Early Exposure to Nonnutritive Sweeteners and Long-term Metabolic Health: A Systematic Review

Non-Nutritive Sweeteners in Human Amniotic Fluid and Cord Blood: Evidence of Transplacental Fetal Exposure

OBJECTIVE

This study aimed to investigate human fetal exposure to non-nutritive sweeteners (NNS) by analyzing amniotic fluid and umbilical cord blood.

STUDY DESIGN

Concentrations of four NNS (acesulfame-potassium [ace-K], saccharin, steviol glucuronide, and sucralose) were measured in amniotic fluid (n = 13) and cord blood samples (n = 15) using liquid chromatography-mass spectrometry. Amniotic fluid samples were obtained for research purposes at the time of term elective cesarean birth or clinically indicated third trimester amnioreduction at Mercy Hospital for Women (Melbourne, Australia). All except four women were in the fasting state. Cord blood samples were obtained from an independent cohort of newborns whose mothers were enrolled in a separate clinical trial at the National Institutes of Health.

RESULTS

Ten of 13 amniotic fluid samples contained at least one NNS (ace-K, saccharin, steviol glucuronide, and/or sucralose). Maximum amniotic fluid NNS concentrations of ace-K, saccharin, steviol glucuronide, and sucralose were 78.9, 55.9, 93.5, and 30.6 ng/mL, respectively. Ace-K and saccharin were present in 100% and 80% of the cord blood samples, with maximal concentrations of 6.5 and 2.7 ng/mL, respectively. Sucralose was not detected and steviol glucuronide was not measurable in any of the cord blood samples.

CONCLUSION

Our results provide evidence of human transplacental transmission of NNS. Based on results predominantly obtained from rodent models, we speculate that NNS exposure may adversely influence the offsprings' metabolic health. Well-designed, prospective clinical trials are necessary to understand the impact of NNS intake during pregnancy on human development and long-term health.

KEY POINTS

· NNS consumption during pregnancy has increased in recent years.. · Maternal NNS intake during pregnancy is associated with preterm birth and higher infant weight gain in epidemiologic studies.. · In rodents, in utero NNS exposure induces metabolic abnormalities in mothers and their offspring, alters offspring gut microbiota composition, and promotes sweet taste preference in adulthood.. · It is presently unknown whether and to what degree maternal NNS ingestion in humans leads to direct in utero exposure.. · This study provides the first evidence of in utero NNS exposure in humans and highlights the urgent need to investigate clinical consequences of early life NNS exposure on metabolism, weight, taste preference, and general health..

The impact of non-caloric artificial sweetener aspartame on female reproductive system in mice model

BACKGROUND

Artificial sweeteners, used as sugar substitutes have found their ways into almost all the food items due to the notion that they are non-caloric. Aspartame is used in numerous food products throughout the world. The primary users of aspartame include diabetics and calorie conscious people who intend to limit their calorie intake.

METHODS

Female Swiss albino mice were divided into three groups (12 mice each) for the duration of 30 and 60 days consecutively. The treatment groups received 40 mg/kg b. w. aspartame orally. Hormone assays using ELISA and tissue histopathology have been performed along with the fertility assay to access the treatment outcomeon the fertility of treated mice in comparison to controls.

RESULTS

Present study reports that female mice treated with aspartame for 30 and 60 days showed significant reduction in body weight, relative organ weight of (liver and kidney) and gonadosomatic index. These changes were more significantly recorded in 60 days treatment group. Aspartame treated animals for 30 and 60 days showed duration-dependent decrease gonandotropins (follicle stimulating hormone and luteinizing hormone), and steroids (estradiol and progesterone). Moreover, severe histopathological changes, reduction in number of growing follicles, degenerative changes in follicular structure, corona radiata and zonagranulosa were also observed. Besides, histomorphological changes were also observed in the uterine structure including atrophic uterine endometrial glands, contracted endometrial lining, disruption of the endometrial structure and the shapes of blood vessels were also altered.

CONCLUSION

Non-nutritive artificial sweeteners including aspartame negatively impact the function of ovaries and feedback mechanism of reproductive hormones by affecting the hypothalamic-pituitary-gonadal axis. In light of present findings the aspartame negatively impacted the reproductive system of female mice. More studies are required to identify the molecular mechanism and the pathways involved.

Maternal consumption and perinatal exposure to non-nutritive sweeteners: should we be concerned?

The context for this review is the rapid increase in the use of non-nutritive sweeteners (NNSs) instead of sugar in foods and beverages, a situation so prevalent in some countries that consumers are finding it increasingly challenging to access foods without NNSs. The benefits of consuming NNSs on obesity and diabetes are now being questioned, and studies have shown that they may exert physiological activities, sometimes independently of sweet taste receptor stimulation. Few studies, limited mainly to North American and European countries, have described the consumption of NNSs by pregnant or lactating women and infants. Most focus on beverages rather than foods, but all agree that consumption levels have increased dramatically. Although some studies report a negative impact of NNSs on the risk of preterm birth, increased birth weight and decreased gestational age, the level of evidence is low. Several studies have also reported increased weight gain in infancy, associated with maternal NNS intake. Interestingly, several NNSs have been detected in amniotic fluid and breast milk, usually (but not always) at concentrations below their established detection limit in humans. Unfortunately, the impact of chronic exposure of the fetus/infant to low levels of multiple NNSs is unknown. In conclusion, there is a stark contrast between the galloping increase in the consumption of NNSs and the small number of studies evaluating their impact in at-risk groups such as pregnant and lactating women and infants. Clearly, more studies are needed, especially in Latin America and Asia, to fill these gaps and update recommendations.

Consensus on complementary feeding from the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition: COCO 2023

Complementary feeding (CF) is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute, and is a process that is more than simply a guide as to what and how to introduce foods. The information provided by healthcare professionals must be up-to-date and evidence-based. Most of the recommendations that appear in the different international guidelines and position papers are widely applicable, but some must be regionalized or adapted to fit the conditions and reality of each geographic zone. The Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) summoned a group of experts from each of the society's member countries, to develop a consensus on CF, incorporating, whenever possible, local information adapted to the reality of the region. The aim of the present document is to show the results of that endeavor. Utilizing the Delphi method, a total of 34 statements on relevant aspects of CF were evaluated, discussed, and voted upon.

Non-nutritive sweeteners and their impacts on the gut microbiome and host physiology

Non-nutritive sweeteners (NNS) are broadly incorporated into foods, especially those representing a growing share of the beverage market. NNS are viewed as a noncaloric and desirable alternative to sugar-based sweeteners and are thought to contribute to reducing overall caloric intake. While these compounds have been studied extensively and have long been considered inert, new research has presented a different view and raises new questions about the effects of NNS on human physiology. Namely, the influence on glucose responses, the gastrointestinal epithelium, and the gut microbiome. As the gut microbiome is now recognized as a major mediator of human health and perturbations to this community are generally associated with negative health trajectories or overt disease, interactions between NNS and the gut microbiome are of increasing interest to clinicians and researchers. Several NNS compounds are now hypothesized to affect human physiology by modulating the gut microbiome, though the mechanism for this action remains unclear. The purpose of this review is to discuss the history and current knowledge of NNS, their reported utility and effects on host physiology and the gut microbiome, and describes a model for investigating the underlying mechanism behind reported effects of NNS on the gut microbiome.

Non-Nutritive Sweetener Intake Is Low in Preschool-Aged Children in the Guelph Family Health Pilot Study

There is limited research on the intake of non-nutritive sweeteners (NNS) among preschool-aged children. Canada’s Food Guide suggests limiting intake of NNS for all population groups and Health Canada recommends that young children (<2 years) avoid consuming beverages containing NNS. The aim of this study was to investigate the frequency and type of non-nutritive sweetener (NNS) intake in preschool-aged children participating in the Guelph Family Health Study pilots. Parents (n = 78 families) completed 3-day food records (n = 112 children; n = 55 females, n = 57 males; 3.6 years ± 1.3). Nineteen children (17%) reported consumption of foods or beverages containing NNS. Food sources with NNS included: freezies, oral nutritional supplements, flavored water, carbonated drinks, sugar free jam and protein powder. The majority of NNS contained in these foods were identified as stevia leaf extract, acesulfame K, sucralose, monk fruit extract and aspartame. Future research should continue to study NNS intake patterns longitudinally in children and examine the association of NNS intake with diet quality and health outcomes.

Food additives in childhood: a review on consumption and health consequences

OBJECTIVE

To discuss the context of scientific publications on the consumption of food additives by children and the possible health consequences in this age group.

METHODS

A literature review, with a search carried out between April 2020 and April 2021 in the Web of Science, Scopus, PubMed and Google Scholar databases, as well as in websites of Brazilian and foreign official bodies. Official documents and studies published since 2000 were selected. Keywords related to food additives, children, food consumption, and health were used for the search.

RESULTS

Food additives are substances intentionally added to foods for technological purposes. Processed foods are the main sources of additives in food and their consumption occurs since childhood. It is observed, however, that there are limitations inherent to the scientific method regarding the analysis of consumption and toxicity of food additives in humans, causing scarcity of data in the scientific literature. Additionally, existing data suggest that the additives have a higher toxic potential in children, considering that the body weight in this age group is lower than in adults. This context emphasizes the need to observe the precautionary principle, according to which risks of harm must be prevented.

CONCLUSIONS

This is a scenario in which the literature points to a risk to people's health and, in particular, to children, about whom the duty of protection must be even greater, with absolute priority. Thus, the relevance of an expanded technical-scientific debate regarding the establishment of specific and stricter parameters for children is considered, regarding the consumption and toxicity of additives, as well as the different sources of exposure to these substances.

Development and Validation of the Chinese Version Non-Nutritive Sweetener Food Frequency Questionnaire with Urinary Biomarker in Children and Adolescents

OBJECTIVE

The purpose of this study was to develop a validated food frequency questionnaire (FFQ) to evaluate the intake of non-nutritive sweeteners (NNSs) in child and adolescent Asian populations.

DESIGN

Intensive and overall market research was performed to create the applicable NNS-FFQ with 13 food categories and 305 items. Six intense sweeteners, including acesulfame potassium, aspartame, sucralose, glycyrrhizin, steviol glycosides and sorbitol, were investigated. The validity and reproducibility of the NNS-FFQ were evaluated. The validity was further assessed by examining the consistency of reported NNS intake compared with urinary biomarkers using Cohen's κ analysis.

SETTINGS

This work was considered to be relevant in Asian societies.

PARTICIPANTS

One hundred and two children and adolescents recruited from several clinics were invited to participate in this study.

RESULTS

High content validity indices and high content validity ratio levels were revealed for each sweetener and food category. Reproducibility among subjects was satisfactory. Significant moderate correlations between estimated steviol glycoside/sucralose consumption and sensitive urinary biomarker levels were demonstrated (κ values were 0.59 and 0.45 for steviol glycosides and sucralose, respectively), indicating that the NNS-FFQ can be used to assess an individual's NNS intake. The dietary intense sweetener consumption pattern evaluated in this measurement was similar to those observed in other Asian countries but differed from those observed in Western populations with respect to types and amounts of NNSs.

CONCLUSIONS

This validated NNS-FFQ can be an applicable and useful tool to evaluate NNS intake in future epidemiological and clinical studies.

Why Don't You [Government] Help Us Make Healthier Foods More Affordable Instead of Bombarding Us with Labels? Maternal Knowledge, Perceptions, and Practices after Full Implementation of the Chilean Food Labelling Law

Experimental and real-life evaluations show that the use of front-of-package warning labels (FoP) in unhealthy foods is well understood and can modify people's behaviors. However, it is unclear whether these effects remain in the long term because of the risk of message fatigue. The purpose of this study is to explore after four years of implementation of the Chilean Food Labelling law people's dietary behavior and FoP labels attention. Nine focus groups of mothers (7-10 people each) of children (2-14 yo) were conducted in Santiago, Chile, and macrocodes were developed, combining an iterative process of deductive and inductive thematic analyses. We found that mothers experienced labels' fatigue but also had greater knowledge about nutrition and appreciation for more natural foods. This greater knowledge about better nutrition interferes with the perception that healthier and less processed foods are financial and physically inaccessible. The key role of schools as an environment for promoting healthier diets in children was strengthened by the mothers. These results suggest that policies based on providing consumer information need reinforcement campaigns to maintain their effectiveness and that we also need to advance policies to improve access and affordability of healthy foods to ensure better diets.

Consumption of Non-nutritive Sweeteners and Risk for Type 2 Diabetes: What Do We Know, and Not?

PURPOSE OF REVIEW

The article explores the relationship between non-nutritive sweetener consumption and the risk of developing type 2 diabetes through reviewing meta-analyses and systematic reviews, as well as clinical trials and observational studies.

RECENT FINDINGS

The data overall has yet to show a strong and clear link between consumption of non-nutritive sweeteners and the development of type 2 diabetes. However, several observational studies have shown a positive relationship between these two variables, with a stronger association found among women. Regarding non-nutritive sweeteners that are currently commercially available, there is not one specific non-nutritive sweetener that appears to be more strongly associated with the development of type 2 diabetes than other non-nutritive sweeteners. There is still much to be learned regarding non-nutritive sweeteners and their potential link to metabolic disorders. Further research is needed to identify the long-term impacts of non-nutritive sweetener consumption and identify the nuances in terms of risk of developing type 2 diabetes concerning specific non-nutritive sweeteners.

Current Knowledge Base of Beverage Health Impacts, Trends, and Intake Recommendations for Children and Adolescents: Implications for Public Health

PURPOSE OF REVIEW

Improving beverage patterns is important for promoting the health of children and adolescents. Food preferences can begin developing at a young age; thus, children and adolescents should be provided healthy beverages in accordance with current recommendations. The purpose of this review is to identify and summarize existing beverage recommendations for children and adolescents. This review also discusses the health impacts of beverages and how beverage consumption has changed among children and adolescents over time.

RECENT FINDINGS

The mean number of calories that children and adolescents are consuming from beverages on a given day has declined in recent years. However, sugar-sweetened beverages (SSB) are the primary source of added sugars in this population. Therefore, SSB consumption remains a concern, and reducing the intake of SSB is still considered a top priority for helping to improve dietary quality. This review uniquely compiles recommendations into one convenient table for the entire age range of 0-19 years and includes recommendations that can be more adequately individualized. Beverage categories where beverage recommendations from authoritative sources are lacking have also been identified. Potential methods that can be implemented to improve beverage patterns and current public policy recommendations have been discussed to provide actionable steps that public health professionals can utilize in practice. The comprehensive table of beverage recommendations could be useful for professionals promoting the health of children and adolescents in research, clinical, and public health settings.

Diet Beverage Intake during Lactation and Associations with Infant Outcomes in the Infant Feeding Practices Study II

Consumption of diet beverages (DB) containing low-calorie sweeteners (LCS) is widespread in the United States. LCS are ingested by nursing infants upon maternal DB consumption, which may impact infants' weight and health. This study aims to examine cross-sectional associations between infants' LCS exposure via maternal DB intake during lactation and infants' health outcomes. Six hundred and eighty-two mother-infant dyads at three months postpartum, from the Infant Feeding Practices Study II, 2005-2007, were included in the analysis. Maternal DB consumption during lactation was estimated using the serving size and frequency of DB consumption reported on the diet history questionnaire. Infants' LCS exposure was estimated by multiplying maternal DB consumption and breastfeeding intensity. Infant outcomes included weight, weight-for-age and BMI-for-age z-scores, overweight, and gastrointestinal (GI) symptoms including diarrhea, reflux, and vomiting. Associations between infants' LCS exposure and continuous and categorical outcomes were examined using linear and logistic regressions adjusting for confounders, respectively. Forty-three percent of lactating women reported DB consumption. While no significant associations were observed between infants' LCS exposure and BMI-for-age or risk of overweight, infants' LCS exposure was associated with a 2.78-fold increased risk of vomiting (95% confidence interval 1.05-7.34). Potential adverse effects of LCS exposure on GI symptoms require further study, and null findings on infant weight should be interpreted with caution, given the small sample size. Additional research is needed to inform recommendations for or against DB consumption during lactation.

Low-calorie sweeteners and human health: a rapid review of systematic reviews

INTRODUCTION

Low-calorie sweeteners are increasingly prevalent in the food supply and their consumption has increased in recent decades. Although low-calorie sweeteners approved for use are considered safe from a toxicological perspective, their short- and long-term impacts on chronic disease risk remain uncertain. The aim of this review was to summarize the evidence from systematic reviews on low-calorie sweetener use and chronic conditions and risk factors in children and adults.

METHODS

MEDLINE and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews of randomized and nonrandomized studies that considered low-calorie sweeteners in relation to type 2 diabetes, cardiovascular disease, cancer, anthropometric measures, hypertension, hyperglycemia, hyperlipidemia, insulin resistance, and dental caries. Data were extracted from 9 reviews deemed of moderate or high quality on the basis of AMSTAR-2.

RESULTS

Narrative synthesis suggested inconsistent evidence on low-calorie sweetener use in relation to chronic conditions and associated risk factors, with nonrandomized studies suggesting positive associations and randomized studies suggesting negative or no associations.

CONCLUSION

Continued research on the long-term health impacts of low-calorie sweeteners across all life stages is warranted.

The consumption of low-calorie sweetener containing foods during pregnancy: results from the ROLO study

Background/objectives

Women with gestational diabetes (GDM) are advised to adapt a low glycaemic index (GI) diet, which may impact consumption of low-calorie sweeteners (LCS). LCS are increasingly popular as they add sweetness without contributing calories. This study aims to investigate the reported intakes of LCS-containing foods in women during pregnancy.

Subjects/methods

Pregnant women recruited for the ROLO study were included in this analysis (n = 571). Women were randomised to receive either an intervention of low-GI dietary advice or usual antenatal care. Women completed a 3-day food diary in each trimester. Nine LCS-containing food groups were identified, and the quantity (g/day) consumed was calculated.

Results

One-third of all pregnant women consumed LCS across each trimester of pregnancy. Of those in the intervention group who were LCS consumers in trimester 1, 71.6% were consumers in trimester 2, and 54.1% remained consumers in trimester 3. In the control group, less women remained consumers in trimester 2 and 3 at 58.1% and 41.9%, respectively. In trimester 2, following the dietary intervention, the proportion of LCS consumers in the intervention group was significantly higher than the proportion of consumers who were in the control group (p < 0.001). The most commonly consumed food groups were low-calorie fruit drinks, diet-cola drinks, and low-calorie yoghurts.

Conclusions

One-third of pregnant women consumed LCS. The proportion of LCS consumers increased in the intervention group compared to the control group. Further research is needed to determine exposure levels to individual LCS, and the effect of prenatal exposure to LCS on maternal and child health outcomes.

Low-energy sweeteners and body weight: a citation network analysis

OBJECTIVE

Reviews on the relationship of low-energy sweeteners (LES) with body weight (BW) have reached widely differing conclusions. To assess possible citation bias, citation analysis was used to quantify the relevant characteristics of cited articles, and explore citation patterns in relation to review conclusions.

DESIGN

A systematic search identified reviews published from January 2010 to March 2020. Different characteristics (for example, type of review or research, journal impact factor, conclusions) were extracted from the reviews and cited articles. Logistic regression was used to estimate likelihood of articles with particular characteristics being cited in reviews. A qualitative network analysis linked reviews sub-grouped by conclusions with the types of articles they cited.

MAIN OUTCOME MEASURES

(OR; 95% CI) for likelihood that articles with particular characteristics were cited as evidence in reviews.

RESULTS

From 33 reviews identified, 183 different articles were cited (including other reviews). Narrative reviews were 62% less likely to be cited than systematic reviews with meta-analysis (OR 0.38; 0.16 to 0.86; p=0.03). Likelihood of being cited was higher for evidence on children than adults (OR 2.27; 1.59 to 3.25; p<0.0001), and with increased journal impact factor (OR 1.15; 1.00 to 1.31; p=0.04). No other factors were statistically significant in the main analysis, and few factors were significant in subgroup analyses. Network analysis showed that reviews concluding a beneficial relationship of LES with BW cited mainly randomised controlled trials, whereas reviews concluding an adverse relationship cited mainly observational studies.

CONCLUSIONS

Overall reference to the available evidence across reviews appears largely arbitrary, making citation bias likely. Differences in the conclusions of individual reviews map onto different types of evidence cited. Overall, inconsistent and selective use of the available evidence may account for the diversity of conclusions in reviews on LES and BW.

TRIAL REGISTRATION NUMBER

Prior to data analysis, the protocol was registered with the Open Science Framework (https://osf.io/9ghws).

Soft drinks and sweeteners intake: Possible contribution to the development of metabolic syndrome and cardiovascular diseases. Beneficial or detrimental action of alternative sweeteners?

The rapid increase in obesity, metabolic syndrome, and cardiovascular diseases (CVDs) has been related to the rise in sugar-added foods and sweetened beverages consumption. An interesting approach has been to replace sugar with alternative sweeteners (AS), due to their impact on public health. Preclinical and clinical studies, which analyze the safety of AS intake, are still limited. Major pathogenic mechanisms of these substances include ROS and AGEs formation. Indeed, endothelial dysfunction involving in the pathogenesis of micro- and macro-vascular diseases is mitochondrial dysfunction dependent. Hyperglycemia and endoplasmic reticulum stress together produce ROS, contributing to the development and progression of cardiovascular complications during type 2 diabetes (T2D), thus causing oxidative changes and direct damage of lipids, proteins, and DNA. Epidemiological studies in healthy subjects have suggested that the consumption of artificial AS can promote CV complications, such as glucose intolerance and predisposition to the onset of T2D, whereas natural AS could reduce hyperglycemia, improve lipid metabolism and have antioxidant effects. Long-term prospective clinical randomized studies are needed to evaluate precisely whether exposure to alternative sugars can have clinical implications on natural history and clinical outcomes, especially in children or during the gestational period through breast milk.

Sucralose and Cardiometabolic Health: Current Understanding from Receptors to Clinical Investigations

The excess consumption of added sugar is consistently found to be associated with weight gain, and a higher risk of type 2 diabetes mellitus, coronary heart disease, and stroke. In an effort to reduce the risk of cardiometabolic disease, sugar is frequently replaced by low- and null-calorie sweeteners (LCSs). Alarmingly, though, emerging evidence indicates that the consumption of LCSs is associated with an increase in cardiovascular mortality risk that is amplified in those who are overweight or obese. Sucralose, a null-caloric high-intensity sweetener, is the most commonly used LCS worldwide, which is regularly consumed by healthy individuals and patients with metabolic disease. To explore a potential causal role for sucralose in increased cardiovascular risk, this present review summarizes the preclinical and clinical data from current research detailing the effects of sucralose on systems controlling food intake, glucose homeostasis, and gut microbiota.

How Does Our Brain Process Sugars and Non-Nutritive Sweeteners Differently: A Systematic Review on Functional Magnetic Resonance Imaging Studies

This systematic review aimed to reveal the differential brain processing of sugars and sweeteners in humans. Functional magnetic resonance imaging studies published up to 2019 were retrieved from two databases and were included into the review if they evaluated the effects of both sugars and sweeteners on the subjects’ brain responses, during tasting and right after ingestion. Twenty studies fulfilled the inclusion criteria. The number of participants per study ranged from 5 to 42, with a total number of study participants at 396. Seven studies recruited both males and females, 7 were all-female and 6 were all-male. There was no consistent pattern showing that sugar or sweeteners elicited larger brain responses. Commonly involved brain regions were insula/operculum, cingulate and striatum, brainstem, hypothalamus and the ventral tegmental area. Future studies, therefore, should recruit a larger sample size, adopt a standardized fasting duration (preferably 12 h overnight, which is the most common practice and brain responses are larger in the state of hunger), and reported results with familywise-error rate (FWE)-corrected statistics. Every study should report the differential brain activation between sugar and non-nutritive sweetener conditions regardless of the complexity of their experiment design. These measures would enable a meta-analysis, pooling data across studies in a meaningful manner.

Nutritional profile of ultra-processed foods consumed by children in Rio de Janeiro

OBJECTIVE

To analyze the nutritional composition of ultra-processed foods consumed by children that attend basic health units.

METHODS

This is a cross-sectional study with a representative probabilistic sample of 536 children aged between 6 and 59 months treated at a health unit in the city of Rio de Janeiro. Nutritional information was extracted from labels of the ultra-processed foods referred to in a 24-hour recall. The 351 foods mentioned were divided into 22 groups and 38 subgroups according to the type of product, and they were characterized according to the averages of the values for energy, total fats, saturated fats, trans fats and sodium in 100 grams of the product, in addition to presence, number, and type of “other sweeteners”. The nutritional Profile Model of the Pan American Health Organization was applied for each food and for the average of nutrient content obtained for each group to examine the occurrence of critical nutrients excess.

RESULTS

Ultra-processed foods contained high energy value and high levels of total fats, saturated fats, trans fats, and sodium. Out of the total of ultra-processed foods, 66% presented excess of at least one critical nutrient, with emphasis on requeijões and ultra-processed cheeses, instant noodles, and industrialized and sausage-like meats, which presented 100% of foods with excess of total fats, saturated fats and sodium. Out of the 21 groups, the following exceeded the limit established by the Pan American Health Organization: for total fats, 10 groups; for saturated fats, 11; for trans fats, 3; and sodium, 13. Requeijões and ultra-processed cheeses; industrialized and sausage-like meats; and biscuits exceeded this limit in all parameters. Out of the set of ultra-processed foods analyzed, 13.4% contained “other sweeteners” (eight different types).

CONCLUSIONS

The ultra-processed foods analyzed presented unbalanced nutritional profile, and two thirds presented excess of at least one critical nutrient. Educational actions and regulatory measures are necessary to better inform the population and to discourage its consumption.

Eating Habits of Children Born after Maternal Bariatric Surgery

Mothers who underwent bariatric surgery (BS) before pregnancy have worrisome eating habits, but little is known about the eating habits of their offspring. EFFECTOR is a cross-sectional, long-term follow-up study of 4-11-year-old children born from mothers that underwent bariatric surgery before pregnancy (n = 36), mothers with overweight/obesity (OW/OB) in a control group (n = 71), and mothers with a normal weight (NW) in a second control group (n = 35). Data on anthropometry and on eating habits obtained through a Food Frequency Questionnaire were collected prospectively. The children's body mass index (BMI) scores significantly correlated with maternal pre-pregnancy BMI. The prevalence of overweight and obesity was the highest in children of the BS group (38.9% vs. 15.5% for children of the OW/OB group and 5.7% for those of the NW group; p = 0.004). Meal-skipping behavior was comparable between the groups. There was no difference in fruit and vegetable consumption. The BS group consumed more low-calorie sweetened beverages compared to the NW group (p = 0.01) but less fruit juice compared to the NW and OW/OB groups (p = 0.01). Our results may indicate a sugar-avoiding behavior in children of the BS group, fitting dietary maternal habits in a strategy to prevent dumping syndrome. In conclusion, maternal pre-pregnancy bariatric surgery does not alter unhealthy eating behaviors and the risk of development of overweight during childhood in their children.

Consumption of non-nutritive sweeteners during pregnancy

In an effort to reduce sugar consumption to prevent diabetes mellitus and cardiovascular diseases, "sugar-free" or "no added sugar" products that substitute sugar with non-nutritive sweeteners (NNSs) (eg, Splenda, Sweet'N Low, and Stevia) have become increasingly popular. The use of these products during pregnancy has also increased, with approximately 30% of pregnant women reporting intentional NNS consumption. In clinical studies with nonpregnant participants and animal models, NNSs were shown to alter gut hormonal secretion, glucose absorption, appetite, kidney function, in vitro insulin secretion, adipogenesis, and microbiome dysbiosis of gut bacteria. In pregnant animal models, NNS consumption has been associated with altered sweet taste preference later in life and metabolic dysregulations in the offspring (eg, elevated body mass index, increased risk of obesity, microbiome dysbiosis, and abnormal liver function tests). Despite the accumulating evidence, no specific guidelines for NNS consumption are available for pregnant women. Furthermore, there are limited clinical studies on the effects of NNS consumption during pregnancy and postpartum and long-term outcomes in the offspring.

Non-nutritive Sweeteners and Their Associations with Obesity and Type 2 Diabetes

Evidence linking the excessive consumption of nutritive sweeteners (NS) to adverse metabolic health outcomes has led to an increase in consumption of non-nutritive sweeteners (NNS), particularly among the obese and individuals with diabetes. NNS are characterized by having zero-to-negligible caloric load, while also having a sweet taste. They are utilized as a replacement for traditional NS to reduce energy intake and to limit carbohydrate-related negative health outcomes. However, recent studies have suggested that NNS may actually contribute to the development or worsening of metabolic diseases, including metabolic syndrome, obesity, type

2 diabetes, and cardiovascular disease. Thus, it is imperative to understand the NNS efficacy and the relationship between NNS and metabolic diseases.

Overuse of Non-caloric Sweeteners in Foods and Beverages in Chile: A Threat to Consumers' Free Choice?

The prevalence of obesity among Chilean adults and children is one of the highest worldwide. To fight the constant increase of non-communicable diseases and the growing sales of sugar-sweetened beverages, the Chilean government recently enacted a new Law of Food Labeling and Advertising imposing the application of front-of-package warning labels in foodstuffs whose composition exceeds limits for critical nutrients including sugar. Accordingly, food companies have been reformulating their products, incorporating non-caloric sweeteners (NCSs) in partial or total replacement of sucrose. The number of NCS-containing foods and beverages, therefore, has been increasing in the last years. This study aims to identify the NCS-containing products from different food/beverage categories currently available on the Chilean market. Nineteen supermarkets and 13 food web pages were visited by trained dietitians to carry out a systematic search of ingredient information from the different food categories. Overall, 1,489 products were analyzed, of which 815 (55.5%) contained at least one NCS, being this proportion particularly high, compared to other countries. 67.1% of the dairy products, 31.5% of the cereal products, 49% of the processed fruits, 74.3% of the non-alcoholic beverages, and 46.2% of sweets and other desserts contained NCS. Considering the food categories more specifically oriented to children, NCSs were present in 98.8% of powder juices, 98.3% of the flavored milks, 91.2% of jellies, and 79% of the dairy desserts. Sucralose and steviol glycosides were the most widely used NCSs, these sweeteners being present, alone or mixed with other, in 73.5 and 39.7% of the NCS-containing products, respectively, while the use of saccharin and cyclamate was low. In addition, 80 tabletop NCSs were available in the local market, 91.2% of them being sucralose and steviol glycosides (alone or combined). The high number of food products containing steviol glycosides makes very plausible that the daily consumption of this NCS in the pediatric populations could exceed its acceptable daily intake (ADI). The fact that there are no NCS-free foods alternatives for certain food categories, especially for children, is worrying.

Perspective: Standards for Research and Reporting on Low-Energy ("Artificial") Sweeteners

Widely differing views exist among experts, policy makers, and the general public with regard to the potential risks and benefits of reduced- or low-energy sweeteners (LES) in the diet. These views are informed and influenced by different types of research in LES, with differing hypotheses, designs, interpretation, and communication. Given the high level of interest in LES, and the public health relevance of the research evidence base, it is important that all aspects of the research process are framed and reported in an appropriate and balanced manner. In this Perspective, we identify and give examples of a number of issues relating to research and reviews on LES, which may contribute toward apparent inconsistencies in the content and understanding of the totality of evidence. We conclude with a set of recommendations for authors, reviewers and journal editors, as general guidance to improve and better standardize the quality of LES research design, interpretation, and reporting. These focus on clarity of underlying hypotheses, characterization of exposures, and the placement and weighting of new research within the wider context of related prior work.

The Use of Nonnutritive Sweeteners in Children

The prevalence of nonnutritive sweeteners (NNSs) in the food supply has increased over time. Not only are more children and adolescents consuming NNSs, but they are also consuming a larger quantity of NNSs in the absence of strong scientific evidence to refute or support the safety of these agents. This policy statement from the American Academy of Pediatrics is intended to provide the pediatric provider with a review of (1) previous steps taken for approved use of NNSs, (2) existing data regarding the safety of NNS use in the general pediatric population, (3) what is known regarding the potential benefits and/or adverse effects of NNS use in children and adolescents, (4) identified gaps in existing knowledge and potential areas of future research, and (5) suggested talking points that pediatricians may use when discussing NNS use with families.

Anticipatory effects of the implementation of the Chilean Law of Food Labeling and Advertising on food and beverage product reformulation

This study evaluated the anticipated food and beverage product reformulation by industry before the Chilean Law of Food Labeling and Advertising (Law 20.606) was implemented in June 2016 requiring a front-of-package (FOP) warning label for products high in sodium, total sugars, saturated fats, and/or total energy. Fieldworkers photographed a purposive sample of packaged food and beverage products in February 2015 (n = 5421) and February 2016 (n = 5479) from six different supermarkets in Santiago, Chile. The same products collected in both years (n = 2086) from 17 food and beverage categories with added critical nutrients (nutrients of concern: sodium, total sugars, and saturated fats) were included in this longitudinal study. The average change in energy and critical nutrient content was estimated by category. The number of warning labels potentially avoided because of reformulation was determined. Between February 2015 and February 2016, no category experienced reductions >5% average change in energy or critical nutrient content; and some increased in critical nutrient content. Few products (<2%) would have avoided at least one warning label with reformulation. In a diverse sample of food and beverage products, there was minimal reformulation by industry in anticipation of the implementation of the 2016 Chilean Law of Food Labeling and Advertising.

Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal

BACKGROUND

Medical nutrition therapy is the cornerstone of gestational diabetes mellitus treatment. However, guidelines often present contradictory guidance to health care practitioners.

OBJECTIVE

To systematically review and critically appraise medical nutrition therapy guidelines for treating patients with gestational diabetes mellitus.

DESIGN

We searched Medline, the Cochrane Library, Guidelines International Network, and Google Scholar to retrieve clinical practice guidelines (CPGs) for medical nutrition therapy in gestational diabetes mellitus from professional or governmental organizations, published in English, between January 1, 2007, and November 24, 2018. CPGs were reviewed and appraised using the Appraisal of Guidelines, Research, and Evaluation II instrument.

RESULTS

Of 1,286 retrieved articles, 21 CPGs fulfilled the inclusion criteria. CPGs of the Academy of Nutrition and Dietetics, Diabetes Canada, and Malaysia Health Technology Assessment Section received the greatest overall scores and the highest scores concerning rigor of recommendations development. Many CPGs failed to involve multidisciplinary teams in their development, including patients, and often, dietitians. Applicability of the recommendations was low, lacking facilitators and tools to enhance implementation. Many CPGs demonstrated low editorial independence by failing to disclose funding and competing interests. More medical nutrition therapy recommendations were incorporated in the Academy of Nutrition and Dietetics and Malaysia Health Technology Assessment Section CPGs. The Malaysia Health Technology Assessment Section, Diabetes Canada, Academy of Nutrition and Dietetics, and Endocrine Society guidelines were recommended by the review panel herein without modifications. Overall, the CPGs suggested the consumption of adequate protein and the selection of foods with low glycemic index, divided into three main meals and two to four snacks. Weight gain recommendations were mostly based on the Institute of Medicine body mass index thresholds.

CONCLUSIONS

With few exceptions, the main developmental limitations of the appraised CPGs involved low rigor of recommendations development, lack of multidisciplinary stakeholder involvement, low applicability, and inadequate editorial independence. This indicates a need for developing more clear, unbiased, practical, and evidence-based CPGs.

Exposure to liquid sweetness in early childhood: artificially-sweetened and sugar-sweetened beverage consumption at 4-5 years and risk of overweight and obesity at 7-8 years

BACKGROUND

A significant gap exists in longitudinal evidence on early exposure to artificially sweetened beverages (ASBs) and weight outcomes for paediatric populations.

OBJECTIVE

The objective of this study is to examine the relationship between ASB/sugar-sweetened beverage (SSB) consumption at 4-5 years and risk of overweight and obesity at 7-8 years.

METHODS

Data from a nationally representative cohort (n = 2986) in Scotland were analysed using logistic regression to evaluate the association between exposure to ASBs/SSBs at 4-5 years and risk of overweight and obesity at 7-8 years.

RESULTS

There were positive unadjusted associations between ASB consumption and risk of obesity, and following adjustment for confounders, ASB associations attenuated, and only the middle consumption category (1 to 6 times per week) remained significant (odds ratio 1.57, 95% confidence interval {CI} 1.05-2.36). For SSB consumption, there were no significant unadjusted associations, and following adjustment for confounders, only the middle consumption category was significant (odds ratio 1.65, 95% CI 1.12-2.44). There were no significant associations for risk of overweight.

CONCLUSIONS

Longitudinal analysis from 4-5 to 7-8 years demonstrated some evidence of associations between ASBs/SSB consumption and risk of obesity. However, non-linear patterns and wide CIs suggest cautious interpretation and need for future studies with long-term follow-up.

Astrogliosis and decreased neural viability as consequences of early consumption of aspartame and acesulfame potassium in male Wistar rats

Artificial sweeteners are mainly used as substitutes for sucrose derivates. In this study, we analyzed if the chronic consumption of aspartame or acesulfame potassium at an early age, produces histological alterations, astrogliosis and decreased neuronal viability, in hippocampus, prefrontal cortex, amygdala and hypothalamus of male Wistar rats. A histological analysis was performed on male Wistar rats that consumed aspartame or acesulfame potassium during 90 days, initiating the consumption of sweeteners immediately after weaning. The evaluation of neuronal morphology in different areas of the brain was performed with hematoxylin - eosin staining. To measure astrogliosis and neuronal viability, we used the immunohistochemical technique, with the glial fibrillary acidic protein immunomodulators (GFAP) and with neuronal-specific enolase (NSE). The consumption of aspartame or acesulfame potassium promoted morphological changes of neurons including increased pyknotic nuclei and vacuolization in all the brain areas studied. In hippocampus, prefrontal cortex, amygdala and hypothalamus, astrogliosis and reduction of neural viability were observed in sweeteners consumers in comparison with the control group. Chronic consumption of ASP and ACK from early stages of development and during long periods, may promote neural modifications, astrogliosis and decrease neuronal viability in prefrontal cortex, amygdala, hippocampus, and hypothalamus.

Pathways and mechanisms linking dietary components to cardiometabolic disease: thinking beyond calories

Calories from any food have the potential to increase risk for obesity and cardiometabolic disease because all calories can directly contribute to positive energy balance and fat gain. However, various dietary components or patterns may promote obesity and cardiometabolic disease by additional mechanisms that are not mediated solely by caloric content. Researchers explored this topic at the 2017 CrossFit Foundation Academic Conference 'Diet and Cardiometabolic Health - Beyond Calories', and this paper summarizes the presentations and follow-up discussions. Regarding the health effects of dietary fat, sugar and non-nutritive sweeteners, it is concluded that food-specific saturated fatty acids and sugar-sweetened beverages promote cardiometabolic diseases by mechanisms that are additional to their contribution of calories to positive energy balance and that aspartame does not promote weight gain. The challenges involved in conducting and interpreting clinical nutritional research, which preclude more extensive conclusions, are detailed. Emerging research is presented exploring the possibility that responses to certain dietary components/patterns are influenced by the metabolic status, developmental period or genotype of the individual; by the responsiveness of brain regions associated with reward to food cues; or by the microbiome. More research regarding these potential 'beyond calories' mechanisms may lead to new strategies for attenuating the obesity crisis.

Prevalence of low-calorie sweetener intake in South Asian adults

BACKGROUND

Consumption of low-calorie sweeteners (LCS) has increased in the US and is associated with cardiometabolic risk. No data exist on LCS consumption in South Asians.

AIM

The aim of this study was to assess the prevalence of LCS use across socio-demographic characteristics, chronic disease status, and cardiometabolic risk factors.

METHODS

Cross-sectional analyses were conducted using data from the Mediators of Atherosclerosis in South Asians Living in America study (N = 892; 47% women; mean age = 55 (standard deviation = 9.4) y). Chi-squared and ANOVA tests were used to compare LCS consumption across socio-demographic characteristics and cardiometabolic risk factors.

RESULTS

Twenty-two percent of participants reported LCS use, with higher consumption among men and those with longer residency in the US. LCS use was associated with adiposity and higher odds of hypertension, high cholesterol, and diabetes.

CONCLUSIONS

LCS use is prevalent among South Asians, emphasizing the need for long-term, prospective studies to investigate its role in incident cardiometabolic risk in an already metabolically vulnerable population.

Consumption of artificial sweetened beverages associated with adiposity and increasing HbA1c in Hispanic youth

Research examining the impact of artificial sweetened beverages (ASBs) on obesity and metabolic diseases in adolescents is limited. The overall goal is to examine the longitudinal effects of ASBs on changes in adiposity and metabolic parameters in Hispanic adolescents. Longitudinal cohort with 98 Hispanics (12-18 years) who were overweight or had obesity with the following data at baseline and 1-year later: anthropometrics, diet (24-h recalls), body composition (DXA), glucose and insulin dynamics (oral glucose tolerance and frequently sampled intravenous glucose tolerance test) and fasting lipids. Repeated measures analyses of covariance assessed changes over time between control (no ASBs at either visit), ASB initiators (no ASBs at baseline/ASBs at 1-year) and chronic ASB consumers (ASBs at both visits). ASB initiators (n = 14) and chronic ASB consumers (n = 9) compared to control (n = 75) had higher total body fat at baseline and 1-year (P = 0.05 for group effect). Chronic ASB consumers had a 6% increase in haemoglobin A1c, 34% increase in energy intake (kcal d-1 ) and 39% increase in carbohydrate intake (g d-1 ) over time, while control and ASB initiators maintained (P < 0.05 for group-by-time interactions). These results do not support promoting ASBs as a strategy for adiposity loss or to improve metabolic health.

Hypotheses and evidence related to intense sweeteners and effects on appetite and body weight changes: A scoping review of reviews

Observed associations between consumption of diet foods and obesity have sparked controversy over whether intense sweeteners may promote weight gain, despite their negligible energy contribution. We conducted a scoping review of reviews, to obtain an overview of hypotheses, research approaches and features of the evidence on intense sweeteners' potential relationships to appetite and weight changes. We searched for reviews of the scientific literature published from 2006 to May 2017. Two reviewers independently assessed title and abstracts, and full text publications. Arksey and O'Malley's framework for scoping reviews guided the process. We extracted and charted data on characteristics of the reviews and the evidence presented. The 40 included reviews present hypotheses both on how intense sweeteners can reduce or maintain body weight and on how these can promote weight gain. We classified only five publications as systematic reviews; another nine presented some systematic approaches, while 26 reviews did not describe criteria for selecting or assessing the primary studies. Evidence was often presented for intense sweeteners as a group or unspecified, and against several comparators (e.g. sugar, water, placebo, intake levels) with limited discussion on the interpretation of different combinations. Apart from the observational studies, the presented primary evidence in humans is dominated by small studies with short follow-up-considered insufficient to assess weight change. Systematic reviews of animal studies are lacking in this topic area. The systematic evidence only partly explore forwarded hypotheses found in the literature. Primary studies in humans seem to be available for systematic exploration of some hypotheses, but long-term experimental studies in humans appear sparse. With few exceptions, the reviews on intense sweeteners and weight change underuse systematic methodology, and thus, the available evidence. Further studies and systematic reviews should be explicit about the hypothesis explored and elucidate possible underlying mechanisms.

Ibero⁻American Consensus on Low- and No-Calorie Sweeteners: Safety, Nutritional Aspects and Benefits in Food and Beverages

International scientific experts in food, nutrition, dietetics, endocrinology, physical activity, paediatrics, nursing, toxicology and public health met in Lisbon on 2⁻4 July 2017 to develop a Consensus on the use of low- and no-calorie sweeteners (LNCS) as substitutes for sugars and other caloric sweeteners. LNCS are food additives that are broadly used as sugar substitutes to sweeten foods and beverages with the addition of fewer or no calories. They are also used in medicines, health-care products, such as toothpaste, and food supplements. The goal of this Consensus was to provide a useful, evidence-based, point of reference to assist in efforts to reduce free sugars consumption in line with current international public health recommendations. Participating experts in the Lisbon Consensus analysed and evaluated the evidence in relation to the role of LNCS in food safety, their regulation and the nutritional and dietary aspects of their use in foods and beverages. The conclusions of this Consensus were: (1) LNCS are some of the most extensively evaluated dietary constituents, and their safety has been reviewed and confirmed by regulatory bodies globally including the World Health Organisation, the US Food and Drug Administration and the European Food Safety Authority; (2) Consumer education, which is based on the most robust scientific evidence and regulatory processes, on the use of products containing LNCS should be strengthened in a comprehensive and objective way; (3) The use of LNCS in weight reduction programmes that involve replacing caloric sweeteners with LNCS in the context of structured diet plans may favour sustainable weight reduction. Furthermore, their use in diabetes management programmes may contribute to a better glycaemic control in patients, albeit with modest results. LNCS also provide dental health benefits when used in place of free sugars; (4) It is proposed that foods and beverages with LNCS could be included in dietary guidelines as alternative options to products sweetened with free sugars; (5) Continued education of health professionals is required, since they are a key source of information on issues related to food and health for both the general population and patients. With this in mind, the publication of position statements and consensus documents in the academic literature are extremely desirable.

Non-Nutritive Sweeteners and Metabolic Health Outcomes in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically assess and quantitatively synthesize the literature regarding the association of consumption of non-nutritive sweeteners (NNS) during childhood with negative metabolic health outcomes.

STUDY DESIGN

Following the PRISMA guidelines, published literature was systematically reviewed. Eligible studies (N = 13) were identified through the screening of over 2500 publications. Random-effects meta-analyses were conducted on the association of NNS consumption with body mass index (BMI) increase. Sensitivity and subgroup analyses by sex were also undertaken.

RESULTS

Consumption of NNS during childhood and adolescence was associated with an increase in BMI (OR 1.15, 95% CI 1.06-1.25); the OR was similar in sensitivity analyses. The associations were positive but marginally significant in subanalyses by sex. The qualitative assessment of existing literature showed nonsignificant associations with other components of metabolic disease, such as waist circumference, fat mass accumulation, and type 2 diabetes.

CONCLUSIONS

Systematic assessment of observational studies showed no association of NNS intake during childhood with fat mass accumulation and waist circumference and a small, but statistically significant association with BMI increase. Inherent methodological weaknesses of to-date published investigations, including mainly underpowered size to explore the hypothesis, call for more research.

Aspartame Consumption for 12 Weeks Does Not Affect Glycemia, Appetite, or Body Weight of Healthy, Lean Adults in a Randomized Controlled Trial

Background

Low-calorie sweeteners are often used to moderate energy intake and postprandial glycemia, but some evidence indicates that they may exacerbate these aims.

Objective

The trial's primary aim was to assess the effect of daily aspartame ingestion for 12 wk on glycemia. Effects on appetite and body weight were secondary aims.

Methods

One hundred lean [body mass index (kg/m2): 18-25] adults aged 18-60 y were randomly assigned to consume 0, 350, or 1050 mg aspartame/d (ASP groups) in a beverage for 12 wk in a parallel-arm design. At baseline, body weight and composition were determined, a 240-min oral-glucose-tolerance test (OGTT) was administered, and measurements were made of appetite and selected hormones. Participants also collected a 24-h urine sample. During the intervention, the 0-mg/d ASP group consumed capsules containing 680 mg dextrose and 80 mg para-amino benzoic acid. For the 350-mg/d ASP group, the beverage contained 350 mg aspartame and the 1050-mg/d ASP group consumed the same beverage plus capsules containing 680 mg dextrose and 700 mg aspartame. Body weight, blood pressure, heart rate, and waist circumference were measured weekly. At weeks 4, 8, and 12, participants collected 24-h urine samples and kept appetite logs. Baseline measurements were repeated at week 12.

Results

With the exception of the baseline OGTT glucose concentration at 60 min (and resulting area under the curve value), there were no group differences for glucose, insulin, resting leptin, glucagon-like peptide 1, or gastric inhibitory peptide at baseline or week 12. There also were no effects of aspartame ingestion on appetite, body weight, or body composition. Compliance with the beverage intervention was ∼95%.

Conclusions

Aspartame ingested at 2 doses for 12 wk had no effect on glycemia, appetite, or body weight among healthy, lean adults. These data do not support the view that aspartame is problematic for the management of glycemia, appetite, or body weight. This trial was registered at www.clinicaltrials.gov as NCT02999321.

Nonnutritive Sweeteners in Weight Management and Chronic Disease: A Review

OBJECTIVE

The objective of this review was to critically review findings from recent studies evaluating the effects of nonnutritive sweeteners (NNSs) on metabolism, weight, and obesity-related chronic diseases. Biologic mechanisms that may explain NNS effects will also be addressed.

METHODS

A comprehensive review of the relevant scientific literature was conducted.

RESULTS

Most cross-sectional and prospective cohort studies report positive associations between NNS consumption, body weight, and health conditions, including type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease. Although findings in cellular and rodent models suggest that NNSs have harmful effects on metabolic health, most randomized controlled trials in humans demonstrate marginal benefits of NNS use on body weight, with little data available on other metabolic outcomes.

CONCLUSIONS

NNS consumption is associated with higher body weight and metabolic disease in observational studies. In contrast, randomized controlled trials demonstrate that NNSs may support weight loss, particularly when used alongside behavioral weight loss support. Additional long-term, well-controlled intervention studies in humans are needed to determine the effects of NNSs on weight, adiposity, and chronic disease under free-living conditions.

Low-/No-Calorie Sweeteners: A Review of Global Intakes

The current review examined published data on the intake of all major low-/no-calorie sweeteners-aspartame, acesulfame-K, saccharin, sucralose, cyclamate, thaumatin and steviol glycosides-globally over the last decade. The most detailed and complex exposure assessments were conducted in Europe, following a standardized approach. Japan and Korea similarly had up-to-date and regular intake data available. The data for other Asian countries, Latin America, Australia/New Zealand and global estimates, evaluated by the Joint FAO/WHO Expert Committee on Food Additives (JECFA), while available, were shown to be more limited in terms of design. Overall, the studies conducted since 2008 raised no concerns with respect to exceedance of individual sweetener acceptable daily intake (ADIs) among the general population globally. The data identified do not suggest a shift in exposure over time, with several studies indicating a reduction in intake. However, some data suggest there may have been an increase in the numbers of consumers of low-/no-calorie-sweetened products. Future research should consider a more standardized approach to allow the monitoring of potential changes in exposure based upon events such as sugar reduction recommendations, to ensure there is no shift in intake, particularly for high-risk individuals, including diabetics and children with specific dietary requirements, and to ensure risk management decisions are based on quality intake analyses.

Early-Life Exposure to Non-Nutritive Sweeteners and the Developmental Origins of Childhood Obesity: Global Evidence from Human and Rodent Studies

Non-nutritive sweeteners (NNS) are increasingly consumed by children and pregnant women around the world, yet their long-term health impact is unclear. Here, we review an emerging body of evidence suggesting that early-life exposure to NNS may adversely affect body composition and cardio-metabolic health. Some observational studies suggest that children consuming NNS are at increased risk for obesity-related outcomes; however, others find no association or provide evidence of confounding. Fewer studies have examined prenatal NNS exposure, with mixed results from different analytical approaches. There is a paucity of RCTs evaluating NNS in children, yielding inconsistent results that can be difficult to interpret due to study design limitations (e.g., choice of comparator, multifaceted interventions). The majority of this research has been conducted in high-income countries. Some rodent studies demonstrate adverse metabolic effects from NNS, but most have used extreme doses that are not relevant to humans, and few have distinguished prenatal from postnatal exposure. Most studies focus on synthetic NNS in beverages, with few examining plant-derived NNS or NNS in foods. Overall, there is limited and inconsistent evidence regarding the impact of early-life NNS exposure on the developmental programming of obesity and cardio-metabolic health. Further research and mechanistic studies are needed to elucidate these effects and inform dietary recommendations for expectant mothers and children worldwide.

Noncaloric Sweeteners in Children: A Controversial Theme

Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.

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.

Consumption of fast food, sugar-sweetened beverages, artificially-sweetened beverages and allostatic load among young adults

This study investigates the associations between recent consumption of fast foods, sugar-sweetened beverages, and artificially-sweetened beverages on level of allostatic load, a measure of cumulative biological risk, in young adults in the US. Data from Wave IV of the National Longitudinal Study of Adolescent to Adult Health were analyzed. Negative binomial regression models were used to estimate the associations between consumption of fast foods, sugar-sweetened, and artificially-sweetened beverages and allostatic load. Poisson and logistic regression models were used to estimate the associations between these diet parameters and combined biomarkers of physiological subsystems that comprise our measure of allostatic load. All analyses were weighted and findings are representative of young adults in the US, ages 24–34 in 2008 (n = 11,562). Consumption of fast foods, sugar-sweetened, and artificially-sweetened beverages were associated with higher allostatic load at a bivariate level. Accounting for demographics and medication use, only artificially-sweetened beverages remained significantly associated with allostatic load. When all three dietary components were simultaneously included in a model, both sugar- and artificially-sweetened beverage consumption were associated with higher allostatic load. Differences in allostatic load emerge early in the life course and young adults consuming sugar- or artificially-sweetened beverages have higher allostatic load, net of demographics and medication use. Public health messages to young adults may need to include cautions about both sugar- and artificially-sweetened beverages.

•

Eating fast food is associated with higher AL at a bivariate level.

•

Sugar-sweetened drinks are associated with higher AL at a bivariate level.

•

Artificially-sweetened drinks are associated with higher AL at a bivariate level.

•

With all three dietary variables together, only drinks remain associated with AL.

•

Differences in AL emerge early in the life course, associated with consumption.

Health outcomes of non-nutritive sweeteners: analysis of the research landscape

BACKGROUND

Food products containing non-nutritive sweeteners (NNSs) instead of sugar have become increasingly popular in the last decades. Their appeal is obviously related to their calorie-free sweet taste. However, with the dramatic increase in their consumption, it is reasonable and timely to evaluate their potential health benefits and, more importantly, potential adverse effects. The main aim of this scoping review was to map the evidence about health outcomes possibly associated with regular NNS consumption by examining the extent, range, and nature of research activity in this area.

METHODS

We systematically searched Ovid MEDLINE, EMBASE and the Cochrane CENTRAL databases for studies on NNSs (artificial sweeteners or natural, non-caloric sweeteners, either used individually or in combination) using text terms with appropriate truncation and relevant indexing terms. All human studies investigating any health outcomes of a NNS intervention or exposure were eligible for inclusion. No studies were excluded based on language, study design or methodological quality. Data for each health outcome were summarized in tabular form and were discussed narratively.

RESULTS

Finally, we included 372 studies in our scoping review, comprising 15 systematic reviews, 155 randomized controlled trials (RCTs), 23 non-randomized controlled trials, 57 cohort studies, 52 case-control studies, 28 cross sectional studies and 42 case series/case reports. In healthy subjects, appetite and short term food intake, risk of cancer, risk of diabetes, risk of dental caries, weight gain and risk of obesity are the most investigated health outcomes. Overall there is no conclusive evidence for beneficial and harmful effects on those outcomes. Numerous health outcomes including headaches, depression, behavioral and cognitive effects, neurological effects, risk of preterm delivery, cardiovascular effects or risk of chronic kidney disease were investigated in fewer studies and further research is needed. In subjects with diabetes and hypertension, the evidence regarding health outcomes of NNS use is also inconsistent.

CONCLUSIONS

This scoping review identifies the needs for future research to address the numerous evidence gaps related to health effects of NNSs use.It also specifies the research questions and areas where a systematic review with meta-analyses is required for the proper evaluation of health outcomes associated to regular NNSs consumption.

Early maternal separation induces preference for sucrose and aspartame associated with increased blood glucose and hyperactivity

Early life stress and exposure to sweeteners lead to physiological and behavioral alterations in adulthood. Nevertheless, many genetic and environmental factors as well as the neurobiological mechanisms that contribute to the development of these disorders are not fully understood. Similarly, evidence about the long-term metabolic effects of exposure to sweeteners in early life is limited and inconsistent. This study used an animal model of maternal separation during breastfeeding (MS) to analyze the effects of early life stress on consumption of sweeteners, weight gain, blood glucose and locomotion. Rats were housed under a reversed light/dark cycle (lights off at 7:00 h) with ad libitum access to water and food. In the MS protocol, MS pups were separated from the dam for 6 h per day in two periods of 180 minutes (7:00-10:00 and 13:00-16:00 h) during the dark phase of postnatal day (PND) 1 to PND 21. Non-separated (NS) pups served as controls. On PND 22 rats were grouped by sex and treatment. From PND 26 to PND 50 sucrose and aspartame were provided to rats, and sweetener intake, body weight and blood glucose-related measures were scored. On PND 50, both male and female rats were exposed to the open field test to obtain locomotion and anxiety-related measures. Results showed that both early maternal separation and sweetener intake during adolescence resulted in increased blood glucose and hyperactivity in male rats but not in female rats. Data suggest that the combination of early stress and exposure to sucrose and aspartame could be a risk factor for the development of chronic diseases such as diabetes, as well as for behavioral alterations.

Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies

BACKGROUND

Nonnutritive sweeteners, such as aspartame, sucralose and stevioside, are widely consumed, yet their long-term health impact is uncertain. We synthesized evidence from prospective studies to determine whether routine consumption of non-nutritive sweeteners was associated with long-term adverse cardiometabolic effects.

METHODS

We searched MEDLINE, Embase and Cochrane Library (inception to January 2016) for randomized controlled trials (RCTs) that evaluated interventions for nonnutritive sweeteners and prospective cohort studies that reported on consumption of non-nutritive sweeteners among adults and adolescents. The primary outcome was body mass index (BMI). Secondary outcomes included weight, obesity and other cardiometabolic end points.

RESULTS

From 11 774 citations, we included 7 trials (1003 participants; median follow-up 6 mo) and 30 cohort studies (405 907 participants; median follow-up 10 yr). In the included RCTs, nonnutritive sweeteners had no significant effect on BMI (mean difference -0.37 kg/m²; 95% confidence interval [CI] -1.10 to 0.36; I² 9%; 242 participants). In the included cohort studies, consumption of nonnutritive sweeteners was associated with a modest increase in BMI (mean correlation 0.05, 95% CI 0.03 to 0.06; I² 0%; 21 256 participants). Data from RCTs showed no consistent effects of nonnutritive sweeteners on other measures of body composition and reported no further secondary outcomes. In the cohort studies, consumption of nonnutritive sweeteners was associated with increases in weight and waist circumference, and higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. Publication bias was indicated for studies with diabetes as an outcome.

INTERPRETATION

Evidence from RCTs does not clearly support the intended benefits of nonnutritive sweeteners for weight management, and observational data suggest that routine intake of nonnutritive sweeteners may be associated with increased BMI and cardiometabolic risk. Further research is needed to fully characterize the long-term risks and benefits of nonnutritive sweeteners. Protocol registration: PROSPERO-CRD42015019749.

Nutritional Counseling for Obese Children with Obesity-Related Metabolic Abnormalities in Korea

Child obesity has become a significant health issue in Korea. Prevalence of obesity in school-age children in Korea has been alarmingly rising since 2008. Prevalence of obesity among infants and preschool-age children in Korea has doubled since 2008. Obese children may develop serious health complications. Before nutritional counseling is pursued, several points should be initially considered. The points are modifiable risk factors, assessment for child obesity, and principles of treatment. Motivational interviewing and a multidisciplinary team approach are key principles to consider in managing child obesity effectively in the short-term as well as long-term. Nutritional counseling begins with maintaining a daily log of food and drink intake, which could possibly be causing obesity in a child. Several effective tools for nutritional counseling in practice are the Traffic Light Diet plan, MyPlate, Food Balance Wheel, and 'Food Exchange Table'. Detailed nutritional counseling supported by a qualified dietitian is an art of medicine enabling insulin therapy and hypoglycemic agents to effectively manage diabetes mellitus in obese children.