Nutritively sweetened beverage consumption and body weight: a systematic review and meta-analysis of randomized experiments

Sugar-Sweetened Beverages and Adverse Human Health Outcomes: An Umbrella Review of Meta-Analyses of Observational Studies

Our aim was to conduct an umbrella review of evidence from meta-analyses of observational studies investigating the link between sugar-sweetened beverage consumption and human health outcomes. Using predefined evidence classification criteria, we evaluated evidence from 47 meta-analyses encompassing 22,055,269 individuals. Overall, 79% of these analyses indicated direct associations between greater sugar-sweetened beverage consumption and higher risks of adverse health outcomes. Convincing evidence (class I) supported direct associations between sugar-sweetened beverage consumption and risks of depression, cardiovascular disease, nephrolithiasis, type 2 diabetes mellitus, and higher uric acid concentrations. Highly suggestive evidence (class II) supported associations with risks of nonalcoholic fatty liver disease and dental caries. Out of the remaining 40 meta-analyses, 29 were graded as suggestive or weak in the strength of evidence (classes III and IV), and 11 showed no evidence (class V). These findings inform and provide support for population-based and public health strategies aimed at reducing sugary drink consumption for improved health.

Introduction to the dietary management of obesity in adults

Obesity is a multifaceted and complex condition that requires holistic management. It currently affects nearly one in four adults in the UK, with the UK ranked 10th globally for the highest obesity rates. Obesity is projected to have an economic burden of ∼£2 billion per year by 2030 in the UK.1 Excess weight gain can coincide with myriad health concerns and multiple health conditions, which can be physical, metabolic or psychosocial. This includes type 2 diabetes mellitus (T2DM), hypertension, coronary heart disease, osteoarthritis, obstructive sleep apnoea, reproductive disorders, depression and cancer2; hence, there has been a significant emphasis on obesity prevention. Obesity is often associated with weight stigma, impacting psychological wellbeing and quality of life. This can influence an individual's likelihood of seeking support, delaying appropriate input from healthcare professionals, with a knock-on effect on pre-existing health conditions. This review explores the management of obesity from a nutritional perspective, because modifying dietary intake is essential to reduce the risk of non-communicable diseases, including those associated with obesity.

Dietary sugar consumption and health: umbrella review

OBJECTIVE

To evaluate the quality of evidence, potential biases, and validity of all available studies on dietary sugar consumption and health outcomes.

DESIGN

Umbrella review of existing meta-analyses.

DATA SOURCES

PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, and hand searching of reference lists.

INCLUSION CRITERIA

Systematic reviews and meta-analyses of randomised controlled trials, cohort studies, case-control studies, or cross sectional studies that evaluated the effect of dietary sugar consumption on any health outcomes in humans free from acute or chronic diseases.

RESULTS

The search identified 73 meta-analyses and 83 health outcomes from 8601 unique articles, including 74 unique outcomes in meta-analyses of observational studies and nine unique outcomes in meta-analyses of randomised controlled trials. Significant harmful associations between dietary sugar consumption and 18 endocrine/metabolic outcomes, 10 cardiovascular outcomes, seven cancer outcomes, and 10 other outcomes (neuropsychiatric, dental, hepatic, osteal, and allergic) were detected. Moderate quality evidence suggested that the highest versus lowest dietary sugar consumption was associated with increased body weight (sugar sweetened beverages) (class IV evidence) and ectopic fatty accumulation (added sugars) (class IV evidence). Low quality evidence indicated that each serving/week increment of sugar sweetened beverage consumption was associated with a 4% higher risk of gout (class III evidence) and each 250 mL/day increment of sugar sweetened beverage consumption was associated with a 17% and 4% higher risk of coronary heart disease (class II evidence) and all cause mortality (class III evidence), respectively. In addition, low quality evidence suggested that every 25 g/day increment of fructose consumption was associated with a 22% higher risk of pancreatic cancer (class III evidence).

CONCLUSIONS

High dietary sugar consumption is generally more harmful than beneficial for health, especially in cardiometabolic disease. Reducing the consumption of free sugars or added sugars to below 25 g/day (approximately 6 teaspoons/day) and limiting the consumption of sugar sweetened beverages to less than one serving/week (approximately 200-355 mL/week) are recommended to reduce the adverse effect of sugars on health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022300982.

Human body weight, nutrients, and foods: a scoping review

Background

The aim of this article (scoping review) is to elucidate the current knowledge for the potential role of body weight for setting and updating Dietary Reference Values (DRVs) and Food-Based Dietary Guidelines (FBDGs). The following research questions were formulated:What is known about the association between intakes of specific nutrient and/or foods (exposure/intervention) and body weight (outcome) in the general population?What is known about the association between body weight (exposure) and intakes of specific nutrient and/or foods (outcomes)?Is there any evidence suggesting specific effects of foods or nutrients on body weight independent of caloric content?

Methods

To identify potentially relevant articles, PubMed was searched from January 1, 2011 to June 9, 2021. The search strategy was drafted by the NNR2022 Committee. The final results were exported into EndNote. Systematic reviews (SRs), scoping reviews (ScRs), reviews, and meta-analyses (MAs) on the topic 'Body weight' published between January 1, 2011 and June 9, 2021, including human participants from the general population, in English or Scandinavian language (Norwegian, Swedish, or Danish), were considered eligible.

Main findings

First, the overall body of evidence based on findings from SRs and MAs of observational and clinical studies indicates that changes in intakes of specific nutrients (sugar, fiber, and fat) and/or foods (sugar sweetened beverages, fiber rich food, and vegetables) are associated with modest or small short-term changes (0.3-1.3 kg) in body weight in the general population (with or without obesity/overweight), while long-term studies are generally lacking. Second, no study in our search assessed any association between body weight (exposure) and intakes of specific nutrients or foods (outcomes). Third, limited evidence suggests, but does not prove, that some foods or nutrients may have specific effects on body weight or body weight measures independent of caloric content (e.g. nuts and dairy). These findings may inform the setting and updating of DRVs and FBDGs in NNR2022.

Sugar-sweetened beverages intake and the risk of obesity in children: An updated systematic review and dose-response meta-analysis

BACKGROUND

The prevalence of childhood obesity has increased worldwide and has reached alarming proportions. Contradictive results from studies and reviews have fuelled an endless debate on the role of SSBs in the development of childhood obesity.

OBJECTIVE

This study aimed to assess the impact of sugar-sweetened beverages (SSBs) intake on body mass index (BMI), body fat percentage (BFP), and waist circumference (WC) among children.

METHODS

Databases including PubMed/MEDLINE, Scopus, Cochrane Library, EMBASE, and Web of Science were searched up to August 2021. Observational studies reporting the relation between SSBs intake and BMI, BFP, and WC were included. STATA version 15 was used to analyse the data.

RESULTS

In this meta-analysis, 33 studies with 121 282 subjects were included. Excessive SSBs intake was associated with 0.75 kg/m² increase in BMI in children and adolescents (WMD: 0.75; CI 0.35-1.15; p < 0.001). In addition, high SSBs intake was significantly associated with higher WC (WMD: 2.35 cm; 95% CI, 1.34, 3.37; p = 0.016) and BFP (WMD: 2.81; CI 2.21-3.41; p < 0.001). No departure from linearity was detected in dose-response meta-analysis between SSBs consumption and changes in BMI, WC, and BFP.

CONCLUSION

High SSBs consumption was associated with increased BMI, WC, and BFP among children and adolescents. Further large prospective long-term interventions are recommended to confirm the observed relationships.

The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases

Sugar-sweetened beverages (SSBs) are a major source of added sugars in the diet. A robust body of evidence has linked habitual intake of SSBs with weight gain and a higher risk (compared with infrequent SSB consumption) of type 2 diabetes mellitus, cardiovascular diseases and some cancers, which makes these beverages a clear target for policy and regulatory actions. This Review provides an update on the evidence linking SSBs to obesity, cardiometabolic outcomes and related cancers, as well as methods to grade the strength of nutritional research. We discuss potential biological mechanisms by which constituent sugars can contribute to these outcomes. We also consider global trends in intake, alternative beverages (including artificially-sweetened beverages) and policy strategies targeting SSBs that have been implemented in different settings. Strong evidence from cohort studies on clinical outcomes and clinical trials assessing cardiometabolic risk factors supports an aetiological role of SSBs in relation to weight gain and cardiometabolic diseases. Many populations show high levels of SSB consumption and in low-income and middle-income countries, increased consumption patterns are associated with urbanization and economic growth. As such, more intensified policy efforts are needed to reduce intake of SSBs and the global burden of obesity and chronic diseases.

Association of number of bites and eating speed with energy intake: Wearable technology results under free-living conditions

Personalized weight management strategies are gaining interest. However, knowledge is limited regarding eating habits and association with energy intake, and current technologies limit assessment in free-living situations. We assessed associations between eating behavior and time of day with energy intake using a wearable camera under free-living conditions and explored if obesity modifies the associations. Sixteen participants (50% with obesity) recorded free-living eating behaviors using a wearable fish-eye camera for 14 days. Videos were viewed by trained annotators who confirmed number of bites, eating speed, and time of day for each eating episode. Energy intake was determined by a trained dietitian performing 24-h diet recalls. Greater number of bites, reduced eating speed, and increased BMI significantly predicted higher energy intake among all participants (P < 0.05, each). There were no significant interactions between obesity and number of bites, eating speed, or time of day (p > 0.05). Greater number of bites and reduced eating speed were significantly associated with higher energy intake in participants without obesity. Results show that under free-living conditions, more bites and slower eating speed predicted higher energy intake when examining consumption of foods with beverages. Obesity did not modify these associations. Findings highlight how eating behaviors can impact energy balance and can inform weight management interventions using wearable technology.

Low-energy sweeteners and body weight: a citation network analysis

OBJECTIVE

Reviews on the relationship of low-energy sweeteners (LES) with body weight (BW) have reached widely differing conclusions. To assess possible citation bias, citation analysis was used to quantify the relevant characteristics of cited articles, and explore citation patterns in relation to review conclusions.

DESIGN

A systematic search identified reviews published from January 2010 to March 2020. Different characteristics (for example, type of review or research, journal impact factor, conclusions) were extracted from the reviews and cited articles. Logistic regression was used to estimate likelihood of articles with particular characteristics being cited in reviews. A qualitative network analysis linked reviews sub-grouped by conclusions with the types of articles they cited.

MAIN OUTCOME MEASURES

(OR; 95% CI) for likelihood that articles with particular characteristics were cited as evidence in reviews.

RESULTS

From 33 reviews identified, 183 different articles were cited (including other reviews). Narrative reviews were 62% less likely to be cited than systematic reviews with meta-analysis (OR 0.38; 0.16 to 0.86; p=0.03). Likelihood of being cited was higher for evidence on children than adults (OR 2.27; 1.59 to 3.25; p<0.0001), and with increased journal impact factor (OR 1.15; 1.00 to 1.31; p=0.04). No other factors were statistically significant in the main analysis, and few factors were significant in subgroup analyses. Network analysis showed that reviews concluding a beneficial relationship of LES with BW cited mainly randomised controlled trials, whereas reviews concluding an adverse relationship cited mainly observational studies.

CONCLUSIONS

Overall reference to the available evidence across reviews appears largely arbitrary, making citation bias likely. Differences in the conclusions of individual reviews map onto different types of evidence cited. Overall, inconsistent and selective use of the available evidence may account for the diversity of conclusions in reviews on LES and BW.

TRIAL REGISTRATION NUMBER

Prior to data analysis, the protocol was registered with the Open Science Framework (https://osf.io/9ghws).

Is the world converging to a 'Western diet'?

OBJECTIVE

To test the nutrition transition hypothesis of global dietary convergence to a 'Western diet'.

DESIGN

Consumer-waste-adjusted FAO Food Balance Sheets are used to construct for each country a Western Diet Similarity Index (WSI), expressed as a ratio of calories from animal-sourced foods, oils, fats and sweeteners to total per capita calories. β-Convergence and associated speed are estimated by growth regressions using 1992-2013 panel data. Speed of convergence, a non-linear function of income per capita, globalisation and urbanisation, determines the steady-state or long-term global WSI. The long-term global WSI is compared with the WSI of the group of countries with the highest population-weighted average WSI. The group, determined by K-means cluster analysis, consists of sixteen Western countries.

SETTING

Worldwide.

PARTICIPANTS

Not applicable.

RESULTS

Strong evidence of global dietary convergence at a speed driven by income per capita, globalisation and urbanisation with a long-term WSI of 38 %. When compared with the WSI of Western countries (68 %), the hypothesis of global dietary convergence to a Western diet is rejected.

CONCLUSIONS

The nutrition transition is acting in two opposing directions. Some countries experienced positive and others negative WSI growth, slowing down the transition to a Western diet in the long run. Policies to further slowdown the transition by some countries to unhealthier dietary patterns are as important as policies to further speed up the transition by other countries to healthier ones.

Tissue-Specific Fructose Metabolism in Obesity and Diabetes

PURPOSE OF REVIEW

The objective of this review is to provide up-to-date and comprehensive discussion of tissue-specific fructose metabolism in the context of diabetes, dyslipidemia, and nonalcoholic fatty liver disease (NAFLD).

RECENT FINDINGS

Increased intake of dietary fructose is a risk factor for a myriad of metabolic complications. Tissue-specific fructose metabolism has not been well delineated in terms of its contribution to detrimental health effects associated with fructose intake. Since inhibitors targeting fructose metabolism are being developed for the management of NAFLD and diabetes, it is essential to recognize how inability of one tissue to metabolize fructose may affect metabolism in the other tissues. The primary sites of fructose metabolism are the liver, intestine, and kidney. Skeletal muscle and adipose tissue can also metabolize a large portion of fructose load, especially in the setting of ketohexokinase deficiency, the rate-limiting enzyme of fructose metabolism. Fructose can also be sensed by the pancreas and the brain, where it can influence essential functions involved in energy homeostasis. Lastly, fructose is metabolized by the testes, red blood cells, and lens of the eye where it may contribute to infertility, advanced glycation end products, and cataracts, respectively. An increase in sugar intake, particularly fructose, has been associated with the development of obesity and its complications. Inhibition of fructose utilization in tissues primary responsible for its metabolism alters consumption in other tissues, which have not been traditionally regarded as important depots of fructose metabolism.

Endogenous versus exogenous carbohydrate oxidation measured by stable isotopes in pre-pubescent children plus 13C abundances in foods consumed three days prior

PURPOSE

The purposes of the present study were to (a) examine resting metabolism, substrate utilization, and endogenous versus exogenous carbohydrate (CHO) oxidation before and after 30-g rapidly-digesting carbohydrate (RDC) ingestion using indirect calorimetry and breath test analysis of stable isotope concentrations in pre-pubescent children and (b) report the 13C abundances in foods consumed for three days prior.

METHODS

Nineteen children (n = 10 boys, n = 9 girls) at Tanner stage I or II participated (mean age ± 95% CI = 9.84 ± 0.77 y) in this study. Food was administered to the children for three days preceding their scheduled breath tests. Breath tests and indirect calorimetry were performed after an 8-h fast before and 60 min following consumption of a 30-g simple RDC drink consisting of maltodextrin and sucrose. Open circuit spirometry and indirect calorimetry monitored resting metabolism and CHO oxidation. Separate breath samples were taken every 15 min. Samples of all foods and breath samples were analyzed for 13C and 12C abundances with a stable-isotope mass spectrometer.

RESULTS

13C in expired breath samples were -23.81 ± 1.64‰ at baseline and increased every 15 min after consumption of the CHO drink (p < 0.001-0.009). Cumulative total, endogenous, and exogenous CHO utilization increased during the post-prandial period (p < 0.001). Endogenous CHO oxidation was consistently greater than exogenous CHO oxidation (p < 0.001-0.002).Blood glucose was elevated from baseline at 30- and 60-min post-prandial (p < 0.001). Insulin did not change over time (p = 0.184).

CONCLUSIONS

The foods provided during the 3-day controlled diet effectively minimized 13C variation prior to metabolic testing. The 13C abundances of foods reported herein should serve as practical recommendations to reduce 13C intake before breath tests. While endogenous CHO oxidation remained greater in proportion to exogenous CHO oxidation, these findings suggest that even a relatively small amount of RDC can increase exogenous CHO oxidation and blood glucose in normal-weight children. To further examine shifts in endogenous versus exogenous CHO utilization, we recommend that future studies take steps to minimize 13C variation before breath tests and examine changes in substrate metabolism at rest and during exercise in normal weight and overweight pre-pubescent children.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03185884.

Association of Sugar-Sweetened Beverage Frequency with Adiposity: Evidence from the "Children of 1997" Birth Cohort

Background: Observationally, sugar-sweetened beverage (SSB) consumption is associated with adiposity in Western children but could be confounded. We examined the association of SSB frequency with adiposity in the non-Western setting of Hong Kong. Methods: We examined the associations of SSB consumption frequency at 11 and 13 years assessed by using a food frequency questionnaire with subsequent body mass index (BMI) z-score and overweight/obesity up to 18 years using generalized estimating equations, and with waist circumference, waist-to-hip ratio, and body fat percentage at 16–19 years using linear regression in a population-representative Chinese birth cohort “Children of 1997” (n = 3628). Results: At 11 and 13 years, 6.8% and 8.2% of children respectively consumed SSB daily. Neither SSB frequency at 11 nor at 13 years was associated with subsequent BMI z-score or overweight/obesity up to 18 years, or with waist circumference, waist-to-hip ratio, or body fat percentage at 16–19 years adjusted for age, sex, socioeconomic position, health status, physical activity and other food consumption, although bias to the null from under-reporting cannot be eliminated. Conclusion: Although we cannot definitively exclude a small association of SSB frequency with adiposity, lack of association of SSB frequency with adiposity in a non-Western setting with low SSB consumption suggests that the role of SSB in adiposity appears to be minor.

Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta-analysis

Context

Consumption of sugar-sweetened beverages (SSBs) among children has been associated with adverse health outcomes. Numerous behavioral interventions aimed at reducing the intake of SSBs among children have been reported, yet evidence of their effectiveness is lacking.

Objective

This systematic review explored the effectiveness of educational and behavioral interventions to reduce SSB intake and to influence health outcomes among children aged 4 to 16 years.

Data Sources

Seven databases were searched for randomized controlled trials published prior to September 2016. Studies identified were screened for eligibility.

Study Selection

Trials were included in the review if they met the PICOS (Population, Intervention, Comparison, Outcome, and Study design) criteria for inclusion of studies.

Data Extraction

Data were extracted by 2 reviewers following Cochrane guidelines and using Review Manager software.

Results

Of the 16 trials included, 12 were school based and 4 were community or home based. Only 3 trials provided data that could be pooled into a meta-analysis for evaluating change in SSB intake. Subgroup analyses showed a trend toward a significant reduction in SSB intake in participants in school-based interventions compared with control groups. Change in body mass index z scores was not statistically significant between groups.

Conclusions

The quality of evidence from included trials was considered moderate, and the effectiveness of educational and behavioral interventions in reducing SSB intake was modest.

Systematic Review Registration

PROSPERO registration number CRD42014004432.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A randomized controlled trial contrasting the effects of 4 low-calorie sweeteners and sucrose on body weight in adults with overweight or obesity

BACKGROUND

Low-calorie sweeteners (LCSs) provide sweetness with little or no energy. However, each LCS's unique chemical structure has potential to elicit different sensory, physiological, and behavioral responses that affect body weight.

OBJECTIVE

The purpose of this trial was to compare the effects of consumption of 4 LCSs and sucrose on body weight, ingestive behaviors, and glucose tolerance over a 12-wk intervention in adults (18-60 y old) with overweight or obesity (body mass index 25-40 kg/m2).

METHODS

In a parallel-arm design, 154 participants were randomly assigned to consume 1.25-1.75 L of beverage sweetened with sucrose (n = 39), aspartame (n = 30), saccharin (n = 29), sucralose (n = 28), or rebaudioside A (rebA) (n = 28) daily for 12 wk. The beverages contained 400-560 kcal/d (sucrose treatments) or <5 kcal/d (LCS treatments). Anthropometric indexes, energy intake, energy expenditure, appetite, and glucose tolerance were measured at baseline. Body weight was measured every 2 wk with energy intake, expenditure, and appetite assessed every 4 wk. Twenty-four-hour urine collections were completed every 4 wk to determine study compliance via para-aminobenzoic acid excretion.

RESULTS

Of the participants enrolled in the trial, 123 completed the 12-wk intervention. Sucrose and saccharin consumption led to increased body weight across the 12-wk intervention (Δweight = +1.85 ± 0.36 kg and +1.18 ± 0.36 kg, respectively; P ≤ 0.02) and did not differ from each other. There was no significant change in body weight with consumption of the other LCS treatments compared with baseline, but change in body weight for sucralose was negative and significantly lower compared with all other LCSs at week 12 (weight difference ≥ 1.37 ± 0.52 kg, P ≤ 0.008). Energy intake decreased with sucralose consumption (P = 0.02) and ingestive frequency was lower for sucralose than for saccharin (P = 0.045). Glucose tolerance was not significantly affected by any of the sweetener treatments.

CONCLUSIONS

Sucrose and saccharin consumption significantly increase body weight compared with aspartame, rebA, and sucralose, whereas weight change was directionally negative and lower for sucralose compared with saccharin, aspartame, and rebA consumption. LCSs should be categorized as distinct entities because of their differing effects on body weight. This trial was registered at clinicaltrials.gov as NCT02928653.

Do low-calorie sweetened beverages help to control food cravings? Two experimental studies

Low-calorie sweetened (LCS) beverages may help consumers to satisfy hedonic food cravings without violating dieting goals, however this remains unexplored. The present research investigated the effect of priming hedonic eating motivations on ad libitum energy intake in frequent and non-consumers of LCS beverages. It was hypothesised that energy intake would be greater after the hedonic eating prime relative to a control prime in non-consumers, but that frequent LCS beverage consumers would be protected from this effect. In Study 1 (N = 120), frequent and non-consumers were exposed to either chocolate or neutral cues (craving vs. control condition) and then completed a beverage-related visual probe task with concurrent eye-tracking. Ad libitum energy intake from sweet and savoury snacks and beverages (including LCS) was then assessed. Study 2 followed a similar protocol, but included only frequent consumers (N = 172) and manipulated the availability of LCS beverages in the ad libitum eating context (available vs. unavailable). Measures of guilt and perceived behavioural control were also included. In Study 1, as hypothesised, non-consumers showed greater energy intake in the craving condition relative to the control condition, but frequent consumers had similar energy intake in both conditions. Frequent consumers (but not non-consumers) also demonstrated an attentional bias for LCS beverage stimuli compared to both sugar and water stimuli. In contrast, in Study 2 frequent consumers showed greater energy intake in the craving condition relative to the control condition; however, overall energy intake was significantly greater when LCS beverages were unavailable compared to when they were available. Ratings of guilt were higher and perceived control was lower in the LCS-unavailable condition relative to the LCS-available condition. Conclusions: LCS beverages did not consistently protect consumers from craving-induced increases in energy intake. However, frequent consumers consumed fewer calories overall when LCS beverages were available (relative to unavailable), as well as perceiving more control over their food intake and feeling less guilty.

Food Groups and Risk of Overweight, Obesity, and Weight Gain: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies

This meta-analysis summarizes the evidence of a prospective association between the intake of foods [whole grains, refined grains, vegetables, fruit, nuts, legumes, eggs, dairy, fish, red meat, processed meat, and sugar-sweetened beverages (SSBs)] and risk of general overweight/obesity, abdominal obesity, and weight gain. PubMed and Web of Science were searched for prospective observational studies until August 2018. Summary RRs and 95% CIs were estimated from 43 reports for the highest compared with the lowest intake categories, as well as for linear and nonlinear relations focusing on each outcome separately: overweight/obesity, abdominal obesity, and weight gain. The quality of evidence was evaluated with use of the NutriGrade tool. In the dose-response meta-analysis, inverse associations were found for whole-grain (RRoverweight/obesity: 0.93; 95% CI: 0.89, 0.96), fruit (RRoverweight/obesity: 0.93; 95% CI: 0.86, 1.00; RRweight gain: 0.91; 95% CI: 0.86, 0.97), nut (RRabdominal obesity: 0.42; 95% CI: 0.31, 0.57), legume (RRoverweight/obesity: 0.88; 95% CI: 0.84, 0.93), and fish (RRabdominal obesity: 0.83; 95% CI: 0.71, 0.97) consumption and positive associations were found for refined grains (RRoverweight/obesity: 1.05; 95% CI: 1.00, 1.10), red meat (RRabdominal obesity: 1.10; 95% CI: 1.04, 1.16; RRweight gain: 1.14; 95% CI: 1.03, 1.26), and SSBs (RRoverweight/obesity: 1.05; 95% CI: 1.00, 1.11; RRabdominal obesity: 1.12; 95% CI: 1.04, 1.20). The dose-response meta-analytical findings provided very low to low quality of evidence that certain food groups have an impact on different measurements of adiposity risk. To improve the quality of evidence, better-designed observational studies, inclusion of intervention trials, and use of novel statistical methods (e.g., substitution analyses or network meta-analyses) are needed.

Wanting and liking for sugar sweetened beverages and snacks differ following depletion and repletion with energy and fluids

Drinking sugar-sweetened beverages (SSBs) seems to uniquely contribute to excess weight gain, and several mechanisms have been proposed to account for this. Here we examine a further proposal, namely that explicit wanting and liking for SSBs may be less sensitive to changes in physiological state, when contrasted to equi-palatable solid sweet snacks. Study 1 explored this by having participants rate wanting for (on seeing) and liking of (on tasting) several SSBs and snacks, before and after receiving a solid lunch with ad libitum water. Participant reports of hunger and thirst, obtained at multiple time-points, equally reduced across lunch. Wanting for the snacks decreased significantly more across lunch than liking, but for the SSBs, wanting and liking decreased in parallel. Study 2 engineered a far more dramatic alteration in thirst, by using fluid deprivation, a liquid lunch, and encouraging drinking to satiation. This time, reduction in thirst exceeded reduction in hunger. However, all this served to achieve was an equivalent change across lunch for snacks and SSBs, with wanting reducing more than liking now for both. These findings suggest that changes in wanting, relative to liking, for SSBs, are less sensitive to alterations in physiological state than equi-palatable solid snacks, enhancing the chance of consumption.

Protocol for the scientific opinion on the Tolerable Upper Intake Level of dietary sugars

In June 2016, EFSA received a mandate from the national food competent authorities of five European countries (Denmark, Finland, Iceland, Norway and Sweden) to provide a dietary reference value (DRV) for sugars, with particular attention to added sugars. A draft protocol was developed with the aim of defining as much as possible beforehand the strategy that will be applied for collecting data, appraising the relevant evidence, and analysing and integrating the evidence in order to draw conclusions that will form the basis for the Scientific Opinion on sugars. As EFSA wished to seek advice from stakeholders on this draft protocol, the NDA Panel endorsed it for public consultation on 12 December 2017. The consultation was open from 9 January to 4 March 2018. A technical meeting with stakeholders was held in Brussels on 13 February 2018, during the consultation period. After consultation with stakeholders and the mandate requestors, EFSA interprets this mandate as a request to provide scientific advice on an Tolerable Upper Intake Level (UL) for (total/added/free) sugars, i.e. the maximum level of total chronic daily intake of sugars (from all sources) judged to be unlikely to pose a risk of adverse health effects to humans. The assessment concerns the main types of sugars (mono- and disaccharides) found in mixed diets (i.e. glucose, fructose, galactose, sucrose, lactose, maltose and trehalose) taken through the oral route. The health outcomes of interest relate to the development of metabolic diseases and dental caries. The final version of the protocol was endorsed by the EFSA Panel on Dietetic Products, Nutrition and Allergies on 28 June 2018.

French Recommendations for Sugar Intake in Adults: A Novel Approach Chosen by ANSES

This article presents a systematic review of the scientific evidence linking sugar consumption and health in the adult population performed by a group of experts, mandated by the French Agence nationale de sécurité sanitaire de l’alimentation, de l’environnement, et du travail (ANSES). A literature search was performed by crossing search terms for overweight/obesity, diabetes/insulin resistance, dyslipidemia/cardiovascular diseases, non-alcoholic fatty liver diseases (NAFLD), and uric acid concentrations on one hand and for intake of sugars on the other. Controlled mechanistic studies, prospective cohort studies, and randomized clinical trials were extracted and assessed. A literature analysis supported links between sugar intake and both total energy intake and body weight gain, and between sugar intake and blood triglycerides independently of total energy intake. The effects of sugar on blood triglycerides were shown to be mediated by the fructose component of sucrose and were observed with an intake of fructose >50 g/day. In addition, prospective cohort studies showed associations between sugar intake and the risk of diabetes/insulin resistance, cardiovascular diseases, NAFLD, and hyperuricemia. Based on these observations, ANSES proposed to set a maximum limit to the intake of total sugars containing fructose (sucrose, glucose–fructose syrups, honey or other syrups, and natural concentrates, etc.) of 100 g/day.

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

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

Perspective: Cardiovascular Responses to Sugar-Sweetened Beverages in Humans: A Narrative Review with Potential Hemodynamic Mechanisms

Cardiovascular diseases are still the primary cause of mortality worldwide, with high blood pressure and type 2 diabetes as major promoters. Over the past 3 decades, almost in parallel with the rise in cardiovascular disease incidence, the consumption of sugar-sweetened beverages (SSBs) has increased. In this context, SSBs are potential contributors to weight gain and increase the risk for elevations in blood pressure, type 2 diabetes, coronary heart disease, and stroke. Nevertheless, the mechanisms underlying the cardiovascular and metabolic responses to SSBs, in particular on blood pressure, are poorly understood. We discuss and propose potential mechanisms underlying differential effects of sugars on postprandial blood pressure regulation; provide evidence for additional molecular contributors, i.e., fibroblast growth factor 21, towards sugar-induced cardiovascular responses; and discuss potential cardiovascular neutral sugars. Furthermore, we explore whether pre-existing glucose intolerance in humans exacerbates the cardiovascular responses to SSBs, thus potentially aggravating the cardiovascular risk in already-susceptible individuals.

Postprandial energy metabolism and substrate oxidation in response to the inclusion of a sugar- or non-nutritive sweetened beverage with meals differing in protein content

Background

The macronutrient composition of the diet may play a more important role in maintaining a healthy body weight and preventing obesity than previously thought. The primary goal of this research was to determine the extent to which the simple addition of a small serving of a sugar-sweetened beverage (SSB) to meals with different macronutrient compositions impacts appetite, energy metabolism and substrate oxidation.

Methods

Appetite, energy metabolism and substrate oxidation were measured in 27 healthy weight adults (age = 23 ± 5 y; BMI = 23 ± 2 kg/m²) on two occasions in a room calorimeter after consuming a SSB or a non-nutritive-sweetened beverage (NNSB) with a standard (15%E) or high- (30%E) protein meal. Meal carbohydrate (CHO) content was adjusted to maintain equivalent calories for both study visits. All meals were composed of the same foods and provided 17 g of fat and 500 non-beverage calories. Study visits were separated by at least 1 week and menstruating females were studied during the luteal phase (Days 15-20). The effects of sex, protein level and beverage type and their interactions on satiety, appetite for foods with specific taste profiles, diet-induced thermogenesis (DIT) and rates of substrate oxidation were assessed using a 3-way Repeated Measures Analysis of Variance.

Results

Increasing dietary protein decreased hunger and increased satiety. Males were hungrier and less satisfied with the meals than females. Increasing dietary protein also decreased the desire to eat something savory, salty and fatty and the males had a greater appetite for food with these taste profiles. Interestingly, there was no effect of sex, dietary protein or beverage type on the desire to eat something sweet. The inclusion of a SSB markedly suppressed DIT (2.42% ± 5.91%) and fat oxidation (9.87 ± 11.09 g).

Conclusion

Appetite sensations, food preferences, energy expenditure and substrate oxidation are significantly altered in response to changes in meal macronutrient composition produced by modifications in the protein content of a meal and consumption of a SSB. Most notably, consumption of a SSB during a meal markedly reduces energy efficiency and fat oxidation independent of macronutrient composition.

Trial registrations

ClinicalTrials.gov: NCT02211599, registered August 05, 2014.

A systematic review of the association between consumption of sugar-containing beverages and excess weight gain among children under age 12

OBJECTIVE

A systematic review was conducted to address this clinical question: Does consumption of (non-dairy) sugar-containing beverages (SCBs) among children under age 12 result in excess weight gain?

METHODS

The authors searched four databases for controlled trials (randomized and non-randomized) and cohort studies published in English through March 29, 2016: PubMed, EMBASE, Cochrane Database of Systematic Reviews, CINAHL. Initial and full-text screening, data abstraction, and risk of bias assessment were performed independently and in duplicate.

RESULTS

Thirty-eight studies met inclusion criteria for this systematic review. One was a randomized controlled trial, and 37 were cohort studies. Though the results of these studies were mixed, the majority demonstrated a statistically significant positive association between SCB consumption in children under age 12 and total adiposity and central adiposity. In contrast, most studies that assessed 100 percent fruit juice consumption only with either total adiposity or central adiposity did not support an association. Among only children under age 5 at baseline, no studies examined central adiposity, but nearly all studies examining SCBs and total adiposity, and a majority examining only fruit juice consumption, demonstrated a statistically significant positive association.

CONCLUSION

Our results support a statistically significant positive association between SCBs and total and central adiposity among children under age 12. This association is most consistent for total adiposity among children <5. Our results for 100 percent fruit juice only suggest differences by age, as most studies among those < 12 were negative but most among those <5 were positive.

The relative reinforcing value of sweet versus savory snack foods after consumption of sugar- or non-nutritive sweetened beverages

The effects of sugar-sweetened (SSB) and non-nutritive sweetened (NSB) beverages on the regulation of appetite, energy intake and body weight regulation remain controversial. Using a behavioral choice paradigm, we sought to determine the effects of consuming a SSB or NSB on appetite and the reinforcing value of sweet relative to salty/savory snack foods. In a randomized crossover study, 21 healthy weight adults consumed 360 ml of SSB (sucrose; 31 g) or NSB (sucralose; 4 g) with a standardized meal. Hedonic ratings for the sweet and salty/savory snack foods used for the reinforcement task were assessed prior to the start of the study. Satiety and the desire to eat foods with a specific taste profile were assessed before and every 30 min post-meal for 4 h. The relative reinforcing value of the snack foods was assessed using a computer-based choice task (operant responding with concurrent schedules of reinforcement) 4 h post-meal. Hedonic ratings did not differ between the most highly liked sweet and salty/savory snack foods. Beverage type did not influence measures of satiety or the desire to eat foods with a specific taste. However, sweet snacks were more (p < 0.05) reinforcing relative to salty/savory snack foods after consuming a NSB than after a SSB. In conclusion, this is the first study to demonstrate that NSB can increase the motivation to gain access to sweet snacks relative to salty/savory snack foods later in the day.

EffectS of non-nutritive sWeetened beverages on appetITe during aCtive weigHt loss (SWITCH): Protocol for a randomized, controlled trial assessing the effects of non-nutritive sweetened beverages compared to water during a 12-week weight loss period and a follow up weight maintenance period

BACKGROUND

Acute and medium-term intervention studies suggest that non-nutritive sweeteners (NNS) are beneficial for weight loss, however there is limited human data on the long-term effects of consuming NNS on weight loss, maintenance, and appetite. Further research is therefore required to elucidate the prolonged impact of NNS consumption on these outcome measures.

METHODS/DESIGN

A randomized parallel groups design will be used to assess whether regular NNS beverage intake is equivalent to a water control in promoting weight loss over 12-weeks (weekly weight loss sessions; Phase I), then supporting weight maintenance over 40-weeks (monthly sessions; Phase II) and subsequently independent weight maintenance over 52-weeks (Phase III) in 432 participants. A subset of these participants (n=116) will complete laboratory-based appetite probe days (15 sessions; 3 sessions each at baseline, at the start of phase I and the end of each phase). A separate subset (n=50) will complete body composition scans (DXA) at baseline and at the end of each phase. All participants will regularly be weighed and will complete questionnaires and cognitive tasks to assess changes in body weight and appetitive behaviours. Measures of physical activity and biochemical markers will also be taken.

DISCUSSION

The trial will assess the efficacy of NNS beverages compared to water during a behavioural weight loss and maintenance programme. We aim to understand whether the impact of NNS on weight, dietary adherence and well-being are beneficial or transient and effects on prolonged successful weight loss and weight maintenance through sustained changes in appetite and eating behaviour.

TRIAL REGISTRATION

Clinical Trials: NCT02591134; registered: 23.10.2015.

Trends in fluid consumption and beverage choices among adults reveal preferences for ayran and black tea in central Turkey

AIM

Beverages are globally significant sources of water in the diet. There is a lack of knowledge about fluid intake from beverage and water consumption in Turkey. Thus, the aim of this study was to examine the type of drinks preferred at meals and snacks as well as the daily fluid, beverage and water intakes based on age and gender.

METHODS

A cross-sectional survey was administered to 3411 randomly chosen adult participants (n = 1522 male, n = 1919 female) representing the general profile of central Turkey. The survey consisted of a demographic/personal information questionnaire, 24-hour dietary recalls and mealtime-based beverage frequency questionnaires. Body weights and heights were measured.

RESULTS

Daily average total fluid consumption was 2270 mL/day, of which water was 1470 mL/day, and other beverages were 800 mL/day. More than 90% of the participants drank black tea at breakfast and snacks. For lunch and dinner, young participants' major choices were carbonated soft drinks followed by ayran (diluted salty plain yoghurt); middle aged and older participants' choices were ayran followed by black tea. Carbonated soft drinks were preferred over ayran in subjects aged 19-39 years.

CONCLUSIONS

Older participants prefer healthy, traditional choices such as ayran and black tea, but younger participants prefer high energy-containing drinks with low nutritional value. Thus, this unique information contributes to the data on beverage consumption patterns in different countries and might be useful for increasing consumption of nutritious fluids and decreasing sugar usage in Turkey.

Beverage Consumption Patterns among Norwegian Adults

Beverages may be important contributors for energy intake and dietary quality. The purpose of the study was to investigate how beverage consumption varies between different meals (breakfast, lunch, dinner, supper/evening meal, snacks) and between weekdays and weekend-days in Norwegian adults. A cross-sectional dietary survey was conducted among Norwegian adults (n = 1787) in 2010-2011. Two telephone-administered 24 h recalls were used for dietary data collection. Breakfast was the most important meal for milk and juice consumption, dinner for sugar-sweetened beverages and wine, and snacks for water, coffee, artificially sweetened beverages, and beer. Consumption of sugar-sweetened and artificially sweetened beverages did not differ between weekdays and weekend-days among consumers. The average intake of wine and beer (men only) was higher on weekend-days. Higher age was positively associated with wine consumption and negatively associated with consumption of water, sugar-sweetened, and artificially sweetened beverages. Higher education was associated with consumption of water, beer, and wine, whereas lower education was associated with sugar-sweetened beverage consumption. Beverage consumption patterns among Norwegian adults vary between different meal types and in subgroups of the population. Alcohol consumption was higher on weekend-days. Knowledge regarding beverage consumption patterns in the population should be considered when revising dietary guidelines in the future.

Impact of sugars and sugar taxation on body weight control: A comprehensive literature review

OBJECTIVE

To conduct a comprehensive literature review in the field of added-sugar consumption on weight gain including the effect of fructose-containing caloric sweeteners and sugar taxation.

METHODS

A search of three databases was conducted in the time period from the inception of the databases to August 2015. Sensitive search strategies were used in order to retrieve systematic reviews (SR) of fructose, sucrose, or sugar-sweetened beverages (SSBs) on weight gain and metabolic adverse effects, conducted on humans and written in English, Spanish, or French. In addition, a review about SSB taxation and weight outcomes was conducted.

RESULTS

The search yielded 24 SRs about SSBs and obesity, 23 SRs on fructose or SSBs and metabolic adverse effects, and 24 studies about SSB taxation and weight control.

CONCLUSIONS

The majority of SRs, especially the most recent ones, with the highest quality and without any disclosed conflict of interest, suggested that the consumption of SSBs is a risk factor for obesity. The effect of fructose-containing caloric sweeteners, on weight gain is mediated by overconsumption of beverages with these sweeteners, leading to an extra provision of energy intake. The tax tool alone on added sugars appears insufficient to curb the obesity epidemic, but it needs to be included in a multicomponent structural strategy.

Perspective: Randomized Controlled Trials Are Not a Panacea for Diet-Related Research

Research into the role of diet in health faces a number of methodologic challenges in the choice of study design, measurement methods, and analytic options. Heavier reliance on randomized controlled trial (RCT) designs is suggested as a way to solve these challenges. We present and discuss 7 inherent and practical considerations with special relevance to RCTs designed to study diet: 1) the need for narrow focus; 2) the choice of subjects and exposures; 3) blinding of the intervention; 4) perceived asymmetry of treatment in relation to need; 5) temporal relations between dietary exposures and putative outcomes; 6) strict adherence to the intervention protocol, despite potential clinical counter-indications; and 7) the need to maintain methodologic rigor, including measuring diet carefully and frequently. Alternatives, including observational studies and adaptive intervention designs, are presented and discussed. Given high noise-to-signal ratios interjected by using inaccurate assessment methods in studies with weak or inappropriate study designs (including RCTs), it is conceivable and indeed likely that effects of diet are underestimated. No matter which designs are used, studies will require continued improvement in the assessment of dietary intake. As technology continues to improve, there is potential for enhanced accuracy and reduced user burden of dietary assessments that are applicable to a wide variety of study designs, including RCTs.

Negative, Null and Beneficial Effects of Drinking Water on Energy Intake, Energy Expenditure, Fat Oxidation and Weight Change in Randomized Trials: A Qualitative Review

Drinking water has heterogeneous effects on energy intake (EI), energy expenditure (EE), fat oxidation (FO) and weight change in randomized controlled trials (RCTs) involving adults and/or children. The aim of this qualitative review of RCTs was to identify conditions associated with negative, null and beneficial effects of drinking water on EI, EE, FO and weight, to generate hypotheses about ways to optimize drinking water interventions for weight management. RCT conditions that are associated with negative or null effects of drinking water on EI, EE and/or FO in the short term are associated with negative or null effects on weight over the longer term. RCT conditions that are associated with lower EI, increased EE and/or increased FO in the short term are associated with less weight gain or greater weight loss over time. Drinking water instead of caloric beverages decreases EI when food intake is ad libitum. Drinking water increases EE in metabolically-inflexible, obese individuals. Drinking water increases FO when blood carbohydrate and/or insulin concentrations are not elevated and when it is consumed instead of caloric beverages or in volumes that alter hydration status. Further research is needed to confirm the observed associations and to determine if/what specific conditions optimize drinking water interventions for weight management.

Effects of dietary high fructose corn syrup on regulation of energy intake and leptin gene expression in rats

OBJECTIVE: To evaluate in Wistar rats the effect of chronic use of high fructose corn syrup on serum lipids, body weight, energy intake regulation, and expression of associated genes. METHODS: For 11 weeks, male rats were fed a standard diet with either water (control) or 15% high fructose corn syrup solution, or fed a high-fat diet. The rats' food intake and body weight were measured weekly. Expression of leptin and fatty acid synthase genes was quantified in their brain and adipose tissue upon sacrifice at age 119 days using real-time polymerase chain reaction. RESULTS: The intake of 15% high fructose corn syrup did not affect the rats' weight, only the rats on the high-fat diet gained significant weight. The rats in both diets had lower levels of leptin expression and high levels of fatty acid synthase in the brain, which were associated with high serum triglycerides. CONCLUSION: Fifteen percent high fructose corn syrup intake and the high-fat diet reduced leptin gene expression in the brain of Wistar rats, with differential effects on weight gain.

Replacing sugary drinks with milk is inversely associated with weight gain among young obesity-predisposed children

The aim of the present study was to examine the associations of sugary drink consumption and its substitution with alternative beverages with body weight gain among young children predisposed to future weight gain. Secondary analysis of the Healthy Start Study, a 1·5-year randomised controlled trial designed to prevent overweight among Danish children aged 2−6 years (n 366), was carried out. Multivariate linear regression models were used to investigate the associations of beverage consumption with change in body weight (Δweight) or BMI(ΔBMI) z-score. Substitution models were used to extrapolate the influence of replacing sugary drinks with alternative beverages (water, milk and diet drinks) on Δweight or ΔBMI z-score. Sugary drink intake at baseline and substitution of sugary drinks with milk were associated with both Δweight and ΔBMI z-score. Every 100 g/d increase in sugary drink intake was associated with 0·10 kg and 0·06 unit increases in body weight (P=0·048) and BMI z-score (P=0·04), respectively. Substitution of 100 g/d sugary drinks with 100 g/d milk was inversely associated with Δweight (β=−0·16 kg; P=0·045) and ΔBMI z-score (β=−0·07 units; P=0·04). The results of this study suggest that sugary drink consumption was associated with body weight gain among young children with high predisposition for future overweight. In line with the current recommendations, sugary drinks, whether high in added or natural sugar, should be discouraged to help prevent childhood obesity. Milk may be a good alternative to sugary drinks with regard to weight management among young obesity-predisposed children.

Beverage Consumption: Are Alcoholic and Sugary Drinks Tipping the Balance towards Overweight and Obesity?

The role that energy-containing beverages may play in the development of overweight and obesity remains highly controversial, in particular the alcoholic and sugar-sweetened beverages (SSB). Both of these beverage formats have been increasing as a percentage of the westernized diet over the past 20 years, and both have contributed significantly to an increase in energy consumed in liquid form. Data from epidemiology and intervention studies however have long been contradictory, despite mechanistic evidence pointing towards poor compensation for addition of "liquid" energy from these two sources into the diet providing a strong rational for the balance to be tipped towards weight gain. Regulatory and government intervention has been increasing globally, particularly with respect to intake of SSBs in children. This narrative review presents evidence which both supports and refutes the link between alcohol and carbohydrate-containing liquids and the regulation of body weight, and investigates mechanisms which may underpin any relationship between increased beverage consumption and increased energy intake, body weight and adiposity.

Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews

BACKGROUND

The prevalence of overweight and obesity among children and adolescents has increased worldwide and has reached alarming proportions. Currently, sugar-sweetened beverages (SSBs) are the primary source of added sugar in the diet of children and adolescents. Contradictive findings from studies and reviews have fueled an endless debate on the role of SSBs in the development of childhood obesity.

OBJECTIVES

The primary aim of the present review of reviews was to assess how review- and study-level methodological factors explain conflicting results across reviews and meta-analyses by providing an up-to-date synthesis of recent evidence regarding the association between SSB consumption and weight gain, overweight, and obesity in a population of 6-month-old to 19-year-old children and adolescents. The secondary aim was to assess the quality of included reviews using the Assessment of Multiple SysTemAtic Reviews (AMSTAR) measurement tool.

METHODS

Systematic literature reviews and meta-analyses were included. The literature search was performed through the platforms Pubmed/Medline, Cinahl, and Web of Knowledge.

RESULTS

Thirteen reviews and meta-analyses were included. Nine reviews concluded that there was a direct association between SSBs and obesity in children and adolescents and four others did not. The quality of the included reviews was low to moderate, and the two reviews with the highest quality scores showed discrepant results.

CONCLUSIONS

The majority of reviews concluded that there was a direct association between SSB consumption and weight gain, overweight, and obesity in children and adolescents. However, recent evidence from well-conducted meta-analyses shows discrepant results regarding the association between SSB and weight gain, overweight, and obesity among children and adolescents. Improving methodological quality of studies and reviews as well as ensuring responsible conduct of research and scientific integrity is essential for the provision of objective results.

Health effects of fructose and fructose-containing caloric sweeteners: where do we stand 10 years after the initial whistle blowings?

Suspicion that fructose-containing caloric sweeteners (FCCS) may play a causal role in the development of metabolic diseases has elicited intense basic and clinical research over the past 10 years. Prospective cohort studies converge to indicate that FCCS, and more specifically sugar-sweetened beverages (SSBs), consumption is associated with weight gain over time. Intervention studies in which FCCS or SSB consumption is altered while food intake is otherwise left ad libitum indicate that increased FCCS generally increases total energy intake and body weight, while FCCS reduction decreases body weight gain. Clinical trials assessing the effects of SSB reduction as a sole intervention however fail to observe clinically significant weight loss. Many mechanistic studies indicate that excess FCCS can cause potential adverse metabolic effects. Whether this is associated with a long-term risk remains unknown. Scientific evidence that excess FCCS intake causes more deleterious effects to health than excess of other macronutrients is presently lacking. However, the large consumption of FCCS in the population makes it one out of several targets for the treatment and prevention of metabolic diseases.

Stevia, Nature's Zero-Calorie Sustainable Sweetener: A New Player in the Fight Against Obesity

Stevia is a plant native to South America that has been used as a sweetener for hundreds of years. Today, zero-calorie stevia, as high-purity stevia leaf extract, is being used globally to reduce energy and added sugar content in foods and beverages. This article introduces stevia, explaining its sustainable production, metabolism in the body, safety assessment, and use in foods and drinks to assist with energy reduction. The article also summarizes current thinking of the evidence for the role of nonnutritive sweeteners in energy reduction. Overall, stevia shows promise as a new tool to help achieve weight management goals.

Maternal depression, stress and feeding styles: towards a framework for theory and research in child obesity

Against the background of rising rates of obesity in children and adults in the USA, and modest effect sizes for obesity interventions, the aim of the present narrative review paper is to extend the UNICEF care model to focus on childhood obesity and its associated risks with an emphasis on the emotional climate of the parent-child relationship within the family. Specifically, we extended the UNICEF model by applying the systems approach to childhood obesity and by combining previously unintegrated sets of literature across multiple disciplines including developmental psychology, clinical psychology and nutrition. Specifically, we modified the extended care model by explicitly integrating new linkages (i.e. parental feeding styles, stress, depression and mother's own eating behaviour) that have been found to be associated with the development of children's eating behaviours and risk of childhood obesity. These new linkages are based on studies that were not incorporated into the original UNICEF model, but suggest important implications for childhood obesity. In all, this narrative review offers important advancements to the scientific understanding of familial influences on children's eating behaviours and childhood obesity.

Is Sugar the new Tobacco? Insights from Laboratory Studies, Consumer Surveys and Public Health

In the Americas, mean energy intake from added sugar exceeds recent World Health Organization recommendations for free sugars in the diet. As a leading contributor to this excess, sugar-sweetened beverage (SSB) overconsumption represents a risk for the population's health. This article provides an overview of clinical and epidemiological evidence, marketing practices, corporate influence and prevention strategies related to added sugar and SSB. For each aspect of this multidimensional profile, we briefly compare SSB to the case of tobacco pointing to similarities but also major differences. Tobacco control has demonstrated the effectiveness of long term multifaceted prevention strategies in multiple settings supported by strong public policies which may be applied to the consumption of SSB. However, translating these policies to the specific case of SSB is urgently needed, to inform preventive actions, decide which intervention mix will be used, and evaluate the process and impact of the chosen strategy.

Factors associated with daily consumption of sugar-sweetened beverages among adult patients at four federally qualified health centers, Bronx, New York, 2013

Introduction

Consumption of sugar-sweetened beverages (SSBs) is associated with cardiovascular disease risk factors. This study examined the relationships between SSB consumption and demographic, health behavior, health service, and health condition characteristics of adult patients of a network of federally qualified health centers (FQHCs) in a low-income, urban setting.

Methods

Validated, standardized self-reported health behavior questions were incorporated into the electronic health record (EHR) and asked of patients yearly, at 4 FQHCs. We conducted cross-sectional analysis of EHR data collected in 2013 from 12,214 adult patients by using logistic regression.

Results

Forty percent of adult patients consumed 1 or more SSBs daily. The adjusted odds ratios indicated that patients who consumed more than 1 SSB daily were more likely to be aged 18 to 29 years versus age 70 or older, current smokers versus never smoking, eating no servings of fruits and/or vegetables daily or 1 to 4 servings daily versus 5 or more servings daily, and not walking or biking more than 10 blocks in the past 30 days. Patients consuming 1 or more servings of SSBs daily were less likely to speak Spanish than English, be women than men, be diagnosed with type 2 diabetes versus no diabetes, and be diagnosed with hypertension versus no hypertension.

Conclusion

SSB consumption differed by certain demographic characteristics, health behaviors, and health conditions. Recording SSB intake and other health behaviors data in the EHR could help clinicians in identifying and counseling patients to promote health behavior changes. Future studies should investigate how EHR data on patient health behavior can be used to improve the health of patients and communities.