Important Food Sources of Fructose-Containing Sugars and Incident Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Health effects of drinking 100% juice: an umbrella review of systematic reviews with meta-analyses

CONTEXT

Low fruit and vegetable intakes are major modifiable determinants of disease. One hundred percent juice may facilitate intake and deliver essential nutrients and bioactive compounds. However, the position of 100% juice in healthy eating guidelines remains controversial due to its lower dietary fiber and higher free-sugar contents compared with whole fruits and vegetables.

OBJECTIVE

To conduct an umbrella review of systematic literature reviews with meta-analyses (MAs) to summarize the health benefits of drinking 100% fruit and/or vegetable juice.

DATA SOURCES

Four databases (Medline, The Cochrane Library, EMBASE, and CINAHL) were systematically searched for MAs of 100% juice and any health outcomes.

DATA ANALYSIS

Screening, quality, risk of bias, and content overlap tools were applied, and extracted data were narratively synthesized. No eligible studies for vegetable juice were found. Fifteen systematic literature reviews (51 primary MAs, 6 dose-response, and 87 subanalyses; 50-1200 mL/day; hours to years of duration) were included. Ten MAs (19.6%) reported health benefits (4 for blood pressure, 2 for vascular function, 3 for inflammation, 1 for stroke mortality), 3 MAs (5.9%) reported adverse risks (1 each for cardiovascular disease mortality, prostate cancer, type 2 diabetes risk), while most (74.5%) reported no effect (blood lipids, body composition, liver function, metabolic health, cancers, and inflammation). Risks were limited to cohort studies and benefits were found in both cohort and intervention studies.

CONCLUSION

The findings collate evidence showing some potential health benefits associated with 100% juice consumption, with fewer potential risks. The balance of evidence does not support the exclusion of 100% juice from food-based guides to healthy eating, although caution may be warranted in certain groups or individuals, and the body of evidence is not yet conclusive.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022380588.

Association of consumption of sugar-sweetened beverages with elevated blood pressure among college students in Yunnan Province, China

OBJECTIVE

Although some studies have examined the association between eating behaviour and elevated blood pressure (EBP) in adolescents, current data on the association between sugar-sweetened beverages (SSB) and EBP in adolescents in Yunnan Province, China, are lacking.

SETTING

Cluster sampling was used to survey freshmen at a college in Kunming, Yunnan Province, from November to December. Data on SSB consumption were collected using an FFQ measuring height, weight and blood pressure. A logistic regression model was used to analyse the association between SSB consumption and EBP, encompassing prehypertension and hypertension with sex-specific analyses.

PARTICIPANTS

The analysis included 4781 college students.

RESULTS

Elevated systolic blood pressure (SBP) and diastolic blood pressure (DBP) were detected in 35·10 % (1678/4781) and 39·34 % (1881/4781) of patients, respectively. After adjusting for confounding variables, tea beverage consumption was associated with elevated SBP (OR = 1·24, 95 % CI: 1·03, 1·49, P = 0·024), and carbonated beverage (OR = 1·23, 95 % CI: 1·04, 1·45, P = 0·019) and milk beverage (OR = 0·81, 95 % CI: 0·69, 0·95, P = 0·010) consumption was associated with elevated DBP in college students. Moreover, fruit beverage (OR = 1·32, 95 % CI: 1·00, 1·75, P = 0·048) and milk beverage consumption (OR = 0·69, 95 % CI: 0·52, 0·93, P = 0·014) was associated with elevated DBP in males.

CONCLUSION

Our findings indicated that fruit and milk beverage consumption was associated with elevated DBP in males, and no association was observed with EBP in females.

Fruit juice - a scoping review for Nordic Nutrition Recommendations 2023

Fruit juice has a similar nutrient content as whole fruit and may in this respect be part of a healthy diet. However, a lower amount or lack of fibre and a higher concentration of sugars and energy could also contribute to less satiation and increase the risk of excess energy intake. The aim of this scoping review is to describe the overall evidence for the role of fruit juice as a basis for setting and updating food-based dietary guidelines in the Nordic Nutrition Recommendations 2023. PubMed was searched for systematic reviews and meta-analyses and evidence was extracted on relevant health outcomes. Current available evidence indicates that low to moderate consumption of fruit juice is not associated with an apparent risk of chronic diseases and may have protective effects on cardiovascular disease. The association between the intake of fruit juice and weight gain remains unclear and might be of concern for some groups of people. Overall, the evidence regarding health effects of fruit juice is limited.

Vegetables, fruits, and berries - a scoping review for Nordic Nutrition Recommendations 2023

Vegetables, fruits, and berries comprise a large variety of foods and are recognised to play an important role in preventing chronic diseases. Many observational studies have been published during the last decade, and the aim of this scoping review is to describe the overall evidence for the role of vegetables, fruits, and berries for health-related outcomes as a basis for setting and updating food-based dietary guidelines. A scoping review was conducted according to the protocol developed within the Nordic Nutrition Recommendations 2023 project. Current available evidence strengthens the role of consuming vegetables, fruits, and berries in preventing chronic diseases. The most robust evidence is found for cancer in the gastric system and lung cancer, cardiovascular disease, and all-cause mortality. Steeper risk reductions are generally seen at the lower intake ranges, but further reductions have been seen for higher intakes for cardiovascular disease. Weaker associations are seen for type 2 diabetes. There is evidence that suggests a beneficial role also for outcomes such as osteoporosis, depression, cognitive disorders, and frailty in the elderly. The observed associations are supported by several mechanisms, indicting causal effects. Some subgroups of vegetables, fruits, and berries may have greater benefits than other subgroups, supporting a recommendation to consume a variety of these foods.

Risk assessment of nutrients: There must be a threshold for their effects

Nutrients serve physiological functions in a dose-dependent manner and that needs to be recognized in risk assessment. An example of the consequences of not properly considering this can be seen in a recent assessment by the European Food Safety Authority (EFSA). EFSA concluded in 2022 that the intake of added and free sugars should be "as low as possible in the context of a nutritionally adequate diet". That conclusion of EFSA is based on the effects on two surrogate endpoints for an adverse effect found in randomized controlled trials with high sugars intake levels: fasting glucose and fasting triglycerides. The lowest intake levels in these trials were around 10 energy% and at this intake level there were no adverse effects on the two outcomes. This indicates that the adverse effects of sugars have an observable threshold value for these two endpoints. The most appropriate interpretation from the vast amount of data is that currently no definitive conclusion can be drawn on the tolerable upper intake level for dietary sugars. Therefore, EFSA's own guidance would lead to the conclusion that the available data do not allow the setting of an upper limit for added sugars and hence, that more robust data are required to identify the threshold value for intake of sugars.

Associations of dietary sugar types with coronary heart disease risk: a prospective cohort study

BACKGROUND

Higher intake of total sugar has been linked with coronary heart disease (CHD) risk, but the role of individual sugars, particularly fructose, is uncertain.

OBJECTIVES

This study aimed to investigate the associations of individual dietary sugars with CHD risk.

METHODS

In prospective cohort studies, we followed 76,815 women (Nurses' Health Study, 1980-2020) and 38,878 men (Health Professionals Follow-up Study, 1986-2016). Sugar and carbohydrate intake, including total fructose equivalents ([TFE] from fructose monosaccharides and sucrose), total glucose equivalents ([TGE] from glucose monosaccharides, disaccharides, and starch), and other sugar types, was measured every 2 to 4 y by semiquantitative food frequency questionnaires.

RESULTS

We documented 9,723 incident CHD cases over 40 years. In isocaloric substitution models with total fat as a comparison nutrient, comparing extreme quintiles of intake, hazard ratios (HRs), 95% confidence interval [CI]) for CHD risk were 1.31 (1.20 to 1.42; Ptrend < 0.001) for TGE and 1.03 (0.94 to 1.11; Ptrend = 0.25) for TFE. TFE from fruits and vegetables was not associated with CHD risk (Ptrend = 0.70), but TFE from added sugar and juice was associated with CHD risk (HR: 1.12, 95% CI: 1.04 to 1.20; Ptrend < 0.01). Intakes of total sugars and added sugar were positively associated with CHD risk (HRs: 1.16, 95% CI: 1.07 to 1.26, Ptrend < 0.001; 1.08, 95% CI: 0.99 to 1.16, Ptrend = 0.04).

CONCLUSIONS

Intakes of TGE, total sugar, added sugar, and fructose from added sugar and juice were associated with higher CHD risk, but TFE and fructose from fruits and vegetables were not.

Sweetened beverages and incident heart failure

AIMS

Recent studies have demonstrated the associations of the consumption of different beverages with cardiometabolic diseases, whereas no studies have investigated such associations in heart failure (HF). Thus, this study aimed to explore the associations of the consumption of sugar-sweetened beverages (SSBs), artificially sweetened beverages (ASBs), and pure fruit/vegetable juices (PJs) with the risk of incident HF.

METHODS AND RESULTS

This prospective cohort study included 209 829 participants in the UK Biobank who completed at least one 24-h diet questionnaire and who were free of baseline HF. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs). During a median follow-up of 9.9 years, 4328 incident HF cases were recorded. Compared to corresponding non-consumers, individuals who consumed >2 L/week SSBs or ASBs had an increased risk of HF (HR: 1.22, 95% CI: 1.08-1.38 and HR: 1.30, 95% CI: 1.16-1.47, respectively) in the multivariate adjusted model. An inverse association was observed between the consumption of >0-1 L/week PJs and the risk of HF (HR, 0.90; 95% CI, 0.83-0.98). Additionally, a significant interaction was observed between PJ consumption and sleep duration on HF risk (P for interaction = 0.030).

CONCLUSIONS

Increased consumption of SSBs or ASBs may be an independent risk factor for HF, whereas moderate intake of PJs may have a protective effect on HF.

Fructose-containing food sources and blood pressure: A systematic review and meta-analysis of controlled feeding trials

Whether food source or energy mediates the effect of fructose-containing sugars on blood pressure (BP) is unclear. We conducted a systematic review and meta-analysis of the effect of different food sources of fructose-containing sugars at different levels of energy control on BP. We searched MEDLINE, Embase and the Cochrane Library through June 2021 for controlled trials ≥7-days. We prespecified 4 trial designs: substitution (energy matched substitution of sugars); addition (excess energy from sugars added); subtraction (excess energy from sugars subtracted); and ad libitum (energy from sugars freely replaced). Outcomes were systolic and diastolic BP. Independent reviewers extracted data. GRADE assessed the certainty of evidence. We included 93 reports (147 trial comparisons, N = 5,213) assessing 12 different food sources across 4 energy control levels in adults with and without hypertension or at risk for hypertension. Total fructose-containing sugars had no effect in substitution, subtraction, or ad libitum trials but decreased systolic and diastolic BP in addition trials (P<0.05). There was evidence of interaction/influence by food source: fruit and 100% fruit juice decreased and mixed sources (with sugar-sweetened beverages [SSBs]) increased BP in addition trials and the removal of SSBs (linear dose response gradient) and mixed sources (with SSBs) decreased BP in subtraction trials. The certainty of evidence was generally moderate. Food source and energy control appear to mediate the effect of fructose-containing sugars on BP. The evidence provides a good indication that fruit and 100% fruit juice at low doses (up to or less than the public health threshold of ~10% E) lead to small, but important reductions in BP, while the addition of excess energy of mixed sources (with SSBs) at high doses (up to 23%) leads to moderate increases and their removal or the removal of SSBs alone (up to ~20% E) leads to small, but important decreases in BP in adults with and without hypertension or at risk for hypertension. Trial registration: Clinicaltrials.gov: NCT02716870.

Urinary Sucrose and Fructose From Spot Urine May Be Used as a Predictive Biomarker of Total Sugar Intake-Findings From a Controlled Feeding Study

BACKGROUND

Recently, we confirmed 24-h urinary sucrose plus fructose (24 uSF) as a predictive biomarker of total sugar intake. However, the collection of 24-h urine samples has limited feasibility in population studies.

OBJECTIVE

We investigated the utility of the urinary sucrose plus fructose (uSF) biomarker measured in spot urine as a measure of 24 uSF biomarker and total sugar intake.

METHODS

Hundred participants, 18-70 y of age, from the Phoenix Metropolitan Area completed a 15-d feeding study. For 2 of the 8 collected 24-h urine samples, each spot urine sample was collected in a separate container. We considered 4 timed voids of the day [morning (AM) void: first void 08:30-12:30; afternoon (PM) void: first void 12:31-17:30; evening (EVE) void: first void 17:31-12:00; and next-day (ND) void: first void 04:00-12:00]. We investigated the performance of uSF from 1 void, and uSF combined from 2 and 3 voids as a measure of 24 uSF and sugar intake.

RESULTS

The biomarker averaged from PM/EVE void strongly correlated with 24 uSF (partial r = 0.75). The 24 uSF predicted from the PM/EVE combination was significantly associated with observed sugar intake and was selected for building the calibrated biomarker equation (marginal R2 = 0.36). Spot urine-based calibrated biomarker, ie, biomarker-estimated sugar intake was moderately correlated with the 15-d mean-observed sugar intake (r = 0.50).

CONCLUSIONS

uSF measured from a PM and EVE void may be used to generate biomarker-based sugar intake estimate when collecting 24-h urine samples is not feasible, pending external validation.

Evidence-based European recommendations for the dietary management of diabetes

Diabetes management relies on effective evidence-based advice that informs and empowers individuals to manage their health. Alongside other cornerstones of diabetes management, dietary advice has the potential to improve glycaemic levels, reduce risk of diabetes complications and improve health-related quality of life. We have updated the 2004 recommendations for the nutritional management of diabetes to provide health professionals with evidence-based guidelines to inform discussions with patients on diabetes management, including type 2 diabetes prevention and remission. To provide this update we commissioned new systematic reviews and meta-analyses on key topics, and drew on the broader evidence available. We have strengthened and expanded on the previous recommendations to include advice relating to dietary patterns, environmental sustainability, food processing, patient support and remission of type 2 diabetes. We have used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to determine the certainty of evidence for each recommendation based on findings from the commissioned and identified systematic reviews. Our findings indicate that a range of foods and dietary patterns are suitable for diabetes management, with key recommendations for people with diabetes being largely similar for those for the general population. Important messages are to consume minimally processed plant foods, such as whole grains, vegetables, whole fruit, legumes, nuts, seeds and non-hydrogenated non-tropical vegetable oils, while minimising the consumption of red and processed meats, sodium, sugar-sweetened beverages and refined grains. The updated recommendations reflect the current evidence base and, if adhered to, will improve patient outcomes.

Dietary sugar consumption and health: umbrella review

OBJECTIVE

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

DESIGN

Umbrella review of existing meta-analyses.

DATA SOURCES

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

INCLUSION CRITERIA

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022300982.

Determination of the level of evidence for the association between different food groups/items and dietary fiber intake and the risk of cardiovascular diseases and hypertension: An umbrella review

Evidence has suggested that nutrition is a preventive factor against cardiovascular disease (CVD) risk. Because of a sharp growth in published meta-analyses and pooled analyses in recent years, a reassessment of old evidence is needed. We aimed to determine the level of evidence for the association between the consumption of different food groups/items and dietary fiber and the incidence risk of CVDs, hypertension, and atrial fibrillation from meta-analyses and pooled analyses of observational studies. Databases Scopus, PubMed/Medline, and Web of Science were searched for related studies. Fifty-eight articles met the inclusion criteria for evidence grading. In summary, grading the level of evidence showed a suggestive inverse association between the higher consumption of fruits, whole grains, fish, legumes, nuts, and dietary fibers with the incidence risk of hypertension and different types of CVD. Also, there was a probable inverse association between the higher consumption of total and low-fat dairy products and the risk of hypertension. Higher red meat consumption had a probable association with the increased risk of ischemic stroke. Higher consumption of processed meat and poultry also had a suggestive direct association with the incidence risk of stroke and hypertension. We have tried to present a comprehensive and useful overview of the level of evidence based on the most updated findings. The summary of results in the current umbrella review can be a helpful tool for nutritionists, dietitians, and researchers to establish new studies and identify research gaps in related issues.

Effect of Important Food Sources of Fructose-Containing Sugars on Inflammatory Biomarkers: A Systematic Review and Meta-Analysis of Controlled Feeding Trials

Background: Fructose-containing sugars as sugar-sweetened beverages (SSBs) may increase inflammatory biomarkers. Whether this effect is mediated by the food matrix at different levels of energy is unknown. To investigate the role of food source and energy, we conducted a systematic review and meta-analysis of controlled trials on the effect of different food sources of fructose-containing sugars on inflammatory markers at different levels of energy control. Methods: MEDLINE, Embase, and the Cochrane Library were searched through March 2022 for controlled feeding trials ≥ 7 days. Four trial designs were prespecified by energy control: substitution (energy matched replacement of sugars); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced). The primary outcome was C-reactive protein (CRP). Secondary outcomes were tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). Independent reviewers extracted data and assessed risk of bias. GRADE assessed certainty of evidence. Results: We identified 64 controlled trials (91 trial comparisons, n = 4094) assessing 12 food sources (SSB; sweetened dairy; sweetened dairy alternative [soy]; 100% fruit juice; fruit; dried fruit; mixed fruit forms; sweetened cereal grains and bars; sweets and desserts; added nutritive [caloric] sweetener; mixed sources [with SSBs]; and mixed sources [without SSBs]) at 4 levels of energy control over a median 6-weeks in predominantly healthy mixed weight or overweight/obese adults. Total fructose-containing sugars decreased CRP in addition trials and had no effect in substitution, subtraction or ad libitum trials. No effect was observed on other outcomes at any level of energy control. There was evidence of interaction/influence by food source: substitution trials (sweetened dairy alternative (soy) and 100% fruit juice decreased, and mixed sources (with SSBs) increased CRP); and addition trials (fruit decreased CRP and TNF-α; sweets and desserts (dark chocolate) decreased IL-6). The certainty of evidence was moderate-to-low for the majority of analyses. Conclusions: Food source appears to mediate the effect of fructose-containing sugars on inflammatory markers over the short-to-medium term. The evidence provides good indication that mixed sources that contain SSBs increase CRP, while most other food sources have no effect with some sources (fruit, 100% fruit juice, sweetened soy beverage or dark chocolate) showing decreases, which may be dependent on energy control. Clinicaltrials.gov: (NCT02716870).

Associations between consumption of three types of beverages and risk of cardiometabolic multimorbidity in UK Biobank participants: a prospective cohort study

BACKGROUND

Although the association between beverages and a single cardiometabolic disease has been well studied, their role in disease progression from the single cardiometabolic disease state to cardiometabolic multimorbidity (CMM) state remains unclear. This study examined the associations between three types of beverages: sugar-sweetened beverages (SSBs), artificially sweetened beverages (ASBs), and pure fruit/vegetable juices, and the incidence of CMM in patients with a single cardiometabolic disease.

METHODS

Our analysis included 37,994 participants from the UK Biobank who completed at least one dietary questionnaire and were diagnosed with only one cardiometabolic disease at the time of recruitment. Competing risk models were used to examine the association between the three types of beverages and incidence of CMM. We conducted analysis both in patients with any single cardiometabolic disease and in patients with specific cardiometabolic disease.

RESULTS

During a median follow-up of 9.1 years (interquartile range [IQR] 9.0-9.8), a total of 6399 participants developed CMM. The consumption of SSBs and ASBs (>1 serving per day) was associated with a higher risk of CMM (SSBs: hazard ratio [HR] 1.19, 95% confidence interval [95% CI] 1.08-1.31; ASBs: HR 1.15, 95% CI 1.04-1.27). Intake of pure fruit/vegetable juices was inversely associated with the incidence of CMM (0-1 serving per day: HR 0.90, 95% CI 0.85-0.94; >1 serving per day: HR 0.90, 95% CI 0.81-0.99). However, the association of the high-level consumption of pure fruit/vegetable juices (>1 serving per day) was not statistically significant after correcting for multiple testing. In the analysis of patients with specific cardiometabolic diseases, positive associations were observed in patients with hypertension for SSBs consumption, while inverse associations persisted in patients with cardiovascular disease (coronary heart disease or stroke) and in hypertensive patients for pure fruit/vegetable juice consumption.

CONCLUSIONS

Consuming >1 serving of SSBs and ASBs per day was associated with a higher risk of CMM in patients with a single cardiometabolic disease. In contrast, intake of pure fruit/vegetable juices was inversely associated with the risk of CMM. Our findings highlight the need to limit the use of SSBs and ASBs in patients with a single cardiometabolic disease.

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.

Intakes of nutrients and food categories in Canadian children and adolescents across levels of sugars intake: cross-sectional analyses of the Canadian Community Health Survey 2015 Public Use Microdata File

Dietary recommendations to reduce sugars consumption may influence choices of sugars-containing foods and affect the intake of key micronutrients. We compared intakes of nutrients and food sources stratified by quintiles of total sugars in Canadian children (2-8 y) and adolescents (9-13 y, 14-18 y) using 24-hour dietary recalls from the 2015 Canadian Community Health Survey-Nutrition. Energy intakes did not differ across quintiles of sugars intake. Those with lower sugars intakes (Q1/Q3) generally had higher protein, fat, sodium, niacin, folate, and zinc and lower vitamin C compared with those with the highest sugars intakes (Q5). Q1 also had lower potassium but higher saturated fat compared with Q5. Further, Q1 generally had higher protein, fats, and niacin compared with Q3, while children in Q3 had higher potassium and riboflavin and older adolescents had higher calcium and fibre. Q5 had highest intakes of multiple sugar-containing food categories (e.g., fruit, confectionary, milks, cakes/pies/pastries), with higher sugars-sweetened beverages in adolescents. Q3 had higher fruit, milks, and fruit juice compared with Q1 and lower sugars/syrups/preserves, confectionary, and fruit juices compared with Q5. Certain nutrient-dense food sources of sugars (fruit, milks) may help increase key nutrients (potassium, calcium, fibre) in older adolescents with low sugars intakes. However, in those with the highest sugars intakes, nutrient-poor foods may displace nutrient-dense foods. Novelty: Canadian children and adolescents with lower sugars intake have better intakes of some nutrients. Energy intakes did not differ across sugars intake. Older adolescents with mean intakes of total sugars had better intakes of some key nutrients (potassium, calcium, fibre).

[¿Cómo tratar la hipertensión arterial sistémica? Estrategias de tratamiento actuales]

Hypertension is a disease that affects almost half of the population. Its complex pathophysiology, mainly affecting the renal, hormonal, cardiovascular and neurological systems, has allowed us to have different pharmacological strategies to treat each of these systems and thus regulate blood pressure. The American Heart Association in 2017, the European Society of Cardiology in 2018, and the American Society of Hypertension in 2020 published their recommendations for the diagnosis, monitoring and treatment of arterial hypertension. The definition of normal blood pressure or hypertension varies according to each guideline. Recommendations on lifestyle and pharmacological therapy are very similar in the guidelines. They recommend blockers of the renin-angiotensin system, calcium antagonists and thiazides, and only in selected cases the use of mineralocorticoid receptor antagonist or beta-blockers.

Fruit Intake to Prevent and Control Hypertension and Diabetes

Fruits are considered healthy because of their high antioxidant, vitamin, mineral, fiber, and phytochemical contents. However, their high sugar content is a concern for glucose, lipid, and uric acid metabolism. We reviewed related articles published in the last 10 years and summarized evidence that relates fruit intake to the prevention and control of hypertension and diabetes mellitus. Clinicians should familiarize themselves with appropriate fruit intake to counsel at-risk patients on hypertension and diabetes.

Fructose and high fructose corn syrup: are they a two-edged sword?

High-fructose syrups are used as sugar substitutes due to their physical and functional properties. High fructose corn syrup (HFCS) is used in bakery products, dairy products, breakfast cereals and beverages, but it has been reported that there might be a direct relationship between high fructose intake and adverse health effects such as obesity and the metabolic syndrome. Thus, fructose has recently received much attention, most of which was negative. Although studies have indicated that there might be a correlation between high fructose-rich diet and several adverse effects, however, the results of these studies cannot be certainly generalised to the effects of HFCS; because they have investigated pure fructose at very high concentrations in measurement of metabolic upsets. This review critically considered the advantages and possible disadvantages of HFCS application and consumption in food industry, as a current challenging issue between nutritionists and food technologists.

Takeaway food, sugar-sweetened beverages and preclinical cardiometabolic phenotypes in children and adults

AIMS

To investigate relationships between takeaway food and sugar-sweetened beverage (SSB) consumption with cardiometabolic phenotypes during childhood and mid-adulthood.

METHOD

Design: Cross-sectional Child Health CheckPoint within the national population-representative Longitudinal Study of Australian Children. Participants: 1838 children (mean age 11.5 years; 49.1% female) and 1846 adults (mean age 43.7 years; 87.6% female). Exposures: Self-reported takeaway food and SSB consumption ('frequent': ≥ weekly). Outcomes: Functional (pulse wave velocity (PWV), blood pressure (BP)) and structural (carotid intima-media thickness, retinal microvascular calibre) preclinical cardiovascular phenotypes; lipids (total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides). Analysis: Linear regression (exposure: takeaway or SSB consumption, individually or together) adjusted for age, sex and socio-economic position; and mediation analysis for body mass index (BMI).

RESULTS

Associations were small among children (standardized mean difference (SMD) ≤0.15). In adults, associations were stronger with functional, but not structural, cardiovascular phenotypes and lipids, particularly for frequent takeaway food consumption (e.g. PWV (0.20 m/s; 95% confidence interval (CI) 0.03 to 0.37); systolic (3.3 mmHg; 95% CI 1.3 to 5.3) and diastolic BP (1.4 mmHg; 95% CI 0.2 to 2.6); LDL (0.10 mmol/L; 95% CI 0.02 to 0.18); HDL (-0.14 mmol/L; 95% CI -0.19 to -0.10) and triglycerides (0.30 mmol/L; 95% CI 0.12 to 0.48)]. BMI mediated associations between takeaway food consumption and PWV, BP, HDL and TG (proportion of mediation 34% to 75%), while mediation effects were smaller for SSB consumption.

CONCLUSIONS

Frequent takeaway food consumption in adults was associated with adverse blood lipids and vascular function (mainly via BMI). Lack of strong associations in children highlights opportunities for prevention.

Cross-sectional analysis of the health profile and dietary intake of a sample of Canadian adults diagnosed with non-alcoholic fatty liver disease

Background

Dietary intake is an important factor in the development and management of non-alcoholic fatty liver disease (NAFLD); however, optimal dietary composition remains unclear. Moreover, there is minimal evidence on the relationship between dietary intake and markers of liver health in Canadian adults diagnosed with NAFLD.

Objective

The aim of this study is to characterize the dietary intake of a sample of Canadian adults diagnosed with NAFLD and examine the correlations with markers of liver health.

Design

Forty-two adults recruited from the community and hepatology clinics in Calgary, Canada from 2016 to 2019 completed a 3-day food record. Anthropometrics, blood biomarkers, liver stiffness (FibroScan), and liver fat (magnetic resonance imaging) were measured. Nutrient intake was compared with the data from the 2004 and 2015 Canadian Community Health Surveys. Relationships were assessed using Pearson’s correlation and regression analysis.

Results

Relative to Canadian dietary recommendations, participants consumed lower magnesium, fiber, calcium, vitamin D, and vitamin E, and higher cholesterol, saturated fat, total fat, fructose, iron, vitamin B12, selenium, phosphorus, and sodium. Compared with the national average, participants consumed more energy, fiber, sodium, total fat, and saturated fat. Systolic blood pressure (P = 0.012), serum α-2 macroglobulin (P = 0.008), carbohydrate (P = 0.022), total fat (P = 0.029), and saturated fat intakes (P = 0.029) were associated with FibroScan scores. Liver fat was correlated with serum triglycerides (P < 0.001), trunk fat (P = 0.029), added sugar (P = 0.042), phosphorus (P = 0.017), and magnesium intake (P = 0.013). In females, selenium intake was associated with liver fat (P = 0.015) and FibroScan score (P = 0.05), while in males, liver fat was associated with trunk fat (P = 0.004), body weight (P = 0.004), high-density lipoprotein (P < 0.001), and fructose intake (P = 0.037). Regression analysis showed that increasing magnesium intake corresponds to a decrease in liver fat.

Conclusion

Despite the higher energy intake of participants, overall nutrient intake is low, suggesting lower diet quality. Associations between select micronutrients and liver health markers warrant further investigation.

Uric Acid and Hypertension: An Update With Recommendations

The association between increased serum urate and hypertension has been a subject of intense controversy. Extracellular uric acid drives uric acid deposition in gout, kidney stones, and possibly vascular calcification. Mendelian randomization studies, however, indicate that serum urate is likely not the causal factor in hypertension although it does increase the risk for sudden cardiac death and diabetic vascular disease. Nevertheless, experimental evidence strongly suggests that an increase in intracellular urate is a key factor in the pathogenesis of primary hypertension. Pilot clinical trials show beneficial effect of lowering serum urate in hyperuricemic individuals who are young, hypertensive, and have preserved kidney function. Some evidence suggest that activation of the renin-angiotensin system (RAS) occurs in hyperuricemia and blocking the RAS may mimic the effects of xanthine oxidase inhibitors. A reduction in intracellular urate may be achieved by lowering serum urate concentration or by suppressing intracellular urate production with dietary measures that include reducing sugar, fructose, and salt intake. We suggest that these elements in the western diet may play a major role in the pathogenesis of primary hypertension. Studies are necessary to better define the interrelation between uric acid concentrations inside and outside the cell. In addition, large-scale clinical trials are needed to determine if extracellular and intracellular urate reduction can provide benefit hypertension and cardiometabolic disease.

Canadian Adults with Moderate Intakes of Total Sugars have Greater Intakes of Fibre and Key Micronutrients: Results from the Canadian Community Health Survey 2015 Public Use Microdata File

Background: Global dietary guidelines recommend reducing free sugars intake, which may affect choices of sugars-containing foods, including important sources of key micronutrients. The purpose of the study was to compare the intakes of nutrients stratified by intakes of sugars in Canadian adults. Methods: The first-day 24-h dietary recalls from adults (n = 11,817) in the 2015 Canadian Community Health Survey-Nutrition were used to compare macronutrients, micronutrients and food categories across quintiles of total sugars [by %energy (%E)], adjusted for misreporting status and covariates. Results: Canadian adults consumed on average 86.9 g/day (18.8 %E) from total sugars and 47.5 g/day (9.9 %E) from free sugars. Mean intakes for the 1st (Q1), 3rd (Q3) and 5th (Q5) quintiles of total sugars were 7.9%E, 18.3%E and 33.3%E, respectively. Q3 had higher fibre, calcium, vitamin D, vitamin A, vitamin C and potassium intakes than Q1 (p < 0.001), reflecting higher fruit, milk and yogurt (p < 0.001) consumption. Compared to Q5, Q3 had higher intakes of folate, vitamin B₁₂, iron and zinc. Conclusion: This study provides the first detailed analyses of Canadian adults’ macro- and micro-nutrient intakes stratified by different intakes of total sugars. Moderate intakes of total sugars may result in greater intakes of fibre and micronutrients. Overall nutrient intake should be considered when making food choices.

Important Food Sources of Fructose-Containing Sugars and Incident Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Background Sugar-sweetened beverages are associated with hypertension. We assessed the relation of important food sources of fructose-containing sugars with incident hypertension using a systematic review and meta-analysis of prospective cohort studies. Methods and Results We searched MEDLINE, EMBASE, and Cochrane (through December week 2, 2018) for eligible studies. For each food source, natural log-transformed risk ratios (RRs) for incident hypertension were pooled using pair-wise meta-analysis and linear and nonlinear dose-response meta-analyses. Certainty in our evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. We identified 26 reports, including 15 prospective cohorts (930 677 participants; 363 459 cases). Sugar-sweetened beverages showed harmful (RRper-355-mL, 1.10 [95% CI, 1.08, 1.12]) whereas fruit (RRper-240-g, 0.94 [95% CI, 0.96, 0.99]) and yogurt showed protective associations (RRper-125-g, 0.95 [95% CI, 0.94, 0.97]) with incident hypertension throughout the dose range. One hundred percent fruit juice showed a protective association only at moderate doses (RRat-100-mL, 0.97 [95% CI, 0.94, 0.99]). The pair-wise protective association of dairy desserts was not supported by linear dose-response analysis. Fruit drinks or sweet snacks were not associated with hypertension. Certainty of the evidence was "low" for sugar-sweetened beverages, 100% fruit juice, fruit, and yogurt and "very low" for fruit drinks, sweet snacks, and dairy desserts. Conclusions The harmful association between sugar-sweetened beverages and hypertension does not extend to other important food sources of fructose-containing sugars. Further research is needed to improve our estimates and better understand the dose-response relationship between food sources of fructose-containing sugars and hypertension. Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02702375.