Beverages and body weight: challenges in the evidence-based review process of the Carbohydrate Subcommittee from the 2010 Dietary Guidelines Advisory Committee

Replacement of refined sugar by natural sweeteners: focus on potential health benefits

Refined sugar is a processed product containing 99% sucrose, which is obtained from sugarcane (70%) or sugar beet (30%). In modern societies, sugar continues to play a significant role in the diet, recognised not only for its flavour and special sweetening properties but also for its role in food preservation. On the other hand, a high consumption of refined sugar is associated with non-communicable diseases and many health issues such as a high risk of dental caries, overweight and neurodevelopmental disorders in children. Alternatives like unrefined sugars have generated a lot of interest as a healthy substitute due to their nutraceutical properties. This paper is aimed to review the beneficial effects of sugar derived from natural sources and highlight health problems that could be caused by refined processed sugar. Refined sugar is frequently used in variety of items including processed foods, soft drinks or ice creams although it is considered unhealthy due to its high salt and sugar content as well as added fats and artificial coloring. Natural sugars are preferred because they have a high nutritional value and a high concentration of healthy compounds, which offset the negative effects of refined sugar. Therefore, removing refined sugar or at least reducing its consumption should be promoted as a healthier option in food choices.

Policy Process And Non-State Actors' Influence On The 2014 Mexican Soda Tax

In January 2014, Mexico introduced a soda tax of 1 Mexican Peso (MXP) per litre. The aim of this paper is to examine the political context out of which this policy emerged, the main drivers for the policy change, and the role of stakeholders in setting the policy agenda and shaping the policy design and outcomes. Thirty-one semi-structured interviews were conducted with key stakeholders, and 145 documents, including peer-reviewed papers, policy briefs, press releases, industry, government, and CSO reports, were analysed. An iterative thematic analysis was conducted based on relevant theories of the policy process using a complementary approach, including Stages Heuristic Model, Policy Triangle Framework, and Multiple Streams Model. Results showed that a major motivation was the new administration seeking funds as they entered government. The soda tax was supported by a key group of legislators, civil society actors and by academics promoting evidence on health effects. However, the policy measure was challenged by the food and beverage industries (F&BI). Non-state actors were both formally and informally involved in setting the agenda, regardless of some of them having opposing interests on the soda tax policy. Approaches used by non-state actors to influence the agenda included: calls for action, marketing strategies, coalition building, challenging evidence, and engaging in public-private partnerships (PPPs). The effectiveness of the soda tax was highly debated and resulted in public polarization, although the framing of the outcomes was instrumental in influencing fiscal policies elsewhere. This study contributes to the debate around implementing fiscal policies for health and how power is exercised and framed in the agenda-setting phase of policy development. The article examines how the F&BI sought to influence the national strategy for obesity prevention. It argues that the experience of the soda tax campaign empowered policy advocates, strengthening national and international civil society networks.

Falsehoods and facts about dietary sugars: a call for evidence-based policy

Sugar, tobacco, and alcohol have been demonized since the seventeenth century. Yet unlike tobacco and alcohol, there is indisputable scientific evidence that dietary sugars were essential for human evolution and are essential for human health and development. Therefore, the purpose of this analytic review and commentary is to demonstrate that anti-sugar rhetoric is divorced from established scientific facts and has led to politically expedient but ill-informed policies reminiscent of those enacted about alcohol a century ago in the United States. Herein, we present a large body of interdisciplinary research to illuminate several misconceptions, falsehoods, and facts about dietary sugars. We argue that anti-sugar policies and recommendations are not merely unscientific but are regressive and unjust because they harm the most vulnerable members of our society while providing no personal or public health benefits.

Total and Added Sugar Intake: Assessment in Eight Latin American Countries

Non-communicable diseases are growing at an alarming rate in Latin America. We assessed total and added sugar intake in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela, to verify the adequacy of the World Health Organization’s recommendations, considering gender, socioeconomic level (SEL) and age. A total of 9218 non-institutionalized individuals living in urban areas (age range 15–65 years) were assessed in the Latin American Study of Nutrition and Health (ELANS), a multicenter household population-based cross-sectional survey. Socio-demographic data were collected. Total and added sugar intakes were measured using two non-consecutive 24-h dietary recalls. The prevalence of excessive sugar intake was estimated. A large proportion of individuals showed high consumption of total and added sugar intake, which reflected in the high prevalence of excessive sugar intake. With minimal differences across countries, in general, women, individuals with high SEL, and younger people had higher percentages of total energy intake from total and added sugar intake, and of contribution of carbohydrates from total and added sugars. Thus, there is high consumption of total and added sugar intake in the Latin American countries with some peculiarities considering socio-demographic variables, which should be considered in each country’s health intervention proposals.

The negative impact of sugar-sweetened beverages on children's health: an update of the literature

While sugar sweetened beverage (SSB) consumption has declined in the last 15 years, consumption of SSBs is still high among children and adolescents. This research synthesis updates a prior review on this topic and examines the evidence regarding the various health impacts of SSBs on children's health (overweight/obesity, insulin resistance, dental caries, and caffeine-related effects). We searched PubMed, CAB Abstracts and PAIS International to identify cross-sectional, longitudinal and intervention studies examining the health impacts of SSBs in children published after January 1, 2007. We also searched reference lists of relevant articles. Overall, most studies found consistent evidence for the negative impact of SSBs on children's health, with the strongest support for overweight/obesity risk and dental caries, and emerging evidence for insulin resistance and caffeine-related effects. The majority of evidence was cross-sectional highlighting the need for more longitudinal and intervention studies to address this research question. There is substantial evidence that SSBs increase the risk of overweight/obesity and dental caries and developing evidence for the negative impact of SSBs on insulin resistance and caffeine-related effects. The vast majority of literature supports the idea that a reduction in SSB consumption would improve children's health.

Sugar in Infants, Children and Adolescents: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

The consumption of sugars, particularly sugar-sweetened beverages (SSBs; beverages or drinks that contain added caloric sweeteners (ie, sucrose, high-fructose corn syrup, fruit juice concentrates), in European children and adolescents exceeds current recommendations. This is of concern because there is no nutritional requirement for free sugars, and infants have an innate preference for sweet taste, which may be modified and reinforced by pre- and postnatal exposures. Sugar-containing beverages/free sugars increase the risk for overweight/obesity and dental caries, can result in poor nutrient supply and reduced dietary diversity, and may be associated with increased risk of type 2 diabetes mellitus, cardiovascular risk, and other health effects. The term "free sugars," includes all monosaccharides/disaccharides added to foods/beverages by the manufacturer/cook/consumer, plus sugars naturally present in honey/syrups/unsweetened fruit juices and fruit juice concentrates. Sugar naturally present in intact fruits and lactose in amounts naturally present in human milk or infant formula, cow/goat milk, and unsweetened milk products is not free sugar. Intake of free sugars should be reduced and minimised with a desirable goal of <5% energy intake in children and adolescents aged ≥2 to 18 years. Intake should probably be even lower in infants and toddlers <2 years. Healthy approaches to beverage and dietary consumption should be established in infancy, with the aim of preventing negative health effects in later childhood and adulthood. Sugar should preferably be consumed as part of a main meal and in a natural form as human milk, milk, unsweetened dairy products, and fresh fruits, rather than as SSBs, fruit juices, smoothies, and/or sweetened milk products. Free sugars in liquid form should be replaced by water or unsweetened milk drinks. National Authorities should adopt policies aimed at reducing the intake of free sugars in infants, children and adolescents. This may include education, improved labelling, restriction of advertising, introducing standards for kindergarten and school meals, and fiscal measures, depending on local circumstances.

What is the appropriate upper limit for added sugars consumption?

Dramatic increases in obesity and diabetes have occurred worldwide over the past 30 years. Some investigators have suggested that these increases may be due, in part, to increased added sugars consumption. Several scientific organizations, including the World Health Organization, the Scientific Advisory Council on Nutrition, the Dietary Guidelines Advisory Committee 2015, and the American Heart Association, have recommended significant restrictions on upper limits of sugars consumption. In this review, the scientific evidence related to sugars consumption and its putative link to various chronic conditions such as obesity, diabetes, heart disease, nonalcoholic fatty liver disease, and the metabolic syndrome is examined. While it appears prudent to avoid excessive calories from sugars, the scientific basis for restrictive guidelines is far from settled.

Caloric compensation for sugar-sweetened beverages in meals: A population-based study in Brazil

Sugar-sweetened beverage (SSB) consumption can cause positive energy balance, therefore leading to weight gain. A plausible biological mechanism to explain this association is through weak caloric compensation for liquid calories. However, there is an ongoing debate surrounding SSB calorie compensation. The body of evidence comes from a diversity of study designs and highly controlled settings assessing food and beverage intake. Our study aimed to test for caloric compensation of SSB in the free-living setting of daily meals. We analyzed two food records of participants (age 10 years or older) from the 2008-2009 National Dietary Survey (Brazil, N = 34,003). We used multilevel analyses to estimate the within-subject effects of SSB on food intake. Sugar-sweetened beverage calories were not compensated for when comparing daily energy intake over two days for each individual. When comparing meals, we found 42% of caloric compensation for breakfast, no caloric compensation for lunch and zero to 22% of caloric compensation for dinner, differing by household per capita income. In conclusion, SSB consumption contributed to higher energy intake due to weak caloric compensation. Discouraging the intake of SSB especially during lunch and dinner may help reduce excessive energy intake and lead to better weight management.

Systematic Review of Pears and Health

Fruit consumption is universally promoted, yet consumption of fruit remains low in the United States. We conducted a systematic review on pear consumption and health outcomes searching both PubMed and Agricola from 1970 to present. The genus Pyrus L. consists of species of pears cultivated in Europe, parts of Asia, South America, and North America. Like most fruit, pears are concentrated in water and sugar. Pears are high in dietary fiber, containing 6 g per serving. Pears, similar to apples, are concentrated in fructose, and the high fiber and fructose in pears probably explain the laxative properties. Pears contain antioxidants and provide between 27 and 41 mg of phenolics per 100 g. Animal studies with pears suggest that pears may regulate alcohol metabolism, protect against ulcers, and lower plasma lipids. Human feeding studies with pears have not been conducted. In epidemiological studies, pears are combined with all fresh fruits or with apples, because they are most similar in composition. The high content of dietary fiber in pears and their effects on gut health set pears apart from other fruit and deserves study.

Bottle and sippy cup use is associated with diet and energy intake in toddlers

The second year of life incorporates a continued shift from a liquid- to solid-based diet. Little is known about the prevalence and dietary impact of bottle and sippy cup use. This paper describes associations between percent of energy consumed via drinking containers (bottles and sippy cups combined) and dietary outcomes, between 1 and 2 years of age. This observational study recruited n = 299 low-income, nutrition programme clients from the Bronx, NY, whose 12 month olds consumed ≥ 2 non-water bottles per day. The main exposure variable was percent of energy intake via drinking containers (PEDC), dichotomized at the median into low-percent-energy-from-drinking-containers (LOW-C) and high-percent-energy-from-drinking-containers (HIGH-C) groups, assessed quarterly, for 1 year. We report 24-hour dietary recall nutrient and food serving data by LOW-C vs. HIGH-C. We employed linear mixed models to study associations between PEDC and nutrient intake. PEDC decreased from 52% to 33% between 1 and 2 years of age in both groups. The LOW-C group had higher intake of energy, dietary fibre, iron and sodium, grains, protein-rich foods and sweets. Conversely, LOW-C group had lower intake of Vitamin D and calcium vs. the HIGH-C group. PEDC was inversely associated with total energy intake in a model controlling for baseline age, baseline-weight-for-length and gender (β = -5.8, P = 0.029, 95% confidence interval (-10.96, -0.6). Lower bottle and sippy cup use had significant, albeit mixed association with diet quality in the second year of life, and was associated with higher energy intake. Evidence-based guidelines are needed to determine the appropriate use of those feeding methods.

Energy Contribution of Beverages in US Children by Age, Weight, and Consumer Status

BACKGROUND

Messaging to reduce unhealthy beverage intake is often targeted to overweight and obese children; however, there is little evidence to show that healthy weight children have healthier beverage intake patterns. Further, data on consumers only may further elucidate beverage intake patterns.

PURPOSE

The aim of this study was to update the current body of literature describing beverage intake in children by weight category, with the addition of consumer-only data.

METHODS

Day one 24-hour recalls from the National Health and Nutrition Examination Survey 2005-2010 were analyzed to assess beverage intake of children 2-18 years old and differences by weight category. Beverages were coded as water, milk, 100% juice, coffee/tea, fruit drinks, soda, or low-calorie/diet drinks.

RESULTS

On average, 18.7% of total daily calories for 2- to 18-year-old children came from beverages; 60% of total daily calories from added sugar came from beverages. Mean calories from beverages were 359, 358, and 386 kcal for normal weight, overweight, and obese children, respectively. Across all weight categories, there were clinically significant differences between overall means and means for consumers only. There were overlapping confidence intervals for intake of calories from soda and fruit drinks consumed by 2- to 5-year-olds and 12- to 18-year-olds, suggesting nonsignificant differences in intake across weight categories for these age groups.

CONCLUSIONS

Messaging around beverage intake may be beneficial for children of all weights, particularly for those known to consume sugar-sweetened beverages. The per-consumer estimates may represent a better measure of intakes in future examinations of 24-hour recall data.

Substitution of sugar-sweetened beverages with other beverage alternatives: a review of long-term health outcomes

BACKGROUND

Excessive consumption of sugar-sweetened beverages (SSBs) has become an intractable public health concern worldwide, making investigation of healthy beverage alternatives for SSBs imperative.

AIM

To summarize the available evidence on the effects of replacing SSBs with beverage alternatives on long-term health outcomes.

METHOD

We systematically retrieved studies from six electronic databases from inception to November 2013. Prospective cohort studies and randomized controlled trials (RCTs) examining the effects of substituting beverage alternatives for SSBs on long-term health outcomes in both children and adults were included. The quality of included studies was assessed using the Scottish Intercollegiate Guidelines Network 50 methodology checklists.

RESULTS

Six cohort studies and four RCTs were included in the systematic review with the quality rating ranging from acceptable to high. Evidence from both cohort studies and RCTs showed substitution of SSBs by various beverage alternatives was associated with long-term lower energy intake and lower weight gain. However, evidence was insufficient to draw conclusions regarding the effect of beverage substitution on other health outcomes, and which beverage alternative is the best choice.

CONCLUSIONS

Although studies on this topic are sparse, the available evidence suggests a potential beneficial effect on body weight outcomes when SSBs are replaced by water or low-calorie beverages. Further studies in this area are warranted to fully understand the long-term health implications of beverage substitutions.

Trends in dietary quality among adults in the United States, 1999 through 2010

IMPORTANCE

Many changes in the economy, policies related to nutrition, and food processing have occurred within the United States since 2000, and the net effect on dietary quality is not clear. These changes may have affected various socioeconomic groups differentially.

OBJECTIVE

To investigate trends in dietary quality from 1999 to 2010 in the US adult population and within socioeconomic subgroups.

DESIGN, SETTING, AND PARTICIPANTS

Nationally representative sample of 29 124 adults aged 20 to 85 years from the US 1999 to 2010 National Health and Nutrition Examination Survey.

MAIN OUTCOMES AND MEASURES

The Alternate Healthy Eating Index 2010 (AHEI-2010), an 11-dimension score (range, 0-10 for each component score and 0-110 for the total score), was used to measure dietary quality. A higher AHEI-2010 score indicated a more healthful diet.

RESULTS

The energy-adjusted mean of the AHEI-2010 increased from 39.9 in 1999 to 2000 to 46.8 in 2009 to 2010 (linear trend P < .001). Reduction in trans fat intake accounted for more than half of this improvement. The AHEI-2010 component score increased by 0.9 points for sugar-sweetened beverages and fruit juice (reflecting decreased consumption), 0.7 points for whole fruit, 0.5 points for whole grains, 0.5 points for polyunsaturated fatty acids, and 0.4 points for nuts and legumes over the 12-year period (all linear trend P < .001). Family income and education level were positively associated with total AHEI-2010, and the gap between low and high socioeconomic status widened over time, from 3.9 points in 1999 to 2000 to 7.8 points in 2009 to 2010 (interaction P = .01).

CONCLUSIONS AND RELEVANCE

Although a steady improvement in AHEI-2010 was observed across the 12-year period, the overall dietary quality remains poor. Better dietary quality was associated with higher socioeconomic status, and the gap widened with time. Future efforts to improve nutrition should address these disparities.

Why Is It So Difficult to Lose Weight?

Obesity is notoriously difficult to treat. Effective treatment has been encumbered by traditional assumptions about the cause of the disease. Obesity is typically considered a manifestation of the patient’s dietary misconduct, a simple lack of willpower, or the inability to modify dysfunctional eating habits. Abundant evidence suggests that eating behavior is much more complex than patient choice alone. Eating and the system of regulating eating and body weight are largely controlled by complex signals from multiple organ systems that monitor food intake, gastrointestinal function, and energy storage and send multiple messages to the brain. The brain coordinates the physiological messages and creates additional signals about eating, appetite, hunger, and satiety. Multiple survival, environmental, and genetic factors become part of a biological regulatory system that controls eating and body weight. The system appears to be unstable and often becomes dysfunctional, particularly in an environment of abundant food and calories. Despite the difficulty in modifying the regulatory system, opportunities for management of the disease do exist. Comprehensive lifestyle management can be useful, as can selective pharmacotherapy and bariatric surgery. Public policy changes will likely be helpful in changing community understanding of the disease and its management.

Systematic review of the evidence for an association between sugar-sweetened beverage consumption and risk of obesity

A systematic review of the evidence for an association between sugar-sweetened beverages and risk of obesity was conducted. This review focused specifically on the role of sugar-sweetened beverages in obesity risk, taking into account energy balance. For the purpose of this review, scientific conclusions could not be drawn from the intervention studies that evaluated the relationship between sugar-sweetened beverage intake and obesity risk. Results of observational studies that examined the relationship between sugar-sweetened beverage intake and obesity risk that were adjusted for energy intake and physical activity were inconsistent for each of the three age groups evaluated (children, adolescents, and adults). From this review, evidence for an association between sugar-sweetened beverage intake and obesity risk is inconsistent when adjustment for energy balance is made.

Addiction to sugar and its link to health morbidity: a primer for newer primary care and public health initiatives in Malaysia

OBJECTIVES

The average consumption of sugar in the Malaysian population has reached an alarming rate, exceeding the benchmark recommended by experts. This article argues the need of a paradigm shift in the management of sugar consumption in the country through evidence derived from addiction research.

METHODS

"Food addiction" could lead to high levels of sugar consumption. This probable link could accelerate the development of diabetes and obesity in the community. A total of 94 reports and studies that describe the importance of addiction theory-based interventions were found through a search on PubMed, Google Scholar, and Academic Search Complete.

RESULTS

Research in the field of addiction medicine has revealed the addictive potential of high levels of sugar intake. Preexisting health promotion strategies could benefit from the integration of the concept of sugar addiction. A targeted intervention could yield more positive results in health outcomes within the country.

CONCLUSION

Current literature seems to support food environment changes, targeted health policies, and special consultation skills as cost-effective remedies to curb the rise of sugar-related health morbidities.

Misconceptions about fructose-containing sugars and their role in the obesity epidemic

A causal role of fructose intake in the aetiology of the global obesity epidemic has been proposed in recent years. This proposition, however, rests on controversial interpretations of two distinct lines of research. On one hand, in mechanistic intervention studies, detrimental metabolic effects have been observed after excessive isolated fructose intakes in animals and human subjects. On the other hand, food disappearance data indicate that fructose consumption from added sugars has increased over the past decades and paralleled the increase in obesity. Both lines of research are presently insufficient to demonstrate a causal role of fructose in metabolic diseases, however. Most mechanistic intervention studies were performed on subjects fed large amounts of pure fructose, while fructose is ordinarily ingested together with glucose. The use of food disappearance data does not accurately reflect food consumption, and hence cannot be used as evidence of a causal link between fructose intake and obesity. Based on a thorough review of the literature, we demonstrate that fructose, as commonly consumed in mixed carbohydrate sources, does not exert specific metabolic effects that can account for an increase in body weight. Consequently, public health recommendations and policies aiming at reducing fructose consumption only, without additional diet and lifestyle targets, would be disputable and impractical. Although the available evidence indicates that the consumption of sugar-sweetened beverages is associated with body-weight gain, and it may be that fructose is among the main constituents of these beverages, energy overconsumption is much more important to consider in terms of the obesity epidemic.

Beverages contribute extra calories to meals and daily energy intake in overweight and obese women

Caloric beverages may promote obesity by yielding energy without producing satiety, but prior laboratory and intervention studies are inconclusive. This study examined whether the diets of free-living overweight and obese women show evidence that calories from beverages are offset by reductions in solid food within individual eating occasions and across entire days. Eighty-two women weighed and recorded all consumed foods and beverages for seven days. Beverages were coded as high-calorie (≥ 0.165 kcal/g) or low-calorie (<0.165 kcal/g), and total energy intake and energy intake from solid food were calculated for each eating occasion and day. In covariate-adjusted models, energy intake from solid food did not differ between eating occasions that included high-calorie or low-calorie beverages and those with no reported beverage. Energy intake from solid food was also unrelated to the number of high-calorie or low-calorie beverages consumed per day. On average, eating occasions that included a high-calorie beverage were 169 kcal higher in total energy than those with no reported beverage, and 195 kcal higher in total energy than those that included a low-calorie beverage. Each high-calorie beverage consumed per day contributed an additional 147 kcal to women's daily energy intake, whereas low-calorie beverage intake was unrelated to daily energy intake. Beverages contributed to total energy intake in a near-additive fashion among free-living overweight and obese women, suggesting a need to develop more effective interventions to reduce caloric beverage intake in the context of weight management, and to potentially reexamine dietary guidelines.

Associations between energy intake, daily food intake and energy density of foods and BMI z-score in 2-9-year-old European children

PURPOSE

The aim of this study was to investigate the associations between proxy-reported energy intake, daily food intake and energy density of foods and body mass index (BMI) z-score in 2-9-year-old European children.

METHODS

From 16,225 children who participated in the identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) baseline examination, 9,782 children with 24-h proxy dietary information and complete covariate information were included in the analysis. Participating children were classified according to adapted Goldberg cutoffs: underreports, plausible energy reports and overreports. Energy intake, daily food intake and energy density of foods excluding noncaloric beverages were calculated for all eating occasions. Effect of energy intake, daily food intake and energy density of foods on BMI z-score was investigated using multilevel regression models in the full sample and subsample of plausible energy reports. Exposure variables were included separately; daily food intake and energy intake were addressed in a combined model to check for interactions.

RESULTS

In the group of plausible energy reports (N = 8,544), energy intake and daily food intake were significantly positively associated with BMI z-score. Energy density of foods was not associated with BMI z-score. In the model including energy intake, food intake and an interaction term, only energy intake showed a significantly positive effect on BMI z-score. In the full sample (N = 9,782), only energy intake was significantly but negatively associated with BMI z-score.

CONCLUSION

Proxy-reporters are subject to misreporting, especially for children in the higher BMI levels. Energy intake is a more important predictor of unhealthy weight development in children than daily food intake.