Practical Strategies to Help Reduce Added Sugars Consumption to Support Glycemic and Weight Management Goals

Healthy nutrition in primary care: instrument on the knowledge, perception, and sugary product consumption in the adult population

Introduction

Introduction: it is necessary to develop an instrument that enables identifying unhealthy eating habits, and to know those erroneous concepts that the adult population may have in relation to sugary products to be able to design and implement appropriate nutritional education strategies for this population sector. Aim: to perform the content validation of a questionnaire to determine the level of knowledge, perception, and habits of sugary product consumption in the adult population through expert judgement. Methods: it is a content and psychometric validation study, carried out between September and October of the last year, in which 13 experts participated, who assessed each one of the instrument's items. Fleiss' kappa coefficient was used with the aim of measuring the degree of agreement. A pre-test was performed with 237 participants to measure the degree of comprehensibility of the instrument. Results: the strength of agreement reached for the dimensions of knowledge and opinion regarding sugary product consumption was almost perfect, and substantial for behaviour with respect to said products. The strength of agreement fluctuated between moderate and almost perfect for each pair of experts. The characteristics of sufficiency and relevance obtained the highest scores using Fleiss' according to the degree of overall agreement between experts. The new version of the questionnaire achieved a high degree of comprehensibility. Conclusions: the results suggest that the instrument is valid and can be applied in future studies to evaluate knowledge, perceptions and habits about sugary products in the adult population, thus contributing to the prevention of chronic diseases and the promotion of a better quality of life.

The Antioxidative, Anti-inflammatory and Anti-apoptotic Effects of Tetrapleura Tetraptera (Aidan) Ethanol Leaf Extract in the Brain of Wistar Rats Exposed to Aspartame

Artificial sweeteners' neurotoxicity remains a significant health concern. This study investigated the neurotoxic effects of aspartame (ASP) and evaluated the neuroprotective potential of Tetrapleura tetraptera ethanol extract (TT) in Wistar rats. Thirty male rats were grouped into six (n = 5) and some received oral ASP administration for 14 days, with some groups post-treated with TT (200 and 400 mg/kg) orally for 14 days. Neurotransmitter function, oxidative stress markers, inflammatory mediators, and apoptotic parameters were assessed using biochemical assays and RT-PCR on serum and brain tissues after the sacrifice. ASP significantly (p < 0.001) increased AChE and BChE activities while decreasing dopamine levels. RT-PCR analysis revealed that ASP upregulated pro-inflammatory genes (TNF-α, IL-6, IL-1β) and pro-apoptotic markers (BAX, CASP3, CASP9, P53) while downregulating anti-apoptotic BCL-2 gene expression. ASP also reduced antioxidant levels (GSH, GCL), elevated S100B level and activated cAMP/PKA signalling. TT post-treatment significantly (p < 0.001) reversed these alterations, reducing MDA and GSSG levels while enhancing GSH/GSSG ratio and antioxidant activities. TT markedly downregulated inflammatory markers and upregulated IL-10 expression. Histopathological examination suggests TT's protective effects against ASP-induced neural damage. These findings indicate that TT exhibits neuroprotective properties through its antioxidant, anti-inflammatory, and anti-apoptotic activities against ASP-induced neurotoxicity.

A Narrative Review of the Interplay Between Carbohydrate Intake and Diabetes Medications: Unexplored Connections and Clinical Implications

This narrative review examines the dynamic interplay between carbohydrate intake and diabetes medications, highlighting their combined molecular and clinical effects on glycemic control. Carbohydrates, a primary energy source, significantly influence postprandial glucose regulation and necessitate careful coordination with pharmacological therapies, including insulin, metformin, glucagon-like peptide (GLP-1) receptor agonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors. Low-glycemic-index (GI) foods enhance insulin sensitivity, stabilize glycemic variability, and optimize medication efficacy, while high-GI foods exacerbate glycemic excursions and insulin resistance. Continuous glucose monitoring (CGM) offers real-time insights to tailor dietary and pharmacological interventions, improving glycemic outcomes and reducing complications. Despite advancements, gaps persist in understanding nutrient-drug interactions, particularly with emerging antidiabetic agents. This review underscores the need for integrating carbohydrate-focused dietary strategies with pharmacotherapy to enhance diabetes management. Future research should prioritize clinical trials leveraging CGM technology to explore how glycemic index, glycemic load, and carbohydrate quality interact with newer diabetes medications. Such studies can refine evidence-based recommendations, support individualized care plans, and improve long-term outcomes. Addressing systemic barriers, such as limited access to dietitians and CGM technology in underserved regions, is critical for equitable care. Expanding the roles of community health workers and training healthcare providers in basic nutrition counseling can bridge gaps, promoting sustainable and inclusive diabetes management strategies. These efforts are essential for advancing personalized, effective, and equitable care for individuals with diabetes.

Effect of a Nutritional Education Intervention on the Reduction of Added Sugar Consumption in Schoolchildren in Southeastern Mexico: Community Study

Consumption of added sugars negatively affects schoolchildren's health, making it essential to promote strategies designed to reduce their intake through educational interventions. This study aimed to evaluate the effect of a nutritional education intervention, INCAI, on the consumption of added sugars among schoolchildren in southeastern Mexico. A 9-month educational intervention was designed to promote healthy eating, physical activity, and the development of socio-emotional skills among primary school children. Information on the usual intake of foods and beverages was collected from 400 schoolchildren at the beginning and end of the intervention using a semiquantitative food frequency questionnaire. For the analysis, a generalized estimating equation (GEE) model was constructed using the Poisson distribution family to estimate the effect of the intervention. The relative incidence in the final stage showed a slight increase of 4% (p = 0.093) in the percentage of added sugars compared with the baseline levels in the control group. By contrast, the intervention effect, represented by the interaction between treatment and time, showed a 10% reduction in the final stage in the intervention group (p < 0.001). Based on these findings, the INCAI educational intervention effectively reduced added sugar consumption by 10% in the intervention group, while no significant reduction was observed in the control group. These results suggest that nutritional education programs can be a useful strategy for lowering added sugar intake among schoolchildren, highlighting the importance of incorporating such interventions into public health policies targeting child populations.

Fructose-Induced Metabolic Dysfunction Is Dependent on the Baseline Diet, the Length of the Dietary Exposure, and Sex of the Mice

Background/Objectives: High sugar intake, particularly fructose, is implicated in obesity and metabolic complications. On the other hand, fructose from fruits and vegetables has undisputed benefits for metabolic health. This raises a paradoxical question-how the same fructose molecule can be associated with detrimental health effects in some studies and beneficial in others. This study investigates how diet and sex interact with fructose to modulate the metabolic outcomes. Methods: Male and female mice were fed different normal chow diets, Boston chow diet (BCD; 23% protein, 22% fat, 55% carbohydrates), Lexington chow diet (LXD; 24% protein, 18% fat, 58% carbohydrates), and low-fat diet (LFD; 20% protein, 10% fat, 70% carbohydrates), supplemented with 30% fructose in water. Results: Fructose-supplemented male mice on BCD gained weight and developed glucose intolerance and hepatic steatosis. Conversely, male mice given fructose on LXD did not gain weight, remained glucose-tolerant, and had normal hepatic lipid content. Furthermore, fructose-fed male mice on LFD did not gain weight. However, upon switching to BCD, they gained weight, exhibited worsening liver steatosis, and advanced hepatic insulin resistance. The effects of fructose are sex-dependent. Thus, female mice did not gain weight and remained insulin-sensitive with fructose supplementation on BCD, despite developing hepatic steatosis. These differences in metabolic outcomes correlate with the propensity of the baseline diet to suppress hepatic ketohexokinase expression and the de novo lipogenesis pathway. This is likely driven by the dietary fat-to-carbohydrate ratio. Conclusions: Metabolic dysfunction attributed to fructose intake is not a universal outcome. Instead, it depends on baseline diet, dietary exposure length, and sex.

Educational Intervention Boosts Dietitians' Knowledge of the Safety and Approval of Low- and No-Calorie Sweeteners

BACKGROUND/OBJECTIVES

Low- and no-calorie sweeteners (LNCSs) provide sweetness in food applications that are suggested to support consumers' reduced consumption of caloric sweeteners and added sugar intake. Consumers seek guidance and advice on using LNCSs from healthcare providers, including dietitians and nutritionists. However, prior research suggests there may be inconsistent guidance on the use of LNCSs. The main goal is to assess dietitians' and nutritionists' perceptions and knowledge of LNCSs. We also evaluate the impact of educational intervention on the perceptions and knowledge of low- and no-calorie sweeteners (LNCSs) among healthcare professionals.

METHODS

Participants completed an online questionnaire on their perceptions of LNCSs before and after viewing a webinar given by a member of the FDA on the safety and approval process of LNCSs. A total of 187 participants completed the pre-questionnaire, and 58 participants completed the post-questionnaire.

RESULTS

The LNCSs most familiar to participants was aspartame, followed by stevia, with thaumatin, advantame, and neotame being the least familiar sweeteners. While all sweeteners were FDA-approved, there were differences in perceived safety and suitability for dietary use. Following the intervention, there was a significant improvement in the participant's knowledge, understanding, and confidence in the safety and approval process of LNCSs and reduced negative perceptions of LNCSs on health.

CONCLUSIONS

With nutritionists and dietitians being the primary sources of nutritional guidance, consumers may seek their recommendations regarding using LNCSs. However, this study revealed differences in suitability across FDA-approved LNCSs and a lack of confidence regarding the safety and approval process. Education programs regarding the safety and approval process of LNCSs increase confidence in advising patients and clients on the use of LNCSs.

The propensity of fructose to induce metabolic dysfunction is dependent on the baseline diet, length of the dietary exposure, and sex of the mice

Background/Objectives

Numerous studies have implicated high intake of sugar, particularly fructose, with the development of obesity and metabolic complications. On the other hand, fructose from fruits and vegetables has undisputed benefits for metabolic health. This paradox questions how the same fructose molecule can be associated with detrimental health effects in some studies and beneficial in others.

Methods

To answer this question, male and female mice were fed different normal chow diets and provided 30% fructose solution in water.

Results

Fructose-supplemented male mice on the Boston Chow Diet (BCD=23% protein, 22% fat, 55% carbs) gained weight, developed glucose intolerance and hepatic steatosis. In contrast, male mice on the Lexington Chow Diet (LXD=24% protein, 18% fat, 58% carbs) did not gain weight, remained glucose tolerant, and had normal hepatic lipid content when supplemented with fructose. Furthermore, fructose-fed male mice on a Low-Fat Diet (LFD=20% protein, 10% fat, 70% carbs) didn't gain weight, but once switched to the BCD, they gained weight, exhibited worsening liver steatosis, and more advanced hepatic insulin resistance. The effects of fructose are sex-dependent, as female mice didn't gain weight and remained insulin-sensitive when given fructose on BCD, despite developing hepatic steatosis.

Conclusions

The differences in metabolic outcomes correlate with the propensity of the baseline diet to suppress hepatic ketohexokinase expression and the de novo lipogenesis pathway. This is likely driven by the dietary fat-to-carbohydrate ratio. Thus, metabolic dysfunction attributed to fructose intake is not a universal outcome; rather, it depends on the baseline diet, sex, and exposure length.

Hard stop: reestablishing the significance of abstinence in the treatment of late stage ultra-processed food addiction

Addiction is a complex neurobiological disorder characterized by compulsive drug-seeking and use despite harmful consequences. While abstinence-based approaches have long been the cornerstone of addiction treatment, recent years have seen legitimate challenges from harm reduction clinicians, and within the food addiction realm, the eating disorder treatment practitioners. This perspective emphasizes the role of abstinence in food addiction recovery using the Koob model and its concept of hyperkatifeia despite these reservations. However, further research is essential before abstinence can be recommended. We need to 1) identify what qualifies as abstinence in relation to ultra-processed food, 2) clarify suitable situations and disease progression for optimal implementation of this approach, 3) provide clear guidelines when it is harmful, and 4) conduct clinical studies to confirm the effectiveness of this strategy for long-term recovery from late-stage food addiction.

Diabetic Patients: Why Stop Sugar?

Diet plays an important role in the complete management of type 1 and type 2 diabetes. The aim of nutritional management of diabetes is to optimize glycemic control, help in achieving ideal body weight, and correct any lipid abnormalities to reduce the risk of long-term complications. However, there are varied and many unscientific beliefs about diet among patients with diabetes as well as in physicians, which very often makes nutritional management challenging. The most common misconception is that patients with diabetes should not consume sugar at all. The taste of food plays an important role in food choices, eating behaviors, food intake, and associated satisfaction. The more distant a recommended change is from the person's actual eating habits, the more difficult it will be to achieve long-term compliance to the recommended change. It is important to provide therefore achievable and sustainable dietary modifications that will encourage people to adopt healthier food choices without compromising their taste preferences. Special attention needs to be given to the nutrition intake in gestational diabetes mellitus. Consensus guidelines have recommended a low glycemic index, high fiber, and protein diet in gestational diabetes mellitus. Alcohol intake in nonpregnant women and supplements rich in micronutrients are both key considerations. There is clearly a need for conducting educational programs for physicians as well as patients to dispel misconceptions regarding the consumption of carbohydrates, especially added sugar, in patients with diabetes. The focus should be on balancing the calorie intake rather than placing unnecessary and inappropriate restrictions.

Are we using more sugar substitutes? Wastewater analysis reveals differences and rising trends in artificial sweetener usage in Swedish urban catchments

The market for artificial sweeteners as substitutes for conventional sugar (sucrose) is growing, despite potential health risks associated with their intake. Estimating population usage of artificial sweeteners is therefore crucial, and wastewater analysis can serve as a complement to existing methods. This study evaluated spatial and temporal usage of artificial sweeteners in five Swedish communities based on wastewater analysis. We further compared their levels measured in wastewater with the restrictions during the COVID-19 pandemic in Sweden and assessed health risks to the Swedish population. Influent wastewater samples (n = 194) collected in March 2019-February 2022 from communities in central and southern Sweden were analyzed for acesulfame, saccharin, and sucralose using liquid-chromatography coupled with tandem mass spectrometry. Spatial differences in loads for individual artificial sweetener were observed, with sucralose being higher in Kalmar (southern Sweden), and acesulfame and saccharin in Enköping and Östhammar (central Sweden). Based on sucrose equivalent doses, all communities showed a consistent prevalence pattern of sucralose > acesulfame > saccharin. Four communities with relatively short monitoring periods showed no apparent temporal changes in usage, but the four-year monitoring in Uppsala revealed a significant (p < 0.05) annual increase of ∼19 % for sucralose, ∼9 % for acesulfame and ∼8 % for saccharin. This trend showed no instant or delayed effects from COVID-19 restrictions, reflecting positively on the studied population which retained similar exposure to the artificial sweeteners despite potential pandemic stresses. Among the three artificial sweeteners, only acesulfame's levels were at the lower end of the health-related threshold for consumption of artificially sweetened beverages; yet, all were far below the acceptable daily intake, indicating no appreciable health risks. Our study provided valuable, pilot insights into the spatio-temporal usage of artificial sweeteners in Sweden and their associated health risks. This shows the usefulness of wastewater analysis for public health authorities wishing to assess future relevant interventions.

The Impact of Excessive Fructose Intake on Adipose Tissue and the Development of Childhood Obesity

Worldwide, childhood obesity cases continue to rise, and its prevalence is known to increase the risk of non-communicable diseases typically found in adults, such as cardiovascular disease and type 2 diabetes mellitus. Thus, comprehending its multiple causes to build healthier approaches and revert this scenario is urgent. Obesity development is strongly associated with high fructose intake since the excessive consumption of this highly lipogenic sugar leads to white fat accumulation and causes white adipose tissue (WAT) inflammation, oxidative stress, and dysregulated adipokine release. Unfortunately, the global consumption of fructose has increased dramatically in recent years, which is associated with the fact that fructose is not always evident to consumers, as it is commonly added as a sweetener in food and sugar-sweetened beverages (SSB). Therefore, here, we discuss the impact of excessive fructose intake on adipose tissue biology, its contribution to childhood obesity, and current strategies for reducing high fructose and/or free sugar intake. To achieve such reductions, we conclude that it is important that the population has access to reliable information about food ingredients via food labels. Consumers also need scientific education to understand potential health risks to themselves and their children.

Effects of reducing free sugars on 24-hour glucose profiles and glycemic variability in subjects without diabetes

Background

The Western diet, especially beverages and high processed food products, is high in sugars which are associated with the development of obesity and diabetes. The reduction of refined carbohydrates including free and added sugars improves glycemic control in individuals with diabetes, but the data regarding effects in subjects without diabetes are limited.

Objective

This study aimed to evaluate the effects of reducing free sugar intake on 24-h glucose profiles and glycemic variability using continuous glucose monitoring (CGM).

Methods

In the randomized controlled study, 21 normal weight and overweight/obese subjects (BMI 18-40 kg/m2) without diabetes were assigned to a 4-week reduced-sugar (RS) diet or control diet after a 2-week baseline phase. During the baseline phase, all participants were advised not to change their habitual diet. During the intervention phase, RS participants were asked to avoid added sugar and white flour products, whereas participants of the control group were requested to proceed their habitual diet. Anthropometric parameters and HbA1c were assessed before and at the end of the intervention phase. Interstitial glucose was measured using continuous glucose monitoring (CGM), and the food intake was documented by dietary records for 14 consecutive days during the baseline phase and for the first 14 consecutive days during the intervention phase. Mean 24-h glucose as well as intra- and inter-day indices of glucose variability, i.e., standard deviation (SD) around the sensor glucose level, coefficient of variation in percent (CV), mean amplitude of glucose excursions (MAGE), continuous overlapping net glycemic action (CONGA), and mean absolute glucose (MAG), were calculated for the baseline and intervention phases.

Results

During the intervention, the RS group decreased the daily intake of sugar (i.e., -22.4 ± 20.2 g, -3.28 ± 3.61 EN %), total carbohydrates (-6.22 ± 6.92 EN %), and total energy intake (-216 ± 108 kcal) and increased the protein intake (+2.51 ± 1.56 EN %) compared to the baseline values, whereby this intervention-induced dietary changes differed from the control group. The RS group slightly reduced body weight (-1.58 ± 1.33 kg), BMI, total fat, and visceral fat content and increased muscle mass compared to the baseline phase, but these intervention-induced changes showed no differences in comparison with the control group. The RS diet affected neither the 24-h mean glucose levels nor intra- and inter-day indices of glucose variability, HbA1c, or diurnal glucose pattern in the within- and between-group comparisons.

Conclusion

The dietary reduction of free sugars decreases body weight and body fat which may be associated with reduced total energy intake but does not affect the daily mean glucose and glycemic variability in individuals without diabetes.

Clinical trial registration

German Clinical Trials Register (DRKS); identifier: DRKS00026699.

Low-Carbohydrate Diets in Children and Adolescents With or at Risk for Diabetes

Carbohydrate restriction is increasingly popular as a weight loss strategy and for achieving better glycemic control in people with diabetes, including type 1 and type 2 diabetes. However, evidence to support low-carbohydrate diets in youth (children and adolescents 2-18 years of age) with obesity or diabetes is limited. There are no guidelines for restricting dietary carbohydrate consumption to reduce risk for diabetes or improve diabetes outcomes in youth. Thus, there is a need to provide practical recommendations for pediatricians regarding the use of low-carbohydrate diets in patients who elect to follow these diets, including those with type 1 diabetes and for patients with obesity, prediabetes, and type 2 diabetes. This clinical report will: Provide background on current dietary patterns in youth, describe how moderate-, low-, and very low-carbohydrate diets differ, and review safety concerns associated with the use of these dietary patternsReview the physiologic rationale for carbohydrate reduction in youth with type 1 diabetes and for youth with obesity, prediabetes, and type 2 diabetesReview the evidence for low-carbohydrate diets in the management of youth with type 1 diabetesReview the evidence for low-carbohydrate diets in the management of youth with obesity, prediabetes, and type 2 diabetesProvide practical information for pediatricians counseling families and youth on carbohydrate recommendations for type 1 diabetes and for obesity, prediabetes, and type 2 diabetes.

Non-nutritive sweeteners and their impacts on the gut microbiome and host physiology

Non-nutritive sweeteners (NNS) are broadly incorporated into foods, especially those representing a growing share of the beverage market. NNS are viewed as a noncaloric and desirable alternative to sugar-based sweeteners and are thought to contribute to reducing overall caloric intake. While these compounds have been studied extensively and have long been considered inert, new research has presented a different view and raises new questions about the effects of NNS on human physiology. Namely, the influence on glucose responses, the gastrointestinal epithelium, and the gut microbiome. As the gut microbiome is now recognized as a major mediator of human health and perturbations to this community are generally associated with negative health trajectories or overt disease, interactions between NNS and the gut microbiome are of increasing interest to clinicians and researchers. Several NNS compounds are now hypothesized to affect human physiology by modulating the gut microbiome, though the mechanism for this action remains unclear. The purpose of this review is to discuss the history and current knowledge of NNS, their reported utility and effects on host physiology and the gut microbiome, and describes a model for investigating the underlying mechanism behind reported effects of NNS on the gut microbiome.

Type 2 Diabetes and Dietary Carbohydrate Intake of Adolescents and Young Adults: What Is the Impact of Different Choices?

Type 2 diabetes mellitus has a high prevalence worldwide, with a rapidly increasing incidence even in youth. Nutrition, dietary macronutrient composition, and in particular dietary carbohydrates play a major role in the development of type 2 diabetes. The aim of this narrative review is to discuss the current evidence on the role of dietary carbohydrates in the prevention and management of type 2 diabetes. The digestibility or availability of carbohydrates and their glycemic index (and glycemic load) markedly influence the glycemic response. High consumption of dietary fiber is beneficial for management of type 2 diabetes, whereas high consumption of both glycemic starch and sugars may have a harmful effect on glucose metabolism, thereby increasing the risk of developing type 2 diabetes in the presence of genetic predisposition or making its glycemic control more difficult to achieve in people with established T2D. Therefore, the same dietary macronutrient may have harmful or beneficial effects on type 2 diabetes mainly depending on the subtypes consumed. Some other factors are involved in glucose metabolism, such as meal composition, gut microbiota and genetics. For this reason, the glycemic response after carbohydrate consumption is not easy to predict in the single individual. Nutrition suggested to subjects with known type 2 diabetes should be always person-centered, considering the individual features of each subject.

Use of sucralose in foods heated during manufacturing does not pose a risk to human health

Regulatory agencies around the world have found sucralose to be a safe ingredient for use in food. A recent review by the German Federal Institute for Risk Assessment (BfR) hypothesized that sucralose use in foods heated during their manufacture might pose a health risk, by resulting in the formation of certain chlorinated compounds; specifically, polychlorinated dibenzodioxins (PCDDs), polychlorinateddibenzofurans (PCDFs) and/or free or bound 3-monochloropropanediol (3-MCPD), some of which are considered potential carcinogens. The BfR further encouraged the European Food Safety Authority (EFSA), which is in the process of conducting a staged re-evaluation of a range of food additives, including sucralose, to specifically address their hypothesis. This paper reports the results of new studies requested by EFSA to analyze for the presence of PCDDs, PCDFs and 3-MCPDs in a range of foods. As requested, foods were prepared with typical sucralose use levels and thermally processed under typical food processing conditions. The presence of the compounds of interest were analyzed using validated and accepted analytical methods (e.g. US Environmental Protection Agency (EPA); American Oil Chemists Society (AOCS)). The results of these new analytical studies show no evidence for the formation of these compounds due to sucralose presence. This paper also reports a critical analysis of the studies cited in the BfR review as the basis for its hypothesis. This analysis shows that the cited studies do not represent food manufacturing conditions and are thus not reliable for predicting the fate of sucralose in foods. This work reaffirms that sucralose is safe for use in food manufacture, including when heating is required.