Low/no calorie sweetened beverage consumption in the National Weight Control Registry

Patterns and Predictors of Low-Calorie Sweetener Consumption during Pregnancy: Findings from a National Survey

Recently, the World Health Organization recommended avoiding low-calorie sweeteners (LCS) during pregnancy due to concerns that it may be linked to adverse pregnancy outcomes and offspring wellbeing. This study examined the patterns and predictors of LCS consumption among pregnant women in Australia. A survey was conducted among 422 pregnant women aged 18-50 years. Sociodemographic, lifestyle, dietary intake including LCS consumption, pregnancy-related characteristics, and awareness about the health effects of LCS were assessed. We used latent class analysis and multinomial logistic regression to identify LCS consumption patterns and predictors of consumption patterns, respectively. The mean (SD) age of the women was 30 (4.6) years. Three LCS consumption patterns were identified: infrequent or non-consumers representing 50% of the women, moderate consumers encompassing 40% of the women, and the remaining were habitual consumers. Over two-thirds (71%) of women were not aware of the potential adverse effects of LCS, and only a quarter of them were concerned about the possible adverse effects on their health and their offspring. Increasing age and living with a medical condition decreased the likelihood of moderate consumption by 7% and 55%, respectively. Frequent sugar-sweetened beverage consumption and gestational diabetes predicted habitual LCS consumption. This research suggested widespread LCS consumption among pregnant women in Australia, but lower awareness of its potential adverse health effects. Interventions to increase awareness of potential adverse effects are warranted.

Updated systematic assessment of human, animal and mechanistic evidence demonstrates lack of human carcinogenicity with consumption of aspartame

Aspartame has been studied extensively and evaluated for its safety in foods and beverages yet concerns for its potential carcinogenicity have persisted, driven primarily by animal studies conducted at the Ramazzini Institute (RI). To address this controversy, an updated systematic review of available human, animal, and mechanistic data was conducted leveraging critical assessment tools to consider the quality and reliability of data. The evidence base includes 12 animal studies and >40 epidemiological studies reviewed by the World Health Organization which collectively demonstrate a lack of carcinogenic effect. Assessment of >1360 mechanistic endpoints, including many guideline-based genotoxicity studies, demonstrate a lack of activity associated with endpoints grouped to key characteristics of carcinogens. Other non-specific mechanistic data (e.g., mixed findings of oxidative stress across study models, tissues, and species) do not provide evidence of a biologically plausible carcinogenic pathway associated with aspartame. Taken together, available evidence supports that aspartame consumption is not carcinogenic in humans and that the inconsistent findings of the RI studies may be explained by flaws in study design and conduct (despite additional analyses to address study limitations), as acknowledged by authoritative bodies.

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.

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.

COUNTERPOINT: Artificial Sweeteners for Obesity-Better than Sugary Alternatives; Potentially a Solution

OBJECTIVE

Nonnutritive (NNSs) are used in place of sugars to reduce caloric and glycemic intake while providing desired sweetness, commonly replacing sugar-sweetened beverages (SSBs) with "diet" (zero-calorie) alternatives. Concern has developed due to observational data associating NNSs with obesity and adiposity-based chronic disease. This counterpoint argues that, in general, NNSs used in place of added or excess sugars in the diet are likely beneficial.

METHODS

A literature review was conducted on interventional trials investigating NNSs and obesity or type 2 diabetes mellitus. Key words used in the search included artificial sweeteners, nonnutritive sweeteners, saccharin, sucralose, aspartame, stevia/steviol, acesulfame potassium, meal replacements, type 2 diabetes mellitus, obesity, and weight.

RESULTS

Interventional data and indirect interventional data consistently showed beneficial effects on weight and cardiometabolic health, including glycemia, when SSBs or other energy-dense foods were replaced by artificially sweetened beverages or artificially sweetened meal replacements.

CONCLUSION

Although NNSs correlate with obesity and adiposity-based chronic disease, those data are fraught with confounding and error. Plausibility has been suggested on the basis of preclinical research on neuroendocrine control of appetite, satiety, and cravings plus the gut microbiome. However, interventional data reveal that replacing caloric/glycemic energy intake via NNSs creates an energy deficit resulting in weight loss and improvement in disease-especially dysglycemic disease. Intensive dietary intervention using artificially sweetened meal replacements shows a marked clinical benefit without detriment from their NNSs. Furthermore, beverages sweetened with NNSs rather than SSBs have been noted to be a critical component for those succeeding in maintaining weight loss. Although individual responses to the effects of NNSs are always warranted just like in any clinical situation, patients should not be advised to avoid NNSs in the context of dietary intervention to improve quality and energy deficit.

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.

Physical Activity, Sleep, and Sedentary Behavior among Successful Long-Term Weight Loss Maintainers: Findings from a U.S. National Study

Despite adults’ desire to reduce body mass (weight) for numerous health benefits, few are able to successfully lose at least 5% of their starting weight. There is evidence on the independent associations of physical activity, sedentary behaviors, and sleep with weight loss; however, this study provided insight on the combined effects of these behaviors on long-term body weight loss success. Hence, the purpose of this cross-sectional study was to evaluate the joint relations of sleep, physical activity, and sedentary behaviors with successful long-term weight loss. Data are from the 2005–2006 wave of the National Health and Examination Survey (NHANES). Physical activity and sedentary behavior were measured with an accelerometer, whereas sleep time was self-reported. Physical activity and sleep were dichotomized into meeting guidelines (active/not active, ideal sleep/short sleep), and sedentary time was categorized into prolonged sedentary time (4th quartile) compared to low sedentary time (1st–3rd quartiles). The dichotomized behaviors were combined to form 12 unique behavioral combinations. Two-step multivariable regression models were used to determine the associations between the behavioral combinations with (1) long-term weight loss success (≥5% body mass reduction for ≥12-months) and (2) the amount of body mass reduction among those who were successful. After adjustment for relevant factors, there were no significant associations between any of the independent body weight loss behaviors (physical activity, sedentary time, and sleep) and successful long-term weight loss. However, after combining the behaviors, those who were active (≥150 min MVPA weekly), regardless of their sedentary time, were significantly (p < 0.05) more likely to have long-term weight loss success compared to the inactive and sedentary referent group. These results should be confirmed in longitudinal analyses, including investigation of characteristics of waking (type, domain, and context) and sleep (quality metrics) behaviors for their association with long-term weight loss success.

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).

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.

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

Overconsumption of added sugars is a key contributor to the growing obesity, prediabetes, and type 2 diabetes pandemics. The nutrition therapy guidance of the American Diabetes Association recognizes that using low- and no-calorie sweeteners (LNCS) to reduce consumption of added sugars can reduce low-nutrient-density sources of calories and carbohydrate to beneficially affect glycemia, weight, and cardiometabolic health. This article provides information for primary care providers, diabetes care and education specialists, and other diabetes clinicians on the safety of LNCS and summarizes research evidence on the role of LNCS in glycemic and weight management. It also provides practical strategies for counseling individuals about how to integrate LNCS into their healthy eating pattern.

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.

Successful weight loss maintenance: A systematic review of weight control registries

Weight loss maintenance is a major challenge for obesity treatment. Weight control registries can be useful in identifying psychological and behavioural factors that could contribute to better long-term success. The objective of this study is to describe the existing weight control registries and their participants and identify correlates of weight loss maintenance. A comprehensive search of peer-reviewed articles published until November 2018 was conducted in PubMed, Web of Science, and Scopus. Studies that reported results from weight control registries were considered. Fifty-two articles, corresponding to five registries (the United States, Portugal, Germany, Finland, and Greece), were included. Registries differed in inclusion criteria and procedures. Of 51 identified weight loss and maintenance strategies, grouped in 14 domains of the Oxford Food and Activity Behaviors taxonomy, the following were the most frequently reported: having healthy foods available at home, regular breakfast intake, increasing vegetable consumption, decreasing sugary and fatty foods, limiting certain foods, and reducing fat in meals. Increased physical activity was the most consistent positive correlate of weight loss maintenance. To our knowledge, this is the first systematic review of information about successful weight loss maintenance obtained from weight control registries. Key common influential characteristics of success were identified, which can inform future prospective studies and weight management initiatives.

SWEET MAPS: A Conceptualization of Low-Calorie Sweetener Consumption Among Young Adults

BACKGROUND

The extent to which low-calorie sweeteners (LCSs) are helpful or harmful for weight management and metabolic health is unclear, because LCS effects may depend on the context in which they are consumed.

OBJECTIVE

To develop a conceptual framework for LCS consumption.

METHODS

Young adults ages 18-35 y, who reported LCS consumption, were recruited from a private, urban, university in the mid-Atlantic United States. Concept mapping, a mixed-method approach was used to identify, organize, and quantify determinants of LCS consumption. First, participants (n = 68) identified reasons for their LCS consumption through brainstorming; content analysis of those reasons identified 37 specific determinants of LCS consumption. Second, participants (n = 93) sorted all 37 determinants conceptually. Third, participants (n = 97) rated the extent to which each of the 37 determinants was reflective of their own consumption. Similarity matrices, multidimensional scaling, and hierarchical cluster analysis produced a series of 2-dimensional concept maps (SWEET MAPS).

RESULTS

The SWEET MAPS identified 37 determinants, organized within 8 factors reflective of 3 overarching motives: perceived health benefits, palatability, and accessibility of LCSs. At the determinant level, the most highly rated determinants that exceeded the boundary (rating >3.0) were: "I want something that tastes sweet," "I am trying to maintain/control my weight," "They contain fewer calories," "They are available," and "I want to save calories because I am eating a high-calorie meal."

CONCLUSIONS

LCS consumption is a function of many inter-related determinants spanning biological, psychological, and social domains. The SWEET MAPS are an important and novel use of concept mapping methods that can be used to inform the design and interpretation of future studies evaluating LCS effects.

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.

Examining the pattern of new foods and beverages consumed during obesity treatment to inform strategies for self-monitoring intake

Maintaining dietary self-monitoring during obesity treatment may improve outcomes. As dietary variety is associated with energy intake, understanding the pattern of when new foods and beverages are consumed may assist with identifying when self-monitoring should occur. This study examined dietary variety (total number of differing foods and beverages consumed) from the first 40 days of self-monitoring records reporting ≥ 3 eating occasions and >600 kcal/day from 60 adults (55.9 ± 9.1 yrs, 35.1 ± 5.3 kg/m², 80.0% female, 95.0% white) participating in a smartphone-based, lifestyle intervention. Dietary variety was coded using an ingredient-based approach. Additionally, new flavors of previously consumed items, and modified and non-modified items contributed to variety. Total number of different foods and beverages consumed over 40 coded days (cumulative variety [cv₄₀]); number of days to reach 50%, 75%, and 100% of cv₄₀; cv₄₀ by eating occasions; and mean number of new items consumed on weekdays and weekend days were calculated. CV₄₀ was 145.4 ± 33.5. Number of coded days to consume 50%, 75%, and 100% of cv₄₀ was 12.7, 25.1, and 40.0, respectively. Dinner was greater (p < 0.0001) in cv₄₀ (58.6 ± 18.5 different items) than other eating occasions, and lunch was greater (p < 0.0001) (38.8 ± 10.7 different items) than breakfast and snack. Weekend days had a greater mean number of new items consumed than weekdays, (3.8 ± 1.0 items vs. 3.6 ± 0.9 items, p = 0.035). Variety of items consumed during obesity treatment is high, and to capture the majority of differing items consumed, at least 4 weeks of detailed recording is needed. After this, to capture new foods and beverages consumed, self-monitoring dinners, lunch, and weekend days may be helpful.

Aspartame Consumption for 12 Weeks Does Not Affect Glycemia, Appetite, or Body Weight of Healthy, Lean Adults in a Randomized Controlled Trial

Background

Low-calorie sweeteners are often used to moderate energy intake and postprandial glycemia, but some evidence indicates that they may exacerbate these aims.

Objective

The trial's primary aim was to assess the effect of daily aspartame ingestion for 12 wk on glycemia. Effects on appetite and body weight were secondary aims.

Methods

One hundred lean [body mass index (kg/m2): 18-25] adults aged 18-60 y were randomly assigned to consume 0, 350, or 1050 mg aspartame/d (ASP groups) in a beverage for 12 wk in a parallel-arm design. At baseline, body weight and composition were determined, a 240-min oral-glucose-tolerance test (OGTT) was administered, and measurements were made of appetite and selected hormones. Participants also collected a 24-h urine sample. During the intervention, the 0-mg/d ASP group consumed capsules containing 680 mg dextrose and 80 mg para-amino benzoic acid. For the 350-mg/d ASP group, the beverage contained 350 mg aspartame and the 1050-mg/d ASP group consumed the same beverage plus capsules containing 680 mg dextrose and 700 mg aspartame. Body weight, blood pressure, heart rate, and waist circumference were measured weekly. At weeks 4, 8, and 12, participants collected 24-h urine samples and kept appetite logs. Baseline measurements were repeated at week 12.

Results

With the exception of the baseline OGTT glucose concentration at 60 min (and resulting area under the curve value), there were no group differences for glucose, insulin, resting leptin, glucagon-like peptide 1, or gastric inhibitory peptide at baseline or week 12. There also were no effects of aspartame ingestion on appetite, body weight, or body composition. Compliance with the beverage intervention was ∼95%.

Conclusions

Aspartame ingested at 2 doses for 12 wk had no effect on glycemia, appetite, or body weight among healthy, lean adults. These data do not support the view that aspartame is problematic for the management of glycemia, appetite, or body weight. This trial was registered at www.clinicaltrials.gov as NCT02999321.

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.

Is There an Optimal Diet for Weight Management and Metabolic Health?

Individuals can lose body weight and improve health status on a wide range of energy (calorie)-restricted dietary interventions. In this paper, we have reviewed the effectiveness of the most commonly utilized diets, including low-fat, low-carbohydrate, and Mediterranean approaches, in addition to commercial slimming programs, meal replacements, and newly popularized intermittent fasting diets. We also consider the role of artificial sweeteners in weight management. Low-fat diets tend to improve low-density lipoprotein cholesterol the most, while lower-carbohydrate diets may preferentially improve triglycerides and high-density lipoprotein cholesterol. However, differences between diets are marginal. Weight loss improves almost all obesity-related co-morbidities and metabolic markers, regardless of the macronutrient composition of the diet, but individuals do vary in preferences and ability to adhere to different diets. Optimizing adherence is the most important factor for weight loss success, and this is enhanced by regular professional contact and supportive behavioral change programs. Maintaining weight losses in the long term remains the biggest challenge, and is undermined by an "obesogenic" environment and biological adaptations that accompany weight loss.

Beverage Intake and Metabolic Syndrome Risk Over 14 Years: The Study of Women's Health Across the Nation

BACKGROUND

Alcohol and energy-dense beverages consumption have been implicated in cardiometabolic disease, albeit inconsistently.

OBJECTIVE

This study tested prospective associations between intakes of alcohol, energy-dense beverages, and low-calorie beverages and cardiometabolic risk in midlife women.

DESIGN

The Study of Women's Health Across the Nation is a 14-year, multisite prospective cohort study (1996-2011). Beverage intake and cardiometabolic risk factors that define the metabolic syndrome (hypertension, abdominal obesity, impaired fasting glucose, low high-density lipoprotein cholesterol level, and hypertriglyceridemia) were assessed throughout follow-up.

PARTICIPANTS/SETTING

Participants (N=1,448) were African American, Chinese, Japanese, and non-Hispanic white midlife women from six US cities.

MAIN OUTCOME MEASURES

The primary outcomes were incident metabolic syndrome and the individual metabolic syndrome components.

STATISTICAL ANALYSES PERFORMED

Generalized linear mixed models tested associations between intakes within each beverage category and odds of meeting criteria for metabolic syndrome and each of the metabolic syndrome components.

RESULTS

Energy-dense beverage consumption was highest among African-American women and lowest among women with college degrees. Non-Hispanic white women consumed the largest quantities of alcohol. Independent of energy intake and potential confounders, each additional 355 mL energy-dense beverages consumed per day was associated with higher odds of developing metabolic syndrome in each successive year of follow-up (odds ratio [OR] 1.05, 95% CI 1.02 to 1.08). Greater energy-dense beverage intake was associated with more rapidly increasing odds of developing hypertension (OR 1.06, 95% CI 1.02 to 1.11) and abdominal obesity (OR 1.10, 95% CI 1.03 to 1.16) over time, but not with the other metabolic syndrome components. Intakes of alcohol and low-calorie coffees, teas, and diet cola were not associated with metabolic syndrome risk.

CONCLUSIONS

Over 14 years of follow-up, energy-dense nonalcoholic beverage consumption was associated with incident metabolic syndrome in midlife women. The observed differences in intakes by ethnicity/race and education suggest that consumption of these beverages may contribute to disparities in risk factors for diabetes and cardiovascular disease.

Long-Term Weight Maintenance Strategies Are Experienced as a Burden by Persons Who Have Lost Weight Compared to Persons with a lifetime Normal, Stable Weight

OBJECTIVE

To assess dietary intake, eating patterns, physical activity and eating behaviors, and to explore strategies and perceptions of the experience of weight maintenance in weight loss maintainers (weight loss maintenance (WLM) ≥ 10% weight loss maintained for ≥1 year) and in matched controls with a lifetime stable normal weight.

METHODS

Volunteers (32) were recruited by a snowball procedure in this cross-sectional, mixed-methods study. Diet, physical activity, and eating behaviors were assessed with validated questionnaires. Strategies and experiences were investigated during interviews. Descriptive coding, thematic analysis (qualitative data) as well as descriptive analysis and t-tests (quantitative data) were performed.

RESULTS

Both groups had similar energy and macronutrient consumption. Those in the WLM group reported higher levels of exercise and scored higher on several dimensions of eating disorders. Four themes - 'food choices,' 'quantities and portion control,' 'physical activity', and 'burden' - emerged from the qualitative data. Both groups used similar weight maintenance strategies, but those in the WLM group experienced a higher burden, expressing effortful control which contrasted with the control group's confidence in their internal cues.

CONCLUSION

Our results show an additional burden related with maintaining weight loss compared to keeping a stable normal weight. They provide evidence to devise interventions that will address the difficulty of regulating intake.

Trends in the consumption of low-calorie sweeteners

Low-calorie sweeteners (LCS) offer a palatable alternative to caloric sugars such as sucrose (table sugar) and high fructose corn syrup and are commonly found in soft drinks, sweetener packets, grains, snack foods, dairy products, hygiene products, and medications. Consumption of LCS has increased significantly in recent years and while this trend is expected to continue, controversy exists surrounding their use. The purpose of this article is to review trends in the consumption of LCS, to summarize differences in LCS consumption across socio-demographic subgroups and subtypes of LCS-containing products, and to highlight important challenges in the accurate assessment of LCS consumption.

Low Calorie Sweetener (LCS) use and energy balance

For thirty years there has been a debate about whether low calorie sweeteners (LCS) provide a benefit for body weight management. Early studies showed that when consumed alone in a beverage appetite and food intake were increased. Some, observational longitudinal cohort studies reported an association between LCS usage and increasing BMI, suggesting that LCS may actually promote weight gain. In the ensuing decades numerous additional observational and experimental trials have been conducted with the experimental trials nearly uniformly showing a benefit for LCS, either in weight loss or weight gain prevention. The observational trials have been more inconsistent with two recent meta-analyses indicating either a small positive association between LCS usage and BMI (weighted group mean correlation, p=0.03) or an inverse association with body weight change (-1.35 kg, p=.004). Numerous potential mechanisms have been explored, mostly in animal models, in an attempt to explain this association but none have yet been proven in humans. It is also possible that the association between LCS and BMI increase in the observational studies may be due to reverse causality or residual confounding. Randomized controlled trials are consistent in showing a benefit of LCS which suggests that simple behavioral engagement by individuals attempting to control their weight is a sufficiently strong signal to overcome any potential mechanism that might act to promote energy intake and weight gain. Based on existing evidence, LCS can be a useful tool for people actively engaged in managing their body weight for weight loss and maintenance.

The use of low-calorie sweeteners is associated with self-reported prior intent to lose weight in a representative sample of US adults

BACKGROUND

Low-calorie sweeteners (LCSs) are said to be a risk factor for obesity and diabetes. Reverse causality may be an alternative explanation.

METHODS

Data on LCS use, from a single 24-h dietary recall, for a representative sample of 22 231 adults were obtained from 5 cycles of the National Health and Nutrition Examination Survey (1999-2008 NHANES). Retrospective data on intent to lose or maintain weight during the prior 12-months and 10-year weight history were obtained from the weight history questionnaire. Objectively measured heights and weights were obtained from the examination. Primary analyses evaluated the association between intent to lose/maintain weight and use of LCSs and specific LCS product types using survey-weighted generalized linear models. We further evaluated whether body mass index (BMI) may mediate the association between weight loss intent and use of LCSs. The association between 10-year weight history and current LCS use was evaluated using restricted cubic splines.

RESULTS

In cross-sectional analyses, LCS use was associated with a higher prevalence of obesity and diabetes. Adults who tried to lose weight during the previous 12 months were more likely to consume LCS beverages (prevalence ratio=1.64, 95% confidence interval (CI) 1.54-1.75), tabletop LCS (prevalence ratio=1.68, 95% CI 1.47-1.91) and LCS foods (prevalence ratio=1.93, 95% CI 1.60-2.33) as compared with those who did not. In mediation analyses, BMI only partially mediated the association between weight control history and the use of LCS beverages, tabletop LCS, but not LCS foods. Current LCS use was further associated with a history of prior weight change (for example, weight loss and gain).

CONCLUSIONS

LCS use was associated with self-reported intent to lose weight during the previous 12 months. This association was only partially mediated by differences in BMI. Any inference of causality between attempts at weight control and LCS use is tempered by the cross-sectional nature of these data and retrospective self-reports of prior weight loss/maintenance intent.

The effects of water and non-nutritive sweetened beverages on weight loss and weight maintenance: A randomized clinical trial

OBJECTIVE

To evaluate the effects of water versus beverages sweetened with non-nutritive sweeteners (NNS) on body weight in subjects enrolled in a year-long behavioral weight loss treatment program.

METHODS

The study used a randomized equivalence design with NNS or water beverages as the main factor in a trial among 303 weight-stable people with overweight and obesity. All participants participated in a weight loss program plus assignment to consume 24 ounces (710 ml) of water or NNS beverages daily for 1 year.

RESULTS

NNS and water treatments were non-equivalent, with NNS treatment showing greater weight loss at the end of 1 year. At 1 year subjects receiving water had maintained a 2.45 ± 5.59 kg weight loss while those receiving NNS beverages maintained a loss of 6.21 ± 7.65 kg (P < 0.001 for difference).

CONCLUSIONS

Water and NNS beverages were not equivalent for weight loss and maintenance during a 1-year behavioral treatment program. NNS beverages were superior for weight loss and weight maintenance in a population consisting of regular users of NNS beverages who either maintained or discontinued consumption of these beverages and consumed water during a structured weight loss program. These results suggest that NNS beverages can be an effective tool for weight loss and maintenance within the context of a weight management program.

Weight maintenance: challenges, tools and strategies for primary care physicians

Obesity is recognized as a chronic disease and one of the major healthcare challenges facing us today. Weight loss can be achieved via lifestyle, pharmacological and surgical interventions, but weight maintenance remains a lifetime challenge for individuals with obesity. Guidelines for the management of obesity have highlighted the role of primary care providers (PCPs). This review examines the long-term outcomes of clinical trials to identify effective weight maintenance strategies that can be utilized by PCPs. Because of the broad nature of the topic, a structured PubMed search was conducted to identify relevant research articles, peer-reviewed reviews, guidelines and articles published by regulatory bodies. Trials have demonstrated the benefit of sustained weight loss in managing obesity and its comorbidities. Maintaining 5-10% weight loss for ≥1 year is known to ameliorate many comorbidities. Weight maintenance with lifestyle modification - although challenging - is possible but requires long-term support to reinforce diet, physical activity and behavioural changes. The addition of pharmacotherapy to lifestyle interventions promotes greater and more sustained weight loss. Clinical evidence and recently approved pharmacotherapy has given PCPs improved strategies to support their patients with maintenance of weight loss. Further studies are needed to assess the translation of these strategies into clinical practice.

Challenging obesity: Patient, provider, and expert perspectives on the roles of available and emerging nonsurgical therapies

OBJECTIVE

Adult obesity is recognized as a chronic disease. According to principles of chronic disease management, healthcare professionals should work collaboratively with patients to determine appropriate therapeutic strategies that address overweight and obesity, specifically considering a patient's disease status in addition to their individual needs, preferences, and attitudes regarding treatment. A central role and responsibility of healthcare professionals in this process is to inform and educate patients about their treatment options. Although current recommendations for the management of adult obesity provide general guidance regarding safe and proper implementation of lifestyle, pharmacological, and surgical interventions, healthcare professionals need awareness of specific evidence-based information that supports individualized clinical application of these therapies. More specifically, healthcare professionals should be up-to-date on approaches that promote successful lifestyle management and be knowledgeable about newer weight loss pharmacotherapies, so they can offer patients with obesity a wide range of options to personalize their treatment. Accordingly, this educational activity has been developed to provide participants with the latest information on treatment recommendations and therapeutic advances in lifestyle intervention and pharmacotherapy for adult obesity management.

DESIGN AND METHODS

This supplement is based on the content presented at a live CME symposium held in conjunction with ObesityWeek 2014.

RESULTS

This supplement provides an expert summary of current treatment recommendations and recent advances in nonsurgical therapies for the management of adult obesity. Patient and provider perspectives on obesity management are highlighted in embedded video clips available via QR codes, and new evidence will be applied using clinically relevant case studies.

CONCLUSIONS

This supplement provides a topical update of obesity management, including clinical practice examples, for healthcare professionals who treat or provide care for adults with obesity.