Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction

Prospective association between added sugars and frailty in older adults

Background

Sugar-sweetened beverages and added sugars (monosaccharides and disaccharides) in the diet are associated with obesity, diabetes, and cardiovascular disease, which are all risk factors for decline in physical function among older adults.

Objective

The aim of this study was to examine the association between added sugars in the diet and incidence of frailty in older people.

Design

Data were taken from 1973 Spanish adults ≥60 y old from the Seniors-ENRICA cohort. In 2008-2010 (baseline), consumption of added sugars (including those in fruit juices) was obtained using a validated diet history. Study participants were followed up until 2012-2013 to assess frailty based on Fried's criteria. Statistical analyses were performed with logistic regression adjusted for age, sex, education, smoking status, body mass index, energy intake, self-reported comorbidities, Mediterranean Diet Adherence Score (excluding sweetened drinks and pastries), TV watching time, and leisure-time physical activity.

Results

Compared with participants consuming <15 g/d added sugars (lowest tertile), those consuming ≥36 g/d (highest tertile) were more likely to develop frailty (OR: 2.27; 95% CI: 1.34, 3.90; P-trend = 0.003). The frailty components "low physical activity" and "unintentional weight loss" increased dose dependently with added sugars. Association with frailty was strongest for sugars added during food production. Intake of sugars naturally appearing in foods was not associated with frailty.

Conclusions

The consumption of added sugars in the diet of older people was associated with frailty, mainly when present in processed foods. The frailty components that were most closely associated with added sugars were low level of physical activity and unintentional weight loss. Future research should determine whether there is a causal relation between added sugars and frailty.

Fluid and total water intake in a senior mediterranean population at high cardiovascular risk: demographic and lifestyle determinants in the PREDIMED-Plus study

PURPOSE

We aimed to evaluate associations between compliance with recommendations for total water intake (TWI) and total water intake from fluids (TWIF), and some socio-demographic and lifestyle factors of a senior Mediterranean population at high cardiovascular risk.

METHODS

Cross-sectional analysis with data of 1902 participants from the PREDIMED-Plus study. A validated 32-item Spanish fluid-intake questionnaire was used to assess beverage consumption and water intake. Multivariable logistic regression models were used to assess the odds ratio (OR) and the 95% confidence interval (CI) for complying with European Food Safety Agency recommendations for TWI and TWIF according to various socio-demographic and lifestyle factors, and for the joint associations of Mediterranean diet (MedDiet) adherence and moderate-vigorous physical activity (MVPA).

RESULTS

The mean total volume of fluid intake in the population studied was 1934 ± 617 mL/day. Water was the most frequently consumed beverage. Significant differences between sex were only observed in alcoholic and hot beverage consumption. Compliance with TWIF was associated with being women (OR 3.02; 2.40, 3.80), high adherence to MedDiet (OR 1.07; 1.02, 1.12), and participants who were more engaged in physical activity (PA) (OR 1.07; 1.02, 1.13). Age was inversely associated (OR 0.96; 0.94, 0.98). Similar results for TWI recommendations compliance were observed in relation to being women (OR 5.34; 3.85, 7.42), adherence to MedDiet (OR 1.16; 1.02, 1.31) and PA (OR 1.07; 1.00, 1.15). The joint association of PA and MedDiet, showed that participants with higher adherence to MedDiet and meeting WHO recommendations for MVPA complied better with the TWI recommendations (OR 1.66; 1.19, 2.32).

CONCLUSIONS

High compliance with recommendations for TWI was associated with being a woman, and a healthy lifestyle characterized by high adherence to the MedDiet and PA.

An update of the KIDMED questionnaire, a Mediterranean Diet Quality Index in children and adolescents

OBJECTIVE

The KIDMED questionnaire was published in 2004 to evaluate adherence to the Mediterranean diet (MD) in children and adolescents. In the last 14 years, several respected official dietetics and health organizations have recommended appropriate dietary habits, including eating whole grains and consuming whole fruit rather than fruit juice. We propose an update of the KIDMED questionnaire.

DESIGN

Based on the scientific evidence, the present commentary suggests some changes to the KIDMED questionnaire.

RESULTS

We suggest deleting 'or fruit juice' from the first question of the questionnaire, rewording the question as 'Takes a fruit every day', and assigning a positive value of +1. We suggest adding 'whole-grain' to the eighth question of the questionnaire, rewording the question as 'Consumes whole-grain pasta or whole-grain rice almost every day (5 or more times per week)', and assigning a positive value of +1. Further, we propose to add 'whole cereals or whole grains' to the ninth question of the questionnaire, reword the question as 'Has whole cereals or whole grains (whole-meal bread, etc.) for breakfast', and assign a positive value of +1.

CONCLUSIONS

The present commentary examines some signs of a paradigm shift about fruit juice and whole grains after the development of the KIDMED questionnaire. The changes are of paramount importance in order to make the questionnaire an updated tool to evaluate adherence to the MD.

Are Fruit Juices Healthier Than Sugar-Sweetened Beverages? A Review

Free sugars overconsumption is associated with an increased prevalence of risk factors for metabolic diseases such as the alteration of the blood lipid levels. Natural fruit juices have a free sugar composition quite similar to that of sugar-sweetened beverages. Thus, could fruit juice consumption lead to the same adverse effects on health as sweetened beverages? We attempted to answer this question by reviewing the available evidence on the health effects of both sugar-sweetened beverages and natural fruit juices. We determined that, despite the similarity of fruits juices to sugar-sweetened beverages in terms of free sugars content, it remains unclear whether they lead to the same metabolic consequences if consumed in equal dose. Important discrepancies between studies, such as type of fruit juice, dose, duration, study design, and measured outcomes, make it impossible to provide evidence-based public recommendations as to whether the consumption of fruit juices alters the blood lipid profile. More randomized controlled trials comparing the metabolic effects of fruit juice and sugar-sweetened beverage consumption are needed to shape accurate public health guidelines on the variety and quantity of free sugars in our diet that would help to prevent the development of obesity and related health problems.

Sugar-Sweetened Soda Consumption Increases Diabetes Risk Among Mexican Women

BACKGROUND

Epidemiological evidence supports an association between sugar-sweetened soda consumption and diabetes. However, evidence regarding this association is limited in countries that have recently undergone a nutritional transition.

OBJECTIVE

We estimated the association between sugar-sweetened soda consumption and incident diabetes. We also determined if the association between sugar-sweetened soda and diabetes differs as a result of early life factors and potential genetic susceptibility.

METHODS

We used data from the Mexican Teachers' Cohort including 72,667 women aged ≥25 y, free of diabetes, cardiovascular disease, and cancer at baseline. We assessed sugar-sweetened soda consumption using a validated food frequency questionnaire (FFQ) at baseline. Diabetes was self-reported. We used Cox proportional hazard regression models to estimate the association between quintiles of sugar-sweetend soda and diabetes. We also estimated the associaiton by increasing one serving per day (355 mL) of sugar-sweetened soda. We conducted prespecified subgroup analysis by potential effect modifiers, namely markers of energy balance of early life factors, family history of diabetes, and Amerindian admixture.

RESULTS

During a median follow-up of 2.16 y (IQR 0.75-4.50) we identified 3,155 incident cases of diabetes. The median consumption of sugar-sweetened soda was 1.17 servings per day (IQR 0.47- 4.00). In multivariable analyses, comparing extreme quintiles showed that higher sugar-sweetened soda consumption was associated with diabetes incidence (HR = 1.32; 95% CI: 1.17, 1.49), and each additional serving per day of sugar-sweetened soda was associated with an increase of 27% in diabetes incidence (HR = 1.27; 95% CI: 1.16, 1.38). The soda-diabetes association was stronger among women who experienced intrauterine and childhood over-nutrition (high birth weight, no short stature, higher adiposity in premenarche, and higher adiposity at age 18-20 y old).

CONCLUSION

Sugar-sweetened soda consumption is associated with an increased risk of diabetes among Mexican women in a magnitude similar to that reported in other populations. The stronger association among individuals with markers of early life over-nutrition reinforce the need for early life interventions.

Biomarker approaches to assessing intakes and health impacts of sweeteners: challenges and opportunities

The term 'sweeteners' encompasses both nutritive and non-nutritive sweeteners, which when added to food/beverages, can enhance the flavour and other functional properties of food/beverage products. This review considers how dietary biomarker approaches may enhance current understanding of nutritive sweetener (namely free sugars) and non-nutritive or low-energy sweetener (LES) intakes and how these may impact health. Recent public health strategies to reduce free sugar consumption will help contribute to challenging sugar intake targets. Robust evaluation is needed to determine the effectiveness of these approaches to reducing free sugar consumption. LES provides a sweet taste without the addition of appreciable energy and can help maintain the palatability of reformulated products. All LES undergo rigorous safety evaluations prior to approval for use. Whilst intervention data suggest LES can be beneficial for health (relating to weight status and glycaemic control), debate persists on their use and findings from population-based research are mixed, in part because of potential contributing factors such as reverse causality. Additionally, assessments often consider only certain sources of LES (e.g. LES-beverages) and/or LES as a homogeneous group despite differing biological fates, thus not adequately capturing intakes of individual LES or allowing for reliable estimation of overall intakes. Urinary biomarker approaches developed/investigated for sweetener consumption have the potential to overcome existing limitations of dietary data by providing more objective intake data, thereby enhancing population-based research. In conclusion, such biomarker approaches to the concomitant study of free sugars and LES intakes are timely and represent interesting developments in an area of significant public health interest.

[Consumption of sweetened beverages and associated factors in adults]

The aim of this study was to evaluate the regular consumption of sweetened beverages and its association with sociodemographic and behavioral aspects in a city in the southwest of Brazil. It involves is a population-based study of 1,226 adults aged 20 to 59 living in the urban area of the municipality of Viçosa in the state of Minas Gerais. A structured questionnaire to measure sociodemographic and behavioral conditions was applied. The consumption of sweetened beverages was considered regular when the frequency of consumption was five or more times a week. Regular consumption of sweetened beverages was higher in men and women aged between 20 and 29 years (p < 0.01). Men with the habit of eating meals in front of the television (p = 0.03) and women dissatisfied with their weight (p = 0.03) consumed greater regular amounts of sweetened beverages. The conclusion reached is that older individuals showed less regular consumption of sweetened beverages and that the consumption of same was associated with obesogenic behaviors, such as the habit of eating meals in front of the television and among individuals dissatisfied with their body weight.

Stromal cell-derived factor 1 (SDF-1) and its receptor CXCR4 improves diabetic retinopathy

Diabetes induced a serious of complications including diabetic retinopathy. Our study aimed to investigate the role of Stromal cell-derived factor 1 (SDF-1) and its receptor CXCR4 in diabetic retinopathy. A mice model of diabetic retinopathy was established, and expression of SDF-1 and CXCR4 in retina was examined by Real-time quantitative PCR (qRT-PCR). Cells of human retinal pigment epithelial cell line ARPE-19 were treated with CXCR4 siRNAs and expression vector, and cell viability was detected by MTT assay. We found that expression of SDF-1 and CXCR4 in retina was significantly downregulated in mice with diabetic retinopathy than in normal healthy mice. High glucose treatment downregulated the expression of SDF-1 and CXCR4 in ARPE-19 cells at both mRNA and protein levels. Transfection with CXCR4 siRNAs decreased, while transfection with CXCR4 expression vector increased cell viability under high glucose treatment. We concluded that SDF-1/CXCR4 pathway improved diabetic retinopathy possibly by increasing cell viability. Abbreviations: SDF-1: Stromal cell-derived factor 1; CXCL12: C-X-C motif chemokine 12; qRT-PCR: Real-time quantitative PCR.

Evaluation of the effects of three sulfa sweeteners on the lifespan and intestinal fat deposition in C. elegans

High sugar content in beverage or food can affect the aging process, and thus natural/artificial sweeteners are widely used as substitutes. However, whether sweeteners have such adverse effects as sugar remains to be clarified. Therefore, in the current study, three sulfa sweeteners, namely, saccharin sodium salt hydrate (SAC²), sodium cyclamate (CYC³) and acesulfame potassium (AceK⁴) were evaluated for their effects on the lifespan, deposition of lipofuscin, exercise activity, food intake, and intestinal fat deposition (IFD⁵) of Caenorhabditis elegans (C. elegans⁶). It was shown that SAC at 0.3 and 10 mg/mL shortened the lifespan of C. elegans and impaired the exercise capacity, while at other concentrations no significant effects were observed. In contrast, CYC at 0.1, 1 and 10 mg/mL prolonged the lifespan of C. elegans. On the other hand, AceK at 1 mg/mL increased the lifespan of C. elegans, and could decrease both lipofuscin deposition and IFD in a dose-dependent manner. Taken together, these results indicated that although SAC, CYC, and AceK all belong to the sulfa sweeteners, each has distinct effects on different physiological activities associated with aging, at least in C. elegans.

Dairy product consumption is associated with pre-diabetes and newly diagnosed type 2 diabetes in the Lifelines Cohort Study

Previous studies show associations between dairy product consumption and type 2 diabetes, but only a few studies conducted detailed analyses for a variety of dairy subgroups. Therefore, we examined cross-sectional associations of a broad variety of dairy subgroups with pre-diabetes and newly diagnosed type 2 diabetes (ND-T2DM) among Dutch adults. In total, 112 086 adults without diabetes completed a semi-quantitative FFQ and donated blood. Pre-diabetes was defined as fasting plasma glucose (FPG) between 5·6 and 6·9 mmol/l or HbA1c% of 5·7-6·4 %. ND-T2DM was defined as FPG ≥7·0 mmol/l or HbA1c ≥6·5 %. Logistic regression analyses were conducted by 100 g or serving increase and dairy tertiles (T1ref), while adjusting for demographic, lifestyle and dietary covariates. Median dairy product intake was 324 (interquartile range 227) g/d; 25 549 (23 %) participants had pre-diabetes; and 1305 (1 %) had ND-T2DM. After full adjustment, inverse associations were observed of skimmed dairy (OR100 g 0·98; 95 % CI 0·97, 1·00), fermented dairy (OR100 g 0·98; 95 % CI 0·97, 0·99) and buttermilk (OR150 g 0·97; 95 % CI 0·94, 1·00) with pre-diabetes. Positive associations were observed for full-fat dairy (OR100 g 1·003; 95 % CI 1·01, 1·06), non-fermented dairy products (OR100 g 1·01; 95 % CI 1·00, 1·02) and custard (ORserving/150 g 1·13; 95 % CI 1·03, 1·24) with pre-diabetes. Moreover, full-fat dairy products (ORT3 1·16; 95 % CI 0·99, 1·35), non-fermented dairy products (OR100 g 1·05; 95 % CI 1·01, 1·09) and milk (ORserving/150 g 1·08; 95 % CI 1·02, 1·15) were positively associated with ND-T2DM. In conclusion, our data showed inverse associations of skimmed and fermented dairy products with pre-diabetes. Positive associations were observed for full-fat and non-fermented dairy products with pre-diabetes and ND-T2DM.

Could the high consumption of high glycaemic index carbohydrates and sugars, associated with the nutritional transition to the Western type of diet, be the common cause of the obesity epidemic and the worldwide increasing incidences of Type 1 and Type 2 diabetes?

The globally increasing incidences of Type 1 diabetes (T1DM) and Type 2 diabetes (T2DM) can have a common background. If challenged by the contemporary high level of nutritional glucose stimulation, the β-cells in genetically predisposed individuals are at risk for damage which can lead to the diseases. The fat to carbohydrate dietary shift can also contribute to the associated obesity epidemic.

Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study

Background

The World Health Organization has advocated for sugar-sweetened beverage (SSB) taxes as part of a broader non-communicable disease prevention strategy, and these taxes have been recently introduced in a wide range of settings. However, much is still unknown about how SSB taxes operate in various contexts and as a result of different tax designs. In 2015, the Government of Barbados implemented a 10% ad valorem (value-based) tax on SSBs. It has been hypothesized that this tax structure may inadvertently encourage consumers to switch to cheaper sugary drinks. We aimed to assess whether and to what extent there has been a change in sales of SSBs following implementation of the SSB tax.

Methods

We used electronic point of sale data from a major grocery store chain and applied an interrupted time series (ITS) design to assess grocery store SSB and non-SSB sales from January 2013 to October 2016. We controlled for the underlying time trend, seasonality, inflation, tourism and holidays. We conducted sensitivity analyses using a cross-country control (Trinidad and Tobago) and a within-country control (vinegar). We included a post-hoc stratification by price tertile to assess the extent to which consumers may switch to cheaper sugary drinks.

Results

We found that average weekly sales of SSBs decreased by 4.3% (95%CI 3.6 to 4.9%) compared to expected sales without a tax, primarily driven by a decrease in carbonated SSBs sales of 3.6% (95%CI 2.9 to 4.4%). Sales of non-SSBs increased by 5.2% (95%CI 4.5 to 5.9%), with bottled water sales increasing by an average of 7.5% (95%CI 6.5 to 8.3%). The sensitivity analyses were consistent with the uncontrolled results. After stratifying by price, we found evidence of substitution to cheaper SSBs.

Conclusions

This study suggests that the Barbados SSB tax was associated with decreased sales of SSBs in a major grocery store chain after controlling for underlying trends. This finding was robust to sensitivity analyses. We found evidence to suggest that consumers may have changed their behaviour in response to the tax by purchasing cheaper sugary drinks, in addition to substituting to untaxed products. This has important implications for the design of future SSB taxes.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0776-7) contains supplementary material, which is available to authorized users.

Intake of Sugar-Sweetened Beverages in Adolescents from Troms, Norway-The Tromsø Study: Fit Futures

High intake of sugar-sweetened beverages (SSB) has been associated with weight gain and chronic disease. The objective of this paper was to study the intake of SSB and characteristics associated with SSB intake in adolescents from Troms, Norway. We present results from a cross-sectional analysis from the Tromsø Study: Fit Futures, with 426 female and 444 male students aged 15⁻17 years (93% participation rate). Descriptive statistics and logistic regression analyses were performed. Among females, 31.8% drank at least one glass of SSB per day on average, compared to 61.0% among males. The adjusted OR (odds ratio) of daily SSB drinking for males vs. females was 3.74 (95% CI (confidence interval) 2.68⁻5.22). Other dietary habits such as eating snacks, drinking artificially sweetened beverages, fruit juice, and seldom eating breakfast were associated with higher odds for daily SSB drinking, as was daily snuffing. Weight class was not associated with daily SSB drinking. Students in vocational studies, particularly males tended to be more likely to be daily SSB drinkers. The prevalence of participants who on average were daily drinkers was higher than in national studies. We have identified several possible targets for interventions. Clustering of unhealthy behaviours and tendencies to socioeconomic differences are of particular concern.

Diet and prevention of type 2 diabetes mellitus: beyond weight loss and exercise

INTRODUCTION

Insulin resistance (IR) and pancreatic beta-cell dysfunction are core pathophysiologic features of type 2 diabetes mellitus (T2DM). Select lifestyle and pharmacologic interventions, including weight loss, physical activity, a Mediterranean diet intervention, and hypoglycemic agents, have been shown to prevent or delay T2DM. However, dietary factors other than weight loss may also impact risk, mainly through effects to enhance insulin sensitivity, although some may also directly or indirectly impact pancreatic beta-cell function.

AREAS COVERED

A literature review of observational studies and randomized controlled trials (RCTs) was conducted, and the research indicates dietary factors showing promise for reducing T2DM risk include higher intakes of cereal fibers, unsaturated fatty acids, magnesium, and polyphenols (e.g. anthocyanins), while reducing dietary glycemic load, added sugars, and high-sugar beverages.

EXPERT COMMENTARY

While these dietary factors are mainly supported by evidence from observational studies and RCTs of surrogate markers for T2DM, they are consistent with current recommendations to emphasize consumption of whole grains, nuts, seeds, legumes, seafood, fruits, and vegetables, while limiting intakes of saturated fatty acids, refined carbohydrates, and processed meats. Additional dietary intervention RCTs are needed to assess the efficacy of these promising dietary interventions for delaying or preventing the onset of T2DM.

Examining changes in school vending machine beverage availability and sugar-sweetened beverage intake among Canadian adolescents participating in the COMPASS study: a longitudinal assessment of provincial school nutrition policy compliance and effectiveness

Background

School nutrition policies can encourage restrictions in sugar-sweetened beverage (SSB) availability in school food outlets in order to discourage students’ SSB intake. The main objective was to examine how beverage availability in school vending machines changes over three school years across schools in distinct school nutrition policy contexts. Secondary objectives were to examine how students’ weekday SSB intake varies with time and identify longitudinal associations between beverage availability and SSB intake.

Methods

This longitudinal study used data from the COMPASS study (2013/14–2015/16), representing 7679 students from 78 Canadian secondary schools and three provincial school nutrition policy contexts (Alberta – voluntary guidelines, Ontario public – mandatory guidelines, and Ontario private schools – no guidelines). We assessed availability of 10 beverage categories in schools’ vending machines via the COMPASS School Environment Application and participants’ intake of three SSB varieties (soft drinks, sweetened coffees/teas, and energy drinks) via a questionnaire. Hierarchical regression models were used to examine whether: i) progression of time and policy group were associated with beverage availability; and, ii) beverage availability was associated with students’ SSB intake.

Results

Ontario public schools were significantly less likely than the other policy groups to serve SSBs in their vending machines, with the exception of flavoured milks. Vending machine beverage availability was consistent over time. Participants’ overall SSB intake remained relatively stable; reductions in soft drink intake were partially offset by increased sweetened coffee/tea consumption. Relative to Ontario public schools, attending school in Alberta was associated with more frequent energy drink intake and overall SSB intake whereas attending an Ontario private school was associated with less frequent soft drink intake, with no differences in overall SSB intake. Few beverage availability variables were significantly associated with participants’ SSB intake.

Conclusions

Mandatory provincial school nutrition policies were predictive of more limited SSB availability in school vending machines. SSB intake was significantly lower in Ontario public and private schools, although we did not detect a direct association between SSB consumption and availability. The findings provide support for mandatory school nutrition policies, as well as the need for comprehensive school- and broader population-level efforts to reduce SSB intake.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0754-5) contains supplementary material, which is available to authorized users.

Risk factors for self-reported diabetes among Bhutanese adults: A nationally representative survey data analysis

Background

Bhutan, a small land-locked country in the eastern Himalayas has been undergoing an epidemiological and nutritional transition in the last two decades. The objective of this paper was to determine the prevalence and explore the risk factors of self-reported diabetes among Bhutanese adults.

Methods

We conducted a secondary data analysis among adults 18 years and older Bhutanese using the data from the National Health Survey 2012 (NHS, 2012) of Bhutan. The self-reported information on risk factors was obtained using standard protocols of the WHO STEPwise approach to Surveillance. The outcome of interest was self-reported diabetes on medication. Adjusted and unadjusted logistic regression analyses were performed to identify the risk factor of diabetes.

Results

A total of 31,066 participants aged 18 years and older were included for the analysis. The prevalence of self-reported hypertension was 1.8% (491). Risk factors for diabetes were: age groups: 35–44 years adjusted odds ratio (AOR) = 2.82 (95% CI, 1.07, 7.41), 45–54 years AOR = 6.02 (95% CI, 2.29, 15.83), 55–64 year AOR = 15.7 (95% CI 5.93, 41.55) and >65 years AOR = 19.60 (95% CI, 6.93, 55.71); high school and diploma/certificate education AOR = 2.57, (95% CI 1.62, 4.07) and AOR = 3.92 (95% CI 1.70, 9.07); and urban dwellers AOR = 2.37, (95% 1.58, 3.57); hypertension AOR = 3.3, (95% CI 2.47, 4.41); and fruit servings of 1–3 per week AOR = 1.63 (95% CI 1.15, 2.31).

Conclusion

The number of Bhutanese adults with diabetes and co-morbidities associated with it is likely to increase with the ageing of the population, nutrition transition, and high rural-urban migration in the near future. This calls for an urgent need to implement strategies to prevent diabetes in the Bhutanese population targeting risk factors including healthy lifestyle with increased physical activities and reduced smoking. At the same time treating other chronic morbidities including hypertension.

A multilevel, multicomponent childhood obesity prevention group-randomized controlled trial improves healthier food purchasing and reduces sweet-snack consumption among low-income African-American youth

BACKGROUND

Consumption of foods and beverages rich in sugar remains high across all races and ages in the United States. Interventions to address childhood obesity and decrease sugar intake are needed, particularly in low-income settings.

METHODS

B'more Healthy Communities for Kids (BHCK) was a group-randomized, controlled trial implemented among 9-15-year olds in 30 low-income areas of Baltimore. We increased access to low-sugar foods and beverages at wholesalers and small food stores. Concurrently, we encouraged their purchase and consumption by children through youth-led nutrition education in recreation centers, in-store promotions, text messaging and a social media program directed at caregivers. Sugar consumption (sugar sweetened beverage (SSB), sweets) in youth was assessed pre- (n = 534) and post-intervention (n = 401) using the Block Kids Food Frequency Questionnaire. Purchasing of 38 healthier and 28 less healthier food/beverage varieties in the previous 7 days was assessed via self-report. Multilevel models at the community and individual levels were used. Analyses were stratified by age (younger: 9-12-year olds (n = 339) vs older: 13-15 (n = 170)). Models were controlled for child's sex, race, total daily caloric intake, and caregiver's age and sex.

RESULTS

Overall baseline mean healthier food purchasing was 2.5 (+ 3.6; min. 0, max. 34 items per week), and unhealthier food purchasing 4.6 (+ 3.7; 0-19 items per week). Mean intake at baseline for kcal from SSB was 176 (+ 189.1) and 153 (+ 142.5), and % of calories from sweets (i.e. cookies, cakes, pies, donuts, candy, ice cream, sweetened cereals, and chocolate beverages) was 15.9 (+ 9.7) and 15.9 (+ 7.7) in comparison and intervention youth, respectively. Intervention youth increased healthier foods and beverages purchases by 1.4 more items per week than comparison youth (β = 1.4; 95% CI: 0.1; 2.8). After the intervention, there was a 3.5% decrease in kcal from sweets for older intervention youth, compared to the control group (β = - 3.5; 95% CI: -7.76; - 0.05). No impact was seen on SSB consumption.

CONCLUSION

BHCK successfully increased healthier food purchasing variety in youth, and decreased % calories from sweet snacks in older youth. Multilevel, multicomponent environmental childhood obesity programs are a promising strategy to improve eating behaviors among low-income urban youth.

TRIAL REGISTRATION

NCT02181010 (July 2, 2014, retrospectively registered).

Industry use of ‘better-for-you’ features on labels of sugar-containing beverages

Objective

To examine the ways in which sugar-containing beverages are being portrayed as ‘better-for-you’ (BFY) via features on product labels.

Design

Cross-sectional audit of beverage labels.

Setting

Adelaide, Australia. Data on beverage labels were collected from seventeen grocery stores during September to November 2016.

Subjects

The content of 945 sugar-containing beverages labels were analysed for explicit and implicit features positioning them as healthy or BFY.

Results

The mean sugar content of beverages was high at 8·3 g/100 ml and most sugar-containing beverages (87·7 %) displayed features that position them as BFY. This was most commonly achieved by indicating the beverages are natural (76·8 %), or contain reduced or natural energy/sugar content (48·4 %), or through suggesting that they contribute to meeting bodily needs for nutrition (28·9 %) or health (15·1 %). Features positioning beverages as BFY were more common among certain categories of beverages, namely coconut waters, iced teas, sports drinks and juices.

Conclusions

A large proportion of sugar-containing beverages use features on labels that position them as healthy or BFY despite containing high amounts of sugar.

The artificial sweetener Splenda intake promotes changes in expression of c-Fos and NeuN in hypothalamus and hippocampus of rats

BACKGROUND

Obesity is the result of the interaction of multiple variables, including the excessive increase of sugar-sweetened beverages consumption. Diets aimed to treat obesity have suggested the use of artificial sweeteners. However, recent evidence has shown several health deficits after intake of artificial sweeteners, including effects in neuronal activity. Therefore, the influence of artificial sweeteners consumption such as Splenda, on the expression of c-Fos and neuronal nuclear protein (NeuN) in hypothalamus and hippocampus remains to be determined.

OBJECTIVES

We investigated the effects on c-Fos or NeuN expression in hypothalamus and hippocampus of Splenda-treated rats.

METHODS

Splenda was diluted in water (25, 75 or 250 mg/100 mL) and orally given to rats during 2 weeks ad libitum. Next, animals were sacrificed by decapitation and brains were collected for analysis of c-Fos or NeuN immunoreactivity.

RESULTS

Consumption of Splenda provoked an inverted U-shaped dose-effect in c-Fos expression in ventromedial hypothalamic nucleus while similar findings were observed in dentate gyrus of hippocampus. In addition, NeuN immunoreactivity was enhanced in ventromedial hypothalamic nucleus at 25 or 75 mg/100 mL of Splenda intake whereas an opposite effect was observed at 250 mg/100 mL of artificial sweetener consumption. Lastly, NeuN positive neurons were increased in CA2/CA3 fields of hippocampus from Splenda-treated rats (25, 75 or 250 mg/100 mL).

CONCLUSION

Consuming Splenda induced effects in neuronal biomarkers expression. To our knowledge, this study is the first description of the impact of intake Splenda on c-Fos and NeuN immunoreactivity in hypothalamus and hippocampus in rats.

Low-Calorie Beverage Consumption, Diet Quality and Cardiometabolic Risk Factors in British Adults

Low-calorie beverages (LCBs) are promoted as healthy alternatives to sugar-sweetened beverages (SSBs); however, their effects on diet quality and cardiometabolic profile are debatable. This study aimed to verify the association between LCB consumption, diet quality and cardiometabolic risk factors in British adults. Data analysis from 5521 subjects aged 16 and older who participated in two waves of the National Diet and Nutrition Survey Rolling Programme (2008–2012 and 2013–2014) was carried out. Compared with SSB consumption, LCB consumption was associated with lower energy (mean difference: −173 kcal, 95% confidence interval, CI: −212; −133) and free sugar intake (−5.6% of energy intake, 95% CI: −6.1; −5.1), while intake of other nutrients was not significantly different across groups. The % difference in sugar intake was more pronounced among the young (16–24 years) (−7.3 of energy intake, 95% CI: −8.6; −5.9). The odds of not exceeding the UK-recommended free sugar intake were remarkably higher in the LCB as compared to the SSB group (OR: 9.4, 95% CI: 6.5–13.6). No significant differences were observed in plasma glucose, total cholesterol, LDL, HDL or triglycerides. Our findings suggest that LCBs are associated with lower free sugar intake without affecting the intake of other macronutrients or negatively impacting cardiometabolic risk factors.

Pathways and mechanisms linking dietary components to cardiometabolic disease: thinking beyond calories

Calories from any food have the potential to increase risk for obesity and cardiometabolic disease because all calories can directly contribute to positive energy balance and fat gain. However, various dietary components or patterns may promote obesity and cardiometabolic disease by additional mechanisms that are not mediated solely by caloric content. Researchers explored this topic at the 2017 CrossFit Foundation Academic Conference 'Diet and Cardiometabolic Health - Beyond Calories', and this paper summarizes the presentations and follow-up discussions. Regarding the health effects of dietary fat, sugar and non-nutritive sweeteners, it is concluded that food-specific saturated fatty acids and sugar-sweetened beverages promote cardiometabolic diseases by mechanisms that are additional to their contribution of calories to positive energy balance and that aspartame does not promote weight gain. The challenges involved in conducting and interpreting clinical nutritional research, which preclude more extensive conclusions, are detailed. Emerging research is presented exploring the possibility that responses to certain dietary components/patterns are influenced by the metabolic status, developmental period or genotype of the individual; by the responsiveness of brain regions associated with reward to food cues; or by the microbiome. More research regarding these potential 'beyond calories' mechanisms may lead to new strategies for attenuating the obesity crisis.

Prevalence of type 2 diabetes, prediabetes, and gestational diabetes mellitus in women of childbearing age in Middle East and North Africa, 2000-2017: protocol for two systematic reviews and meta-analyses

BACKGROUND

Diabetes mellitus (DM) in women of childbearing age may affect the fetus, thereby accelerating the intergenerational risk of DM. The Middle East and North Africa (MENA) region is experiencing a growing epidemic of DM. We aim to conduct two systematic reviews to summarize the burden of DM in women of childbearing age in the MENA region. In the systematic review 1, we aim to (1) systematically aggregate the evidence on type 2 DM (T2DM) and prediabetes and (2) to synthesize overall estimate on the prevalence of T2DM and overall estimate on the prevalence of prediabetes, in women of childbearing age (15-49 years). In the systematic review 2, we aim to (1) systematically aggregate the evidence on gestational DM (GDM) and (2) to synthesize overall estimate on the prevalence of GDM in pregnant women.

METHODS

For systematic reviews 1 and 2, we will conduct a comprehensive search of the literature published in six electronic databases (MEDLINE-PubMed, EMBASE, Web of Science, SCOPUS, Cochrane Library, and Academic Search Complete). Variant and broad search terms will be designed to identify epidemiologic studies on the prevalence of T2DM and prediabetes in women of childbearing age, and GDM in pregnant women, published between 2000 and 2017. The MENA region will be defined according to the World Bank Country and Lending Groups. Retrieved citations will be screened, and data from the eligible research reports against specific eligibility criteria will be extracted. The findings of each systematic review will be reported separately following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA).

DISCUSSION

Published literature on the prevalence of different types of DM among different population groups has been recently increased in the MENA region. This is the first review to fill an evidence gap on the overall burden, in the form of prevalence, of T2DM, prediabetes, and GDM in women of childbearing age in the MENA region. The findings of the two reviews will help in understanding the regional burden of these three types of DM in specific population groups to identify priority areas for interventions.

SYSTEMATIC REVIEW REGISTRATION

The PROSPERO registration number for the systematic review 1 is " CRD42017069231 " dated 12/06/2017 and for the systematic review 2 is " CRD42018100629 " dated 18/06/2018.

Acute saccharin infusion has no effect on renal glucose handling in normal rats in vivo

Artificial sweeteners are extensively used by the food industry to replace sugar in food and beverages and are widely considered to be a healthy alternative. However, recent data suggest that artificial sweeteners may impact intestinal glucose absorption and that they might lead to glucose intolerance. Moreover, chronic consumption of artificial sweeteners has also been linked to detrimental changes in renal function. Using an in vivo approach, our study aimed to determine if short-term infusion of the artificial sweetener saccharin can alter renal function and renal glucose absorption. We show that saccharin infusion does not induce any major change in GFR or urine flow rate at either the whole kidney or single nephron level, suggesting that any reported change in renal function with artificial sweeteners must depend on chronic consumption. As expected for a nondiabetic animal, glucose excretion was low; however, saccharin infusion caused a small, but significant, decrease in fractional glucose excretion. In contrast to the whole kidney data, our micropuncture results did not show any significant difference in fractional glucose reabsorption in either the proximal or distal tubules, indicating that saccharin does not influence renal glucose handling in vivo under euglycemic conditions. In keeping with this finding, protein levels of the renal glucose transporters SGLT1 and SGLT2 were also unchanged. In addition, saccharin infusion in rats undergoing a glucose tolerance test failed to induce a robust change in renal glucose excretion or renal glucose transporter expression. In conclusion, our results demonstrate that saccharin does not induce acute physiologically relevant changes in renal function or renal glucose handling.

Sugar sweetened beverages and cardiometabolic health

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Calorie Intake and Gambling: Is Fat and Sugar Consumption 'Impulsive'?

Excessive calorie intake constitutes a global public health concern, due to its associated range of untoward outcomes. Gambling is commonplace and gambling disorder is now considered a behavioral addiction in DSM-5. The relationships between calorie intake, gambling, and other types of putatively addictive and impulsive behaviors have received virtually no research attention. Two-hundred twenty-five young adults who gamble were recruited from two Mid-Western university communities in the United States using media advertisements. Dietary intake over the preceding year was quantified using the Dietary Fat and Free Sugar Short questionnaire (DFS). Clinician rating scales, questionnaires, and cognitive tests germane to impulsivity were completed. Relationships between dietary fat/sugar intake and gambling behaviors, as well as other measures of psychopathology and cognition germane to addiction, were evaluated using correlational analyses controlling for multiple comparisons. Greater dietary fat and sugar intake were associated with lower educational levels and with male gender. Controlling for these variables, higher dietary fat and sugar intake were correlated significantly with worse gambling pathology and anxiety scores. Dietary sugar intake was also significantly associated with higher depressive scores, more alcohol intake, lower self-esteem, and with greater risk of having one or more mental disorders in general. Dietary intake did not correlate significantly with ADHD symptoms, presence of one or more impulse control disorders, Barratt impulsiveness, or cognitive functioning. These data suggest a particularly strong relationship between fat/sugar intake and symptoms of gambling pathology, but not most other forms of impulsivity and behavioral addiction (excepting alcohol intake). Providing education about healthy diet may be especially valuable in gamblers and in community settings where gambling advertisements feature prominently. Future work should explore the mediating mechanisms between calorie intake and gambling symptoms, such as whether this could be driven by environmental factors (e.g. advertising) or common dysfunction of brain reward pathways.

Attenuation of the association between sugar-sweetened beverages and diabetes risk by adiposity adjustment: a secondary analysis of national health survey data

Purpose

While weight gain and obesity are the dominant factors, dietary sugar and specifically sugar-sweetened beverages (SSB) has been implicated in causing type 2 diabetes (T2DM). We assessed how much of the apparent effect of SSB is explained by adiposity, but not captured by adjustment for BMI, which is a poor index of body fat.

Methods

We examined data from 5187 adults (mean age 50.8 years, SD = 16.4, 172 (3.3%) T2DM), from the Scottish Health Survey 2003 and 2008–2010 databases. Logistic regression was used to assess the association between SSB consumption and T2DM (non-insulin treated) and its attenuation (reduction in odds ratios, ORs), after entering published anthropometric indices of adiposity into the regression model, adjusted for age, sex, social class, education, smoking, alcohol consumption and physical activity.

Results

Compared with low SSB categories (“less often/never”, once/week or 1–3 times/month), the OR without adiposity adjustment for having T2DM in high SSB consumers (2–3, 4–5, ≥ 6/day) was 2.56 (95% CI 1.12–5.83; p = 0.026). That OR was marginally changed by adjusting for BMI (+ 4.3%), WC (+ 5.5%) or total body fat (− 4.3%), but greatly attenuated by adjusting for estimated %body fat (− 23.4%). These indices had similar influences on the associations between SSB and T2DM combining known T2DM patients with unknown HbA_1c > 6.5%, > 48 mmol/mol.

Conclusions

Associations between SSB and T2DM are attenuated more markedly by adjustment with estimated %body fat than with BMI, indicating an adiposity effect not captured using BMI. Future research should employ best available estimates of adiposity.

Characterization of the Degree of Food Processing in Relation With Its Health Potential and Effects

Up today technological processes are intended to produce safe and palatable food products. Yet, it is also expected that processing produces healthy and sustainable foods. However, due to the dramatic increase of chronic diseases prevalence worldwide, i.e., obesity, type 2 diabetes, cardiovascular diseases, and some cancers, ultraprocessing has been pointed out as producing unhealthy foods, rich in energy and poor in protective micronutrients and fiber, i.e., "empty" calories. Indeed the 1980s saw massive arrivals of ultraprocessed foods in supermarkets, i.e., fractionated-recombined foods with added ingredients and/or additives. Epidemiological studies clearly emphasized that populations adhering the most to ultraprocessed foods, e.g., processed meat, refined grains, ultraprocessed plant-based foods, and/or sweetened beverages, exhibited the higher prevalence of chronic diseases. This prompted researchers to classify foods according to their degree of processing as with the international NOVA classification (i.e., un/minimally processed, processed, and ultraprocessed foods). More and more studies showed that such a classification makes sense for health. Overall one distinguishes three categories of processes: mechanical, thermal, and fermentative treatments, this latter being the more favorable to food health potential. This chapter has therefore several ambitions: (1) to review association between degree of food processing and chronic disease risk prevalence; (2) to explore the impact of technological processes on food health potential considering both matrix and compositional effects; (3) to discuss the need for classifying food according to their degree of processing in future epidemiological studies; and (4) to analyze consequences of adhering to a more holistic paradigm in both food processing and nutrition.

Associations Between Nonnutritive Sweetener Intake and Metabolic Syndrome in Adults

OBJECTIVE

Individuals looking to improve their health or weight status often use nonnutritive sweeteners (NNS), yet NNS consumption has been associated with increased risk factors for metabolic syndrome (MetS). Most studies examining NNS only assess total intake using diet soda as a proxy for NNS consumption, without distinguishing potential risks associated with individual sweeteners. The objective of this cross-sectional investigation was to identify whether there were associations between NNS consumption (total or individual) and risk factors for MetS in adults (n = 125) from Southwest Virginia.

METHODS

Participants provided three 24-hour dietary recalls and blood pressure, waist circumference, fasting glucose, triglycerides, and high-density lipoprotein cholesterol were assessed. Linear regression models, adjusted for age, sex, caloric intake, dietary quality, and physical activity, examined associations between total and individual types of NNS with MetS and MetS risk factors.

RESULTS

Sixty-three participants were classified as NNS consumers and eighteen met the criteria for MetS. While no significant associations between MetS and NNS consumption were found, waist circumference was positively associated with total NNS, saccharin, sucralose, and acesulfame potassium, and both fasting glucose and triglyceride values were positively associated with total NNS and aspartame consumption.

CONCLUSION

While these cross-sectional data are consistent with previous work implicating NNS in development of MetS, additional research using randomized controlled trials is needed to clarify whether and how NNS in general or specific NNS might contribute to risk factors for MetS. This trial was registered at clinicaltrials.gov (NCT03364452).

Burden and trend of diet-related non-communicable diseases in Australia and comparison with 34 OECD countries, 1990-2015: findings from the Global Burden of Disease Study 2015

BACKGROUND

Diet is a major determining factor for many non-communicable chronic diseases (NCDs). However, evidence on diet-related NCD burden remains limited. We assessed the trends in diet-related NCDs in Australia from 1990 to 2015 and compared the results with other countries of the Organization for Economic Co-operation and Development (OECD).

METHODS

We used data and methods from the Global Burden of Disease (GBD) 2015 study to estimate the NCD mortality and disability-adjusted life years (DALYs) attributable to 14 dietary risk factors in Australia and 34 OECD nations. Countries were further ranked from the lowest (first) to highest (35th) burden using an age-standardized population attributable fraction (PAF).

RESULTS

In 2015, the estimated number of deaths attributable to dietary risks was 29,414 deaths [95% uncertainty interval (UI) 24,697 - 34,058 or 19.7% of NCD deaths] and 443,385 DALYs (95% UI 377,680-511,388 or 9.5% of NCD DALYs) in Australia. Young (25-49 years) and middle-age (50-69 years) male adults had a higher PAF of diet-related NCD deaths and DALYs than their female counterparts. Diets low in fruits, vegetables, nuts and seeds and whole grains, but high in sodium, were the major contributors to both NCD deaths and DALYs. Overall, 42.3% of cardiovascular deaths were attributable to dietary risk factors. The age-standardized PAF of diet-related NCD mortality and DALYs decreased over the study period by 28.2% (from 27.0% in 1990 to 19.4% in 2015) and 41.0% (from 14.3% in 1990 to 8.4% in 2015), respectively. In 2015, Australia ranked 12th of 35 examined countries in diet-related mortality. A small improvement of rank was recorded compared to the previous 25 years.

CONCLUSIONS

Despite a reduction in diet-related NCD burden over 25 years, dietary risks are still the major contributors to a high burden of NCDs in Australia. Interventions targeting NCDs should focus on dietary behaviours of individuals and population groups.

Effects of Social Norms Information and Self-Affirmation on Sugar-Sweetened Beverage Consumption Intentions and Behaviors

The separate and combined efficacy of a social norms and a self-affirmation intervention to motivate decreased sugar-sweetened beverage (SSB) consumption was examined in two experiments. College students were randomly assigned to receive information about SSB consumption risks, norms, both, or neither. In addition, participants performed either a self-affirmation or control task. Self-affirmation only weakly affected SSB consumption intentions and behaviors. However, participants in Experiment 2 who received risks information, norms information, or both reported greater SSB reduction intentions than did those who received no information. Two-weeks later, those who received both types of information reported more frequent behavior change preparations, and it appears this effect may have been partially mediated by the changes in intentions to reduce SSB consumption.

Noncaloric Sweeteners in Children: A Controversial Theme

Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.

Intake of non-nutritive sweeteners is associated with an unhealthy lifestyle: a cross-sectional study in subjects with morbid obesity

Background

Subjects with morbid obesity commonly use Non-Nutritive Sweeteners (NNS), but the health-related effects of NNS have been questioned. The objectives of this study were to explore the associations between theuse of NNS and the health and lifestyle in subjects with morbid obesity.

Methods

This cross-sectional study included subjects with morbid obesity (BMI ≥ 40 kg/m² or ≥35 kg/m² with obesity-related comorbidity). Information about demographics, physical and mental health, and dietary habits was collected, and a blood screen was taken. One unit of NNS was defined as 100 ml beverages with NNS or 2 tablets/units of NNS for coffee or tea. The associations between the intake of NNS and the health-related variables were analyzed with ordinal regression analyses adjusted for age, gender and BMI.

Results

One hundred subjects (women/men 83/17; mean age 44.3 years (SD 8.5)) were included. Median intake of NNS was 3.3 units (range 0 - 43). Intake of NNS was not associated with BMI (p = 0.64). The intake of NNS was associated with reduced heavy physical activity (p = 0.011), fatigue (p < 0.001), diarrhea (p = 0.009) and reduced well-being (p = 0.046); with increased intake of total energy (p = 0.003), fat (p = 0.013), carbohydrates (p = 0.002), sugar (p = 0.003) and salt (p = 0.001); and with reduced intake of the vitamins A (p = 0.001), C (p = 0.002) and D (p = 0.016).

Conclusions

The use of NNS-containing beverages was associated with an unhealthy lifestyle, reduced physical and mental health and unfavourable dietary habits with increased energy intake including sugar, and reduced intake of some vitamins.

Health outcomes of non-nutritive sweeteners: analysis of the research landscape

BACKGROUND

Food products containing non-nutritive sweeteners (NNSs) instead of sugar have become increasingly popular in the last decades. Their appeal is obviously related to their calorie-free sweet taste. However, with the dramatic increase in their consumption, it is reasonable and timely to evaluate their potential health benefits and, more importantly, potential adverse effects. The main aim of this scoping review was to map the evidence about health outcomes possibly associated with regular NNS consumption by examining the extent, range, and nature of research activity in this area.

METHODS

We systematically searched Ovid MEDLINE, EMBASE and the Cochrane CENTRAL databases for studies on NNSs (artificial sweeteners or natural, non-caloric sweeteners, either used individually or in combination) using text terms with appropriate truncation and relevant indexing terms. All human studies investigating any health outcomes of a NNS intervention or exposure were eligible for inclusion. No studies were excluded based on language, study design or methodological quality. Data for each health outcome were summarized in tabular form and were discussed narratively.

RESULTS

Finally, we included 372 studies in our scoping review, comprising 15 systematic reviews, 155 randomized controlled trials (RCTs), 23 non-randomized controlled trials, 57 cohort studies, 52 case-control studies, 28 cross sectional studies and 42 case series/case reports. In healthy subjects, appetite and short term food intake, risk of cancer, risk of diabetes, risk of dental caries, weight gain and risk of obesity are the most investigated health outcomes. Overall there is no conclusive evidence for beneficial and harmful effects on those outcomes. Numerous health outcomes including headaches, depression, behavioral and cognitive effects, neurological effects, risk of preterm delivery, cardiovascular effects or risk of chronic kidney disease were investigated in fewer studies and further research is needed. In subjects with diabetes and hypertension, the evidence regarding health outcomes of NNS use is also inconsistent.

CONCLUSIONS

This scoping review identifies the needs for future research to address the numerous evidence gaps related to health effects of NNSs use.It also specifies the research questions and areas where a systematic review with meta-analyses is required for the proper evaluation of health outcomes associated to regular NNSs consumption.

Globalisation and national trends in nutrition and health: A grouped fixed-effects approach to intercountry heterogeneity

Using a panel dataset of 70 countries spanning 42 years (1970-2011), we investigate the distinct effects of social globalisation and trade openness on national trends in markers of diet quality (supplies of animal proteins, free fats and sugar, average body mass index, and diabetes prevalence). Our key methodological contribution is the application of a grouped fixed-effects estimator, which extends linear fixed-effects models. The grouped fixed-effects estimator partitions our sample into distinct groups of countries in order to control for time-varying unobserved heterogeneity that follows a group-specific pattern. We find that increasing social globalisation has a significant impact on the supplies of animal protein and sugar available for human consumption, as well as on mean body mass index. Specific components of social globalisation such as information flows (via television and the Internet) drive these results. Trade openness has no effect on dietary outcomes or health. These findings suggest that the social and cultural aspects of globalisation should receive greater attention in research on the nutrition transition.

The impact of low and no-caloric sweeteners on glucose absorption, incretin secretion, and glucose tolerance

The consumption of non-nutritive, low, or no-calorie sweeteners (LCS) is increasing globally. Previously thought to be physiologically inert, there is a growing body of evidence that LCS not only provide a sweet taste but may also elicit metabolic effects in the gastrointestinal tract. This review provides a brief overview of the chemical and receptor-binding properties and effects on chemosensation of different LCS but focuses on the extent to which LCS stimulates glucose transport, incretin and insulin secretion, and effects on glucose tolerance. Aspartame and sucralose both bind to a similar region of the sweet receptor. For sucralose, the data are contradictory regarding effects on glucose tolerance in humans and may depend on the food or beverage matrix and the duration of administration, as suggested by longer term rodent studies. For aspartame, there are fewer data. On the other hand, acesulfame-potassium (Ace-K) and saccharin have similar binding characteristics to each other but, while Ace-K may increase incretin secretion and glucose responses in humans, there are no data on saccharin except in rats, which show impaired glucose tolerance after chronic administration. Additional research, particularly of the effects of chronic consumption, is needed to provide concrete evidence for beneficial or detrimental effects of LCS on blood glucose regulation in humans.

Dietary intake and factors influencing eating behaviours in overweight and obese South Asian men living in the UK: mixed method study

OBJECTIVE

It is widely recognised that South Asian men living in the UK are more likely to develop type 2 diabetes mellitus (T2DM) than their white British counterparts. Despite this, limited data have been published quantifying current dietary intake patterns and qualitatively exploring eating behaviours in this population. The objectives of this study were to (1) assess diet, (2) explore perceptions of T2DM, (3) investigate factors influencing eating behaviours in overweight/obese South Asian men and (4) determine the suitability of the UK Diet and Diabetes Questionnaire (UKDDQ) for use in this population.

SETTING

Community-based setting in the Greater London, UK area.

PARTICIPANTS

South Asian men aged 18-64 years, with a body mass index of over 23.0 kg/m², not previously diagnosed with T2DM.

METHODS

A cross-sectional mixed-methods design, including assessment of dietary intake using UKDDQ (n=63), followed by semistructured interviews in a purposive sample (n=36).

RESULTS

UKDDQ scores indicated 54% of participants had a 'healthy' diet with a mean sample score of 3.44±0.43 out of a maximum of 5. Oily fish consumption was low (1.84±1.85). Body weight was positively associated with a high-added sugar subscore (r=0.253, p=0.047), with 69.8% of the men having 'unhealthy' intakes of sugar-sweetened beverages. Cultural commitments (eg, extended family and faith events), motivation and time were identified as key barriers to dietary change, with family support an important facilitator to making healthy dietary changes. Participants stated that UKDDQ was suitable for assessing diets of South Asians and made suggestions for tailoring questions related to rice consumption, providing examples of Indian sweets, and including ghee as a fat source.

CONCLUSION

Many of the areas of dietary improvement and factors affecting eating behaviours identified in this study are similar to those observed in the general UK population. Consumption of sugar-sweetened beverages in particular was high; given the association between their consumption and the risk of T2DM, this should be an area of primary focus for healthcare professionals. Nevertheless, there are sociocultural factors unique to this population that need to be considered when designing culturally specific programs to reduce the development of T2DM in this high-risk population.

Application of Liquid Chromatography-Tandem Mass Spectrometry To Determine Urinary Concentrations of Five Commonly Used Low-Calorie Sweeteners: A Novel Biomarker Approach for Assessing Recent Intakes?

Although the use of low-calorie sweeteners (LCSs) is widespread, methods of assessing consumption within free-living populations have inherent limitations. Five commonly consumed LCSs, namely, acesulfame-K, saccharin, sucralose, cyclamate, and steviol glycosides, are excreted via the urine, and therefore a urinary biomarker approach may provide more objective LCS intake data. A LC-ESI-MS/MS method of simultaneously determining acesulfame-K, saccharin, sucralose, cyclamate, and the excretory metabolite of steviol glycosides, steviol glucuronide, in human urine was developed and validated. Linearity was observed over a concentration range of 10-1000 ng/mL with coefficients of determination ranging from 0.9969 to 0.9997. Accuracy ranged from 92 to 104%, and intrabatch and interday precisions were within acceptable limits with %CV below 8% for all compounds. A double-blind, randomized crossover dose-response study was conducted to assess the usefulness of urinary LCS excretions (from both fasting spot and a full 24-h urine collection) for investigating recent intakes. Both modes of sampling were useful for distinguishing between the three short-term intakes of acesulfame-K, saccharin, cyclamates, and steviol glycosides (p < 0.001), whereas for sucralose, urinary concentrations were useful for distinguishing between low (0.1% ADI) and high doses (10% ADI) only (p < 0.001). In summary, this biomarker approach may be useful for assessing intakes of five commonly consumed LCSs.

Dietary Patterns Derived by Reduced Rank Regression Are Inversely Associated with Type 2 Diabetes Risk across 5 Ethnic Groups in the Multiethnic Cohort

Background: Reduced rank regression (RRR) is an approach to identify dietary patterns associated with biochemical markers and risk of type 2 diabetes (T2D). Objective: We aimed to derive dietary patterns associated with adiponectin, leptin, C-reactive protein (CRP), and triglycerides (TGs) and to examine the prospective associations of these patterns with T2D risk in 5 ethnic/racial groups with differences in T2D rates. Methods: The Multiethnic Cohort (MEC) included 215,831 African-American, Japanese-American, Latino, Native Hawaiian, and white adults living in Hawaii and California who completed a validated quantitative food-frequency questionnaire in 1993-1996. T2D status was based on self-report with confirmation by administrative data. Serum CRP and TGs and plasma adiponectin and leptin were measured ∼10 y after baseline in a subset (n = 10,008) of participants. RRR was applied to dietary data and biomarker information of 10,008 MEC participants in the combined population and in each ethnic/racial group. RRR-derived dietary patterns, simplified by removal of foods that were not found to be important, were subsequently evaluated for association with T2D risk in 155,316 cohort members (8687 incident T2D cases diagnosed by 2010) by using Cox proportional hazards regression. Results: Combining ethnic/racial groups, we identified a dietary pattern low in processed and red meat, sugar-sweetened beverages, diet soft drinks, and white rice and high in whole grains, fruit, yellow-orange vegetables, green vegetables, and low-fat dairy that was inversely associated with CRP, TGs, and leptin and positively related to adiponectin. Comparing extreme tertiles, the dietary pattern predicted a 16-28% significantly lower T2D risk in the combined study population and also separately in African Americans, Japanese Americans, Latinos, Native Hawaiians, and whites. Ethnicity-specific derived patterns varied only modestly from the overall pattern and resulted in comparable associations with T2D. Conclusion: This identified dietary pattern may lower T2D risk through its impact on adipokines, by lowering chronic inflammation and dyslipidemia across 5 ethnic/racial groups.

The Health and Working Conditions of Women Employed in Child Care

Over one million women are employed in child care and are among the lowest wage workers in the US. The health and working conditions of 674 child care workers (118 administrators and 556 staff) from 74 centers is described using baseline data from a larger intervention trial. Participants were 39.9 (±13.0) years old; 55.4% African American, 37.1% Caucasian, and 5.3% of Hispanic ethnicity. Seventy-six percent reported having an Associate’s degree or less; 42% were classified as at or below poverty (<$20,000); and exhibited many health risks such as excess weight, insufficient activity, poor diet, and inadequate sleep. We investigated potential differences by income and job category. Lower income participants were significantly more likely to be current smokers (19.9% vs. 11.7%), drink more sweetened beverages (1.9 vs. 1.5), and report higher depressive symptoms (15.5 vs. 12.6). Administrators worked more hours weekly compared to staff (46.4 vs. 40.6), are less active (100 vs. 126 min/week), more sedentary (501 vs. 477 min/day), and reported higher job demands (13.3 vs. 12.5). Given the numerous health issues and challenging work conditions, we hope our results serve as a call to action for addressing low wages and the work environment as a means of influencing the health and well-being of child care workers.

Effects and Mechanisms of Fruit and Vegetable Juices on Cardiovascular Diseases

Many studies have indicated that consumption of vegetables and fruits are positively related to lower incidence of several chronic noncommunicable diseases. Although composition of fruit and vegetable juices is different from that of the edible portion of fruits and vegetables, they contain polyphenols and vitamins from fruits and vegetables. Drinking vegetable and fruit juices is very popular in many countries, and also an efficient way to improve consumption of fruits and vegetables. The studies showed that fruit and vegetable juices affect cardiovascular risk factors, such as lowering blood pressure and improving blood lipid profiles. The main mechanisms of action included antioxidant effects, improvement of the aspects of the cardiovascular system, inhibition of platelet aggregation, anti-inflammatory effects, and prevention of hyperhomocysteinemia. Drinking juices might be a potential way to improve cardiovascular health, especially mixtures of juices because they contain a variety of polyphenols, vitamins, and minerals from different fruits and vegetables. This review summarizes recent studies on the effects of fruit and vegetable juices on indicators of cardiovascular disease, and special attention is paid to the mechanisms of action.

A prospective study of water intake and subsequent risk of all-cause mortality in a national cohort

BACKGROUND

Water, an essential nutrient, is believed to be related to a variety of health outcomes. Published studies have examined the association of fluid or beverage intake with risk of mortality from coronary diseases, diabetes, or cancer, but few studies have examined the association of total water intake with all-cause mortality.

OBJECTIVE

We examined prospective risk of mortality from all causes in relation to intakes of total water and each of the 3 water sources.

DESIGN

We used public-domain, mortality-linked water intake data from the NHANES conducted in 1988-1994 and 1999-2004 for this prospective cohort study (n = 12,660 women and 12,050 men; aged ≥25 y). Mortality follow-up was completed through 31 December 2011. We used sex-specific Cox proportional hazards regression methods that were appropriate for complex surveys to examine the independent associations of plain water, beverage water, water in foods, and total water with multiple covariate-adjusted risk of mortality from all causes.

RESULTS

Over a median of 11.4 y of follow-up, 3504 men and 3032 women died of any cause in this cohort. In men, neither total water intake nor each of the individual water source variables (plain water, water in beverages, and water in foods) was independently related with risk of all-cause mortality. In women, risk of mortality increased slightly in the highest quartile of total or plain water intake but did not approach the Bonferroni-corrected level of significance of P < 0.002.

CONCLUSIONS

There was no survival advantage in association with higher total or plain water intake in men or women in this national cohort. The slight increase in risk of mortality noted in women with higher total and plain water intakes may be spurious and requires further investigation.

The website-based eaTracker®‘My Goals’ feature: a qualitative evaluation

Objective

In 2011, Dietitians of Canada added ‘My Goals’ to its website-based nutrition/activity tracking program (eaTracker®,http://www.eaTracker.ca/); this feature allows users to choose ‘ready-made’ or ‘write-your-own’ goals and to self-report progress. The purpose of the present study was to document experiences and perceptions of goal setting and My Goals, and report users’ feedback on what is needed in future website-based goal setting/tracking tools.

Design

One-on-one semi-structured interviews were conducted with (i) My Goals users and (ii) dietitians providing a public information support service, EatRight Ontario (ERO).

Setting

My Goals users from Ontario and Alberta, Canada were recruited via an eaTracker website pop-up box; ERO dietitians working in Ontario, Canada were recruited via ERO.

Subjects

My Goals users (n23; age 19–70 years; 91 % female;n5 from Alberta/n18 from Ontario) and ERO dietitians (n5).

Results

Dietitians and users felt goal setting for nutrition (and activity) behaviour change was both a beneficial and a challenging process. Dietitians were concerned about users setting poor-quality goals and users felt it was difficult to stick to their goals. Both users and dietitians were enthusiastic about the My Goals concept, but felt the current feature had limitations that affected use. Dietitians and users provided suggestions to improve My Goals (e.g. more prominent presence of My Goals in eaTracker; assistance with goal setting; automated personalized feedback).

Conclusions

Dietitians and users shared similar perspectives on the My Goals feature and both felt goal use was challenging. Several suggestions were provided to enhance My Goals that are relevant to website-based goal setting/tracking tool design in general.

The impact of dietary risk factors on the burden of non-communicable diseases in Ethiopia: findings from the Global Burden of Disease study 2013

BACKGROUND

The burden of non-communicable diseases (NCDs) has increased in sub-Saharan countries, including Ethiopia. The contribution of dietary behaviours to the NCD burden in Ethiopia has not been evaluated. This study, therefore, aimed to assess diet-related burden of disease in Ethiopia between 1990 and 2013.

METHOD

We used the 2013 Global Burden of Disease (GBD) data to estimate deaths, years of life lost (YLLs) and disability-adjusted life years (DALYs) related to eight food types, five nutrients and fibre intake. Dietary exposure was estimated using a Bayesian hierarchical meta-regression. The effect size of each diet-disease pair was obtained based on meta-analyses of prospective observational studies and randomized controlled trials. A comparative risk assessment approach was used to quantify the proportion of NCD burden associated with dietary risk factors.

RESULTS

In 2013, dietary factors were responsible for 60,402 deaths (95% Uncertainty Interval [UI]: 44,943-74,898) in Ethiopia-almost a quarter (23.0%) of all NCD deaths. Nearly nine in every ten diet-related deaths (88.0%) were from cardiovascular diseases (CVD) and 44.0% of all CVD deaths were related to poor diet. Suboptimal diet accounted for 1,353,407 DALYs (95% UI: 1,010,433-1,672,828) and 1,291,703 YLLs (95% UI: 961,915-1,599,985). Low intake of fruits and vegetables and high intake of sodium were the most important dietary factors. The proportion of NCD deaths associated with low fruit consumption slightly increased (11.3% in 1990 and 11.9% in 2013). In these years, the rate of burden of disease related to poor diet slightly decreased; however, their contribution to NCDs remained stable.

CONCLUSIONS

Dietary behaviour contributes significantly to the NCD burden in Ethiopia. Intakes of diet low in fruits and vegetables and high in sodium are the leading dietary risks. To effectively mitigate the oncoming NCD burden in Ethiopia, multisectoral interventions are required; and nutrition policies and dietary guidelines should be developed.

The effect of changing the built environment on physical activity: a quantitative review of the risk of bias in natural experiments

BACKGROUND

Evidence regarding the association of the built environment with physical activity is influencing policy recommendations that advocate changing the built environment to increase population-level physical activity. However, to date there has been no rigorous appraisal of the quality of the evidence on the effects of changing the built environment. The aim of this review was to conduct a thorough quantitative appraisal of the risk of bias present in those natural experiments with the strongest experimental designs for assessing the causal effects of the built environment on physical activity.

METHODS

Eligible studies had to evaluate the effects of changing the built environment on physical activity, include at least one measurement before and one measurement of physical activity after changes in the environment, and have at least one intervention site and non-intervention comparison site. Given the large number of systematic reviews in this area, studies were identified from three exemplar systematic reviews; these were published in the past five years and were selected to provide a range of different built environment interventions. The risk of bias in these studies was analysed using the Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI).

RESULTS

Twelve eligible natural experiments were identified. Risk of bias assessments were conducted for each physical activity outcome from all studies, resulting in a total of fifteen outcomes being analysed. Intervention sites included parks, urban greenways/trails, bicycle lanes, paths, vacant lots, and a senior citizen's centre. All outcomes had an overall critical (n = 12) or serious (n = 3) risk of bias. Domains with the highest risk of bias were confounding (due to inadequate control sites and poor control of confounding variables), measurement of outcomes, and selection of the reported result.

CONCLUSIONS

The present review focused on the strongest natural experiments conducted to date. Given this, the failure of existing studies to adequately control for potential sources of bias highlights the need for more rigorous research to underpin policy recommendations for changing the built environment to increase physical activity. Suggestions are proposed for how future natural experiments in this area can be improved.

A retrospective analysis of real-world use of the eaTracker® My Goals website by adults from Ontario and Alberta, Canada

Background

Little is known about use of goal setting and tracking tools within online programs to support nutrition and physical activity behaviour change. In 2011, Dietitians of Canada added “My Goals,” a nutrition and physical activity behaviour goal setting and tracking tool to their free publicly available self-monitoring website (eaTracker® (http://www.eaTracker.ca/)). My Goals allows users to: a) set “ready-made” SMART (Specific, Measurable, Attainable, Realistic, Time-related) goals (choice of n = 87 goals from n = 13 categories) or “write your own” goals, and b) track progress using the “My Goals Tracker.” The purpose of this study was to characterize: a) My Goals user demographics, b) types of goals set, and c) My Goals Tracker use.

Methods

Anonymous data on all goals set using the My Goals feature from December 6/2012-April 28/2014 by users ≥19y from Ontario and Alberta, Canada were obtained. This dataset contained: anonymous self-reported user demographic data, user set goals, and My Goals Tracker use data. Write your own goals were categorized by topic and specificity. Data were summarized using descriptive statistics. Multivariate binary logistic regression was used to determine associations between user demographics and a) goal topic areas and b) My Goals Tracker use.

Results

Overall, n = 16,511 goal statements (75.4 % ready-made; 24.6 % write your own) set by n = 8,067 adult users 19-85y (83.3 % female; mean age 41.1 ± 15.0y, mean BMI 28.8 ± 7.6kg/m²) were included for analysis. Overall, 33.1 % of ready-made goals were from the “Managing your Weight” category. Of write your own goal entries, 42.3 % were solely distal goals (most related to weight management); 38.6 % addressed nutrition behaviour change (16.6 % had unspecific general eating goals); 18.1 % addressed physical activity behaviour change (47.3 % had goals without information on exercise amount and type). Many write your own goals were poor quality (e.g., non-specific (e.g., missing amounts)), and possibly unrealistic (e.g., no sugar). Few goals were tracked (<10 %). Demographic variables had statistically significant relations with goal topic areas and My Goals Tracker use.

Conclusions

eaTracker® users had high interest in goal setting and the My Goals feature, however, self-written goals were often poor quality and goal tracking was rare. Further research is needed to better support users.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3640-6) contains supplementary material, which is available to authorized users.