Energy compensation following consumption of sugar-reduced products: a randomized controlled trial

Change in liking following reduction in sweetness level of carbonated beverages: a randomized controlled parallel trial

Despite recommendations to reduce sweet-tasting foods and beverage consumption, there is limited understanding of our ability to adapt to a less sweet diet and the optimal method for doing so. Thus, we conducted two parallel, double-blind, randomized controlled trials in the USA and Mexico to investigate whether different methods of reducing sweetness could change sweetness preferences. Over 6 months, habitual consumers of full-sugar sweetened (FSS-CSD) or low-calorie sweetened carbonated soft drinks (LCS-CSD) consumed a full sweetness CSD (Control), CSD with gradually decreasing sweetness levels (StepR), and a reduced sweetness test CSD (DirR). The StepR and DirR methods were similarly effective in helping the USA FSS-CSD cohort maintain their preference for reduced-sweetness CSD, without affecting sweetness intensity perception. However, neither method significantly impacted the sweetness intensity perception or preference of the USA LCS-CSD cohort, and the FSS-CSD and LCS-CSD cohorts in Mexico. Nevertheless, participants from both sweetness reduction groups in all cohorts were more willing to purchase reduced sweetness CSD compared to Control, underscoring the potential for consumer acceptance of less sweet beverages regardless of adaptation strategies.This trial was registered at www.clinicaltrials.gov as NCT04609657 and NCT05010408.

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

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

Important food sources of fructose-containing sugars and adiposity: A systematic review and meta-analysis of controlled feeding trials

BACKGROUND

Sugar-sweetened beverages (SSBs) providing excess energy increase adiposity. The effect of other food sources of sugars at different energy control levels is unclear.

OBJECTIVES

To determine the effect of food sources of fructose-containing sugars by energy control on adiposity.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library were searched through April 2022 for controlled trials ≥2 wk. We prespecified 4 trial designs by energy control: substitution (energy-matched replacement of sugars), addition (energy from sugars added), subtraction (energy from sugars subtracted), and ad libitum (energy from sugars freely replaced). Independent authors extracted data. The primary outcome was body weight. Secondary outcomes included other adiposity measures. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the certainty of evidence.

RESULTS

We included 169 trials (255 trial comparisons, n = 10,357) assessing 14 food sources at 4 energy control levels over a median 12 wk. Total fructose-containing sugars increased body weight (MD: 0.28 kg; 95% CI: 0.06, 0.50 kg; P_MD = 0.011) in addition trials and decreased body weight (MD: -0.96 kg; 95% CI: -1.78, -0.14 kg; P_MD = 0.022) in subtraction trials with no effect in substitution or ad libitum trials. There was interaction/influence by food sources on body weight: substitution trials [fruits decreased; added nutritive sweeteners and mixed sources (with SSBs) increased]; addition trials [dried fruits, honey, fruits (≤10%E), and 100% fruit juice (≤10%E) decreased; SSBs, fruit drink, and mixed sources (with SSBs) increased]; subtraction trials [removal of mixed sources (with SSBs) decreased]; and ad libitum trials [mixed sources (with/without SSBs) increased]. GRADE scores were generally moderate. Results were similar across secondary outcomes.

CONCLUSIONS

Energy control and food sources mediate the effect of fructose-containing sugars on adiposity. The evidence provides a good indication that excess energy from sugars (particularly SSBs at high doses ≥20%E or 100 g/d) increase adiposity, whereas their removal decrease adiposity. Most other food sources had no effect, with some showing decreases (particularly fruits at lower doses ≤10%E or 50 g/d). This trial was registered at clinicaltrials.gov as NCT02558920 (https://clinicaltrials.gov/ct2/show/NCT02558920).

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

BACKGROUND

Fructose-containing sugars as sugar-sweetened beverages (SSBs) may increase inflammatory biomarkers. Whether this effect is mediated by the food matrix at different levels of energy is unknown. To investigate the role of food source and energy, we conducted a systematic review and meta-analysis of controlled trials on the effect of different food sources of fructose-containing sugars on inflammatory markers at different levels of energy control.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched through March 2022 for controlled feeding trials ≥ 7 days. Four trial designs were prespecified by energy control: substitution (energy matched replacement of sugars); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced). The primary outcome was C-reactive protein (CRP). Secondary outcomes were tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). Independent reviewers extracted data and assessed risk of bias. GRADE assessed certainty of evidence.

RESULTS

We identified 64 controlled trials (91 trial comparisons, n = 4094) assessing 12 food sources (SSB; sweetened dairy; sweetened dairy alternative [soy]; 100% fruit juice; fruit; dried fruit; mixed fruit forms; sweetened cereal grains and bars; sweets and desserts; added nutritive [caloric] sweetener; mixed sources [with SSBs]; and mixed sources [without SSBs]) at 4 levels of energy control over a median 6-weeks in predominantly healthy mixed weight or overweight/obese adults. Total fructose-containing sugars decreased CRP in addition trials and had no effect in substitution, subtraction or ad libitum trials. No effect was observed on other outcomes at any level of energy control. There was evidence of interaction/influence by food source: substitution trials (sweetened dairy alternative (soy) and 100% fruit juice decreased, and mixed sources (with SSBs) increased CRP); and addition trials (fruit decreased CRP and TNF-α; sweets and desserts (dark chocolate) decreased IL-6). The certainty of evidence was moderate-to-low for the majority of analyses.

CONCLUSIONS

Food source appears to mediate the effect of fructose-containing sugars on inflammatory markers over the short-to-medium term. The evidence provides good indication that mixed sources that contain SSBs increase CRP, while most other food sources have no effect with some sources (fruit, 100% fruit juice, sweetened soy beverage or dark chocolate) showing decreases, which may be dependent on energy control.

CLINICALTRIALS

gov: (NCT02716870).

Association between dietary saturated fat with cardiovascular disease risk markers and body composition in healthy adults: findings from the cross-sectional BODYCON study

Background

Diets high in saturated fatty acids (SFAs) and greater abdominal obesity are both associated with raised low-density lipoprotein cholesterol (LDL-C) concentrations, an independent cardiovascular disease (CVD) risk marker. Although reducing SFA intake is a public health strategy for CVD prevention, the role of body fat distribution on the relationship between SFA and LDL-C is unclear. Therefore, our objective was to investigate whether the association between dietary SFAs and LDL-C concentrations is related to body composition.

Methods

In the BODYCON (impact of physiological and lifestyle factors on body composition) study, 409 adults [mean age 42 ± 16 years and median BMI of 23.5 (21.5–25.9) kg/m²] underwent a measure of body composition by dual energy x-ray absorptiometry, assessment of habitual dietary intake using a 4-day weighed food diary and physical activity level using a tri-axial accelerometer. Blood pressure was measured, and a fasting blood sample was collected to determine cardiometabolic disease risk markers. Correlations between body composition, circulating risk markers and dietary macronutrients were assessed prior to multivariate regression analysis. The effect of increasing intakes of dietary SFA on outcome measures was assessed using ANCOVA after adjusting for covariates.

Results

Abdominal visceral adipose tissue (VAT) mass was moderately positively correlated with total cholesterol (TC), LDL-C, systolic blood pressure (SBP), diastolic blood pressure and HOMA-IR (r_s = 0.25–0.44, p < 0.01). In multiple regression analysis, 18.3% of the variability in LDL-C was explained by SFA intake [% total energy (TE)], abdominal VAT mass, carbohydrate%TE and fat%TE intakes. When data were stratified according to increasing SFA%TE intakes, fasting TC, LDL-C and non-high-density lipoprotein-cholesterol were higher in Q4 compared with Q2 (p ≤ 0.03). SBP was higher in Q4 versus Q3 (p = 0.01). Android lean mass was also higher in Q3 versus Q1 (p = 0.02). Other anthropometric and CVD risk markers were not different across quartile groups.

Conclusions

Although dietary SFA was found to explain 9% of the variability in LDL-C, stratification of data according to quartiles of SFA intake did not reveal a dose-dependent relationship with LDL-C concentration. Furthermore, this association appeared to be independent of abdominal obesity in this cohort.

Clinical Trail registration: Trial registration: clinicaltrials.gov as NCT02658539. Registered 20 January 2016, https://clinicaltrials.gov/ct2/show/NCT02658539.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-022-00650-y.

Tolerable upper intake level for dietary sugars

Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50-75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15-50% probability) and very low for hypertension (0-15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

High versus low-added sugar consumption for the primary prevention of cardiovascular disease

BACKGROUND

High intake of added sugar have been suggested to impact the risk for cardiovascular disease (CVD). Knowledge on the subject can contribute to preventing CVD.

OBJECTIVES

To assess the effects of a high versus low-added sugar consumption for primary prevention of CVD in the general population.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) on 2 July 2021. We also conducted a search of ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) Search Portal for ongoing or unpublished trials. The search was performed together with reference checking, citation searching and contact with study authors to identify additional studies. We imposed no restriction on language of publication or publication status.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cross-over trials, that compared different levels of added sugar intake. Exclusion criteria were: participants aged below 18 years; diabetes mellitus (type 1 and 2); and previous CVD. Primary outcomes were incident cardiovascular events (coronary, carotid, cerebral and peripheral arterial disease) and all-cause mortality. Secondary outcomes were changes in systolic and diastolic blood pressure, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, fasting plasma glucose and adverse events (gastrointestinal symptoms and impaired dental health).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 21 RCTs (1110 participants completing the interventions) examining the effects of different levels of added sugar intake with a mean duration of 14 weeks. The study participants were generally described as healthy and the mean age ranged from 22 to 57 years. No studies reported on cardiovascular events or all-cause mortality. There was minimal effect of low intake of added sugar on total cholesterol levels (MD 0.11, 95% CI 0.01 to 0.21; I² = 0%; 16 studies; 763 participants; low certainty of evidence) and triglycerides (MD 0.10, 95% CI 0.03 to 0.17; I² = 3%; 14 studies; 725 participants) but no evidence of effect on LDL-cholesterol and HDL-cholesterol. There was minimal effect on diastolic blood pressure (MD 1.52, 95% CI 0.67 to 2.37; I² = 0%; 13 studies; 873 participants) and on systolic blood pressure (MD 1.44, 95% 0.08 to 2.80; I² = 27%, 14 studies; 873 participants; low certainty of evidence), but no evidence of effect on fasting plasma glucose. Only one study reported on dental health, with no events. No other trials reported adverse events (impaired dental health or gastrointestinal symptoms). All results were judged as low-quality evidence according to GRADE. The risk of bias was generally unclear, five studies were classified at an overall low risk of bias (low risk in at least four domains, not including other bias).

AUTHORS' CONCLUSIONS

No trials investigating the effect of added sugar on cardiovascular events or all-cause mortality were identified in our searches. Evidence is uncertain whether low intake of added sugar has an effect on risk factors for CVD; the effect was small and the clinical relevance is, therefore, uncertain. Practical ways to achieve reductions in dietary added sugar includes following current dietary recommendations. Future trials should have longer follow-up time and report on all-cause mortality and cardiovascular events in order to clarify the effect of added sugar on these outcomes. Future trials should also aim for more direct interventions and preferably be more independent of industry funding.

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.

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).

What is the impact of food reformulation on individuals' behaviour, nutrient intakes and health status? A systematic review of empirical evidence

Food reformulation aimed at improving the nutritional properties of food products has long been viewed as a promising public health strategy to tackle poor nutrition and obesity. This paper presents a review of the empirical evidence (i.e., modelling studies were excluded) on the impact of food reformulation on food choices, nutrient intakes and health status, based on a systematic search of Medline, Embase, Global Health and sources of grey literature. Fifty-nine studies (in 35 papers) were included in the review. Most studies examined food choices (n = 27) and dietary intakes (n = 26). The nutrients most frequently studied were sodium (n = 32) and trans fatty acids (TFA, n = 13). Reformulated products were generally accepted and purchased by consumers, which led to improved nutrient intakes in 73% of studies. We also conducted two meta-analyses showing, respectively, a -0.57 g/day (95%CI, -0.89 to -0.25) reduction in salt intake and an effect size for TFA intake reduction of -1.2 (95% CI, -1.79 to -0.61). Only six studies examined effects on health outcomes, with studies on TFA reformulation showing overall improvement in cardiovascular risk factors. For other nutrients, it remains unclear whether observed improvements in food choices or nutrient intakes may have led to an improvement in health outcomes.

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.

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

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

Effects on weaned male Wistar rats after 104, 197, and 288 days of chronic consumption of nutritive and non-nutritive additives in water

Abstract

It has been suggested that the consumption of artificial sweeteners is related to greater body mass gain and diverse metabolic alterations. In this study, the effect of chronic consumption of nutritive sweeteners (fructose 7% and sucrose 10%) and non-nutritive or low-calorie sweeteners (acesulfame 0.015%, aspartame 0.3%, aspartame:acesulfame mixture 0.04%, saccharin 0.3%, and sucralose 0.19%), in drinking water, as well as a control group with no sweeteners, was evaluated. Body mass gain and glucose, insulin, triglycerides, and total cholesterol levels in blood were the parameters considered. For this purpose, 120 weaned male Wistar rats of the HsdHan:WIST line were used, 15 per group in first stage, then 10 and 5 per group for 2nd and 3rd stages, respectively. Body mass gain, food intake, and beverage consumption were daily quantified. After 104, 197, and 288 days of experimentation the concentrations of glucose, triglycerides, cholesterol, and insulin were determined. Only in the first stage there were significant differences in the body mass gain. In the three stages there were significant differences in the patterns of beverage intake and food consumption. The trend was the same in all 3 stages: rats drank more in the groups of drinks sweetened with nutritive sweeteners and ate more in the groups that drank non-nutritive artificial sweeteners. Regarding the biochemical profile, no sweetener either nutritive or non-nutritive caused that the serum levels of glucose, triglycerides, and cholesterol were at pathological levels. It is concluded that the sweeteners by themselves can modify certain biochemical parameters but not at a pathological level. Furthermore, by themselves they are not capable of triggering excess of body mass or obesity in the early and medium stages of life when consumed together with a balanced diet.

Graphic abstract

Healthy Foods and Healthy Diets. How Government Policies Can Steer Food Reformulation

Food reformulation policies aimed at reducing the risk of diet-related non-communicable diseases have been implemented in many countries. The degree of success of reformulation policies in changing the range of food options available to consumers has been a function of the design of these policies. Our objective was to review the different factors making the design and implementation of a food reformulation policy effective at improving populations’ diets and health. In this narrative review, we present a logic model of the action of reformulation policies on consumer behaviour, dietary intake and population health. We set out how policy design could drive outcomes, and highlight the role for governments and public health agencies in promoting food reformulation that is effective in improving diet and health. The key drivers of success for reformulation policies include strong incentives, a tight implementation strategy, a focus on the overall nutritional quality of food products, rather than on individual nutrients, and effective monitoring and evaluation. Additionally, policies should mark the distinction between product reformulation and product differentiation, which have different nutrition and health outcomes.

Effects of product reformulation on sugar intake and health-a systematic review and meta-analysis

Context

Obesity, type 2 diabetes, and dental caries are all major public health problems in the United Kingdom and contribute substantially to healthcare costs.

Objective

A systematic review and meta-analysis was conducted to determine the effect of product reformulation measures on sugar intake and health outcomes.

Data sources

Using a combination of terms, the following databases were searched-The Cochrane Library, EMBASE, MEDLINE (Ovid), and Scopus. Additionally, multiple gray literature searches were undertaken.

Data extraction

A total of 16 studies met the inclusion criteria. There were 4 randomized controlled trials, 6 studies that modeled reformulation in a country, 5 studies that modeled a different approach of reformulation, and 1 study was both a modelling study of a different approach to reformulation and a retrospective observational study. The studies were assessed for risk of bias and overall quality of evidence was rated using the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) framework.

Results

Results from randomized controlled trials suggest that consumption of reformulated products can reduce sugar intake and body weight. The pooled estimates were -11.18% (95% confidence interval [CI], -19.95 to -2.41; P < 0.00001) for changes in percentage of sugar intake, -91.00 g/day (95%CI, -148.72 to -33.28; P< 0.00001) for changes in sugar intake in grams per day, and -1.04 kg (95%CI, -2.16 to -0.08; P= 0.0002) for changes in body weight. However, the quality of the evidence was very low. Results from the other studies suggested that reformulation can reduce sugar intake and improve health. Much of the evidence draws on modeling studies.

Conclusions

This systematic review and meta-analysis suggests that product reformulation to reduce sugar content could reduce sugar intake in individuals and thus improve population health. These findings provide an important starting point for ongoing work on sugar reformulation.

Body Mass Index Z-Score Modifies the Association between Added Sugar Intake and Arterial Stiffness in Youth with Type 1 Diabetes: The Search Nutrition Ancillary Study

The relationship between added sugar and arterial stiffness in youth with type 1 diabetes (T1D) has not been well-described. We used data from the SEARCH for Diabetes in Youth Study (SEARCH), an ongoing observational cohort study, to determine the association between added sugar and arterial stiffness in individuals diagnosed with T1D <20 years of age (n = 1539; mean diabetes duration of 7.9 ± 1.9 years). Added sugar intake was assessed by a food frequency questionnaire, and arterial stiffness measures included pulse wave velocity (PWV) and augmentation index. Separate multivariate linear regression models were used to evaluate the association between added sugar and arterial stiffness. Separate interaction terms were included to test for effect modification by body mass index (BMI) z-score and physical activity (PA). Overall, there was no association between added sugar and arterial stiffness (P > 0.05); however, the association between added sugar and arterial stiffness differed by BMI z-score (P for interaction = 0.003). For participants with lower BMI z-scores, added sugar intake was positively associated with PWV trunk measurements, whereas there was no association for those who had a higher BMI z-score. PA did not significantly modify the association between added sugar and arterial stiffness. Further research is needed to determine the longitudinal relationship and to confirm that obesity differentially affects this association.

Popular Nutrition-Related Mobile Apps: An Agreement Assessment Against a UK Reference Method

BACKGROUND

Nutrition-related apps are commonly used to provide information about the user's dietary intake, but limited research has been performed to assess how well their outputs agree with those from standard methods.

OBJECTIVE

The objective of our study was to evaluate the level of agreement of popular nutrition-related apps for the assessment of energy and available macronutrients and micronutrients against a UK reference method.

METHODS

We compared dietary analysis of 24-hour weighed food records (n=20) between 5 nutrition-related apps (Samsung Health, MyFitnessPal, FatSecret, Noom Coach, and Lose It!) and Dietplan6 (reference method), using app versions available in the United Kingdom. We compared estimates of energy, macronutrients (carbohydrate, protein, fat, saturated fat, and fiber), and micronutrients (sodium, calcium, iron, vitamin A, and vitamin C) using paired t tests and Wilcoxon signed-rank tests, correlation coefficients, and Bland-Altman plots. We obtained 24-hour weighed food records from 20 participants (15 female, 5 male participants; mean age 36.3 years; mean body mass index 22.9 kg/m²) from previous controlled studies conducted at the Hugh Sinclair Unit of Human Nutrition, University of Reading, Reading, UK. Participants had recorded their food consumption over a 24-hour period using standard protocols.

RESULTS

The difference in estimation of energy and saturated fat intake between Dietplan6 and the diet apps was not significant. Estimates of protein and sodium intake were significantly lower using Lose It! and FatSecret than using Dietplan6. Lose It! also gave significantly lower estimates for other reported outputs (carbohydrate, fat, fiber, and sodium) than did Dietplan6. Samsung Health and MyFitnessPal significantly underestimated calcium, iron, and vitamin C compared with Dietplan6, although there was no significant difference for vitamin A. We observed no other significant differences between Dietplan6 and the apps. Correlation coefficients ranged from r=-.12 for iron (Samsung Health vs Dietplan6) to r=.91 for protein (FatSecret vs Dietplan6). Noom Coach was limited to energy output, but it had a high correlation with Dietplan6 (r=.91). Samsung Health had the greatest variation of correlation, with energy at r=.79. Bland-Altman analysis revealed potential proportional bias for vitamin A.

CONCLUSIONS

The findings suggest that the apps provide estimates of energy and saturated fat intake comparable with estimates by Dietplan6. With the exception of Lose It!, the apps also provided comparable estimates of carbohydrate, total fat, and fiber. FatSecret and Lose It! tended to underestimate protein and sodium. Estimates of micronutrient intake (calcium, iron, vitamin A, and vitamin C) by 2 apps (Samsung Health and MyFitnessPal) were inconsistent and less reliable. Lose It! was the app least comparable with Dietplan6. As the use and availability of apps grows, this study helps clinicians and researchers to make better-informed decisions about using these apps in research and practice.

Food sources of fructose-containing sugars and glycaemic control: systematic review and meta-analysis of controlled intervention studies

OBJECTIVE

To assess the effect of different food sources of fructose-containing sugars on glycaemic control at different levels of energy control.

DESIGN

Systematic review and meta-analysis of controlled intervention studies.

DATA SOURCES

Medine, Embase, and the Cochrane Library up to 25 April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Controlled intervention studies of at least seven days' duration and assessing the effect of different food sources of fructose-containing sugars on glycaemic control in people with and without diabetes were included. Four study designs were prespecified on the basis of energy control: substitution studies (sugars in energy matched comparisons with other macronutrients), addition studies (excess energy from sugars added to diets), subtraction studies (energy from sugars subtracted from diets), and ad libitum studies (sugars freely replaced by other macronutrients without control for energy). Outcomes were glycated haemoglobin (HbA1c), fasting blood glucose, and fasting blood glucose insulin.

DATA EXTRACTION AND SYNTHESIS

Four independent reviewers extracted relevant data and assessed risk of bias. Data were pooled by random effects models and overall certainty of the evidence assessed by the GRADE approach (grading of recommendations assessment, development, and evaluation).

RESULTS

155 study comparisons (n=5086) were included. Total fructose-containing sugars had no harmful effect on any outcome in substitution or subtraction studies, with a decrease seen in HbA1c in substitution studies (mean difference -0.22% (95% confidence interval to -0.35% to -0.08%), -25.9 mmol/mol (-27.3 to -24.4)), but a harmful effect was seen on fasting insulin in addition studies (4.68 pmol/L (1.40 to 7.96)) and ad libitum studies (7.24 pmol/L (0.47 to 14.00)). There was interaction by food source, with specific food sources showing beneficial effects (fruit and fruit juice) or harmful effects (sweetened milk and mixed sources) in substitution studies and harmful effects (sugars-sweetened beverages and fruit juice) in addition studies on at least one outcome. Most of the evidence was low quality.

CONCLUSIONS

Energy control and food source appear to mediate the effect of fructose-containing sugars on glycaemic control. Although most food sources of these sugars (especially fruit) do not have a harmful effect in energy matched substitutions with other macronutrients, several food sources of fructose-containing sugars (especially sugars-sweetened beverages) adding excess energy to diets have harmful effects. However, certainty in these estimates is low, and more high quality randomised controlled trials are needed.

STUDY REGISTRATION

Clinicaltrials.gov (NCT02716870).

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.