The effect of sugar-free versus sugar-sweetened beverages on satiety, liking and wanting: an 18 month randomized double-blind trial in children

Sensing the Snacking Experience: Bodily Sensations Linked to the Consumption of Healthy and Unhealthy Snack Foods-A Comparison between Body Mass Index Levels

The World Health Organisation (WHO) has highlighted the need for immediate action regarding the escalating global prevalence of overweight and obesity. Based on the need for long-term strategies supporting dietary behaviour changes, the concept of 'interoception' (i.e., sensing the body's internal state) has been proposed as promising for understanding and controlling food intake behaviours. As eating behaviours are motivated by the need for securing energy demands as well as the desire for pleasure, investigating the bodily sensations perceived in relation to food consumption can support our understanding of human food and eating behaviours. Here, a consumer study was conducted on 286 Danish consumers to explore the interoceptive experience of snack food consumption. This study included an investigation of the consumers' interoceptive capabilities and ability to feel pleasure, intuitive eating behaviours, snack food consumption frequency, the drivers of snack food consumption, food-related pleasure, and post-ingestive sensations linked to snack food consumption. The study was conducted on consumers with different Body Mass Index (BMI) levels to study potential differences between these groups. The study showed normal interoceptive capabilities and abilities to feel pleasure, with no differences between BMI groups. Regarding intuitive eating, the study found intuitive eating to be more prevalent among the group holding normal BMI. No significant differences between BMI groups were found in terms of snack intake frequency. However, differences between BMI groups were found in terms of: the drivers of snack consumption, the aspects bringing food-related pleasure from snack consumption, and the post-ingestive sensations felt after eating snack foods.

Child Involvement in Choosing a Recipe, Purchasing Ingredients, and Cooking at School Increases Willingness to Try New Foods and Reduces Food Neophobia

OBJECTIVE

To investigate the effect of involving children in their feeding process (choosing a recipe, purchasing the ingredients, and cooking) on their lunch food choice in a school environment.

DESIGN

Quasi-experimental.

SETTING

Two schools in Bilbao, Spain.

PARTICIPANTS

A total of 202 children (aged 8-9 years) participated in the study (43% girls), with 99 in the nutrition education (NE) group and 103 in the hands-on (HO) group.

INTERVENTION

Three 1-hour workshops (1 workshop/wk), different for each group: HO, cooking-related activities, and NE, healthy habits promotion through nutrition education activities.

MAIN OUTCOME MEASURES

Food neophobia, diet quality, cooking self-efficacy and attitudes toward cooking, and food intake and selection of the experimental lunches.

ANALYSIS

Chi-square test of independence, ANCOVA, and t tests were performed.

RESULTS

Students from the HO group selected and ate more spinach/broccoli (P < 0.001 and P = 0.02, respectively) for the first lunch; and selected more spinach/broccoli (P = 0.04) for the second lunch. After the intervention, improvements were observed for spinach liking and neophobia for the HO group and cooking self-efficacy and KidMed score for both groups.

CONCLUSIONS AND IMPLICATIONS

Both interventions succeeded in improving children's diet quality, but only the HO group reduced food neophobia levels. Therefore, involving children in choosing a recipe, purchasing ingredients, and cooking may promote changing eating behaviors toward healthy habits such as increasing vegetable consumption.

The effect of taste and taste perception on satiation/satiety: a review

As the prevalence of being overweight and obesity has increased worldwide, there is an increasing concern about satiation/satiety that can be achieved by eating. The ability of an individual to perceive tastes in the mouth is believed to be one of the many factors that influence food intake; the taste may affect appetite regulation and energy intake, playing an important role in promoting satiation/satiety. Satiation/satiety is actually induced by food and may be related to physiological and psychological factors such as several basic tastes, the exposure time of the taste and the cognition of different groups and individuals. This paper reviews the mechanism by which taste regulates satiation/satiety and demonstrates how taste and the taste perception of food prompt the brain to send satiation/satiety signals. Existing problems in taste and satiation/satiety and the prospective application of related research in the food industry are addressed, providing a scientific basis and theoretical guidance for the development and utilization of satiation/satiety from the perspective of taste.

Low-calorie sweetener use, weight, and metabolic health among children: A mini-review

A reduction in the consumption of added sugars and sugar-sweetened beverages (SSBs) is a key focus of public health recommendations for a healthy diet among children. One approach to lower added sugar intake is to instead use low-calorie sweeteners (LCSs), which contain no or few calories. Consumption of LCSs is increasing worldwide, with the most marked rise observed among children and adolescents. However, the extent to which LCS consumption is helpful or harmful for weight management is controversial, particularly when LCS consumption begins in childhood. Herein, we summarize the limited existing literature examining effects of paediatric LCS consumption on appetite, energy intake, and body weight. While positive associations between LCS consumption and weight gain are reported in observational analyses, the majority of intervention studies, some of which blinded children to the contents of the drinks, report benefits of LCSs for reducing excessive child weight gain. Several potential mechanisms have been proposed to explain LCS effects on body weight, including LCS-induced promotion of appetite and energy intake. Yet studies assessing effects of beverages with LCSs (LCSBs) compared with SSBs on child appetite report mixed findings. Some demonstrate that children completely compensate for the diluted energy content of LCSBs by eating more solid food calories at subsequent meals compared with children administered SSBs, while others report a reduction in total energy intake with LCSB ingestion. Given the limited studies and resulting uncertainty as to whether LCSs benefit or worsen weight and metabolic health in children is integral that effects of LCS use during childhood continue to be investigated in future prospective studies.

Sugar-Containing Beverages Consumption and Obesity in Children Aged 4-5 Years in Spain: the INMA Study

The consumption of sugar-containing beverages (SCB) has been associated with obesity although the evidence in preschool children is scarce. Cross-sectional analyses were performed to assess the association between obesity and SCB consumption (packaged juices and sugar-sweetened soft drinks) in 1823 children at the age of 4-5 years from the INfancia y Medio Ambiente (INMA) Project. One drink was defined as a glass of 175 mL, and the consumption of SCB was categorized in <1, 1-7 drinks/week and > 1 drink/day. We used multiple logistic regression to estimate odds ratios (OR). The average SCB consumption was 79.1 mL/day, mainly from packaged juices (80.9%). The SCB consumption was lower in non-obese children than in children with obesity, 76.6 vs 118.4 mL/day (p = 0.02). After adjusting for covariates, children who consumed >1 drink/day showed elevated odds of obesity, OR = 3.23 (95% confidence interval (CI): 1.48-6.98) compared to children who consumed <1 SCB drink a week. Each additional SCB drink per day was associated with higher odds of obesity, OR = 1.55 (1.14-2.09). Higher consumption of packaged juices, but not sugar-sweetened soft drinks, was significantly associated with higher odds of obesity, OR = 1.55 (1.09-2.15) and OR = 1.59 (0.76-3.39), respectively. A higher SCB consumption is associated with obesity in preschool children, mainly due to the consumption of packaged juices.

Interventions for preventing obesity in children

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Alaska Native Children Do Not Prefer Sugar-Sweetened Fruit Drinks to Sugar-Free Fruit Drinks

BACKGROUND

Alaska Native children, including children of Yup'ik descent, consume large volumes of sugar-sweetened fruit drinks, which contain added sugars that contribute to obesity, diabetes, and dental caries. To date, taste preference evaluations have not been conducted on commercially available sugar-free fruit drinks.

OBJECTIVE

The study tested the hypothesis that children would have equal preference for sugar-free and sugar-sweetened fruit drinks.

DESIGN

This was an experimental two-alternative forced-choice paired preference test.

PARTICIPANTS/SETTING

The study focused on a convenience sample of Yup'ik children, aged 7 to 10 years, recruited and enrolled from the Yukon-Kuskokwim Health Corporation dental clinic in Bethel, AK (N=89).

INTERVENTION

Children evaluated four different commercially available sugar-free fruit drinks paired with the sugar-sweetened versions of each flavor. Order of flavor pair presentation was alternated across children, and order of presentation within each of the four pairs was randomized across pairs.

MAIN OUTCOME MEASURES

The outcome was taste preference for the sugar-free versus the sugar-sweetened version of a fruit drink.

STATISTICAL ANALYSES PERFORMED

A test of equivalence was run across all four flavors and separately for each flavor using two one-sided tests.

RESULTS

The data failed to demonstrate equivalence of the sugar-free and sugar-sweetened fruit drinks across all four flavors (P=0.51) or separately for each flavor. However, this was not because of a preference for sugar-sweetened drinks. The preference for sugar-free drinks overall and for each flavor was >50%. Although the lower bounds of the 90% CIs were within the range of equivalence (40% to 60%), the upper bounds were outside the range of equivalence (>60%). According to post hoc analyses, similar preferences were observed for Yup'ik and non-Yup'ik children, boys and girls, and children of different ages.

CONCLUSIONS

Taste preference findings suggest that sugar-free fruit drinks may be a well-tolerated alternative to sugar-sweetened fruit drinks for Yup'ik children in Alaska Native communities.

Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies

OBJECTIVE

To assess the association between intake of non-sugar sweeteners (NSS) and important health outcomes in generally healthy or overweight/obese adults and children.

DESIGN

Systematic review following standard Cochrane review methodology.

DATA SOURCES

Medline (Ovid), Embase, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and reference lists of relevant publications.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies including generally healthy adults or children with or without overweight or obesity were eligible. Included study designs allowed for a direct comparison of no intake or lower intake of NSS with higher NSS intake. NSSs had to be clearly named, the dose had to be within the acceptable daily intake, and the intervention duration had to be at least seven days.

MAIN OUTCOME MEASURES

Body weight or body mass index, glycaemic control, oral health, eating behaviour, preference for sweet taste, cancer, cardiovascular disease, kidney disease, mood, behaviour, neurocognition, and adverse effects.

RESULTS

The search resulted in 13 941 unique records. Of 56 individual studies that provided data for this review, 35 were observational studies. In adults, evidence of very low and low certainty from a limited number of small studies indicated a small beneficial effect of NSSs on body mass index (mean difference -0.6, 95% confidence interval -1.19 to -0.01; two studies, n=174) and fasting blood glucose (-0.16 mmol/L, -0.26 to -0.06; two, n=52). Lower doses of NSSs were associated with lower weight gain (-0.09 kg, -0.13 to -0.05; one, n=17 934) compared with higher doses of NSSs (very low certainty of evidence). For all other outcomes, no differences were detected between the use and non-use of NSSs, or between different doses of NSSs. No evidence of any effect of NSSs was seen on overweight or obese adults or children actively trying to lose weight (very low to moderate certainty). In children, a smaller increase in body mass index z score was observed with NSS intake compared with sugar intake (-0.15, -0.17 to -0.12; two, n=528, moderate certainty of evidence), but no significant differences were observed in body weight (-0.60 kg, -1.33 to 0.14; two, n=467, low certainty of evidence), or between different doses of NSSs (very low to moderate certainty).

CONCLUSIONS

Most health outcomes did not seem to have differences between the NSS exposed and unexposed groups. Of the few studies identified for each outcome, most had few participants, were of short duration, and their methodological and reporting quality was limited; therefore, confidence in the reported results is limited. Future studies should assess the effects of NSSs with an appropriate intervention duration. Detailed descriptions of interventions, comparators, and outcomes should be included in all reports.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42017047668.

Reprint of "Beverages containing low energy sweeteners do not differ from water in their effects on appetite, energy intake and food choices in healthy, non-obese French adults"

The usefulness of replacement of caloric sugars by low-calorie sweeteners (LCS) for weight management has been questioned on the grounds that the uncoupling of LCS sweet taste and dietary energy may confuse physiological mechanisms, leading potentially to higher energy and sugar intake. The aim of the present study was to determine whether LCS beverages compared to water, when consumed with meals, differ in their effects on energy and food intake in acute trials and after long-term habituation. Ad libitum food intake of 166 (80 women; 86 men) healthy non-obese adults (BMI between 19 and 28 kg/m²), infrequent consumers of LCS was measured in four 2-consecutive-day testing sessions (Day 1 in the laboratory, Day 2 free-living). During the first 3 sessions, held one-week apart, participants were required to drink either water or commercial non-carbonated LCS lemonade (330 ml) with their main meals (randomised cross-over design). On Day 1, motivational ratings were obtained using visual analogue scales and ad libitum food intakes (amounts and types of foods selected) were measured using the plate waste method. On Day 2, participants reported their ad libitum intakes using a food diary. After Session 3, participants were randomly assigned to the LCS habituation group or to the water control group. The habituation (660 ml LCS lemonade daily vs 660 ml water) lasted 5 weeks. The fourth and final test session measured food intakes and motivational ratings after habituation. Water and LCS beverage did not differ in their effects on total energy intake, macronutrient intakes or the selection of sweet foods and on motivational ratings. Similar results were obtained in both LCS-naïve and LCS-habituated individuals.

Personal Variation in Preference for Sweetness: Effects of Age and Obesity

BACKGROUND

Use of nonnutritive sweeteners (NNSs), which provide sweet taste with few to no calories, has increased, but data on whether children's hedonic responses to NNSs differ from nutritive sugars or from adults' hedonic responses are limited.

METHODS

Most preferred levels of sucrose and the NNS sucralose were determined via a forced-choice tracking procedure in 48 children, 7-14 years (mean = 10 years), and 34 adults. Each participant also rated the liking of these taste stimuli, as well as varying concentrations of aspartame on 3- and 5-point facial hedonic scales. Anthropometric measures were obtained, and motives for palatable food intake were assessed with the Palatable Eating Motives Scale (PEMS, adults) and Kids PEMS.

RESULTS

While use of the 3-point scale showed no age-related differences in liking of sweeteners, the 5-point scale showed that more children than adults liked higher concentrations of sucrose, sucralose, and aspartame, and the tracking procedure showed that children most preferred higher concentrations of sucrose and sucralose than adults. Regardless of age, sweet preference did not differ between obese and nonobese participants and showed no association with motives for eating palatable foods. Children's body mass index z-scores were positively associated with social and conformity motive scores for eating palatable foods.

CONCLUSION

Research should move beyond measures of variation in sweet taste hedonics to include identifying motives, and the physiological and psychological consequences of eating sweets, to shed light on what children are more vulnerable to develop unfavorable eating habits, increasing risk for obesity, and other diseases.

An Investigation of Sensory Specific Satiety and Food Size When Children Consume a Whole or Diced Vegetable

Children’s vegetable consumption is often lower than that needed to promote optimal health and development, and practical approaches for increasing vegetable consumption are needed. Sensory Specific Satiety (SSS) reduces the liking and consumption of a consumed food over the course of an eating occasion and is an important factor in meal termination. The present study aimed to investigate the development of SSS when children ate vegetables of different sizes. The absence of SSS would be an encouraging sign to provide children more vegetables during a meal. Seventy-two children (33 boys, ages 8.8 ± 1.5 years) were recruited from Australian primary schools. Participating children consumed either whole or diced carrots for a maximum period of 10-min from a 500 g box. Cucumber was used as a control vegetable. Children’s liking of carrots and cucumber was measured with a 5-point child friendly hedonic scale prior to and after carrot consumption. In comparison to cucumber, liking for neither diced (p = 0.57) nor whole carrots (p = 0.18) changed during ad libitum consumption of carrots, indicating that SSS did not occur. However, children (n = 36) who finished eating carrots within the 10-min time limit, spent more time eating the whole carrots compared to the diced carrots (p < 0.05), which tended to result in a higher consumption of whole carrots (p < 0.06). This suggests that, in order to increase vegetable consumption, it is better to present children whole carrots than diced carrots. These findings might aid in the development of strategies to promote children’s greater vegetable consumption.

Postprandial energy metabolism and substrate oxidation in response to the inclusion of a sugar- or non-nutritive sweetened beverage with meals differing in protein content

Background

The macronutrient composition of the diet may play a more important role in maintaining a healthy body weight and preventing obesity than previously thought. The primary goal of this research was to determine the extent to which the simple addition of a small serving of a sugar-sweetened beverage (SSB) to meals with different macronutrient compositions impacts appetite, energy metabolism and substrate oxidation.

Methods

Appetite, energy metabolism and substrate oxidation were measured in 27 healthy weight adults (age = 23 ± 5 y; BMI = 23 ± 2 kg/m²) on two occasions in a room calorimeter after consuming a SSB or a non-nutritive-sweetened beverage (NNSB) with a standard (15%E) or high- (30%E) protein meal. Meal carbohydrate (CHO) content was adjusted to maintain equivalent calories for both study visits. All meals were composed of the same foods and provided 17 g of fat and 500 non-beverage calories. Study visits were separated by at least 1 week and menstruating females were studied during the luteal phase (Days 15-20). The effects of sex, protein level and beverage type and their interactions on satiety, appetite for foods with specific taste profiles, diet-induced thermogenesis (DIT) and rates of substrate oxidation were assessed using a 3-way Repeated Measures Analysis of Variance.

Results

Increasing dietary protein decreased hunger and increased satiety. Males were hungrier and less satisfied with the meals than females. Increasing dietary protein also decreased the desire to eat something savory, salty and fatty and the males had a greater appetite for food with these taste profiles. Interestingly, there was no effect of sex, dietary protein or beverage type on the desire to eat something sweet. The inclusion of a SSB markedly suppressed DIT (2.42% ± 5.91%) and fat oxidation (9.87 ± 11.09 g).

Conclusion

Appetite sensations, food preferences, energy expenditure and substrate oxidation are significantly altered in response to changes in meal macronutrient composition produced by modifications in the protein content of a meal and consumption of a SSB. Most notably, consumption of a SSB during a meal markedly reduces energy efficiency and fat oxidation independent of macronutrient composition.

Trial registrations

ClinicalTrials.gov: NCT02211599, registered August 05, 2014.

Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years

BACKGROUND

Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and long-term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages.

OBJECTIVES

To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta-analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence.Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.As the meta-analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post-intervention follow-up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post-intervention was no longer evident at follow-up at less than six months, which has to be investigated in further trials.

AUTHORS' CONCLUSIONS

Multi-component behaviour-changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour-changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour-changing interventions on health-related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer-term follow-up and further research on the most appropriate forms of post-intervention maintenance in order to ensure intervention benefits are sustained over the longer term.

Sugar-sweetened beverage consumption and genetic predisposition to obesity in 2 Swedish cohorts

BACKGROUND

The consumption of sugar-sweetened beverages (SSBs), which has increased substantially during the last decades, has been associated with obesity and weight gain.

OBJECTIVE

Common genetic susceptibility to obesity has been shown to modify the association between SSB intake and obesity risk in 3 prospective cohorts from the United States. We aimed to replicate these findings in 2 large Swedish cohorts.

DESIGN

Data were available for 21,824 healthy participants from the Malmö Diet and Cancer study and 4902 healthy participants from the Gene-Lifestyle Interactions and Complex Traits Involved in Elevated Disease Risk Study. Self-reported SSB intake was categorized into 4 levels (seldom, low, medium, and high). Unweighted and weighted genetic risk scores (GRSs) were constructed based on 30 body mass index [(BMI) in kg/m(2)]-associated loci, and effect modification was assessed in linear regression equations by modeling the product and marginal effects of the GRS and SSB intake adjusted for age-, sex-, and cohort-specific covariates, with BMI as the outcome. In a secondary analysis, models were additionally adjusted for putative confounders (total energy intake, alcohol consumption, smoking status, and physical activity).

RESULTS

In an inverse variance-weighted fixed-effects meta-analysis, each SSB intake category increment was associated with a 0.18 higher BMI (SE = 0.02; P = 1.7 × 10(-20); n = 26,726). In the fully adjusted model, a nominal significant interaction between SSB intake category and the unweighted GRS was observed (P-interaction = 0.03). Comparing the participants within the top and bottom quartiles of the GRS to each increment in SSB intake was associated with 0.24 (SE = 0.04; P = 2.9 × 10(-8); n = 6766) and 0.15 (SE = 0.04; P = 1.3 × 10(-4); n = 6835) higher BMIs, respectively.

CONCLUSIONS

The interaction observed in the Swedish cohorts is similar in magnitude to the previous analysis in US cohorts and indicates that the relation of SSB intake and BMI is stronger in people genetically predisposed to obesity.

The Macronutrients, Appetite, and Energy Intake

Each of the macronutrients-carbohydrate, protein, and fat-has a unique set of properties that influences health, but all are a source of energy. The optimal balance of their contribution to the diet has been a long-standing matter of debate. Over the past half century, thinking has progressed regarding the mechanisms by which each macronutrient may contribute to energy balance. At the beginning of this period, metabolic signals that initiated eating events (i.e., determined eating frequency) were emphasized. This was followed by an orientation to gut endocrine signals that purportedly modulate the size of eating events (i.e., determined portion size). Most recently, research attention has been directed to the brain, where the reward signals elicited by the macronutrients are viewed as potentially problematic (e.g., contribute to disordered eating). At this point, the predictive power of the macronutrients for energy intake remains limited.

Low Calorie Beverage Consumption Is Associated with Energy and Nutrient Intakes and Diet Quality in British Adults

It is unclear whether consumption of low-calorie beverages (LCB) leads to compensatory consumption of sweet foods, thus reducing benefits for weight control or diet quality. This analysis investigated associations between beverage consumption and energy intake and diet quality of adults in the UK National Diet and Nutrition Survey (NDNS) (2008–2011; n = 1590), classified into: (a) non-consumers of soft drinks (NC); (b) LCB consumers; (c) sugar-sweetened beverage (SSB) consumers; or (d) consumers of both beverages (BB), based on 4-day dietary records. Within-person data on beverage consumption on different days assessed the impact on energy intake. LCB consumers and NC consumed less energy and non-milk extrinsic sugars than other groups. Micronutrient intakes and food choices suggested higher dietary quality in NC/LCB consumers compared with SSB/BB consumers. Within individuals on different days, consumption of SSB, milk, juice, and alcohol were all associated with increased energy intake, while LCB and tea, coffee or water were associated with no change; or reduced energy intake when substituted for caloric beverages. Results indicate that NC and LCB consumers tend to have higher quality diets compared with SSB or BB consumers and do not compensate for sugar or energy deficits by consuming more sugary foods.

Review of the nutritional benefits and risks related to intense sweeteners

BACKGROUND

The intense sweeteners currently authorised in Europe comprise ten compounds of various chemical natures. Their overall use has sharply risen in the last 20 years. These compounds are mainly used to formulate reduced-calorie products while maintaining sweetness.

METHODS

This extensive analysis of the literature reviews the data currently available on the potential nutritional benefits and risks related to the consumption of products containing intense sweeteners.

RESULTS AND CONCLUSIONS

Regarding nutritional benefits, the available studies, while numerous, do not provide proof that the consumption of artificial sweeteners as sugar substitutes is beneficial in terms of weight management, blood glucose regulation in diabetic subjects or the incidence of type 2 diabetes. Regarding nutritional risks (incidence of type 2 diabetes, habituation to sweetness in adults, cancers, etc.), it is not possible based on the available data to establish a link between the occurrence of these risks and the consumption of artificial sweeteners. However, some studies underline the need to improve knowledge of the links between intense sweeteners consumption and certain risks.

Trends in Sugar-Sweetened Beverages: Are Public Health and the Market Aligned or in Conflict?

Adverse health consequences of consuming sugar-sweetened beverages are frequently cited as an example of market failure, justifying government intervention in the marketplace, usually in the form of taxation. However, declining sales of sugar-sweetened beverages in Australia and a corresponding increase in sales of drinks containing non-nutritive sweeteners, in the absence of significant government regulation, appear to reflect market forces at work. If so, the public health challenge in relation to sugar-sweetened beverages may have less to do with regulating the market and more to do with harnessing it. Contrary to assertions that consumers fail to appreciate the links between their choice of beverage and its health consequences, the health conscious consumer appears to be driving the changes taking place in the beverage market. With the capacity to meet consumer expectations for convenience and indulgence without unwanted kilojoules, drinks containing non-nutritive sweeteners enable the "small change" in health behaviour that individuals are willing to consider. Despite the low barriers involved in perpetuating the current trend of replacing sugar-sweetened beverages with drinks containing non-nutritive sweeteners, some public health advocates remain cautious about advocating this dietary change. In contrast, the barriers to taxation of sugar-sweetened beverages appear high.

A dynamic panel model of the associations of sweetened beverage purchases with dietary quality and food-purchasing patterns

Investigating the association between consumption of sweetened beverages and dietary quality is challenging because issues such as reverse causality and unmeasured confounding might result in biased and inconsistent estimates. Using a dynamic panel model with instrumental variables to address those issues, we examined the independent associations of beverages sweetened with caloric and low-calorie sweeteners with dietary quality and food-purchasing patterns. We analyzed purchase data from the Homescan survey, an ongoing, longitudinal, nationally representative US survey, from 2000 to 2010 (n = 34,294). Our model included lagged measures of dietary quality and beverage purchases (servings/day in the previous year) as exposures to predict the outcomes (macronutrient (kilocalories per capita per day; %), total energy, and food purchases) in the next year after adjustment for other sociodemographic covariates. Despite secular declines in purchases (kilocalories per capita per day) from all sources, each 1-serving/day increase in consumption of either beverage type resulted in higher purchases of total daily kilocalories and kilocalories from food, carbohydrates, total sugar, and total fat. Each 1-serving/day increase in consumption of either beverage was associated with more purchases of caloric-sweetened desserts or sweeteners, which accounted for a substantial proportion of the increase in total kilocalories. We concluded that consumers of both beverages sweetened with low-calorie sweeteners and beverages sweetened with caloric sweeteners had poorer dietary quality, exhibited higher energy from all purchases, sugar, and fat, and purchased more caloric-sweetened desserts/caloric sweeteners compared with nonconsumers.

Fructose decreases physical activity and increases body fat without affecting hippocampal neurogenesis and learning relative to an isocaloric glucose diet

Recent evidence suggests that fructose consumption is associated with weight gain, fat deposition and impaired cognitive function. However it is unclear whether the detrimental effects are caused by fructose itself or by the concurrent increase in overall energy intake. In the present study we examine the impact of a fructose diet relative to an isocaloric glucose diet in the absence of overfeeding, using a mouse model that mimics fructose intake in the top percentile of the USA population (18% energy). Following 77 days of supplementation, changes in body weight (BW), body fat, physical activity, cognitive performance and adult hippocampal neurogenesis were assessed. Despite the fact that no differences in calorie intake were observed between groups, the fructose animals displayed significantly increased BW, liver mass and fat mass in comparison to the glucose group. This was further accompanied by a significant reduction in physical activity in the fructose animals. Conversely, no differences were detected in hippocampal neurogenesis and cognitive/motor performance as measured by object recognition, fear conditioning and rotorod tasks. The present study suggests that fructose per se, in the absence of excess energy intake, increases fat deposition and BW potentially by reducing physical activity, without impacting hippocampal neurogenesis or cognitive function.

Intense Sweeteners, Appetite for the Sweet Taste, and Relationship to Weight Management

High intensity, low-energy sweeteners (LES) are used by many consumers in order to limit energy intake and possibly facilitate body weight control. These beneficial effects are often questioned in the scientific and lay media. LES are frequently accused of stimulating and/or maintaining a liking for sweetness which in turn would be deleterious for adequate body weight control. Evidence for the specific effects of LES use on appetite for sweet products will be extracted from observational studies, experimental laboratory studies, randomized controlled trials, and finally brain imaging studies. While many of the existing studies cannot identify any causal links between use of LES and appetite for sweetness, randomized trials in children and adults suggest that use of LES tends to reduce rather than increase the intake of sugar-containing foods and to facilitate, rather than impair, weight loss.

Sugar-containing beverage intake in toddlers and body composition up to age 6 years: the Generation R study

BACKGROUND/OBJECTIVE

Intake of sugar-containing beverages (SCBs) has been associated with higher body mass index (BMI) in childhood. The potential effect of SCB intake during infancy is unclear. We examined the association of SCB intake at 13 months with BMI development until 6 years and body composition at age 6 years.

SUBJECTS/METHODS

This study included 2371 Dutch children from a population-based prospective cohort study. SCB intake at 13 months was assessed using a Food Frequency Questionnaire with validation against 24-h recalls and was standardized for total energy. BMI was calculated from repeated weight and height measurements, and age- and sex-specific s.d. scores were calculated. Adiposity was measured using Dual-energy X-ray absorptiometry.

RESULTS

In girls, higher SCB intake at 13 months was significantly associated with higher BMI at ages 2, 3, 4 and 6 years (at age 6 years BMI (s.d. score) increase 0.11 (95% confidence interval (CI) +0.00; 0.23), high versus low intake). We observed a tendency towards higher android/gynoid fat ratio in girls with high intake (s.d. increase 0.14 (95% CI -0.02; 0.29), versus low intake) but not with body fat percentage. In boys, there was no association with BMI or body composition, but boys with high SCB intake at 13 months were taller at age 6 years (s.d. increase 0.14 (95% CI +0.00; 0.27), versus low intake).

CONCLUSIONS

Higher SCB intake at 13 months was associated with higher BMI up to age 6 years in girls but not in boys. Our results imply that the unfavorable effects of SCB intake start early in life and that dietary advice regarding limiting SCB intake should already be given early in life.

Can children discriminate sugar-sweetened from non-nutritively sweetened beverages and how do they like them?

Background

Replacement of sugar-sweetened by non-nutritively sweetened beverages or water may reduce excess weight gain in children. However, it is unclear whether children like non-nutritively sweetened beverages as much as sugar-sweetened beverages. We examined whether children could taste a difference between non-nutritively sweetened beverages and matching sugar-sweetened beverages, and which of the two types of beverage they liked best.

Methods

89 children aged 5 to 12 tasted seven non-nutritively sweetened beverages and matching sugar-sweetened beverages, for a total of 14 beverages. We used Triangle tests to check their ability to discriminate between the matched versions, and a 5-point scale to measure how much the children liked each individual beverage.

Results

Overall, 24% of children appeared to be genuinely capable of distinguishing between non-nutritively sweetened and sugar-sweetened beverages. The mean ± SD score for how much the children liked the non-nutritively sweetened beverages was 3.39±0.7 and that for the sugar-sweetened beverages 3.39±0.6 (P = 0.9) on a scale running from 1 (disgusting) to 5 (delicious). The children preferred some beverages to others irrespective of whether they were sugar-sweetened or non-nutritively sweetened (P = 0.000). Children who correctly identified which of three drinks contained the same sweetener and which one was different also showed no preference for either type.

Conclusion

We found that about one in four children were able to discriminate between non-nutritively sweetened and sugar-sweetened beverages but children liked both varieties equally. Non-nutritively sweetened beverages may therefore be an acceptable alternative to sugar-sweetened beverages although water remains the healthiest beverage for children.

Do low-calorie drinks 'cheat' the enteral-brain axis?

PURPOSE OF REVIEW

The consumption of low-calorie beverages has increased worldwide, mainly because of their combination of sweet taste without adding significant calories to the diet. However, some epidemiological studies have linked the higher consumption of low-calorie beverages with increased body weight gain.

RECENT FINDINGS

Although a matter of debate, this paradoxical association between low-calorie beverages and weight gain has been attributed to their effect on the enteral-brain axis. More specifically, artificial sweeteners present in low-calorie beverages could induce appetite increase, probably due to an ambiguous psychobiological signal (uncoupling sweet taste from calorie intake) that confounds the appetite's regulatory mechanisms, promoting overeating and, ultimately, leading to weight gain. However, many studies do not support this assumption, and the mechanisms underlying the interaction between low-calorie beverages and the enteral-brain axis remain to be defined.

SUMMARY

The understanding of the effects of low-calorie drinks on the enteral-brain axis still remains in its infancy and needs to be unveiled. The consumption of low-calorie beverages reduces the calories from that drink, but compensatory phenomena may increase energy intake, and if so must be recognized and avoided.

Artificial Sweetened Beverages and Pediatric Obesity: The Controversy Continues

The pediatric obesity epidemic has gathered public and political interest recently. People often choose “diet” or artificial sweetened beverages (ASB) to combat this epidemic, but the obesity incidence continues to rise. First, I review the pediatric studies on the effect of ASB consumption with subsequent food intake. Next, I present pediatric studies of chronic ASB consumption and weight change. Some epidemiologic pediatric studies have supported an association between artificial sweetener use and increased BMI but cannot prove causation. Randomized control trials have provided some evidence of weight loss with ASB ingestion among children, but study limitations may minimize these conclusions. Finally, I summarize the possible mechanisms that may drive potential effects of artificial sweeteners.