Objective Biomarkers for Total Added Sugar Intake - Are We on a Wild Goose Chase?

Metabolomics signatures of sweetened beverages and added sugar are related to anthropometric measures of adiposity in young individuals: results from a cohort study

BACKGROUND

The associations of sweetened beverages (SBs) and added sugar (AS) intake with adiposity are still debated. Metabolomics could provide insights into the mechanisms linking their intake to adiposity.

OBJECTIVES

We aimed (1) to identify metabolomics biomarkers of intake of low and no-calorie sweetened beverages (LNCSB), sugar-sweetened beverages (SSB), and AS, and (2) to investigate their associations with body mass index, body fat percentage, and waist circumference.

METHODS

We analyzed three datasets from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) cohort study, of children who provided two urine samples (n = 297), adolescents who provided a single urine sample (n = 339), and young adults who provided a single plasma sample (n = 195). Urine and plasma were analyzed by untargeted metabolomics. Dietary intakes were assessed using 3-day weighed dietary records. The random forest, partial least squares, and least absolute shrinkage and selection operator were jointly employed for metabolite selection. We examined associations of intakes with metabolites and anthropometric measures using linear and mixed-effects regression.

RESULTS

In adolescents, LNCSB were positively associated with acesulfame, β = 0.0012, 95% confidence interval, CI (0.0006, 0.0019) and saccharin β = 0.0009, 95% CI (0.0002, 0.0015). In children, the association was observed with saccharin β = 0.0016, 95% CI (0.0005, 0.0027). In urine and plasma, SSB were positively associated with 1-methylxanthine, β = 0.0005, 95% CI (0.0003, 0.0008), β = 0.0010, 95% CI (0.0004, 0.0015) and 5-acetylamino-6-amino-3-methyluracil, β = 0.0005, 95% CI (0.0002, 0.0008), β = 0.0009, 95% CI (0.0003, 0.0014), respectively. AS was associated with urinary sucrose, β = 0.0095, 95% CI (0.0069, 0.0121) in adolescents. Some of the food-related metabolic profiles were also associated with adiposity measures.

CONCLUSIONS

We identified SBs- and AS-related metabolites, which may be important for understanding the interplay between these intakes and adiposity in young individuals.

Twenty-Four-Hour Urinary Sugars Biomarker in a Vending Machine Intake Paradigm in a Diverse Population

Accurately measuring dietary sugars intake in large-scale epidemiological studies is necessary to understand dietary sugars' true impact on health. Researchers have developed a biomarker that can be used to assess total sugars intake. Our objective is to test this biomarker in diverse populations using an ad libitum intake protocol. Healthy adult participants (n = 63; 58% Indigenous Americans/Alaska Natives; 60% male; BMI (mean ± SD) = 30.6 ± 7.6 kg.m2) were admitted for a 10-day inpatient stay. On day 2, body composition was measured by DXA, and over the last 3 days, ad libitum dietary intake was measured using a validated vending machine paradigm. Over the same days, participants collected daily 24 h urine used to measure sucrose and fructose. The 24 h urinary sucrose and fructose biomarker (24hruSF) (mg/d) represents the sum of 24 h urinary sucrose and fructose excretion levels. The association between the 3-day mean total sugars intake and log 24uSF level was assessed using the Pearson correlation. A linear mixed model regressing log-biomarker on total sugars intake was used to investigate further the association between biomarker, diet, and other covariates. Mean (S.D.) total sugars intake for the group was 197.7 g/d (78.9). Log 24uSF biomarker was moderately correlated with total sugars intake (r = 0.33, p = 0.01). In stratified analyses, the correlation was strongest in females (r = 0.45, p = 0.028), the 18-30 age group (r = 0.44, p = 0.079), Indigenous Americans (r = 0.51, p = 0.0023), and the normal BMI category (r = 0.66, p = 0.027). The model adjusted for sex, age, body fat percent, and race/ethnicity demonstrated a statistically significant association between 24uSF and total sugars intake (β = 0.0027, p < 0.0001) and explained 31% of 24uSF variance (marginal R2 = 0.31). Our results demonstrated a significant relationship between total sugars intake and the 24uSF biomarker in this diverse population. However, the results were not as strong as those of controlled feeding studies that investigated this biomarker.

Development of a Multibiomarker Panel of Healthy Eating Index in United States Adults: A Machine Learning Approach

BACKGROUND

Dietary and nutritional biomarkers are objective dietary assessment tools that will enable a more accurate and precise determination of diet-disease relations. However, the lack of established biomarker panels for dietary patterns is concerning, as dietary patterns continue to be the focus of dietary guidelines.

OBJECTIVES

We aimed to develop and validate a panel of objective biomarkers that reflects the Healthy Eating Index (HEI) by applying machine learning approaches to the National Health and Nutrition Examination Survey data.

METHODS

Cross-sectional population-based data (eligible criteria: age ≥20 y, not pregnant, no reported supplement use of dedicated vitamin A, D, E, or fish oils; n = 3481) from the 2003 to 2004 cycle of the NHANES were used to develop 2 multibiomarker panels of the HEI, 1 with (primary panel) and 1 without (secondary panel) plasma FAs. Up to 46 blood-based dietary and nutritional biomarkers (24 FAs, 11 carotenoids, and 11 vitamins) were included for variable selection using the least absolute shrinkage and selection operator controlling for age, sex, ethnicity, and education. The explanatory impact of selected biomarker panels was assessed by comparing the regression models with and without the selected biomarkers. In addition, 5 comparative machine learning models were constructed to validate the biomarker selection.

RESULTS

The primary multibiomarker panel (8 FAs, 5 carotenoids, and 5 vitamins) significantly improved the explained variability of the HEI (adjusted R² increased from 0.056 to 0.245). The secondary multibiomarker panel (8 vitamins and 10 carotenoids) had lesser predictive capabilities (adjusted R² increased from 0.048 to 0.189).

CONCLUSIONS

Two multibiomarker panels were developed and validated to reflect a healthy dietary pattern consistent with the HEI. Future research should seek to test these multibiomarker panels in randomly assigned trials and identify whether they have broad application in healthy dietary pattern assessment.

Added Sugar, Sugar-Sweetened Beverages, and Artificially Sweetened Beverages and Risk of Cardiovascular Disease: Findings from the Women’s Health Initiative and a Network Meta-Analysis of Prospective Studies

Much remains unknown about the role of added sugar in relation to cardiovascular disease (CVD) and the relative contributions of sugar-sweetened beverages (SSB) or artificially sweetened beverages (ASB) to CVD risk. Among the 109,034 women who participated in Women’s Health Initiative, we assessed average intakes of added sugar, SSB and ASB, and conducted Cox regression to estimate the hazard ratios (HRs) and their 95% confidence intervals for CVD risk. The consistency of findings was compared to a network meta-analysis of all available cohorts. During an average of 17.4 years of follow-up, 11,597 cases of total CVD (nonfatal myocardial infarction, coronary heart disease (CHD) death, stroke, coronary revascularization, and/or incident heart failure) were confirmed. Added sugar as % energy intake daily (%EAS) at ≥15.0% was positively associated with total CVD (HR = 1.08 [1.01, 1.15]) and CHD (HR = 1.20 [1.09, 1.32]). There was also a higher risk of total CVD associated with ≥1 serving of SSB intake per day (HR = 1.29 [1.17, 1.42]), CHD (1.35 [1.16, 1.57]), and total stroke (1.30 [1.10, 1.53]). Similarly, ASB intake was associated with an increased risk of CVD (1.14 [1.03, 1.26]) and stroke (1.24 [1.04, 1.48]). According to the network meta-analysis, there was a large amount of heterogeneity across studies, showing no consistent pattern implicating added sugar, ASB, or SSB in CVD outcomes. A diet containing %EAS ≥15.0% and consuming ≥1 serving of SSB or ASB may be associated with a higher CVD incidence. The relative contribution of added sugar, SSB, and ASB to CVD risk warrants further investigation.

Intervention effects of a school-based health promotion programme on children’s nutrition behaviour

Aim

The programme “Join the Healthy Boat” promotes amongst other things a healthy diet in primary school children. In order to evaluate the programme’s effectiveness, this study longitudinally investigated children’s nutrition behaviour.

Subject and methods

A total of 1564 children (7.1 ± 0.6 years) participated in a cluster-randomised study. Teachers delivered lessons including behavioural contracting and budgeting. Nutritional behaviours of parents and child were assessed via parental report. Anthropometrics were measured on site.

Results

After one year, children in the intervention group (IG) showed a significant reduction in the consumption of pure juices (p ≤ 0.001). Soft drink consumption reduced in both groups, although with a trend towards a slightly greater reduction in the IG. Children with fathers of normal weight as well as first graders showed a significant reduction of soft drink consumption in the IG (p = 0.025 and p = 0.022 respectively). Fruit and vegetable intake increased significantly for first graders (p = 0.050), children from families with a high parental education level (p = 0.023), and for children with an overweight father (p = 0.034). Significant group differences were found for fruit and vegetable intake of children with migration background (p = 0.01) and children of parents with a high school degree could be observed (p = 0.019).

Conclusion

This shows that the programme appeals to a wider range of children, and is therefore more likely to compensate for differences due to origin or other social inequalities, which also shows that active parental involvement is vital for successful interventions.

Total and Free Sugar Levels and Main Types of Sugars Used in 18,784 Local and Imported Pre-Packaged Foods and Beverages Sold in Hong Kong

There is limited information regarding the free sugar content of pre-packaged foods in Hong Kong. This study aims to assess the free sugar content and identify the most frequently used free sugar ingredients (FSI) in pre-packaged foods in Hong Kong. Data from 18,784 products from the 2019 FoodSwitch Hong Kong database were used in this analysis. Ingredient lists were screened to identify FSI. Total sugar content was derived from nutrition labels on packaging. Free sugar content was estimated based on adaptation of a previously established systematic methodology. Descriptive statistics of the total sugar and free sugar content, as well as the mean ± SD contribution of free sugar to total sugar of the audited products were calculated, stratified by food groups. Almost two-thirds (64.5%) of the pre-packaged foods contained at least one FSI. 'Sugar (sucrose)' was the most popular FSI that was found in more than half (54.7%) of the products. 'Fruit and vegetable juices' (median 10.0; IQR 8.3-11.5 g/100 mL) were found to have a higher median free sugar content than 'Soft drinks' (8.0; 6.0-10.6 g/100 mL). Mean ± SD contribution of free sugar to the total sugar content was 65.8 ± 43.4%, with 8 out of 14 food groups having >70% total sugar as free sugar. To conclude, free sugar, especially sucrose, was extensively used in a wide variety of pre-packaged products sold in Hong Kong. Further studies are needed to assess the population intake of free sugar in Hong Kong to inform public health policy on free sugar reduction.

A Systematic Review of Metabolomic Biomarkers for the Intake of Sugar-Sweetened and Low-Calorie Sweetened Beverages

Intake of added sugars (AS) is challenging to assess compared with total dietary sugar because of the lack of reliable assessment methods. The reliance on self-reported dietary data in observational studies is often cited as biased, with evidence of AS intake in relation to health outcomes rated as low to moderate quality. Sugar-sweetened beverages (SSBs) are a major source of AS. A regular and high intake of SSBs is associated with an overall poor diet, weight gain, and cardiometabolic risks. An elevated intake of low-calorie sweetened beverages (LCSBs), often regarded as healthier alternatives to SSBs, is also increasingly associated with increased risk for metabolic dysfunction. In this review, we systematically collate evidence and provide perspectives on the use of metabolomics for the discovery of candidate biomarkers associated with the intake of SSBs and LCSBs. We searched the Medline, Embase, Scopus, and Web of Science databases until the end of December 2020. Seventeen articles fulfilled our inclusion criteria. We evaluated specificity and validity of the identified biomarkers following Guidelines for Biomarker of Food Intake Reviews (BFIRev). We report that the ¹³C:¹²C carbon isotope ratio (δ¹³C), particularly, the δ¹³C of alanine is the most robust, sensitive, and specific biomarker of SSBs intake. Acesulfame-K, saccharin, sucralose, cyclamate, and steviol glucuronide showed moderate validity for predicting the short-term intake of LCSBs. More evidence is required to evaluate the validity of other panels of metabolites associated with the intake of SSBs.

Current perspectives on global sugars consumption: definitions, recommendations, population intakes, challenges and future direction

Currently there is considerable emphasis on the relationship between dietary sugars consumption and various health outcomes, with some countries and regions implementing national sugar reduction campaigns. This has resulted in significant efforts to quantify dietary sugars intakes, to agree on terms to describe dietary sugars and to establish associated recommendations. However, this information is infrequently collated on a global basis and in a regularised manner. The present review provides context regarding sugars definitions and recommendations. It provides a global review of the available data regarding dietary sugars intake, considering forms such as total, free and added sugars. A comprehensive breakdown of intakes is provided by age-group, country and sugars form. This analysis shows that free sugars intakes as a percentage of total energy (%E) are the highest for children and adolescents (13-14%E) and the lowest for older adults (8%E). This trend across lifecycle stages has also been observed for added sugars. The available data also suggest that while some reductions in sugars intake are observed in a few individual studies, overall intakes of free/added sugars remain above recommendations. However, any wider conclusions are hampered by a lack of detailed high quality data on sugars intake, especially in developing countries. Furthermore, there is a need for harmonisation of terms describing sugars (ideally driven by public health objectives) and for collaborative efforts to ensure that the most up-to-date food composition data are used to underpin recommendations and any estimates of intake or modelling scenarios.

Using Oral Microbiota Data to Design a Short Sucrose Intake Index

Excessive sucrose consumption is associated with numerous health problems, including dental caries, and is considered to play a critical role in shaping the human microbiota. Here, we aimed to confirm the association between sucrose exposure and oral microbiota profile, develop a short food-based index capturing variation among sucrose consumers and validate it against oral microbiota and dental caries in a derivation cohort with 16- to 79-year-old participants (n = 427). Intake and food preferences were recorded by questionnaires and saliva microbiota by 16S rDNA sequencing. Taxonomic similarities clustered participants into five clusters, where one stood out with highest sucrose intake and predicted sugar related metabolic pathways but lowest species diversity in the microbiota. Multivariate modelling of food intake and preferences revealed foods suitable for a sucrose index. This, similarly to sucrose intake, was related to bacterial pattern and caries status. The validity of the sucrose index was replicated in the population-based Gene-Lifestyle Interactions in Dental Endpoints (GLIDE, n = 105,520 Swedish adults) cohort. This suggested that the index captured clinically relevant variation in sucrose intake and that FFQ derived information may be suitable for screening of sucrose intake in the clinic and epidemiological studies, although adjustments to local consumption habits are needed.