Artificially Sweetened Beverages and Health Outcomes: An Umbrella Review

Non-Sugar-Sweetened Beverages and Risk of Chronic Diseases: An Umbrella Review of Meta-analyses of Prospective Cohort Studies

CONTEXT

Several effects of non-sugar-sweetened beverage (NSSBs) intake on health outcomes have been reported; however, the evidence on the association between NSSBs intake and chronic diseases and mortality risk is still inconclusive.

OBJECTIVE

This umbrella review aimed to summarize the evidence on the association between NSSBs intake and the risk of chronic diseases and mortality.

DATA SOURCES

Embase, ISI Web of Science, Cochrane Central, and PubMed were searched up to September 2023 for relevant meta-analyses of observational prospective cohort studies.

DATA EXTRACTION

Two groups of researchers independently extracted study data and assessed the risk of bias for meta-analyses and primary studies.

DATA ANALYSIS

Six meta-analyses, reporting 74 summary hazard ratios (HRs) for different outcomes obtained from 50 primary studies, were included. The summary HRs, 95% CIs, and certainty of evidence on the association of NSSBs intake with risk of chronic diseases and mortality were as follows: all-cause mortality (per 355 mL/d: 1.06 [1.01 to 1.10]; moderate certainty); stroke (per 250 mL/d: 1.09 [1.04 to 1.13]; high certainty); coronary heart disease (CHD) (per 250 mL/d: 1.06 [1.02 to 1.11]; high certainty); hypertension (HTN) (high vs low intake: 1.14 [1.09 to 1.18]; moderate certainty); type 2 diabetes (T2D) (high vs low intake: 1.16 [1.08 to 1.26]; low certainty); metabolic syndrome (MetS) (high vs low intake: 1.32 [1.22 to 1.43]; low certainty); colorectal cancer (high vs low intake: 0.78 [0.62 to 0.99]; moderate certainty); and leukemia (high vs low intake: 1.35 [1.03 to 1.77]; moderate certainty). For other outcomes, including the risk of cardiovascular and cancer mortality, chronic kidney diseases, breast cancer, prostate cancer, endometrial cancer, pancreatic cancer, multiple myeloma, and non-Hodgkin lymphoma, no association was found.

CONCLUSION

This study provides further evidence that NSSBs are associated with increased risk of all-cause mortality, stroke, CHD, HTN, T2D, MetS, and leukemia. Moreover, a higher intake of NSSBs was associated with a lower risk of colorectal cancer. However, it should be noted that the magnitudes of the associations are not large. Further studies are needed to clarify the long-term effects of different NSSBs intakes on health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO no. CRD42023429981.

Associations between different coffee types, neurodegenerative diseases, and related mortality: findings from a large prospective cohort study

BACKGROUND

Observational studies have suggested associations between amount of coffee consumption and decreased risk of neurodegenerative diseases. However, these studies do not consider differences among coffee types, including sweetened, unsweetened, caffeinated, and decaffeinated varieties.

OBJECTIVES

This study aims to identify associations between the consumption of various coffee types (sugar-sweetened, artificially sweetened, unsweetened, caffeinated, and decaffeinated) and risks of Alzheimer's disease and related dementias (ADRD) and Parkinson's disease (PD), along with related mortality.

METHODS

This prospective study included 204,847 participants (44.7% males) from the UK Biobank. Cox proportional hazards models were used to assess the associations of coffee type with neurodegenerative outcome. On the basis of coffee consumption, participants were divided into 5 groups: non-coffee consumers, >0-1 cup/d, ≥1-2 cups/d, ≥2-3 cups/d, and ≥3 cups/d.

RESULTS

Over a median follow-up of 9 y, the study documented 1696 cases of ADRD, 1093 cases of PD, and 419 neurodegenerative-related deaths. In the multivariate analysis, compared with non-coffee consumers, those with the highest intake of unsweetened and caffeinated coffee (≥3 cups/d) showed hazard ratios (95% confidence intervals) of 0.75 (0.62, 0.91) for ADRD, 0.71 (0.56, 0.91) for PD, and 0.67 (0.44, 1.01) for neurodegenerative-related death. However, no significant associations were noted in either decaffeinated or sugar/artificially sweetened coffee groups (P > 0.05).

CONCLUSIONS

Higher intake of caffeinated coffee, particularly the unsweetened variety, was associated with reduced risks of ADRD and PD. No such associations were observed for sugar-sweetened or artificially sweetened coffee.

Risks and benefits of nonsugar sweeteners: conflicting evidence between observational studies and randomized controlled trials

PURPOSE OF REVIEW

Recommendations on the use of nonsugar sweeteners are contradictory, even if they come from official sources. The aim is to review and discuss recent findings on the potential impact of nonsugar sweeteners on human health.

RECENT FINDINGS

While randomized controlled trials (RCTs) with short duration and risk factors endpoints mostly show favourable effects on body weight and cardiometabolic parameters when nonsugar sweeteners are used to replaced sugar-sweetened products, observational studies mostly show a positive association between the consumption of nonsugar sweeteners and cardiometabolic diseases. The conflicting results may be explained by the heterogenous nature of nonsugar sweeteners but also likely is a consequence of serious weaknesses of available studies.

SUMMARY

For more evidence-based recommendations for practice and policy, scientifically sound studies with long follow-up are required.

Linking artificial sweetener intake with kidney function: insights from NHANES 2003-2006 and findings from Mendelian randomization research

Background

The current investigation examines the association between artificial sweetener (AS) consumption and the likelihood of developing chronic kidney disease (CKD), along with its impact on kidney function.

Methods

We utilized data from the National Health and Nutrition Examination Survey from 2003-2006 to conduct covariance analysis and weighted adjusted logistic regression, aiming to assess the association between artificial sweetener intake and CKD risk, as well as kidney function indicators. Subsequently, we employed Mendelian randomization methods to validate the causal relationship between the intake of artificial sweeteners, CKD risk, and kidney function indicators. Instrumental variable analysis using inverse-variance weighting and Robust adjusted profile score were the primary analytical methods employed.

Results

A total of 20,470 participants were included in the study, with 1,257 participants ultimately included in the analysis. In all adjusted logistic regression models, no significant association was found between the intake of artificial sweeteners and CKD risk. Similarly, the summary odds ratios (OR) for each unit change in genetically predicted CKD risk were 2.14 (95% CI: 0.83, 5.21, p = 0.092), 1.41 (95% CI: 0.54, 3.63, p = 0.482), and 1.50 (95% CI: 0.50, 4.52, p = 0.468) for the impact of artificial sweeteners added to cereals, tea, and coffee, respectively. It was only observed that adding artificial sweeteners to coffee was associated with a modest reduction in urinary albumin-to-creatinine ratio (OR = 0.94, 95% CI: -0.108, -0.022, p = 0.003), the effect appeared to be relatively small and may not directly impact the individual level.

Conclusion

Our study does not support a causal relationship between artificial sweetener intake and the risk of CKD. However, due to the limitations and potential confounding factors, these findings need to be further validated through larger sample sizes in observational studies and Mendelian randomization analyses.

U.S. food policy to address diet-related chronic disease

Poor diet is the leading cause of mortality in the U.S. due to the direct relationship with diet-related chronic diseases, disproportionally affects underserved communities, and exacerbates health disparities. Evidence-based policy solutions are greatly needed to foster an equitable and climate-smart food system that improves health, nutrition and reduces chronic disease healthcare costs. To directly address epidemic levels of U.S. diet-related chronic diseases and nutritional health disparities, we conducted a policy analysis, prioritized policy options and implementation strategies, and issued final recommendations for bipartisan consideration in the 2023-24 Farm Bill Reauthorization. Actional recommendations include: sugar-sweetened beverage taxation, Supplemental Nutrition Assistance Program (SNAP) fruit and vegetable subsidy expansion, replacement of ultra-processed foods (UPF) with sustainable, diverse, climate-smart agriculture and food purchasing options, and implementing "food is medicine."

Sugar-sweetened or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in adults: a prospective cohort study

BACKGROUND

Whether physical activity could mitigate the adverse impacts of sugar-sweetened beverages (SSBs) or artificially sweetened beverages (ASBs) on incident cardiovascular disease (CVD) remains uncertain.

OBJECTIVES

This study aimed to examine the independent and joint associations between SSB or ASB consumption and physical activity and risk of CVD, defined as fatal and nonfatal coronary artery disease and stroke, in adults from 2 United States-based prospective cohort studies.

METHODS

Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% CIs between SSB or ASB intake and physical activity with incident CVD among 65,730 females in the Nurses' Health Study (1980-2016) and 39,418 males in the Health Professional's Follow-up Study (1986-2016), who were free from chronic diseases at baseline. SSBs and ASBs were assessed every 4-y and physical activity biannually.

RESULTS

A total of 13,269 CVD events were ascertained during 3,001,213 person-years of follow-up. Compared with those who never/rarely consumed SSBs or ASBs, the HR for CVD for participants consuming ≥2 servings/d was 1.21 (95% CI: 1.12, 1.32; P-trend < 0.001) for SSBs and 1.03 (95% CI: 0.97, 1.09; P-trend = 0.06) for those consuming ≥2 servings/d of ASBs. The HR for CVD per 1 serving increment of SSB per day was 1.18 (95% CI: 1.10, 1.26) and 1.12 (95% CI: 1.04, 1.20) for participants meeting and not meeting physical activity guidelines (≥7.5 compared with <7.5 MET h/wk), respectively. Compared with participants who met physical activity guidelines and never/rarely consumed SSBs, the HR for CVD was 1.47 (95% CI: 1.37, 1.57) for participants not meeting physical activity guidelines and consuming ≥2 servings/wk of SSBs. No significant associations were observed for ASB when stratified by physical activity.

CONCLUSIONS

Higher SSB intake was associated with CVD risk regardless of physical activity levels. These results support current recommendations to limit the intake of SSBs even for physically active individuals.

Sweetened Beverage Intake and Incident Chronic Kidney Disease in the UK Biobank Study

Importance

An increasing body of evidence indicates an association between consuming sugar or its alternatives and cardiometabolic diseases. However, the effects of the consumption of sugar-sweetened beverages, artificially sweetened beverages, and natural juices on kidney health remain unclear.

Objective

To investigate the association of the intake of sugar-sweetened beverages, artificially sweetened beverages, and natural juices with the risk of chronic kidney disease (CKD), and the effect of substituting these beverage types for one another on this association.

Design, Setting, and Participants

This prospective, population-based cohort study analyzed data from the UK Biobank. Participants without a history of CKD who completed at least 1 dietary questionnaire were included. The follow-up period was from the date of the last dietary questionnaire until October 31, 2022, in England; July 31, 2021, in Scotland; and February 28, 2018, in Wales. Data were analyzed from May 1 to August 1, 2023.

Exposures

Consumption of sugar-sweetened beverages, artificially sweetened beverages, and natural juices.

Main Outcomes and Measures

The primary outcome was incident CKD. Multivariable Cox proportional hazards models were used to estimate the associations between the 3 beverage types and incident CKD. A substitution analysis was used to evaluate the effect on the associations of substituting one beverage type for another.

Results

A total of 127 830 participants (mean [SD] age, 55.2 [8.0] years; 66 180 female [51.8%]) were included in the primary analysis. During a median (IQR) follow-up of 10.5 (10.4-11.2) years, 4459 (3.5%) cases of incident CKD occurred. The consumption of more than 1 serving per day of sugar-sweetened beverages was associated with higher risk of incident CKD (adjusted hazard ratio [AHR], 1.19 [95% CI, 1.05-1.34]) compared with not consuming sugar-sweetened beverages. The AHR for participants consuming more than 0 to 1 serving per day of artificially sweetened beverages was 1.10 (95% CI, 1.01-1.20) and for consuming more than 1 serving per day was 1.26 (95% CI, 1.12-1.43) compared with consuming no artificially sweetened beverages. By contrast, there was no significant association between natural juice intake and incident CKD (eg, for >1 serving per day: HR, 0.99 [95% CI, 0.87-1.11]; P = .10). Substituting sugar-sweetened beverages with artificially sweetened beverages did not show any significant difference in the risk of CKD (HR, 1.03 [95% CI, 0.96-1.10]). Conversely, replacing 1 serving per day of sugar-sweetened beverage with natural juice (HR, 0.93 [95% CI, 0.87-0.97]) or water (HR, 0.93 [95% CI, 0.88-0.99]) or replacing 1 serving per day of artificially sweetened beverage with natural juice (HR, 0.90 [95% CI, 0.84-0.96]) or water (HR, 0.91 [95% CI, 0.86-0.96]) was associated with a reduced risk of incident CKD.

Conclusions and Relevance

Findings from this cohort study suggest that lower consumption of sugar-sweetened beverages or artificially sweetened beverages may reduce the risk of developing CKD.