A randomized trial of sugar-sweetened beverages and adolescent body weight

Effects of Nonnutritive Sweeteners on the BMI of Children and Adolescents: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Prospective Cohort Studies

The effect of nonnutritive sweeteners (NNSs) on the body mass index [BMI (in kg/m2)] of children and adolescents remains unclear despite rising consumption. Detailed systematic evaluations are warranted. We aimed to summarize evidence on NNS consumption and BMI sex- and age-specific absolute changes (kg/m2) in pediatric populations, by NNS type, study design, duration, analysis type, conflicts of interest (COI), geographical region, age, sex, and baseline BMI. We searched randomized controlled trials (RCTs) and prospective cohort studies in children (2-9 y), adolescents (10-24 y), and young adults (20-24 y). Pooled estimates derived from random-effects meta-analysis for BMI changes, and the evidence quality was evaluated overall and by subgroup. From 2789 results, we included 4 RCTs [n = 1372; mean follow-up = 42.6 wk (standard deviation = 18.4); 2 (50%) with COI], and 8 prospective cohort studies [n = 35,340; median follow-up 2.5 y (interquartile range = 1.7-6.3), 2 (25%) with COI]. No identified studies evaluated NNS in food, NNS beverages compared with water, or participants aged 20-24 y. Random allocation to NNS beverages (25-2400 mg/d, from beverages) showed less BMI gain [mean difference = -0.114 kg/m2 (95% confidence interval [CI]: -0.207, -0.021); I2 = 87.02%] compared with sugar-sweetened beverages (SSBs). Stratified estimates resulted in less BMI gain in adolescents, participants with baseline obesity, consumers of mixed NNS, longer trials, and trials without COI. Pooled estimates from prospective cohorts showed a nonsignificant association between NNS beverages and BMI gain [0.05 kg/m2 (95% CI: -0.03, 0.13); I2 = 75.06%; per daily 355 mL serving]. Stratified estimates remained consistent. Removing studies with COI attenuated estimates. Evidence had low to moderate quality. In summary, pooled results from RCTs comparing NNS beverages compared with SSBs showed less BMI gain in adolescents with obesity. Meta-analyses of long-term cohort studies did not display a significant association between NNS beverages and BMI changes. This trial was registered at PROSPERO as CRD42022352284.

Effect of a higher protein diet and lifestyle camp intervention on childhood obesity (The COPE study): results from a nonrandomized controlled trail with 52-weeks follow-up

PURPOSE

In adults, diets rich in protein seem beneficial in relation to satiety, weight loss, and weight management; however, studies investigating dietary protein and weight development in children are scarce and inconsistent. This nonrandomized controlled trial aimed to investigate the effect of a higher protein diet during lifestyle intervention on anthropometry and metabolic biomarkers in children with overweight and obesity.

METHODS

Children (n:208) were recruited from two multicomponent lifestyle camps. One camp was assigned as the intervention group. In the intervention group, carbohydrates-rich foods at breakfast and two in-between-meals were replaced with protein-containing foods to increase the amount of protein from ~ 10-15 energy percent (E%) per day to ~ 25E% per day. Other components were similar between groups. Anthropometry and biochemical measurements were collected at baseline, 10 weeks (after camp) and 52 weeks.

RESULTS

The intervention group had a non-significant improvement in BMI-SDS (- 0.07 SD (- 0.19; 0.05), p = 0.24) compared to the control group, but in general, there was no effect of a higher protein diet on anthropometry and metabolic biomarkers. Overall, 10 weeks at camp resulted in a more favorable body composition [- 6.50 kg (p < 0.00), - 0.58 BMI-SDS (p < 0.00), and - 5.92% body fat (p < 0.00)], and improved metabolic health, with most changes maintained at 52 weeks.

CONCLUSION

A higher protein diet had no significant effect on body composition and metabolic health; however, these lifestyle camps are an efficiatious treatment strategy for childhood obesity.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov with ID: NCT04522921. Preregistered August 21st 2020.

Western diets and chronic diseases

'Westernization', which incorporates industrial, cultural and dietary trends, has paralleled the rise of noncommunicable diseases across the globe. Today, the Western-style diet emerges as a key stimulus for gut microbial vulnerability, chronic inflammation and chronic diseases, affecting mainly the cardiovascular system, systemic metabolism and the gut. Here we review the diet of modern times and evaluate the threat it poses for human health by summarizing recent epidemiological, translational and clinical studies. We discuss the links between diet and disease in the context of obesity and type 2 diabetes, cardiovascular diseases, gut and liver diseases and solid malignancies. We collectively interpret the evidence and its limitations and discuss future challenges and strategies to overcome these. We argue that healthcare professionals and societies must react today to the detrimental effects of the Western diet to bring about sustainable change and improved outcomes in the future.

Association Between Child Sugary Drink Consumption and Serum Lipid Levels in Electronic Health Records

Sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption may promote lipid abnormalities in childhood. We examined the association between SSB/FJ intake and lipid levels using electronic health record data for 2816 adolescents. Multivariable logistic regression models treated clinical cutpoints for abnormal lipid levels (triglycerides [TG], high-density lipoprotein (HDL), low-density lipoprotein [LDL], and total cholesterol) as dependent variables. In models not adjusted for adiposity, elevated SSB and FJ consumption was associated with increased odds of having abnormally high TG (SSB: odds ratio [OR] = 1.28 (95% confidence interval [CI] = [1.07-1.52], P = .007); FJ: 1.35 ([1.09-1.69], P = .007)) and abnormally low HDL (SSB: 1.47 ([1.17-1.86], P = .001); FJ: 1.35 ([1.02-1.78], P = .03)). Adjusting for adiposity, a likely mediator of the relationship, attenuated these associations. These findings support the need for identifying unhealthy beverage consumption habits during childhood health care visits as a modifiable behavior associated with cardiometabolic risk.

Sustaining Healthy Habits: The Enduring Impact of Combined School-Family Interventions on Consuming Sugar-Sweetened Beverages among Pilot Chinese Schoolchildren

This study assesses the enduring impact of combined school- and family-based interventions on reducing the consumption of sugar-sweetened beverages (SSBs) among schoolchildren in China. Two primary schools were assigned at random to either the Intervention Group or the Control Group, in Nanjing, eastern China. All students were in grade three and received an invitation to participate. In the first year, students in the Intervention Group received one-year intervention measures, including monthly monitoring, aiming to decrease the consumption of SSBs. Students in the Control Group only received regular monitoring without interventions. In the second year, both groups received only regular monitoring, without active interventions. A generalized estimating equations model (GEE) was used to assess the intervention effects. After two years, relative to the Control Group, the Intervention Group had a significantly improved knowledge of SSBs and an improved family environment with parents. In the Intervention Group, 477 students (97.3%) had adequate knowledge about SSBs, compared to 302 students (83.2%) in the Control Group (X2 = 52.708, p < 0.001). Two years later, the number of students who stated 'my home always has SSBs' in the Intervention Group (7.8%) was fewer than that in the Control Group (12.4%), which was a statistically significant finding (p < 0.05). One year later, both the frequency and the quantity of SSB consumption in the Intervention Group were less than those in the Control Group; such differences between the groups remained statistically significant for the quantity but not for the frequency of SSB consumption two years later. In the Intervention Group, the frequency of SSB consumption was significantly reduced by 1.0 times per week, compared to a reduction of 0.1 times per week in the Control Group in the first year (p < 0.05). In the second year, the frequency of SSB consumption was reduced by 0.8 times per week in the Intervention Group, compared to 0.5 times per week in the Control Group (p > 0.05). In the first year, the volume of SSB consumption was significantly reduced by 233 mL per week in the Intervention Group, compared to an increase of 107 mL per week in the Control Group (p < 0.05). In the second year, the volume of SSB consumption was reduced by 122 mL per week in the Intervention Group compared to an increase of 31 mL per week in the Control Group (p > 0.05). The combined school-based and family-based interventions had a positive effect on the students' knowledge of SSBs and their family dynamics during the first and second year. Relative to the Control Group, the Intervention Group had a statistically significant reduction in SSB consumption after 1 year, but not after 2 years.

Substituting Low-Calorie Sweetened Beverages for Sugar-Sweetened Beverages to Prevent Obesity and Cardiometabolic Diseases: Still a Good Idea?

Low-calorie sweeteners (LCSs) and LCS-containing beverages have been proposed as appropriate substitutes for caloric sugars in recent years. In this Perspective, we highlight the recent findings from observational and interventional studies, focusing on obesity, gut microbiome, and cardiometabolic health. We provide public health actors and health care professionals with an insightful overview of recent evidence to bridge the gap between research and practice.

Estimated reductions in type 2 diabetes burden through nutrition policies in AZAR cohort population: A PRIME microsimulation study for primary health care

Background

Given the impact of high intake of sugar-sweetened beverages on type 2 diabetes, intervention to reduce their consumption can be a top priority for any health system. Thus, the purpose of the present study is to simulate the impact of policy options related to reduce consumption of sugar-sweetened beverages (SSBs) on the prevalence and mortality of type 2 diabetes in Iranian men and women.

Methods

A discrete event simulation (DES) model was used to predict the effect of several policy options on the prevalence and death from type 2 diabetes in Azar Cohort Databases. Population age- and sex-specific prevalence and incidence rate of diagnosed diabetes were derived from the national health data. The Preventable Risk Integrated Model (PRIME) model was used for coding the input parameters of simulation using R and Python software.

Results

The prevalence and mortality rate of type 2 diabetes under the scenario of reduced consumption of SSBs indicated that the highest and the lowest prevalence and mortality rates of type 2 diabetes for men and women were related to no policy condition and replacing SSBs with healthy drinks, like water, respectively. Also, the maximum "number of deaths postponed/ prevented" from type 2 diabetes was related to replacing SSBs with water (n=2015), and an integration of reformulation and applying 10% tax on SSBs (n=1872), respectively.

Conclusion

Simulating the effect of different policy options on reducing the consumption of SSBs showed "replacing of SSBs with water" as the most effective policy option in Iranian setting.

Impact of the UK soft drinks industry levy on health and health inequalities in children and adolescents in England: An interrupted time series analysis and population health modelling study

BACKGROUND

The soft drinks industry levy (SDIL) in the United Kingdom has led to a significant reduction in household purchasing of sugar in drinks. In this study, we examined the potential medium- and long-term implications for health and health inequalities among children and adolescents in England.

METHODS AND FINDINGS

We conducted a controlled interrupted time series analysis to measure the effects of the SDIL on the amount of sugar per household per week from soft drinks purchased, 19 months post implementation and by index of multiple deprivation (IMD) quintile in England. We modelled the effect of observed sugar reduction on body mass index (BMI), dental caries, and quality-adjusted life years (QALYs) in children and adolescents (0 to 17 years) by IMD quintile over the first 10 years following announcement (March 2016) and implementation (April 2018) of the SDIL. Using a lifetable model, we simulated the potential long-term impact of these changes on life expectancy for the current birth cohort and, using regression models with results from the IMD-specific lifetable models, we calculated the impact of the SDIL on the slope index of inequality (SII) in life expectancy. The SDIL was found to have reduced sugar from purchased drinks in England by 15 g/household/week (95% confidence interval: -10.3 to -19.7). The model predicts these reductions in sugar will lead to 3,600 (95% uncertainty interval: 946 to 6,330) fewer dental caries and 64,100 (54,400 to 73,400) fewer children and adolescents classified as overweight or obese, in the first 10 years after implementation. The changes in sugar purchasing and predicted impacts on health are largest for children and adolescents in the most deprived areas (Q1: 11,000 QALYs [8,370 to 14,100] and Q2: 7,760 QALYs [5,730 to 9,970]), while children and adolescents in less deprived areas will likely experience much smaller simulated effects (Q3: -1,830 QALYs [-3,260 to -501], Q4: 652 QALYs [-336 to 1,680], Q5: 1,860 QALYs [929 to 2,890]). If the simulated effects of the SDIL are sustained over the life course, it is predicted there will be a small but significant reduction in slope index of inequality: 0.76% (95% uncertainty interval: -0.9 to -0.62) for females and 0.94% (-1.1 to -0.76) for males.

CONCLUSIONS

We predict that the SDIL will lead to medium-term reductions in dental caries and overweight/obesity, and long-term improvements in life expectancy, with the greatest benefits projected for children and adolescents from more deprived areas. This study provides evidence that the SDIL could narrow health inequalities for children and adolescents in England.

Substitution of sugar-sweetened beverages with non-caloric alternatives and weight change: A systematic review of randomized trials and meta-analysis

BACKGROUND

Intake of sugar-sweetened beverages has been associated with weight gain. It is uncertain if replacing an existing use of sugar-sweetened beverages with non-caloric beverages results in long-term reduction in body weight.

OBJECTIVE

The objective of this study is to explore if a long-term reduction in body weight can be achieved by replacing an existing intake of sugar-sweetened beverages with non-caloric beverages.

METHODS

Systematic review and meta-analysis of randomized clinical trials in accordance with PRISMA guidelines. PubMed and EMBASE were searched for literature. Studies with a "substitution" design were included, that is, studies where subjects substituted an existing intake of sugar-sweetened beverages with either artificially sweetened beverages or unsweetened beverages/water. Studies with 6 months or longer follow-up of weight change were included.

RESULTS

Six trials with a total of 1729 participants were included in the meta-analysis. Replacing an existing intake of sugar-sweetened beverages with a non-caloric beverage resulted in a long-term BMI reduction of 0.31 kg/m2 compared with the sugar-sweetened beverage-group (95% CI; 0.17-0.44). One study with 1 year's intervention and 2 years follow-up showed a regression towards baseline BMI after the intervention had ended.

CONCLUSION

Replacing an existing use of sugar-sweetened beverages with artificially sweetened beverages or unsweetened beverages resulted in a long-term 0.31 kg/m2 reduction in BMI equivalent to 0.5-1 kg in children and adults, respectively, as long as the interventions lasted.

Health and economic burden of sugar-sweetened beverages consumption in Brazil

Sugar-sweetened beverages (SSBs) are a major source of added sugar and are associated with noncommunicable diseases (NCDs) such as obesity and diabetes. This study assessed the impact of SSBs consumption on disease burden in Brazil, including deaths, disability-adjusted life years (DALYs), and healthcare costs. A 3-stage methodology was used to assess the direct effects of SSBs on diabetes, cardiovascular diseases, and body mass index (BMI), along with the influence of BMI on disease incidence. These assessments were then used to estimate the economic and health burden using population-attributable factors. Results showed that 2.7% and 11% of adult and children overweight/obesity cases were attributable to SSBs, respectively. SSBs consumption in Brazil led to 1,814,486 cases, 12,942 deaths, 362,088 DALYs, and USD 2,915.91 million in medical costs related to diabetes, cardiovascular diseases, oncological diseases, and other NCDs. Urgent implementation of public policies is crucial to address the consumption of SSBs, recognized as a key risk factor for NCDs.

Childhood Sugar-Sweetened Beverage Consumption: an Agent-Based Model of Context-Specific Reduction Efforts

INTRODUCTION

Despite widespread recognition among public health experts that childhood sugar-sweetened beverage consumption should be reduced, doing so has proven to be a challenge. An agent-based model of early childhood sugar-sweetened beverage consumption was applied to data from three high-quality, longitudinal cohort studies to gain insight into potentially effective intervention strategies across contexts.

METHODS

From 2021 to 2023, a single agent-based model design was applied to data sets derived from three separate cohorts of children followed from infancy to childhood, with very different populations and environments (participants recruited in 1999-2002; 2003-2010; and 2009-2014). After assessing its ability to reproduce observed consumption patterns across cohorts, it was used to simulate potential impacts of multiple intervention strategies across contexts.

RESULTS

Interventions reducing home availability of sugar-sweetened beverages consistently had the largest potential effects. Impact differed between cohort settings: a complete decrease in availability resulted in an estimated 87% decrease in overall early childhood consumption for one of the cohorts, compared with 61% and 54% in the others. Reducing availability in center-based child care resulted in substantially greater reduction in one cohort relative to the other two.

CONCLUSIONS

There is untapped potential for strategies targeting children's sugar-sweetened beverage consumption in the home, but in some instances, other approaches might also yield meaningful effects. Tailoring approach to setting may be important, and agent-based models can be informative for doing so. This agent-based model has broad generalizability and potential to serve as a tool for designing effective, context-specific strategies to reduce childhood sugar-sweetened beverage consumption.

Subjective Sleep Quality, Caffeine, and Dieting Behaviors Among University-Attending Young Adults

Background

Research has shown that university students engage in behaviors that are associated with poor sleep quality, such as higher caffeine and alcohol intake. Yet studies exploring eating habits and weight loss mechanisms related to sleep quality have generally been inconclusive. This study explored total daily caffeine consumption (along with different sources of caffeine) as well as dieting and exercising to lose weight in the last 30 days as risk factors for poor sleep quality among an undergraduate university population.

Methods

Full-time undergraduate students (n = 400) participated in an anonymous online survey about various health behaviors at a large, mid-Atlantic university. Multivariable linear regressions were run to consider subjective sleep quality in relation to caffeine consumption and dieting behavior along with other covariates. A sensitivity analysis was run to explore how different types of caffeinated beverages were associated with sleep quality as well. All analyses were conducted using SAS JMP Version 16.

Results

A stepwise multivariable linear regression controlling for alcohol use, grade point average, biological sex, and stress showed significant increases in sleep quality scores (indicating worsening sleep quality). Total caffeine consumption remained significant through the models until psychosocial factors were added (B = 0.003, p = 0.0035). The sensitivity analysis indicated that total caffeine consumption from soda remained significant across all models, significantly increasing sleep quality scores (B = 0.01; p = 0.0054).

Discussion

Higher amounts of caffeine from sodas were associated with more significant decreases in sleep quality than other types of caffeine, including energy drinks, coffee, and tea. Dieting or exercising to lose weight was not significantly associated with sleep quality. The results of this study can help to refine intervention efforts designed to improve sleep quality among undergraduate university students. Behavioral interventions specific to reducing caffeine intake, specifically from caffeinated sodas, may prove to be beneficial with this population.

Evaluation of health and economic effects of United States school meal standards consistent with the 2020-2025 dietary guidelines for Americans

BACKGROUND

The current school meal nutrition standards, established in 2010, are not fully aligned with the 2020-2025 Dietary Guideline for Americans (DGA). This study evaluates the potential short-term and long-term health and economic benefits of strengthening the school meal standards on added sugars, sodium, and whole grains to be aligned with current guidelines.

METHODS

We used comparative risk assessment frameworks based on nationally representative data incorporating current demographics, dietary habits, and risk factors of United States children aged 5-18 y from 3 cycles of the National Health and Nutrition Examination Survey (2013-2018). To estimate short-term impact, the model incorporated estimated dietary changes owing to potential new DGA-aligned school meal nutrition standards and the effect of these changes on childhood body mass index (in kg/m2) and blood pressure. To estimate long-term impact, the model further incorporated data on the sustainability of childhood dietary changes into adulthood, and on demographics and risk factors of United States adults, diet-disease associations, and disease-specific national mortality.

RESULTS

In a best-case scenario assuming full school compliance, implementing new DGA-aligned nutritional standards would lower elementary children's BMI by an average 0.14 (95% UI: 0.08-0.20) kg/m2 and systolic blood pressure by 0.13 (95% UI: 0.06-0.19) (95% mm Hg. Later in life, the new standards were estimated to prevent 10,600 [95% uncertainty interval (UI): 4820-16,800) annual deaths from cardiovascular disease (CVD), diabetes, and cancer in adulthood; and save 355,000 (95% UI: 175,000-538,000) disability-adjusted life years and $19.3 (95% UI: 9.35-30.3) B in direct and indirect medical costs each year. Accounting for plausible (incomplete) school compliance, implementation would save an estimated 9110 (95% UI: 2740-15,100) deaths, 302,000 (95% UI: 120,000-479,000) disability-adjusted life years, and $15.9 (95% UI: 4.54-27.2) B in healthcare-related costs per year in later adulthood.

CONCLUSIONS

Stronger school meal nutrition standards on added sugars, sodium, and whole grains aligned with the 2020-2025 DGA recommendations may improve diet, childhood health, and future adult burdens of CVD, diabetes, cancer, and associated economic costs.

Ultraprocessed Foods and Obesity Risk: A Critical Review of Reported Mechanisms

Epidemiologic evidence supports a positive association between ultraprocessed food (UPF) consumption and body mass index. This has led to recommendations to avoid UPFs despite very limited evidence establishing causality. Many mechanisms have been proposed, and this review critically aimed to evaluate selected possibilities for specificity, clarity, and consistency related to food choice (i.e., low cost, shelf-life, food packaging, hyperpalatability, and stimulation of hunger/suppression of fullness); food composition (i.e., macronutrients, food texture, added sugar, fat and salt, energy density, low-calorie sweeteners, and additives); and digestive processes (i.e., oral processing/eating rate, gastric emptying time, gastrointestinal transit time, and microbiome). For some purported mechanisms (e.g., fiber content, texture, gastric emptying, and intestinal transit time), data directly contrasting the effects of UPF and non-UPF intake on the indices of appetite, food intake, and adiposity are available and do not support a unique contribution of UPFs. In other instances, data are not available (e.g., microbiome and food additives) or are insufficient (e.g., packaging, food cost, shelf-life, macronutrient intake, and appetite stimulation) to judge the benefits versus the risks of UPF avoidance. There are yet other evoked mechanisms in which the preponderance of evidence indicates ingredients in UPFs actually moderate body weight (e.g., low-calorie sweetener use for weight management; beverage consumption as it dilutes energy density; and higher fat content because it reduces glycemic responses). Because avoidance of UPFs holds potential adverse effects (e.g., reduced diet quality, increased risk of food poisoning, and food wastage), it is imprudent to make recommendations regarding their role in diets before causality and plausible mechanisms have been verified.

Life Satisfaction and Emerging Health Behaviors in Underserved Adolescents: A Narrative Review

Objectives: Obesity rates continue to rise in underserved adolescents. Obesity is linked to poor mental health outcomes. The purpose of this narrative review is to examine existing literature on life satisfaction and obesity-related emerging health behaviors (sugar-sweetened beverage consumption, sleeping patterns, and screen time) in underserved adolescents. Methods: We conducted a review of articles published in English between January 1995 and November 2021 to develop a narrative summary. Results: In general, few studies have been conducted investigating life satisfaction and the emerging behaviors of sugar-sweetened beverage consumption, sleeping patterns, and screen time use with adolescents, especially underserved adolescents. In the studies reviewed, we noted links between lower life satisfaction and more than once-a-day sugar consumption, including sugar-sweetened beverages, lower life satisfaction and lower sleep duration, and life satisfaction and screen-time, with both positive and negative relationships shown. Conclusions: Given the limitations in the number of studies, recommendations are provided for future research.

Obesity Management in Children and Adolescents

Obesity in the pediatric population is increasing in the United States and globally. Childhood obesity is associated with cardiometabolic and psychosocial comorbidities and decreased overall life span. The cause of pediatric obesity is multifactorial and includes genetic predisposition, lifestyle, behavioral patterns, and consequences of social determinants of health. Routine screening of BMI and comorbid conditions is essential to identifying patients who require treatment. The AAP recommends immediate Intensive Health Behavior and Lifestyle Treatment for children with obesity, encompassing lifestyle changes, behavioral changes, and mental health treatments. Pharmacologic interventions and metabolic and bariatric surgery are also available when indicated.

Staff Knowledge, Attitudes, and Beliefs About Child Sugar-Sweetened Beverage Intake and Acceptability of a Pediatric Clinic-Based Beverage Screener

Beverages are the leading source of sugar in children's diets and a modifiable risk factor for adverse health conditions. Electronic health record-based screeners could facilitate health systems' efforts to reduce child consumption of sugary beverages. Before implementing a sugar-sweetened beverage screener in the electronic health record within academic healthcare system, 228 pediatric and family medicine clinic staff completed an online educational training to familiarize them with the screener and its rationale. Pretraining and posttraining surveys were used to examine the association between staff knowledge of sugar-sweetened beverages and the acceptability of the screening workflow. Respondents displayed high levels of pretraining knowledge about health consequences of added sugar intake, but lower levels of pediatric beverage guideline knowledge. Knowledge improved from pretraining to posttraining surveys, with high acceptability of the screening process. Staff compliance with sugar-sweetened beverage screening was examined using electronic health record data. During the 6 months after screener implementation, 47% of eligible pediatric patients were screened, with some variation in compliance by age group and practice type. This study demonstrated that engaging nursing and frontline staff to screen pediatric patients for behavioral determinants of health is feasible. Ongoing outreach and refreshers may improve sustainability.

Effects of Nonnutritive Sweeteners on Body Composition Changes during Pubertal Growth

The effects of consuming specific types of nonnutritive sweeteners (NNSs) on adiposity changes in children have remained inconsistent. In this study, we aimed to investigate the effects of the intake of different kinds of NNSs on long-term adiposity changes during pubertal growth. Furthermore, we examined the above relationships among different sexes, pubertal stages, and levels of obesity. A total of 1893 6-15-year-old adults were recruited and followed-up every 3 months. The NNS-FFQ (Food Frequency Questionnaire) was conducted and urine samples were collected to investigate the effects of the selected sweeteners, which included acesulfame potassium, aspartame, sucralose, glycyrrhizin, steviol glycosides, and sorbitol. Multivariate linear mixed-effects models were used to examine the relationship between NNS intake and body composition. The consumption of aspartame, sucralose, glycyrrhizin, stevioside, and sorbitol was associated with decreased fat mass and increased fat-free mass. In the highest tertile group, the effects of NNS consumption on fat mass corresponded to values of -1.21 (95% CI: -2.04 to -0.38) for aspartame, -0.62 (95% CI: -1.42 to 0.19) for sucralose, -1.26 (95% CI: -2.05 to -0.47) for glycyrrhizin, -0.90 (95% CI: -2.28 to 0.48) for stevioside, and -0.87 (95% CI: -1.67 to -0.08) for sorbitol, while the effects on fat-free mass corresponded to values of 1.20 (95% CI: 0.36 to -0.38) for aspartame, 0.62 (95% CI: -0.19 to 1.43) for sucralose, 1.27 (95% CI: 0.48 to 2.06) for glycyrrhizin, 0.85 (95% CI: -0.53 to 2.23) for stevioside, and 0.87 (95% CI: 0.08 to 1.67) for sorbitol. Particularly, aspartame and sorbitol revealed a dose-responsiveness effect. The above finding was more prominent among girls than boys. Moreover, fat mass was significantly reduced in normal-weight children who consumed a moderate amount of aspartame and a large amount of glycyrrhizin and sorbitol compared with obese children. In conclusion, the NNS-specific and sex-specific effects of long-term NNS consumption revealed associations of decreasing fat mass and increasing fat-free mass for children undergoing pubertal growth.

Switching from Sugar- to Artificially-Sweetened Beverages: A 12-Week Trial

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) forms the primary source of added sugar intake and can increase the risk of metabolic disease. Evidence from studies in humans and rodents also indicates that consumption of SSBs can impair performance on cognitive tests, but that removing SSB access can ameliorate these effects.

METHODS

The present study used an unblinded 3-group parallel design to assess the effects of a 12-week intervention in which young healthy adults (mean age = 22.85, SD = 3.89; mean BMI: 23.2, SD = 3.6) who regularly consumed SSBs were instructed to replace SSB intake with artificially-sweetened beverages (n = 28) or water (n = 25), or (c) to continue SSB intake (n = 27).

RESULTS

No significant group differences were observed in short-term verbal memory on the Logical Memory test or the ratio of waist circumference to height (primary outcomes), nor in secondary measures of effect, impulsivity, adiposity, or glucose tolerance. One notable change was a significant reduction in liking for strong sucrose solutions in participants who switched to water. Switching from SSBs to 'diet' drinks or water had no detectable impact on cognitive or metabolic health over the relatively short time frame studied here. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615001004550; Universal Trial Number: U1111-1170-4543).

Impact of acute consumption of beverages containing plant-based or alternative sweetener blends on postprandial appetite, food intake, metabolism, and gastro-intestinal symptoms: Results of the SWEET beverages trial

Project SWEET examined the barriers and facilitators to the use of non-nutritive sweeteners and sweetness enhancers (hereafter "S&SE") alongside potential risks/benefits for health and sustainability. The Beverages trial was a double-blind multi-centre, randomised crossover trial within SWEET evaluating the acute impact of three S&SE blends (plant-based and alternatives) vs. a sucrose control on glycaemic response, food intake, appetite sensations and safety after a carbohydrate-rich breakfast meal. The blends were: mogroside V and stevia RebM; stevia RebA and thaumatin; and sucralose and acesulfame-potassium (ace-K). At each 4 h visit, 60 healthy volunteers (53% male; all with overweight/obesity) consumed a 330 mL beverage with either an S&SE blend (0 kJ) or 8% sucrose (26 g, 442 kJ), shortly followed by a standardised breakfast (∼2600 or 1800 kJ with 77 or 51 g carbohydrates, depending on sex). All blends reduced the 2-h incremental area-under-the-curve (iAUC) for blood insulin (p < 0.001 in mixed-effects models), while the stevia RebA and sucralose blends reduced the glucose iAUC (p < 0.05) compared with sucrose. Post-prandial levels of triglycerides plus hepatic transaminases did not differ across conditions (p > 0.05 for all). Compared with sucrose, there was a 3% increase in LDL-cholesterol after stevia RebA-thaumatin (p < 0.001 in adjusted models); and a 2% decrease in HDL-cholesterol after sucralose-ace-K (p < 0.01). There was an impact of blend on fullness and desire to eat ratings (both p < 0.05) and sucralose-acesulfame K induced higher prospective intake vs sucrose (p < 0.001 in adjusted models), but changes were of a small magnitude and did not translate into energy intake differences over the next 24 h. Gastro-intestinal symptoms for all beverages were mostly mild. In general, responses to a carbohydrate-rich meal following consumption of S&SE blends with stevia or sucralose were similar to sucrose.

A Technology-Driven, Healthcare-Based Intervention to Improve Family Beverage Choices: Results from a Pilot Randomized Trial in the United States

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent-child dyads, in which children were 1-8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (-0.80 (95% CI: -1.54, -0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

Use and Acceptance of Drinking Fountains: A Pilot Study in Two Secondary Schools in Dortmund, Germany

(1) Background: Water drinking is essential to reduce obesity in children, but effective means for implementation remain controversial. Our study assesses students' and teachers' use of and attitudes towards drinking fountains in two urban secondary schools. (2) Methods: In a cross-sectional study, answers from students and teachers to a 28- and 19-item questionnaire, respectively, containing closed- and open-ended questions and short interviews with the schools' two principals were described and analysed using the question-specific number of responses as the denominator. (3) Results: Questionnaires of one hundred sixty-two students and ten teachers were analysed; 36.1% of students responded. Students viewed the schools' two fountains as a good idea (73.3%, n = 118), recommended them to other schools (73.1%, n = 117), and felt able to distinguish healthy from unhealthy drinks (70.5%, n = 110). In contrast, 55.7% (n = 88) reported using the fountains regularly; over a week, 39.8% (n = 47) used them less than once; 26.3% (n = 31) used them one to two times. Only about a third (26.5%, n = 43) reported consuming more water since the fountains' installation. Teachers' responses were similar to students'; principals stressed planning and costs. (4) Conclusions: A discrepancy between a good attitude towards and actual use of drinking fountains may exist; school communities may need to look for measures to overcome it.

Metabolic-Associated Fatty Liver Disease in Childhood and Adolescence

Metabolic-associated fatty liver disease (MAFLD) has become the most common cause for chronic liver disease among children and adolescents globally. Although liver biopsy remains the gold standard for diagnosis, emerging technology, like velocity controlled transient elastography, a noninvasive method, is being utilized to evaluate degree of fibrosis in these patients. The discovery of multiple gene polymorphisms has brought new hope for possible treatment targets. However, this research is still ongoing, making lifestyle changes and weight reduction the current mainstay of treatment. This review briefly reviews the most recent data regarding the epidemiology, pathophysiology, diagnostic modalities, and treatment of pediatric MAFLD.

Sex differences in the association between sugar-sweetened beverages consumption and metabolic risks among the working-age population in Taiwan

OBJECTIVE

Sugar-sweetened beverages (SSB) are linked to increased metabolic risk. However, the sex differences in the relationship between SSB intake and adverse health effects remain unclear. Therefore, the present study examined the association between SSB consumption and metabolic risks among working-age males and females from Taiwanese communities.

DESIGN

A community-based study utilised data from a comprehensive health screening project conducted by the Public Health Bureau in Changhua County, Taiwan. Metabolic risks included waist circumference, systolic blood pressure, diastolic blood pressure, total cholesterol, TAG, LDL cholesterol and fasting glucose level using serum tests.

SETTING

Participants were recruited in Changhua County, Taiwan.

PARTICIPANTS

Between 2005 and 2014, 92 724 citizens participated in the health screening; our data analysis included 75 278 respondents between 30 and 64.

RESULTS

The results showed that the frequency of SSB consumption was associated with abnormal waist circumference and elevated total cholesterol, TAG, LDL and glucose in both men and women. Increased SSB consumption frequency was associated with elevated glucose and hypertension in women. Even a slight increase in SSB intake frequency was related to raising the metabolic risks. Similar patterns were evident when models included BMI; however, the associations were attenuated. In the BMI-stratified subgroup analysis, the relationship between SSB consumption and metabolic risks was more pronounced in participants without obesity.

CONCLUSION

The present study suggests that SSB consumption carries metabolic risk among working-age Taiwanese, particularly women and those without obesity. Health promotion programmes should raise awareness of the health hazards associated with SSB.

The burden of disease and economic impact of sugar-sweetened beverages' consumption in Argentina: A modeling study

BACKGROUND

Approximately two-thirds of Argentine adults are overweight or obese, and 11% have diabetes. Over the last two decades, all population groups have increased their consumption of ultra-processed foods and sugar-sweetened beverages (SSB). We aimed to estimate the disease burden-deaths, events, and costs to the health system-attributed to SSB consumption in Argentina.

METHODS

We used a comparative risk assessment framework to estimate the health and economic impacts that would be avoided in a scenario without sugar-sweetened beverage (SSB) consumption. We calculated the direct effects on diabetes, cardiovascular disease, and BMI, and then estimated the effects of BMI on disease incidence. Finally, we applied the population attributable factor to calculate the health and economic burden avoided in Argentina in 2020.

RESULTS

Our model estimated that about 4,425 deaths, 110,000 healthy life years lost to premature death and disability, more than 520,000 cases of overweight and obesity in adults, and 774,000 in children and adolescents would be attributed to SSB Consumption in Argentina. This disease burden corresponds to 23% of type-2 diabetes cases and other significant proportions of cardiovascular disease and cancer. The overweight and obesity costs attributable to SSB totaled approximately $47 million in adults and $15 million in children and adolescents.

CONCLUSION

A significant number of disease cases, deaths, and health care costs could be attributed to SSB consumption in Argentina. Implementing measures to reduce the sugar content in beverages is a pending debt for the country and could lead to measurable improvements in population health, especially among children and adolescents.

The health and economic burden associated with sugar-sweetened beverage consumption in Trinidad and Tobago

BACKGROUND

In Trinidad and Tobago, non-communicable diseases (NCDs) are the leading cause of death. Unhealthy diet is one modifiable NCD risk factor, which contributes to the NCD burden. The consumption of sugar-sweetened beverages (SSBs) has been associated with an increased risk of NCDs.

AIM

The aim of this paper is to estimate the burden of disease and economic costs associated with the consumption of SSBs in Trinidad and Tobago as evidence to support the implementation of health and fiscal policies on SSB consumption.

METHODS

The results of this study were obtained through the use of a mathematical model which used a comparative risk assessment approach to estimate the health and economic burden associated with SSB intake, by sex and age.

RESULTS

Estimates for one year showed that SSB consumption was associated with approximately 15,000 cases of overweight and obesity in adults and 11,700 cases in children, 28% of all the cases of diabetes and overall, an estimated 387 deaths and 9000 years of healthy life were lost due to premature death and disability. Approximately US$23.1 million was spent in the public healthcare system to treat diseases associated with consumption of sugary beverages.

CONCLUSIONS

The consumption of SSBs is associated with increases in diseases, deaths and rising healthcare costs in Trinidad and Tobago. It is hoped that the results of this study will provide an added rationale and impetus for the implementation of policies to reduce the consumption of SSBs.

Health and economic burden of disease of sugar-sweetened beverage consumption in four Latin American and Caribbean countries: a modelling study

OBJECTIVE

Overweight and obesity are important contributors to the non-communicable disease burden. The consumption of sugar-sweetened beverages (SSBs) has been associated with an increased risk of type 2 diabetes mellitus (T2DM), cardiovascular disease, cancer and other conditions. The objective of this study was to estimate the burden of disease attributable to the consumption of SSBs and the costs to the healthcare systems in Argentina, Brazil, El Salvador, and Trinidad and Tobago.

DESIGN

Following a systematic review of models, a comparative risk assessment framework was developed to estimate the health and economic impact associated with the consumption of SSBs.

SETTING

Argentina, Brazil, El Salvador, and Trinidad and Tobago.

PARTICIPANTS

Overall population.

PRIMARY AND SECONDARY OUTCOME MEASURES

The model estimated the effects of SSB consumption on health through two causal pathways: one mediated by body mass index (BMI) and health conditions associated with BMI and another that reflected the independent effects of SSB consumption on T2DM and cardiovascular diseases.

RESULTS

The model results indicated that for all four countries, in 1 year, SSB consumption was associated with 18 000 deaths (3.2% of the total disease-related deaths), seven million disease events (3.3% of the total disease-related events), a half-million DALYs and US$2 billion in direct medical costs. This included 1.5 million cases of overweight and obesity in children/adolescents (12% of the excess weight cases) and 2.8 million cases in adults (2.8%); 2.2 million cases of type 2 diabetes (19%); 200 000 cases of heart disease (3.8%); 124 000 strokes (3.9%); 116 000 cases of musculoskeletal disease (0.2%); 102 000 cases of kidney disease (0.9%); and 45 000 episodes of asthma (0.4%). The Trinidad and Tobago population were the most affected by disease events.

CONCLUSIONS

The study results indicate that the consumption of SSBs is associated with a significant burden of disease and death in Latin America and the Caribbean.

Effects of foods, beverages and macronutrients on BMI z-score and body composition in children and adolescents: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

A healthy diet is fundamental for healthy growth and for future disease prevention. However, scientific consensus on how to compose healthy diets for children has not been established. Therefore, a systematic review and meta-analysis was performed to investigate if an independent effect exists between foods, beverages or the composition of macronutrients and body composition in children and adolescents.

METHODS

A systematic search was performed in four databases up to July 2021. A systematic review of randomized controlled studies (RCTs) and meta-analyses were carried out by extracting mean difference (MDs) and standard deviation (SD) and performed using the random effect model.

RESULTS

Sixteen RCTs met inclusion criteria. Beyond dairy, sugar-sweetened beverages and macronutrient composition, no trials were identified for other food groups. Based on five RCTs (n:5), a higher-dairy diet was found to reduce body fat percentage - 0.47 [- 0.92, - 0.03] (p = 0.04). A higher-dairy diet was also found to increase lean body mass (kg) 0.34 [0.06, 0.62] (p = 0.02) (n:2), but did not affect BMI z-score - 0.05 [- 0.16, 0.06] (p = 0.39) (n:4). Substituting sugar-sweetened beverage with non-caloric beverages or flavored milk reduced body fat percentage (- 0.70 [- 0.78, - 0.62] (p < 0.001)) (n:3) but did not change BMI z-score (- 0.05 [- 0.20, 0.09] (p = 0.48)) (n:2). No significant effects were found between different macronutrient compositions and BMI z-score or body fat percentage.

CONCLUSION

Changes in diet from low to higher-dairy consumption and from sugar-sweetened beverages to non-caloric beverages or flavored milk resulted in favorable changes in body composition among children and adolescents. Eligible studies investigating other foods are lacking.

TRIAL REGISTRATION

PROSPERO registration number (CRD42020173201).

How to change consumer behaviours

Changing consumer behaviour has potential benefits for health, the economy and the environment. Change is possible, and behavioural change has been the purpose of much research; nevertheless we can still observe limited success, as in the case of food in public policies or individual diets. One reason is that models driving behavioural change interventions tend to neglect some important contextual factors. The three layers of components that channel behaviour ('installations' in the material, embodied and social realms) are described here and how this channelling can be hacked, modified and leveraged to foster behavioural change. Installations scaffold and control individual and collective behaviour at each step of the behavioural path with their three-layered and partly redundant structure. This redundancy makes the channelling resilient enough to train novices and to guide and repair behaviour. The three layers, physical affordances, embodied competences and social regulation are described in detail. To change eating behaviour, installations must be adapted at all steps of behaviour, from procurement to storage, preparation, meal and disposal. This adaptation can be done through the various layers in an opportunistic way, according to the agency of those who endeavour to change behaviour (e.g. budget, time, political power, etc.) Finally the steps necessary to design behavioural change interventions leveraging installations are listed.

Sugar-Sweetened Beverages and Metabolic Risk in Children and Adolescents with Obesity: A Narrative Review

Sugar-sweetened beverages (SSBs) are major contributors of free sugars to the diet. A strong relationship between SSB intake and weight gain is described.

METHODS

we performed a narrative review to present an overview of the role of SSBs as a pivotal contributor in the development of obesity and metabolism-related complications.

RESULTS

different factors influence SSB consumption in children, including economic variables, individual attributes and behaviors to environmental factors, parent features and parents' behaviors. Data suggest that SSB intake has a negative effect on weight and obesity-related diseases. The leading mechanism linking SSB intake to the risk of gaining weight is decreased satiety and incomplete compensatory reduction in energy intake at meals following ingestion of liquid calories. Additionally, the effects of SSBs on gut microbiota and on eating behaviors were also reported. An association between SSB intake, weight gain and cardiometabolic risks is evident. Consumption of SSBs had a significant impact on the prevalence of obesity and related metabolic risks, including insulin resistance, type 2 diabetes, hypertension and metabolic syndrome.

CONCLUSIONS

Limiting consumption of SSBs and increasing knowledge of the effect of SSBs on early metabolic and cardiovascular disorders will be useful in developing strategies to counteract the problem and to prevent obesity and related complications.Key future research areas for which further studies are needed include investigating the long-term effects of SSBs on health outcomes as well as analyzing the health effects of sugar consumed in solid compared to liquid forms and further elucidating the biological mechanisms of sugar addiction and energy compensation.

Use of a Water Filter at Home Reduces Sugary Drink Consumption among Parents and Infants/Toddlers in a Predominantly Hispanic Community: Results from the Water Up!@ Home Intervention Trial

BACKGROUND

Water is recommended as an alternative for sugar-sweetened beverages (SSBs). Low-income, minority groups in the United States continue to exhibit high SSB and low water consumption, and are more likely to exceed 100% fruit juice recommendations.

OBJECTIVE

To test the effects of a home-based intervention designed to replace SSBs with tap water and reduce excess juice consumption among parents and their infants/toddlers.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Parents (n = 92) of infants/toddlers who participated in three Early Head Start home-visiting programs that serve predominantly Hispanic, low-income communities during 2019-2021.

INTERVENTION

The 12-week intervention (Water Up!@Home) simultaneously addressed physical barriers to tap water consumption (via a water filter) and sociocultural barriers to replacing SSBs and juice with water (via a curriculum). Comparison group received a water filter only. We hypothesized that the intervention would lead to a reduction of 6 fl oz/d in SSB and juice consumption.

MAIN OUTCOMES

Parent-reported self and infant/toddler SSBs, water (filtered, tap, or bottled), and 100% fruit juice consumption.

STATISTICAL ANALYSES

Analysis of covariance to compare changes in consumption between experimental groups was performed. We also conducted t tests to assess changes within groups.

RESULTS

Participants in both groups reported significant reductions in SSBs from baseline (parents: intervention [-11.2 fl oz/d; P < 0.01]; comparison [-8.0 fl oz/d; P < 0.01]; children: intervention [-1.50 fl oz/d; P = 0.03]; comparison [-1.56 fl oz/d; P = 0.02]), increased water consumption (parents in both groups [+5.6 fl oz/d]; children: intervention [+3.61 fl oz/d; P = 0.01], comparison [+2.24 fl oz/d; P = 0.05]), mostly from filtered tap water. Differences between groups were not statistically significant. Intervention participants reported significant reductions in 100% fruit juice vs comparison (parents: -3.6 fl oz/d vs -1.0 fl oz/d; P < 0.01; children: -0.73 fl oz/d vs +0.48 fl oz/d; P = .03).

CONCLUSIONS

The intervention effectively reduced 100% fruit juice consumption. Water security should be examined as a contributor to SSB consumption in this population.

Sugar-sweetened beverage consumption and weight gain in children and adults: a systematic review and meta-analysis of prospective cohort studies and randomized controlled trials

BACKGROUND

Sugar-sweetened beverages (SSBs) have been implicated in fueling the obesity epidemic.

OBJECTIVES

This study aimed to update a synthesis of the evidence on SSBs and weight gain in children and adults.

METHODS

MEDLINE, Embase, and Cochrane databases were searched through September 8, 2022, for prospective cohort studies and randomized controlled trials (RCTs) that evaluated intake of SSBs in relation to BMI and body weight in children and adults, respectively. Eligible interventions were compared against a noncaloric control. Study-level estimates were pooled using random-effects meta-analysis and presented as β-coefficients with 95% CIs for cohorts and weighted mean differences (MDs) with 95% CIs for RCTs.

RESULTS

We identified 85 articles including 48 in children (40 cohorts, n = 91,713; 8 RCTs, n = 2783) and 37 in adults (21 cohorts, n = 448,661; 16 RCTs, n = 1343). Among cohort studies, each serving/day increase in SSB intake was associated with a 0.07-kg/m² (95% CI: 0.04 kg/m², 0.10 kg/m²) higher BMI in children and a 0.42-kg (95% CI: 0.26 kg, 0.58 kg) higher body weight in adults. RCTs in children indicated less BMI gain with SSB reduction interventions compared with control (MD: -0.21 kg/m²; 95% CI: -0.40 kg/m², -0.01 kg/m²). In adults, randomization to addition of SSBs to the diet led to greater body weight gain (MD: 0.83 kg; 95% CI: 0.47 kg, 1.19 kg), and subtraction of SSBs led to weight loss (MD: -0.49 kg; 95% CI: -0.66 kg, -0.32 kg) compared with the control groups. A positive linear dose-response association between SSB consumption and weight gain was found in all outcomes assessed.

CONCLUSIONS

Our updated systematic review and meta-analysis expands on prior evidence to confirm that SSB consumption promotes higher BMI and body weight in both children and adults, underscoring the importance of dietary guidance and public policy strategies to limit intake. This meta-analysis was registered at the International Prospective Register of Systematic Reviews as CRD42020209915.

EASO and EFAD Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Children and Adolescents

INTRODUCTION

This position statement on medical nutrition therapy in the management of overweight or obesity in children and adolescents was prepared by an expert committee convened by the European Association for the Study of Obesity (EASO) and developed in collaboration with the European Federation of the Associations of Dietitians (EFAD).

METHODS

It is based on the best evidence available from systematic reviews of randomized controlled trials on child and adolescent overweight and obesity treatment and other relevant peer-reviewed literature.

RESULTS

Multicomponent behavioural interventions are generally considered to be the gold standard treatment for children and adolescents living with obesity. The evidence presented in this position statement confirms that dietary interventions can effectively improve adiposity-related outcomes. Dietary strategies should focus on the reduction of total energy intake through promotion of food-based guidelines that target modification of usual eating patterns and behaviours. These should target increasing intakes of nutrient-rich foods with a lower energy density, specifically vegetables and fruits, and a reduction in intakes of energy-dense nutrient-poor foods and beverages. In addition, higher intensity, longer duration treatments, delivered by interventionists with specialized dietetic-related skills and co-designed with families, are associated with greater treatment effects.

DISCUSSION

Such interventions should be resourced adequately so that they can be implemented in a range of settings and in different formats, including digital or online delivery, to enhance accessibility.

Improving Obesogenic Dietary Behaviors among Adolescents: A Systematic Review of Randomized Controlled Trials

The overweight and obesity epidemic persists, and over 340 million children and adolescents aged 5–19 were classified as overweight or obese worldwide in 2020. Obesity intervention becomes crucial during the adolescent years due to the increased autonomy and adolescent motivation to oversee one’s own behaviors and lifestyle-related decisions. The objective of the current study was to conduct a systematic review of randomized controlled trials aimed at improving dietary intake and behaviors among adolescents. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized. The key terms used in the searches referred to the study population and the topic of interest and included words and phrases such as “obesity or overweight and adolescents”, “dietary behaviors and adolescents”, “dietary intake and adolescents”, and “dietary habits and adolescents.” A tertiary screening process was employed, and the National Heart, Lung, and Blood Institute Quality Assessment of Controlled Intervention Studies quality scoring tool was utilized to assess the quality of research articles independently by n = 2 researchers. A total of 7441 articles were identified through the database search, and 36 were included in the current systematic review. The most common outcomes explored included dietary behaviors, anthropometric or biometric outcomes, and physical activity. Approximately half of the studies demonstrated significant improvements in the primary outcomes investigated. The majority of the high-impact studies where significant improvements in primary outcomes were demonstrated were conducted in school settings or were multicomponent or multilevel in nature. Thus, interventions targeting dietary behaviors in adolescents that are delivered in the school setting and are multicomponent or multilevel in nature are the most effective in terms of impact on dietary intake, anthropometric or biometric outcomes, and physical activity.

An agent-based model of child sugar-sweetened beverage consumption: implications for policies and practices

BACKGROUND

A strong body of evidence links young children's intake of sugar-sweetened beverages (SSBs) with myriad negative outcomes.

OBJECTIVES

Our research provides insight into whether and to what extent potential intervention strategies can reduce young children's consumption of SSBs.

METHODS

We built an agent-based model (ABM) of SSB consumption representing participants in the Project Viva longitudinal study between ages 2 and 7 y. In addition to extensive data from Project Viva, our model used nationally representative data as well as recent, high-quality literature. We tested the explanatory power of the model through comparison to consumption patterns observed in the Project Viva cohort. Then, we applied the model to simulate the potential impact of interventions that would reduce SSB availability in 1 or more settings or affect how families receive and respond to pediatrician advice.

RESULTS

Our model produced age-stratified trends in beverage consumption that closely match those observed in Project Viva cohort data. Among the potential interventions we simulated, reducing availability in the home-where young children spend the greatest amount of time-resulted in the largest consumption decrease. Removing access to all SSBs in the home resulted in them consuming 1.23 (95% CI: 1.21, 1.24) fewer servings of SSBs per week on average between the ages of 2 and 7 y, a reduction of ∼60%. By comparison, removing all SSB availability outside of the home (i.e., in schools and childcare) had a smaller impact (0.77; CI: 0.75, 0.78), a reduction of ∼40%.

CONCLUSIONS

These results suggest that interventions reducing SSB availability in the home would have the strongest effects on SSB consumption.

Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

Reduced Consumption of Sugar-Sweetened Beverages Is Associated with Lower Body Mass Index Z-Score Gain among Chinese Schoolchildren

To examine whether reducing sugar-sweetened beverage (SSB) consumption is associated with reduced body mass index z-score gain among Chinese schoolchildren in Nanjing, China, a randomized controlled trial (RCT) was conducted in four selected primary schools from September 2019 to September 2020. Students in the third grade in the Intervention Group received school-based and home-based interventions for two consecutive semesters to reduce SSB consumption, while two schools in the Control Group did not receive any interventions. Weight changes were expressed as body mass index (BMI) z-scores as standard deviations of the BMI distribution per age and sex group. Changes in SSB consumption before and after the interventions were categorized into Level-Up if it increased, Level-Same if it was maintained and Level-Down if it decreased. Multivariable linear regression models were used to explore the association of different levels of changes in SSB consumption pre- and post-intervention with the BMI z-score. Among 1633 participants who completed the trial, the mean age at baseline was 9.36 years (±0.48 SD).The median baseline BMI z-score was −0.24 (25th percentile −0.72; 75th percentile 0.58). After the intervention, the median BMI z-score increased by 0.06 (−0.17~0.37) in the Intervention Group and by 0.14 (−0.08~0.41) in the Control Group (p < 0.001). A higher increase in BMI was found in the Control Group than in the Intervention Group (1.20 vs. 0.94) during the 12-month period. Among participants whose parents’ educational attainment was above 9 years, the median BMI z-score increased by 0.07 (−0.17~0.37) in the Intervention Group and by 0.16 (−0.06~0.41) in the Control Group (p < 0.001). In a linear regression analysis adjusted for potential confounders, the BMI z-score decreased by 0.057 more in Level-Down than in Level-Up (95% CI: −0.103 to −0.012, p = 0.014). These results indicate that the decreased consumption of SSBs might have reduced the prevalence of overweight in schoolchildren in China, especially in students whose parents had high educational levels.

Battling the obesity epidemic with a school-based intervention: Long-term effects of a quasi-experimental study

Background

School-based health-promoting interventions are increasingly seen as an effective population strategy to improve health and prevent obesity. Evidence on the long-term effectiveness of school-based interventions is scarce. This study investigates the four-year effectiveness of the school-based Healthy Primary School of the Future (HPSF) intervention on children’s body mass index z-score (BMIz), and on the secondary outcomes waist circumference (WC), dietary and physical activity (PA) behaviours.

Methods and findings

This study has a quasi-experimental design with four intervention schools, i.e., two full HPSFs (focus: diet and PA), two partial HPSFs (focus: PA), and four control schools. Primary school children (aged 4–12 years) attending the eight participating schools were invited to enrol in the study between 2015 and 2019. Annual measurements consisted of children’s anthropometry (weight, height and waist circumference), dietary behaviours (child- and parent-reported questionnaires) and PA levels (accelerometers). Between 2015 and 2019, 2236 children enrolled. The average exposure to the school condition was 2·66 (SD 1·33) years, and 900 participants were exposed for the full four years (40·3%). After four years of intervention, both full (estimated intervention effect (B = -0·17 (95%CI -0·27 to -0·08) p = 0·000) and partial HPSF (B = -0·16 (95%CI-0·25 to -0·06) p = 0·001) resulted in significant changes in children’s BMIz compared to control schools. Likewise, WC changed in favour of both full and partial HPSFs. In full HPSFs, almost all dietary behaviours changed significantly in the short term. In the long term, only consumption of water and dairy remained significant compared to control schools. In both partial and full HPSFs, changes in PA behaviours were mostly absent.

Interpretation

This school-based health-promoting intervention is effective in bringing unfavourable changes in body composition to a halt in both the short and long term. It provides policy makers with robust evidence to sustainably implement these interventions in school-based routine.

Feasibility and acceptability of home delivery of water for dental caries control in Latinx children-"Sediento por una Sonrisa," Thirsty for a Smile: Single-arm feasibility study

Background

Outcomes of surgical treatments under general anesthesia for early childhood caries of young children from low-income groups are poor requiring retreatment within 2 years. Dietary sugar is an ideal intervention target given that it is the most prominent risk factor for dental caries and there is increasing evidence of successful interventions to reduce its intake. Our aim is to investigate the feasibility and acceptability of the Thirsty for a Smile intervention, designed to promote consumption of water in lieu of sugar sweetened beverages, among children who underwent surgery for early childhood caries and their caregivers, mostly from Latino heritage.

Methods

A single-arm feasibility study was conducted in a dental practice from a community health center in eastern Washington State. Bottled water was delivered to the participants' homes and caregivers received patient-centered counseling for setting goals to increase children's water intake and reduce sugar sweetened beverages consumption. We assessed the feasibility and acceptability of the intervention and study procedures through participation rates, interviews and a questionnaire completed by the caregivers. Data was analyzed and themes and descriptive statistics presented.

Results

Twenty-two dyads of caregivers and their children between 2 and 9 years old who recently had surgical treatment for early childhood dental caries were enrolled. All study assessments were completed by more than 90% of participants, except for the final 24-h dietary recall (73%). Dietary counseling, both in person and brief telephone calls, was highly acceptable to the caregivers, and they also reported their children enjoyed and used the water bottles. On a scale from 1 to 10, the average rating for the helpfulness of the dietary counseling component for changing child's drinking habits was 9.62 and for the water delivery component, 8.86.

Conclusions

This study tested the feasibility of conducting a trial in a dental practice setting, and the acceptability among caregivers of young children who underwent surgery for early childhood caries. It demonstrated that the Thirsty for a Smile intervention and study processes were feasible and acceptable. The study provides useful information for implementation of a two-arm randomized controlled trial in this setting and may also benefit other researchers attempting to test similar interventions.

Application of a composite scoring protocol to identify factors that contribute to the risk of overweight and obesity in Irish children

BACKGROUND

Investigations into the main drivers of childhood obesity are vital to implement effective interventions to halt the global rise in levels. The use of a composite score may help to identify children most at risk of overweight/obesity.

OBJECTIVES

To investigate the cumulative impact of factors associated with overweight/obesity risk in children.

METHODS

Data were analysed from the Irish National Children's Food Survey II which included 600 children, aged 5-12-years. The risk factors examined included social class, parental, early life, lifestyle, and dietary components. A composite score was calculated which ranged from 0 (no risk factors for overweight/obesity) to 4 (4 risk factors for overweight/obesity).

RESULTS

In model 1 (%BF) the four factors associated with overweight/obesity risk were having a parent with overweight/obesity (odds ratio 3.1; 95% confidence interval 1.9-4.8), having a high birth weight of ≥4 kg (2.5; 1.6-3.9), being from a low social class (2.3; 1.4-3.8) and low physical activity (1.9; 1.2-2.8). Children who scored 3-4 points on the composite score had a 10-fold (10.0; 4.2-23.9) increased risk of overweight/obesity compared to those with 0 points, a sevenfold (7.2; 3.9-13.5) increased risk compared to those with 1 point and a threefold (2.6; 1.4-4.8) increased risk compared to those with 2 points, with similar results observed in model 2 (BMI).

CONCLUSION

The use of a composite score is a beneficial means of identifying children at risk of overweight/obesity and may prove useful in the development of effective interventions to tackle childhood obesity.

Excessive intake of sugar: An accomplice of inflammation

High sugar intake has long been recognized as a potential environmental risk factor for increased incidence of many non-communicable diseases, including obesity, cardiovascular disease, metabolic syndrome, and type 2 diabetes (T2D). Dietary sugars are mainly hexoses, including glucose, fructose, sucrose and High Fructose Corn Syrup (HFCS). These sugars are primarily absorbed in the gut as fructose and glucose. The consumption of high sugar beverages and processed foods has increased significantly over the past 30 years. Here, we summarize the effects of consuming high levels of dietary hexose on rheumatoid arthritis (RA), multiple sclerosis (MS), psoriasis, inflammatory bowel disease (IBD) and low-grade chronic inflammation. Based on these reported findings, we emphasize that dietary sugars and mixed processed foods may be a key factor leading to the occurrence and aggravation of inflammation. We concluded that by revealing the roles that excessive intake of hexose has on the regulation of human inflammatory diseases are fundamental questions that need to be solved urgently. Moreover, close attention should also be paid to the combination of high glucose-mediated immune imbalance and tumor development, and strive to make substantial contributions to reverse tumor immune escape.

Exploring an Artificial Intelligence–Based, Gamified Phone App Prototype to Track and Improve Food Choices of Adolescent Girls in Vietnam: Acceptability, Usability, and Likeability Study

Background

Adolescents’ consumption of healthy foods is suboptimal in low- and middle-income countries. Adolescents’ fondness for games and social media and the increasing access to smartphones make apps suitable for collecting dietary data and influencing their food choices. Little is known about how adolescents use phones to track and shape their food choices.

Objective

This study aimed to examine the acceptability, usability, and likability of a mobile phone app prototype developed to collect dietary data using artificial intelligence–based image recognition of foods, provide feedback, and motivate users to make healthier food choices. The findings were used to improve the design of the app.

Methods

A total of 4 focus group discussions (n=32 girls, aged 15-17 years) were conducted in Vietnam. Qualitative data were collected and analyzed by grouping ideas into common themes based on content analysis and ground theory.

Results

Adolescents accepted most of the individual- and team-based dietary goals presented in the app prototype to help them make healthier food choices. They deemed the overall app wireframes, interface, and graphic design as acceptable, likable, and usable but suggested the following modifications: tailored feedback based on users’ medical history, anthropometric characteristics, and fitness goals; new language on dietary goals; provision of information about each of the food group dietary goals; wider camera frame to fit the whole family food tray, as meals are shared in Vietnam; possibility of digitally separating food consumption on shared meals; and more appealing graphic design, including unique badge designs for each food group. Participants also liked the app’s feedback on food choices in the form of badges, notifications, and statistics. A new version of the app was designed incorporating adolescent’s feedback to improve its acceptability, usability, and likability.

Conclusions

A phone app prototype designed to track food choice and help adolescent girls from low- and middle-income countries make healthier food choices was found to be acceptable, likable, and usable. Further research is needed to examine the feasibility of using this technology at scale.

Clinical Intervention to Reduce Dietary Sugar Does Not Affect Liver Fat in Latino Youth, Regardless of PNPLA3 Genotype: A Randomized Controlled Trial

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) among Latinos is partially attributed to a prevalent C>G polymorphism in the patatin-like phospholipase 3 (PNPLA3) gene. Cross-sectional analyses in Latino children showed the association between dietary sugar and liver fat was exacerbated by GG genotype. Pediatric feeding studies show extreme sugar restriction improves liver fat, but no prior trial has examined the impact of a clinical intervention or whether effects differ by PNPLA3 genotype.

OBJECTIVES

We aimed to test effects of a clinical intervention to reduce dietary sugar compared with standard dietary advice on change in liver fat, and secondary-endpoint changes in liver fibrosis, liver enzymes, and anthropometrics; and whether effects differ by PNPLA3 genotype (assessed retrospectively) in Latino youth with obesity (BMI ≥ 95th percentile).

METHODS

This parallel-design trial randomly assigned participants (n = 105; mean baseline liver fat: 12.7%; mean age: 14.8 y) to control or sugar reduction (goal of ≤10% of calories from free sugar) for 12 wk. Intervention participants met with a dietitian monthly and received delivery of bottled water. Changes in liver fat, by MRI, were assessed by intervention group via general linear models.

RESULTS

Mean free sugar intake decreased in intervention compared with control [11.5% to 7.3% compared with 13.9% to 10.7% (% energy), respectively; P = 0.02], but there were no significant effects on liver outcomes or anthropometrics (Pall > 0.10), and no PNPLA3 interactions (Pall > 0.10). In exploratory analyses, participants with whole-body fat mass (FM) reduction (mean ± SD: -1.9 ± 2.4 kg), irrespective of randomization, had significant reductions in liver fat compared with participants without FM reduction (median: -2.1%; IQR: -6.5% to -0.8% compared with 0.3%; IQR: -1.0% to 1.1%; P < 0.001).

CONCLUSIONS

In Latino youth with obesity, a dietitian-led sugar reduction intervention did not improve liver outcomes compared with control, regardless of PNPLA3 genotype. Results suggest FM reduction is important for liver fat reduction, confirming clinical recommendations of weight loss and a healthy diet for pediatric NAFLD.This trial was registered at clinicaltrials.gov as NCT02948647.

Resource mobilization combined with motivational interviewing to promote healthy behaviors and healthy weight in low-income families: An intervention feasibility study

Objectives

This non-randomized pilot trial examined the feasibility and acceptability of an intervention for low-income families with one parent with obesity, glucose intolerance and/or diabetes.

Methods

The 12-month intervention combined health coaching using motivational interviewing to promote lifestyle behavior change and community resource mobilization to assist with basic needs plus diet quality and physical activity. Outcome measures included process measures, open-ended questions, and the Family Nutrition and Physical Activity scale.

Results

Forty-five families completed an average of 2.1 health coach in-person visits, including 15 families lost to follow-up. Parents who stayed in the intervention reported the intervention was helpful. Some families and the health coach had difficulties contacting one another, and some of these families reported they would have liked more sessions with the coach. The Family Nutrition and Physical Activity scores improved significantly for all children (6 months: 2.9; p < .01; 12 months: 3.2; p < .05) and at 6 months for index children (6 months: 3.5; p < .01; 12 months: 2.9; p = .09). There was variation in the FNPA and other outcome changes between families.

Conclusion

This intervention was feasible in terms of recruitment and delivery of family sessions and community referrals and acceptable to participants, but maintaining contact with participants was difficult. Findings warrant improvements to help retention and logistical aspects of communication between families and coaches and testing in a randomized, controlled trial.

Diabetogene Umweltfaktoren

Das Risiko, an einem Diabetes mellitus Typ 2 zu erkranken, wird maßgeblich von Merkmalen unserer physischen und sozialen Umwelt beeinflusst. Diese Umweltfaktoren wirken sich insbesondere auf das Ausmaß individueller körperlicher Aktivität sowie das Ernährungsverhalten aus. Weiterhin zählen die Exposition gegenüber Tabakrauch sowie Luftverschmutzung zu den etablierten Risikofaktoren. In den letzten Jahren rückten darüber hinaus weitere mögliche diabetogene Umweltaspekte in den Fokus der Forschung, darunter Umgebungslärm und andere stressfördernde Einflüsse sowie Chemikalien mit endokriner Wirkung. Im folgenden Beitrag wird der Forschungsstand zur Rolle von Umweltfaktoren bei der Entstehung eines Typ-2-Diabetes vorgestellt. Zudem wird diskutiert, wie diese Umweltfaktoren günstig beeinflusst werden können und was DiabetologInnen und andere Diabetesfachkräfte sowie PatientInnen mit Diabetes hierzu beitragen können.

Association of sweetened carbonated beverage consumption during pregnancy and ADHD symptoms in the offspring: a study from the Norwegian Mother, Father and Child Cohort Study (MoBa)

PURPOSE

Intrauterine exposures influence offspring health and development. Here we investigated maternal intake of sweetened carbonated beverages (SCB) during pregnancy and its association with ADHD symptoms in the offspring.

METHODS

This study was based on the Norwegian Mother, Father and Child Cohort Study (MoBa) and the Medical Birth Registry of Norway. Maternal diet mid-pregnancy was assessed using a food frequency questionnaire (FFQ). All mothers who responded to the FFQ and a questionnaire when their child was 8 years of age were included (n = 39,870). The exposure was defined as maternal intake (daily servings) of SCB, using no daily intake as reference. Outcome was offspring ADHD symptoms, evaluated as a continuous standardized ADHD score and as a binary outcome of six or more ADHD symptoms vs. five symptoms or less. Associations were analysed using log-binomial regression and linear mixed regression models with adjustment for covariates.

RESULTS

The adjusted regression coefficients for the standardized ADHD offspring symptom score were 0.31 [95% confidence intervals (0.001, 0.62)] and 0.46 (0.15, 0.77) for maternal daily intake of ≥ 1 glasses of SCB, when the models included adjustments for total energy intake or energy intake from other sources than SCBs and sweet drinks, respectively. The corresponding adjusted relative risks were 1.16 (1.004, 1.34) and 1.21. (1.05, 1.39) for drinking ≥ 1 glasses daily.

CONCLUSION

In a large pregnancy cohort with offspring followed until 8 years of age, we found an association between maternal daily intake of SCB and offspring ADHD symptoms. These results suggest a weak positive relationship between prenatal exposure to SCB and offspring ADHD.