, as they are measures that potentially reduce consumption. This study is an ex ante risk comparison that estimates the impact of three tax scenarios (20, 25, and 30%) with a 100% pass-on rate to SSBs on the prevalence of high weight and obesity in the Brazilian population. Data on the consumption habits, weight, and height of 46,164 adults aged 20 years or over from Brazilian recent national surveys were used. The shift in consumption after taxation was estimated based on the price elasticity of the demand. The percentage changes in overweight for 20, 25, and 30% taxation were 1.84% (95%CI: 1.82; 1.86), 1.89% (95%CI: 1.87; 1.90), and 2.25% (95%CI: 2.24; 2.27), respectively. The change in the prevalence of obesity was 1.93% (95%CI: 1.87; 2.00), 2.90% (95%CI: 2.80; 3.02), and 4.16% (95%CI: 4.01; 4.32), respectively. Taxes on SSBs may have a more favorable result among the heaviest consumers, who are young adults (20-29 years), especially men, thereby promoting a greater reduction in the prevalence of high weight and obesity.

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.

Is Adolescents' Free Sugar Intake Associated with the Free Sugar Intake of Their Parents?

High free sugar intake can lead to increased dental caries, obesity, and other health risks among adolescents. Studies have shown that family factors, especially parents, are one of the primary factors influencing adolescents' sugar intake. This study aims to investigate the influence of adolescent parents' free sugar intake, knowledge, attitude, and practice (KAP) on adolescents' free sugar intake. A total of 1090 pairs of adolescents and their parents from 10 secondary schools in Changsha were enrolled in a cross-sectional study. Free sugar intakes of parents and adolescents were measured using the food frequency questionnaire (FFQ). The current status of parents' knowledge, attitude, and practice in consuming free sugar was investigated using online and offline questionnaires. Parental free sugar intake was 11.55 (5.08, 21.95) g/d, and that of adolescents was 41.13 (19.06, 80.58) g/d. Parental free sugar intake, free sugar knowledge level, intake behavior, and guidance behavior were associated with adolescent free sugar intake. A superior level of parental free sugar knowledge (adjusted OR = 0.726, 95% CI: 0.557~0.946) was a protective factor for adolescent free sugar intake. Moderate and high levels of parental free sugar intake (adjusted OR = 1.706, 95% CI: 1.212~2.401; adjusted OR = 2.372, 95% CI: 1.492~3.773, respectively) were risk factors for free sugar intake in adolescents. Given the importance of parental influence on the adolescent free sugar intake, further limiting parental intake and increasing awareness of free sugars could play an active role in future interventions for adolescents' free sugar intake.

Behavioural Nudges, Physico-Chemical Solutions, and Sensory Strategies to Reduce People’s Salt Consumption

This narrative historical review examines the wide range of approaches that has been trialled/suggested in order to reduce the consumption of salt. While sodium is an essential micronutrient, there is widespread evidence that high levels of consumption are leading to various negative health outcomes. This review summarises the evidence relating to the various approaches that have been put forward to date to help reduce salt consumption over the years, while also highlighting a number of important questions that remains for future research. Solutions to reducing salt consumption include everything from the gradual reduction in salt in foods through to the reduction in the number/size of holes in saltshakers (what one might consider a behavioural nudge). Physico-chemical solutions have included salt replacers, such as monosodium glutamate (MSG) through to the asymmetric distribution of salt in processed (e.g., layered) foods. A wide range of sensory approaches to modulating expected and perceived saltiness have also been suggested, including the use of salty aromas, as well as suggesting the use of colour cues, sonic seasoning, and even textural primes. It is currently unclear whether different salty aromas can be combined to increase odour-induced taste enhancement (OITE) effectiveness. In the years ahead, it will be interesting to assess how long such solutions remain effective, as well as whether different solutions can be combined to help reduce salt consumption without having to compromise on taste/flavour

Simulation models of sugary drink policies: A scoping review

INTRODUCTION

Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models.

METHODS

We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22.

RESULTS

Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8).

DISCUSSION

Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.

Reduced Consumption of Sugar-Sweetened Beverages Is Associated with Lower Body Mass Index Z-Score Gain among Chinese Schoolchildren

To examine whether reducing sugar-sweetened beverage (SSB) consumption is associated with reduced body mass index z-score gain among Chinese schoolchildren in Nanjing, China, a randomized controlled trial (RCT) was conducted in four selected primary schools from September 2019 to September 2020. Students in the third grade in the Intervention Group received school-based and home-based interventions for two consecutive semesters to reduce SSB consumption, while two schools in the Control Group did not receive any interventions. Weight changes were expressed as body mass index (BMI) z-scores as standard deviations of the BMI distribution per age and sex group. Changes in SSB consumption before and after the interventions were categorized into Level-Up if it increased, Level-Same if it was maintained and Level-Down if it decreased. Multivariable linear regression models were used to explore the association of different levels of changes in SSB consumption pre- and post-intervention with the BMI z-score. Among 1633 participants who completed the trial, the mean age at baseline was 9.36 years (±0.48 SD).The median baseline BMI z-score was −0.24 (25th percentile −0.72; 75th percentile 0.58). After the intervention, the median BMI z-score increased by 0.06 (−0.17~0.37) in the Intervention Group and by 0.14 (−0.08~0.41) in the Control Group (p < 0.001). A higher increase in BMI was found in the Control Group than in the Intervention Group (1.20 vs. 0.94) during the 12-month period. Among participants whose parents’ educational attainment was above 9 years, the median BMI z-score increased by 0.07 (−0.17~0.37) in the Intervention Group and by 0.16 (−0.06~0.41) in the Control Group (p < 0.001). In a linear regression analysis adjusted for potential confounders, the BMI z-score decreased by 0.057 more in Level-Down than in Level-Up (95% CI: −0.103 to −0.012, p = 0.014). These results indicate that the decreased consumption of SSBs might have reduced the prevalence of overweight in schoolchildren in China, especially in students whose parents had high educational levels.

Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies

BACKGROUND

Adverse associations of low- and no-calorie sweetened beverages (LNCSB) with cardiometabolic outcomes in observational studies may be explained by reverse causality and residual confounding.

PURPOSE

To address these limitations we used change analyses of repeated measures of intake and substitution analyses to synthesize the association of LNCSB with cardiometabolic outcomes.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were searched up to 10 June 2021 for prospective cohort studies with ≥1 year of follow-up duration in adults.

STUDY SELECTION

Outcomes included changes in clinical measures of adiposity, risk of overweight/obesity, metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease, and total mortality.

DATA EXTRACTION

Two independent reviewers extracted data, assessed study quality, and assessed certainty of evidence using GRADE. Data were pooled with a random-effects model and expressed as mean difference (MD) or risk ratio (RR) and 95% CI.

DATA SYNTHESIS

A total of 14 cohorts (416,830 participants) met the eligibility criteria. Increase in LNCSB intake was associated with lower weight (5 cohorts, 130,020 participants; MD -0.008 kg/year [95% CI -0.014, -0.002]). Substitution of LNCSB for sugar-sweetened beverages (SSB) was associated with lower weight (three cohorts, 165,579 participants; MD, -0.12 [-0.14, -0.10,] kg/y) and lower incidence of obesity (OB) (one cohort, 15,765 participants; RR 0.88 [95% CI 0.88, 0.89]), coronary heart disease (six cohorts, 233,676 participants; 0.89 [0.81, 0.98]), cardiovascular disease mortality (one cohort, 118,363 participants; 0.95 [0.90, 0.99]), and total mortality (one cohort, 118,363 participants; 0.96 [0.94, 0.98]) with no adverse associations across other outcomes. Substitution of water for SSB showed lower weight (three cohorts, 165,579 participants; MD -0.10 kg/year [-0.13, -0.06]), lower waist circumference (one cohort, 173 participants; -2.71 cm/year [-4.27, -1.15]) and percent body fat (one cohort, 173 participants; -1.51% per year [-2.61, -0.42]), and lower incidence of OB (one cohort, 15,765 participants; RR 0.85 [0.75, 0.97]) and T2D (three cohorts, 281,855 participants; 0.96 [0.94, 0.98]). Substitution of LNCSB for water showed no adverse associations.

LIMITATIONS

The evidence was low to very low certainty owing to downgrades for imprecision, indirectness, and/or inconsistency.

CONCLUSIONS

LNCSB were not associated with cardiometabolic harm in analyses that model the exposure as change or substitutions. The available evidence provides some indication that LNCSB in their intended substitution for SSB may be associated with cardiometabolic benefit, comparable with the standard of care, water.

Associations between free sugar intake and markers of health in the UK population: an analysis of the National Diet and Nutrition Survey rolling programme

Recommendations for free sugar intake in the UK should be no more than 5 % of total energy due to increased health risks associated with overconsumption. It was therefore of interest to examine free sugar intakes and associations with health parameters in the UK population. The UK National Diet and Nutrition Survey rolling programme (2008-2017) was used for this study. Dietary intake, anthropometrical measurements and clinical biomarker data collated from 5121 adult respondents aged 19-64 years were statistically analysed. Compared with the average total carbohydrate intake (48 % of energy), free sugars comprised 12·5 %, with sucrose 9 % and fructose 3·5 %. Intakes of these sugars, apart from fructose, were significantly different over collection year (P < 0·001) and significantly higher in males (P < 0·001). Comparing those consuming above or below the UK recommendations for free sugars (5 % energy), significant differences were found for BMI (P < 0·001), TAG (P < 0·001), HDL (P = 0·006) and homocysteine concentrations (P = 0·028), and significant sex differences were observed (e.g. lower blood pressure in females). Regression analysis demonstrated that free sugar intake could predict plasma TAG, HDL and homocysteine concentrations (P < 0·0001), consistent with the link between these parameters and CVD. We also found selected unhealthy food choices (using the UK Eatwell Guide) to be significantly higher in those that consumed above the recommendations (P < 0·0001) and were predictors of free sugar intakes (P < 0·0001). We have shown that adult free sugar intakes in the UK population are associated with certain negative health parameters that support the necessary reduction in free sugar intakes for the UK population.

Consumer Expectation of Flavored Water Function, Sensory Quality, and Sugar Reduction, and the Impact of Demographic Variables and Woman Consumer Segment

This study aimed to investigate consumer expectation of flavored water and potential consumer segments. The results showed flavored water was ranked the fourth most popular drink, after plain water, tea, and coffee, by 901 participants. Consumers highly expected functional flavored water with refreshing (87.4% selection), thirst-quenching (73.7%), and tasty (65.7%) qualities, containing vitamins, minerals, and antioxidants, and providing energy. Expected flavored water sensory qualities included temperature (62.4%), flavor (52.4%), and sweet taste (47.4%); lemon, berry, and lime flavors were most preferred, while bitterness, irritation, astringency, and sourness were least preferred. Pure sugar and honey were rated highest as the sweeteners for flavored water. Likewise, consumers were mostly concerned with taste followed by calories. Single demographic variables (age, reported health condition, drinking frequency, educational level) significantly influenced (p ≤ 0.05) flavored water function, sensory quality, and sugar reduction expectations. Females had higher expectation of flavored water’s refreshing and antioxidant functions. Cluster analysis revealed two consumer segments. The younger, low-education, self-reportedly less healthy cluster (mainly college students) expected various functions and flavors such as low temperature, cooling taste, diverse flavors, and sweet taste (and disliked bitterness). The older, educated, employed, self-reportedly healthy cluster had lower expectations of flavored water functions, were less sensitive to bitterness, and preferred no sweetness or little sweetness. These findings provide informative data to establish marketing and sales strategies for promoting flavored water.

The Combination of School-Based and Family-Based Interventions Appears Effective in Reducing the Consumption of Sugar-Sweetened Beverages, a Randomized Controlled Trial among Chinese Schoolchildren

To examine whether environmental interventions, student awareness and parents’ model roles are associated with the consumption of sugar-sweetened beverages (SSBs), a randomized controlled trial was conducted among Chinese schoolchildren. A multi-stage cluster random sampling method was applied to select four primary schools, two in urban areas and two in rural areas, in Nanjing, eastern China. Classes of the third grade in the selected four schools were randomly assigned to the intervention group and control group. Among selected students in those classes, aged 9–10 years, those in the intervention group received intervention measures comprising school-based and family-based measures and accepted monthly monitoring along with interventions, for two consecutive semesters, while those in the control group did not receive any specific interventions. After intervention, there was a significant increase in SSB knowledge and an improvement in the family environment with parents in the intervention group. The proportion of frequent consumption (≥4 times/week) of any SSBs in the intervention group was lower than that in the control group (31.5% vs. 56.2%, p < 0.01). Multivariate analysis indicated that parental education level is positively associated with reduced SSB consumption. Interventions showed an average decrease in SSBs consumption by 1.77 units, those living in urban areas decreased by 2.05 units. The combination of school-based and family-based interventions appears effective in reducing SSB consumption among Chinese schoolchildren, especially in urban areas and for those with parents with lower educational levels.

Nudging sugar portions: a real-world experiment

BACKGROUND

Sugar overconsumption is a major contributor to overweight and obesity, with daily consumption greatly exceeding the WHO's recommendations. The aim of the present study was to determine whether using a functionally modified sugar shaker as a food environment nudge could be an effective means to reduce the sugar used in hot beverages.

METHODS

Sugar shakers were functionally modified to reduce the amount of sugar in each pour by 47%. A real-world experiment was conducted to compare the amount of added sugar per hot beverage during default and nudge conditions over the course of four weeks (17,233 hot beverages sold) in a university take-away café. In addition, 59 customers were surveyed to evaluate the acceptance of the intervention.

RESULTS

Modifying the functional design of sugar shakers resulted in a reduction of added sugar by 20% (d = 1.35) compared to the default condition. In the survey, most participants evaluated the intervention strategy positively.

CONCLUSION

The present real-world experiment demonstrates that a simple environmental intervention can significantly reduce sugar consumption in public places while meeting with consumer approval, making it a promising means of reducing sugar overconsumption.

Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study

BACKGROUND

High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear.

METHODS

A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education.

RESULTS

Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans.

CONCLUSIONS

Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

Association between ultrapocessed food and chronic kidney disease

The modern diet is closely linked to the consumption of processed foods, causing an increase in the intake of salt, simple sugars, phosphorus and added potassium. This excess intake is associated with an increased risk of obesity, diabetes, hypertension and chronic kidney disease (CKD). CKD, which according to data from the ENRICA study affects 15% of the population, magnifies its impact due to the higher prevalence of diabetes and hypertension and due to limitations in the management of sodium and phosphorus. The intake of these products far exceeds the established recommendations, assuming 72% of total sodium, 25%-35% of phosphorus, 12%-18% of potassium and exceeding 10% of the caloric intake in simple sugars. Measures are necessary to reduce their contribution through nutritional advice, labeling review, education campaigns on healthy habits, fees and institutional actions that involve food safety agencies, industry, distribution and scientific societies.

Sugar sweetened beverages attributable disease burden and the potential impact of policy interventions: a systematic review of epidemiological and decision models

BACKGROUND

Around 184,000 deaths per year could be attributable to sugar-sweetened beverages (SSBs) consumption worldwide. Epidemiological and decision models are important tools to estimate disease burden. The purpose of this study was to identify models to assess the burden of diseases attributable to SSBs consumption or the potential impact of health interventions.

METHODS

We carried out a systematic review and literature search up to August 2018. Pairs of reviewers independently selected, extracted, and assessed the quality of the included studies through an exhaustive description of each model's features. Discrepancies were solved by consensus. The inclusion criteria were epidemiological or decision models evaluating SSBs health interventions or policies, and descriptive SSBs studies of decision models. Studies published before 2003, cost of illness studies and economic evaluations based on individual patient data were excluded.

RESULTS

We identified a total of 2766 references. Out of the 40 included studies, 45% were models specifically developed to address SSBs, 82.5% were conducted in high-income countries and 57.5% considered a health system perspective. The most common model's outcomes were obesity/overweight (82.5%), diabetes (72.5%), cardiovascular disease (60%), mortality (52.5%), direct medical costs (57.35%), and healthy years -DALYs/QALYs- (40%) attributable to SSBs. 67.5% of the studies modelled the effect of SSBs on the outcomes either entirely through BMI or through BMI plus diabetes independently. Models were usually populated with inputs from national surveys -such us obesity prevalence, SSBs consumption-; and vital statistics (67.5%). Only 55% reported results by gender and 40% included children; 30% presented results by income level, and 25% by selected vulnerable groups. Most of the models evaluated at least one policy intervention to reduce SSBs consumption (92.5%), taxes being the most frequent strategy (75%).

CONCLUSIONS

There is a wide range of modelling approaches of different complexity and information requirements to evaluate the burden of disease attributable to SSBs. Most of them take into account the impact on obesity, diabetes and cardiovascular disease, mortality, and economic impact. Incorporating these tools to different countries could result in useful information for decision makers and the general population to promote a deeper implementation of policies to reduce SSBs consumption.

PROSPERO PROTOCOL NUMBER

CRD42020121025 .

Potential impact of gradual reduction of fat content in manufactured and out-of-home food on obesity in the United Kingdom: a modeling study

BACKGROUND

Manufactured and out-of-home foods contribute to excessive calories and have a critical role in fueling the obesity epidemic. We propose a 20% fat reduction in these foods.

OBJECTIVES

To evaluate the potential impact of the proposed strategy on energy intake, obesity and related health outcomes in the population.

METHODS

We used the National Diet and Nutrition Survey rolling program (NDNS RP) data to calculate fat and energy contributions from 46 manufactured and out-of-home food categories. We considered a gradual fat reduction-focusing on SFA-in these categories to achieve a 20% reduction in 5 years. We estimated the reduction in energy intake in the NDNS RP population and predicted the body weight reduction using a weight loss model. We scaled up the body weight reduction to the UK adult population. We estimated reductions in overweight/obesity and type 2 diabetes cases. We calculated the reductions of LDL, ischemic heart disease (IHD), and stroke deaths that could be prevented from the SFA reduction.

RESULTS

The selected categories contributed to 38.6% of the population's energy intake. By the end of the fifth year, our proposed strategy would reduce the mean energy intake by 67.6 kcal/d/person (95% CI: 66.1-68.8). The energy reduction would reduce the mean body weight by 2.7 kg (95% CI: 2.6-2.8). The obesity prevalence would be reduced by 5.3% and the overweight prevalence by 1.5%, corresponding to 3.5 and 1 million cases of obesity and overweight, respectively, being reduced in the United Kingdom. The body weight reduction could prevent 183,000 (95% CI: 171,000-194,000) cases of type 2 diabetes over 2 decades. Energy from SFA would fall by 2.6%, lowering LDL by 0.13 mmol/L and preventing 87,560 IHD deaths (95% CI: 82,260-112,760) and 9520 stroke deaths (95% CI: 4400-14,660) over 20 years.

CONCLUSIONS

A modest fat reduction (particularly in SFA) in widely consumed foods would prevent obesity, type 2 diabetes, and cardiovascular disease.

Association between ultrapocessed food and chronic kidney disease

The modern diet is closely linked to the consumption of processed foods, causing an increase in the intake of salt, simple sugars, phosphorus and added potassium. This excess intake is associated with an increased risk of obesity, diabetes, hypertension and chronic kidney disease (CKD). CKD, which according to data from the ENRICA study affects 15% of the population, magnifies its impact due to the higher prevalence of diabetes and hypertension and due to limitations in the management of sodium and phosphorus. The intake of these products far exceeds the established recommendations, assuming 72% of total sodium, 25-35% of phosphorus, 12-18% of potassium and exceeding 10% of the caloric intake in simple sugars. Measures are necessary to reduce their contribution through nutritional advice, labeling review, education campaigns on healthy habits, fees and institutional actions that involve food safety agencies, industry, distribution and scientific societies.

Taxation of Beverages and Sweetened Products in Morocco: A Major Achievement and a Model to Follow In the Mena Region

The analysis of the various reports of the epidemiological situation of obesity and diabetes in Morocco with in particular the reports of the WHO, the High Commission for Planning of Morocco (HCP) and the report of the American Mc Kinsey Study Bureau in 2014, shows a sharp increase in diabetes, obesity and their morbidity and mortality. With a Moroccan population of 35 million inhabitants in 2017, the number of people with diabetes (2.5 million), pre-diabetes (2.4 million), obesity (3.6 million), overweight (10 million including 63% of women and 16% of children) is alarming. The consequences in terms of morbidity and mortality and direct and indirect health costs through reduced productivity for the economy of Morocco and for society as a whole are very high. Total annual expenditure related to obesity amounts to $ 2.4 billion, or 3% of Morocco's GDP. The causes of this increase in obesity and diabetes are closely linked to profound changes in lifestyle: high-calorie diet rich in fast sugars, reduction in physical activity, etc. This is how it is demonstrated that too much consumption of sugary drinks is harmful to weight maintenance, metabolic balance and cardiovascular health. Conversely in many experiments around the world, the number of people with overweight and a risk of diabetes decreases significantly when the reduction of refined sugars is carried out by several preventive measures including increasing the tax on sodas, juices and other sugary drinks. The members of the Working Group who have been working together for several years in Morocco on the “Taxation of sweet products” within the framework of the Moroccan League for the Fight against Diabetes and the Moroccan Society of Nutrition, Health and Environment, have carried out multiple actions advocacy and sensitization with the government, the ministry of health, the parliament, the university, civil society and the media. The soda tax was finally adopted by the Moroccan Parliament in the 2019 finance bill. A first in the Middle East and North Africa region. In December 2019, a new acquisition was made during the discussion of the Finance Law Project (FLP) 2020 by the introduction of a progressive Internal Consumption Tax (ICT) on sugary drinks in proportion to their sugar concentration. The aim is to encourage manufacturers to reduce the sugar content of sugary drinks and energy drinks to avoid over-taxation. On the other hand, the support recently given in 2020 by the National Council of Human Rights of Morocco to this tax constitutes a very large acquisition, with a new institutional and socio-cultural dimension of human rights for the preservation health in Morocco. Members of the working group will continue their efforts to extend this tax to all products containing a significant amount of sugar. The same is true for other toxic products such as salt, fat and tobacco. Keywords: Diabetes, Obesity, Prevention, Tax soda, Morocco

The health and financial impacts of a sugary drink tax across different income groups in Canada

BACKGROUND

Overconsumption of sugar-sweetened beverages (SSBs) contributes to childhood and adult obesity and numerous related diseases, including heart disease, strokes, cancers, and type 2 diabetes. It also increases healthcare costs. Sugary drink taxes have been implemented in several countries to curb sugar intake. However, there is a concern that sugary drink taxes are regressive. This study assessed the health and financial impacts of a simulated sugary drink tax across different income groups in Canada.

METHODS

A proportional multi-state life table-based Markov model simulated the 2016 Canadian population by income quintile. The model applied a 20 % tax on sugary drinks and determined the effects on type 2 diabetes and BMI-related diseases compared to no intervention. The income-specific parameters modelled included: population demographics; cross- and own-price elasticities; mean BMI; sugary drink consumption; mortality; and disease epidemiology.

RESULTS

A 20 % sugary drink tax was estimated to reduce the consumption of sugary drinks by an average of around 15 %, with a greater reduction in the lowest income quintile. The estimated mean reduction in BMI ranged from 0.21 to 0.33, dependent upon sex and income quintile; these reductions were greater among the lower income quintiles for both females and males. The 20 % sugary drink tax was estimated to avert approximately 690,000 DALYs over a lifetime among the 2016 Canadian adult population; estimated DALYs averted were approximately 156,000, 140,000, 137,000, 134,000, and 125,000 for the lowest through to the highest income quintile, respectively. Lifetime health care savings were estimated to be $2.27bn, $2.16bn, $2.17bn, $2.12bn, and $1.98bn for the lowest through to the highest income quintile, respectively. The estimated annual tax burden for the 2016 Canadian population was $1.4bn. The average absolute tax burden was estimated to be $39.00 to $44.30 per person, with the middle-income quintile bearing the heaviest absolute tax burden. The lowest income quintile would pay the highest proportion of income in tax, implying that the tax is regressive.

CONCLUSIONS

Low-income Canadians would gain the most health benefit from a sugary drinks tax. However, the lowest income quintile would also pay the largest proportion of income in tax. A tax on sugary drinks is therefore financially regressive but forecast to reduce health disparities across Canada.

Sugar and artificially sweetened beverages and risk of obesity, type 2 diabetes mellitus, hypertension, and all-cause mortality: a dose-response meta-analysis of prospective cohort studies

Although consumption of sugar-sweetened beverages (SSBs) and artificially sweetened beverages (ASBs) has increasingly been linked with obesity, type 2 diabetes mellitus, hypertension, and all-cause mortality, evidence remains conflicted and dose-response meta-analyses of the associations are lacking. We conducted an updated meta-analysis to synthesize the knowledge about their associations and to explore their dose-response relations. We comprehensively searched PubMed, EMBASE, Web of Science, and Open Grey up to September 2019 for prospective cohort studies investigating the associations in adults. Summary relative risks (RRs) and 95% confidence intervals (CIs) were estimated for the dose-response association. Restricted cubic splines were used to evaluate linear/non-linear relations. We included 39 articles in the meta-analysis. For each 250-mL/d increase in SSB and ASB intake, the risk increased by 12% (RR = 1.12, 95% CI 1.05-1.19, I² = 67.7%) and 21% (RR = 1.21, 95% CI 1.09-1.35, I² = 47.2%) for obesity, 19% (RR = 1.19, 95% CI 1.13-1.25, I² = 82.4%) and 15% (RR = 1.15, 95% CI 1.05-1.26, I² = 92.6%) for T2DM, 10% (RR = 1.10, 95% CI 1.06-1.14, I² = 58.4%) and 8% (RR = 1.08, 95% CI 1.06-1.10, I² = 24.3%) for hypertension, and 4% (RR = 1.04, 95% CI 1.01-1.07, I² = 58.0%) and 6% (RR = 1.06, 95% CI 1.02-1.10, I² = 80.8%) for all-cause mortality. For SSBs, restricted cubic splines showed linear associations with risk of obesity (P_{non-linearity} = 0.359), T2DM (P_{non-linearity} = 0.706), hypertension (P_{non-linearity} = 0.510) and all-cause mortality (P_{non-linearity} = 0.259). For ASBs, we found linear associations with risk of obesity (P_{non-linearity} = 0.299) and T2DM (P_{non-linearity} = 0.847) and non-linear associations with hypertension (P_{non-linearity} = 0.019) and all-cause mortality (P_{non-linearity} = 0.048). Increased consumption of SSBs and ASBs is associated with risk of obesity, T2DM, hypertension, and all-cause mortality. However, the results should be interpreted cautiously because the present analyses were based on only cohort but not intervention studies.

Dietary sucrose induces metabolic inflammation and atherosclerotic cardiovascular diseases more than dietary fat in LDLr-/-ApoB100/100 mice

BACKGROUND AND AIMS

Poor dietary habits contribute to the obesity pandemic and related cardiovascular diseases but the respective impact of high saturated fat versus added sugar consumption remains debated. Herein, we aimed to disentangle the individual role of dietary fat versus sugar in cardiometabolic disease progression.

METHODS

We fed pro-atherogenic LDLr^-/-ApoB^100/100 mice either a low-fat/high-sucrose (LFHS) or a high-fat/low-sucrose (HFLS) diet for 24 weeks. Weekly body weight gain was registered. 16S rRNA gene-based gut microbial analysis was performed to investigate gut microbial modulations. Intraperitoneal insulin (ipITT) and oral glucose tolerance test (oGTT) were conducted to assess glucose homeostasis and insulin sensitivity. Cytokines were assessed in fasted plasma, epididymal white adipose tissue and liver lysates. Heart function was evaluated by echocardiography. Aortic atheroma lesions were quantified according to the en face technique.

RESULTS

HFLS feeding increased obesity, insulin resistance and dyslipidemia compared to LFHS feeding. Conversely, high sucrose consumption decreased gut microbial diversity while augmenting inflammation and the adaptative immune defense against metabolic endotoxemia and reduced macrophage cholesterol efflux capacity. This led to more severe cardiovascular complications as revealed by remarkably high level of atherosclerotic lesions and the early development of cardiac dysfunction in LFHS vs HFLS fed mice.

CONCLUSIONS

We uncoupled obesity-associated insulin resistance from cardiovascular diseases and provided novel evidence that dietary sucrose, not fat, is the main driver of metabolic inflammation accelerating severe atherosclerosis in hyperlipidemic mice.

Spatiotemporal trends and influence factors of global diabetes prevalence in recent years

Diabetes is one of the most widespread global epidemics and has become the main component of the global disease burden. Based on data regarding the prevalence of diabetes in 203 countries and territories from 2013 to 2017, we employed the Bayesian space-time model to investigate the spatiotemporal trends in the global diabetes prevalence. The factors influencing the diabetes prevalence were assessed by the Bayesian LASSO regression model. We identified 77 (37.9%) hotspots with a higher diabetes prevalence than the global average, 10 (0.4%) warm spots with global average level and 116 (57.1%) cold spots with lower level than global average. Of the 203 countries and territories, 68 (33.5%), including 31 hotspots, 5 warm spots and 32 cold spots, exhibited an increasing trend. Of these, 60 experienced an annual increase of more than 0.25%, and 8 showed an increasing trend. Three populous countries, namely China, the USA and Mexico, exhibited a high prevalence and an increasing trend simultaneously. Three socioeconomic factors, body mass index (BMI), urbanization rate (UR) and gross domestic product per capita (GDP-PC), and PM_2.5 pollution were found to significantly influence the prevalence of diabetes. BMI was the strongest factor; for every 1% increase in BMI, the prevalence of diabetes increased by 2.371% (95% confidence interval (95% CI): 0.957%, 3.890%) in 2013 and by 3.045% (95% CI: 1.803%, 4.397%) in 2015 and 2017. PM_2.5 pollution could be a risk factor, and its influencing magnitude gradually increased as well. With an annual PM_2.5 concentrations increase of 1.0% in a country, the prevalence of diabetes increased by 0.196% (95% CI: 0.020%, 0.356%). The UR, on the other hand, was found to be inversely associated with the prevalence of diabetes; with each UR increase of 1%, the prevalence of diabetes decreased by 0.006% (95% CI: 0.001%, 0.011%).

Effects of product reformulation on sugar intake and health-a systematic review and meta-analysis

Context

Obesity, type 2 diabetes, and dental caries are all major public health problems in the United Kingdom and contribute substantially to healthcare costs.

Objective

A systematic review and meta-analysis was conducted to determine the effect of product reformulation measures on sugar intake and health outcomes.

Data sources

Using a combination of terms, the following databases were searched-The Cochrane Library, EMBASE, MEDLINE (Ovid), and Scopus. Additionally, multiple gray literature searches were undertaken.

Data extraction

A total of 16 studies met the inclusion criteria. There were 4 randomized controlled trials, 6 studies that modeled reformulation in a country, 5 studies that modeled a different approach of reformulation, and 1 study was both a modelling study of a different approach to reformulation and a retrospective observational study. The studies were assessed for risk of bias and overall quality of evidence was rated using the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) framework.

Results

Results from randomized controlled trials suggest that consumption of reformulated products can reduce sugar intake and body weight. The pooled estimates were -11.18% (95% confidence interval [CI], -19.95 to -2.41; P < 0.00001) for changes in percentage of sugar intake, -91.00 g/day (95%CI, -148.72 to -33.28; P< 0.00001) for changes in sugar intake in grams per day, and -1.04 kg (95%CI, -2.16 to -0.08; P= 0.0002) for changes in body weight. However, the quality of the evidence was very low. Results from the other studies suggested that reformulation can reduce sugar intake and improve health. Much of the evidence draws on modeling studies.

Conclusions

This systematic review and meta-analysis suggests that product reformulation to reduce sugar content could reduce sugar intake in individuals and thus improve population health. These findings provide an important starting point for ongoing work on sugar reformulation.

Reducing the Population Burden of Coronary Heart Disease by Modifying Adiposity: Estimates From the ARIC Study

Background

Excess adiposity, which affects 69% of US adults, increases coronary heart disease (CHD) risk in an association that manifests below conventional obesity cut points. The population‐level impact on CHD risk that is attainable through modest adiposity reductions in populations is not well characterized. We estimated the effect of hypothetical reductions in both body mass index (BMI) and waist circumference (WC) on CHD incidence.

Methods and Results

The study population included 13 610 ARIC (Atherosclerosis Risk in Communities) participants. Our hypothetical reduction in BMI or WC was applied relative to the temporal trend, with no hypothetical reduction among those with BMI >24 or WC >88 cm, respectively. This threshold for hypothetical reduction is near the clinical guidelines for excess adiposity. CHD risk differences compared the hypothetical reduction with no reduction. Sensitivity analysis was conducted to estimate the effect of applying the hypothetical BMI reduction at the established overweight cut point of 25. Cumulative 12‐year CHD incidence with no intervention was 6.3% (95% CI, 5.9–6.8%). Risk differences following the hypothetical BMI and WC reductions were −0.6% (95% CI, −1.0% to −0.1%) and −1.0% (95% CI, −1.4% to −0.5%), respectively. These results were robust for the sensitivity analyses. Consequently, we estimated that this hypothetical reduction of 5% in BMI and WC, respectively, could have prevented 9% and 16%, respectively, of the CHD events occurring in this study population over 12 years, after adjustment for established CHD risk factors.

Conclusions

Meaningful CHD risk reductions could derive from modest reductions in adiposity attainable through lifestyle modification.

Association Between Sugar-Sweetened Beverage Consumption as Meal Substitutes, Workload, and Obesity in Nurses: A Cross-Sectional Study

Background: High occupational stress has been associated with altered eating behaviors and obesity. Occupational stress is reported to be high in Asian countries. Furthermore, many Asian countries are increasingly consuming Western-type foods (e.g., incorporating drinks with meals) which collectively may also be contributing to obesity. Therefore, the aim of this study was to examine (a) associations between sugar-sweetened beverage (SSB) consumption as meal replacement and obesity and (b) associations between workload and substituting meals with SSB in nurses. Methods: A representative sample of 854 hospital-based nurses completed a structured questionnaire about SSB consumption, workload, and body mass index (BMI). Log binomial regression models were employed to test associations between SSBs and obesity rates and associations between workload and SSBs. Results: Most participants (57.6%) consumed SSBs as meal replacements during work. This was related to high workloads during shifts. Substituting SSBs for meals was significantly associated with increased likelihood of obesity (aPRR = 1.4, 95% CI (1.1, 1.7)). Workload was positively associated with SSB intake as meal substitutes (aPRR = 1.4, 95% CI (1.2, 1.6)). Conclusions: Our findings show that SSBs are used as meal substitutes and is due to the workload demands. Sugar-sweetened beverage consumption is also positively associated with the increased likelihood of obesity. Interventions that modify workloads and decrease SSB consumption may improve workers’ eating behaviors and health.

A multilevel life course perspective on type 2 diabetes

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

Influences of added sugar consumption in adults with type 2 diabetes risk: A principle-based concept analysis

AIM

The aim of this study is to describe the concept added sugar in the context of type 2 diabetes (T2D) risk in adults.

BACKGROUND

Dietary added sugars are associated with a greater risk for T2D; however, it is unclear if added sugars influence T2D risk directly or if their effects are mediated by excess caloric intake and weight gain.

DESIGN

A principle-based concept analysis following the PRISMA guidelines was conducted to clarify the concept of added sugar. A systematic search was conducted using PubMed and Embase. Multidisciplinary, empirical evidence was appraised using four guiding principles outlined by the principle-based concept analysis method.

RESULTS

Thirty-five publications were included in this concept analysis. The concept, added sugar in the context of T2D risk, was found to be epistemologically immature and lacked conceptual clarity.

CONCLUSIONS

Added sugar is an immature concept warranting further refinement for conceptual advancement. To enhance conceptual clarity, the term "added sugar" should be used consistently in the scientific literature when discussing foods or beverages containing added sugars or caloric sweeteners. A clearer delineation of added sugar and its association with T2D risk in adults is critical to advance this concept within the scientific literature.

Diabetes in developing countries

There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro- and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost-effective, but targeted high-risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, "fatalistic attitudes", high cost and non-availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low-cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non-medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.

Variations in Sugar Content of Flavored Milks and Yogurts: A Cross-Sectional Study across 3 Countries

BACKGROUND

The consumption of dairy products is encouraged at all life stages as a nutrient-rich component of the diet. However, many milk and yogurt products, particularly flavored varieties, may contain large amounts of free sugar.

OBJECTIVES

The aim of this paper was to evaluate the availability and sugar content of flavored milks and yogurts in supermarkets across 3 countries: Australia, England, and South.

METHODS

Nutrition information for flavored milks and yogurts was collected by trained researchers and supplemented by crowd-sourced data from a smartphone application. Data were extracted in April 2018 and 3724 milk and yogurt products were available for analysis. Mean sugar concentrations were compared across countries with the use of ANOVA followed by Tukey's post-hoc pairwise comparisons. Sugar concentrations were compared with the UK's "green" traffic-light classifications.

RESULTS

Approximately 74% (n = 2753) of all products were flavored. Flavored products contained nearly twice the average total sugar content of unflavored products, with substantial variability: mean total sugar was 9.1 g/100 mL (range: 4.3-15.0 g/100 mL) and 11.5 g/100 g (range: 0.1-22.6 g/100 g) for flavored milks and yogurts, respectively. Free sugars contributed an estimated 41% and 42% of total sugar in milks and yogurts, respectively. Flavored milks in England had ∼0.7 g/100 mL higher total sugar on average compared with Australia and South Africa (P ≤ 0.04), whereas flavored yogurts in South Africa had the lowest average total sugar (∼2 g/100 g lower than England and Australia; P < 0.001). Less than 4% of flavored products would receive a "green" rating under the UK traffic-light labeling scheme.

CONCLUSIONS

In Australia, England, and South Africa, flavored milks and yogurts are highly prevalent in the food supply and contain significantly higher concentrations of total and added sugars than unflavored products.

Carbonated beverage consumption is associated with lower C-peptide in adolescents

Background Too much consumption of carbonated beverages increases the risk of diabetes. Insulin deficiency and the body's decreased sensitivity to insulin cause diabetes. C-peptide can assess a person's own insulin secretion. The decrease of C-peptide is closely related to the occurrence of diabetes and its chronic complications. The present study assessed the effect of carbonated beverages on C-peptide in adolescents and analyzed the correlation between C-peptide and the drinking index (DI). Methods The subjects investigated including 463 adolescents were divided into a carbonated beverages group, a non-carbonated beverages group and a control group. The general demographic characteristics, beverage consumption status, physical activity and family history of hypertension and diabetes were interviewed with a questionnaire designed by us. All the subjects maintained their original lifestyle and received the oral glucose tolerance test. Various biochemical indicators and C-peptides were detected in these three groups. The data were analyzed by statistical analysis, and multivariate logistic regression analysis was used to examine the risk factors related to C-peptide. Results Blood glucose, blood lipid, liver function and renal function had no statistically significant difference among the three groups. C-peptide levels were lower in the carbonated beverages group and the non-carbonated beverages group than in the control group. Compared to the non-carbonated beverages group, there was a significant decrease in C-peptide levels in the carbonated beverages group. Logistic analysis demonstrated that DI was negatively correlated with C-peptide levels when the physical activity was adjusted. The odds ratio (OR) (OR = 2.540, 95% confidence interval [CI] 1.121-5.752) value difference was statistically significant at a stratification level of DI ≥ 6. Conclusions The C-peptide of adolescents was affected by the long-term consumption of beverages, and the effect of carbonated beverages was even more obvious. DI ≥ 6 bottle-years was a risk factor for diabetes, and we can constitute prevention and control measures accordingly so as to reduce the incidence of diabetes.

The impact of food reformulation on nutrient intakes and health, a systematic review of modelling studies

BACKGROUND

Unhealthy diet is a risk factor for adverse health outcomes. Reformulation of processed foods has the potential to improve population diet, but evidence of its impact is limited. The purpose of this review was to explore the impact of reformulation on nutrient intakes, health outcomes and quality of life; and to evaluate the quality of modelling studies on reformulation interventions.

METHODS

A systematic review of peer-reviewed articles published between January 2000 and December 2017 was performed using MEDLINE, ScienceDirect, Embase, Scopus, Cochrane, and the Centre for Reviews and Dissemination of the University of York. Additional studies were identified through informal searches on Google and specialized websites. Only simulation studies modelling the impact of food reformulation on nutrient intakes and health outcomes were included. Included articles were independently extracted by 2 reviewers using a standardized, pre-piloted data form, including a self-developed tool to assess study quality.

RESULTS

A total of 33 studies met the selected inclusion criteria, with 20, 5 and 3 studies addressing sodium, sugar and fats reformulation respectively, and 5 studies addressing multiple nutrients. Evidence on the positive effects of reformulation on consumption and health was stronger for sodium interventions, less conclusive for sugar and fats. Study features were highly heterogeneous including differences in methods, the type of policy implemented, the extent of the reformulation, and the spectrum of targeted foods and nutrients. Nonetheless, partial between-study comparisons show a consistent relationship between percentages reformulated and reductions in individual consumption. Positive results are also shown for health outcomes and quality of life measures, although comparisons across studies are limited by the heterogeneity in model features and reporting. Study quality was often compromised by short time-horizons, disregard of uncertainty and time dependencies, and lack of model validation.

CONCLUSIONS

Reformulation models highlight relevant improvements in diets and population health. While models are valuable tools to evaluate reformulation interventions, comparisons are limited by non-homogeneous designs and assumptions. The use of validated models and extensive scenario analyses would improve models' credibility, providing useful insights for policy-makers.

REVIEW REGISTRATION

A research protocol was registered within the PROSPERO database (ID number CRD42017057341).

Gradual reduction of free sugars in beverages on sale by implementing the beverage checklist as a public health strategy

Background

Sugar-sweetened beverages (SSBs) are a major source of free sugar intake and contribute to obesity and obesity-related diseases. Therefore, we analyzed the effect of a gradual sugar reduction strategy within the so-called 'beverage checklist' on free sugar content in beverages on sale in Austria.

Methods

From 2010 until 2017, data on the amount of free sugar of sweetened beverages (sweetened with sugars, fruit juice and artificial sweeteners) with 0.20-0.75l serving sizes in all main supermarkets and from industry was collected. These data were published annually as the beverage checklist, which displays beverages on sale in Austria. The checklist aims to encourage beverage production with a free sugar content of ≤7.4 g/100 ml and no artificial sweeteners.

Results

Free sugar content in the total supply decreased significantly [7.53 (2.86) vs. 6.75 (2.79) g/100 ml; 10.4%; P < 0.001] over time and also in those for which follow-up data were available until 2017 (n = 100) [7.55 (2.46) vs. 7.28 (2.44) g/100 ml; 3.5%; P < 0.001]. The percentage of beverages fulfilling the guiding criteria increased by 12.8% (P < 0.001) and of those containing sweeteners decreased by 13.3% (after 2012; P = 0.034).

Conclusions

This public health strategy, conducted by a small non-profit organization, showed a reduction in the mean free sugar content by working with the industry to voluntarily reformulate beverages. More beverages with less added sugar were brought to the market, which implies healthier choices. The challenge now is to further engage the industry and also policy makers to achieve a greater reduction in the future.

Expected changes in obesity after reformulation to reduce added sugars in beverages: A modeling study

BACKGROUND

Several strategies have been proposed to reduce the intake of added sugars in the population. In Mexico, a 10% sugar-sweetened beverages (SSBs) tax was implemented in 2014, and the implementation of other nutritional policies, such as product reformulation to reduce added sugars, is under discussion. WHO recommends that all individuals consume less than 10% of their total energy intake (TEI) from added sugars. We propose gradually reducing added sugars in SSBs to achieve an average 10% consumption of added sugars in the Mexican population over 10 years and to estimate the expected impact of reformulation in adult body weight and obesity.

METHODS AND FINDINGS

Baseline consumption for added sugars and SSBs, sex, age, socioeconomic status (SES), height, and weight for Mexican adults were obtained from the 2012 Mexico National Health and Nutrition Survey (ENSANUT). On average, 12.6% of the TEI was contributed by added sugars; we defined a 50% reduction in added sugars in SSBs over 10 years as a reformulation target. Using a dynamic weight change model, sugar reductions were translated into individual expected changes in body weight assuming a 43% caloric compensation and a 2-year lag for the full effect of reformulation to occur. Results were stratified by sex, age, and SES. Twelve years after reformulation, the TEI from added sugars is expected to decrease to 10%, assuming no compensation from added sugars; 44% of the population would still be above WHO recommendations, requiring further sugar reductions to food. Body weight could be reduced by 1.3 kg (95% CI -1.4 to -1.2) in the adult population, and obesity could decrease 3.9 percentage points (pp; -12.5% relative to baseline). Our sensitivity analyses suggest that the impact of the intervention could vary from 0.12 kg after 6 months to 1.52 kg in the long term.

CONCLUSIONS

Reformulation to reduce added sugars in SSBs could produce large reductions in sugar consumption and obesity in the Mexican adult population. This study is limited by the use of a single dietary recall and by data collected in all seasons except summer; still, these limitations should lead to conservative estimates of the reformulation effect. Reformulation success could depend on government enforcement and industry and consumer response, for which further research and evidence are needed.

Sugar and energy content of carbonated sugar-sweetened beverages in Haidian District, Beijing: a cross-sectional study

OBJECTIVE

The consumption of carbonated sugar-sweetened beverages (CSSBs) is associated with a range of health problems, but little is known about the sugar and energy content of CSSBs in China. The study aimed to investigate the sugar and energy content of CSSBs in Beijing, China.

STUDY DESIGN

We carried out a cross-sectional survey in 15 different supermarkets from July to October 2017 in Haidian District, Beijing.

METHODS

The product packaging and nutrient labels of CSSBs were recorded by a snapshot in time to obtain company name, product name, serving size, and nutrient content, that is, carbohydrate, sugar and energy. For CSSB labels not showing sugar content, we used carbohydrate content as substitute. The sugar and energy content of CSSBs within each type of flavour were compared using Kruskal-Wallis test. The sugar content within the recommended levels was described using frequency. We also compared the sugar and energy content of top 5 CSSBs in terms of sales among three countries (China, UK and USA).

RESULTS

A total of 93 CSSB products were found. The median sugar content was 9.3 (IQR: 5.7-11.2) g/100 mL, and the energy content was 38 (IQR: 23-46) kcal/100 mL. There were 79 products labelled 'Red' (high) per serving based on the criteria set in the UK (>11.25 g/100 mL). We found 62.4% of CSSBs had sugar content per serving that exceeds the daily free sugar intake for adults (25 g) recommended by the WHO. Some of the branded products sold in China had higher sugar content when they were compared with those in Western countries.

CONCLUSIONS

CSSBs in Beijing, China have high sugar and energy content. Reduction in sugar content and serving size of CSSBs and taxation policy on beverages will be beneficial in reducing sugar intake in China.