A trial of sugar-free or sugar-sweetened beverages and body weight in children

Clinical Intervention to Reduce Dietary Sugar Does Not Affect Liver Fat in Latino Youth, Regardless of PNPLA3 Genotype: A Randomized Controlled Trial

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) among Latinos is partially attributed to a prevalent C>G polymorphism in the patatin-like phospholipase 3 (PNPLA3) gene. Cross-sectional analyses in Latino children showed the association between dietary sugar and liver fat was exacerbated by GG genotype. Pediatric feeding studies show extreme sugar restriction improves liver fat, but no prior trial has examined the impact of a clinical intervention or whether effects differ by PNPLA3 genotype.

OBJECTIVES

We aimed to test effects of a clinical intervention to reduce dietary sugar compared with standard dietary advice on change in liver fat, and secondary-endpoint changes in liver fibrosis, liver enzymes, and anthropometrics; and whether effects differ by PNPLA3 genotype (assessed retrospectively) in Latino youth with obesity (BMI ≥ 95th percentile).

METHODS

This parallel-design trial randomly assigned participants (n = 105; mean baseline liver fat: 12.7%; mean age: 14.8 y) to control or sugar reduction (goal of ≤10% of calories from free sugar) for 12 wk. Intervention participants met with a dietitian monthly and received delivery of bottled water. Changes in liver fat, by MRI, were assessed by intervention group via general linear models.

RESULTS

Mean free sugar intake decreased in intervention compared with control [11.5% to 7.3% compared with 13.9% to 10.7% (% energy), respectively; P = 0.02], but there were no significant effects on liver outcomes or anthropometrics (Pall > 0.10), and no PNPLA3 interactions (Pall > 0.10). In exploratory analyses, participants with whole-body fat mass (FM) reduction (mean ± SD: -1.9 ± 2.4 kg), irrespective of randomization, had significant reductions in liver fat compared with participants without FM reduction (median: -2.1%; IQR: -6.5% to -0.8% compared with 0.3%; IQR: -1.0% to 1.1%; P < 0.001).

CONCLUSIONS

In Latino youth with obesity, a dietitian-led sugar reduction intervention did not improve liver outcomes compared with control, regardless of PNPLA3 genotype. Results suggest FM reduction is important for liver fat reduction, confirming clinical recommendations of weight loss and a healthy diet for pediatric NAFLD.This trial was registered at clinicaltrials.gov as NCT02948647.

Association of sweetened carbonated beverage consumption during pregnancy and ADHD symptoms in the offspring: a study from the Norwegian Mother, Father and Child Cohort Study (MoBa)

PURPOSE

Intrauterine exposures influence offspring health and development. Here we investigated maternal intake of sweetened carbonated beverages (SCB) during pregnancy and its association with ADHD symptoms in the offspring.

METHODS

This study was based on the Norwegian Mother, Father and Child Cohort Study (MoBa) and the Medical Birth Registry of Norway. Maternal diet mid-pregnancy was assessed using a food frequency questionnaire (FFQ). All mothers who responded to the FFQ and a questionnaire when their child was 8 years of age were included (n = 39,870). The exposure was defined as maternal intake (daily servings) of SCB, using no daily intake as reference. Outcome was offspring ADHD symptoms, evaluated as a continuous standardized ADHD score and as a binary outcome of six or more ADHD symptoms vs. five symptoms or less. Associations were analysed using log-binomial regression and linear mixed regression models with adjustment for covariates.

RESULTS

The adjusted regression coefficients for the standardized ADHD offspring symptom score were 0.31 [95% confidence intervals (0.001, 0.62)] and 0.46 (0.15, 0.77) for maternal daily intake of ≥ 1 glasses of SCB, when the models included adjustments for total energy intake or energy intake from other sources than SCBs and sweet drinks, respectively. The corresponding adjusted relative risks were 1.16 (1.004, 1.34) and 1.21. (1.05, 1.39) for drinking ≥ 1 glasses daily.

CONCLUSION

In a large pregnancy cohort with offspring followed until 8 years of age, we found an association between maternal daily intake of SCB and offspring ADHD symptoms. These results suggest a weak positive relationship between prenatal exposure to SCB and offspring ADHD.

Current Hydration Habits: The Disregarded Factor for the Development of Renal and Cardiometabolic Diseases

Improper hydration habits are commonly disregarded as a risk factor for the development of chronic diseases. Consuming an intake of water below recommendations (underhydration) in addition to the substitution of sugar-sweetened beverages (SSB) for water are habits deeply ingrained in several countries. This behavior is due to voluntary and involuntary dehydration; and because young children are exposed to SSB, the preference for a sweet taste is profoundly implanted in the brain. Underhydration and SSB intake lead to mild hyperosmolarity, which stimulates biologic processes, such as the stimulation of vasopressin and the polyol-fructose pathway, which restore osmolarity to normal but at the expense of the continued activation of these biological systems. Unfortunately, chronic activation of the vasopressin and polyol-fructose pathways has been shown to mediate many diseases, such as obesity, diabetes, metabolic syndrome, chronic kidney disease, and cardiovascular disease. It is therefore urgent that we encourage educational and promotional campaigns that promote the evaluation of personal hydration status, a greater intake of potable water, and a reduction or complete halting of the drinking of SSB.

Food and nutrient intake of school-aged children in Lebanon and their adherence to dietary guidelines and recommendations

BACKGROUND

Lebanon, an Eastern Mediterranean country, is witnessing a remarkable nutrition transition, and the diets of school-aged children may be amongst those most affected. However, limited studies have examined the food consumption patterns and nutrient adequacy in this age group.

OBJECTIVES

The present study aimed to evaluate the dietary intakes of school-aged children in Lebanon and assess their adherence to nutrition guidelines and recommendations.

METHODS

This study used data for 4-13 y-old children (n = 711) from a national cross-sectional survey conducted in 2014-2015 on a representative sample of Lebanese households with children. Dietary intake was assessed using single 24-h recall method. Estimated food group and nutrient intakes were compared to dietary recommendations and age-specific dietary reference intakes (DRI), including Estimated Average Requirements (EAR) and Acceptable Macronutrient Distribution Range (AMDR). Food group, energy, macro- and micro-nutrient intakes were presented for all children in the sample and stratified by age (4-8 y and 9-13 y) and sex.

RESULTS

Mean energy intake of 4-13-year-old children was 1804 kcal/d. Almost half of the energy was provided by carbohydrates while 12% of children had protein intakes below EAR. Approximately three-quarters of children (4-13 y) exceeded the AMDR for total fat and saturated fats, and a similar proportion over consumed added sugars. The main sources of energy intake (EI) among children were the sweets, sweetened beverages and desserts followed by grains and mixed dishes. No significant differences were noted in %EI from different food groups, by sex, in either age groups. The highest adherence of children to food group recommendations was observed for the grains' food group (47.2-54.4%EI), while the lowest adherence was found for vegetables (3.1-14.1%EI). A high prevalence of vitamin and mineral inadequacies was noted amongst 4-13 y old children for key micronutrients, including vitamin D (99%), calcium (81%), and vitamin A (69.5%). Risk of inadequate micronutrient intakes was significantly increased among the older age group (p-value < 0.05).

CONCLUSION

Nutrient intakes of school-aged children in Lebanon reflect suboptimal nutrition. Educational and public health interventions are needed to promote healthier diets among children and prevent micronutrient deficiencies during this critical phase.

Fructose Intake, Hypertension and Cardiometabolic Risk Factors in Children and Adolescents: From Pathophysiology to Clinical Aspects. A Narrative Review

Arterial hypertension, dyslipidemia, alterations in glucose metabolism and fatty liver, either alone or in association, are frequently observed in obese children and may seriously jeopardize their health. For obesity to develop, an excessive intake of energy-bearing macronutrients is required; however, ample evidence suggests that fructose may promote the development of obesity and/or metabolic alterations, independently of its energy intake. Fructose consumption is particularly high among children, because they do not have the perception, and more importantly, neither do their parents, that high fructose intake is potentially dangerous. In fact, while this sugar is erroneously viewed favorably as a natural nutrient, its excessive intake can actually cause adverse cardio-metabolic alterations. Fructose induces the release of pro-inflammatory cytokines, and reduces the production of anti-atherosclerotic cytokines, such as adiponectin. Furthermore, by interacting with hunger and satiety control systems, particularly by inducing leptin resistance, it leads to increased caloric intake. Fructose, directly or through its metabolites, promotes the development of obesity, arterial hypertension, dyslipidemia, glucose intolerance and fatty liver. This review aims to highlight the mechanisms by which the early and excessive consumption of fructose may contribute to the development of a variety of cardiometabolic risk factors in children, thus representing a potential danger to their health. It will also describe the main clinical trials performed in children and adolescents that have evaluated the clinical effects of excessive intake of fructose-containing drinks and food, with particular attention to the effects on blood pressure. Finally, we will discuss the effectiveness of measures that can be taken to reduce the intake of this sugar.

Home Delivery of Water for Caries Prevention in Latinx Children (“Sediento por una Sonrisa,” Thirsty for a Smile): Protocol for a Single-Arm Feasibility Study

Background

Dental caries has significant public health implications afflicting young children. In addition to low social economic status, the most prominent risk factor for early childhood caries is sugar in the diet, particularly sugar-sweetened beverages. Dental treatment for caries in young children is commonly performed under general anesthesia and a significant proportion of children require repeated treatment. Interventions to reduce sugar-sweetened beverage consumption could lead to reduced rates of retreatment for dental caries in young children.

Objective

This protocol describes the rationale, design, and methods of the “Thirsty for a Smile” feasibility study. The aim of the study is to assess the feasibility, acceptability, and appropriateness of a dietary intervention promoting water consumption in lieu of sugar-sweetened beverages among young patients, mostly from Latino heritage.

Methods

This protocol describes a single-arm feasibility study. Twenty-one dyads of children and their caregivers will be recruited. Children between 2 and 9 years old who recently had treatment under general anesthesia for early childhood dental caries will be eligible to participate. The intervention has two components: (1) environmental, in which bottled water is delivered to participants’ homes; and (2) behavioral, in which caregivers will receive patient-centered counseling to increase children’s water intake and reduce sugar-sweetened beverages consumption. Dental caries and anthropometric data will be collected at examination during baseline and final visits. The primary outcome is feasibility and secondary outcomes are acceptability and appropriateness of the intervention.

Results

Funding has been obtained from the National Institute of Dental and Craniofacial Research and the University of Washington approved the study. The feasibility study was conducted from March to November 2019.

Conclusions

This feasibility study will test the study processes prior to a two-arm randomized controlled trial to determine feasibility and acceptability of the intervention and study procedures. This study may provide useful information for other researchers attempting to test similar interventions.

International Registered Report Identifier (IRRID)

RR1-10.2196/37200

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.

Water Wins, Communication Matters: School-Based Intervention to Reduce Intake of Sugar-Sweetened Beverages and Increase Intake of Water

We compared three interventions designed for reducing the consumption of sugar-sweetened beverages (SSBs) aimed at decreasing the risk of overweight and obesity among children. We included three experimental (n = 508) and one control school (n = 164) in Slovenia (672 children; 10–16 years) to evaluate interventions that influence behaviour change via environmental (E), communication (C), or combined (i.e., double) environmental and communication approaches (EC) compared to no intervention (NOI). Data of children from the ‘intervention’ and ‘non-intervention’ schools were compared before and after the interventions. The quantity of water consumed (average, mL/day) by children increased in the C and EC schools, while it decreased in the E and NOI schools. Children in the C and EC schools consumed less beverages with sugar (SSBs + fruit juices), and sweet beverages (beverages with: sugar, low-calorie and/or noncaloric sweeteners) but consumed more juices. The awareness about the health risks of SSB consumption improved among children of the ‘combined intervention’ EC school and was significantly different from the awareness among children of other schools (p = 0.03). A communication intervention in the school environment has more potential to reduce the intake of SSBs than a sole environmental intervention, but optimum results can be obtained when combined with environmental changes.

The Effect of Artificial Sweeteners Use on Sweet Taste Perception and Weight Loss Efficacy: A Review

Excessive consumption of sugar-rich foods is currently one of the most important factors that has led to the development of the global pandemic of obesity. On the other hand, there is evidence that obesity contributes to reduced sensitivity to sweet taste and hormonal changes affecting appetite, leading to an increased craving for sweets. A high intake of sugars increases the caloric value of the diet and, consequently, leads to weight gain. Moreover, attention is drawn to the concept of the addictive properties of sugar and sugary foods. A potential method to reduce the energy value of diet while maintaining the sweet taste is using non-nutritive sweeteners (NNS). NNS are commonly used as table sugar substitutes. This wide group of chemical compounds features high sweetness almost without calories due to its high sweetening strength. NNS include aspartame, acesulfame-K, sucralose, saccharin, cyclamate, neohesperidin dihydrochalcone (neohesperidin DC), neotame, taumatin, and advantame. The available evidence suggests that replacing sugar with NNS may support weight control. However, the effect of NNS on the regulation of appetite and sweet taste perception is not clear. Therefore, the review aimed to summarize the current knowledge about the use of NNS as a potential strategy for weight loss and their impact on sweet taste perception. Most studies have demonstrated that consumption of NNS-sweetened foods does not increase sweetness preference orenergy intake. Nonetheless, further research is required to determine the long-term effects of NNS on weight management.

Association of Low- and No-Calorie Sweetened Beverages as a Replacement for Sugar-Sweetened Beverages With Body Weight and Cardiometabolic Risk: A Systematic Review and Meta-analysis

Importance

There are concerns that low- and no-calorie sweetened beverages (LNCSBs) do not have established benefits, with major dietary guidelines recommending the use of water and not LNCSBs to replace sugar-sweetened beverages (SSBs). Whether LNCSB as a substitute can yield similar improvements in cardiometabolic risk factors vs water in their intended substitution for SSBs is unclear.

Objective

To assess the association of LNCSBs (using 3 prespecified substitutions of LNCSBs for SSBs, water for SSBs, and LNCSBs for water) with body weight and cardiometabolic risk factors in adults with and without diabetes.

Data Sources

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception through December 26, 2021.

Study Selection

Randomized clinical trials (RCTs) with at least 2 weeks of interventions comparing LNCSBs, SSBs, and/or water were included.

Data Extraction and Synthesis

Data were extracted and risk of bias was assessed by 2 independent reviewers. A network meta-analysis was performed with data expressed as mean difference (MD) or standardized mean difference (SMD) with 95% CIs. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the certainty of the evidence.

Main Outcomes and Measures

The primary outcome was body weight. Secondary outcomes were other measures of adiposity, glycemic control, blood lipids, blood pressure, measures of nonalcoholic fatty liver disease, and uric acid.

Results

A total of 17 RCTs with 24 trial comparisons were included, involving 1733 adults (mean [SD] age, 33.1 [6.6] years; 1341 women [77.4%]) with overweight or obesity who were at risk for or had diabetes. Overall, LNCSBs were a substitute for SSBs in 12 RCTs (n = 601 participants), water was a substitute for SSBs in 3 RCTs (n = 429), and LNCSBs were a substitute for water in 9 RCTs (n = 974). Substitution of LNCSBs for SSBs was associated with reduced body weight (MD, -1.06 kg; 95% CI, -1.71 to -0.41 kg), body mass index (MD, -0.32; 95% CI, -0.58 to -0.07), percentage of body fat (MD, -0.60%; 95% CI, -1.03% to -0.18%), and intrahepatocellular lipid (SMD, -0.42; 95% CI, -0.70 to -0.14). Substituting water for SSBs was not associated with any outcome. There was also no association found between substituting LNCSBs for water with any outcome except glycated hemoglobin A1c (MD, 0.21%; 95% CI, 0.02% to 0.40%) and systolic blood pressure (MD, -2.63 mm Hg; 95% CI, -4.71 to -0.55 mm Hg). The certainty of the evidence was moderate (substitution of LNCSBs for SSBs) and low (substitutions of water for SSBs and LNCSBs for water) for body weight and was generally moderate for all other outcomes across all substitutions.

Conclusions and Relevance

This systematic review and meta-analysis found that using LNCSBs as an intended substitute for SSBs was associated with small improvements in body weight and cardiometabolic risk factors without evidence of harm and had a similar direction of benefit as water substitution. The evidence supports the use of LNCSBs as an alternative replacement strategy for SSBs over the moderate term in adults with overweight or obesity who are at risk for or have diabetes.

Childhood obesity: A review of current and future management options

Obesity is becoming increasingly prevalent in paediatric populations worldwide. In addition to increasing prevalence, the severity of obesity is also continuing to rise. Taken together, these findings demonstrate a worrying trend and highlight one of the most significant challenges to public health. Childhood obesity affects multiple organs in the body and is associated with both significant morbidity and ultimately premature mortality. The prevalence of complications associated with obesity, including dyslipidaemia, hypertension, fatty liver disease and psychosocial complications are becoming increasingly prevalent within the paediatric populations. Treatment guidelines currently focus on intervention with lifestyle and behavioural modifications, with pharmacotherapy and surgery reserved for patients who are refractory to such treatment. Research into adult obesity has established pharmacological novel therapies, which have been approved and established in clinical practice; however, the research and implementation of such therapies in paediatric populations have been lagging behind. Despite the relative lack of widespread research in comparison to the adult population, newer therapies are being trialled, which should allow a greater availability of treatment options for childhood obesity in the future. This review summarizes the current evidence for the management of obesity in terms of medical and surgical options. Both future therapeutic agents and those which cause weight loss but have an alternative indication are also included and discussed as part of the review. The review summarizes the most recent research for each intervention and demonstrates the potential efficacy and limitations of each treatment option.

Impact of Lifestyle Modifications on Alterations in Lipid and Glycemic Profiles and Uric Acid Values in a Pediatric Population

Cardiometabolic risk factors are frequent in children and adolescents with excess weight. The aim of this study was to evaluate the effects of lifestyle modifications on alterations in lipid and glycemic profiles and uric acid values in a pediatric population at increased cardiovascular risk. The study involved 276 subjects with a mean age of 10.6 (2.3) years. Body mass index (BMI) z-score and biochemical parameters (serum low-density lipoprotein (LDL) cholesterol, triglycerides and uric acid and homeostasis model assessment to quantify insulin resistance (HOMA index)) were assessed at baseline and at the end of a median follow-up of 14.7 (12.4, 19.3) months. Throughout follow-up, all children received a non-pharmacological treatment based on increased physical activity, reduced sedentary activity and administration of a personalized, healthy and balanced diet. All children attended periodic quarterly control visits during follow-up. Multivariable statistical analyses showed that each BMI z-score point reduction at follow-up was associated with an 8.9 (95% CI −14.2; −3.6) mg/dL decrease in LDL cholesterol (p = 0.001), 20.4 (95% CI −30.0; −10.7) mg/dL in triglycerides (p < 0.001), 1.6 (95% CI −2.2; −1.0) in HOMA index (p < 0.001), and 0.42 (95% CI −0.66; −0.18) mg/dL in uric acid (p = 0.001) values. At each reduction of the BMI z-score by one point, the odds of presenting with insulin resistance and hyperuricemia at follow-up significantly decreased (OR 0.23, 95% CI 0.10−0.50, and OR 0.32, 95% CI 0.10−0.95, p < 0.001 and p < 0.05, respectively). Improvement of dietary habits and lifestyles may improve lipid and glycemic profiles and serum uric acid values in a pediatric population.

Trending Nutrition Controversies #3: Top Controversies in 2021

Each year, patients are bombarded with diverging and even contradictory reports concerning the impact of certain additives, foods, and nutrients on cardiovascular health and its risk factors. Accordingly, this third review of nutrition controversies examines the impact of artificial sweeteners, cacao, soy, plant-based meats, nitrates, and meats from grass compared to grain-fed animals on cardiovascular and other health outcomes with the goal of optimizing clinician-led diet counseling.

A Comparative Analysis of Rural versus Urban Preschool Children's Sugar-Sweetened Beverage Consumption, Body Mass Index and Parent's Weight Status

Background

Childhood overweight and obesity continues to be a major public health concern, especially in minority, low-income, and rural populations. In order to develop health promotion interventions aimed at reducing obesity rates, there is a need to identify which populations have the highest rates of obesity and the risk factors associated with these high rates.

Methods

Data collected from low-income, preschool children and their parents in an urban community and a rural community in Alabama were analyzed and compared. Body Mass Index (BMI) was collected during school based health screenings, and information regarding parent's BMI and child's consumption of sugar-sweetened beverages (SSBs) were collected by parent report.

Results

Of the 363 children screened, 12.8% (15.2% rural and 11.9% urban) were considered overweight, and 15.8% (20.2% rural and 14.2% urban) of the sample was classified as obese. Rates of overweight and obesity for mothers were 27.6% (25.3% rural and 28.4% urban) and 48% (56.3% rural and 44.8% urban) respectively and 39.6% (53.3% rural and 34.4% urban) and 34.6% (28.3% rural and 36.9% urban) for fathers. Parents reported their child consumed 3.82 SSBs per day. Overall, mother's BMI, father's BMI and sugar-sweetened beverage consumption was positively associated with child's BMI. However, there were no significant interactions between the rural and urban groups.

Conclusion

Rates of overweight and obesity remain high in low-income, predominantly minority preschool children and their parents in two communities in Alabama. Consumption of SSBs, mother's BMI, and father's BMI are three factors impacting the weight status of low-income preschool children. These factors are significant in both rural and urban children.

Longitudinal geo-referenced field evidence for the heightened BMI responsiveness of obese women to price discounts on carbonated soft drinks

There is increasing interest in the effect that food environments may have on obesity, particularly through mechanisms related to the marketing and consumption of calorie-dense, nutrient-poor foods and sugary beverages. Price promotions, such as temporary price discounts, have been particularly effective in the marketing of carbonated soft drinks (CSDs) among consumers. Research has also suggested that the purchasing behavior of consumer groups may be differentially sensitive to price discounts on CSDs, with obese women particularly sensitive. In addition, the intensity of price discount in a person's food environment may also vary across geography and over time. This study examines whether the weight change of obese women, compared to overweight or normal BMI women, is more sensitive to the intensity of price discounts on CSDs in the food environment. This study used longitudinal survey data from 1622 women in the Montreal Neighborhood Networks and Health Aging (MoNNET-HA) Panel. Women were asked to report their height and weight in 2008, 2010 and 2013 in order to calculate women's BMI in 2008 and their change of weight between 2008 and 2013. Women's exposure to an unhealthy food environment was based on the frequency in which their neighborhood food stores placed price discounts on CSDs in 2008. The price discount frequency on CSDs within women's neighborhoods was calculated from Nielsen point-of sales transaction data in 2008 and geocoded to participant's forward sortation area. The prevalence of obesity and overweight among MoNNET-HA female participants was 18.3% in 2008, 19.9% in 2010 and 20.7% in 2013 respectively. Results showed that among obese women, exposure to unhealthy food environments was associated with a 3.25 kilogram (SE = 1.35, p-value = 0.02) weight gain over the five-year study period. Exposure to price discounts on CSDs may disproportionately affect and reinforce weight gain in women who are already obese.

Molecular aspects of fructose metabolism and metabolic disease

Excessive sugar consumption is increasingly considered as a contributor to the emerging epidemics of obesity and the associated cardiometabolic disease. Sugar is added to the diet in the form of sucrose or high-fructose corn syrup, both of which comprise nearly equal amounts of glucose and fructose. The unique aspects of fructose metabolism and properties of fructose-derived metabolites allow for fructose to serve as a physiological signal of normal dietary sugar consumption. However, when fructose is consumed in excess, these unique properties may contribute to the pathogenesis of cardiometabolic disease. Here, we review the biochemistry, genetics, and physiology of fructose metabolism and consider mechanisms by which excessive fructose consumption may contribute to metabolic disease. Lastly, we consider new therapeutic options for the treatment of metabolic disease based upon this knowledge.

Brain responses to glucose ingestion are greater in children than adults and are associated with overweight and obesity

OBJECTIVE

This study investigated whether brain regions involved in the regulation of food intake respond differently to glucose ingestion in children and adults and the relationship between brain responses and weight status.

METHODS

Data included 87 children (ages 7-11 years) and 94 adults (ages 18-35 years) from two cohorts. Healthy weight, overweight, and obesity were defined by Centers for Disease Control and Prevention criteria. Brain responses to glucose were determined by measuring cerebral blood flow using arterial spin labeling magnetic resonance imaging in brain regions involved in the regulation of eating behavior.

RESULTS

Children showed significantly larger increases in brain responses to glucose than adults in the dorsal striatum (p < 0.01), insula (p < 0.01), hippocampus (p < 0.01), and dorsal-lateral prefrontal cortex (p < 0.01). Responses to glucose in the dorsal striatum (odds ratio [OR] = 1.52, 95% CI 1.05-2.20; p = 0.03), hippocampus (OR = 1.51, 95% CI: 1.02-2.22; p = 0.04), insula (OR = 1.64, 95% CI: 1.11-2.42; p = 0.01), and orbitofrontal cortex (OR = 1.63 95% CI: 1.12-2.39; p = 0.01) were positively associated with overweight or obesity, independent of age group.

CONCLUSIONS

Children have greater brain responses to glucose ingestion than adults in regions involved in eating behavior, and these responses are associated with weight status.

Perspectives of Adult Singaporeans toward Potential Policies to Reduce the Consumption of Sugar Sweetened Beverages-A Cross-Sectional Study

Excessive consumption of sugar sweetened beverages (SSB) is of growing concern, and several countries are implementing measures to reduce SSB consumption. Understanding perceptions towards SSB policies is crucial to prioritize policy actions and to effectively frame public communication. We conducted a cross-sectional study in a sample of 754 adult Singaporeans to examine support towards 10 hypothetical policies to reduce SSB consumption. Policy scenarios were presented to participants and support was assessed using a 5-point Likert scale. Opinions about policies were elicited by asking participants "What other thoughts do you have about this policy?". We used logistic regression to examine determinants of policy support, and thematic analyses to understand opinions about policies. We observed good public support for a variety of SSB policies. In general, less restrictive policies such as traffic light labels (85.0% agreed/strongly agreed) and free access to water at eateries (77.1%) were better supported as compared to restrictive policies such as portion-size restrictions (64.5%) and taxation (55.0%). There was limited variation by age, ethnicity, income, physical activity and body mass index. Concerns about policies largely centered on loss of personal autonomy and economic implications for businesses. Nevertheless, participants also recognized that policies could support healthier beverage consumption by increasing awareness and enabling informed decision making. Findings from this study provide insights into consumer's perceptions of SSB policies, and can inform public health advocacy and government action in this area.

Current Knowledge Base of Beverage Health Impacts, Trends, and Intake Recommendations for Children and Adolescents: Implications for Public Health

PURPOSE OF REVIEW

Improving beverage patterns is important for promoting the health of children and adolescents. Food preferences can begin developing at a young age; thus, children and adolescents should be provided healthy beverages in accordance with current recommendations. The purpose of this review is to identify and summarize existing beverage recommendations for children and adolescents. This review also discusses the health impacts of beverages and how beverage consumption has changed among children and adolescents over time.

RECENT FINDINGS

The mean number of calories that children and adolescents are consuming from beverages on a given day has declined in recent years. However, sugar-sweetened beverages (SSB) are the primary source of added sugars in this population. Therefore, SSB consumption remains a concern, and reducing the intake of SSB is still considered a top priority for helping to improve dietary quality. This review uniquely compiles recommendations into one convenient table for the entire age range of 0-19 years and includes recommendations that can be more adequately individualized. Beverage categories where beverage recommendations from authoritative sources are lacking have also been identified. Potential methods that can be implemented to improve beverage patterns and current public policy recommendations have been discussed to provide actionable steps that public health professionals can utilize in practice. The comprehensive table of beverage recommendations could be useful for professionals promoting the health of children and adolescents in research, clinical, and public health settings.

A Rationale for a Gamified E-Coach Application to Decrease the Consumption of Sugar Sweetened Beverages

The design and implementation of applications for behavior change should be preceded by careful analysis of the behavior change process and the target population. We, therefore, present on the basis of a blended research approach a rationale, opportunities and basic requirements for an application that offers a program for reducing intake of sugar sweetened beverages (SSB) by adolescents. This paper discusses the role of e-coaching and gamification as two high-touch design patterns in the behavior change process. Both design patterns aim at supporting the individual in a transformational journey from a current state toward a desired state where the detrimental behavior should be replaced by healthy alternative behavior. First, an elementary behavior scheme is introduced that frames three empirical studies. In the first study (plenary focus groups; n = 13), participants advised to include system recommendations for alternative healthy behavior, stressed the need for personalization of the e-coach and showed strong appreciation for the inclusion of gamification elements. The second study (online survey; n = 249) showed that SSB-intake is highly contextual and that reasons for (limiting) consumption SSB varies greatly between individuals, which the e-coach application should take into account. In a final small-scale pilot study (n = 27), we observed the potential of the inclusion of gamification elements, such as challenges and rewards, to increase compliance to the self-monitoring process of SSB consumption. Building upon these insights and prior studies, we argue that an e-coach mimics the collaborative practice of the program; its main task is to enrich the interaction with cooperative conversational experiences, in particular with respect to the alignment between user and system, motivational encouragement, personalized advice, and feedback about the activities. In addition, we outline that gamification not only has the potential to increase self-monitoring of the target behavior, user engagement, and commitment with the intervention program, but also enables a designer to shift long-term negative outcome of excessive intake in real life to short-term consequences in a virtual environment. In future larger follow-up studies, we advise to integrate the two design patterns within a social network of virtual and human agents that play a variety of competitive, normative and supportive roles.

The "Adipo-Cerebral" Dialogue in Childhood Obesity: Focus on Growth and Puberty. Physiopathological and Nutritional Aspects

Overweight and obesity in children and adolescents are overwhelming problems in western countries. Adipocytes, far from being only fat deposits, are capable of endocrine functions, and the endocrine activity of adipose tissue, resumable in adipokines production, seems to be a key modulator of central nervous system function, suggesting the existence of an “adipo-cerebral axis.” This connection exerts a key role in children growth and puberty development, and it is exemplified by the leptin–kisspeptin interaction. The aim of this review was to describe recent advances in the knowledge of adipose tissue endocrine functions and their relations with nutrition and growth. The peculiarities of major adipokines are briefly summarized in the first paragraph; leptin and its interaction with kisspeptin are focused on in the second paragraph; the third paragraph deals with the regulation of the GH-IGF axis, with a special focus on the model represented by growth hormone deficiency (GHD); finally, old and new nutritional aspects are described in the last paragraph.

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.

A youth empowerment intervention to prevent childhood obesity: design and methods for a cluster randomized trial of the H2GO! program

BACKGROUND

Reducing sugar-sweetened beverage (SSB) consumption is a promising dietary target for childhood obesity prevention. This paper describes the design and methods of a cluster randomized trial of H2GO!, a youth empowerment intervention to prevent childhood obesity through reducing SSB consumption among a low-income, ethnically diverse sample of youth.

METHODS

This cluster randomized controlled trial is an academic-community partnership with the Massachusetts Alliance of Boys and Girls Clubs (BGC). Ten BGC sites will be randomly assigned to the H2GO! intervention or a wait-list, usual care control. Eligible study participants will be N = 450 parent-child pairs (youth ages 9-12 years and their parents/caregivers) recruited from participating BGCs. The 6-week in-person H2GO! intervention consists of 12 group-based sessions delivered by BGC staff and youth-led activities. An innovative feature of the intervention is the development of youth-produced narratives as a strategy to facilitate youth empowerment and parental engagement. Child outcomes include measured body mass index z scores (zBMI), beverage intake, and youth empowerment. Parent outcomes include beverage intake and availability of SSBs at home. Outcomes will be measured at baseline and at 2, 6, and 12 months. With a 75% retention rate, the study is powered to detect a minimum group difference of 0.1 zBMI units over 12 months.

DISCUSSION

Empowering youth may be a promising intervention approach to prevent childhood obesity through reducing SSB consumption. This intervention was designed to be delivered through BGCs and is hypothesized to be efficacious, relevant, and acceptable for the target population of low-income and ethnically diverse youth.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04265794 . Registered 11 February 2020.

Analysis of Caloric and Noncaloric Sweeteners Present in Dairy Products Aimed at the School Market and Their Possible Effects on Health

Over the past decades, Mexico has become one of the main sweetener-consuming countries in the world. Large amounts of these sweeteners are in dairy products aimed at the children’s market in various presentations such as yogurt, flavored milk, flan, and cheeses. Although numerous studies have shown the impact of sweeteners in adults, the current evidence for children is insufficient and discordant to determine if these substances have any risk or benefit on their well-being. Therefore, this study aimed to describe the sweeteners present in 15 dairy products belonging to the school-age children’s market in Mexico and their impact on health. These dairy products were selected through a couple of surveys directed at parents of school-age children. After that, the list of ingredients of each product was analyzed to identify their sweetener content. From there, exhaustive bibliographic research on sweeteners and their possible health effects was carried out, which included 109 articles and 18 studies. The results showed that at a neurological, endocrinological, cardiovascular, metabolic, osseous, renal, hepatic, dental, reticular, carcinogenic, and gut microbiota level; sucrose, fructose, high-fructose corn syrup, maltodextrins, sucralose, and acesulfame K, have a negative effect. While maltodextrins, stevia, polydextrose, and modified starch have a positive one. For these reasons, it is necessary to evaluate the advantages and disadvantages that the consumption of each sweetener entails, as well as a determination of the appropriate acceptable daily intake (ADI).

Preliminary assessment of the Healthy Beverage Index for U.S. Children and Adolescents: a tool to quantify the overall beverage intake quality of 2- to 19-year-olds

BACKGROUND

Improving beverage patterns of children and adolescents is recommended for combatting obesity and reducing disease risk. Therefore, it is important to assess beverage intake quality in this population. For adults, the Healthy Beverage Index (HBI) was created to assess beverage intake quality, but a similar tool did not exist for children and adolescents.

OBJECTIVE

The objective was to develop an HBI for U.S. Children and Adolescents (HBI-CA), and then assess the validity and reliability of this tool.

DESIGN

Modeled after the adult HBI, age-specific, evidence-based beverage recommendations were compiled. Ten components were included to assess beverage intake quality. Validity and reliability were assessed using cross-sectional data and methods similar to those used for the evaluation of the Healthy Eating Index.

PARTICIPANTS

The 2015-2016 National Health and Nutrition Examination Survey provided 24-hour dietary recall data for 2,874 children and adolescents aged 2-19 years.

MAIN OUTCOME MEASURES

HBI-CA scores were the main outcome measure.

STATISTICAL ANALYSES PERFORMED

To assess validity, independent t-tests were used to determine differences in HBI-CA component and total scores among groups, and principal component analysis (PCA) was completed to examine multidimensionality of the HBI-CA. Pearson's bivariate correlations were used to assess reliability.

RESULTS

The HBI-CA produced a (mean±standard error) total score of 69.2±0.8, which is similar to the adult HBI mean total score of 63. PCA identified six factors, indicating the multidimensionality of the HBI-CA, with more than one combination of components contributing to variation in total scores. Most HBI-CA components were significantly correlated to the total score, with met fluid requirements, total beverage energy, sugar-sweetened beverage, and water components demonstrating the strongest correlations (r ranged 0.335-0.735, P-value ≤0.01).

CONCLUSIONS

The results provide preliminary evidence to support the validity and reliability of the HBI-CA. If future research establishes the predictive validity and sensitivity of the HBI-CA, this tool could be useful to quantify the beverage intake quality of children and adolescents.

Effects of Unsweetened Preloads and Preloads Sweetened with Caloric or Low-/No-Calorie Sweeteners on Subsequent Energy Intakes: A Systematic Review and Meta-Analysis of Controlled Human Intervention Studies

Effects of isocaloric (sweetness differences but constant calories) preloads and isosweet (caloric differences but constant sweetness) preloads, as well as preloads that were neither isosweet nor isocaloric (sweetness and caloric differences) on subsequent ad libitum meal and total (preload + ad libitum) energy intakes were investigated. Thirty-five crossover studies were eligible for inclusion, representing 116 comparisons (41, isocaloric; 41, isosweet; and 34, neither isosweet nor isocaloric). References of existing reviews and literature from 4 databases were searched. The calculated raw mean differences in ad libitum and total energy intakes were pooled in meta-analyses using a random-effects model and the inverse of the variance as the weighting factor. Energy intakes at an ad libitum meal were significantly lower for low-/no-calorie sweetener (LNCS)-sweetened compared with unsweetened preloads in the isocaloric comparison (-55.5 kcal; 95% CI: -82.9, -28.0 kcal; P < 0.001); however, the difference in energy intake was not significant in additional sensitivity analyses (i.e., removal of comparisons where the matrix was a capsule and when xylitol was the LNCS). For the isosweet comparison, although the pooled energy intake at the ad libitum meal was significantly greater with the LNCS-sweetened preload compared with the caloric sweetener (CS)-sweetened preload (58.5 kcal; 95% CI: 35.4, 81.7 kcal; P < 0.001), the pattern was reversed when total energy intake was considered (-132.4 kcal; 95% CI: -163.2, -101.6 kcal; P < 0.001), explained by only partial compensation from the CS-sweetened preload. The results were similar when assessing ad libitum and total energy intakes when unsweetened compared with CS-sweetened preloads were consumed. Unsweetened or LNCS-sweetened preloads appear to have similar effects on intakes when compared with one another or with CS-sweetened preloads. These findings suggest that LNCS-sweetened foods and beverages are viable alternatives to CS-sweetened foods and beverages to manage short-term energy intake.

Measuring the Healthiness of Ready-to-Eat Child-Targeted Cereals: Evaluation of the FoodSwitch Platform in Sweden

BACKGROUND

Childhood obesity is a major public health issue. The increase in the consumption of foods with poor nutritional value, such as processed foods, contributes to this. Breakfast cereals are often advertised as a healthy way to start the day, but the healthiness of these products varies greatly.

OBJECTIVE

Our main objective was to gather information about the nutritional characteristics of ready-to-eat breakfast cereals in Sweden and to investigate the healthiness of products targeted at children compared to other cereals by use of the FoodSwitch platform. A secondary objective was to evaluate the alignment between the Keyhole symbol and the Health Star Rating.

METHODS

The FoodSwitch app is a mobile health (mHealth) tool used to present nutrition data and healthier alternative products to consumers. Ready-to-eat breakfast cereals from the largest Swedish grocery retailers were collected using the FoodSwitch platform. Products were defined as targeting children if they presented features addressing children on the package.

RESULTS

Overall, information on 261 ready-to-eat cereals was examined. Of this total, 8% (n=21) were targeted at children. Child-targeted cereals were higher in sugar (22.3 g/100 g vs 12.8 g/100 g, P<.001) and lower in fiber (6.2 g/100 g vs 9.8 g/100 g, P<.001) and protein (8.1 g/100 g vs 10.5 g/100 g, P<.001). Total fat (3 g/100 g vs 10.5 g/100 g, P<.001) and saturated fat (0.8 g/100 g vs 2.6 g/100 g, P<.001) were also lower. No difference was found in salt content (P=.61). Fewer child-targeted breakfast cereals displayed an on-pack Keyhole label (n=1, 5% vs n=53, 22%; P=.06), and the mean Health Star Rating value was 3.5 for child-targeted cereals compared to others (mean 3.8, P=.07). A correlation was found between the Keyhole symbol and the Health Star Rating.

CONCLUSIONS

Ready-to-eat breakfast cereals targeted at children were less healthy in terms of sugar and fiber content compared to products not targeted at children. There is a need to improve the nutritional quality of child-targeted cereals.

Gamification and Sugar: A School-Based Pilot Study of Social Marketing and Gamification Approaches to Reduce Sugary Drink Intake in Pasifika School Students

The aim of this study was to investigate a social marketing-gamification intervention to reduce sugary drink intake drawing on popular culture of Pasifika secondary school students in Auckland, New Zealand. Students aged 11 to 14 years from one coeducational high school participated in the 11-week pilot study. The 9-week intervention was undertaken in assemblies and classrooms. Baseline and follow-up measures were completed by 227 and 220 students, respectively, of 298 enrolled students. Retention of the "3-6-9" teaching related to maximum daily sugar intake increased from 9% at baseline to 97% at follow-up (P < .0001). Significant increases were observed of students who correctly answered sugar content of drinks. Overall consumption of sugary drink decreased at follow-up by 0.46 glasses per day. The main conclusion from this study was that this school-based gamification educational package to convey messages about sugar content of drinks using popular modes of engagement is a promising intervention that was acceptable and well supported by school staff and students.

Obesity prevention in early care and education: a comparison of licensing regulations across Canadian provinces and territories

BACKGROUND

Early care and education (ECE) settings represent an important point of intervention for childhood obesity prevention efforts. The objective of this paper was to compare ECE licensing regulations for each Canadian province/territory to evidence-based, obesity prevention standards.

METHODS

Two authors reviewed existing ECE regulations for each province/territory and examined whether the regulatory text supported standards for nutrition (n = 11), physical activity (n = 5) and screen time (n = 4). Provinces/territories were evaluated on the strength of regulatory language for each standard (i.e. fully, partially, or not addressed) and a total comprehensiveness score (maximum score of 20). ECE centres and homes were examined separately.

RESULTS

The majority of provinces/territories required providers to follow Canada's Food Guide, but few had regulations for specific foods or beverages. Most provinces/territories included standards related to written menus and drinking water, but the strength of these standards was weak. Many provinces/territories required physical activity and outdoor opportunities to be provided daily, but few included a time requirement. Only two provinces included any screen time standards. Total comprehensiveness scores averaged 5.7 for centres and 5.4 for homes.

CONCLUSIONS

Canadian provinces/territories have insufficient obesity prevention regulations in ECE settings, highlighting a potential point of intervention to prevent obesity.

Sugar-Sweetened Beverage Consumption and Calcified Atherosclerotic Plaques in the Coronary Arteries: The NHLBI Family Heart Study

Background: Sugar-sweetened beverage (SSB) intake is associated with higher risk of weight gain, diabetes, hypertension, cardiovascular disease, and cardiovascular mortality. However, the association of SSB with subclinical atherosclerosis in the general population is unknown. Objective: Our primary objective was to investigate the association between SSB intake and prevalence of atherosclerotic plaque in the coronary arteries in The National Heart, Lung, and Blood Institute (NHLBI) Family Heart Study. Methods: We studied 1991 participants of the NHLBI Family Heart Study without known coronary heart disease. Intake of SSB was assessed through a semi-quantitative food frequency questionnaire. Coronary artery calcium (CAC) was measured by cardiac Computed Tomography (CT) and prevalent CAC was defined as an Agatston score ≥100. We used generalized estimating equations to calculate adjusted prevalence ratios of CAC. A sensitivity analysis was also performed at different ranges of cut points for CAC. Results: Mean age and body mass index (BMI) were 55.0 years and 29.5 kg/m², respectively, and 60% were female. In analysis adjusted for age, sex, BMI, smoking, alcohol use, physical activity, energy intake, and field center, higher SSB consumption was not associated with higher prevalence of CAC [prevalence ratio (95% confidence interval) of: 1.0 (reference), 1.36 (0.70–2.63), 1.69 (0.93–3.09), 1.21 (0.69–2.12), 1.05 (0.60–1.84), and 1.58 (0.85–2.94) for SSB consumption of almost never, 1–3/month, 1/week, 2–6/week, 1/day, and ≥2/day, respectively (p for linear trend 0.32)]. In a sensitivity analysis, there was no evidence of association between SSB and prevalent CAC when different CAC cut points of 0, 50, 150, 200, and 300 were used. Conclusions: These data do not provide evidence for an association between SSB consumption and prevalent CAC in adult men and women.

Availability of a Flavored Beverage and Impact on Children's Hydration Status, Sleep, and Mood

Euhydration remains a challenge in children due to lack of access and unpalatability of water and to other reasons. The purpose of this study was to determine if the availability/access to a beverage (Creative Roots^®) influences hydration in children and, therefore, sleep quality and mood. Using a crossover investigation, 46 participants were randomly assigned to a control group (CON) or an intervention group and received Creative Roots^® (INT) for two-week periods. We recorded daily first morning and afternoon urine color (Ucol), thirst perception, and bodyweight of the two groups. Participants reported to the lab once per week and provided first morning urine samples to assess Ucol, urine specific gravity (USG), and urine osmolality (Uosmo). Participants also completed the questionnaires Profile of Mood States-Adolescents (POMS-a) and Pittsburgh Sleep Quality Index (PSQI). Dependent t-tests were used to assess the effects of the intervention on hydration, mood, and sleep quality. Uosmo was greater and Ucol was darker in the control group (mean ± SD) [Uosmo: INT = 828 ± 177 mOsm·kg⁻¹, CON = 879 ± 184 mOsm·kg⁻¹, (p = 0.037], [Ucol:INT = 5 ± 1, CON = 5 ± 1, p = 0.024]. USG, POMS-a, and PSQI were not significant between the groups. At-home daily afternoon Ucol was darker in the control group [INT = 3 ± 1, CON = 3 ± 1, p = 0.022]. Access to Creative Roots^® provides a small, potentially meaningful hydration benefit in children. However, children still demonstrated consistent mild dehydration based on Uosmo, despite consuming the beverage.

Impact of slow versus rapid digesting carbohydrates on substrate oxidation in pre-pubertal children: A randomized crossover trial

BACKGROUND & AIMS

Consumption of rapid digesting sugars by children are under increased scrutiny because of their contribution to unhealthy weight gain. Previous studies in adults and children have suggested that altering the blend of carbohydrates (CHOs) consumed may cause shifts in substrate utilization. The purpose of this study was to examine the effects of consuming a slow digesting carbohydrate (SDC) and rapid digesting carbohydrate (RDC) on CHO and fat oxidation, glucose, and insulin responses at rest, during exercise, and post-exercise rest in pre-pubescent children.

METHODS

A randomized, double-blind, crossover design was used. Nineteen pre-pubescent children (n = 10 boys, n = 9 girls, mean ± standard error, age = 9.84 ± 0.37-yrs) participated. Visits to the laboratory began with a 30-min measurement of resting metabolism followed by consumption of either an RDC or SDC drink. Postprandial resting metabolism was recorded for 60-min, immediately followed by 60-min of submaximal cycling exercise while metabolism was recorded, which was immediately followed by another 60-min recording of post-exercise metabolism. Total CHO and fat oxidation, endogenous and exogenous CHO oxidation, blood glucose, and insulin were assessed.

RESULTS

Total CHO oxidation rate (g∙min^-1) was greater after the RDC drink at 60 min (p = 0.032). Endogenous CHO oxidation rate (g∙min^-1) was greater after the SDC drink at 15 min (p ≤ 0.010). Cumulative endogenous CHO oxidation (g) was greater after the SDC drink at 45 min (p = 0.009). Endogenous CHO oxidation accounted for a greater proportion of substrate oxidation after the first 60-min rest period (p = 0.028), while exogenous CHO oxidation accounted for a greater proportion of substrate oxidation for the RDC at all time points (p ≤ 0.019).

CONCLUSIONS

The present study provides novel data suggesting that an SDC promotes greater endogenous substrate utilization in pre-pubertal children, which may have beneficial health impacts on energy intake and carbohydrate regulation/metabolism during growth and development.

CLINICAL TRIALS REGISTRY NUMBER

NCT03185884, clinicaltrials.gov.

Fructose Consumption-Free Sugars and Their Health Effects

BACKGROUND

The excessive consumption of free sugars, including fructose, is considered a cause of overweight and metabolic syndrome throughout the Western world. In Germany, the prevalence of overweight and obesity among adults (54%, 18%) and children (15%, 6%) has risen in the past few decades and has now become stable at a high level. The causative role of fructose is unclear.

METHODS

This review is based on publications retrieved by a selective search in PubMed and the Cochrane Library, with special attention to international guidelines and expert recommendations.

RESULTS

The hepatic metabolism of fructose is insulin-independent; because of the lack of a feedback mechanism, it leads to substrate accumulation, with de novo lipogenesis and gluconeogenesis. Recent meta-analyses with observation periods of one to ten weeks have shown that the consumption of fructose in large amounts leads to weight gain (+ 0.5 kg [0.26; 0.79]), elevated triglyceride levels (+ 0.3 mmol/L [0.11; 0.41]), and steatosis hepatis (intrahepatocellular fat content: + 54% [29; 79%]) when it is associated with a positive energy balance (fructose dose + 25-40% of the total caloric requirement). Meta-analyses in the isocaloric setting have not shown any comparable effects. Children, with their preference for sweet foods and drinks, are prone to excessive sugar consumption. Toddlers under age two are especially vulnerable.

CONCLUSION

The effects that have been observed with the consumption of large amounts of fructose cannot be reliably distinguished from the effects of a generally excessive caloric intake. Further randomized and controlled intervention trials of high quality are needed in order to determine the metabolic effects of fructose consumed under isocaloric conditions. To lessen individual consumption of sugar, sugary dietary items such as sweetened soft drinks, fruit juice, and smoothies should be avoided in favor of water as a beverage and fresh fruit.

Effect of temperature and/or sweetness of beverages on body composition in rats

Sweetened beverages are mainly consumed cold and various processes are activated in response to external temperature variations. However, the effect of internal temperature variations through the ingestion of cold beverages is far from clear. Two experiments were conducted to investigate the effect of beverage temperature on body composition. Sprague-Dawley rats (5-6-week-old males) had free access to food and beverage for 8 weeks. Energy intake, body weight and body composition were monitored. In Expt 1, two groups of rats (n 9) consumed water at room temperature (NW about 22°C) or cold (CW about 4°C). In Expt 2, rats were offered room-temperature (N) or cold (C) sweetened water (10 % sucrose CSu (n 7) and NSu (n 8); or 0·05 % acesulfame K CAk (n 6) and NAk (n 8)) for 12 h, followed by plain water. Our results show that in Expt 1, CW had higher lean body mass (P < 0·001) and lower body fat gain (P = 0·004) as compared with NW. In Expt 2, body weight (P = 0·013) and fat (P ≤ 0·001) gains were higher in the non-energetic sweetened groups, while lean body mass was not affected by the type of sweeteners or temperature. In conclusion, cold water ingestion improved lean body mass gain and decreased fat gain because of increased energy expenditure, while non-energetic sweetener (acesulfame K) increased body fat gain due to improved energy efficiency. Internal cold exposure failed to increase energy intake in contrast to that of external cold exposure.

The awareness of water intake and its correlation with BMI among students attending national and international secondary schools in Riyadh, Saudi Arabia

Dehydration is linked to worse cognitive functions and preference for beverages that are linked to obesity and other health conditions. Saudi Arabia’s hot climate can exacerbate these effects and it is important to ensure that children in the region understand the benefits of adequate water intake. To evaluate secondary school student perceptions and practices regarding water intake, investigate how water intake is related to BMI and school performance, and compare international schools to national schools. This cross-sectional study surveyed understanding and practices relating to water intake of national and international secondary school students using a questionnaire based on a random selection of schools and students. One-hundred and sixty-two students from international schools (I) and 157 from national schools (N) responded. Most were aged 16 and 17 years old (I:61.1%, N:76.5%, p = .005). The average BMI of all students was 24.9 ± 6.013 (I:23.6 ± 4.658, N:26.1 ± 6.931, p < 0.001). Students understood beverages do not replace water intake (I:80.2%, N:75.8%, p = .337) and preferred water when thirsty (I:77.8%, N:75.2%, p = .549). However, water consumption was low with more than 50% of students drinking less than 1500 ml a day (I:54.3%, N:70.7%, p = .002). A positive correlation between BMI and water intake was observed only among international school students. Students have inadequate water intake despite understanding the importance of hydration. There are some differences between international school students and national school students that can be attributed to the availability and sources of water, though other factors cannot be excluded.

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

OBJECTIVE

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

DESIGN

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

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

Using a Microsimulation of Energy Balance to Explore the Influence of Prenatal Sugar-Sweetened Beverage Intake on Child BMI

OBJECTIVE

Experiments with animals suggest that high sugar consumption during pregnancy may predispose offspring to obesity, but few human studies have examined this relationship. This study explored the association between the consumption of sugar-sweetened beverages (SSBs) during pregnancy and caloric intake through childhood.

METHODS

Using cohort data on child weight, height, and physical activity levels, a lab-validated microsimulation model of energy balance was employed to infer the caloric intake of children through age 11 years. Random effects models were then employed to explore the relationships between prenatal maternal consumption and inferred caloric intake during childhood.

RESULTS

An additional daily serving of SSBs during the second trimester of pregnancy was associated with an increase in child consumption of 13 kcal/d (95% CI: 1.2-26.8). Age-stratified models adjusting for maternal and child covariates suggested that this association was strongest for children aged 2.5 to 5.5 years. The consumption of SSBs during the first trimester was not found to have a consistently positive relationship to caloric intake.

CONCLUSIONS

These findings suggest that SSB consumption during the second trimester of pregnancy is associated with child energy intake and may influence anthropometry in early childhood, which is consistent with and suggestive of the presence of biological causal pathways alongside likely simultaneous contributions of social and environmental influences.

Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020

BACKGROUND

Policies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies.

OBJECTIVES

To develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time.

DESIGN

For measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020.

SUBJECTS/SETTING

Child care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC.

OUTCOME MEASURES

Strength and comprehensiveness scores for state licensing regulations.

STATISTICAL ANALYSES

Intraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020.

RESULTS

Interrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states' healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks.

CONCLUSIONS

This study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.

Nutritional Education Is an Effective Tool in Improving Beverage Assortment in Nurseries in Poland

The aim of the study was to assess the impact of education on improving the assortment of beverages served in nurseries in Poland. This analysis focused on beverages served to children with meals and between meals. We examined: water, tea, juices, soft/fruit drinks, compote, milk, cocoa, and coffee substitute. The study involved 93 nurseries enrolled in the Eating Healthy, Growing Healthy project and was conducted from 2015 to 2017. Nutritional education was carried out by dieticians or nutritionists and included 24 h of lectures given to the staff of nurseries. Training was conducted in a form of workshops that were divided into 12 topics. Additionally, consultations regarding infants and young children nutrition were available to the staff. Typically, education training was completed within 1–2 months in each nursery. The effectiveness of education was verified based on data on beverage supply in 186 ten-day menus, 1860 daily inventory reports before (at baseline), and 3–6 months after staff training (post baseline). Data were analyzed in a total group, and separately for public and non-public nurseries. Statistical analyses for categorical variables were done with Chi² Pearson test. The differences were considered significant at p < 0.05. After education, a significant increase in the supply of water as a beverage served with meals was observed in all nurseries (68% vs. 87%; p = 0.002), both in public (72% vs. 90%, p = 0.036) and non-public (62% vs. 84%, p = 0.017) ones. Moreover, a decrease in served tea was noted: in all nurseries (71% vs. 44%, p < 0.001) and in public nurseries (77% vs. 42%, p < 0.001). Water was available between meals in almost all nurseries. Nutritional education for staff is an important tool for improving adherence to the nutritional recommendation in the case of core beverage supply in Polish nurseries.

The effects of low-calorie sweeteners on energy intake and body weight: a systematic review and meta-analyses of sustained intervention studies

Previous meta-analyses of intervention studies have come to different conclusions about effects of consumption of low-calorie sweeteners (LCS) on body weight. The present review included 60 articles reporting 88 parallel-groups and cross-over studies ≥1 week in duration that reported either body weight (BW), BMI and/or energy intake (EI) outcomes. Studies were analysed according to whether they compared (1) LCS with sugar, (2) LCS with water or nothing, or (3) LCS capsules with placebo capsules. Results showed an effect in favour of LCS vs sugar for BW (29 parallel-groups studies, 2267 participants: BW change, -1.06 kg, 95% CI -1.50 to -0.62, I2 = 51%), BMI and EI. Effect on BW change increased with 'dose' of sugar replaced by LCS, whereas there were no differences in study outcome as a function of duration of the intervention or participant blinding. Overall, results showed no difference in effects of LCS vs water/nothing for BW (11 parallel-groups studies, 1068 participants: BW change, 0.10 kg, 95% CI -0.87 to 1.07, I2 = 82%), BMI and EI; and inconsistent effects for LCS consumed in capsules (BW change: -0.28 kg, 95% CI -0.80 to 0.25, I2 = 0%; BMI change: 0.20 kg/m2, 95% CI 0.04 to 0.36, I2 = 0%). Occurrence of adverse events was not affected by the consumption of LCS. The studies available did not permit robust analysis of effects by LCS type. In summary, outcomes were not clearly affected when the treatments differed in sweetness, nor when LCS were consumed in capsules without tasting; however, when treatments differed in energy value (LCS vs sugar), there were consistent effects in favour of LCS. The evidence from human intervention studies supports the use of LCS in weight management, constrained primarily by the amount of added sugar that LCS can displace in the diet.

Consumption of Beverages Containing Low-Calorie Sweeteners, Diet, and Cardiometabolic Health in Youth With Type 2 Diabetes

BACKGROUND

Low-calorie sweetened beverages (LCSBs) are commonly used as a lower-calorie alternative to sugar-sweetened beverages (SSBs) by individuals with type 2 diabetes. However, little is known about how intake of LCSBs is related to dietary intake and cardiometabolic health, particularly among youth.

OBJECTIVE

To test the hypothesis that having higher baseline LCSB intake and increasing LCSB intake over 2 years of follow-up are associated with poorer dietary intake and higher cardiometabolic risk factors among youth enrolled in the Treatment Option for Type 2 Diabetes in Adolescents and Youth (TODAY) study.

DESIGN

Secondary, exploratory, analysis of baseline and longitudinal data from the TODAY study, which was a randomized, multisite trial conducted from 2004 to 2012, to compare effects of 3 interventions (metformin alone, metformin + rosiglitazone, and metformin + intensive lifestyle intervention) on glycemic control in youth with type 2 diabetes.

PARTICIPANTS/SETTING

The study included 476 children and adolescents (10-17 years, mean body mass index 34.9 ± 7.8 kg/m²), who were participants in the multicenter (n = 15) TODAY study.

MAIN OUTCOME MEASURES

Diet was assessed using a food frequency questionnaire. Differences in energy intake, macronutrients, food group intakes, and cardiometabolic biomarkers were evaluated in 3 groups of LCSB consumers at baseline (low [1-4 servings/wk], medium [5-11 servings/wk], and high [≥12 servings/wk]), each compared with nonconsumers, and between 4 groups of change in LCSB intake (nonconsumption at start of study and nonconsumption after 2 years, increase in consumption after 2 years, decrease in consumption after 2 years, and high consumption at start of study and high consumption after 2 years).

STATISTICAL ANALYSES PERFORMED

Multivariable linear regression was performed at baseline and longitudinally over 2 years of follow-up.

RESULTS

Energy (kilocalories), fiber, carbohydrate, total fat, saturated fat, and protein intake (grams) were higher among high LCSB consumers compared with nonconsumers at baseline. No associations were observed between LCSB consumption and cardiometabolic risk factors at baseline. Change in LCSB intake between baseline and follow-up was not associated with change in energy intake or cardiometabolic risk factors. Participants who decreased LCSB consumption reported greater increases in sugar intake (18.4 ± 4.8 g) compared with those who increased LCSB consumption (5.7 ± 4.9 g) or remained high LCSB consumers (5.9 ± 7.4 g), but this trend was not statistically significant after a correction for multiple testing.

CONCLUSIONS

LCSB consumption was associated with higher energy intake in youth with type 2 diabetes, with the highest energy intakes reported in high LCSB consumers. Those who reduced LCSB consumption tended to report greater increases in sugar intake during follow-up, but further studies are needed to better understand this trend.

Salt and Sugar: Two Enemies of Healthy Blood Pressure in Children

The prevalence of essential arterial hypertension in children and adolescents has grown considerably in the last few decades, making this disease a major clinical problem in the pediatric age. The pathogenesis of arterial hypertension is multifactorial, with one of the components being represented by incorrect eating habits. In particular, excessive salt and sugar intake can contribute to the onset of hypertension in children, particularly in subjects with excess weight. Babies have an innate predisposition for sweet taste, while that for salty taste manifests after a few weeks. The recent modification of dietary styles and the current very wide availability of salt and sugar has led to an exponential increase in the consumption of these two nutrients. The dietary intake of salt and sugar in children is in fact much higher than that recommended by health agencies. The purpose of this review is to explore the mechanisms via which an excessive dietary intake of salt and sugar can contribute to the onset of arterial hypertension in children and to show the most important clinical studies that demonstrate the association between these two nutrients and arterial hypertension in pediatric age. Correct eating habits are essential for the prevention and nondrug treatment of essential hypertension in children and adolescents.

Soft drinks and sweeteners intake: Possible contribution to the development of metabolic syndrome and cardiovascular diseases. Beneficial or detrimental action of alternative sweeteners?

The rapid increase in obesity, metabolic syndrome, and cardiovascular diseases (CVDs) has been related to the rise in sugar-added foods and sweetened beverages consumption. An interesting approach has been to replace sugar with alternative sweeteners (AS), due to their impact on public health. Preclinical and clinical studies, which analyze the safety of AS intake, are still limited. Major pathogenic mechanisms of these substances include ROS and AGEs formation. Indeed, endothelial dysfunction involving in the pathogenesis of micro- and macro-vascular diseases is mitochondrial dysfunction dependent. Hyperglycemia and endoplasmic reticulum stress together produce ROS, contributing to the development and progression of cardiovascular complications during type 2 diabetes (T2D), thus causing oxidative changes and direct damage of lipids, proteins, and DNA. Epidemiological studies in healthy subjects have suggested that the consumption of artificial AS can promote CV complications, such as glucose intolerance and predisposition to the onset of T2D, whereas natural AS could reduce hyperglycemia, improve lipid metabolism and have antioxidant effects. Long-term prospective clinical randomized studies are needed to evaluate precisely whether exposure to alternative sugars can have clinical implications on natural history and clinical outcomes, especially in children or during the gestational period through breast milk.

Sucralose and Cardiometabolic Health: Current Understanding from Receptors to Clinical Investigations

The excess consumption of added sugar is consistently found to be associated with weight gain, and a higher risk of type 2 diabetes mellitus, coronary heart disease, and stroke. In an effort to reduce the risk of cardiometabolic disease, sugar is frequently replaced by low- and null-calorie sweeteners (LCSs). Alarmingly, though, emerging evidence indicates that the consumption of LCSs is associated with an increase in cardiovascular mortality risk that is amplified in those who are overweight or obese. Sucralose, a null-caloric high-intensity sweetener, is the most commonly used LCS worldwide, which is regularly consumed by healthy individuals and patients with metabolic disease. To explore a potential causal role for sucralose in increased cardiovascular risk, this present review summarizes the preclinical and clinical data from current research detailing the effects of sucralose on systems controlling food intake, glucose homeostasis, and gut microbiota.