Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies

Sugar-Sweetened Beverages and Cancer Risk: A Narrative Review

Cancer continues to be a major public health challenge worldwide, not only for being one of the leading causes of death but also because the number of incident cases is projected to grow in the next decades. Meanwhile, sugar-sweetened beverages (SSB) consumption has risen since the past century and constitutes a considerable fraction of added sugars in daily diet. Several studies have analyzed the relationship between SSB intake and health and found substantial evidence for effects on obesity, type 2 diabetes and metabolic syndrome. However, there is little knowledge about the relationship of SSB with cancer risk. It may be speculated that there is an indirect relationship between SSB and cancer through obesity and metabolic syndrome, but obesity-independent associations through hormonal imbalances or chronic inflammation could also exist. In this review, we describe the epidemiological evidence of the association of SSB and the risk of cancer in adults. Although the epidemiological evidence linking SSB consumption and cancer risk is still limited, prospective studies suggest that high SSB intake may increase the risk of obesity-related cancers, breast and prostate cancer.

Defining Energy-Dense, Nutrient-Poor Food and Drinks and Estimating the Amount of Discretionary Energy

Overconsumption of energy provided by energy-dense, nutrient-poor (EDNP) food and drinks increases the risk of unhealthy weight gain and of obesity-related health outcomes. The aim of this study was to develop a nutrient profiling model for classifying EDNP food and drinks and to estimate the amount of discretionary energy for EDNP food and drinks in a recommended diet. A stepwise approach was used first to develop a nutrient profiling model for classifying EDNP food and drinks and then to estimate the amount of discretionary energy in a recommended diet using diet modeling. The nutrition profiling model comprised 24 macro- and micronutrients and energy density. The model classified 67% of 1482 foods and 73% of 161 drinks correctly as EDNP food and drinks compared with an expert-adjusted model. Sweets, chocolate, cake, cookies and biscuits, sweet and salty snacks, sugar-sweetened and artificially sweetened drinks, and alcoholic drinks were classified as EDNP food and drinks. The estimated amount of discretionary energy for EDNP food and drinks was 4–6% of the energy requirements for 4–75-year-old Danes. It seems prudent to have special attention on EDNP food and drinks in dietary guidelines and future public health initiatives to avoid overconsumption of energy.

Trends and amounts of consumption of low-calorie sweeteners: A cross-sectional study

BACKGROUND AND AIMS

White sugar has been blamed to cause health consequences including diabetes and obesity. With the increased need to decrease sugar intake, attention was shifted towards sugar alternatives also known as low-calorie sweeteners. Low-calorie sweeteners are ubiquitous within food products, but their consumption among Lebanese adults isn't well elucidated. Our study aims to investigate the trends and amounts of low-calorie sweeteners' consumption in addition to their main sources among a sample of Lebanese adults.

METHODS

A cross-sectional study was conducted over 384 adult Lebanese individuals from both genders residing in Beirut and Mount-Lebanon from February to August 2020. After excluding eight individuals, 376 completed the survey. To assess the trends, frequency and quantity of low-calorie sweeteners' consumption, a questionnaire was filled by trained and licensed dietitians in addition to a previously validated food frequency questionnaire adapted to the most widely known products in the Lebanese market. Food products were divided into categories, amount of sweeteners in each item was obtained from the label, and analysis was performed according to the type of sweetener they are made of. Frequencies were converted into numbers of servings per day and multiplied by the standard portion size. Daily individual consumption of each sweetener apart was obtained by multiplying the amount of sweetener in each item consumed by total daily consumption. The amount in mg/kg was obtained by dividing total consumption of each sweetener apart by the mean weight of our population. The Statistical Package for Social Sciences (SPSS) was used for data entry and analysis.

RESULTS

Results showed that 94.4% were consuming an artificially-sweetened item at least once in the last six months. While weight loss and healthy lifestyle constituted the main reasons for past and current consumption respectively, safety and unpleasant taste affected consumption trends. Pills and powders' consumption was significantly associated with gender (p = 0.032) and dieting (p = 0.000) but not with age (p = 0.831), educational level (p = 0.294), living district (p = 0.421) or income (p = 0.828) where women and dieters used significantly more pills and powders than their counterparts. "Food and beverages" consumption was independent of all factors except age (p = 0.001); it peaked at 26-40 and declined thereafter. Consumption of low-calorie sweeteners came mainly from beverages and was as follows while remaining within the acceptable daily intake limits: aspartame: 98.9 mg/d (1.38 mg/kg/d); sucralose: 22.19 mg/d (0.31 mg/kg/d); acesulfame-K: 39.12 mg/d (0.55 mg/kg/d); stevia 3.28 mg/d (0.05 mg/kg/d). Food and beverages were consumed more than pills and powders due to unintentional consumption.

CONCLUSION

Despite that safety and unpleasant taste affected consumption of low-calorie sweetened products, intake of such products was found to be highly prevalent in the studied population. While remaining within the acceptable daily intake limits, consumption of food and beverages exceeded that of pills and powders due to unintentional consumption making awareness a necessity to help consumers make an informed decision. Moreover, a nation-level study is needed to generalize the results.

Is There an Academic Bias against Low-Energy Sweeteners?

This perspective considers evidence of a common academic bias against low-energy sweeteners (LES). The core proposition is that this bias is manifested in research and reporting focused on generating and placing a negative spin on LESs, largely through selective citation, interpretation and reporting. The evidence centres on three inter-related points, which together may generate a misleading impression of the balance of evidence: (1) basic and mechanistic research on LES perpetuates “explanations” for unsubstantiated adverse effects of LES; (2) the literature on LES—particularly narrative reviews and commentaries—continually reprises hypotheses of adverse effects without acknowledging where these hypotheses have been rigorously tested and rejected; and (3) negative interpretations of the effects of LES largely rely upon selectively emphasising lower-quality research whilst ignoring or dismissing higher-quality evidence. The expert community should consider these issues in assuring scientific integrity and balance in the academic discourse on LES, and how this is translated into messages for public health and consumers.

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.

Long-term trends in the consumption of sugary and diet soft drinks among adolescents: a cross-national survey in 21 European countries

PURPOSE

To assess country-level trends in the prevalence of daily consumption of sugary (2002-2018) and diet (2006-2018) soft drinks among European adolescents, overall and by family material affluence.

METHODS

We used 2002, 2006, 2010, 2014 and 2018 data from the 'Health Behaviour in School-aged Children' survey. Nationally representative samples of adolescents completed a standardised questionnaire at school, including a short food frequency questionnaire (n = 530,976 and 21 countries for sugary soft drinks; n = 61,487 and 4 countries for diet soft drinks). We classified adolescents into three socioeconomic categories for each country and survey year, using the Family Affluence Scale. Multilevel logistic models estimated time trends, by country.

RESULTS

Sugary soft drinks: the prevalence of daily consumption (≥ 1×/day) declined in 21/21 countries (P_{linear trends} ≤ 0.002). Absolute [range - 31.7 to - 3.4% points] and relative [range - 84.8 to - 22.3%] reductions varied considerably across countries, with the largest declines in Ireland, England and Norway. In 3/21 countries, the prevalence of daily consumption decreased more strongly in the most affluent adolescents than in the least affluent ones (P ≤ 0.002). Daily consumption was more prevalent among the least affluent adolescents in 11/21 countries in 2018 (P ≤ 0.002). Diet soft drinks: overall, daily consumption decreased over time in 4/4 countries (P_{linear trends} ≤ 0.002), more largely among the most affluent adolescents in 1/4 country (P ≤ 0.002).

CONCLUSIONS

Daily consumption of sugary and diet soft drinks in European adolescents decreased between 2002 (2006 for diet drinks) and 2018. Public health interventions should continue discouraging daily soft drink consumption, particularly among adolescents from lower socioeconomic groups.

Sweet Beverages and Cancer: A Scoping Review of Quantitative Studies

We conducted a scoping review of sweet beverages (SB) and cancer outcomes to ascertain SB's relationship with cancer by SB type and cancer type. We used the PRISMA Scoping Review Guidelines to review quantitative studies of SB and cancer. Eligible studies included articles reporting a quantitative association between SB intake and a cancer-related health outcome in humans, including adiposity-related vs. non-adiposity-related cancers. Studies included analyses not confounded by artificial sweeteners. SB was defined as beverages with added sugars, 100% fruit juices, or fruit drinks that were not 100% fruit juice. We used a data-charting form to extract study characteristics and results. A total of 38 were included. The sample consisted predominately of adults from European countries outside of the U.S. or predominately White samples in the U.S. Across all conceptualizations of SB, a greater proportion of studies examining carbonated drinks reported SB's relationship with poorer cancer outcomes, which was exacerbated in adiposity-related cancers. The composition of different types of SB (e.g. high fructose corn syrup, natural fructose) as they relate to cancer is important. Studies including more diverse populations that bear a disproportionate burden of both SB intake and cancer are needed.

Long-term consumption of artificial sweeteners does not affect cardiovascular health and survival in rats

Background

Recent epidemiological cohort studies have suggested that consumption of artificial sweeteners (AS) is associated with adverse cardiovascular events and mortality. However, these population association studies cannot establish a causal relationship. In this study we investigated the effect of long-term (1-year) consumption of AS (Equal and Splenda, two commonly used AS) on cardiovascular health and survival in rats.

Methods

Adult Sprague-Dawley rats (both sexes, 4-5 months old) were randomized into the following 3 groups: control (n = 21), AS Equal (n = 21) and Splenda (n = 18). In the AS groups, Equal or Splenda was added to the drinking water (2-packets/250 ml), while drinking water alone was used in the control rats. The treatment was administered for 12 months. Cardiovascular function and survival were monitored in all animals.

Results

It was found that rats in the AS groups consistently consumed more sweetened water than those in the control group. AS did not affect body weight, non-fasting blood cholesterol, triglycerides, blood pressure or pulse wave velocity. There were no significant differences in left ventricular wall thicknesses, chamber dimension, cardiac function or survival. AS did not affect heart rate or atrial effective refractory period. However, rats in both Equal and Splenda groups had prolonged PR intervals (63 ± 5ms in Equal, 68 ± 6 ms in Splenda, vs 56 ± 8 ms in control, p < 0.05) and a tendency of increased atrial fibrillation inducibility.

Conclusion

Long-term consumption of AS does not affect cardiovascular structure, function or survival but may cause some electrophysiological abnormalities with prolonged PR intervals and a tendency of increased atrial fibrillation inducibility in rats.

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.

Artificial sweeteners and cancer risk: Results from the NutriNet-Santé population-based cohort study

BACKGROUND

The food industry uses artificial sweeteners in a wide range of foods and beverages as alternatives to added sugars, for which deleterious effects on several chronic diseases are now well established. The safety of these food additives is debated, with conflicting findings regarding their role in the aetiology of various diseases. In particular, their carcinogenicity has been suggested by several experimental studies, but robust epidemiological evidence is lacking. Thus, our objective was to investigate the associations between artificial sweetener intakes (total from all dietary sources, and most frequently consumed ones: aspartame [E951], acesulfame-K [E950], and sucralose [E955]) and cancer risk (overall and by site).

METHODS AND FINDINGS

Overall, 102,865 adults from the French population-based cohort NutriNet-Santé (2009-2021) were included (median follow-up time = 7.8 years). Dietary intakes and consumption of sweeteners were obtained by repeated 24-hour dietary records including brand names of industrial products. Associations between sweeteners and cancer incidence were assessed by Cox proportional hazards models, adjusted for age, sex, education, physical activity, smoking, body mass index, height, weight gain during follow-up, diabetes, family history of cancer, number of 24-hour dietary records, and baseline intakes of energy, alcohol, sodium, saturated fatty acids, fibre, sugar, fruit and vegetables, whole-grain foods, and dairy products. Compared to non-consumers, higher consumers of total artificial sweeteners (i.e., above the median exposure in consumers) had higher risk of overall cancer (n = 3,358 cases, hazard ratio [HR] = 1.13 [95% CI 1.03 to 1.25], P-trend = 0.002). In particular, aspartame (HR = 1.15 [95% CI 1.03 to 1.28], P = 0.002) and acesulfame-K (HR = 1.13 [95% CI 1.01 to 1.26], P = 0.007) were associated with increased cancer risk. Higher risks were also observed for breast cancer (n = 979 cases, HR = 1.22 [95% CI 1.01 to 1.48], P = 0.036, for aspartame) and obesity-related cancers (n = 2,023 cases, HR = 1.13 [95% CI 1.00 to 1.28], P = 0.036, for total artificial sweeteners, and HR = 1.15 [95% CI 1.01 to 1.32], P = 0.026, for aspartame). Limitations of this study include potential selection bias, residual confounding, and reverse causality, though sensitivity analyses were performed to address these concerns.

CONCLUSIONS

In this large cohort study, artificial sweeteners (especially aspartame and acesulfame-K), which are used in many food and beverage brands worldwide, were associated with increased cancer risk. These findings provide important and novel insights for the ongoing re-evaluation of food additive sweeteners by the European Food Safety Authority and other health agencies globally.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03335644.

What are the benefits and risks of nutrition policy actions to reduce added sugar consumption? An Australian case study

OBJECTIVE

This study aimed to critically analyse Australia's current and proposed policy actions to reduce added sugar consumption. Over-consumption of added sugar is a significant public health nutrition issue. The competing interests, values and beliefs among stakeholders mean they have disparate views regarding which policy actions are preferable to reduce added sugar consumption.

DESIGN

Semi-structured interviews using purposive, snowball sampling and policy mapping. Policy actions were classified by two frameworks: NOURISHING (e.g. behaviour change communication, food environment and food system) and the Orders of Change (e.g. first order: technical adjustments, second order: reforming the system, third order: transforming the system).

SETTING

Australia.

PARTICIPANTS

Twenty-two stakeholders from the food industry, food regulation, government, public health groups and academia.

RESULTS

All proposed and existing policy actions targeted the food environment/behaviour change; most were assessed as first-order changes, and reductionist (nutrient specific) in nature. Influences on policy actions included industry power, stakeholder fragmentation, government ideology/political will and public pressure. Few stakeholders considered potential risks of policy actions, particularly of non-nutritive sweetener substitution or opportunity costs for other policies.

CONCLUSIONS

Most of Australia's policy actions to reduce added sugar consumption are reductionist. Preferencing nutrient specific, first-order policy actions could reflect the influence of vested interests, a historically dominant reductionist orientation to nutrition science and policy, and the perceived difficulty of pursuing second- or third-order changes. Pursuing only first-order policy actions could lead to 'regrettable' substitutions and creates an opportunity cost for more comprehensive policy aimed at adjusting the broader food system.

A Rocky Discontinuation of Diet Mountain Dew

A 62-year-old man with a past medical history of recently diagnosed type II diabetes mellitus presented for multiple episodes of nephrolithiasis after stopping Diet Mountain Dew ingestion. Stone analysis confirmed calcium oxalate stones. It was theorized that the high citrate in Diet Mountain Dew was protective against his newly recurrent nephrolithiasis. For lifestyle preference, the patient chose lemonade-flavored Crystal Light—known to be high in citrate—instead of potassium citrate 30—40 mEq supplementation. To date, the patient’s nephrolithiasis has not recurred. Potassium citrate is a preventive strategy against calcium oxalate stones in patients with suspected or confirmed hypocitraturia. Citrate binds calcium, therefore, preventing the interaction between calcium and oxalate. Alternative supplementation strategies, such as citrus-flavored sodas (eg, Diet Mountain Dew), powdered drinks (eg, Crystal Light), and natural juices (eg, lemon juice), may be plausible alternatives to potassium citrate. Patient lifestyle and the risks and benefits to a particular supplemental choice must be considered for every patient.

Caregivers' Understanding of Ingredients in Drinks Served to Young Children: Opportunities for Nutrition Education and Improved Labeling

BACKGROUND

Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness can contribute to caregivers' provision.

OBJECTIVES

To assess caregivers' reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1-5 y) and perceptions of product healthfulness and drink ingredients.

METHODS

A cross-sectional online survey assessed participants' (n = 1614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients [added sugar, nonnutritive sweeteners (NNSs), percentage juice]. One-factor ANOVA compared perceived healthfulness of drink categories and types of sugar and NNSs, and differences between participants who could compared with those who could not accurately identify drink ingredients.

RESULTS

Participants' top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters, and, lastly, fruit drinks (P < 0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0% and 64.9%) and/or added sugars (20.1% and 42.2%), when in fact they did, and 81.3-91.1% overestimated the percentage juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers' belief that the drink contained added sugar (P < 0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (P < 0.05).

CONCLUSIONS

Inaccurate understanding of added sugar, NNSs, and percentage juice in drinks served to young children was common and could contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages.

Consumption of Non-nutritive Sweeteners and Risk for Type 2 Diabetes: What Do We Know, and Not?

PURPOSE OF REVIEW

The article explores the relationship between non-nutritive sweetener consumption and the risk of developing type 2 diabetes through reviewing meta-analyses and systematic reviews, as well as clinical trials and observational studies.

RECENT FINDINGS

The data overall has yet to show a strong and clear link between consumption of non-nutritive sweeteners and the development of type 2 diabetes. However, several observational studies have shown a positive relationship between these two variables, with a stronger association found among women. Regarding non-nutritive sweeteners that are currently commercially available, there is not one specific non-nutritive sweetener that appears to be more strongly associated with the development of type 2 diabetes than other non-nutritive sweeteners. There is still much to be learned regarding non-nutritive sweeteners and their potential link to metabolic disorders. Further research is needed to identify the long-term impacts of non-nutritive sweetener consumption and identify the nuances in terms of risk of developing type 2 diabetes concerning specific non-nutritive sweeteners.

Validation of an HPLC Method for Pretreatment of Steviol Glycosides in Fermented Milk

Steviol glycosides are used in food and beverages worldwide as natural sweeteners, serving as a low-calorie sugar substitute. The acceptable daily intake of steviol is 0-4 mg/kg body weight. The rising demand for dairy products has led to a corresponding increase in the use of steviol glycosides in such products. Therefore, it is important to analyze the levels of steviol glycosides in dairy products. Dairy products have high fat contents and unique emulsion characteristics, conferred by a mixture of fat globules, casein micelles, whey proteins, and numerous other small molecules. These characteristics may interfere with the estimation of steviol glycoside levels; therefore, dairy samples require pretreatment. We aimed to develop an objective test for measuring the levels of steviol glycosides through the development of an efficient pretreatment method. In this study, the steviol glycoside content in dairy products was evaluated by using various methods, and an optimal pretreatment method was determined. We used high-performance liquid chromatography to assess the selectivity, linearity, limit of detection, limit of quantification, accuracy, precision, and recovery rate. Calibration curves were linear in the range of 1-50 mg/kg, with a coefficient of determination of ≥0.999. The limit of detection and limit of quantification were in the ranges of 0.11-0.56 and 0.33-1.69 mg/kg, respectively. The relative standard deviation (%) represents the precision of a measurement. The RSD relative standard deviationof recovery varied between 0.16% and 2.83%, and recovery of the analysis varied between 83.57% and 104.84%. These results demonstrate the reliability of the method for measuring the steviol glycoside content. This method can be used for the simple pretreatment of steviol glycosides and can provide an accurate determination of steviol glycoside content in emulsified food matrices, such as dairy products.

Misperceptions about added sugar, non-nutritive sweeteners and juice in popular children's drinks: Experimental and cross-sectional study with U.S. parents of young children (1-5 years)

BACKGROUND

Experts recommend against serving sugary drinks and non-nutritive sweeteners to young children, but misperceptions about drink ingredients may contribute to consumption.

OBJECTIVES

Assess parents' ability to identify added sugar, non-nutritive sweeteners and juice in children's drinks.

METHODS

Researchers recruited U.S. parents of young children (1-5 years) through an online survey panel (N = 1603). In a randomized experiment, participants indicated whether eight popular children's drink products contained added sugar or non-nutritive sweeteners and percentage of juice after viewing (a) front-of-package alone or (b) front-of-package plus nutrition/ingredient information. Participants also viewed common statements of identity on children's drinks to identify product ingredients.

RESULTS

When viewing front-of-packages alone, most participants accurately identified products with (83%-90%) and without (51%-65%) added sugar. Showing nutrition/ingredient information increased accuracy. However, the majority could not identify drinks with non-nutritive sweeteners (53%-58%), and many incorrectly believed that unsweetened juices contained added sugar (38%-43%), sweetened flavoured waters had no added sugar (24%-25%), and 100% juice contained less than 100% juice (37%). Furthermore, the majority could not identify product ingredients from statement of identity terms.

CONCLUSIONS

Misperceptions about product ingredients under current labelling practices indicate that updated regulations are necessary, including clear disclosures of sweetener and juice content on package fronts.

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.

Prevalence and Types of Non-Nutritive Sweeteners in the New Zealand Food Supply, 2013 and 2019

The widely recognized association between high sugar intakes and adverse health outcomes has increased consumer demand for products lower in sugar. This may lead to increased use of other sweeteners by the food industry. The current study investigated the prevalence and types of non-nutritive sweeteners over time (2013-2019) in New Zealand's packaged food and beverages, overall and between categories. A New Zealand database of packaged foods and beverages was used to investigate the presence of Food Standards Australia New Zealand Code-approved non-nutritive sweeteners (n = 12). Products available in 2013 (n = 12,153) and 2019 (n = 14,645) were compared. Between 2013 and 2019, the prevalence of non-nutritive sweeteners in products increased from 3% to 5%. The most common non-nutritive sweeteners in both years were acesulphame-potassium, sucralose, aspartame, and stevia, which were predominantly found in special foods (breakfast beverages and nutritional supplements), non-alcoholic beverages, dairy products, and confectionery. The prevalence of non-nutritive sweeteners is increasing over time in New Zealand's packaged foods and beverages and is likely a consequence of consumer demand for lower-sugar products. Ongoing monitoring of the prevalence and type of NNS is important to detect further increases.

Disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens, 2007-2013

The objective of this study was to estimate disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens. Data (2007-2013) came from the National Consumer Survey and included 115,510 adult respondents (age 18+) and 8635 teen respondents (age 12-17). The data was originally accessed in 2018 and analyzed in 2019-2020. The main outcomes were individual-level estimated exposure to advertisements for regular soda, diet soda, and energy/sport drinks. The main exposures were by race/ethnicity, household income, and educational attainment. Non-white adults (teens) were exposed to an estimated (per year) 101.5 (190.1) regular soda ads, 49.5 (61.2) diet soda ads, and 157.1 (279.6) energy/sport ads per year while white respondents were exposed to 97.5 (127.7) regular soda ads, 45.8 (44.2) diet soda ads, and 123.9 (192.0) energy/sport ads per year. Adult (teen) respondents who were non-white with low incomes and with low educational attainment were exposed to 4.7% (53.7%) more regular soda ads, 6.6% (43.8%) more diet ads, and 23.2% (56.2%) more energy/sport ads than respondents who were white with high incomes and high educational attainment. Demographic and socio-economic groups with a higher prevalence of obesity were exposed to significantly more advertisements for sugar-sweetened beverages. When evaluating potential policies to regulate marketing of sugar-sweetened and non-nutritive sweetened beverages, policymakers should consider the disparate exposure of at-risk populations to advertising of sugar-sweetened and non-nutritive sweetened beverages.

Obesity and Sex-Related Associations With Differential Effects of Sucralose vs Sucrose on Appetite and Reward Processing: A Randomized Crossover Trial

IMPORTANCE

Nonnutritive sweeteners (NNSs) are used as an alternative to nutritive sweeteners to quench desire for sweets while reducing caloric intake. However, studies have shown mixed results concerning the effects of NNSs on appetite, and the associations between sex and obesity with reward and appetitive responses to NNS compared with nutritive sugar are unknown.

OBJECTIVE

To examine neural reactivity to different types of high-calorie food cues (ie, sweet and savory), metabolic responses, and eating behavior following consumption of sucralose (NNS) vs sucrose (nutritive sugar) among healthy young adults.

DESIGN, SETTING, AND PARTICIPANTS

In a randomized, within-participant, crossover trial including 3 separate visits, participants underwent a functional magnetic resonance imaging task measuring blood oxygen level-dependent signal in response to visual cues. For each study visit, participants arrived at the Dornsife Cognitive Neuroimaging Center of University of Southern California at approximately 8:00 am after a 12-hour overnight fast. Blood was sampled at baseline and 10, 35, and 120 minutes after participants received a drink containing sucrose, sucralose, or water to measure plasma glucose, insulin, glucagon-like peptide(7-36), acyl-ghrelin, total peptide YY, and leptin. Participants were then presented with an ad libitum meal. Participants were right-handed, nonsmokers, weight-stable for at least 3 months before the study visits, nondieters, not taking medication, and with no history of eating disorders, illicit drug use, or medical diagnoses. Data analysis was performed from March 2020 to March 2021.

INTERVENTIONS

Participants ingested 300-mL drinks containing either sucrose (75 g), sucralose (individually sweetness matched), or water (as a control).

MAIN OUTCOMES AND MEASURES

Primary outcomes of interest were the effects of body mass index (BMI) status and sex on blood oxygen level-dependent signal to high-calorie food cues, endocrine, and feeding responses following sucralose vs sucrose consumption. Secondary outcomes included neural, endocrine, and feeding responses following sucrose vs water and sucralose vs water (control) consumption, and cue-induced appetite ratings following sucralose vs sucrose (and vs water).

RESULTS

A total of 76 participants were randomized, but 2 dropped out, leaving 74 adults (43 women [58%]; mean [SD] age, 23.40 [3.96] years; BMI range, 19.18-40.27) who completed the study. In this crossover design, 73 participants each received water (drink 1) and sucrose (drink 2), and 72 participants received water (drink 1), sucrose (drink 2), and sucralose (drink 3). Sucrose vs sucralose was associated with greater production of circulating glucose, insulin, and glucagon-like peptide-1 and suppression of acyl-ghrelin, but no differences were found for peptide YY or leptin. BMI status by drink interactions were observed in the medial frontal cortex (MFC; P for interaction < .001) and orbitofrontal cortex (OFC; P for interaction = .002). Individuals with obesity (MFC, β, 0.60; 95% CI, 0.38 to 0.83; P < .001; OFC, β, 0.27; 95% CI, 0.11 to 0.43; P = .002), but not those with overweight (MFC, β, 0.02; 95% CI, -0.19 to 0.23; P = .87; OFC, β, -0.06; 95% CI, -0.21 to 0.09; P = .41) or healthy weight (MFC, β, -0.13; 95% CI, -0.34 to 0.07; P = .21; OFC, β, -0.08; 95% CI, -0.23 to 0.06; P = .16), exhibited greater responsivity in the MFC and OFC to savory food cues after sucralose vs sucrose. Sex by drink interactions were observed in the MFC (P for interaction = .03) and OFC (P for interaction = .03) after consumption of sucralose vs sucrose. Female participants had greater MFC and OFC responses to food cues (MFC high-calorie vs low-calorie cues, β, 0.21; 95% CI, 0.05 to 0.37; P = .01; MFC sweet vs nonfood cues, β, 0.22; 95% CI, 0.02 to 0.42; P = .03; OFC food vs nonfood cues, β, 0.12; 95% CI, 0.02 to 0.22; P = .03; and OFC sweet vs nonfood cues, β, 0.15; 95% CI, 0.03 to 0.27; P = .01), but male participants' responses did not differ (MFC high-calorie vs low-calorie cues, β, 0.01; 95% CI, -0.19 to 0.21; P = .90; MFC sweet vs nonfood cues, β, -0.04; 95% CI, -0.26 to 0.18; P = .69; OFC food vs nonfood cues, β, -0.08; 95% CI, -0.24 to 0.08; P = .32; OFC sweet vs nonfood cues, β, -0.11; 95% CI, -0.31 to 0.09; P = .31). A sex by drink interaction on total calories consumed during the buffet meal was observed (P for interaction = .03). Female participants consumed greater total calories (β, 1.73; 95% CI, 0.38 to 3.08; P = .01), whereas caloric intake did not differ in male participants (β, 0.68; 95% CI, -0.99 to 2.35; P = .42) after sucralose vs sucrose ingestion.

CONCLUSIONS AND RELEVANCE

These findings suggest that female individuals and those with obesity may be particularly sensitive to disparate neural responsivity elicited by sucralose compared with sucrose consumption.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02945475.

Overall lack of genotoxic activity among five common low- and no-calorie sweeteners: A contemporary review of the collective evidence

Low- and no-calorie sweeteners (LNCS) are food additives that have been widely consumed for many decades. Their safety has been well established by authoritative bodies globally and is re-evaluated periodically. The objective herein was to survey and summarize the genotoxicity potential of five commonly utilized LNCS: acesulfame potassium (Ace-K), aspartame, saccharin, steviol glycosides and sucralose. Data from peer-reviewed literature and the ToxCast/Tox21 database were evaluated and integrated with the most recent weight-of-evidence evaluations from authoritative sources. Emphasis was placed on assays most frequently considered for hazard identification and risk assessment: mutation, clastogenicity and/or aneugenicity, and indirect DNA damage, such as changes in DNA repair mechanisms or gene expression data. These five sweeteners have been collectively evaluated in hundreds of in vivo or in vitro studies that employ numerous testing models, many of which have been conducted according to specific testing guidelines. The weight-of-evidence demonstrates overall negative findings across assay types for each sweetener when considering the totality of study design, reliability and reporting quality, as well as the lack of carcinogenic responses (or lack of responses relevant to humans) in animal cancer bioassays as well as observational studies in humans. This conclusion is consistent with the opinions of authoritative sources that have consistently determined that these sweeteners lack mutagenic and genotoxic potential.

The relationship between the use of artificial sweeteners and cancer: A meta-analysis of case-control studies

Although there are reports that artificial sweeteners (AS) are safe, the relationship between artificial sweeteners and cancer remains controversial. The purpose of the study is to evaluate whether the consumption of artificial sweeteners is associated with the risk of cancers. We conducted a comprehensive search of multiple databases, including MEDLINE, EMBASE, Web of Science, and Cochrane Library. We found all the literature that studied the relationship between artificial sweeteners and cancer. Ten case-control studies were included in the meta-analysis. Our findings indicated that the consumption of artificial sweeteners was not associated with an increase in cancer when all types of cancers are analyzed comprehensively (OR 0.91, 95% CI 0.75-1.11). Interestingly, the use of artificial sweeteners is inversely related to urinary system cancer risk when analyzing women individually (OR 0.76, 95% CI 0.60-0.97). Our meta-analysis found that these is no correlation between artificial sweeteners and occurrence of cancer except urinary system cancer in women. Considering some limitations found in this study, additional data from large clinical trials are needed.

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.

A Fit-for-Purpose Nutrient Profiling Model to Underpin Food and Nutrition Policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.

Estimated effects of the implementation of the Mexican warning labels regulation on the use of health and nutrition claims on packaged foods

BACKGROUND

The use of health and nutrition claims on front-of-pack labels may impact consumers' food choices; therefore, many countries have established regulations to avoid misinformation. This study describes the prevalence of health and nutrition claims on the front-of-pack of food products in retail stores in Mexico and estimate the potential effects of the Official Mexican Standards 051 (new regulation that includes specifications for implementing warning labels and other packaging elements such as health and nutrition claims on less healthy foods) on the prevalence of these claims.

METHODS

This is a cross-sectional study in which health and nutrition claims, nutrition information panels, and the list of ingredients of all foods and beverages available in the main retail stores in Mexico City were collected. The products were grouped by level of processing according to the NOVA food system classification. Claims were classified using the internationally harmonized INFORMAS taxonomy. According to the criteria of the new Mexican front-of-pack labelling regulation, the effect on the reduction on the prevalence of health and nutrition claims was estimated by type of food and by energy and nutrients of concern thresholds.

RESULTS

Of 17,264 products, 33.8% displayed nutrition claims and 3.4% health claims. In total, 80.8% of all products in the Mexican market were classified as "less healthy"; 48.2% of products had excess calories, 44.6% had excess sodium, and 40.7% excess free sugars. The new regulation would prevent 39.4% of products with claims from displaying health and nutrition claims (P < 0.001); the largest reduction is observed for ultra-processed foods (51.1%, P < 0.001). The regulation thresholds that resulted in the largest reduction of claims were calories (OR 0.62, P < 0.001) and non-sugar sweeteners (OR 0.54, P < 0.001).

CONCLUSIONS

The new Mexican front-of-pack labelling regulation will prevent most processed and ultra-processed foods from displaying health and nutrition claims and will potentially improve information on packaging for consumers.

Perceived Healthiness of Sweeteners among Young Adults in Canada

Purpose: To compare the perceived healthiness of different sweeteners relative to table sugar and examine efforts to consume less sugars and sweeteners.Methods: As part of the 2017 Canada Food Study online survey, 1000 youth and young adults were randomized to rate the healthiness of 1 of 6 sweeteners (aspartame, sucralose, stevia, agave, high-fructose corn syrup, "raw" sugar) or 1 sweetener brand name (Splenda) compared with "table sugar".Results: Perceptions of sweeteners varied widely. For example, the majority of respondents perceived high-fructose corn syrup (63.9%) and aspartame (52.4%) as less healthy than table sugar, whereas almost half (47.8%) perceived raw sugar as being healthier than table sugar. No assessed socio-demographic variables were significantly associated with perceived healthiness of sweeteners compared with table sugar (P ≥ 0.05). More consumers had attempted to consume less sugar (65.4%) compared with less "artificial" (31.2%) or "natural" (24.0%) low-calorie sweeteners.Conclusions: Perceptions of sweetener healthiness may be related to sweeteners' perceived level of "naturalness" rather than energy content. This has important implications for understanding consumer preferences, particularly given greater use of low-calorie sweeteners in the food supply and policy developments such as sugar taxes and enhanced sugar labelling.

Low- and No-Calorie Sweetener (LNCS) Consumption Patterns Amongst the Spanish Adult Population

Low- and no-calorie sweeteners (LNCS) are a group of food additives characterized by their high sweetness intensity and virtually zero caloric content, attributes that make them potential substitutes for added sugars in processed foods and beverages. However, there is currently scarce information available about both the different LNCS used in food products available in Spain and their consumption patterns. Prompted by these reasons, the aim of this research work was to identify the presence and consumption of LNCS in food and beverages consumed by a representative sample of the Spanish adult population (n = 507). For this purpose, a Food Frequency Questionnaire was carried out. Overall, it was found that 4.5% of the foods and 22.3% of the beverages consumed by the surveyed population contained LNCS. The food groups that presented the highest percentage of daily servings containing LNCS were non-alcoholic beverages such as soft drinks and juices (36.1%); sugars and sweets such as chocolates, candies, or chewing gum (14.2%); milk and dairy products (7.0%); meat and derivative products (5.1%); cereals and derivatives (4.3%); appetizers (1.7%); and, finally, sauces and condiments such as ketchup or mustard (1.0%). The main LNCS consumed were acesulfame-K, sucralose, sorbitol, aspartame, and cyclamate, although their prevalence of use differs greatly among foods, beverages, or tabletop sweeteners. Our results show the great diversity of food groups that are currently including these compounds as ingredients. Consequently, there is a need for these food additives to be included in food composition databases, which should be regularly updated to include LNCS in order to facilitate their assessment and monitoring in dietary nutritional surveys.

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

OBJECTIVE

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

DESIGN

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

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

Is sugar extracted from plants less healthy than sugar consumed within plant tissues? The sugar anomaly

There are dilemmas in the minds of consumers with respect to sugar consumption - they would like to consume sugars for sweetness, but in a healthy (and perhaps guilt free!) way. In a sense, consumers believe that if sugar does not appear as an ingredient on the product label, but is intrinsic in the food (and will appear as a nutrient), it is 'good'. As an ingredient, however, it is viewed as a 'bad chemical' associated with tooth decay and obesity. The reality is that unless processing induced modifications have occurred, the sugar molecule within a plant tissue is the same molecule structure as present in purified sugar. The same calorific value. However, there is an argument that humans eat too refined food and that if sugars were eaten in their natural context (e.g. within a fruit), their presence and concentration would be in harmony (where different nutrients complement and balance the sugar concentration) with the human body. This reflects the process of eating, satiety, presence of other nutrients (including water) and the associated impact of the indigestible components of plant foods on the transit/nutrient bioavailability control and thus benefits through the gut. The authors explore these issues in this article and seek to provide a scientific basis to different sides of the argument - sugar is good or bad depending on how (in which format and how much/how concentrated) it is consumed. More importantly perhaps, how should sugar consumption - an important nutrient - be managed to optimize the benefits but reduce the disadvantages? © 2020 Society of Chemical Industry.

Does the Australian Health Star Rating System Encourage Added Sugar Reformulation? Trends in Sweetener Use in Australia

Dietary risk factors, including excess added sugar intake, are leading contributors to Australia's burden of disease. An objective of the Australian Health Star Rating (HSR) system is to encourage the reformulation of packaged foods. Manufacturers may improve a product's HSR by replacing added sugar with non-nutritive sweeteners (NNS). Concerns have been raised regarding the potential substitution effects of ultra-processed foods containing NNS for whole foods, and the long-term impact this may have on population health. The aim of this study was to determine whether the implementation of the HSR system has impacted the use of added sugars and NNS in the food supply. Four product categories were used: products with no added sweetener, products containing added sugar only, products containing NNS only, and products containing a combination of added sugar and NNS. Of 6477 newly released products analyzed displaying a HSR in Australia between 2014-2020, 63% contained added sugars. The proportion of new products sweetened with added sugars increased over time, while NNS use did not, despite a higher average and median HSR for products sweetened with NNS. These findings suggest that at the current time, the HSR system may not discourage the use of added sugars in new products or incentivize the reformulation of added sugar with NNS. As the health risks of NNS are questioned, increased reformulation of products with NNS to reduce the presence of added sugar in the food supply may not address broader health concerns. Instead, supporting the promotion of whole foods and drinks should be prioritized, as well as policy actions that reduce the proliferation and availability of UPFs.

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.

Phenotyping Aquatic Neurotoxicity Induced by the Artificial Sweetener Saccharin at Sublethal Concentration Levels

Artificial sweeteners (ASs) have generally been applied as food additives to improve the taste of sweetness. Thus, their potential toxic effects have received extensive attention. Saccharin (SAC), discovered more than a century ago, has been used as the first noncaloric AS in foods and beverages for over 100 years. Although the toxicological effects such as carcinogenicity of SAC have been controversial for a long time, there is a paucity of knowledge covering its potential behavioral toxicity and neurotoxicity. Methodologically, in current research, adult zebrafish neurobehavioral phenotypic screening approaches were introduced to systematically delineate the potential behavioral and neural toxicity of SAC by phenotyping the comprehensive neuro-behavioral profiles of adult zebrafish, which were chronically (2 months) subject to SAC (0, 1, 10, and 50 mg/L) exposure. Subsequently, a cohort of standard neurobehavioral tests including the light/dark preference (LDP) test, novel tank diving (NTD) test, novel object recognition (NOR) test, social interaction test (SIT), color-associated learning and memory test, and conditional place preference test were applied to delineate the general adverse effect of SAC. Specifically, in a concentration-dependent manner, SAC significantly increased the preference toward the dark side in the LDP test, inhibited exploratory behavior to the top arena in the NTD test, dampened the motivation to explore the novel object in the NOR test, weakened social preference in the SIT, and interfered in the color-based associative learning and memory ability. For example, in the LDP test, SAC remarkably increased the swimming distance of zebrafish in the dark part from 222 ± 34.6 (control group) to 675 ± 35.0 (50 mg/L group). Finally, the quantity of certain key neurotransmitters was further measured to determine the alteration induced by SAC on the brain chemistry. In total, the current research would provide a versatile neurobehavioral phenomics-based strategy to phenotypically screen the neurotoxicity of food additives at the overall animal level and provide a reference for further neurotoxicity exploration at the tissue and molecular level.

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.

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.

Consumption of Sweet Beverages and Cancer Risk. A Systematic Review and Meta-Analysis of Observational Studies

The consumption of sweet beverages, including sugar-sweetened beverages (SSB), artificial-sweetened beverages (ASB) and fruit juices (FJ), is associated with the risk of different cardiometabolic diseases. It may also be linked to the development of certain types of tumors. We carried out a systematic review and meta-analysis of observational studies aimed at examining the association between sweet beverage intake and cancer risk. Suitable articles published up to June 2020 were sourced through PubMed, Web of Science and SCOPUS databases. Overall, 64 studies were identified, of which 27 were selected for the meta-analysis. This was performed by analyzing the multivariable-adjusted OR, RR or HR of the highest sweet beverage intake categories compared to the lowest one. Random effects showed significant positive association between SSB intake and breast (RR: 1.14, 95% CI: 1.01–1.30) and prostate cancer risk (RR: 1.18, 95% CI: 1.10–1.27) and also between FJs and prostate cancer risk (RR: 1.03, 95% CI: 1.01–1.05). Although the statistically significant threshold was not reached, there tended to be positive associations for the following: SSBs and colorectal and pancreatic cancer risk; FJs and breast, colorectal and pancreatic cancer risk; and ASBs and pancreatic cancer risk. This study recommends limiting sweet beverage consumption. Furthermore, we propose to establish a homogeneous classification of beverages and investigate them separately, to better understand their role in carcinogenesis.

Use of advertising strategies to target children in sugar-sweetened beverages packaging in Mexico and the nutritional quality of those beverages

BACKGROUND

A product package can be a powerful marketing tool to persuade and attract consumers at the point-of-sale. Evidence shows that most advertised products have low nutritional quality. Currently, Mexico has incorporated advertising regulations on food and beverage packaging.

OBJECTIVES

To analyze the advertising strategies used to target children on packaging and to assess the nutritional quality of sugar-sweetened beverages available in the Mexican market.

METHODS

Photographs of 2380 beverages available in retail stores in Mexico City from January to March 2017 were analyzed. Beverages were classified as displaying child-directed strategies or nondirected strategies. Nutrition quality was evaluated using the Pan American Health Organization nutrient profile model.

RESULTS

The use of characters was the most frequent strategy among beverages with child-directed strategies (82.0%). The evaluation of nutrition quality found that 88.0% (P < .001) of sugar-sweetened beverages with child-directed strategies were excessive in free sugars and 56.9% (P < .001) contained other sweeteners. Beverages with more than two advertising strategies have the highest proportion of excessive free sugars (93.4%, 95% CI 82.8-98.6).

CONCLUSIONS

The use of characters and other visual strategies were frequently used in the packaging of sugar-sweetened beverages with child-directed strategies. In addition, these beverages are excessive in free sugars and contain a large number of products with other sweeteners.

Low-calorie sweeteners in the human diet: scientific evidence, recommendations, challenges and future needs. A symposium report from the FENS 2019 conference

Overconsumption of free sugars, particularly from sugar-sweetened beverages (SSB), has potential negative health impacts. Implementation of a range of public health strategies is needed to reduce intakes of free sugars, including reducing portion sizes, promoting healthier dietary choices and reformulating foods and beverages. Although low-calorie sweeteners (LCS) are a useful tool for reducing energy intake and control glucose response when consuming sweet foods and drinks, several opinions persist about the adverse health effects of LCS, many of which are based on poor, little or no scientific evidence. This symposium report summarises key messages of the presentations and related discussions delivered at a scientific symposium at the 13th European Nutrition Conference (FENS 2019). These presentations considered the scientific evidence and current recommendations about the use and potential benefits of LCS for human health, with a particular focus on current evidence in relation to body weight and glycaemic control. Many of the studies to date on LCS have focused on low-calorie sweetened beverages (LCSB); however, the psychological and behavioural factors influencing consumer beliefs and consumption of LCSB need to be further explored. Current recommendations for LCS use are described, including the conclusions from a recent expert consensus report identifying the challenges that remain with LCS research. Finally, existing knowledge gaps and future actions are described, as well as two large ongoing research projects: SWITCH and SWEET.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

A rational review on the effects of sweeteners and sweetness enhancers on appetite, food reward and metabolic/adiposity outcomes in adults

Numerous strategies have been investigated to overcome the excessive weight gain that accompanies a chronic positive energy balance. Most approaches focus on a reduction of energy intake and the improvement of lifestyle habits. The use of high intensity artificial sweeteners, also known as non-caloric sweeteners (NCS), as sugar substitutes in foods and beverages, is rapidly developing. NCS are commonly defined as molecules with a sweetness profile of 30 times higher or more that of sucrose, scarcely contributing to the individual's net energy intake as they are hardly metabolized. The purpose of this review is first, to assess the impact of NCS on eating behaviour, including subjective appetite, food intake, food reward and sensory stimulation; and secondly, to assess the metabolic impact of NCS on body weight regulation, glucose homeostasis and gut health. The evidence reviewed suggests that while some sweeteners have the potential to increase subjective appetite, these effects do not translate in changes in food intake. This is supported by a large body of empirical evidence advocating that the use of NCS facilitates weight management when used alongside other weight management strategies. On the other hand, although NCS are very unlikely to impair insulin metabolism and glycaemic control, some studies suggest that NCS could have putatively undesirable effects, through various indirect mechanisms, on body weight, glycemia, adipogenesis and the gut microbiota; however there is insufficient evidence to determine the degree of such effects. Overall, the available data suggests that NCS can be used to facilitate a reduction in dietary energy content without significant negative effects on food intake behaviour or body metabolism, which would support their potential role in the prevention of obesity as a complementary strategy to other weight management approaches. More research is needed to determine the impact of NCS on metabolic health, in particular gut microbiota.

Evaluation of the Accurateness of the Nutritional Labels of Processed and Ultra-Processed Products Available in Supermarkets of Ecuador

Nutrition labeling is a public health tool that allows consumers to choose healthier foods and beverages. For this reason, there are protocols in place to monitor the food environment. The purpose of this study was to evaluate the consistency of nutrition labeling on packages for processed and ultra-processed products (UPPs) found at the main supermarkets in Cuenca, Ecuador. We conducted a descriptive cross-sectional study in which we identified label components on the packages of 1725 foods and beverages—including the nutrition table, statement on sweeteners, ingredient list, and the traffic light (TL) label—and determined the degree of consistency between the indicators reported on the traffic light label and those obtained from the information in the nutrition table. We found that 24% of products had inconsistencies in the traffic light label, and 10.9% of products had inconsistencies in the indicator for sugar specifically. The majority of inconsistencies were in the medium indicators for sugar (K = 0.68) and fat (0.75). The products with a medium indicator for sugar had a 1.98 (p < 0.05, 95% CI 1.15, 3.39) times higher chance of having inconsistencies in comparison with the low indicator. Health authorities must create new guidelines to allow for continued monitoring of the nutrition and traffic light labels on products accessible to consumers.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.