Will reducing sugar-sweetened beverage consumption reduce obesity? Evidence supporting conjecture is strong, but evidence when testing effect is weak

Exposure to sugar rationing in the first 1000 days of life protected against chronic disease

We examined the impact of exposure to sugar restrictions within 1000 days after conception on type 2 diabetes and hypertension, leveraging quasi-experimental variation from the end of the United Kingdom's sugar rationing in September 1953. Rationing restricted sugar intake to levels within current dietary guidelines, and consumption nearly doubled immediately after rationing ended. Using an event study design with UK Biobank data comparing adults conceived just before or after rationing ended, we found that early-life rationing reduced type 2 diabetes and hypertension risk by about 35 and 20% and delayed disease onset by 4 and 2 years, respectively. Protection was evident with in utero exposure and increased with postnatal sugar restriction, especially after 6 months, when eating of solid foods likely began. In utero sugar rationing alone accounted for about one-third of the risk reduction.

Dietary fructose: from uric acid to a metabolic switch in pediatric metabolic dysfunction-associated steatotic liver disease

Fructose consumption in pediatric subjects is rising, as the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH). Despite increasing evidence supporting the detrimental effects of fructose in the development of Metabolic Syndrome (MetS) and its related comorbidities, the association between fructose intake and liver disease remains unclear, mainly in youths. The current narrative review aims to illustrate the correlation between fructose metabolism and liver functions besides its impact on obesity and MASLD in pediatrics. Fructose metabolism is involved in the liver through the classical lipogenic pathway via de novo lipogenesis (DNL) or in the alternative pathway via uric acid accumulation. Hyperuricemia is one of the main features of MALSD patients, underlining how uric acid is growing interest as a new marker of disease. Observational and interventional studies conducted in children and adolescents, who consumed large amounts of fructose and glucose in their diet, were included. Most of these studies emphasized the association between high fructose intake and weight gain, dyslipidemia, insulin resistance, and MASLD/MASH, even in normal-weight children. Conversely, reducing fructose intake ameliorates liver fat accumulation, lipid profile, and weight. In conclusion, fructose seems a potent inducer of both insulin resistance and hepatic fat accumulation.

Economic Evaluations of Obesity-Targeted Sugar-Sweetened Beverage (SSB) Taxes-A Review to Identify Methodological Issues

INTRODUCTION

Economic evaluations of public health interventions like sugar-sweetened beverage (SSB) taxes face difficulties similar to those previously identified in other public health areas. This stems from challenges in accurately attributing effects, capturing outcomes and costs beyond health, and integrating equity effects. This review examines how these challenges were addressed in economic evaluations of SSB taxes.

METHODS

A systematic review was conducted to identify economic evaluations of SSB taxes focused on addressing obesity in adults, published up to February 2021. The methodological challenges examined include measuring effects, valuing outcomes, assessing costs, and incorporating equity.

RESULTS

Fourteen economic evaluations of SSB taxes were identified. Across these evaluations, estimating SSB tax effects was uncertain due to a reliance on indirect evidence that was less robust than evidence from randomised controlled trials. Health outcomes, like quality-adjusted life years, along with a healthcare system perspective for costs, dominated the evaluations of SSB taxes, with a limited focus on broader non-health consequences. Equity analyses were common but employed significantly different approaches and exhibited varying degrees of quality.

CONCLUSION

Addressing the methodological challenges remains an issue for economic evaluations of public health interventions like SSB taxes, suggesting the need for increased attention on those issues in future studies. Dedicated methodological guidelines, in particular addressing the measurement of effect and incorporation of equity impacts, are warranted.

Adapting the Dietary Fat and Free Sugar Short Questionnaire: A Comprehensive Polish Modification for Enhanced Precision in Nutritional Assessments

BACKGROUND

This study aimed to investigate whether The Dietary Fat and Free Sugar-Short Questionnaire (DFS) is a reliable and valid measure that can be used in Polish conditions. It involved 291 participants, aged 14 to 70 (M = 25.9, SD = 10.1), the majority of whom were women (75%).

METHODS

The questionnaire consisted of, among others, Polish DFS version, FFQ-6, TFEQ, and SCOFF. Test-retest reliability was established on the group of 26 students with a 2-week interval. Participants' percentage of energy intake from both free sugars and saturated fats based on FFQ was correlated with DFS total and subscales scores. To investigate convergent and divergent validity, DFS scores with TFEQ correlations were performed. Diagnostic validity was established based on difference analysis between groups with the risk of eating disorders and those without the risk of those based on SCOFF.

RESULTS

Test-retest reliability (rtr = 0.856) and internal consistency (α = 0.797) indicated excellent reliability. DFS correlated significantly with FFQ for both total scores (r = 0.82) and each subscale: sugar (0.79), fat (0.75), and fat-sugar (0.59). The correlations of DFS and TFEQ were statistically significant for cognitive restraint (r = 0.32) and uncontrolled eating (r = 0.19). There also have been found significant differences based on SCOFF regarding DFS.

CONCLUSIONS

The results suggest good reliability and validity of the Polish version of DFS.

Substitution of sugar-sweetened beverages with non-caloric alternatives and weight change: A systematic review of randomized trials and meta-analysis

BACKGROUND

Intake of sugar-sweetened beverages has been associated with weight gain. It is uncertain if replacing an existing use of sugar-sweetened beverages with non-caloric beverages results in long-term reduction in body weight.

OBJECTIVE

The objective of this study is to explore if a long-term reduction in body weight can be achieved by replacing an existing intake of sugar-sweetened beverages with non-caloric beverages.

METHODS

Systematic review and meta-analysis of randomized clinical trials in accordance with PRISMA guidelines. PubMed and EMBASE were searched for literature. Studies with a "substitution" design were included, that is, studies where subjects substituted an existing intake of sugar-sweetened beverages with either artificially sweetened beverages or unsweetened beverages/water. Studies with 6 months or longer follow-up of weight change were included.

RESULTS

Six trials with a total of 1729 participants were included in the meta-analysis. Replacing an existing intake of sugar-sweetened beverages with a non-caloric beverage resulted in a long-term BMI reduction of 0.31 kg/m2 compared with the sugar-sweetened beverage-group (95% CI; 0.17-0.44). One study with 1 year's intervention and 2 years follow-up showed a regression towards baseline BMI after the intervention had ended.

CONCLUSION

Replacing an existing use of sugar-sweetened beverages with artificially sweetened beverages or unsweetened beverages resulted in a long-term 0.31 kg/m2 reduction in BMI equivalent to 0.5-1 kg in children and adults, respectively, as long as the interventions lasted.

The effects of a sugar-sweetened beverage tax: moving beyond dental health outcomes and service utilisation

Despite considerable academic and policy interest in the taxation of sugar-sweetened beverages (SSBs), its extra-health implications remain largely unexplored. We investigated the impact of an SSB tax on school absenteeism due to improved dental health, in a framework that accounted for the distribution of the benefit. We designed a quantitative, decision-analytic model that synthesised existing evidence in the areas of dental epidemiology, public health and economics, and simulated causal mechanisms that lead to changes in school attendance in Australian children and adolescents aged 6-17, in a tax vs no tax scenarios. Introducing a 20% sales tax on SSBs would result in a 0.73% (95% confidence interval: 0.38; 1.10), or 4684 (2412; 7071) days per year nationwide, reduction in school absences attributable to dental health reasons. While positive impacts would be seen across the board, the distribution of benefit was favourable towards boys, older teens and those from lower socio-economic status. Our study highlights the need for, and the viability of, quantifying distributions of direct and indirect consequences of public health policy. Despite modest effect size, the equity profile of SSB tax, the long-lasting benefits of educational gains, and potential synergies with other interventions, make it an attractive option for policymakers to consider.

Important food sources of fructose-containing sugars and adiposity: A systematic review and meta-analysis of controlled feeding trials

BACKGROUND

Sugar-sweetened beverages (SSBs) providing excess energy increase adiposity. The effect of other food sources of sugars at different energy control levels is unclear.

OBJECTIVES

To determine the effect of food sources of fructose-containing sugars by energy control on adiposity.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library were searched through April 2022 for controlled trials ≥2 wk. We prespecified 4 trial designs by energy control: substitution (energy-matched replacement of sugars), addition (energy from sugars added), subtraction (energy from sugars subtracted), and ad libitum (energy from sugars freely replaced). Independent authors extracted data. The primary outcome was body weight. Secondary outcomes included other adiposity measures. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the certainty of evidence.

RESULTS

We included 169 trials (255 trial comparisons, n = 10,357) assessing 14 food sources at 4 energy control levels over a median 12 wk. Total fructose-containing sugars increased body weight (MD: 0.28 kg; 95% CI: 0.06, 0.50 kg; P_MD = 0.011) in addition trials and decreased body weight (MD: -0.96 kg; 95% CI: -1.78, -0.14 kg; P_MD = 0.022) in subtraction trials with no effect in substitution or ad libitum trials. There was interaction/influence by food sources on body weight: substitution trials [fruits decreased; added nutritive sweeteners and mixed sources (with SSBs) increased]; addition trials [dried fruits, honey, fruits (≤10%E), and 100% fruit juice (≤10%E) decreased; SSBs, fruit drink, and mixed sources (with SSBs) increased]; subtraction trials [removal of mixed sources (with SSBs) decreased]; and ad libitum trials [mixed sources (with/without SSBs) increased]. GRADE scores were generally moderate. Results were similar across secondary outcomes.

CONCLUSIONS

Energy control and food sources mediate the effect of fructose-containing sugars on adiposity. The evidence provides a good indication that excess energy from sugars (particularly SSBs at high doses ≥20%E or 100 g/d) increase adiposity, whereas their removal decrease adiposity. Most other food sources had no effect, with some showing decreases (particularly fruits at lower doses ≤10%E or 50 g/d). This trial was registered at clinicaltrials.gov as NCT02558920 (https://clinicaltrials.gov/ct2/show/NCT02558920).

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

BACKGROUND

Sugar-sweetened beverages (SSBs) have been implicated in fueling the obesity epidemic.

OBJECTIVES

This study aimed to update a synthesis of the evidence on SSBs and weight gain in children and adults.

METHODS

MEDLINE, Embase, and Cochrane databases were searched through September 8, 2022, for prospective cohort studies and randomized controlled trials (RCTs) that evaluated intake of SSBs in relation to BMI and body weight in children and adults, respectively. Eligible interventions were compared against a noncaloric control. Study-level estimates were pooled using random-effects meta-analysis and presented as β-coefficients with 95% CIs for cohorts and weighted mean differences (MDs) with 95% CIs for RCTs.

RESULTS

We identified 85 articles including 48 in children (40 cohorts, n = 91,713; 8 RCTs, n = 2783) and 37 in adults (21 cohorts, n = 448,661; 16 RCTs, n = 1343). Among cohort studies, each serving/day increase in SSB intake was associated with a 0.07-kg/m² (95% CI: 0.04 kg/m², 0.10 kg/m²) higher BMI in children and a 0.42-kg (95% CI: 0.26 kg, 0.58 kg) higher body weight in adults. RCTs in children indicated less BMI gain with SSB reduction interventions compared with control (MD: -0.21 kg/m²; 95% CI: -0.40 kg/m², -0.01 kg/m²). In adults, randomization to addition of SSBs to the diet led to greater body weight gain (MD: 0.83 kg; 95% CI: 0.47 kg, 1.19 kg), and subtraction of SSBs led to weight loss (MD: -0.49 kg; 95% CI: -0.66 kg, -0.32 kg) compared with the control groups. A positive linear dose-response association between SSB consumption and weight gain was found in all outcomes assessed.

CONCLUSIONS

Our updated systematic review and meta-analysis expands on prior evidence to confirm that SSB consumption promotes higher BMI and body weight in both children and adults, underscoring the importance of dietary guidance and public policy strategies to limit intake. This meta-analysis was registered at the International Prospective Register of Systematic Reviews as CRD42020209915.

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.

The effects of the form of sugar (solid vs. beverage) on body weight and fMRI activation: A randomized controlled pilot study

Objective

To test if sugar sweetened beverages (SSBs) and sugar sweetened solids (SSSs) have differential effects on body weight and reward processing in the brain.

Methods

In a single blind randomized controlled pilot trial (RCT), twenty participants with BMI between 20 and 40 kg/m² were randomized to consume a 20 fluid ounce soda (SSB, 248 kcal) or the equivalent in solid form (SSS; similar to thick gelatin or gummy candy) daily. At baseline and day 28, fasting body weight and fed-state BOLD fMRI of the brain were assessed. Differences in fMRI signals between views of low-fat (LF (<30%)) high sugar (HS (>30%)) food, and non-food images were calculated in brain regions implicated in energy homeostasis, taste, and reward.

Results

All participants in the SSB (6F 4M; 8 Caucasian; 36±14 y, 28.2±5.5 kg/m²; Mean±SD) and SSS (3F 7M; 6 Caucasian; 39±12; 26.3±4.4) groups completed the study. Weight change was 0.27±0.78 kg between SSB and SSS participants. Changes in the fMRI response to LF/HS foods in reward, homeostatic and taste regions tended to not be different between the groups over the four weeks. However, activation of the right substantia nigra increased following the SSB but decreased activation following the SSS in response to LF/HS foods over 28 days (-0.32±0.12). Ratings of wanting for LF/HS foods were correlated with activation in several brain regions, including the OFC.

Conclusions

Change in weight was modest between the groups in this study. Daily consumption of a SSB over 28 days led to mixed responses to LF/HS foods in areas of the brain associated with reward. Ratings of wanting are correlated with fMRI activation inside an MRI scanner.

Associations between Diet Quality and Body Composition in Young Children Born with Very Low Body Weight

BACKGROUND

Very low birth weight (VLBW; <1500 g) infants have increased adiposity and metabolic disease risk in adulthood. Limited evidence suggests low-quality childhood diets are a predisposing risk factor. Despite this, to our knowledge no study has yet examined associations between diet quality and body composition in VLBW individuals.

OBJECTIVE

The objective of this study was to determine associations between Healthy Eating Index-2010 (HEI-2010) scores and consumption of fruits/vegetables, added sugars, and macronutrients with body composition in 5.5-y-old children born VLBW. We hypothesized HEI-2010 scores were inversely associated with adiposity.

METHODS

This cohort study leveraged the 5.5-y follow-up to the Donor Milk for Improved Neurodevelopmental Outcomes randomized controlled trial. From June 2016 to July 2018, participants attended a follow-up visit at The Hospital for Sick Children, Canada, or were visited in their home. All 316 surviving infants from the trial were eligible, and the caregivers of 158 children (50%; 53% male) consented to follow-up. Diet quality (HEI-2010) and usual intake of fruits/vegetables, added sugars, and macronutrients were determined from two 24-h dietary recalls (ASA24). Linear regressions evaluated associations of diet with BMI (kg/m2) and waist circumference z-scores, total fat, fat-free mass (air displacement plethysmography), and skinfolds.

RESULTS

Mean ± SD age at follow-up was 5.7 ± 0.2 y, birth weight was 1013 ± 264 g, and gestational age was 27.9 ± 2.5 wk. Dietary data and BMI z-scores were available for all children; 123 completed air displacement plethysmography. HEI-2010 score was 58.2 ± 12.4 out of 100, and 27% of children had poor quality diets (scores ≤50). HEI-2010 scores were inversely associated with BMI z-score, but only in children with obese mothers. A 10-point increase in HEI-2010 score was associated with reduced BMI (β: -0.5 SD; 95% CI: -0.7, -0.2) and subscapular (-0.3 SD; 95% CI: -0.6, -0.06) z-scores.

CONCLUSIONS

Improving diet quality in children born VLBW with obese mothers may be an important strategy to prevent excess adiposity. This trial was registered at clinicaltrials.gov as Optimizing Mothers' Milk for Preterm Infants (OptiMoM) Program of Research: Study 1-Impact of Donor Milk at Kindergarten, NCT02759809.

Opposing Consumption Trends for Sugar-Sweetened Beverages and Plain Drinking Water: Analyses of NHANES 2011-16 Data

Background: Choosing water in place of sugar-sweetened beverages (SSB) can reduce added sugars while maintaining adequate hydration. The present goal was to examine 2011-16 time trends in SSB vs. water consumption across US population subgroups. Methods: Dietary intake data for 22,716 persons aged >4 years came from two 24-h dietary recalls in successive cycles of the National Health and Examination Survey (NHANES 2011-16). Water intakes (in mL/d) from plain water (tap and bottled) and from beverages (SSB and not-SSB) were the principal outcome variables. Intakes were analyzed by age group, income to poverty ratio (IPR), and race/ethnicity. Time trends by demographics were also examined. Results: SSB and water intakes followed distinct social gradients. Most SSB was consumed by Non-Hispanic Black and lower-income groups. Most tap water was consumed by Non-Hispanic White and higher-income groups. During 2011-16, water from SSB declined from 322 to 262 mL/d (p < 0.005), whereas plain water increased (1,011-1,144 mL/d) (p < 0.05). Groups aged <30 years reduced SSB consumption (p < 0.0001) but it was groups aged >30 years that increased drinking water (p < 0.001). Non-Hispanic White groups reduced SSB and increased tap water consumption. Non-Hispanic Black and lower income groups reduced SSB and increased bottled water, not tap. Conclusion: The opposing time trends in SSB and water consumption were not uniform across age groups or sociodemographic strata. Only the non-Hispanic White population reduced SSB and showed a corresponding increase in tap water. Lower-income and minority groups consumed relatively little plain drinking water from the tap.

Falsehoods and facts about dietary sugars: a call for evidence-based policy

Sugar, tobacco, and alcohol have been demonized since the seventeenth century. Yet unlike tobacco and alcohol, there is indisputable scientific evidence that dietary sugars were essential for human evolution and are essential for human health and development. Therefore, the purpose of this analytic review and commentary is to demonstrate that anti-sugar rhetoric is divorced from established scientific facts and has led to politically expedient but ill-informed policies reminiscent of those enacted about alcohol a century ago in the United States. Herein, we present a large body of interdisciplinary research to illuminate several misconceptions, falsehoods, and facts about dietary sugars. We argue that anti-sugar policies and recommendations are not merely unscientific but are regressive and unjust because they harm the most vulnerable members of our society while providing no personal or public health benefits.

Overconsumption of sugar-sweetened beverages: Why is it difficult to control?

The consumption of sugar-sweetened beverages is a known contributory factor of childhood obesity that is documented around the globe. More importantly, reducing the consumption of sugar-sweetened beverages could reduce weight gain among overweight or obese children. Although sugar is present in many natural foods, artificial sugar is added into sugar-sweetened beverages, which has little or no nutritional value. However, the calories obtained from the sugar-sweetened beverages are linked to overweight and obesity, and an increase serving sizes of sugar-sweetened beverages over the years partly contributed to the alarming rise of childhood obesity around the globe. The sugar-sweetened beverages not only contain a high amount of sugar, but also contain a high amount of phosphate, and the possibility exists for an enhancing dual adverse health effects of sugar and phosphate. Increasing health awareness and limiting marketing approaches targeted towards the younger population are essential to reduce long-term health burdens that are linked to the overconsumption of sugar-sweetened beverages.

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.

High-sugar diet leads to obesity and metabolic diseases in ad libitum -fed rats irrespective of caloric intake

Objective Provide a comprehensive view of the events surrounding the sugar consumption, under conditions of energy equivalence; through the analysis of behavioral aspects of intake, and of biochemical, metabolic and physiological parameters, as well as the effect of this nutrient on the plasticity of adipose tissue. Materials and methods Newly weaned male Wistar rats were classified in two groups and subjected to the following normocaloric diets: standard chow diet or to high-sugar diet (HSD) ad libitum for 18 weeks. Results The animals submitted to the HSD were associated with a lower caloric intake during the 18 weeks of experimentation. However, the HSD induced a significant increase in body weight, white adipose tissue weight, adiposity index, Lee index, and the levels of triglycerides and very low-density lipoprotein in the serum. In addition, it induced glucose intolerance, insulin resistance and compensatory increase of insulin secretion by pancreatic β-cells. Also increased heart rate and induced hyperplasia, and hypertrophy of retroperitoneal visceral adipose tissue. In the liver, the HSD was associated with increased hepatic lipid content (i.e., triglycerides and cholesterol) and hepatomegaly. Conclusion The post-weaning consumption of HSD induces an adaptive response in metabolism; however, such an event is not enough to reverse the homeostatic imbalance triggered by the chronic consumption of this macronutrient, leading to the development of metabolic syndrome, irrespective of caloric intake. These findings corroborate recent evidence indicating that sugar is a direct contributor to metabolic diseases independent of a positive energy balance. Arch Endocrinol Metab. 2020;64(1):71-81.

High Intake of Free Sugars, Fructose, and Sucrose Is Associated with Weight Gain in Japanese Men

BACKGROUND

Available evidence for associations between sugar intake and body weight is largely from short-term controlled trials and studies focusing on sugar-sweetened beverages. Studies on long-term weight change related to the intake of types of sugar are thus needed.

OBJECTIVE

We examined the associations between weight change and the intake of various types of carbohydrates, including starch, total sugars, and free or naturally occurring sugars and saccharides (i.e., glucose, fructose, sucrose, and lactose), among Japanese men and women.

METHODS

This prospective cohort study included 14,971 residents of Takayama City in Japan who were aged 35-69 y at the first survey in 1992 and responded to a self-administrated questionnaire at the second survey in 2002. We excluded those with cancer, coronary artery disease, stroke, or diabetes on the first survey and those with missing information about body weight on both surveys, leaving 13,229 participants for analysis (5879 men and 7350 women). Mean (95% CI) values of 10-y weight change according to types of carbohydrates were estimated using linear regression models with adjustment for total energy intake and other dietary and lifestyle factors. Dietary intake was assessed at the first survey using a validated FFQ.

RESULTS

Among men, free sugar intake was associated with weight gain and the estimated means (95% CIs) of weight change were -0.60 (-0.67, -0.54), -0.31 (-0.38, -0.24), -0.12 (-0.19, -0.05), and 0.20 (0.13, 0.27) kg from the first to fourth quartiles (P-trend = 0.002). Moreover, high intakes of sucrose and fructose were associated with weight gain (P-trend: 0.018 for sucrose and 0.001 for fructose). Among women, the intake of any type of carbohydrate was not significantly associated with weight change.

CONCLUSIONS

These results suggested that high intakes of free sugars, sucrose, and fructose were associated with long-term weight gain among Japanese men.

Sugar-Sweetened Beverages and Cardiometabolic Health: An Update of the Evidence

Sugar-sweetened beverages (SSBs) have little nutritional value and a robust body of evidence has linked the intake of SSBs to weight gain and risk of type 2 diabetes (T2D), cardiovascular disease (CVD), and some cancers. Metabolic Syndrome (MetSyn) is a clustering of risk factors that precedes the development of T2D and CVD; however, evidence linking SSBs to MetSyn is not clear. To make informed recommendations about SSBs, new evidence needs to be considered against existing literature. This review provides an update on the evidence linking SSBs and cardiometabolic outcomes including MetSyn. Findings from prospective cohort studies support a strong positive association between SSBs and weight gain and risk of T2D and coronary heart disease (CHD), independent of adiposity. Associations with MetSyn are less consistent, and there appears to be a sex difference with stroke with greater risk in women. Findings from short-term trials on metabolic risk factors provide mechanistic support for associations with T2D and CHD. Conclusive evidence from cohort studies and trials on risk factors support an etiologic role of SSB in relation to weight gain and risk of T2D and CHD. Continued efforts to reduce intake of SSB should be encouraged to improve the cardiometabolic health of individuals and populations.

The complex relationship between diet, quality of life and life expectancy: a narrative review of potential determinants based on data from Italy

The increasing life expectancy at birth and the improvement of general health observed worldwide over the previous years are likely due to many factors. In this regard, the Organisation for Economic Cooperation and Development (OECD) has highlighted the favourable situation of the Italian population, which is amongst the most privileged in the world. In Italy, the national healthcare system is easily accessible to the whole population without direct costs, and alcohol abuse and cigarette smoke are less widespread compared to neighbouring countries. Moreover, the population still largely follows a dietary pattern characterised by the consumption of foods rich in protective compounds (plant foods and their components, such as fibre, polyphenols and polyunsaturated fatty acids). According to recent data, a significant consumption of these foods, which are key components of the Mediterranean model, is likely to play a more important role compared to the limited consumption of nutrients considered less favourable (essentially, saturated fat and sugar). Based on these assumptions, it can be inferred that the adoption of coercive legislative interventions-which have been introduced in other western countries to improve diet quality-may not be an optimal strategy in a country like Italy. Such an intervention would contend with psychological and social aspects (namely with the belief that participating in decision-making is an essential right) and with broader indications emerging in the research within this field (the effectiveness of a nudge approach as opposed to constraining interventions). These factors may limit any expected positive impact on health within this context. LEVEL OF EVIDENCE: Level V, narrative review.

Food sources of fructose-containing sugars and glycaemic control: systematic review and meta-analysis of controlled intervention studies

OBJECTIVE

To assess the effect of different food sources of fructose-containing sugars on glycaemic control at different levels of energy control.

DESIGN

Systematic review and meta-analysis of controlled intervention studies.

DATA SOURCES

Medine, Embase, and the Cochrane Library up to 25 April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Controlled intervention studies of at least seven days' duration and assessing the effect of different food sources of fructose-containing sugars on glycaemic control in people with and without diabetes were included. Four study designs were prespecified on the basis of energy control: substitution studies (sugars in energy matched comparisons with other macronutrients), addition studies (excess energy from sugars added to diets), subtraction studies (energy from sugars subtracted from diets), and ad libitum studies (sugars freely replaced by other macronutrients without control for energy). Outcomes were glycated haemoglobin (HbA1c), fasting blood glucose, and fasting blood glucose insulin.

DATA EXTRACTION AND SYNTHESIS

Four independent reviewers extracted relevant data and assessed risk of bias. Data were pooled by random effects models and overall certainty of the evidence assessed by the GRADE approach (grading of recommendations assessment, development, and evaluation).

RESULTS

155 study comparisons (n=5086) were included. Total fructose-containing sugars had no harmful effect on any outcome in substitution or subtraction studies, with a decrease seen in HbA1c in substitution studies (mean difference -0.22% (95% confidence interval to -0.35% to -0.08%), -25.9 mmol/mol (-27.3 to -24.4)), but a harmful effect was seen on fasting insulin in addition studies (4.68 pmol/L (1.40 to 7.96)) and ad libitum studies (7.24 pmol/L (0.47 to 14.00)). There was interaction by food source, with specific food sources showing beneficial effects (fruit and fruit juice) or harmful effects (sweetened milk and mixed sources) in substitution studies and harmful effects (sugars-sweetened beverages and fruit juice) in addition studies on at least one outcome. Most of the evidence was low quality.

CONCLUSIONS

Energy control and food source appear to mediate the effect of fructose-containing sugars on glycaemic control. Although most food sources of these sugars (especially fruit) do not have a harmful effect in energy matched substitutions with other macronutrients, several food sources of fructose-containing sugars (especially sugars-sweetened beverages) adding excess energy to diets have harmful effects. However, certainty in these estimates is low, and more high quality randomised controlled trials are needed.

STUDY REGISTRATION

Clinicaltrials.gov (NCT02716870).

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.

Sugar sweetened beverages and cardiometabolic health

PURPOSE OF REVIEW

It is widely accepted that sugar sweetened beverages (SSB) are implicated in weight gain and adverse cardiometabolic heath. To make informed recommendations about SSB, new evidence needs to be considered against existing literature. The present review will provide an update on the epidemiological and trial evidence linking intake of SSB to cardiometabolic outcomes.

RECENT FINDINGS

The weight of the evidence from prospective cohort studies supports a strong positive association between intake of SSB and weight gain and risk type 2 diabetes (T2D) and coronary heart disease (CHD) that is independent of adiposity. Associations with stroke are less clear and suggestive of greater risk in women than men. Findings from short-term trials of SSB and markers of cardiometabolic risk including lipids, glucose, blood pressure, and inflammatory cytokines provide mechanistic support for associations with T2D and CHD. Putative underlying mechanisms include adverse glycemic effects and increased hepatic metabolism of fructose.

SUMMARY

Conclusive evidence from epidemiological studies and trials on markers of cardiometabolic risk support an etiologic role of SSB in relation to weight gain and risk of T2D and CHD that is independent of weight. Continued efforts to reduce intake of SSB should be encouraged to improve the cardiometabolic health of individuals and populations.

Adiposity among 132 479 UK Biobank participants; contribution of sugar intake vs other macronutrients

Background

Policy makers are being encouraged to specifically target sugar intake in order to combat obesity. We examined the extent to which sugar, relative to other macronutrients, was associated with adiposity.

Methods

We used baseline data from UK Biobank to examine the associations between energy intake (total and individual macronutrients) and adiposity [body mass index (BMI), percentage body fat and waist circumference]. Linear regression models were conducted univariately and adjusted for age, sex, ethnicity and physical activity.

Results

Among 132 479 participants, 66.3% of men and 51.8% of women were overweight/obese. There was a weak correlation (r = 0.24) between energy from sugar and fat; 13% of those in the highest quintile for sugar were in the lowest for fat, and vice versa. Compared with normal BMI, obese participants had 11.5% higher total energy intake and 14.6%, 13.8%, 9.5% and 4.7% higher intake from fat, protein, starch and sugar, respectively. Hence, the proportion of energy derived from fat was higher (34.3% vs 33.4%, P < 0.001) but from sugar was lower (22.0% vs 23.4%, P < 0.001). BMI was more strongly associated with total energy [coefficient 2.47, 95% confidence interval (CI) 2.36-2.55] and energy from fat (coefficient 1.96, 95% CI 1.91-2.06) than sugar (coefficient 0.48, 95% CI 0.41-0.55). The latter became negative after adjustment for total energy.

Conclusions

Fat is the largest contributor to overall energy. The proportion of energy from fat in the diet, but not sugar, is higher among overweight/obese individuals. Focusing public health messages on sugar may mislead on the need to reduce fat and overall energy consumption.

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.

Feasibility and acceptability of a beverage intervention for Hispanic adults: a protocol for a pilot randomized controlled trial

BACKGROUND

In the U.S., Hispanics have among the highest rates of overweight and obesity when compared to other racial/ethnic groups placing them at a greater risk for obesity-related disease. Identifying intervention strategies to reduce caloric intake and/or improve cardiometabolic health in Hispanics is critical to reducing morbidity and mortality among this large and growing population. Evidence exists to support diet-specific behavioral interventions, including beverage modifications, in reducing obesity-related health risks. However, the acceptability and feasibility of a beverage intervention in obese Hispanic adults has not been robustly evaluated.

METHODS

The objective of this pilot study is to assess the feasibility and acceptability of a randomized, controlled beverage intervention in 50 obese Hispanic adults ages 18-64 over 8-weeks. Eligible participants were obese (30-50.0 kg/m2), between the ages 18-64, self-identified as Hispanic, and were able to speak, read, and write in either English and/or Spanish. Study recruitment was completed August 2017. Upon the completion of baseline assessments, participants will be randomized to either Mediterranean lemonade, Green Tea, or flavored water control. After completing a 2-week washout period, participants will be asked to consume 32 oz. per day of study beverage for 6-weeks while avoiding all other sources of tea, lemonade, citrus, juice, and other sweetened beverages; water is permissible. Primary outcomes will be recruitment, retention, and acceptability of the intervention strategies. Our study will also evaluate participant-reported tolerance and as an exploratory aim, assess safety/toxicity-related to renal and/or liver function. Fasting blood samples will be collected at baseline and 8-weeks to assess the primary efficacy outcomes: total cholesterol, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Secondary outcomes include fasting glucose, hemoglobin A1c (HbA1c), and high-sensitivity C-reactive protein (hs-CRP).

DISCUSSION

This pilot study will provide important feasibility, safety, and early efficacy data necessary to design a larger, adequately-powered randomized controlled trial.

TRIAL REGISTRATION

NCT02911753 ( ClinicalTrials.gov ). Registered September 19, 2016. Last updated November 1, 2017.

Validation of a Rapid Method to Assess Habitual Beverage Intake Patterns

The Healthy Beverage Index (HBI) is an emerging approach to assess beverage pattern quality. HBI total scores range from 0 to 100, with higher scores indicating greater adherence to proposed beverage recommendations. However, assessing patterns is resource-intensive due to the need for extensive dietary data, typically 24-h dietary records or recalls. The BEVQ-15, a beverage intake questionnaire, may be used as an alternative method to rapidly measure HBI scores. The objective of this cross-sectional investigation is to assess the comparative validity of the HBI-Q, a method to rapidly assess HBI scores via the BEVQ-15, as compared to the traditional method of deriving HBI scores via dietary recalls/records. Between 2012 and 2016, a cross-sectional sample of adults in southwest Virginia completed three 24-h dietary recalls (30-60 min administration and analysis time per recall) and the BEVQ-15 (3-4 min administration time). HBI scores were generated by both methods, and compared via paired-samples t-tests, correlations, and Bland-Altman analysis. Among 404 adults (mean age = 40 years), total mean HBI scores were 63.7 from the HBI-Q and 67.3 from the recalls (mean difference = 3.6 out of 100; r = 0.63; both p ≤ 0.001). Agreement between the two methods for total HBI scores via Bland-Altman plots was 92%. Using the HBI-Q to rapidly assess HBI scores in adults will increase the utility of the HBI by decreasing the time and resources required, thus allowing researchers and practitioners to provide targeted feedback for improvement.

Sugars, exercise and health

BACKGROUND

There is a direct link between a variety of addictions and mood states to which exercise could be relieving. Sugar addiction has been recently counted as another binge/compulsive/addictive eating behavior, differently induced, leading to a high-significant health problem. Regularly exercising at moderate intensity has been shown to efficiently and positively impact upon physiological imbalances caused by several morbid conditions, including affective disorders. Even in a wider set of physchiatric diseases, physical exercise has been prescribed as a complementary therapeutic strategy.

METHOD

A comprehensive literature search was carried out in the Cochrane Library and MEDLINE databases (search terms: sugar addiction, food craving, exercise therapy, training, physical fitness, physical activity, rehabilitation and aerobic).

RESULTS

Seeking high-sugar diets, also in a reward- or craving-addiction fashion, can generate drastic metabolic derangements, often interpolated with affective disorders, for which exercise may represent a valuable, universal, non-pharmachological barrier.

LIMITATIONS

More research in humans is needed to confirm potential exercise-mechanisms that may break the bond between sugar over-consumption and affective disorders.

CONCLUSIONS

The purpose of this review is to address the importance of physical exercise in reversing the gloomy scenario of unhealthy diets and sedentary lifestyles in our modern society.

Sugar in Infants, Children and Adolescents: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

The consumption of sugars, particularly sugar-sweetened beverages (SSBs; beverages or drinks that contain added caloric sweeteners (ie, sucrose, high-fructose corn syrup, fruit juice concentrates), in European children and adolescents exceeds current recommendations. This is of concern because there is no nutritional requirement for free sugars, and infants have an innate preference for sweet taste, which may be modified and reinforced by pre- and postnatal exposures. Sugar-containing beverages/free sugars increase the risk for overweight/obesity and dental caries, can result in poor nutrient supply and reduced dietary diversity, and may be associated with increased risk of type 2 diabetes mellitus, cardiovascular risk, and other health effects. The term "free sugars," includes all monosaccharides/disaccharides added to foods/beverages by the manufacturer/cook/consumer, plus sugars naturally present in honey/syrups/unsweetened fruit juices and fruit juice concentrates. Sugar naturally present in intact fruits and lactose in amounts naturally present in human milk or infant formula, cow/goat milk, and unsweetened milk products is not free sugar. Intake of free sugars should be reduced and minimised with a desirable goal of <5% energy intake in children and adolescents aged ≥2 to 18 years. Intake should probably be even lower in infants and toddlers <2 years. Healthy approaches to beverage and dietary consumption should be established in infancy, with the aim of preventing negative health effects in later childhood and adulthood. Sugar should preferably be consumed as part of a main meal and in a natural form as human milk, milk, unsweetened dairy products, and fresh fruits, rather than as SSBs, fruit juices, smoothies, and/or sweetened milk products. Free sugars in liquid form should be replaced by water or unsweetened milk drinks. National Authorities should adopt policies aimed at reducing the intake of free sugars in infants, children and adolescents. This may include education, improved labelling, restriction of advertising, introducing standards for kindergarten and school meals, and fiscal measures, depending on local circumstances.

Cross-sectional association between soda consumption and body mass index in a community-based sample of twins

BACKGROUND

Consumption of sugar-sweetened beverages, such as soda, have been shown to play an important role in weight gain. Although soda consumption has been associated with body mass index (BMI) in many studies, it has been difficult to ascertain a true causal relationship between soda consumption and BMI for two reasons. First, findings have been based largely on observational and cross-sectional studies, with much less evidence from randomized controlled trials. Second, the reported relationships may be confounded by genetic and shared environmental factors that affect both soda consumption and BMI. In the present study, we used the twin design to better understand the relationship between soda consumption and BMI by accounting for measured and unmeasured confounds in non-experimental data. Associations from genetically informed tests in twins are considered "quasi-causal," suggesting that our confidence in the causal underpinning of the association between soda consumption and BMI has been strengthened. We hypothesized that the association between soda consumption and BMI would be significant both between and within twins.

METHODS

This was a cross sectional study of 5787 same sex adult twin pairs (18-97 years, 66% female) from the community based Washington State Twin Registry. Structural equation modeling (SEM) was employed to investigate associations between soda consumption and BMI in the population (the phenotypic association between exposure and outcome among all twins treated as individuals) and within pairs of identical and fraternal twins (the quasi-causal association controlling for between pair genetic and environmental confounds).

RESULTS

Among all twins, there was a significant phenotypic association between soda consumption and BMI that held when controlling for age, sex, race, annual household income, and education level (P < 0.05). In the quasi-causal model, however, the effect of soda consumption on BMI was greatly reduced and no longer significant, with a large genetic confound in both men and women (P < 0.05).

CONCLUSION

Among a large group of adult twin pairs, increased soda consumption was associated with increased BMI; however, the observed association was mediated by a genetic background common to both.

Milk Options Observation (MOO): A Mixed-Methods Study of Chocolate Milk Removal on Beverage Consumption and Student/Staff Behaviors in a Rural Elementary School

Providing flavored milk in school lunches is controversial, with conflicting evidence on its impact on nutritional intake versus added sugar consumption and excess weight gain. Nonindustry-sponsored studies using individual-level analyses are needed. Therefore, we conducted this mixed-methods study of flavored milk removal at a rural primary school between May and June 2012. We measured beverage selection/consumption pre- and post-chocolate milk removal and collected observation field notes. We used linear and logistic mixed models to assess beverage waste and identified themes in staff and student reactions. Our analysis of data from 315 unique students and 1,820 beverages choices indicated that average added sugar intake decreased by 2.8 g postremoval, while average reductions in calcium and protein consumption were negligible (12.2 mg and 0.3 g, respectively). Five thematic findings emerged, including concerns expressed by adult staff about student rebellion following removal, which did not come to fruition. Removing flavored milk from school-provided lunches may lower students' daily added sugar consumption without considerably decreasing calcium and protein intake and may promote healthy weight.

Relation of total sugars, fructose and sucrose with incident type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies

BACKGROUND

Sugar-sweetened beverages are associated with type 2 diabetes. To assess whether this association holds for the fructose-containing sugars they contain, we conducted a systematic review and meta-analysis of prospective cohort studies.

METHODS

We searched MEDLINE, Embase, CINAHL and the Cochrane Library (through June 2016). We included prospective cohort studies that assessed the relation of fructose-containing sugars with incident type 2 diabetes. Two independent reviewers extracted relevant data and assessed risk of bias. We pooled risk ratios (RRs) using random effects meta-analyses. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Fiffeen prospective cohort studies (251 261 unique participants, 16 416 cases) met the eligibility criteria, comparing the highest intake (median 137, 35.2 and 78 g/d) with the lowest intake (median 65, 9.7 and 25.8 g/d) of total sugars, fructose and sucrose, respectively. Although there was no association of total sugars (RR 0.91, 95% confidence interval [CI] 0.76-1.09) or fructose (RR 1.04, 95% CI 0.84-1.29) with type 2 diabetes, sucrose was associated with a decreased risk of type 2 diabetes (RR 0.89, 95% CI 0.80-0.98). Our confidence in the estimates was limited by evidence of serious inconsistency between studies for total sugars and fructose, and serious imprecision in the pooled estimates for all 3 sugar categories.

INTERPRETATION

Current evidence does not allow us to conclude that fructose-containing sugars independent of food form are associated with increased risk of type 2 diabetes. Further research is likely to affect our estimates.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01608620.

A brief review of salient factors influencing adult eating behaviour

A better understanding of the factors that influence eating behaviour is of importance as our food choices are associated with the risk of developing chronic diseases such as obesity, CVD, type 2 diabetes or some forms of cancer. In addition, accumulating evidence suggests that the industrial food production system is a major contributor to greenhouse gas emission and may be unsustainable. Therefore, our food choices may also contribute to climate change. By identifying the factors that influence eating behaviour new interventions may be developed, at the individual or population level, to modify eating behaviour and contribute to society’s health and environmental goals. Research indicates that eating behaviour is dictated by a complex interaction between physiology, environment, psychology, culture, socio-economics and genetics that is not fully understood. While a growing body of research has identified how several single factors influence eating behaviour, a better understanding of how these factors interact is required to facilitate the developing new models of eating behaviour. Due to the diversity of influences on eating behaviour this would probably necessitate a greater focus on multi-disciplinary research. In the present review, the influence of several salient physiological and environmental factors (largely related to food characteristics) on meal initiation, satiation (meal size) and satiety (inter-meal interval) are briefly discussed. Due to the large literature this review is not exhaustive but illustrates the complexity of eating behaviour. The present review will also highlight several limitations that apply to eating behaviour research.

Pathogenesis of Cardiovascular and Metabolic Diseases: Are Fructose-Containing Sugars More Involved Than Other Dietary Calories?

There is increasing concern that sugar consumption may be linked to the development of metabolic and cardiovascular diseases. There is indeed strong evidence that consumption of energy-dense sugary beverages and foods is associated with increased energy intake and body weight gain over time. It is further proposed that the fructose component of sugars may exert specific deleterious effects due to its propension to stimulate hepatic glucose production and de novo lipogenesis. Excess fructose and energy intake may be associated with visceral obesity, intrahepatic fat accumulation, and high fasting and postprandial blood triglyceride concentrations. Additional effects of fructose on blood uric acid and sympathetic nervous system activity have also been reported, but their link with metabolic and cardiovascular diseases remains hypothetical. There is growing evidence that fructose at physiologically consumed doses may exert important effects on kidney function. Whether this is related to the development of high blood pressure and cardiovascular diseases remains to be further assessed.

Energy contribution of sugar-sweetened beverage refills at fast-food restaurants

OBJECTIVE

To identify demographic and consumer characteristics associated with refilling a soft drink at fast-food restaurants and the estimated energy content and volume of those refills.

DESIGN

Logistic and linear regression with cross-sectional survey data.

SETTING

Data include fast-food restaurant receipts and consumer surveys collected from restaurants in New York City (all boroughs except Staten Island), and Newark and Jersey City, New Jersey, during 2013 and 2014.

SUBJECTS

Fast-food restaurant customers (n 11795) from ninety-eight restaurants.

RESULTS

Thirty per cent of fast-food customers ordered a refillable soft drink. Nine per cent of fast-food customers with a refillable soft drink reported refilling their beverage (3 % of entire sample). Odds of having a beverage refill were higher among respondents with a refillable soft drink at restaurants with a self-serve refill kiosk (adjusted OR (aOR)=7·37, P<0·001) or who ate in the restaurant (aOR=4·45, P<0·001). KFC (aOR=2·18, P<0·001) and Wendy's (aOR=0·41, P<0·001) customers had higher and lower odds, respectively, of obtaining a refill, compared with Burger King customers. Respondents from New Jersey (aOR=1·47, P<0·001) also had higher odds of refilling their beverage than New York City customers. Customers who got a refill obtained on average 29 more 'beverage ounces' (858 ml) and 250 more 'beverage calories' (1046 kJ) than customers who did not get a refill.

CONCLUSIONS

Refilling a beverage was associated with having obtained more beverage calories and beverage ounces. Environmental cues, such as the placement and availability of self-serve beverage refills, may influence consumer beverage choice.

Natural sweetener agave inhibits gastric emptying in rats by a cholecystokinin-2- and glucagon like peptide-1 receptor-dependent mechanism

Low-calorie sweeteners are considered to be beneficial in calorie control, but the impact of these sweeteners on gastric emptying is not well described. The purpose of this study was to compare the gastric emptying rate of agave nectar with those of glucose and fructose, and to evaluate the interaction of cholecystokinin (CCK)-1, CCK-2 and glucagon-like peptide-1 (GLP-1) receptors in agave-induced alterations in gastric emptying. Female Sprague-Dawley rats were fitted with gastric cannulas. Following the recovery, the gastric emptying rates of glucose, fructose and agave at 12.5%, 15% or 50% concentrations were measured and compared with that of saline. GLP-1 receptor antagonist exendin fragment 9-39 (30 μg kg^-1), CCK-1 receptor antagonist devazepide (1 mg kg^-1) or gastrin/CCK-2 receptor antagonist YM022 (1 mg kg^-1) was injected subcutaneously 1 min before the emptying of glucose, fructose or agave at their 50% concentrations. When compared with saline emptying, gastric emptying of glucose was significantly delayed at its 25% and 50% concentrations, but the emptying of 12.5% glucose was not different from that of saline. Agave emptying, which was delayed with respect to saline emptying, was not altered by CCK-1 receptor blockade; but agave emptied from the stomach as rapidly as saline following the blockade of either CCK-2 or GLP-1 receptors. The findings demonstrate that the inhibitory effect of agave on gastric emptying is mediated by both CCK-2 and GLP-1 receptors, suggesting that natural sweeteners including agave may have satiating effects through the inhibition of gastric motility via enteroendocrine mechanisms.

Metabolic effects of intermittent access to caloric or non-caloric sweetened solutions in mice fed a high-caloric diet

Human consumption of obesogenic diets and soft drinks, sweetened with different molecules, is increasing worldwide, and increases the risk of metabolic diseases. We hypothesized that the chronic consumption of caloric (sucrose, high-fructose corn syrup (HFCS), maltodextrin) and non-caloric (sucralose) solutions under 2-hour intermittent access, alongside the consumption of a high-fat high-sucrose diet, would result in differential obesity-associated metabolic abnormalities in mice. Male C57BL/6 mice had ad libitum access to an HFHS diet and to water (water control group). In addition, some mice had access, 2h/day, 5days/week (randomly chosen) for 12weeks, to different solutions: i) a sucrose solution (2.1kJ/ml), ii) an HFCS solution (2.1kJ/ml), iii) a maltodextrin solution (2.1kJ/ml) and a sucralose solution (60mM) (n=15/group). Despite no changes in total caloric intake, 2h-intermittent access to the sucrose, HFCS or maltodextrin solutions led to increased body weight and accumulation of lipids in the liver when compared to the group consuming water only. The HFCS and sucrose solutions induced a higher fat mass in various fat depots, glucose intolerance, increased glucose oxidation at the expense of lipid oxidation, and a lower hypothalamic expression of NPY in the fasted state. HFCS also reduced proopiomelanocortin expression in the hypothalamus. 2h-intermittent access to sucralose did not result in significant changes in body composition, but caused a stronger expression of CART in the hypothalamus. Finally, sucrose intake showed a trend to increase the expression of various receptors in the nucleus accumbens, linked to dopamine, opioid and endocannabinoid signaling. In conclusion, 2h-intermittent access to caloric solutions (especially those sweetened with sucrose and HFCS), but not sucralose, resulted in adverse metabolic consequences in high-fat high-sucrose-fed mice.

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.

What is the appropriate upper limit for added sugars consumption?

Dramatic increases in obesity and diabetes have occurred worldwide over the past 30 years. Some investigators have suggested that these increases may be due, in part, to increased added sugars consumption. Several scientific organizations, including the World Health Organization, the Scientific Advisory Council on Nutrition, the Dietary Guidelines Advisory Committee 2015, and the American Heart Association, have recommended significant restrictions on upper limits of sugars consumption. In this review, the scientific evidence related to sugars consumption and its putative link to various chronic conditions such as obesity, diabetes, heart disease, nonalcoholic fatty liver disease, and the metabolic syndrome is examined. While it appears prudent to avoid excessive calories from sugars, the scientific basis for restrictive guidelines is far from settled.

Added sugars and risk factors for obesity, diabetes and heart disease

The effects of added sugars on various chronic conditions are highly controversial. Some investigators have argued that added sugars increase the risk of obesity, diabetes and cardiovascular disease. However, few randomized controlled trials are available to support these assertions. The literature is further complicated by animal studies, as well as studies which compare pure fructose to pure glucose (neither of which is consumed to any appreciable degree in the human diet) and studies where large doses of added sugars beyond normal levels of human consumption have been administered. Various scientific and public health organizations have offered disparate recommendations for upper limits of added sugar. In this article, we will review recent randomized controlled trials and prospective cohort studies. We conclude that the normal added sugars in the human diet (for example, sucrose, high-fructose corn syrup and isoglucose) when consumed within the normal range of normal human consumption or substituted isoenergetically for other carbohydrates, do not appear to cause a unique risk of obesity, diabetes or cardiovascular disease.

Nutritional interventions or exposures in infants and children aged up to 3 years and their effects on subsequent risk of overweight, obesity and body fat: a systematic review of systematic reviews

This study, performed as part of the international EarlyNutrition research project (http://www.project-earlynutrition.eu), provides a systematic review of systematic reviews on the effects of nutritional interventions or exposures in children (up to 3 years of age) on the subsequent risk of obesity, overweight and adiposity. Electronic databases (including MEDLINE, Embase and Cochrane Library) were searched up until September 2015. Forty systematic reviews were included. A consistent association of breastfeeding with a modest reduction in the risk of later overweight and obesity in childhood and adulthood was found (the odds decreased by 13% based on high-quality studies), but residual confounding cannot be excluded. Lowering the protein content of infant formula is a promising intervention to reduce the risk of later overweight and obesity in children. There is no consistent evidence of an association of the age of introducing complementary foods, sugar-sweetened beverage or energy intake in early childhood with later overweight/obesity, but there are some indications of an association of protein intake during the complementary feeding period with later overweight/obesity. There was inadequate evidence to determine the effects of other nutritional interventions or exposures, including modifications of infant formula composition, fat intake or consumption of different food groups.

Relationship between Soft Drink Consumption and Obesity in 9-11 Years Old Children in a Multi-National Study

The purpose of this study was to determine the association between regular (sugar containing) and diet (artificially sweetened) soft drink consumption and obesity in children from 12 countries ranging in levels of economic and human development. The sample included 6162 children aged 9–11 years. Information on soft drink consumption was obtained using a food frequency questionnaire. Percentage body fat (%BF) was estimated by bio-electrical impedance analysis, body mass index (BMI) z-scores were computed using World Health Organization reference data, and obesity was defined as a BMI > +2 standard deviations (SD). Multi-level models were used to investigate trends in BMI z-scores, %BF and obesity across categories of soft drink consumption. Age, sex, study site, parental education and physical activity were included as covariates. There was a significant linear trend in BMI z-scores across categories of consumption of regular soft drinks in boys (p = 0.049), but not in girls; there were no significant trends in %BF or obesity observed in either boys or girls. There was no significant linear trend across categories of diet soft drink consumption in boys, but there was a graded, positive association in girls for BMI z-score (p = 0.0002) and %BF (p = 0.0001). Further research is required to explore these associations using longitudinal research designs.

Relationship between Added Sugars Consumption and Chronic Disease Risk Factors: Current Understanding

Added sugars are a controversial and hotly debated topic. Consumption of added sugars has been implicated in increased risk of a variety of chronic diseases including obesity, cardiovascular disease, diabetes and non-alcoholic fatty liver disease (NAFLD) as well as cognitive decline and even some cancers. Support for these putative associations has been challenged, however, on a variety of fronts. The purpose of the current review is to summarize high impact evidence including systematic reviews, meta-analyses, and randomized controlled trials (RCTs), in an attempt to provide an overview of current evidence related to added sugars and health considerations. This paper is an extension of a symposium held at the Experimental Biology 2015 conference entitled “Sweeteners and Health: Current Understandings, Controversies, Recent Research Findings and Directions for Future Research”. We conclude based on high quality evidence from randomized controlled trials (RCT), systematic reviews and meta-analyses of cohort studies that singling out added sugars as unique culprits for metabolically based diseases such as obesity, diabetes and cardiovascular disease appears inconsistent with modern, high quality evidence and is very unlikely to yield health benefits. While it is prudent to consume added sugars in moderation, the reduction of these components of the diet without other reductions of caloric sources seems unlikely to achieve any meaningful benefit.

Environmental components of childhood obesity prevention interventions: an overview of systematic reviews

Childhood obesity has a complex multi-factorial aetiology grounded in environmental and individual level factors that affect behaviour and outcomes. An ecological, systems-based approach to addressing childhood obesity is increasingly being advocated. The primary aim of this review is to summarize the evidence reported in systematic reviews on the effectiveness of population-level childhood obesity prevention interventions that have an environmental component. We conducted a systematic review of reviews published since 1995, employing a standardized search strategy in nine databases. Inclusion criteria required that reviews be systematic and evaluated at least one population-level, environmental intervention in any setting aimed at preventing or reducing obesity in children (5-18 years). Sixty-three reviews were included, ten of which were of high quality. Results show modest impact of a broad range of environmental strategies on anthropometric outcomes. Systematic reviews vary in methodological quality, and not all relevant primary studies may be included in each review. To ensure relevance of our findings to practice, we also report on relevant underlying primary studies, providing policy-relevant recommendations based on the evidence reviewed. Greater standardization of review methods and reporting structures will benefit policymakers and public health professionals seeking informed decision-making.